Antidepressants like Sarafem®, Prozac®, and Zoloft® are the most commonly prescribed medications for PMDD and PMS. In fact, if you’ve talked to a doctor or done a little internet research about PMDD and PMS, there’s a good chance you’re already familiar with the use of the selective serotonin reuptake inhibitor (SSRI) class of drugs for the treatment of PMDD and severe PMS.
We discussed previously how Sarafem® was brought to market for PMS only after the patent on Prozac was about to expire, and that before Sarafem®, PMDD was not a household word. And, of course, like all medications, antidepressant side effects are a real concern.
Recently an even more important question has come to the forefront, accentuated by the recent New York Times Magazine article by Siddhartha Mukherjee which discussed, among other things, the research of the Ph.D. psychologist Irving Kirsch, who conducted groundbreaking research showing that SSRI antidepressants do not work much better than placebo (sugar pill.) Kirsch also found that the drug companies and the FDA suppressed negative studies of SSRI antidepressants, and this resulted in a skewed and overly optimistic estimate of their effects. At this point, the the research on SSRIs adds up to one unavoidable conclusion: most of the prescriptions for Prozac®, Zoloft®, and similar drugs are of questionable utility, because these drugs don’t work significantly better than placebo for mild and moderate depression. SSRIs do work well for serious, major depression.
This brings us to the important question of whether SSRI antidepressants for PMDD and PMS are a good idea. Do they work? Are they better than placebo? How can we tell which woman really needs antidepressants for PMDD, and who doesn’t? Is the risk of side effects worth the risk of trying a medication that may be no better than sugar pill?
The answer to the first question is yes – antidepressants work for PMDD. The tricky part is that it is now a clear scientific fact that for mild and moderate depression, antidepressants aren’t superior to placebo, so it is unlikely that they are better than placebo for severe PMS and PMDD. But the real crux of the issue is the third question: how does anyone know if antidepressants are the right choice?
There is no way to determine this answer based on blood tests or a doctor’s exam. This important decision must be based on the severity of the symptoms, as determined by both the prescribing health care practitioner, and the patient. Do the symptoms resemble those of major depressive disorder? Are they truly debilitating and oppressive so that they are major impediment to functioning in the world, living life, and fulfilling one’s role and responsibilities?
There are certainly cases of major depression that meet these criteria, and they often respond to the SSRI antidepressants. Similarly, we can expect that when PMDD symptoms are so severe that they might as well be major depressive disorder for days to weeks out of the month, SSRIs are appropriate.
However, as we referenced earlier, SSRI antidepressants have side effects, and many women prefer to avoid them. When PMS and even PMDD symptoms fall short of the kind of interference with living that major depression causes, there are a wealth of excellent alternatives that have few side effects; are effective, and more effective than placebo; and that in some cases have been shown to be as effective as antidepressants.
Women and doctors should consider diet and stress management, as well as other lifestyle factors, as effective PMS & PMDD therapies. Proven remedies like Vitex agnus-castus, or Chasteberry; calcium; magnesium; and vitamin B6 as first line natural PMDD treatments that can be used before, or even instead of, antidepressants. Other supplements and herbs such as B-complex vitamins; the herbs Dong Quai and Black Cohosh; and the problems of food allergy and hypoglycemia are all worth adding to the list of natural PMDD alternatives.
Life is stressful, and PMS and PMDD make life more stressful. And as I wrote in my first blog post here, life stresses cause PMS. Well, PMDD, or Premenstrual Dysphoric Disorder—the most severe form of PMS—is just as tied into stress, and researchers have proven it. Increase your stress, and you increase your chances of having PMDD, which is a lot like having PMS depression: you sleep too much or too little, you’re tense and on edge, you feel sad and lose interest in things you usually like, plus women with PMDD can get all the same symptoms like bloating and cramps that are usually associated with PMS.
Not everyone is equally likely to develop PMS, though, and there are many factors that determine who will get it. We know there’s an inherited genetic tendency to PMDD, plus there’s also the stress component, and there’s definitely a hormonal and a brain chemistry aspect (we know this because PMDD has been treated with birth control hormones and antidepressants.) To that list, we can now officially add another likely culprit: discrimination.
That’s right—when minority women feel discrimination on the basis of gender, race, weight, or other factors, they’re more likely to have PMDD. Just to be clear, this doesn’t mean that these women felt discriminated against and then went home and felt bad about it. It means that when they felt this kind of prejudice directed towards them, weeks later it threw off their hormones, their brain chemistry, and their whole lives!
These findings were published in a paper in the Journal of Women’s Health from June of this year. Over 2700 Latina, Black, and Asian women reported their experiences and 83% reported experiencing discrimination during their lifetime. Interestingly, PMDD was connected more to subtle prejudice than to overt bias, which makes some sense: overt discrimination is mostly frowned upon in the culture, plus you know when it’s there. It’s the sneaky underhanded stuff that creates more stress. It's akin to the difference between an out-and-out argument with a friend that blows over rapidly like a violent thunderstorm, versus a simmering feud that boils below the surface and goes on and on.
Corey J. Pilver, the lead author on this scientific paper, is a researcher with the Connecticut Veteran’s Administration, and wrote the paper as part of her doctoral dissertation at Yale University.
One final note: minority women aren’t the only ones subject to gender discrimination: all women experience it. We’d love to see a study that looks at women of all ethnicities who feel gender discrimination to see if they experience more PMS/PMDD. There’s every reason to think that this form of bias causes stress for all women—and we know what stress can do.
What symptoms really mean you have PMS? Many reliable sources suggest there are over 150 PMS symptoms. Academic studies typically rely on a mere 17 symptoms that are often considered to be the true PMS symptoms. Most women have some idea of what most of those 17 are, including cramping, bloating, irritability, anger, headaches, crying easily, and the like.
A 2011 paper published in the Journal of Women's Health followed 1,081 women who were seeking conventional medical treatment for PMS and attempted to determine which of their symptoms were the most accurate predictors of PMS. That is, which symptoms really distinguished PMS from "not-PMS"? Keep reading and you'll find out what they discovered!
This might seem like a waste of time. After all, if you get crabby and crampy every month a week before your period, you have PMS, right? The problem is two-fold: it turns out that when people have to remember and record symptoms, their memory and accuracy are less than perfect. Apparently, we all have trouble comparing how we feel now to how we felt before; and our criteria for what a symptom is, or what its severity is or was, shifts continuously. So, it's important for researchers to be able to distinguish true PMS from "not-PMS."
An illustration might be in order: let's say our patient "Chantal" has actual clinical depression. It makes her lose interest in her usual activities and she has a tendency to withdraw from others when she's feeling down. And, like almost everyone with some depression, some days are better than others. Let's also say that, for cultural reasons, it's difficult for Chantal to admit depression (many cultures have a social taboo against psychological illness) but easier to admit to a condition that tends to be considered physical, like PMS. Since Chantal's symptoms are worse on some days than others, it's fairly easy to pay closer attention before the period and conclude that that is when the symptoms are occurring the most. Chantal probably isn't aware of her own cultural bias either, so she does not have an objective view of her own symptoms.
A doctor or researcher, who wants to help other doctors and researchers treat and investigate PMS, needs to have a way to distinguish PMS from clinical depression that could be mistaken for PMS. In conventional medicine, most treatments are drugs that have side effects and have the potential to cause bigger problems than they solve, so it's important to get the right fit between the diagnosis and the treatment. And, suggesting therapy or counseling to someone who has PMS—a biochemical disorder—rather than depression might end up being pretty frustrating for everyone!
So, back to the study. These researchers found that just six symptoms worked as well as the full 17 symptoms to distinguish PMS from "not PMS."
Those six symptoms: food cravings; cramps; anxiety/tension; mood swings; decreased interest in usual activities; and aches. These symptoms probably sound very familiar to anyone who has, or has had, PMS. Interestingly, this study found that food cravings were the most reliable indicator of PMS.
Does this mean that if your symptoms aren't on this list, you don't have PMS? Not at all. If you have (to pick a few symptoms that were not part of the six) premenstrual headaches, fatigue, irritability, and sadness most months, and these symptoms interfere with your life, you almost certainly do have PMS. What this research tells us is that those six symptoms, when they occur before the period, are very accurate predictors of PMS.
You might have read all this, and still think: "This is silly. What does it matter which six or nine or 18 symptoms I have? They happen every month before my period, so it must be PMS. Duh!" To that, we can only say, this is how medical research works. It's not perfect. It never correctly predicts anything with 100% accuracy. Over time, though, if enough studies can look at a similar set of circumstances from several different angles, we end up with a very accurate sense of what is going on.