Fluvoxamine in the treatment of menstrually related mood disorders

Selective serotonin reuptake inhibitors for premenstrual syndrome and premenstrual dysphoric disorder

BACKGROUND

Premenstrual syndrome (PMS) is a combination of physical, psychological and social symptoms in women of reproductive age, and premenstrual dysphoric disorder (PMDD) is a severe type of the syndrome, previously known as late luteal phase dysphoric disorder (LLPDD). Both syndromes cause symptoms during the two weeks leading up to menstruation (the luteal phase). Selective serotonin reuptake inhibitors (SSRIs) are increasingly used as a treatment for PMS and PMDD, either administered in the luteal phase or continuously. We undertook a systematic review to assess the evidence of the positive effects and the harms of SSRIs in the management of PMS and PMDD.

OBJECTIVES

To evaluate the benefits and harms of SSRIs in treating women diagnosed with PMS and PMDD.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase and PsycINFO for randomised controlled trials (RCTs) in November 2023. We checked reference lists of relevant studies, searched trial registers and contacted experts in the field for any additional trials. This is an update of a review last published in 2013.

SELECTION CRITERIA

We considered studies in which women with a prospective diagnosis of PMS, PMDD or LLPDD were randomised to receive SSRIs or placebo.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We pooled data using a random-effects model. We calculated standardised mean differences (SMDs) with 95% confidence intervals (CIs) for premenstrual symptom scores, using 'post-treatment' scores for continuous data. We calculated odds ratios (ORs) with 95% CIs for dichotomous outcomes. We stratified analyses by type of administration (luteal phase or continuous). We calculated absolute risks and the number of women who would need to be taking SSRIs in order to cause one additional adverse event (i.e. the number needed to treat for an additional harmful outcome (NNTH)). We rated the overall certainty of the evidence for the main findings using GRADE.

MAIN RESULTS

We included 34 RCTs in the review. The studies compared SSRIs (i.e. fluoxetine, paroxetine, sertraline, escitalopram and citalopram) to placebo. SSRIs probably reduce overall self-rated premenstrual symptoms in women with PMS and PMDD (SMD -0.57, 95% CI -0.72 to -0.42; I2 = 51%; 12 studies, 1742 participants; moderate-certainty evidence). SSRI treatment was probably more effective when administered continuously than when administered only in the luteal phase (P = 0.03 for subgroup difference; luteal phase group: SMD -0.39, 95% CI -0.58 to -0.21; 6 studies, 687 participants; moderate-certainty evidence; continuous group: SMD -0.69, 95% CI -0.88 to -0.51; 7 studies, 1055 participants; moderate-certainty evidence). The adverse effects associated with SSRIs were nausea (OR 3.30, 95% CI 2.58 to 4.21; I2 = 0%; 18 studies, 3664 women), insomnia (OR 1.99, 95% CI 1.51 to 2.63; I2 = 0%; 18 studies, 3722 women), sexual dysfunction or decreased libido (OR 2.32, 95% CI 1.57 to 3.42; I2 = 0%; 14 studies, 2781 women), fatigue or sedation (OR 1.52, 95% CI 1.05 to 2.20; I2 = 0%; 10 studies, 1230 women), dizziness or vertigo (OR 1.96, 95% CI 1.36 to 2.83; I2 = 0%; 13 studies, 2633 women), tremor (OR 5.38, 95% CI 2.20 to 13.16; I2 = 0%; 4 studies, 1352 women), somnolence and decreased concentration (OR 3.26, 95% CI 2.01 to 5.30; I2 = 0%; 8 studies, 2050 women), sweating (OR 2.17, 95% CI 1.36 to 3.47; I2 = 0%; 10 studies, 2304 women), dry mouth (OR 2.70, 95% CI 1.75 to 4.17; I2 = 0%; 11 studies, 1753 women), asthenia or decreased energy (OR 3.28, 95% CI 2.16 to 4.98; I2 = 0%; 7 studies, 1704 women), diarrhoea (OR 2.06, 95% CI 1.37 to 3.08; I2 = 0%; 12 studies, 2681 women), and constipation (OR 2.39, 95% CI 1.09 to 5.26; I2 = 0%; 7 studies, 1022 women). There was moderate-certainty evidence for all adverse effects other than somnolence/decreased concentration, which was low-certainty evidence. Overall, the certainty of the evidence was moderate. The main weakness was poor reporting of study methodology. Heterogeneity was low or absent for most outcomes, although there was moderate heterogeneity in the analysis of overall self-rated premenstrual symptoms. Based on the meta-analysis of response rate (the outcome with the most included studies), there was suspected publication bias. In total, 68% of the included studies were funded by pharmaceutical companies. This stresses the importance of interpreting the review findings with caution.

AUTHORS' CONCLUSIONS

SSRIs probably reduce premenstrual symptoms in women with PMS and PMDD and are probably more effective when taken continuously compared to luteal phase administration. SSRI treatment probably increases the risk of adverse events, with the most common being nausea, asthenia and somnolence.

Selective serotonin reuptake inhibitors for premenstrual syndrome

BACKGROUND

Premenstrual syndrome (PMS) is a common cause of physical, psychological and social problems in women of reproductive age. The key characteristic of PMS is the timing of symptoms, which occur only during the two weeks leading up to menstruation (the luteal phase of the menstrual cycle). Selective serotonin reuptake inhibitors (SSRIs) are increasingly used as first line therapy for PMS. SSRIs can be taken either in the luteal phase or else continuously (every day). SSRIs are generally considered to be effective for reducing premenstrual symptoms but they can cause adverse effects.

OBJECTIVES

The objective of this review was to evaluate the effectiveness and safety of SSRIs for treating premenstrual syndrome.

SEARCH METHODS

Electronic searches for relevant randomised controlled trials (RCTs) were undertaken in the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, and CINAHL (February 2013). Where insufficient data were presented in a report, attempts were made to contact the original authors for further details.

SELECTION CRITERIA

Studies were considered in which women with a prospective diagnosis of PMS, PMDD or late luteal phase dysphoric disorder (LPDD) were randomised to receive SSRIs or placebo for the treatment of premenstrual syndrome.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies, assessed eligible studies for risk of bias, and extracted data on premenstrual symptoms and adverse effects. Studies were pooled using random-effects models. Standardised mean differences (SMDs) with 95% confidence intervals (CIs) were calculated for premenstrual symptom scores, using separate analyses for different types of continuous data (that is end scores and change scores). Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for dichotomous outcomes. Analyses were stratified by type of drug administration (luteal or continuous) and by drug dose (low, medium, or high). We calculated the number of women who would need to be taking a moderate dose of SSRI in order to cause one additional adverse event (number needed to harm: NNH). The overall quality of the evidence for the main findings was assessed using the GRADE working group methods.

MAIN RESULTS

Thirty-one RCTs were included in the review. They compared fluoxetine, paroxetine, sertraline, escitalopram and citalopram versus placebo. SSRIs reduced overall self-rated symptoms significantly more effectively than placebo. The effect size was moderate when studies reporting end scores were pooled (for moderate dose SSRIs: SMD -0.65, 95% CI -0.46 to -0.84, nine studies, 1276 women; moderate heterogeneity (I(2) = 58%), low quality evidence). The effect size was small when studies reporting change scores were pooled (for moderate dose SSRIs: SMD -0.36, 95% CI -0.20 to -0.51, four studies, 657 women; low heterogeneity (I(2)=29%), moderate quality evidence).SSRIs were effective for symptom relief whether taken only in the luteal phase or continuously, with no clear evidence of a difference in effectiveness between these modes of administration. However, few studies directly compared luteal and continuous regimens and more evidence is needed on this question.Withdrawals due to adverse effects were significantly more likely to occur in the SSRI group (moderate dose: OR 2.55, 95% CI 1.84 to 3.53, 15 studies, 2447 women; no heterogeneity (I(2) = 0%), moderate quality evidence). The most common side effects associated with a moderate dose of SSRIs were nausea (NNH = 7), asthenia or decreased energy (NNH = 9), somnolence (NNH = 13), fatigue (NNH = 14), decreased libido (NNH = 14) and sweating (NNH = 14). In secondary analyses, SSRIs were effective for treating specific types of symptoms (that is psychological, physical and functional symptoms, and irritability). Adverse effects were dose-related.The overall quality of the evidence was low to moderate, the main weakness in the included studies being poor reporting of methods. Heterogeneity was low or absent for most outcomes, though (as noted above) there was moderate heterogeneity for one of the primary analyses.

AUTHORS' CONCLUSIONS

SSRIs are effective in reducing the symptoms of PMS, whether taken in the luteal phase only or continuously. Adverse effects are relatively frequent, the most common being nausea and asthenia. Adverse effects are dose-dependent.

Psychotropic medications and other non-hormonal treatments for premenstrual disorders

Selective serotonin re-uptake inhibitors have well-established efficacy for severe premenstrual syndrome and premenstrual dysphoric disorder. Efficacy has been reported with both continuous dosing (all cycle) and intermittent or luteal phase dosing (from ovulation to menses). Efficacy may be less with intermittent dosing, particularly for premenstrual physical symptoms. The efficacy of symptom-onset dosing (medication taken only on luteal days when symptoms occur) needs further systematic study. Women going through the menopausal transition may need to adjust their antidepressant dosing regimen due to the change in frequency of menstruation. Anxiolytics, calcium, chasteberry and cognitive-behaviour therapy may also have a role in the treatment of premenstrual symptoms.

Selective serotonin reuptake inhibitors for premenstrual syndrome

BACKGROUND

This is a substantive update of a previous review. Severe premenstrual syndrome (PMS) affects between 3% to 5% of women of reproductive age. Severe PMS is classified under the Diagnostic and Statistical Manual of Mental Disorders as premenstrual dysphoric disorder (PMDD). Selective serotonin reuptake inhibitors (SSRIs) are increasingly used as front-line therapy for PMS. A systematic review was undertaken on the efficacy of SSRIs in the management of severe PMS, or PMDD, to assess the evidence for this treatment option.

OBJECTIVES

The objective of this review was to evaluate the effectiveness of SSRIs in reducing premenstrual syndrome symptoms in women diagnosed with severe premenstrual syndrome.

SEARCH STRATEGY

Electronic searches for relevant randomised controlled trials were undertaken in the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, PsycInfo, and CINAHL (March 2008). Where insufficient data were presented in a report the original authors were contacted for further details.

SELECTION CRITERIA

All trials were considered in which women with a prospective diagnosis of PMS, PMDD or late luteal phase dysphoric disorder (LPDD) were randomised to receive SSRIs or placebo for the treatment of premenstrual syndrome in a blinded trial.

DATA COLLECTION AND ANALYSIS

Forty randomised controlled trials were identified which reported the use of SSRIs in the management of PMS. Fifty-six trials were excluded. The review authors extracted the data independently and estimated standardised mean differences for continuous outcomes.

MAIN RESULTS

Due to heterogeneity, analyses were subgrouped into change and absolute scores. The primary analysis of reduction in overall symptomatology included data on 2294 women with premenstrual syndrome. SSRIs were found to be highly effective in treating the premenstrual symptoms (SMD -0.53, 95% CI 0.68 to -0.39; P < 0.00001). Secondary analysis showed that they were effective in treating physical (SMD -0.34, 95% CI -0.45 to -0.22; P < 0.00001), functional (SMD -0.30, 95% CI -0.43 to -0.17; P < 0.00001), and behavioural symptoms (SMD -0.41, 95% CI -0.53 to -0.29; P < 0.00001). Luteal phase only and continuous administration were both effective and there was no influence of a placebo run-in period on reduction in symptoms. All SSRIs (fluoxetine, paroxetine, sertraline, fluvoxamine, citalopram, and clomipramine) were effective in reducing premenstrual symptoms. Withdrawals due to side effects were twice as likely to occur in the treatment group (OR 2.18, 95% CI 1.62 to 2.92; P < 0.00001).

AUTHORS' CONCLUSIONS

The evidence supports the use of selective serotonin reuptake inhibitors in the management of severe premenstrual syndrome.

Selective serotonin reuptake inhibitors and initial oral contraceptives for the treatment of PMDD: effective but not enough

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are almost unanimously considered to be very efficacious and the first line of pharmacologic treatment for premenstrual dysphoric disorder (PMDD) and premenstrual syndrome (PMS). There is a need to examine if this is actually the case. More recently, combined oral contraceptives (COCs) have been pursued due to their ovulation suppression effects. Their effects on PMS/PMDD should be further examined as well.

METHODS

For this review of the literature from 1990 to the present, MEDLINE, PsychLit, and Cochrane controlled trials register were searched. Randomized, double-blind, placebo-controlled clinical trials of SSRIs and COCs (N>20) that report the rate of responders and not just percent improvement in severity of symptoms were selected for study. The data extraction were the percentage or number of responders as reported by the original authors.

RESULTS

In many studies, only mean improvement in severity was reported. In all studies, the main inclusion criterion was meeting criteria for PMDD; this has not, however, been an outcome measure. However, only 16 reports that provided actual rate of responders could be included. The percentage of non-responders (100% minus active medication) to SSRIs and COCs was found to be higher than the reported percentage of women who responded to active medication (response rate to an SSRI or COC minus the response rate to placebo).

CONCLUSION

In the majority of larger-scale studies, once the placebo effect is accounted for, the percentage of women who respond to SSRIs or COCs is actually less than the percentage of women who do not respond at all. SSRIs provide an important step forward in the treatment of PMDD and PMS. COCs provide a different option, still, approximately 40% of women with PMDD do not respond to SSRIs. Treatment with a currently approved COC does not substantially improve the percentage of responders. Therefore, additional alternative targeted treatment modalities need to be developed.

Selective serotonin reuptake inhibitors for premenstrual syndrome and premenstrual dysphoric disorder: a meta-analysis

OBJECTIVE

To systematically review evidence of the treatment benefits of selective serotonin reuptake inhibitors (SSRIs) for symptoms related to severe premenstrual syndrome (PMS) and premenstrual dysphoric disorder.

DATA SOURCES

We conducted electronic database searches of MEDLINE, Web of Science, Cochrane Library, Embase, PsycINFO, and Cinahl through March 2007, and hand-searched reference lists and pertinent journals.

METHODS OF STUDY SELECTION

Studies included in the review were double-blind, randomized, controlled trials comparing an SSRI with placebo that reported a change in a validated score of premenstrual symptomatology. Studies had to report follow-up for any duration longer than one menstrual cycle among premenopausal women who met clinical diagnostic criteria for PMS or premenstrual dysphoric disorder. From 2,132 citations identified, we pooled results from 29 studies (in 19 citations) using random-effects meta-analyses and present results as odds ratios (ORs).

TABULATION, INTEGRATION, AND RESULTS

Our meta- analysis, which included 2,964 women, demonstrates that SSRIs are effective for treating PMS and premenstrual dysphoric disorder (OR 0.40, 95% confidence interval [CI] 0.31-0.51). Intermittent dosing regimens were found to be less effective (OR 0.55, 95% CI 0.45-0.68) than continuous dosing regimens (OR 0.28, 95% CI 0.18-0.42). No SSRI was demonstrably better than another. The choice of outcome measurement instrument was associated with effect size estimates. The overall effect size is smaller than reported previously.

CONCLUSION

Selective serotonin reuptake inhibitors were found to be effective in treating premenstrual symptoms, with continuous dosing regimens favored for effectiveness.

Management Strategies for Premenstrual Syndrome/Premenstrual Dysphoric Disorder

Objective:

To evaluate the current nonpharmacologic and pharmacologic treatment options for symptoms of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD).

Data Sources:

Literature was obtained through searches of MEDLINE Ovid (1950–March week 3, 2008) and EMBASE Drugs and Pharmacology (all years), as well as a bibliographic review of articles identified by the searches. Key terms included premenstrual syndrome, premenstrual dysphoric disorder, PMS, PMDD, and treatment.

Study Selection/Data Extraction:

All pertinent clinical trials, retrospective studies, and case reports in human subjects published in the English language were identified and evaluated for the safety and efficacy of pharmacologic and nonpharmacologic treatments of PMS/PMDD. Data from these studies and information from review articles were included in this review.

Data Synthesis:

Selective serotonin-reuptake inhibitors (SSRIs) have been proven safe and effective for the treatment of PMDD and are recommended as first-line agents when pharmacotherapy is warranted. Currently fluoxetine, controlled-release paroxetine, and sertraline are the only Food and Drug Administration-approved agents (or this indication. Suppression of ovulation using hormonal therapies is an alternative approach to treating PMDD when SSRIs or second-line psychotropic agents are ineffective; however, adverse effects limit their use. Anxiolytics, spironolactone, and nonsteroidal antiinflammatory drugs can be used as supportive care to relieve symptoms. Despite lack of specific evidence, lifestyle modifications and exercise are first-line recommendations for all women with PMS/PMDD and may be all that is needed to treat mild-to-moderate symptoms. Herbal and vitamin supplementation and complementary and alternative medicine have been evaluated for use in PMS/PMDD and have produced unclear or conflicting results. More controlled clinical trials are needed to determine their safety and efficacy and potential for drug interactions.

Conclusions:

Healthcare providers need to be aware of the symptoms of PMS and PMDD and the treatment options available. Treatment selection should be based on Individual patient symptoms, concomitant medical history, and need for contraception.

Escitalopram administered in the luteal phase exerts a marked and dose-dependent effect in premenstrual dysphoric disorder

This is the first placebo-controlled trial evaluating the efficacy of the selective serotonin reuptake inhibitor (SSRI), escitalopram, in the treatment of premenstrual dysphoric disorder (PMDD). Women with PMDD (intention-to-treat population, n = 151) were treated intermittently for 3 months, during luteal phases only, with 10 mg/d escitalopram, 20 mg/d escitalopram, or placebo. Escitalopram was found to exert a marked and a dose-dependent symptom-reducing effect, 20 mg/d being clearly superior to 10 mg/d. Although the primary outcome parameter, that is, the sum of the symptoms irritability, depressed mood, tension, and affective lability, was decreased by 90% with 20 mg/d escitalopram, the effect of active treatment on breast tenderness, food craving, and lack of energy was more modest and not significantly different from that of placebo; this outcome supports our previous assumption that the former symptoms are more inclined to respond to intermittent administration of an SSRI than are the latter. Although the placebo response was high, the difference between the placebo group and the 20-mg/d escitalopram group with respect to the percentage of subjects displaying 80% or greater reduction in the rating of the cardinal symptom of PMDD, that is, irritability, was considerable: 30% versus 80%. Adverse events were those normally reported in SSRI trials, such as nausea and reduced libido, and were not more common in patients given 20 mg/d of escitalopram than in patients given the lower dose. This study supports the usefulness of escitalopram for the treatment of PMDD and sheds further light on how different components of this syndrome are differently influenced by intermittent administration of an SSRI.

The pharmacologic management of premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) is characterized by physical, affective and behavioral symptoms that are linked to the luteal phase of the menstrual cycle and relieved soon after the onset of menses. The disorder is chronic and exerts a major impact on personal relationships and occupational productivity for the estimated 6% of reproductive-aged women who fulfill strict PMDD criteria and the almost 20% of women who nearly meet these criteria. There are now various pharmacologic options that have demonstrated efficacy for PMDD and two of these approaches have an approved indication for treatment from the US FDA: three selective serotonin re-uptake inhibitors; and for women who also desire hormonal contraception, a low dose oral contraceptive pill containing the progestin drospirenone, in a new dosing regimen. Due to the unique pathophysiology of the disorder, the selective serotonin re-uptake inhibitors can be effectively administered intermittently, with dosing limited to the luteal phase of the cycle (2 weeks prior to menses). In the future, new pharmacotherapy will likely evolve from research evaluating other hormonal formulations that inhibit ovulation, without simulating PMDD-like symptoms, or novel pharmacologic agents that modulate the central neurotransmission.

Are there differential symptom profiles that improve in response to different pharmacological treatments of premenstrual syndrome/premenstrual dysphoric disorder?

Current evidence suggests that the accepted treatments for premenstrual syndrome (PMS)/premenstrual dysphoric disorder (PMDD) have similar overall efficacy. While these treatments are more effective than placebo, response rates associated with them are far from satisfactory (<60%), such that, irrespective of treatment modality, there remain a significant number of women who are unresponsive to current conventional pharmacological therapy. The available data on response rates of specific types of premenstrual symptoms to, or symptom profiles that are most amenable to, each treatment modality are limited and not well defined because most studies were not designed to assess specific symptom profiles. Those studies that have attempted to evaluate which symptom profiles respond to specific therapies have revealed variations within the individual modalities, as well as between the different modalities. It appears that suppression of ovulation ameliorates a broad range of behavioural as well as physical premenstrual symptoms. SSRIs are most effective for irritability and anxiety symptoms, with lesser efficacy for 'atypical' premenstrual symptoms. GABAergic compounds are most efficacious for anxiety and anxious/depressive symptoms, while dopamine agonists, particularly bromocriptine, are perhaps most efficacious for mastalgia. Overall treatment response rates may improve if treatments are targeted at well-defined subgroups of patients. Re-analysis of available datasets from randomised clinical trials may shed more light on the notion that targeting women with specific premenstrual symptom profiles for specific treatment modalities would improve response rates beyond the current ceiling of approximately 60%. Such information would also improve understanding of the putative pathophysiological mechanisms underlying PMS and PMDD, and may point to a more specific diagnosis of these conditions.

Luteal phase administration of agents for the treatment of premenstrual dysphoric disorder

This review focuses on current information about luteal phase administration (i.e. typically for the last 2 weeks of the menstrual cycle) of pharmacological agents for the treatment of premenstrual dysphoric disorder (PMDD). Compared with continuous administration, a luteal phase administration regimen reduces the exposure to medication and lowers the costs of treatment. Based on evidence from randomised clinical trials, SSRIs are the first-line treatment for PMDD at this time. Of these agents, sertraline, fluoxetine and paroxetine (as an extended-release formulation) are approved by the US FDA for luteal phase, as well as continuous, administration. Clinical trials of these agents and citalopram have demonstrated that symptom reduction is similar with both administration regimens. When used to treat PMDD, SSRI doses are consistent with those used for major depressive disorder. The medications are well tolerated; discontinuation symptoms with this intermittent administration regimen have not been reported. Other medications that have been examined in clinical trials for PMDD or severe premenstrual syndrome (PMS) using luteal phase administration include buspirone, alprazolam, tryptophan and progesterone. Buspirone and alprazolam show only modest efficacy in PMS (in some but not all studies), but there may be a lower incidence of sexual adverse effects with these medications than with SSRIs. Symptom reduction with tryptophan was significantly greater than with placebo, but the availability of this medication is strictly limited because of safety concerns. Progesterone has consistently failed to show efficacy for severe PMS/PMDD in large, randomised, placebo-controlled trials.

Treatment of Premenstrual Dysphoric Disorder with Selective Serotonin Reuptake Inhibitors

Premenstrual dysphoric disorder (PMDD) is considered a severe form of premenstrual syndrome. Symptoms of PMDD occur during the last week of the luteal phase of the menstrual cycle and usually abate at the onset of menses. About 3-8% of all menstruating women experience PMDD, which can lead to significant functional impairment. Several randomized, controlled trials have assessed the efficacy of selective serotonin reuptake inhibitors (SSRIs) in the treatment of PMDD. The SSRIs were found to significantly improve symptoms, particularly psychological or behavioral symptoms, during the luteal phase in women with PMDD. Also, SSRIs were found to improve the quality of life in women with PMDD. Headache, fatigue, insomnia, and anxiety were often reported as adverse effects. A decrease in libido or sexual dysfunction also was reported. In recent studies, intermittent SSRI therapy was found to be effective treatment for PMDD and allows a woman to take the drug for only 14 days each month. Intermittent SSRI therapy should be recommended before continuous daily dosing of SSRIs in the treatment of PMDD.

Novel Uses of Selective Serotonin Reuptake Inhibitors in Women

Selective serotonin reuptake inhibitors (SSRIs) are commonly used as first-line therapy to treat mood disorders due to their demonstrated efficacy, safety, and tolerability profiles. SSRIs may play an intricate role in treating hormone-mediated disorders that disturb the quality of life for women. Selected uses of SSRIs, specifically in the treatment of hot flashes, premenstrual dysphoric disorder, and postpartum depression, are explored in this article. Data from several studies support the use of SSRIs in these conditions, and therefore, these agents have the potential to significantly improve mood, cognitive function, physical symptoms, and social functioning in patients with these disorders. In addition, SSRIs may prove to be viable alternatives to current therapies that may be contraindicated, poorly tolerated, or lack efficacy in patients with these disorders.

Selective serotonin reuptake inhibitors for premenstrual dysphoric disorder: the emerging gold standard?

There have been a large number of studies conducted investigating the use of selective serotonin reuptake inhibitors (SSRIs) in the treatment of patients with premenstrual dysphoric disorder (PMDD). The 12 randomised, controlled trials with continuous dose administration of SSRIs and the eight randomised, controlled trials with luteal phase dose administration (from ovulation to menses) are reviewed. All the treatment studies on fluoxetine, sertraline, paroxetine and citalopram have reported positive efficacy. Fluoxetine and sertraline have the largest literature, with a smaller number of studies endorsing paroxetine and citalopram. Mixed efficacy results have been reported with fluvoxamine. In general, adverse effects from the use of SSRIs in women with PMDD are the usual mild and transient adverse effects from SSRIs including anxiety, dizziness, insomnia, sedation, nausea and headache. Sexual dysfunction and weight gain can be problematic long-term adverse effects of SSRIs, but these effects have not been systematically evaluated with long-term SSRI use in women with PMDD. Serotonergic antidepressants have differential superiority over nonserotonergic antidepressants in the treatment of PMDD. Treatments that enhance serotonergic action improve premenstrual irritability and dysphoria with a rapid onset of action, suggesting a different mechanism of action than in the treatment of depression. It is possible that neurosteroids, such as progesterone metabolites, are involved in the rapid action of serotonergic antidepressants in PMDD. Future research needs to address less frequent dose administration regimens, such as 'symptom-onset' dose administration, and the recommended length of treatment.

Review of fluoxetine and its clinical applications in premenstrual dysphoric disorder

The largest number of antidepressant treatment trials in premenstrual syndrome and premenstrual dysphoric disorder (PMDD) have been conducted with fluoxetine. Fluoxetine and other selective serotonin re-uptake inhibitors (SSRIs) clearly reduce premenstrual emotional and physical symptoms and improve premenstrual psychosocial functioning. Fluoxetine was the first SSRI to be approved by the FDA as a treatment for the emotional and physical symptoms of PMDD. Fluoxetine 20 mg has been reported to be effective for emotional and physical premenstrual symptoms with continuous daily dosing (every day of the menstrual cycle) and with luteal phase daily dosing (from ovulation to menses). In addition, premenstrual emotional symptoms have been reported to improve with fluoxetine 10 mg in luteal phase daily dosing and with 90 mg 2 and 1 weeks prior to menses. Fluoxetine is generally a well-tolerated treatment for PMDD and discontinuation effects have not been reported with intermittent dosing regimens.

Selective serotonin reuptake inhibitors for premenstrual syndrome

BACKGROUND

Severe premenstrual syndrome affects between 3-5% of women of reproductive age. Such severe PMS is classified under the Diagnostic and Statistical Manual of Mental Disorders as premenstrual dysphoric disorder, PMDD. Selective serotonin reuptake inhibitors (SSRIs) are increasingly being used as a front-line therapy for premenstrual syndrome (PMS). A systematic review was undertaken on the efficacy of SSRIs in the management of severe PMS/PMDD, to assess the evidence for this treatment option.

OBJECTIVES

The objective of this review was to evaluate the effectiveness of SSRIs in reducing premenstrual syndrome symptoms in women diagnosed with severe premenstrual syndrome.

SEARCH STRATEGY

Electronic searches for relevant randomised controlled trials of the Cochrane Menstrual Disorders and Subfertility Group specialised register of controlled trials, Cochrane Controlled Trials Register, MEDLINE, EMBASE and PsychLit were undertaken. References were searched interactively to identify missed trials. Where insufficient data were presented original authors were contacted for further details.

SELECTION CRITERIA

All trials were considered in which women with a prospective diagnosis of PMS/ PMDD were randomised to receive SSRIs or placebo in a double blind trial for the treatment of premenstrual syndrome.

DATA COLLECTION AND ANALYSIS

31 randomised controlled trials were identified which reported the use of SSRIs in the management of PMS. 16 trials were excluded, 15 trials were included in the systematic review, and ten trials were included in the main analyses. The reviewers extracted the data independently and standardised mean differences for continuous outcomes were estimated from the data.

MAIN RESULTS

The primary analysis of reduction in overall symptomatology included data on 844 women with premenstrual syndrome. SSRIs were found to be highly effective in treating premenstrual symptoms. Secondary analysis showed that they were as effective in treating physical as well as behavioural symptoms. There was no significant difference between trials funded by pharmaceutical companies and those independently funded. Withdrawals due to side effects were 2.5 times more likely to occur in the treatment group, particularly at higher doses.

REVIEWER'S CONCLUSIONS

There is now very good evidence to support the use of selective serotonin reuptake inhibitors in the management of severe premenstrual syndrome.

Treating premenstrual dysphoric disorder using serotonin agents

Premenstrual syndrome (PMS) affects 20%-50% of all women. Premenstrual dysphoric disorder (PMDD), which can be conceptualized as a more severe variant of PMS, can affect 3%-9% of all women. Because a significant number of women suffer from premenstrual disorders and afflicted women may spend up to half the month suffering from symptoms, it is important to identify and provide effective treatment for such women. Historically, it has been difficult to distinguish premenstrual disorders from other depressive disorders, given the high comorbidity of the two disorders. Most studies attempt to remove this confounding factor by excluding women with concurrent depressive disorders. Despite the difficulties and limitations inherent in studying treatments for premenstrual disorders, most investigations support the use of serotonin agents in treating PMDD.

Efficacy of selective serotonin-reuptake inhibitors in premenstrual syndrome: a systematic review

BACKGROUND

Selective serotonin-reuptake inhibitors (SSRIs) are increasingly being used as first-line therapy for severe premenstrual syndrome (PMS). We undertook a meta-analysis on the efficacy of SSRIs in this disorder.

METHODS

We searched medical and scientific databases, approached pharmaceutical companies, and reviewed citations of relevant articles to identify 29 studies of the use of SSRIs in PMS. 14 were excluded (no placebo group, preliminary report of included trial, or low quality). 15 randomised placebo-controlled trials were included. Information on study design, participants, drugs used and dosing regimens, outcome measures, side-effects, and sources of funding was extracted. Standardised mean differences between treatment and placebo groups were calculated to obtain an overall estimate of efficacy. The primary outcome measure was a reduction in overall PMS symptoms.

FINDINGS

The primary analysis included data on 904 women (570 assigned active treatment and 435 assigned placebo, including 101 in crossover trials). The overall standardised mean difference was -1.066 (95% CI -1.381 to -0.750), which corresponds to an odds ratio of 6.91 (3.90 to 12.2) in favour of SSRIs. SSRIs were effective in treating physical and behavioural symptoms. There was no significant difference in symptom reduction between continuous and intermittent dosing or between trials funded by pharmaceutical companies and those independently funded. Withdrawal due to side-effects was 2.5 times more likely in the active-treatment group than in the placebo group.

INTERPRETATION

SSRIs are an effective first-line therapy for severe PMS. The safety of these drugs has been demonstrated in trials of affective disorder, and the side-effects at low doses are generally acceptable.

The role of fluoxetine in the treatment of premenstrual dysphoric disorder

Many women experience psychological and physical symptoms associated with the menstrual cycle, commonly referred to as premenstrual syndrome (PMS). For the 3% to 5% of women who meet Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for premenstrual dysphoric disorder (PMDD), symptoms are severe and impair social and occupational functioning. Although the etiology of PMDD is unknown, symptoms of dysphoria, including depression and anxiety, predominate and indicate a link to serotonergic neurotransmission. Pharmacotherapy trials have shown greater efficacy with serotonergic versus nonserotonergic compounds. We reviewed the published literature and found 7 controlled and 4 open-label clinical trials of fluoxetine, a selective serotonin reuptake inhibitor, in the treatment of PMDD. These trials demonstrate that PMDD symptoms decreased during treatment with fluoxetine. Preliminary findings suggest that intermittent luteal-phase fluoxetine dosing may also be a suitable treatment strategy for selected patients with PMDD. At 20 mg/d, adverse events were usually transient, rarely caused discontinuation, and were consistent with fluoxetine's known safety profile. Fluoxetine 20 mg/d is an effective and well-tolerated treatment for women with PMDD, a severe variant of PMS.

A placebo-controlled clinical trial of L-tryptophan in premenstrual dysphoria

BACKGROUND

Antidepressant drugs, including specific serotonin reuptake inhibitors, have been shown to be beneficial in the treatment of premenstrual dysphoric disorders. The present study tests the efficacy of L-tryptophan, which acts specifically on serotonergic neurons, in this disorder.

METHODS

In a randomized controlled clinical trial, 37 patients with premenstrual dysphoric disorder were treated with L-tryptophan 6 g per day, and 34 were given placebo. The treatments were administered under double-blind conditions for 17 days, from the time of ovulation to the third day of menstruation, during three consecutive menstrual cycles.

RESULTS

The Visual Analogue Scales (VAS) revealed a significant (p = .004) therapeutic effect of L-tryptophan relative to placebo for the cluster of mood symptoms comprising the items of dysphoria, mood swings, tension, and irritability. The magnitude of the reduction from baseline in maximum luteal phase VAS-mood scores was 34.5% with L-tryptophan compared to 10.4% with placebo.

CONCLUSIONS

These results suggest that increasing serotonin synthesis during the late luteal phase of the menstrual cycle has a beneficial effect in patients with premenstrual dysphoric disorder.

Serotonin re-uptake inhibitors in the treatment of premenstrual dysphoria: Current state of knowledge

Late luteal phase dysphoric disorder (LLPDD) and the more recently introduced premenstrual dysphoric disorder (PMDD) are recognized psychiatric disorders that consist of distressing emotional and behavioural symptoms that occur premenstrually. Recently, advances have been made in understanding the aetiology of the disorder, with clear evidence to implicate the serotonergic system. In women with predominately psychological symptoms, selective serotonin re-uptake inhibitors (SSRIs), as well as clomipramine, have demonstrated excellent efficacy and minimal side effects.

Premenstrual dysphoric disorder. An update

The recent inclusion of research criteria for premenstrual dysphoric disorder (PMDD) in the DSM-IV should help physicians recognize women with symptoms of irritability, tension, dysphoria, and lability of mood which seriously interfere with their lifestyle. PMDD can be differentiated from premenstrual syndrome (PMS) which is primarily reserved for milder physical symptoms and minor mood changes. The use of DSM-IV criteria in conjunction with prospective daily charting for at least two cycles is now accepted as common practice in confirming the diagnosis. Treatment options range from conservative lifestyle and stress management to treatment with psychotropic medications and hormonal or surgical interventions to eliminate ovulation for the more extreme cases. Results from several randomized placebo-controlled trials have clearly demonstrated that selective serotonin reuptake inhibitors as well as medical or surgical oophorectomy are very effective in treating PMDD. Taken together, these data indicate that treatment may be accomplished by either eliminating the hormonal trigger or by reversing the sensitivity of the serotonergic system.

The management of treatment-resistant depression in disorders on the interface of psychiatry and medicine. Fibromyalgia, chronic fatigue syndrome, migraine, irritable bowel syndrome, atypical facial pain, and premenstrual dysphoric disorder

We have reviewed studies examining the efficacy of various psychotropic medications, primarily antidepressant agents, in the treatment of a group of disorders that appear to exhibit some phenomenologic and genetic relationship to major depression. These disorders all appear to benefit (albeit to varying degrees) from antidepressant medications of several different chemical families. This observation has important theoretical and clinical implications. From a theoretical perspective, these results invite the hypothesis that these various disorders may share some particular etiologic "step" in common with major depression-and that the various antidepressant classes benefit these various disorders and major depression via a common action at this hypothetical "step". Although there is an appealing parsimony to this hypothesis, several reservations must be considered. First, it must be recognized that the quality of the available studies varies widely. As noted in the text, these studies used numerous different designs, varying diagnostic criteria for the disorders under study, and diverse methods of rating outcome. Interpretation is further complicated by the fact that many studies included other concomitant medications or therapeutic interventions in addition to the psychotropic drugs administered. Also, the dose of antidepressant medications administered in many of these studies, especially those using TCAs, was often much less than that normally administered in the treatment of major depressive disorder itself. Finally, many of the studies did not systematically evaluate improvement in both the physical and psychological symptoms of a given disorder. For all of these reasons, any theoretic discussion of the results must be tentative. Nevertheless, the overall tally of results strongly favors the hypothesis that antidepressant agents, regardless of their chemical class, are generally useful in the treatment of these disorders. At a minimum, therefore, we can conclude that antidepressant treatment in these disorders deserves aggressive further investigation in studies with modern, rigorous designs. Second, even allowing that multiple antidepressant agents are effective in these various disorders, it still may be premature to conclude that these disorders are related to major depressive disorder. In particular, many of the studies found little correlation between improvement in psychological symptoms and physical symptoms of a given disorder. This observation would seem to argue against a relationship with major depressive disorder. The alternative hypothesis, however, namely, that these disorders do not share a common etiologic "step," seems even less attractive. It would be a remarkable coincidence if, say, fluoxetine possessed an antidepressant property, an independent antimigraine property, and a third, independent, antipremenstrual dysphoric disorder property. And it would be even more peculiar if various other antidepressant medications chemically unrelated to fluoxetine also, by chance alone, benefited all of these same disorders via still other independent mechanisms. Although we cannot, of course, rule out the possibility of multiple mechanisms and multiple causes, the experience of scientific research often has been that the simpler explanation of a phenomenon has proved to be correct. Therefore, the possibility of a link among these various antidepressant-responsive disorders deserves investigation. From a clinical perspective, too, these results are important. They suggest that trials of antidepressant medications should be strongly considered in patients with these disorders. Furthermore, other types of psychotropic medication appear to have a role in the treatment of individual disorders, as discussed in the corresponding sections.(ABSTRACT TRUNCATED)

Paroxetine as a treatment for premenstrual dysphoric disorder

Research into the psychobiology of premenstrual dysphoric disorder (PDD) finds alterations in markers associated with serotonergic neurotransmission. Supporting this is work showing that patients with PDD respond to some agents that block the reuptake of serotonin. In this open trial, patients were treated for one cycle with placebo and then for three consecutive cycles with the serotonin reuptake inhibitor paroxetine. The study population was composed of 14 participants who met DSM-IV criteria for PDD with moderate to severe symptomatology and specifically endorsed anger and irritability as a central premenstrual complaint. Patients showed modest improvement over the course of the pretreatment evaluation, with significant improvement occurring for feelings of worthlessness, decreased interest, and low energy. The effects of active treatment were marked by the first active cycle with luteal phase 17-item Hamilton Rating Scale for Depression scores decreasing from 14.9 (+/- 5.3) to 8.2 (+/- 4.9) in the first, 7.8 (+/- 5.1) in the second, and 7.8 (+/- 6.8) in the third active treatment cycles (F[1,13] = 17.6; p < 0.0001). A group of items from daily ratings indicative of anger and irritability (mood swings, anger and irritability, behavioral dyscontrol, and interpersonal conflicts) also showed improvement (F[1,13] = 5.94; p < 0.03). Various definitions of response were applied to treatment completers. The most conservative measure, the Clinical Global Impression (CGI), revealed that 7 of 14 patients had a complete response (CGI = 1 or 2) whereas 4 patients had a partial response (CGI = 3). These open trial findings are consistent with the notion that paroxetine is effective in the acute phase for the treatment of PDD.

Fluoxetine in the treatment of premenstrual dysphoria. Canadian Fluoxetine/Premenstrual Dysphoria Collaborative Study Group

BACKGROUND

Premenstrual dysphoria shares certain features with depression and anxiety states, which have been linked to serotonergic dysregulation. We evaluated the efficacy and safety of fluoxetine (which selectively inhibits the reuptake of serotonin) in the treatment of premenstrual dysphoria.

METHODS

The trial consisted of a single-blind, placebo washout period lasting two menstrual cycles, followed by a randomized, double-blind, placebo-controlled trial of fluoxetine at a dose of either 20 mg or 60 mg per day or placebo for six menstrual cycles. Healthy women meeting criteria for what was then called late-luteal-phase dysphoric disorder were recruited at seven university-affiliated women's health clinics in Canada. The primary outcome measure consisted of visual-analogue scales for tension, irritability, and dysphoria during the late luteal phase of each cycle.

RESULTS

Of 405 women enrolled in the placebo washout period, 313 subsequently entered the randomized phase of the study, which lasted six menstrual cycles, and 180 completed it. Fluoxetine at a dose of 20 or 60 mg per day was significantly superior to placebo in reducing symptoms of tension, irritability, and dysphoria, as measured by the visual-analogue scales (P < 0.001). The women who received 60 mg of fluoxetine per day reported significantly more side effects than those who received 20 mg per day or placebo (P < 0.001).

CONCLUSIONS

Fluoxetine is useful in the treatment of premenstrual dysphoria. Treatment with fluoxetine at a dose of 20 mg per day reduces the potential for side effects while maximizing therapeutic efficacy.

Altered serotonergic activity in women with dysphoric premenstrual syndromes

OBJECTIVE

Dysphoric Premenstrual Syndromes (PMS) are quite prevalent and in some women they are severe enough to warrant treatment. Their pathophysiology is still unknown, despite increased interest and research. Here we review the possible role of serotonin in the multidimensional interactive pathophysiology of PMS.

METHOD

Over 170 articles are reviewed. An extensive library search has been conducted and articles are included because of their relevance to: 1) the phenomenology of PMS; 2) the putative association of serotonergic (5-HT) activity with syndromes that occur premenstrually; 3) changes in 5-HT activity along the menstrual cycle, especially the late luteal phase; 4) influence of gonadal hormones on serotonergic functions; 5) endocrine strategies for assessment of 5-HT abnormalities; and 6) treatment studies of PMS with serotonergic agonists.

RESULTS AND CONCLUSIONS

The data presented here suggest that post-synaptic serotonergic responsivity might be altered during the late-luteal-premenstrual phase of the menstrual cycle. Some serotonergic functions of women with PMS might be altered during the entire cycle and be associated with a vulnerability trait. It is hypothesized that gonadal hormones might cause changes in levels of activity of 5-HT systems as part of a multidimensional interactive system. Strategies to evaluate 5-HT activities in the context of the menstrual cycle are discussed--leading to the conclusion that the most promising approach is active stimulation with specific post-synaptic serotonin agonists. Treatment outcome studies of some imperfect compounds that are currently applied as a symptomatic treatment of PMS support the notion that 5-HT is involved in the pathophysiology of these syndromes.

Serotonin, carbohydrates, and atypical depression

At least three categories of atypical depression have been described. The hysteroid dysphoria is characterized by repeated episodes of depressed mood in response to feeling rejected, and a craving for sweets and chocolate. Two other issues are characterized by a cyclical occurrence of changes of mood and appetite, i.e., the late luteal phase dysphoric disorder (DSM-III-R, appendix), or "the premenstrual syndrome" (PMS), and the major depression with seasonal pattern (DSM-III-R), or seasonal affective disorder (SAD). The reactive mood changes are frequently accompanied by features as hypersomnia, lethargy and increased appetite, particularly with a preference for carbohydrates. Central serotonin pathways participate in the regulation of mood and behavioural impulsivity, and modulate eating patterns qualitatively and quantitatively. Depressives with PMS og SAD benefit, in general, from treatments with serotonin potentiating drugs, suggesting that brain serotonin plays a role in the pathophysiology. Ingestion of carbohydrates increases the plasma ratio of tryptophan to other large neutral amino acids in man and animal, and the serotonin synthesis in the rat brain. Based on these findings it has been suggested that the excessive carbohydrate intake by patients with PMS and SAD reflects a self-medication that temporarily relieves the vegetative symptoms via an increased central serotonergic activity.

Clomipramine effectively reduces premenstrual irritability and dysphoria: a placebo-controlled trial

Forty nondepressed women displaying severe premenstrual irritability and/or dysphoria and fulfilling the DSM-III-R criteria of late luteal phase dysphoric disorder were treated daily for 3 menstrual cycles with either the potent serotonin reuptake inhibitor clomipramine (25-75 mg; flexible dosage) (n = 20) or placebo (n = 20). In both treatment groups premenstrual irritability and dysphoria (as rated daily by the patients using a visual analogue scale) were significantly reduced as compared with the rating during 2 pretreatment reference cycles; however, in the placebo group this reduction was only about 40% whereas, in the clomipramine group, the symptom decrease was greater than 80%. At all 3 treatment cycles, patients on clomipramine displayed significantly lower symptom rating than controls. Also with respect to the rating of global improvement, the results obtained with clomipramine were considerably and significantly better than those obtained with placebo. It is concluded that low doses of clomipramine effectively reduce premenstrual irritability and dysphoria with a response rate close to 100%. The possible role of serotonin in the pathophysiology of the premenstrual syndrome is discussed.