Laura Binns was surprised when her GP offered her antidepressants. She had visited her with symptoms of premenstrual syndrome (PMS) which included feeling angry and restless, but not depressed.
“I told my GP that I wanted to see a specialist in PMS and not, as she suggested, a psychiatrist,” says Binns.
“I didn’t take the antidepressants.”
Last month the BBC reported a rise in the number of young women being diagnosed with depression when they really had PMS and of women with PMS being handed antidepressants before trying anything else.
The report was based on anecdotal evidence from the United Kingdom’s National Association for Premenstrual Syndrome (Naps). “We’ve noticed that it seems to be more of an issue. About 25% to 35% of the emails we get are from women saying they have been offered antidepressants,” says Jackie Howe, a founder member of Naps.
“I think for some GPs these women are heart-sink patients who come in every month, in their bad times, and it may be easier for a doctor to give them antidepressants than go through other treatments. One woman was told by her doctors in the last six months to put a flag on her desk when she had PMS so no one would come near her. Another said her GP offered her some bits of paper to read and some antidepressants. She was told to come back when she was feeling calmer. She said to me: ‘I’ve never felt such anger before’. This woman may have been difficult but then she has never been treated properly.”
If a woman has psychological and or physical symptoms during the second half of her menstrual cycle, which usually get better by the end of her period, it is likely she has PMS.
Clinical Evidence, a digest of the evidence from research studies, published by the British Medical Journal (BMJ), says that while 95% of women of child-bearing age experience some symptoms, only 5% have them severely. Most women will recognise at least some of the symptoms which include feeling hopeless, guilty, angry, having difficulty in concentrating, fatigue, food cravings, headaches, bloating, cramps and breast tenderness.
Some women have problems with balance and some do feel depressed, but usually only for the seven days after they ovulate (commonly day 14 of their cycle, which begins on the first day of their period).
But should doctors be prescribing antidepressants to treat PMS symptoms? Guidelines from the UK’s Royal College of Obstetricians and Gynaecologists (RCOG) recommend antidepressants, specifically selective serotonin reuptake inhibitors (SSRIs) such as Prozac, to treat severe PMS. They also seem to work on some of the other symptoms of PMS such as the abdominal cramps, not just the depression.
Despite the guidelines, however, there is no consensus on how the condition should be treated. Many doctors do not know that guidelines exist. Drug treatments, Cinical Evidence warns, often have side-effects and the risks and benefits of antidepressants need to be carefully assessed. It also finds that Vitamin B6 (50mg to 100mg a day) works, for the depressive symptoms.
The RCOG guidelines say that doctors should first give advice about exercise, diet (caffeine-free, high in complex carbohydrates and low in sugar is best) and stress reduction before reaching for drugs.
They suggest talking therapies such as cognitive behavioural therapy, which aims to make people feel better about life events, and hormone treatment such as the contraceptive pill. Many women say they benefit from acupuncture and reflexology, and, while the scientific evidence for their effectiveness is weak, they don’t have side-effects.
Nick Panay, a senior gynaecologist at Queen Charlotte’s Hospital and the Chelsea and Westminster Hospital in London, is a specialist in PMS, who works closely with Naps.
“SSRIs are one of the options but not to the exclusion of suggesting changes in lifestyle. Suppressing the menstrual cycle by giving oral contraceptives or hormone patches can work,” he says.
“GPs do vary in how they treat the condition; some are sympathetic and some are less interested. We would like to standardise the training of health professionals and have a more uniform approach,” he says.
PMS can be life-destroying. It can ruin women’s careers because they can’t concentrate and it can break up relationships. In its severest form it can cause violence. Low-dose SSRIs given only during the time of the month that women have symptoms can work quickly and women with PMS do not seem to develop the dependency that people who take it for depression do.”
Des Spence, a GP in Glasgow, prescribed antidepressants for a couple of women with PMS some years ago, but says they didn’t seem to help.
“Giving women SSRIs for PMS is medicalising a problem and saying that it is amenable to treatment. It oversimplifies the problem. It may work in some people but it isn’t a long-term solution.”
“A lot of women don’t get better on the oral contraceptive pill. If their PMS was entirely hormonal, you would expect it to make a difference.”
Binns has developed her own strategies to deal with her PMS. “I’ve started to take responsibility for treating it and to be open about having it,” she says. “My symptoms are largely psychological. I have three days’ insanity a month and I work at home on those days because my emotional reactions aren’t right. I’ve started cancelling social events when I’m premenstrual.
“When I’m asked to fill in a list of symptoms for PMS and I get to ‘irritability’ it makes me laugh. When I have PMS I’m not irritable. I’m ready to kill someone. I’m 42 and single and PMS has completely affected my previous relationships.
“It makes me abusive; I bully people and try to demean them. Nothing triggers it, I just wake up incredibly angry. Then when my period comes, it stops. For years, until I started reading about PMS, I thought the way I could treat people meant I was a horrible, destructive person. The more people that know about PMS and can stop thinking it’s their fault, the better.”–