Many medications start out with the intention to treat a specific condition, and over time it is discovered that the medication is beneficial in other medical situations.
Many antidepressants that were traditionally used by psychiatrists to treat depression, have been found to be remarkably useful as remedies for a variety of gynecologic conditions. Over the years, many of these medications have become first line treatments for premenstrual mood disorders, as well as being successfully used in the treatment of significant menopausal symptoms.
Many women experience symptoms of PMS (premenstrual syndrome) where mood changes and physical symptoms like bloating, breast tenderness and headache occur only in the second half of the cycle (after ovulation), and resolve within a few days of the onset of menses. The mood changes can be irritability, depressed mood, anxiety or mood swings. (ACOG reference).
The patient is symptom free for the first 2 weeks after a period, and then symptoms can begin any time after that (usually after ovulation) and impair function in some manner. In women who have these mood symptoms in the first half of the cycle as well, other mood disorders have to be considered and a mental health professional should be consulted.
PMDD (premenstrual dysphoric disorder) is a severe form of PMS where anger, irritability and tension are significant. The American Psychiatric Association creates a diagnosis book called the DSM5 that gives criteria to be met for different disease processes, and for PMDD, you must have 5 or more of the following symptoms occur in the time frame in your cycle that we spoke about above.
(UpToDate- Clinical manifestations and diagnosis of premenstrual syndrome and premenstrual dysphoric disorder).
Symptoms must have occurred for most of the menstrual cycles over the last year, and also and have a significant impact on life activities.
One or more must be present:
-sensitivity to rejection
-tension, anxiety, feeling on edge
One or more must be present to reach a total of 5 symptoms overall
-change in appetite, food cravings, overeating
-diminished interest in usual activities
-easy fatigability,decreased energy
-feeling overwhelmed, or out of control
-breast tenderness, bloating, weight gain, or joint/muscle aches
-sleeping too much or not enough
For women with mild to moderate PMS, treatment with medication is not necessary, and success can be realized with lifestyle modifications that include increased exercise, a healthy diet and an increase in sleep.
In women who are plagued by symptoms of PMDD, and who have interference with the quality of their life, where work, school, and social relationships are affected, intervention with medication can be life changing. There are different categories of medications that can be used to treat PMDD (such as oral contraceptive pills) but the first line treatment is SSRIs (selective serotonin reuptake inhibitors).
This category of medication, which includes drugs such as prozac, paxil, celexa and zoloft, were medications that were traditionally used by psychiatrists to treat depression. We as gynecologists use these medications very successfully for PMDD.
Serotonin is the “happy chemical” in the brain, and this category of medication prevents the re uptake and destruction of serotonin in the brain, and keeps the serotonin around longer and therefore decreases the mood symptoms experienced by patients with PMDD. When patients take this category of medication for depression it can take 6-8 weeks to see a response. In patients with PMDD however, the response is usually more rapid.
In addition, in patients with depression, these medications are given on a daily basis and cannot be taken intermittently. With PMDD, we most often prescribe what we call “luteal phase dosing”. What that means is that we have the patient keep track of her symptoms for a few months to see where in the cycle her symptoms begin (how many days before the period they begin) and when after the period do they end. If on average the symptoms start 7 days before the onset of menses and finish 2 days into the period and the patient has regular cycles, we will only give the patient the medication for that time frame every month.
For example, if a patient has menstrual cycles that are every 28-30 days and has symptoms 7 days before and 2 days after the period, we will have her start medication on day 21 of her cycle (with day one being the first day of menses), and she will stop taking the medicine 2 days into her period). This only exposes her to a short window of time that she is taking medicine, which can minimize the side effects. SSRIs are usually very efficacious and are well tolerated, but like any other medication, side effects can occur.
The most common side effects seen with the use of SSRIs is nausea and headache, but the most problematic ones are weight gain and decrease in sexual libido. Luckily this only occurs in some patients, but taking it by luteal phase dosing can help. In those patients who do not respond over a few cycles to this regimen, a switch in the SSRI to a different one may help, and in some patients, they respond better by taking it on a continuous basis (daily), instead of just in the luteal phase.
Some pharmacists are not familiar with luteal phase dosing of SSRIs for PMDD and will tell patients that the medication cannot be taken like this and you need to take it daily for it to work. That is not true, and luteal phase dosing is what we use most in our PMDD patients and is what works best in the majority of patients.
Another important use of SSRIs in gynecology involves the treatment of peri-menopausal and menopausal symptoms.
There are many different types of symptoms that women can experience as they approach and enter menopause. Some women are completely asymptomatic and have an easy time, while others are plagued with a variety of symptoms that include but are not limited to hot flashes, night sweats, insomnia, mood changes, depression, and anxiety.
Traditionally, women were treated with hormonal products such as estrogen and progesterone to replace what has diminished as the ovaries failed to produce these substances over time. Hormonal products are very effective and are still used in many women with significant vasomotor symptoms that interfere with the quality of life, but as a result of many studies that have showed a small increase in stroke, heart attack and breast cancer (usually about 7-8 extra cases of each per 10,000 women), the use of hormone replacement therapy has decreased over the years.
As a result, women have turned to using other non-hormonal modalities to treat significant symptoms in the peri menopause and menopause. As with any medical situation, use of dietary and lifestyle modifications is always the most important step, as all medications have side effects. Decreasing caffeine and other items that increase hot flashes (red wine, peanuts, caffeine, hot beverages) and increasing exercise, and striving for a healthy weight all help.
In women who are still plagued by symptoms, where they experience an alteration in their quality of life and function due to menopausal symptoms SSRIS are an excellent choice. All SSRIs will work in this setting, but there are a few where there is particular success. Extended release Effexor works particularly well to abolish hot flashes and night sweats, and to ameliorate the mood symptoms. Another medication called Brisdelle is specially marketed for menopausal symptoms (the generic is Paxil) and also works quite well. It usually takes 2-3 weeks to see beneficial effects, but patients are usually very happy with the results.
Unfortunately, there is often a stigmata associated with taking anti-depressants, and some patients are reluctant to take these medications for fear that people will label them “crazy."
Patients are very excited to hear that there is a potential solution to a problem that is plaguing them that can be very safe and efficacious, but once they hear that the medication is also used by psychiatrists to treat depression, they are often reluctant to use the medication. Drug companies have picked up on this and have “renamed” many of these medications to decrease the stigmata. “Sarafem” is used an marketed to treat PMDD- it is prozac, and “Brisdelle” is marketed to treat menopausal symptoms- it is Paxil.
Medications that improve the quality of life in women that suffer from PMDD and menopausal symptoms started out as antidepressant medications prescribed by psychiatrists, but are now being used successfully by gynecologists to treat patients who suffer from these gynecologic conditions. These medications are safe and very efficacious.
If you are experiencing the symptoms that we talked about and they are affecting your life or the quality of your life, we encourage you to schedule an appointment to chat with us at
We answer questions like this every day and would love to meet you! We're conveniently located off the Northern State Parkway on New Hyde Park Road just minutes from North Shore University Hopital and Northwell Health.