In a systematic review of five randomized controlled trials

comparing COCs containing drospirenone to placebo or other COCs for effect on

premenstrual symptoms, the authors concluded that drospirenone 3 mg plus ethinyl

estradiol 20 mcg may help treat PMDD better than placebo.

177 They were unable to

determine whether this combination would help women with less severe symptoms

or would be more effective than other COCs. For women desiring contraception,

these particular agents have only been evaluated for efficacy in PMDD when used for

up to three cycles. The effects of other contraceptive agents for PMDD symptoms are

currently under investigation.

p. 1025

p. 1026

Table 50-6

Menstrual Cycle Daily Diary Chart

Month 1

Grading Severity of Symptoms:

1 = Mild; general awareness of discomfort but does not interfere with daily activities

2 = Moderate; interferes with activities but not disabling

3 = Severe; symptoms disabling, unable to meet daily social, family, or work obligations

* = Menstrual bleeding

Blank = no symptoms

Each Day

1. List the myour menstr2. Grade th3. Record d4. Record b5. Check thDay of month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Day of menstrual

cycle

18 19 20 21 22 23 24 25 26 27 28 1 2 3 4 5

Menses * * * *

Breast tenderness

and pain

1 1 1 1 1 1 1 1

Sadness or

depression

1 2 3 3 3 3 3 3 2 1

Fatigue 3 3 3 3 3 3 3 3 2 1

Irritability 2 2 3 3 3 3 3

Inability to

concentrate

2 2 3 3 3

Daily weight (lb) 130 130 130 130 130 130 130 130 130 130 130 131 131 131 130 130

Basal body

temperature (°F)

98.0 98.2 98.0 98.2 98.0 98.0 98.2 97.8 98.0 97.8 97.6 97.8

Month 2

Day of month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Day of menstrual

cycle

21 22 23 24 25 26 27 28 1 2 3 4 5 6 7 8

Menses * * * *

Breast tenderness

and pain

1 1 1 1 1 1 1

Sadness/depression 1 2 3 3 3 3 3 2 2 1

Fatigue 2 2 3 3 3 3 3 2 1

Irritability 1 2 2 2 3 3 3 3 3 2 2 1

Inability to

concentrate

1 1 2 2 3 3

Daily weight (lb) 128 128 128 128 128 128 128 129 129 129 128 128 128 128 128 128

Basal body

temperature (°F)

98.0 98.2 98.4 98.0 98.2 97.8 98.0 97.4 97.6 97.6 97.8 97.8

p. 1026

p. 1027

Table 50-7

Psychotropic Drugs for the Management of Premenstrual Syndrome or

Premenstrual Dysphoric Disorder

Drug (Brand Name)

Daily Dosing Regimen

(mg) Intermittent Dosing Regimen (mg)

a

SSRI

Citalopram (Celexa) 5–30 10–30

Escitalopram (Lexapro) 10–20 10–20

Fluoxetine (Prozac or Sarafem

b

) 20–60 20 or 90 weekly

Fluvoxamine (Luvox) 50–150 NS

Paroxetine (Paxil) 10–30 NS

Paroxetine controlled release (Paxil CR)

b 12.5–25 12.5–25

Sertraline (Zoloft)

b 50–150 100

Other Serotonergic Antidepressants

Nefazodone (Serzone) 200–600 NS

Venlafaxine (Effexor) 50 NS

Anxiolytics

Alprazolam (Xanax) NS 1–2

c

Buspirone (BuSpar) NS 25–60

aDay 14 until onset of menses.

bMedication has FDA-approved indication for premenstrual dysphoric disorder.

cDose to be tapered during 2 days after onset of menses to prevent withdrawalsymptoms.

NS, not studied; SSRI, selective serotonin reuptake inhibitors.

OTHER AGENTS

Treatment with GnRH agonists has been used for the physical and psychological

symptoms of PMS.

178 These agents are not typically used for long periods of time,

however, because of vasomotor symptoms and the potential for negative long-term

effects on bone. They also have to be administered by injection or nasal spray which

may affect adherence. This treatment is reserved for women with very severe PMDD

who do not respond to other treatments.

Danazol has been investigated for the treatment of PMS with moderate results.

Danazol 200 mg orally BID provides greater symptom relief than placebo for

symptoms of severe PMS; however, luteal phase treatment does not appear effective

for PMS symptoms.

179 Potential side effects are also a concern with this agent, and

therefore, its use in women should be limited to those who have failed other

therapies.

C.P. has PMDD and does not need contraception because she uses condoms. Mood

symptoms predominate and are impairing her functionality. An SSRI should be

started in either a continuous or intermittent manner. C.P. appears to be a good

candidate for intermittent therapy because she can adhere to the regimen and does not

have a concurrent depression or anxiety disorder. An appropriate initial treatment

regimen is fluoxetine 20 mg orally daily for the last 2 weeks of the menstrual cycle.

Her response rate should be assessed after three cycles of treatment. An anxiolytic

could be tried for symptoms not relieved by the SSRI.

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