Pmdd Treatment Options, or is that an oxymoron? Options

[Sunshine]

I'm 36 with BPII, GAD and PMDD. It seems that my BPII is fairly stable with only a few glitches here and there. However, for two weeks out of each and every month my life is turned inside out. This has gone on since my son was born five years ago. It is distinctly linked to my menstrual cycle and my pdoc has ruled out that it is "simply" my BP being exacerbated by my hormones. I've tried several flavors of both birth control pills (including the much-touted Yaz) and ADs to no avail. I have also tried mood stabilizers (they definitely keep the BPII in line but do nothing for the PMDD), anti-pyschotics and benzos. The benzos help with acute anxiety, but do nothing to change the overall pattern.

I am desperate. I'm doing a lit review of the current research on PMDD treatment options to share with my pdoc. I have come across chemically-induced menopause (Lupron), GABA agonists, increasing ADs during the luteal phase of menstruation and total hysterectomies. The problem with both Lupron and a hysterectomy is that I would need hormone-replacement therapy along with these "treatments"...which is what causes the problem in the first place. I currently take a GABA agonist: xanax (2 mg/day and up to 4 mg/day during luteal phase. Please, no warnings about benzos. I appreciate concern, but I know the risks involved). I haven't tried increasing AD dosages during the luteal phase. I take Paxil b/c of its reputation for easing PMDD, but I am nervous about increasing my AD level due to the chance of inducing mania.

Anyone out there with moderate to severe PMDD? Have you tried the treatment options I mentioned? Or did you find another way to treat it? I would also like to know if anyone has a PMDD treatment preference when it comes to ADs.

Thanks in advance!

This post has been edited by Sunshine: Tue 13 May 2008 11:48:33 GMT +0000

[unreliable narra...]

Hi Sunshine--I'm sorry I have no answers, only share your questions! Some thoughts, though....

I've tried several flavors of both birth control pills (including the much-touted Yaz)....

I too have had TOTAL failure on about half-a-dozen BCPs which invariably worsened the monthly horror. Being off them the last couple of years helped, but only gradually (after about 6-8 months).

...and ADs to no avail. I have also tried mood stabilizers (they definitely keep the BPII in line but do nothing for the PMDD), anti-pyschotics and benzos. The benzos help with acute anxiety, but do nothing to change the overall pattern.

ADs haven't done much for me either (Prozac/Zoloft/Celexa/Remeron/Effexor/Wellbutrin). And the AAPs actually seemed to increase premenstrual agitation/anxiety/tendency to spend money, clean the house top to bottom and start twenty new projects/possible hypomania (Abilify in particular--although Zyprexa was great until I gained a zillion pounds).

I take Paxil b/c of its reputation for easing PMDD, but I am nervous about increasing my AD level due to the chance of inducing mania.

Oh yeah, I heard that! Right now I'm in the middle of a big MAOI detox now before starting something new--it's time for a big cocktail overhaul, I can tell. So for ADs, I'm now thinking Cymbalta, Lexapro, or Luvox, very low doses PRN/during luteal phase? and maybe with a different mood stabilizer (maybe it's time for lithium, or to retry Lamictal) to keep me from feeling TOO good, iykwim.

But I'm nervous, because the plain vanilla SSRI/SNRIs have done so little for me in the past, and/or have initiated manic-type reactions in my brainpan....

....my pdoc has ruled out that it is "simply" my BP being exacerbated by my hormones.

Just out of curiousity...HOW did s/he do this? I'm wondering how you can tell the difference between one kind of dysphoria and another....? Hm....

Anyway, I will let you know what MY new pdoc says when I see her next Friday--I'll have had a two-week clear-out of selegiline by then and will be nicely premenstrual too, so....we shall see.

Anyone else?

[Sunshine]

Hi Unreliable Narrator,

I don't know how much you know about the ebb and flow of hormones during the menstrual cycle, so I thought I'd do some serious paraphrasing from the book, "Women's Moods: What Every Woman Must Know About Hormones, the Brain, and Emotional Health" by Deborah Sichel and Jeanne Watson Driscoll. Here's the deal...

"The brain pathways in a woman with BPII are exquisitely sensitive to the flucuation of hormones....In some women the mood swings of BPII occur in relation to the menstrual cycle. Because BPII manifests itself as severe irritability and mood swings premenstrually, it is often mistaken for a premenstrual mood disorder." pp68 and 69

From day 1-14 of your cycle the hypothalamus gland secretes gonadotropin-releasing hormone (GnRH) and "tells" the pituitary gland to release follicle-stimulating hormone (FSH) to stimulate egg release. As the hormones gad about, they release estrogen. As estrogen levels rise, the hypothalums turns down the secretion of GnRH and FSH. As FSH decreases, estrogen levels from the maturing egg rise abruptly. This spike in estrogen tells the pituitary gland to release luteinizing hormone (LH), which causes a mature follicle to release an egg. While estrogen rises during the first two weeks, endorphins are released, which have the ability to elevate your mood. Endorphins increase to a peak at ovulation and decrease thereafter. After ovulation, estrogen plunges and the luteal phase beings. Now the empty follicle in the ovary forms the corpus luteum or "yellow body" which secretes estrogen and progesterone. As a result, estrogen levels start to increase again, but drop again during the last week of the cycle. It is believed that the first drop in estrogen sets the stage for the impact in the brain of the second drop. Each decrease creates an estrogen withdrawal state, like coming off a drug. The withdrawal sets off a cascade of biological reactions, including decreases in serotonin and other neurotransmitters. It appears that it isn't the amount of estrogen per se, but the rapid change in levels that induce dysregulation in the brain, causing mood and anxiety symptoms. pp 81-83

Having said all that, I'm still not sure if I have BPII exacerbated by hormones or BpII plus PMDD. My pdoc is treating it like PMDD b/c none of the "conventional" treatments to address my symptoms as BPII have solved the problem. And I only experience the wild mood swings from ovulation through menses (everything else is pretty well under control mood disorder-wise.)

My latest experiment (suggested by pdoc) is to fiddle with my provigil dose during dysphoric mania (decrease from 200 to 150 mg) plus adding .5 mg xanax and then to increase provigil to 250 during the depressed phase. It worked pretty darn well this last cycle; my symptoms were greatly reduced. However, I'm experiencing some serious anxiety/paranoia/anger that I believe is due to the increase in provigil. (Provigil is used to treat folks with sleep apnea, which I have, and also has been used to treat depression in BP patients. Therefore, it has a stimulant component that I think is messing with me in the slightly increased dose).

So now I've told you way more than you ever wanted to know about the joys of PMDD and BPII exacerbated by hormones.

I'm really interested to hear what your pdoc has to say. Please post, if you don't mind.

Peaceful wishes,
Sunshine

[Diana]

I am glad I found this topic - These posts descibe me perfectly. From ovulation to period: chaos. 2-3 days before period: catastrophe. Thought about Lupron. Thought about hysterectomy. Another prob created having add back on hormones but then you can add on estrogen without anything else because there is no uterus. Sounds terribly drastic....then again the problem is huge.

I would like to ask why someone mentioned very low dose luvox...what is special about luvox - different than the other SSRIs...I don't like to touch those anyway - tried Zoloft, Lexapro....I am now on Abilify and waiting to see how things go this time around.
I am glad to read that other women also know about this - not glad....just that I know I am not alone. It is just terrible.

PS my generalist, and I respect his opinion a lot - told me that I would be making things much worse if I used Lupron and went "into a menopause".

Xanax is my base med. Klonopin is my emergency med 2mg. (I am flipping out and I am going to explode and so is everyone and everything else.)

I am interested in to hear others' comments and med trials.

Thanks
Diana

[Diana]

PS PDoc said she thought I was Bipolar (2?) and I have always explained that one week I am "normal". Certainly hormone related. I don't really care what IT is called but I certainly need some treatment so I am trying everything...Meds for bipolar, depression, panic, and for PMDD - the pill never worked and prob made me worse and I became fat. Gyn blamed it on me and said the this pill won't make you gain weight - you just must pay attention to what you eat. I told her that I will now pay attention to who I hire next as my gyn.

Tried Lutenyl under another GYN- just progesterone - felt terrible - stopped after a few days.

Diana

[notfred]

Consult with GYN. If that fails, the next step is a reproductive endocrinologist, which I think would be better that just an endocrinologist.


nf

[Guest_magic1_*]

Thank you, Sunshine, for that quote from "Women's Moods"! I will have to check that book out, god knows I have tried everything else. And the thing that baffles all my docs is the fact that I have TWO times of ugliness - the first one usually happens around day 11-13 of my cycle and is mostly just increased hunger and bloating. The real horror show begins around day 20 and peaks at day 23. I currently have a 26-27 day cycle. So if there are two estrogen dips it makes sense that is what is happening to me.

Believe me, I HAVE tried everything. I was already taking Prozac for depression when the first studies came out in the 90s suggesting that it would help PMDD, so my doc increased my dose. Nada. Then came the years of trying various BCPs - Loestrin, Yazmine, Seasonale. (Seasonale never even stopped my periods at all, and something about the hormone mixture there drove me completely off a cliff.) Then back to a psych, who tried various combos of Prozac, Wellbutrin and Effexor. She sold me on the Effexor - even though she warned me that withdrawal could be "difficult" - by pointing out that Effexor could help with the hot flashes I was starting to get around then. (I'm 42 now and this was when I was 38 or so). Well, the Effexor did nothing for the hotflashes OR the PMDD, but the withdrawal sure was a bitch.

About a year ago I got off the Effexor and the rest of the ADs, swearing I would never take them again. Boy did I crash hard, peaking around Feb-March of this year. Also during this time, I started seeing a reproductive endocrinologist (a very prominent one in NY), who could only suggest HRT to me, esp. since the hot flashes were still a problem. Well, the progesterone (Prometrium, which supposedly "everyone" can tolerate) made me so depressed that I absolutely could not go to work. One day when I did manage to get out of bed, I went to my usual coffee place and when the girl asked me how I was, I burst into tears. So the repro endo took me off progesterone and now I'm on unopposed estrogen, which every other dr I have ever asked about it says is a terrible idea.

So here I am - back on Wellbutrin (up to 450mg a day), taking 0.45mg of Femtrace (with no progesterone) and I just started on Klonopin yesterday. I feel really out of it, and reading what I have about K's addictive potential I am very skeptical. My psych (new one - not the Effexor woman, I fired her FAST!) wants me taking up to 4mg of the Klonopin every day, not just during the last half of my cycle!

One thing I have tried lately that seemed to help is accupuncture! I went on day 23 of my cycle and for the first 5 minutes after the practioner "stuck" me, I was bawling like a baby. About 5 minutes later, I calmed down and eventually my right leg started to uncontrollably twitch! This upset me, because I thought it was supposed to be a more meditative experience, but the accupuncturist said that was common and I was probably "releasing excess feminine energy." But it did seem to help, and god knows I have lost all faith in traditional meds to take4 care of this.

Sorry for being so long winded....good luck to you all!!!!

[martasi2]

I have posted elsewhere in this section but will mention this book again: Hormones and the Mind by Edward Klaiber M.D. This will give you a lot of useful info. In HTR there are many different forms of the hormones available: different doses, dosing schedules and types of products, everything from patches to injections. This goes for progesterone too. It has to be custom-prescribed. Unfortunately too many women are treated on a "one size fits all" basis, and that can cause a lot of unnecessary problems. I assume your doctor tested your hormone levels to determine a dosing amount, but often it can take quite a while to find what works. Ideally it is useful to test several times during the month to see the relationship of the various hormones, especially if you're still having a monthly cycle. You might also try to find a menopause clinic (not mood disorders but more gynecological emphasis).

It doesn't matter how "prominent" a doctor is if he/she doesn't have the answer you need. If I were you I'd continue to seek out medical advice. It doesn't sound to me like you have adequate information on what is causing your symptoms -- from the hormonal perspective. You could be going through early menopause and need a higher estrogen dose. Is this in fact the case? Do you know what your hormone levels are and what they are doing relative to one another during your cycle? That's important to know. FYI I can't tolerate Prometrium either.

IMO it's very difficult to find doctors who are knowledgeable about hormones and mood. A lot of self-education is required, and it may take time to resolve. I doubt taking 4 mg. of Klonopin will solve your problems, but it will sedate you enough to get some sleep.

I have also posted elsewhere in this section about studies and books that discuss a possible genetic link between female hormones, serotonin and mood disorders.

[Chloe34]

And I only experience the wild mood swings from ovulation through menses (everything else is pretty well under control mood disorder-wise.)

This describes me totally! I feel great right around ovulation, then crash.


I was just in to see my pdoc today. Just started lamictal and I'm hoping it helps. I have asked several OB/GYNs about this mood/hormone deal and none knew of a connection, or more acurately how to treat it. I just started Lamictal and it seems to help. I am also on Seroquel and Klonopin as needed. I did also notice that during all three of my pregnancies, especially towards the end, I was hypomanic. I used to joke that I'd pay somebody alot of money to feel as happy as I was when pg.

The most dramatic change occured during my last pregnancy( my little spitfire who's now two). I was hypomanic to the point of being delusional ( didn't realize it until later) and crashed like a plane out of the sky at 10 days post partum. I started realizing it wasn't garden variety post partum when the ADs that supposedly helped all the other new moms just made me want to dance around the kitchen at 1 am and spend money like I ,uh, actually had some. My insomnia after her was also wicked. It took a three pill combo to knock me out. I saw a pdoc who specialized in ppd and while he helped, it was the one I see now who really caught the bipolar tendancies. She also recently told me of a study linking bipolar and ppd.

Anyway, I'll let you know how it goes. I just reserved the 'Mood' book from my library. I'm intregued ( sp?)

[hoya]

Don't you just love PMDD?

I'm not BP.....but I certainly have enough anxiety from PTSD that if spread around the country, we'd all look like a group of crackheads....

Now that the intro is over....

I do take 3mg Klonopin a day. (It stops my anxiety, but doesn't leave me sleepy or jacked. Big dose? Maybe. Does it do it's job better than anything I've tried? Yes. I hate having to defend benzo's. It's like the drug addicts of the med world...)

What finally kicked my PMDD in the 'nads? Kicking out hormonal fluctuation altogether. Seasonique keeps me even for three months. Granted, I get to spend one single week feeling like a trainwreck, but that's a small payoff opposed to having one week of Sanity a month. Oh....and it took about three to four months to feel truly stable on Seaonsique. No lie that it took some time.

The idea behind Seasonique was that the hormone pills don't fluctuate throughout the month, they have the same dosage for three months straight. I've tried other "same dose" pills, but they didn't fit with my brain cooties just right. At least they're a few out there for the many flavors or hormonal insanity...

Obviously, nothing tried beyond what you've done already.

However, I think the endocrine system, blood sugar levels, yadda yadda are all related to mood swings in general. I know a series of blood tests are what's next on my list to hopefully cut out any other culprits. Have you given that a try?

[strawberrygurl]

I am 36 and have severe endometriosis. I get a monthly Zoladex shot (similar to Lupron) every month to control my cystic growths. I've been in chemical menopause for 20 of the last 24 months, stopping only for a 4 months because of concerns over the Zoladex side effects (primarily being bone density issues). Those four months were a freaking nightmare.

Let me just say that I love being in menopause. The hot flashes are nothing compared to the emotional roller coast rides of brought on by PMDD. I've had a few other issues too, I don't metabolize alcohol the same way (suddenly I'm a lightweight), I tire a bit easier, and it's been much harder for me to lose weight (I've lost 26 lbs on weight watchers, and it's taken me 18 months to do it). It's not a pretty shot, it's given via a 12 gauge needle into the belly once a month. I was in severe pain from the cysts, and had terrible mood swings and been suffering from heavy, painful periods. Zoladex changed my life. My bone density scans were normal this year, so I will continue on the Zoladex until either the insurance stops or I show bone density loss. if I have to go off of it, I will need to consult with my neurologist to work through the PMDD, which is pretty bad.

Lupron is very expensive ($900 per shot last I checked a year ago), and I'm sure not an insurer would be willing to prescribe this for PMDD only. Zoladex is more widely used in the UK than in the US and is much less expensive. Well worth it all, as far as I'm concerned.

[BadChele]

Hello. I suffer severe PMDD since, well, forever. I am 34 with two children, conditions worsening after child bearing. I have about one "normal" week a month. The rest is pre-during-post cycle misery. Pain, bloating, HEADACHES, irritability, SEVERE mood swings, depression, anger, NO libido (why my husband would want to have sex with me while I am such a witch is really beyond my comprehension), lethargy, scratch that, ridiculously tired and finally, one week of feeling normal that is inevitably ruined by the guilt I feel for how I treated my family for the last three weeks. Never ending cycle.
With a string of doctors, I have tried Prozac, WellButrin (bi-polar med), light therapy, copious vitamins, primrose, flax, safflower, fish oils, diet changes that were not fun, exercise until I dropped (although no weight loss, of course), Birth Control Pills (seriously, are they just crazy or having fun messing with me?). Nothing worked.
A new doctor recently put me on Lupron (with a glint of excitement in her eye - I think I was a prime severe PMDD patient to practice on). I have only received one shot of Lupron and I am scheduled for my next monthly shot in one week. The day after my shot, I would have sucked the venom from my body if I could have - I was out of my head, crazy irritability and complete inability to deal with anything. That passed and on came my period. What a period it was. My DR warned me - your body 'purges' like it is your last. Fair warning, she was right and it did. Bad symptoms were definitely on the mild side comparatively speaking. They were there, just less. I was able to control the 'creeping black cloud'. Even though experience has taught me different, I actually am holding out a small amount of hope here! I will post more as I progress through this. You know, it is almost funny. I just re-read what I wrote. I truly sound insane.
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