‘Optimal’ treatment for premenstrual depressive symptoms remains elusive
Although combined oral contraceptives improved overall premenstrual symptomatology in women with PMS or premenstrual dysphoric disorder, the birth control pills did not improve premenstrual depressive symptoms, data show.
In addition, there was “no evidence for one combined oral contraceptive being more efficacious than any other” for these conditions, researchers said.
Data indicate as many as 12.2% of menstruating women are affected by PMS and as many as 5.3% of these women experience PMDD.
“Combined oral contraceptives containing drospirenone are the only formulations that are approved by the FDA for treating PMDD,” Anouk E. de Wit, MD, of the department of psychiatry at the University Medical Center Groningen in the Netherlands, told Healio.
In addition, the results of previous trials involving various dosing levels of ethinylestradiol/drospirenone (including 20 µg/3 mg and 30 µg/3 mg) and ethinylestradiol/levonorgestrel (such as 20 µg/90 ug), when analyzed separately, have left doubt regarding their efficacy for treating premenstrual symptomatology in PMS and PMDD, according to the researchers.
Therefore, de Wit and colleagues conducted a meta-analysis of nine randomized trials that evaluated the effect of combined oral contraceptives in women with PMS or PMDD. The analysis included a total 1,205 women (mean age per study range = 24.6-36.5 years).
Their results, published in the American Journal of Obstetrics & Gynecology, indicated that the combined oral contraceptives were more efficacious when compared with placebo in treating overall premenstrual symptomatology (standardized mean difference = 0.41; 95% CrI, 0.17-0.67) but not premenstrual depressive symptoms specifically (standardized mean difference = 0.22; 95% CrI, –0.06 to 0.47). None of the combined oral contraceptives was more effective than the other in reducing premenstrual depressive symptoms and overall premenstrual symptomatology.
“Physicians should take this into account when prescribing combined oral contraceptives, as depressive symptoms are often the main symptoms in women with PMDD,” the researchers wrote.
The results also indicate that “patients with PMDD can opt for their preferred combined oral contraceptive,” de Wit said in the interview.
In addition to the oral contraceptives in the study, serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy have also been used to treat premenstrual-related depressive symptoms, according to the researchers. They cautioned that the “certainty of evidence for all available treatments is very low to moderate at best, which highlights that optimal treatment strategies are not yet well-established.”
Perspective
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Quite honestly, this study by de Wit and colleagues is neither a landmark study nor a memorable one. It brings very little new information to this clinical area.
In addition, the quality of the studies de Wit and colleagues looked at for this meta-analysis of premenstrual syndrome and premenstrual dysphoric disorder — which is predominantly depression — were very poor. For example, the studies they used to draw their conclusion used a variety of both birth control pills and depression tests. If we take each factor separately, this is akin to comparing apples and oranges or pears and plums and peaches. The researchers also admitted only one of the tests in their meta-analysis has been validated to measure depression. This is troublesome because just as there is no universal answer to asking people to rate their pain on a scale of one to 10, there is no universal answer to the question: “How depressed are you?”
A positive from the de Wit meta-analysis is that it helps debunk the thought that the birth control pill alone is going to be all that somebody needs to take care of their dysphoric disorder. In addition, if newer clinicians are not aware of these things I have discussed, then this meta-analysis also provides a great educational service.
We have known for years that birth control pills do not significantly affect the depression, irritability and anxiety that many women experience around the time of their period. We are far better off recommending women who experience these symptoms to drink less alcohol, get better sleep, raise their natural level of endorphins through exercise and receive medications such as SSRIs to ease their menstrual-related depression. When it comes to these SSRIs and birth control pills, we should utilize shared decision-making to decide which ones are best for patients, since there is not a one-size-fits-all therapeutic with either of these medications.
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