When faced with a patient who is suffering from Premenstrual syndrome [PMS] what is a doctor supposed to do? Evidence suggests that SSRi use benefits those who suffer with PMS but there are also those who have tried this therapy who have claimed that the medication has actually made them worse.
It's a given that SSRi use can bring on agitation when first starting and stopping abruptly, in some cases it can bring on feelings of suicide and also homicidal thoughts have been reported.
PMS is a subject that I, as a man, should steer clear of. What could I possibly know about PMS and how it should be treated? I pretty much know the time of the month when the need to walk on eggshells is approaching...or at least I did when I was married.
I could write a post making light of PMS, that would be wrong but most that know me personally would know that there was no malice
A week or so ago, a reader of my blog was sitting in the waiting room at her doctor's practice. To pass the time she started flicking through the array of magazines strewn around the waiting room. One such magazine was called "Healthy Magazine". The article that caught her attention was written by a doctor [male] and was about treating Premenstrual syndrome, also known as Premenstrual tension [PMT]. She was actually visiting her doctor because she was struggling to taper off Seroxat, in fact she had been struggling for over two years and was finally down to 1.5mg, a tapering process that had caused her feelings of suicide, anxiety, head zaps, profuse sweating, vivid nightmares, weight gain, plus a whole host of other adverse events.
The article, entitled, "Your PMS Action Plan", offered advice, much of which was about tweaking your lifestyle etc.
In finishing his article, Dr Nick Panay suggested that if the 'tweaking' wasn't helping then talking to your doctor may help. He went on to suggest that your GP may recommend an SSRi if it was the emotional aspects of the PMS that you were struggling with. The article made no mention of the dangers of this group of drugs, no mention of suicidal thoughts, no mention of withdrawal problems and no mention of the teratogenic effects that they cause. This bothered me, so I wrote to the editor of the magazine:
I have been sent a segment of your magazine 'Healthy'' that a reader of my blog, Seroxat Sufferers, sent me.
The article in question, "Your PMS Action Plan", offers advice, it appears, from Mr Nick Panay. [Jpeg attached]
I'd like, if I may, to draw your attention to the heading "When to seek help".
The advice about SSRi's is unbalanced and inaccurate.
Mr Panay claims that SSRi's increase levels of serotonin, suggesting that levels may be too low.
This has never been proven, it is just a theory and one that may be misleading to your readers. I'd be grateful if this section could be edited or an announcement in your next edition of 'Healthy' be made to correct this misleading statement by Mr Panay.
I am intrigued to learn what studies Mr Panay refers to in his column when he writes: "...research has shown that taking them for two weeks at the end of your cycle is as effective as using them continuously - without the risk of becoming hooked."
Two queries about the above statement by Mr Panay:
i; Could Mr Panay provide me with the research he refers to?
ii; Does Dr Panay claim that one can become 'hooked' on SSRi medication?
Dr Panay offers no warning about taking SSRi medication during pregnancy, in particular during first trimester where studies have shown that [in the instance of Seroxat] increases the chance of the fetus developing serious heart defects. I refer you to the recent trial of Kilker Vs GlaxoSmithKline, where GlaxoSmithKline's Seroxat was deemed responsible for the causation of Lyam Kilker being born with serious heart defects. GlaxoSmithKline have quietly settled, out of court, a further 800 cases regarding Seroxat's teratogenic properties.
A video deposition of how they [GlaxoSmithKline] knew years ago about this problem, but failed to act, can be seen here - http://fiddaman.blogspot.com/2011/09/exclusive-jane-nieman-video-testimony.html
I'd be grateful if you could pass my concerns on to Mr Panay and ask him to answer me directly as I intend to write an article about his column.
I was grateful to Dr Panay for answering my query personally, many column writers or TV doctors tend to ignore opposition.
Dr Panay wrote via his editor:
Could you please forward the RCOG evidence based guidelines to the gentleman. These were developed by a group of experts including myself and ratified by the RCOG.
With regards to his numbered queries
1) If he looks at refs 13 and 14 these are two of the studies (there are others) which show that luteal phase treatment with SSRIs is as effective as continuous usage.
2) I would never personally use the term "hooked" - but, it is well recognised some women do experience withdrawal symptoms when discontinuing SSRIs abruptly - the point is that SSRIs should be withdrawn gradually to avoid these side effects.
Other points of accuracy
1) I do not suggest that there is a serotonin deficiency - the hypothesis is that women with severe PMS (possibly genetically predisposed) can respond adversely to the physiological fall in serotonin levels in the days leading up to menstruation (as estrogen levels fall)
2) As far as early pregnancy is concerned, it is a case of weighing up pros and cons, risks v benefits. Specifically, do the benefits of continuing SSRIs into early pregnancy outweigh the risks in that individual. By the way, we do prescribe Seroxat in our PMS patients.
I hope this addresses all his concerns - I am sure that he is aware of how underestimated the problem of PMS/PMDD is and would support an evidence based approach to managing this difficult problem so I thank him for his concern and critique.
The *RCOG evidence that Dr Panay sent me was attached and is available for perusal here.
It is quite clear that the evidence supplied does suggest that SSRi use for PMS is effective, quite whether we should believe this evidence is another matter. We have seen, in the past, how, for instance, GlaxoSmithKline showed how 'safe and effective' Seroxat was in children and adolescents - we now know that the study was not only deeply flawed, it was also ghostwritten. I'm not suggesting for one minute that the RCOG evidence is flawed or indeed ghostwritten but I reserve judgement as I have spoken with many women who have experienced severe withdrawal problems on the medication recommended by Dr Paney. That's me addressing the balance issue, the risk v benefits if you will. One such friend who, upon hearing about Dr Panay's advice, told me, "Talk about throwing gas on a fire!"
I disagree that medication such as Seroxat can be started then abruptly stopped [RCOG evidence - luteal phase treatment with SSRIs is as effective as continuous usage]
I also disagree with Dr Panay and his stance on the usage of the word 'hooked' - if people experience withdrawal symptoms then do we suggest that the drug is not addictive?
The article will be read by many, men, women and possibly teenage girls as they sit and wait for their names to be called out for their appointment with their GP's. My only hope is that they don't take what is written at face value, that they do their research on SSRi type medication and that they are each able to make an informed choice on all the evidence which should include anecdotal evidence of the many women who have experienced the horrific side effects that these drugs cause.
One of they key words in Dr Panay's response to me sticks out like a sore thumb. "Hypothesis"
Be it depression, shyness or indeed PMS - The treatment of SSRi use and the diagnoses of the illness it is prescribed to treat is based purely on hypothesis. That is the risk when taking these drugs, you are taking something based on guess work and also based on clinical trials from pharmaceutical companies who have been less than forthright with trial results in the past. All I ask for is informed consent, by that I mean list every single side effect these drugs cause and not just the minor ones such as dizziness, sickness and diarrhea. Don't ever feel you may put people off receiving the medication that may or may not help them by hiding the more severe side effects. Patients have a right to know what they are putting into their bodies, be that in the form of a patient information leaflet or a column written by a doctor in a health magazine.
Would I recommend an SSRi for PMS?
No, I wouldn't.
Could I offer an alternative?
No, I couldn't.
Herein lies the problem. A problem that the pharmaceutical industry have the monopoly on.
To be honest I wouldn't give my worst enemy Seroxat, I've experienced the harm it can cause. If it can turn normal healthy people into killers then one can only imagine what it could do to a woman suffering from PMS. If drugs like Prozac and Cipramil can induce suicide and homicidal thoughts then the last thing I would recommend to somebody suffering severe tension would be drugs of this ilk.
I'd like to thank Dr Panay for his response. I don't agree with his stance and I cannot offer an alternative... that doesn't mean that I am wrong now, does it?
If you have been treated with SSRi medication for PMS and you have found the treatment to be efficacious or indeed the opposite, then please feel free to drop me a line with your story.
*Royal College of Obstetricians and Gynaecologists.
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