If you have premenstrual symptoms that are moderate to severe and are regularly disrupting your life, you're probably looking for ways to take charge of your body. Consider the following when choosing your treatment options:

• Before trying a medication for your symptoms, it's best to stabilize your body's endocrine system by reducing your caffeine, refined sugar, and sodium intake; getting regular aerobic exercise, such as walking or jogging; eating a balanced diet; and getting enough calcium, vitamin B6, and magnesium. After two to three menstrual cycles, you're likely to notice some improvement.
• For premenstrual and menstrual pain, you can use a nonsteroidal anti-inflammatory drugs (NSAID), such as Motrin or Advil. NSAIDs block pain-producing prostaglandins, which increase during the premenstrual period.
• If you have disruptive emotional and physical PMS symptoms that persist even with lifestyle and dietary changes, a selective serotonin reuptake inhibitor (SSRI) is a treatment option. An SSRI is often effective for PMS and can be taken during the premenstrual weeks, or continuously.¹ But, if you are trying to get pregnant, talk to your doctor-taking Paxil or Paxil CR in the early weeks of pregnancy may increase your chance of having a baby with birth defects.²
• If you have had a manic episode, have bipolar disorder or a seizure disorder, or take another medication that cannot be used along with an SSRI, your doctor may recommend treatments other than SSRIs for your PMS.

What is premenstrual syndrome?

For as long as you have a menstrual cycle and ovulate, your hormone-producing endocrine system has powerful, cyclic effects on your body. While some women barely notice these effects, up to 85% of women normally have one or more premenstrual symptoms. These happen between the time you ovulate and the first days of your menstrual period.³ When premenstrual physical and emotional symptoms interfere with your relationships or responsibilities, they are called premenstrual syndrome (PMS). When these emotional symptoms or aggression become severe, it is called premenstrual dysphoric disorder (PMDD). In contrast to PMS, PMDD affects only 3% to 8% of women.⁴

Because a woman's endocrine system is so complex, there are a number of possible hormones and other chemicals in the body that can trigger PMS symptoms. Serotonin is the best-known neurotransmitter chemical that impacts symptoms in many women with PMS. For many women, improving the brain's use of serotonin helps relieve a number of emotional and physical PMS symptoms.

What are selective serotonin reuptake inhibitors (SSRIs)?

SSRIs are a class of medication that affects the brain's use of the neurotransmitter serotonin. This improvement in serotonin use is known to improve physical and emotional PMS symptoms. SSRIs are also used to treat depression, anxiety, menopausal hot flashes, and chronic pain.

SSRIs are usually the first-choice medication for treating severe PMS and PMDD symptoms, including depression, anxiety, irritability, anger, mood swings, breast tenderness, bloating, headache, and joint and muscle pain. SSRI treatment only during the premenstrual phase appears to be as effective as continuous SSRI treatment.¹ And, it costs less. If you have PMS symptoms that completely subside during your period, this approach is likely to work for you. But, if you have emotional symptoms of depression or anxiety all of the time, taking an SSRI continuously may be a better option for you.

Commonly used SSRIs for PMS include sertraline (Zoloft), fluoxetine (Prozac, Sarafem), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa). They each have slightly different effects on mood. While one SSRI may not be right for you, another SSRI may work well. SSRI therapy for PMS usually brings relief within a few days of starting medication but can take longer.^{3, 4}

What are the side effects of SSRI treatment?

Side effects from SSRI treatment are usually not serious. But, these side effects are fairly common, and they are why some people stop taking SSRI medicine.⁵ Some side effects will tend to subside over several weeks. Among women taking an SSRI for PMS, several side effects have been widely studied, including:

• Nausea, appetite changes, weight loss.
• Headache.
• Insomnia, fatigue.
• Nervousness.
• Difficulty with sexual desire, arousal, or orgasm.
• Dizziness.
• Tremors.
• Dry mouth.
• Rash (rare).
• Weight gain (rare), with long-term use.

FDA Advisories. The U.S. Food and Drug Administration (FDA) has issued:

• An advisory on antidepressant medicines and the risk of suicide. The FDA does not recommend that people stop using these medicines. Instead, a person taking an SSRI should be watched for any warning signs of suicide. This is especially important at the beginning of treatment or when doses are changed.
• A warning about the antidepressants Paxil and Paxil CR and birth defects. Taking these medicines in the first 12 weeks of pregnancy may increase your chance of having a baby with a birth defect.²

Your choices are:

• Continue using healthy lifestyle and dietary measures to reduce PMS or PMDD symptoms.
• Try an SSRI, either continuously or only during your premenstrual weeks.
• Talk to your health professional about other treatment options.

If you need more information, see the topic Premenstrual Syndrome (PMS) or selective serotonin reuptake inhibitors (SSRIs) for PMS and PMDD.

The decision about whether to try SSRI treatment for moderate to severe premenstrual symptoms takes into account your personal feelings and the medical facts.

SSRI treatment for premenstrual symptoms

Reasons to use an SSRI for premenstrual symptoms	Reasons not to use an SSRI for premenstrual symptoms
You have moderate to severe premenstrual symptoms that are disrupting your personal or work life. You have another ongoing condition that can benefit from SSRI treatment, such as depression, anxiety, or chronic pain. Are there other reasons you might want to use an SSRI?	You have a history of mania (including bipolar disorder), which can be made worse by an SSRI. You have a seizure disorder, which may be made worse by an SSRI. You are taking another medication that should not be used with an SSRI. Discuss your medication and dietary supplement use with health professional. Are there other reasons you might not want to use an SSRI?

These personal stories may help you make your decision.

Use this worksheet to help you make your decision. After completing the worksheet, you should have a better idea of how you feel about using an SSRI. Discuss the worksheet with your doctor.

Circle the answer that best applies to you.

I need to find a way to control moderate to severe premenstrual symptoms.	Yes	No	Unsure
I have made adjustments to my diet and exercise routine and need to use additional measures to control my symptoms.	Yes	No	Unsure
I have a separate chronic condition (such as depression, anxiety, or chronic pain) in addition to premenstrual symptoms.	Yes	No	Unsure
I have had manic symptoms in the past.	Yes	No	Unsure
I have a seizure disorder.	Yes	No	Unsure
I have discussed my medication and dietary supplement history with my health professional.	Yes	No	Unsure
I tried an SSRI for premenstrual symptoms but had side effects.	Yes	No	Unsure

Use the following space to list any other important concerns you have about this decision.

What is your overall impression?

Your answers in the above worksheet are meant to give you a general idea of where you stand on this decision. You may have one overriding reason to use or not use a selective serotonin reuptake inhibitor (SSRI).

Check the box below that represents your overall impression about your decision.

Leaning toward using an SSRI for PMS

Leaning toward NOT using an SSRI for PMS

Citations

1. Freeman EW, et al. (2004). Continuous or intermittent dosing with sertraline for patients with severe premenstrual syndrome or premenstrual dysphoric disorder. American Journal of Psychiatry, 161(2): 343–351.

2. U.S. Food and Drug Administration (2006). FDA Public Health Advisory: Paroxetine. Available online: http://www.fda.gov/cder/drug/advisory/paroxetine200512.htm.

3. Dickerson LM, et al. (2003). Premenstrual syndrome. American Family Physician, 76(8): 1743–1752.

4. Steiner M, Born L (2000). Diagnosis and treatment of premenstrual dysphoric disorder: An update. International Clinical Psychopharmacology, 15(Suppl 3): S5–S17.

5. Wyatt K (2004). Premenstrual syndrome. Clinical Evidence (12): 2686–2705.

Author	Kathe Gallagher, MSW
Editor	Kathleen M. Ariss, MS
Associate Editor	Pat Truman
Primary Medical Reviewer	Renée M. Crichlow, MD - Family Medicine
Primary Medical Reviewer	Kathleen Romito, MD - Family Medicine
Specialist Medical Reviewer	Deborah A. Penava, BA, MD, FRCSC, MPH - Obstetrics and Gynecology
Last Updated	July 7, 2006