Prozac for PMS: A dissenting view

Last June, the news media carried reports of a new use for Prozac, the widely touted antidepressant drug. The headlines left the impression that Prozac can now be effectively prescribed to women with premenstrual syndrome (PMS). Who's to argue? After all, the finding came from a clinical trial published in The New England Journal of Medicine (8 June 1995).

"Good science but bad medicine" was the response to this trial by Jerilynn C. Prior, M.D., and colleagues at the University of British Columbia, Vancouver, Canada. In a recent letter to The New England Journal of Medicine (26 October 1995), they noted, "The cyclic changes in breast tenderness, fluid retention, nutrition, and emotional experiences are normal, are modulated by lifestyle, and are related to the emotional and social environment and culture." They questioned the use of a medication with short-term and unknown long-term adverse effects when effective approaches to depression, such as aerobic exercise, are well documented. "Why test an expensive drug when an inexpensive change in lifestyle, free of side effects and with positive effects on cardiovascular disease and the risk of osteoporosis, can be expected to provide benefit?"

The clinical trial took place at several Canadian teaching hospitals over the course of six menstrual cycles. The 313 women with PMS were randomly assigned to receive either 20 mg, 60 mg, or a placebo daily. Improvement was determined by a scoring system of all symptoms associated with PMS with ratings done at each cycle. The Prozac-treated women showed four times greater improvement compared to those on the placebo. But by the fourth cycles, the difference between the groups was not as great (20%).

"Is it good medicine to treat women with a medication and dosage that one third of a highly motivated symptomatic group of patients feel they must discontinue?" wrote Dr. Prior and colleagues. One-third of the women receiving 60 mg Prozac daily dropped out because of unpleasant side effects, which included insomnia, nausea, tremor, fatigue, dizziness, and appetite disturbances. (The women on the smaller dose of Prozac had a lower incidence of adverse effects.)

This letter adds to the continuing controversy over PMS, an illness which some believe does not exist. When PMS was first included the diagnostic manual of the psychiatric profession, it was cited by many female members of the therapeutic profession as one more example of women being "pathologized" by the pharmaceutical industry and some physicians. In this case, menstruation had become a mental illness. (See They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal, by Paula Caplan, Ph.D, HealthFacts, August 1995.)

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