pills for PMS: hope or hype?

Can a pill tame the worst pre-menstrual symptoms? There's a lot to consider before asking your doctor for a prescription.

The ads have the feel of a summer garden party on one of those days when sunshine streams down from a sky that's been gloomy too long. Dotted with sunflowers and brightened by beaming faces, they convey the hopeful message that relief from the dark cloud of premenstrual misery--mood swings, bloating, irritability--is as close as your doctor's prescription pad.

Don't dismiss your monthly distress as mere PMS, the ads admonish. You could be suffering from a more serious condition called PMDD: premenstrual dysphoric disorder. But there's no need to despair; there's a new medicine that can deflate your bloated belly as it boosts your spirits.

Never heard of PMDD? Neither had a lot of other women until those ads came along--making some wonder whether the syndrome was indeed a true diagnosable condition. But PMDD--the severe end of the VMS spectrum, characterized by incapacitating mood and physical symptoms--is all too real for the women who suffer from it. Research on these severe premenstrual problems goes back 15 years or more, and so does the possibility of treating the condition with pills--specifically mood-altering drugs. (More recently, research has focused on calcium as an answer to premenstrual problems. See "Calcium for PMS?" on page 76.)

Despite the mixed results of early research, there's now strong evidence that newer antidepressants relieve both physical and emotional symptoms in many sufferers. Hence, the new ads: Sarafem, the drug they promote, is fluoxetine hydrochloride, also known as Prozac. In clinical trials, daily doses of fluoxetine have been shown to reduce bloating, breast tenderness, tension, irritability, depression, and mood swings in women with PMDD.

Still, there's a lot to consider before asking your doctor for a prescription. To meet the official criteria for PMDD, a woman must check off at least five or more symptoms from a list of 11 (see sidebar at right), and at least one must involve mood. Symptoms must be most severe during the week before menstruation, improve significantly or disappear within a few days after your period starts, and cause problems at work or school, during social activities, or in relationships with others. While most women in their reproductive years have premenstrual complaints ranging from tender breasts and swollen gums to anger and anxiety, only 3 to 5 percent have symptoms--mainly mood-related--serious enough to make life miserable.

Beverly Palmer (name has been changed) is one of those women. Before the 38-year-old flight attendant recognized the premenstrual pattern and sought treatment, she suffered for years with extreme tension, irritability, and emotional sensitivity.

"I cried, I yelled, I felt like an overwound spring," says Palmer, who lives in Las Flores, California. Normally a peacemaker, she'd turn sarcastic and pick fights with her husband just before every period. "If he told me the sky was blue, and I saw a cloud, then we had an issue," Palmer recalls. She'd end up sobbing hard enough to hyperventilate, leaving her bewildered mate "looking like he had been sideswiped," she says. But the looks that pained her most were on the faces of her two little girls, sitting sad and silent in the backseat of the car after she exploded at them for taking too long to lace up their shoes.

Psychologist Jean Edicott, Ph.D., director of the Premenstrual Evaluation Unit at Columbia Presbyterian Medical Center, says PMDD has a wide-reaching effect on the women who suffer from it. "For women with PMDD, it really impairs their lives. For a week to 10 days of the month, they're having really major problems," she says. The severity of PMDD was confirmed in a study by Eli Lilly and Company researchers on the impact of premenstrual problems; it was published last October in the Journal of Women's Health & Gender-Based Medicine. In the survey of 1,022 women between the ages of 18 and 49, 83 percent of those reporting PMDD symptoms said they had marital troubles, 78 percent said they had problems in relationships with their children, and 69 percent said their symptoms interfered with their social lives. It seems relationships often suffer more than work performance. While women often say they feel fuzzyheaded, forgetful, and slow just before their periods, researchers have found no evidence of impaired memory, attention, or learning.

PMS, the milder-mannered sister of PMDD, is not as clearly delineated. Women with PMS may have any of 100 or more physical and emotional symptoms in the two weeks before their periods. Symptoms vary from woman to woman, and even from month to month. With the syndrome so broadly and vaguely defined, it's hard to say exactly how many women have it--estimates range from 30 to 80 percent. While PMS may interfere somewhat with everyday life, it's not as consistently devastating as PMDD, and it often can be managed through diet and lifestyle changes.

That said, not everyone who slams doors, snaps at her spouse, or suddenly turns tearful in the days leading up to her period has VMS or PMDD. Many women who think they have PMS or PMDD actually have chronic anxiety or depression that gets worse just before their periods, says Endicott. Since there are no medical tests for PMS or PMDD, the only way to know whether symptoms are confined to the premenstrual phase of a woman's cycle--the two weeks or so bounded by ovulation and the first day of menstrual bleeding--is to jot down the severity of symptoms daily for at least a couple of months, rating them on a scale from 1 (not present) to 6 (extreme). "When they do the daily ratings, a lot of women realize that something is going on all month. It gets worse premenstrually, but it's going on all the time," says Endicott.

So just what is at the root of this distress? Many researchers suspect the brain chemical serotonin, though its exact role in PMS and PMDD isn't clear. "If you look at what drives women to see a doctor for premenstrual problems, it's feeling irritable and out of control," says psychiatrist Diana Dell, M.D., of Duke University Medical Center, who has conducted clinical trials of various drug treatments for PMDD. "We have pretty good evidence from animal models that irritability may be a serotonin-deficit symptom."

Furthermore, a number of studies over the past 11 years have shown that antidepressants in the category known as selective serotonin reuptake inhibitors (SSRIS), which include Prozac and Zoloft, relieve a range of premenstrual symptoms--tension, irritability, mood swings, sadness, bloating, and breast tenderness--usually within a month or two after treatment begins. These PMDD-pacifying drugs act by keeping levels of serotonin elevated in the brain; antidepressants that don't affect serotonin levels generally have no effect on VMS or PMDD. And women who take the drugs for their symptoms don't have to take them all month--only in the two weeks before menstruation. They also can get the benefit from lower doses than are used for depression, so the side effects are minimized. SSRIS don't work for everyone--in studies, about 50 to 65 percent of PMDD patients get relief--and researchers aren't sure why that is.

But for that 50 to 65 percent, symptom improvements translate into happier lives, Yale University School of Medicine psychiatrist Kimberly Yonkers, M.D., and colleagues have found. They studied 200 women with PMDD whose problems with relationships, family life, and social and leisure activities were similar to those of patients with severe depression. Women who took Zoloft said their productivity improved and they felt more sociable and interested in their hobbies, but the biggest change was in their relationships. Forty-two percent of women taking the drug reported improvement in that area, compared to 15 percent of those taking an inactive, dummy pill.

Not everyone believes in using SSRIS for PMS and PMDD. When Prozac was introduced by Eli Lilly and Company in 1988, many people raised concerns about overuse of the drug; there was a similar outcry when it came out under the name Sarafem last year. Since Eli Lilly's patent on fluoxetine for depression is being debated in the courts, the timing of Sarafem's appearance has made some people suspicious. Eli Lilly maintains, however, that the development of Sarafem began years before they knew one of Prozac's patents would be invalidated. And because the company has a seven-year method-of-use patent on fluoxetine for PMDD, don't expect generic versions of Sarafem to show up any time soon.

Critics also worry that women who take antidepressants for PMDD will be labeled as mentally ill, which they fear could lead to a host of consequences, from workplace discrimination to loss of parental rights. And just like Prozac before it, Sarafem raises questions about whether the drug is being used to treat an illness or simply to change normal--albeit unpleasant--personality traits.

If your tension and tearfulness have you making an appointment at your doctor's office, find out if he or she is comfortable treating premenstrual problems. Ask what approach the doctor uses, Yonkers advises. Be wary of a physician who advocates only one type of treatment or who wants to prescribe pills without having you keep a symptom diary. Track your symptoms for two or three months; then discuss them--and all the treatment options--with your doctor. Keep tracking them after starting treatment so you can see if you're getting results.

And buy yourself a bunch of sunflowers. They won't do a thing for your premenstrual problems, but they seem to have a way of making people smile.

h online
What works for your worst PMS symptoms? What doesn't? Share your experiences at HEALTH.COM: just click on "Discussions."

Do you have PMDD?
The first step is paying attention to your body. Listed below are the criteria doctors use for diagnosing PMDD. Symptoms should occur during the last week of the luteal phase (the time between ovulation and the onset of your menstrual period) and be resolved within a few days after your period starts. Five or more of the following symptoms must be present and at least one must involve mood:

feelings of sadness or hopelessness, possible suicidal thoughts
feelings of tension or anxiety
mood swings marked by periods of teariness
persistent irritability or anger that affects other people
disinterest in daily activities and relationships
trouble concentrating
fatigue or low energy
food cravings or bingeing
sleep disturbances
feeling out of control
physical symptoms, such as bloating, breast tenderness, headaches, and joint or muscle pain
Medical NOTES Got a Sore Throat?
If your tonsils start giving you trouble,just nuke 'em. Mansoor Mandani, M.D., director of Pennsylvania's Center for Corrective Surgery, has developed tonsillar coblation, a procedure that uses microwave-like radio frequency probes to reduce the size of the tonsils. The upside? Unlike a traditional tonsillectomy, which usually involves general anesthesia and some post-surgery bleeding, patients getting a "microwave tonsillectomy" need only a local anesthetic and experience little to no bleeding. The downside? The $2,100 procedure isn't covered by most insurance companies yet. Call 800-206-2000 or visit www.snorenet.com for more info.

CYBER CAUTION
Sure, you know not to believe everything you read on the Internet. But two recent studies show the extent of misinformation online: At least 40% of the info on the health-care Web sites the researchers examined was either misleading or downright wrong. Julius Linn, M.D., director of medical publications at the University of Alabama at Birmingham, suggests taking these steps:

Choose sites where content is reviewed by health professionals (such as medical centers and national organizations).
Look for the Health on the Net Foundation's Code of Conduct (HON) logo, which means the site abides by its code of honor.
Check for consistency on a topic with several reputable sites.
Most important, check with your doctor before following any medical advice you find on the Web.
chill out
As if stress itself weren't bad enough, now there's evidence that it could put young women on a high-risk track to heart attacks later in life. Research presented earlier this year at the American Psychosomatic Society's annual meeting showed that when put in stressful situations, monkeys (which, like humans, have a 28-day menstrual cycle) produced less estrogen, a known protector against heart disease. An ongoing study of human autopsy results suggests that pre-menopausal women with reduced estrogen levels, which can result from stress, may react in a similar manner. So relax--your heart wilt thank you.

calcium for PMS?
Can calcium ease symptoms of PMS and PMDD? Some researchers think so. Susan Thys-Jacobs, M.D., an assistant professor of medicine at Columbia University in New York, is convinced that calcium combats even severe premenstrual symptoms at least as effectively as antidepressants. In a multi-center study of women with moderate to severe premenstrual symptoms, she and her colleagues found that more than half of those who took 1,200 milligrams of CalCium a day showed a greater than 50% improvement over a period of three months. Women in the study kept track of 17 symptoms, including mood swings, tension-irritability, anxiety-nervousness, abdominal bloating, cramps, low back pain, and food cravings; all improved.

Based on that study and others, some doctors tell their PMS and PMDD patients to try taking 600 to 1,200 milligrams of calcium daily for a few months before resorting to medication.

PHOTOS (COLOR): PMDD, more severe than PMS, can reportedly toy with a woman's body and trample her sunny nature. Whether newly released medicines are the answer is still up for debate. Many see the drugs as a marketing ploy, but some women, now symptom-free, have a different story.

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By Nancy Ross-Flanigan

Nancy Ross-Flanigan is a contributing editor.

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