and duloxetine; see the appendix for details). You can take these pills all month long or just during the week before your period. The shorter-half-life medicines, like paroxetine and venlafaxine, are not good choices here, as coming off them tends to be uncomfortable; you don’t need to deal with antidepressant withdrawal every month. I prefer to use escitalopram, which starts working quickly and is easier to taper. I have quite a few patients who used to take antidepressants every day but now take only 5 milligrams of escitalopram for the four to seven days before their period every month, and this can be perfectly effective.
Another treatment option is to go on oral contraceptives, which create steady hormone levels. For many women, PMS is markedly reduced, as are cramping and heavy bleeding. Often, the longer you’re on the Pill, the lighter your periods are. There is also the option of taking oral contraceptives continually, where you stop the hormones only three or four times a year to have withdrawal bleeding. More gynecologists are recommending continual use of the Pill, especially in patients with endometriosis (a condition that causes extremely painful menses). Just how often you need to come off the hormones in order to shed the uterine lining is a subject of some debate, but the FDA has approved the use of Alesse and Levlen, which allow only four periods a year. And I certainly have patients who are enjoying fewer than that.
However, I have a few complaints and caveats about oral contraceptives, so I’d prefer that you don’t rush to use them to treat PMS until you read on.
The Pill’s Dirty Little Secrets
Using oral contraceptives to manage PMS is not an option for everyone. Flatlined hormone levels have the potential to throw things off dramatically; it’s not what’s natural for us. It is extremely hard to predict who is going to do well on the Pill versus who won’t. I have some patients who are typically very moody and erratic, seemingly tossed about on a stormy sea of hormones throughout the month. Those patients often do better on the Pill, having fewer mood swings and minimal PMS once they get past the first few months of taking oral contraceptives. For them, the Pill ends up being stabilizing, providing steady levels of the same hormones day in and day out, which is what they need to manage their moods and minimize PMS.
But many of my patients find that they cannot tolerate how emotional the Pill makes them, and after trying several different brands over the years, they abandon the idea of using oral contraception for birth control. For these patients, the Pill is destabilizing. I have heard this sentence countless times when first meeting a patient and asking about contraception: “The Pill made me crazy.” Those exact words. It’s not clear why so many women in my office are reporting this phenomenon, except that many are coming to me for complaints of depression, not just PMS. In one study of women who started oral contraceptives, 16 percent noted that their moods had worsened, while 12 percent noted improvement in their moods and 71 percent had no change in their moods. Women who had PMS prior to the Pill reported significant improvement in their PMS on the Pill, while those with a history of depression, not just PMS, had worsening moods.
Some women are simply more sensitive to hormones affecting their moods than others are. The Pill works by presenting just enough estrogen and progesterone to the pituitary that it thinks ovulation has already occurred and so won’t trigger the follicle to release an egg. Estrogen and serotonin regulate each other in a complicated dance, like so many things in the brain and body. Anything that affects estrogen is going to have an impact on serotonin. One possible reason the Pill may make some women a bit bonkers: estrogen causes the manufacture of a serotonin receptor called 5HT2A. This is the receptor that mediates the effects of hallucinogens like LSD and is the target of some antipsychotic medications. About a third of women have variations on this receptor that may cause problems when estrogen levels are higher.
But the bigger culprit is likely the progesterone. Synthetic progestin is horrible for your mood, and about 10 percent of women really can’t tolerate it at all. The oral contraceptive Yaz is preferable when it comes to mood effects, perhaps due to one component, drospirenone, which is more similar to natural progesterone than other synthetics are, or due to the fact that it acts more like a diuretic, lessening water retention during the premenstrual phase. (Being bloated does bad things to your brain.)
Another reason oral contraceptives may worsen mood is that synthetic hormones seem to interfere with tryptophan metabolism and vitamin B6 levels, both of which are necessary to make serotonin. If you’re on the Pill, you should supplement with B6.
You could say that the Pill basically tricks your body into thinking it’s pregnant already, so that no egg gets released. Also, the cervix becomes plugged up with thick mucus, the way it does in pregnancy. Because there is no thinner cervical mucus flowing, the Pill can make your vagina drier, and sex may become painful. If you’re not on the Pill, your cervical mucus is an easy way for you to track your cycle and fertility. Midcycle, the mucus is runny like egg whites. When you’re fertile, nature ensures you’ll be naturally more lubricated when you need it. On the Pill, you’re not fertile, so there is less mucus and you’re not well lubricated.
For many women, the Pill makes their skin clearer; estrogen does help give you that peaches-and-cream complexion. Your breasts tend to get a bit larger on the Pill, just as they do in pregnancy, likely due to the steady progesterone levels the Pill provides. So lighter periods, less acne, and lovely boobs sound great, I know, but there are some downsides to being on the Pill. First, there is the issue of weight gain, but, more accurately, a change in weight distribution. Estrogen dictates where fat gets placed in the body. It makes you put on weight in your hips and thighs, and also in the backs of your arms. There is a logical reason for this. Women of childbearing potential need a different center of gravity. If you’re going to carry a baby in your belly, you need ballast in your backside; estrogen tends to make your stomach flatter because that’s not where fat distribution is needed. (FYI, when you’re perimenopausal, your belly starts to store fat because your estrogen levels are waning. Beware the menopot.)
Second, oral contraceptives can really cut into your sexual desire. I tell my patients this is the “dirty little secret” of the Pill. For some women, being liberated from the fear of unwanted pregnancy may allow them to relax and experience sexual pleasure more, but a slew of other women are unhappy to discover that their desire for sex and their ability to achieve orgasm are muted by being on the Pill. There are two factors at work here. The first is, the longer you’re on the Pill, the lower your testosterone levels become, and the less horny you are over time. Taking extra estrogen orally increases levels of something called sex hormone binding globulin (SHBG), a protein in the blood that binds up testosterone, so you end up with lower circulating levels of “free” testosterone, one-tenth to one-twentieth of normal. If the hormone is bound up, it doesn’t hit the receptor, so it’s useless to your brain. It gets worse: a research study showed that women who’d been off the Pill for four months still had SHBG levels four times that of normal. When I spoke with one of the investigators, he told me it never returns to normal. Another gynecologist told me, “It should be a warning on the box,” but instead it’s something no one seems to talk about.
Testosterone, while twenty times more prevalent in men, is also present in women, and it is the primary hormone responsible for sexual drive and desire. Part of every woman’s monthly cycle includes testosterone levels that rise and fall, peaking just as fertility peaks, midcycle. Normal testosterone levels not only vary throughout the cycle but also go up and down throughout the day (higher in the morning in most women) and
