Elimination of caffeine from the diet
Stress reduction can be accomplished by reducing or delegating responsibilities, insofar as that is possible, and devoting part of every day to relaxation techniques such as meditation and yoga. Many women experience stress factors over which they have no control (59).
For premenstrual dysphoric disorder, several selective serotonin reuptake inhibitors (SSRIs) proved effective in clinical trials (62–65). Although SSRIs and all other antidepressants require about 2 weeks of daily administration to achieve therapeutic effect for other depressive disorders, it appears that ﬂuoxetine is effective for PMDD when taken in the usual daily doses for the 1 to 2 weeks preceding menstruation. The medication is packaged for this specific indication and dosage. It is thought that the mode of action of SSRIs when used in this fashion differs from that which alleviates major depression (65). Other medications for the treatment of PMS and PMDD are shown in Table 12.2. There is some interest in the role of oral contraceptives in management of PMDD, and for patients interested in contraception, trials of oral contraceptives are a reasonable approach (66). Symptoms must be carefully monitored to determine whether the hormonal intervention improves or exacerbates the problem mood changes.
Infertility is described by most women who undergo treatment for it as the most stressful event of their lives. Each unsuccessful treatment episode is experienced as the loss of a hoped-for pregnancy (67). The loss of a fetus or newborn induces grief, with some of the same symptoms as depression. Depression is associated with guilt, whereas bereavement is not. However, women who lose pregnancies or infants often do feel guilty, regardless of whether these feelings are logically justified. Patients should not be pressed to “put the loss behind them” or expected to be “over it” within several months. Some feelings of sadness may persist for years. However, their sleep, appetite, and other vital functions and behaviors should begin to improve after a few weeks (68). Grief that persists and interferes with normal function is characterized as pathologic. Depression can complicate grief and should be treated (69).
Table 12.2 Scientific Basis of Selected Medications Used to Treat Premenstrual Syndrome
Alprazolam Several double-blind, placebo-controlled, randomized crossover studies. Results were mixed. Placebo was as effective as alprazolam in some studies.
Oral medication Potential for The studies involved appears to be more dependence; requires highly selective groups of effective in alleviating tapering; drowsiness women. There was a high depression and anxiety reported by many dropout rate in one of the symptoms than subjects; long-term positive studies. In one physical symptoms. effects unknown; safety study that found during pregnancy alprazolam effective, unknown. 87% of the women had a history of major depression or an anxiety disorder. Different doses were used in the studies (0.75–2.25 mg); the standard effective dosage is unknown.
Several double-blind, randomized, placebo-controlled, crossover trials. All found ﬂuoxetine effective.
Well tolerated; single daily oral dose. Significant decrease in psychic and behavioral symptoms.
Long-term effects unknown. Safety during pregnancy unknown. Appears less effective in controlling physical symptoms.
Trials involved very small, highly select groups of women. Duration of treatment did not exceed 3 months. All trials used 20 mg orally daily.
Several small, double-blind, randomized, placebo-controlled, crossover trials. Most patients experienced improvement.
Rapidly reversible; many patients report being virtually symptom-free during therapy.
Produces pseudomenopause; expensive; risk for osteoporosis, hypoestrogenic symptoms. Usually given for only short periods of time.