Remedies

Finally, a PMS Pill That Works

For women with severe premenstrual syndrome, antidepressants really can lift the blues-although some worries linger

It wasn't just the New England winters that got June Lapidow down: She had bouts of bone-wearying fatigue year-round. And she couldn't blame her job as full-time mother of three-year-old twins, because she'd suffered as much from irritability and mood swings before her kids were born. "I thought it was just me," she says, "that I was an irrational person."

Lapidow's misery was so deep that she thought that she might be suffering from depression. Then her husband pointed out that the blues seemed to strike only when she was pre-menstrual.

Last spring, the 39-year-old homemaker found a doctor specializing in premenstrual syndrome and came home with a prescription for progesterone-one of the hormones naturally produced during the menstrual cycle and widely used to treat PMS. But Lapidow still feels like she's sitting on the sidelines for a few days every month. "Now," she says, "I'd like to try Prozac."

The Brooklyn mom isn't alone. In the past five years, as tantalizing results have emerged from a few small studies, more and more people have begun looking at the antidepressant as a possible treatment for PMS. Last summer, new evidence gave some basis to the buzz. In three studies, women with severe PMS (also known as premenstrual dysphoric disorder) found that the world seemed a little calmer and their symptoms less bothersome when they took Prozac, Zoloft (another antidepressant), or alprazolam, the active ingredient in the anti-anxiety drug Xanax.

This is welcome news. By some estimates, 70 percent of all women suffer before their menstrual period. Some have physical problems (headaches, breast tenderness, weight gain), and some have emotional distress (depression, moodiness, anxiety). Many find their symptoms merely irritating, while others are incapacitated for a week or more each month--flying into rages without reason, say, or climbing into bed for days at a time. But most cope in the same way: They just try to take life a little easier for a few days. Doctors haven't had much else to offer. More than 50 treatments for PMS have been proposed over the years, only to be eventually discarded.

The two treatments most frequently prescribed these days are highly controversial. Progesterone is supposed to even out a woman's hormonal tides and reduce mood swings. But while some clinicians still swear by the hormone, it has performed no better than sugar pills in a number of studies. GnRH agonists, hormones that suppress the production of estrogen and progesterone, are effective, but the treatment is a drastic one: It stops ovulation and menstruation, catapulting the body into a temporary menopause. Only women with the most extreme symptoms are given agonists, and they must take estrogen supplements to prevent osteoporosis and heart disease.

So the recent studies have researchers excited. "The anti-depressants are definite breakthroughs for women with very troubling PMS who haven't responded to other treatment," says psychopharmacologist Joseph Martorano, author of Unmasking PMS. In the Prozac study, done at St. Joseph's Hospital in Hamilton, Ontario, and other Canadian clinics, about 300 women with severe VMS took Prozac or a placebo every day for six months. Women on the antidepressant reported about twice as much psychological improvement as the other women--feeling more energetic, content, and in control in the days before their period. Many stayed on the drug after the study ended. One woman told Montreal psychiatrist Susanne Steinberg, one of the researchers on the study, "I used to be Dr. Jekyll and Mr. Hyde every month. Now I'm even-tempered all month long."

Zoloft, Prozac's less well-known cousin, performed similarly in research done at the University of Texas Southwestern Medical Center in Dallas. Women on the drug found their jobs and housework easier to manage than did women on a placebo, and they had fewer premenstrual flare-ups with family members and colleagues. Many women on Prozac and Zoloft also reported relief from some physical complaints, like headaches and breast tenderness, as well.

The success of antidepressants does not mean that women with PMS are really just depressed, as some cynics have said. The drugs usually take as long as six weeks to work for depression; PMS symptoms began tapering off within a single cycle when women started taking Prozac or Zoloft. But whether taken for PMS or for depression, the drugs appear to work by tinkering with brain chemistry. Scientists believe that levels of serotonin--a brain chemical that helps regulate mood--fluctuate too widely in PMS sufferers in the days before their period. Prozac and other antidepressants dampen the chemical waves.

Alprazolam, the active ingredients in the tranguilizer Xanax, also monkeys with chemical messengers in the brain, cutting down on chemicals like adrenaline that trigger stress, anxiety, and moodiness. But the drug doesn't appear to be as effective against PMS as the antidepressants. While half the women taking Prozac said they felt at least a moderate improvement, only 37 percent of the women in the alprazolam study, at the University of Pennsylvania, reported feeling less tense and irritable. But many of the women were bothered by the tranquilizer's side effects, such as fatigue, headache, and insomnia.

Doctors call another of alprazolam's traits even more worrisome. "It's addicting," says Martorano. "There are books on how to get off it. I don't advocate it." (Women in the alprazolam study took the drug for only two weeks out of each menstrual cycle, which lessens the chances of dependency.)

In fact, side effects can pose problems for women on any of these drugs. Many Zoloft users feel nauseous. Women on Prozac often complain of insomnia, shakiness, or decreased sex drive. In the recent study, a third of the women given a high dose of Prozac-60 milligrams daily, or about three times the amount normally given for depression--dropped out because of side effects. Women taking 20 mg a day, though, had few complaints. And the low dose proved just as effective.

"Which drug a woman should take depends a lot on which side effects she can stand," says Steinberg. Psychiatrist Kimberly Yonkers, of the Zoloft study, says that Zoloft is a good first choice, since it generally has fewer side effects than Prozac and yet seemed as successful in cutting symptoms.

Of course, women who struggle with heavy-duty PMS--like those in the recent studies--tend to be more forgiving of problems stemming from treatment than someone with a milder case. In hopes of cutting side effects, Steinberg and colleagues plan to test a scaled-down version of therapy, giving an antidepressant for about a week after ovulation.

Still, many women with moderate or mild symptoms won't want to turn to the medicine chest at all, even if there's finally something useful in it. Fortunately, a change in habits is often enough to lighten the monthly mood indigo. But first things first. Before you try to treat your PMS, most specialists suggest keeping a daily record of how you feel, physically and emotionally. Month after month, your symptoms should take a dramatic drop when your period starts. If they continue unabated, VMS is not your problem--some-thing else is.

ILLUSTRATION

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By ROBIN SPARKMAN

HOMESPUN HELP FOR PMS SUFFERERS
Most women with mild to moderate PMS won't be interested in prescription drugs, But a number of more modest approaches seem to help at least some women some of the time-although supporting evidence is scarce.

Cutting back on caffeine and alcohol is a sensible first step. Caffeine- in coffee, colas, chocolate, and many over-the-counter medicines-can increase anxiety and irritability. Alcohol can worsen headaches, fatigue, and depression.

Lightening up on salt reduces water retention and the sensation of being puffy or bloated.

Eating plenty of calcium-rich foods helps cut down on water retention and moodiness, according to a 1991 study. Women who consumed 1,300 milligrams of calcium daily, in foods like skim milk or non-fat yogurt, reported an easing of symptoms. (Most women get only about 550 mg each day.)

Getting some exercise eases premenstrual cramps and improves mood. Studies show that the key is a moderate aerobic workout--as in walking, biking, or swimming.

Adding complex carbohydrates to your diet may help fight mood swings and fatigue. Some people have suggested that women with PMS are overly sensitive to insulin before their period, leaving them hypoglycemic after eating refined carbohydrates like candy or soft drinks. That could account for bouts of depression, irritability, and fatigue. There's scant evidence for this theory, but some women find it helpful to snack frequently on complex carbohydrates like whole wheat crackers or vegetables.

Taking a multivitamin supplement is low-cost insurance, although there's little support for the theory that a lack of vitamins A, B-6, C, and D can contribute to PMS symptoms, such as mood swings, water retention, and breast tenderness. Taking vitamin megadoses is a trickier proposition, since high doses increase the risk of serious side effects.

Going in for acupuncture seems to reduce abdominal cramps. Breathing deeply or practicing other forms of stress reduction, such as yoga or meditation, can help dissipate anxiety and depression.

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By Karmen Butterer

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