A 27-year-old woman comes to the physician with a 1-year history of periodic irritability, anger, tension, and sleep disturbance. The symptoms begin predictably a week before her periods and resolve with menstrual bleeding. She has increased appetite, headaches, breast tenderness, and ankle swelling before her periods. The symptoms are severe enough to impair her performance at work. The patient's past medical history is insignificant. Her cycles are regular and last 29 days. She has no intermenstrual bleeding or vaginal discharge. She has never been pregnant. The patient does not use tobacco, alcohol, or illicit drugs. She has been sexually active with 1 partner for the last 3 years and uses condoms for contraception. The physician prescribes fluoxetine 20 mg/day. The patient returns after 4 months and says that her symptoms have not improved significantly. She stopped taking fluoxetine 5 days back.
What is the best next step in management of this patient?

Question

A 27-year-old woman comes to the physician with a 1-year history of periodic irritability, anger, tension, and sleep disturbance.  The symptoms begin predictably a week before her periods and resolve with menstrual bleeding.  She has increased appetite, headaches, breast tenderness, and ankle swelling before her periods.  The symptoms are severe enough to impair her performance at work.  The patient's past medical history is insignificant.  Her cycles are regular and last 29 days.  She has no intermenstrual bleeding or vaginal discharge.  She has never been pregnant.  The patient does not use tobacco, alcohol, or illicit drugs.  She has been sexually active with 1 partner for the last 3 years and uses condoms for contraception.  The physician prescribes fluoxetine 20 mg/day.  The patient returns after 4 months and says that her symptoms have not improved significantly.  She stopped taking fluoxetine 5 days back. 
What is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Premenstrual syndrome (PMS) is characterized by emotional and physical symptoms that occur in the second half of the menstrual cycle and resolve promptly with the onset of menses. Typical symptoms include depression, anxiety, irritability, bloating, and breast tenderness. Premenstrual dysphoric disorder (PMDD) is a severe form of PMS characterized by predominant anger and irritability. Selective serotonin reuptake inhibitors (SSRIs) are the first-line therapy for PMS/PMDD. Fluoxetine has been studied best and has been demonstrated to relieve both affective and physical symptoms in patients with PMS/PMDD. Any single SSRI may fail to relieve symptoms in about 1/3 of patients, and so a trial of a second SSRI is usually warranted given their overall effectiveness and favorable side effect profile. If SSRIs fail and the patient does not wish to become pregnant, oral contraceptives containing estrogen and progestin are a reasonable second-line therapy (progestin-only contraceptives have not been proven effective). (Choice A) Benzodiazepines such as alprazolam are effective in treating symptoms of PMS/PMDD. However, the risk of sedation and dependence is significant, and they are usually recommended only if SSRIs fail. (Choice B) Bupropion is effective in treating depression. It also very useful in combination with SSRIs in women as it can reverse many of the SSRI sexual side effects. However, bupropion alone has only limited benefit in PMS/PMDD. (Choice D) GnRH agonists such as leuprolide suppress production of estrogen and induce a hormonal state similar to menopause. They are effective in the management of PMS/PMDD but, due to significant side effects and cost, are not generally used unless better-tolerated options fail. (Choice E) Spironolactone has anti-aldosterone and anti-testosterone effects. It is useful in reducing androgen-related symptoms such as acne and hirsutism in women. It may have some benefit for bloating and breast tenderness in PMS but otherwise is not effective in PMS/PMDD, which is not driven by testosterone. Educational objective: Selective serotonin reuptake inhibitors (SSRIs) are considered the first-line therapy for premenstrual syndrome/premenstrual dysphoric disorder. If the first SSRI is ineffective, another SSRI or an estrogen-progesterone oral contraceptive may be tried. Benzodiazepines and GnRH agonists such as leuprolide can also be effective but have more significant adverse effects. References: Premenstrual syndrome and premenstrual dysphoric disorder. (http://www.ncbi.nlm.nih.gov/pubmed/22010771)

A 27-Year-Old Woman Comes to the Physician with a 1-Year