Are You Missing Important Changes in Your Women Patients?

This article addresses an important and often neglected aspect of treatment for women—the fluctuation of psychiatric symptoms across the menstrual cycle.

Women often note changes or worsening of symptoms during the luteal phase, although the patterns of hormonal mood and anxiety symptoms vary widely. Many women have not consciously correlated symptom fluctuation with their menstrual cycle. Mood charting can be quite helpful in this regard. These mood changes are one among many reasons clinicians should ask their menstruating patients about their menstrual cycle, mood changes around those times, and use of hormonal contraception.

Although these patients do not technically meet criteria for premenstrual dysphoric disorder (PMDD), many of the strategies that are helpful for PMDD patients are also helpful for women with premenstrual exacerbations. Some of these strategies include dietary changes, supplementation with calcium and magnesium, exercise, herbal formulations, cognitive-behavioral strategies, and intermittent light therapy. In addition, women on hormonal contraception or who have an indication for it may consider switching formulations or working with their gynecologists to discuss whether they may benefit from continuous dosing of the oral contraceptive, decreasing the number of menstrual cycles (and possibly the related mood disruptions) in the year.

As the author describes below, I too have found intermittent increases in SSRI dosing to be helpful for a number of women with luteal phase exacerbation. Such a dosing schedule can minimize side effects such as sexual dysfunction at other times of the cycle. —Elizabeth Fitelson, M.D., assistant professor of psychiatry and director of the Women’s Program in the Department of Psychiatry at Columbia University Medical Center.

Advice on Diagnosing, Treating Premenstrual Exacerbations of Mood Disorders

Laura G. Leahy, Dr.N.P., A.P.R.N.

It is widely known that menstrual cycle fluctuations can significantly impact the mood, behavior, and quality of life of women over the course of their reproductive years.

In fact, women are twice as likely as men to experience a mood disorder, and they experience considerably higher levels of disability due to depression, anxiety, and somatic complaints. Some of what they experience may be due to reproductive hormonal variations during the course of the menstrual cycle.

While it is common for women to report mild premenstrual symptoms, 3 to 8 percent of women with severe premenstrual symptoms meet the diagnostic criteria for PMDD—a syndrome characterized by the emergence of mood lability, irritability, dysphoria, and anxiety symptoms that occur repeatedly during the premenstrual phase and interfere with daily life and remit after the onset of menses.

Many physical and mental disorders may worsen during the premenstrual phase; however, as DSM-5 states clearly, “The absence of a symptom-free period during the postmenstrual interval obviates a diagnosis of premenstrual dysphoric disorder.”

According to Massachusetts General Hospital, an estimated 40 percent of women who seek treatment for PMDD actually have a premenstrual exacerbation (PME) of a mood disorder.

Premenstrual symptom exacerbation of a mood disorder occurs during the second half (luteal phase) of the menstrual cycle and abates at the onset of menses. Symptoms, which include irritability, anger, anxiety, tearfulness, depressed mood, social withdrawal, impaired cognition, fatigue and lack of energy, food cravings, disrupted sleep, and overwhelmed feelings that interfere with daily functioning, may last 1 to 14 days.

As the symptoms of PME mimic those of various psychiatric illnesses, it can be difficult for practitioners to differentiate the root cause of the symptom presentation. For this reason, it is important for practitioners treating women with psychiatric illness to thoroughly explore abrupt symptom changes and their timing in relation to a woman’s menses.

Treatment Strategy for Comorbid PME, Psychiatric Illness

Although little is known about potential remedies to treat PME of mood disorders, practitioners can optimize symptom relief and improve the quality of life for women with PME and psychiatric comorbidities by drawing on current dosing strategies for SSRIs.

One recommended approach for the treatment of this patient population is semi-intermittent dosing, which involves treating continuously with an SSRI whose dose is increased during the luteal phase and then reduced to the prior level upon the onset of menses.

The case study that follows provides an example of a strategy we use at my clinic to treat patients with PME of a mood disorder:

Jane is a 38-year-old woman who is being treated for major depressive disorder with a combination of duloxetine 60 mg daily and lamotrigine 200 mg daily. During her medication management appointment, she says, “My mood is great except for the week before my period.” She describes increased irritability, anger and verbal aggression toward her fiancé and coworkers, as well as bloating, carbohydrate cravings, and tearfulness that seem to “just come on,” making her miserable until the start of her period.

Based on the PME treatment algorithm we use at my clinic, Jane’s dose of duloxetine was increased to 90 mg the week prior to her menses.

When she returned after two menstrual cycles, Jane reported a decrease in the cravings and tearfulness, but only a slight decrease in the irritability, anger, and verbal aggression. Jane’s dose of duloxetine was once again increased to 120 mg for the seven days prior to her menses.

At her follow-up appointment six weeks later, Jane reported, “My fiancé is no longer afraid I’m going to bite his head off, and I feel so much better.”

Over the past two years, Jane has continued this regimen of lamotrigine 200 mg and duloxetine 60 mg daily with an increase to 120 mg seven days prior to her menses, resuming the 60 mg daily upon the onset of bleeding.

While further research is necessary to provide the evidence that such treatments are deemed effective and without adverse events, over the course of my 25 years in practice, many women have reported that this dosing algorithm helps to provide them with symptom relief every week of their cycle and improved overall quality of life. ■