Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and Acetaminophen
Nonsteroidal anti-inflammatory drugs (NSAIDs) block prostaglandins, substances that dilate blood vessels and cause inflammation. NSAIDs are usually among the first drugs recommended for almost any kind of minor pain. The most common ones used for PMS are nonprescription ibuprofen (Advil, Motrin, Midol, generic) and naproxen (Aleve, generic) or prescription mefenamic acid (Postel, generic). NSAIDs are most helpful when started 7 days before menstruation and continued for 4 days into the cycle.
Long-term daily use of any NSAID can increase the risk for gastrointestinal bleeding and ulcers. Long-term NSAID use can also increase the risk for heart attack and stroke.
Acetaminophen (Tylenol, generic) is a good alternative to NSAIDs, especially when stomach problems, ulcers, or allergic reactions prohibit their use. Products that combine acetaminophen with other drugs that reduce PMS symptoms may be helpful. Brands include Pamprin and Premsyn, which are also available as generics. Such drugs typically include a diuretic to reduce fluid and an antihistamine to reduce tension.
Selective Serotonin-Reuptake Inhibitors. Selective serotonin-reuptake inhibitors (SSRIs) are the main type of antidepressants used to treat premenstrual dysphoric disorder (PMDD) and severe PMS mood symptoms.
In the United States, three SSRIs are approved by the FDA for the treatment of PMDD:
- Fluoxetine (Prozac, Sarafem, generic)
- Sertraline (Zoloft, generic)
- Paroxetine (Paxil, generic)
Other SSRIs sometimes prescribed for PMDD include citalopram (Celexa, generic) and escitalopram (Lexapro, generic). The serotonin-noradrenaline reuptake inhibitor venlafaxine (Effexor, generic) has also shown benefit in some studies.
SSRIs appear to work much faster for relieving PMS-related depression than when used to treat major depression. These drugs are typically prescribed with either continuous (daily) dosing throughout the month or an intermittent dosing regimen. With intermittent dosing, women take the antidepressant during the 14-day premenstrual period of their luteal phase.
General side effects of SSRIs may include nausea, drowsiness, headache, weight gain and sexual dysfunction. Antidepressants may increase the risk for suicidal thinking and behavior in young adults ages 18 - 24. This risk for “suicidality” generally occurs during the first few months of treatment.
Antianxiety drugs (called anxiolytics) may be helpful for women with severe premenstrual anxiety that is not relieved by SSRIs or other treatments.
Benzodiazepines. Alprazolam (Xanax) is a benzodiazepine antxiolytic often prescribed for PMS. However, benzodiazepines have a lot of serious side effects. Dependence is a risk and can occur after as short a time as 3 months of use. (Using alprazolam for only a few days per month when symptoms are most severe reduces this risk.) Common side effects are daytime drowsiness and a hung-over feeling. Respiratory problems may be worsened. Benzodiazepines also increase appetite, particularly for fats. Overdose is very serious, although rarely fatal. Benzodiazepines are potentially dangerous when used in combination with alcohol.
Buspirone. Buspirone (BuSpar, generic) is a drug used to treat anxiety. It may help reduce premenstrual irritability. Unlike benzodiazepines, buspirone is not addictive. Buspirone also seems to have less pronounced side effects than benzodiazepines and no withdrawal effects, even when the drug is discontinued quickly. Common side effects include dizziness, drowsiness, and nausea.
Hormone therapies are used to interrupt the hormonal cycle that triggers premenstrual syndrome symptoms. One method to accomplish this is through birth control pills.
Birth Control Pills. Oral contraceptives (OCs) contain combinations of an estrogen (usually estradiol) and a progestin (the synthetic form of progesterone).
The birth control pill Yaz is approved specifically for treatment of premenstrual dysmorphic disorder (PMDD). A related birth control pill, Beyaz, which is supplemented with the B vitamin folate, is also approved for treatment of PMDD. Both of these pills contain a newer type of progestin called drospirenone. The FDA warns that birth control pills that contain drospirenone may increase the risk for blood clots much more than the progestin levonorgestrel contained in other types of birth control pills. Some studies have indicated that the risk for blood clots is 3 times higher with drospirenone.
Because of the high risk for blood clots, stroke, and heart attack, Yaz and Beyaz should not be used by women who are over age 35 or by those who smoke. In addition, Yaz and Beyaz should not be used by women with kidney, liver, or adrenal disease. Drospirenone is related to spironolactone, a diuretic, and can increase potassium levels.
Some women with PMS use extended-cycle (continuous-dosing) OCs to reduce or eliminate their monthly periods:
- Seasonique and Seasonale reduce periods to about 3 or 4 times a year
- Lybrel eliminates monthly periods in most women (some women continue to experience spotting)
Side effects of OCs include nausea, breakthrough bleeding, breast tenderness, headache (which may worsen in smokers or women with a history of migraine), and weight gain. Women who are over age 35 and smoke, or who are at risk for blood clots, heart attack, or stroke, should not take combination birth control pills.. Some women may experience worsening of PMS symptoms with oral contraceptives.
GnRH Agonists. Gonadotropin-releasing hormone (GnRH) agonists (also called analogs) are powerful hormonal drugs that suppress ovulation and, thereby, the hormonal fluctuations that produce PMS. They are sometimes used for very severe PMS symptoms and to improve breast tenderness, fatigue, and irritability. GnRH analogs appear to have little effect on depression.
GnRH agonists include the implant goserelin (Zoladex), a monthly injection of leuprolide (Lupron Depot, generic), and the nasal spray nafarelin (Synarel).
Common side effects (which can be severe in some women) include menopausal-like symptoms such as hot flashes, night sweat, weight change, and depression. The side effects vary in intensity, depending on the particular GnRH agonist. The most important concern is possible osteoporosis from estrogen loss. Doctors recommend that women not take these drugs for more than 6 months.
The most important concern is possible osteoporosis from estrogen loss. Doctors recommend that women not take these drugs for more than 6 months.
Danazol. Danazol (Danocrine, generic) is a synthetic substance that resembles male hormones. It has very severe side effects and is used only if other therapies fail. It suppresses estrogen and menstruation and is used in low doses for severe PMS and premenstrual migraines. Side effects include masculinizing effects such as facial hair growth, deepening of the voice, and acne.
Diuretics for Fluid Retention
Diuretics are drugs that increase urination and help eliminate water and salt from the body. They reduce bloating and breast tenderness in women with PMS. Diuretics can have considerable side effects and should not be used for mild or moderate PMS symptoms. Spironolactone (Aldactone, generic) is the most commonly prescribed diuretic for PMS.
Spironolactone can increase potassium levels in the body. Women should be sure not to take additional potassium if they are taking spironolactone, and patients with kidney disease should avoid this medication. Diuretics interact with a number of other drugs, including certain antidepressants. Women who are considering diuretics should let their doctors know of any other drugs or supplements that they are taking.