SSRI therapy and premenstrual syndrome

Serotonin specific reuptake inhibitors are effective in reducing the physical and psychological symptoms of the premenstrual syndrome (1).

• recommended as a first line agent in the treatment of severe PMS
• treatment should be managed by psychiatrics or GP’s with a special interest
• can be used as either continuous dosing or just during the luteal phase
  • use of newer SSRIs, such as citalopram, may produce resolution of symptoms where other SSRIs have failed (1)
  • severe PMS also improves significantly with either luteal-phase or symptom-onset dosing of escitalopram with good tolerability (1)
    
    
• if used on continuous basis withdrawal of the SSRI therapy should be done gradually to minimize withdrawal symptoms
  
  
• women should be informed about possible side effects such as nausea, insomnia and reduction in libido
  
  
• women should be provided with prepregnancy counselling at every opportunity. They should be informed that PMS symptoms will abate during pregnancy and SSRIs should therefore be discontinued safely prior to and during pregnancy
  • women with PMS who become pregnant while taking an SSRI/SNRI should be aware of any possible association with congenital malformations
    • there has been data to support an association between the maternal use of SSRIs in late pregnancy and persistent pulmonary hypertension of the newborn in the offspring (2)
      • MHRA advice suggests that epidemiological data suggest that the use of SSRIs in pregnancy, particularly in the later stages, may increase the risk of persistent pulmonary hypertension in the newborn. Healthcare professionals are encouraged to enquire about the use of SSRIs and SNRIs, particularly in women in the later stages of pregnancy. Close observation of neonates exposed to SSRIs or SNRIs for signs of PPHN is recommended after birth (3)
    • a retrospective epidemiological study has suggested that the use of paroxetine during the first trimester of pregnancy may be associated with an increased incidence of birth abnormalities compared to use of other antidepressants (4). The types of abnormalities seen were reflective of those seen in the general population. The most common birth abnormalities seen were cardiovascular (of which the most common were ventral septal defects)
      
      
    • the BJOG review states that published data are conflicting and it is still possible that SSRI or SNRI use in very early pregnancy may be associated with a small increased risk of congenital malformations (1)
      • a study by Furu et al points against a substantial teratogenic risk associated with exposure to these drugs during the first trimester, and suggests that the reported risk is driven by yet to be determined confounding factors. In addition, women with PMS are likely to discontinue treatment soon after the first missed period rather than later in the first trimester and therefore the risk may be further diminished
        
        
• there are also data supporting the use of serotonin–noradrenaline reuptake inhibitors (SNRIs) for premenstrual dysphoric disorders
  
  
• currently, most SSRIs are licensed in the USA for PMDD, but not in the UK. (1).

Tricyclic antidepressants are no more effective than placebo in most studies.

Reference:

• (1) Management of Premenstrual Syndrome: Green-top Guideline No. 48. BJOG. 2017;124(3):e73-e105.
• (2) Chambers CD et al. Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. N Engl J Med. 2006 Feb 9;354(6):579-87
• (3) MHRA.Drug Safety Update. May 2010;3(10):7-8
• (4) GSK (December 2005). Paroxetine - Important Prescribing Information.