Depression in women is more likely to be associated with anxiety. This is related to imbalances in the serotonin system, or hypersensitivity to changes in serotonin. In general, women do better on SSRI’s, Lexapro, Zoloft, Prozac, Celexa, Paxil and lower doses of Effexor XR. Women with pain, fatigue, or severe melancholic depression do better on antidepressants that also enhance norepinephrine. These include Effexor XR in higher doses, Cymbalta, and Remeron.
Premenstrual depression responds quicker than other forms of depression to medication. For PMDD, there are many advantages to using medication just for the last few days of the menstrual cycle and not during the entire month. The advantages include protection against long term weight gain, sluggishness, and decreased libido.
Rate of onset of medication effect is partly related to how much it gets tied to protein. Only the part not tied to protein crosses into the brain.
Protein binding of antidepressant medications:
Effexor XR-26%
Lexapro-56%
Celexa, Wellbutrin XL, Remeron-80%
Prozac, Paxil, Cymbalta-96%
Zoloft-98%
Since Effexor XR and Lexapro have much lower protein binding, they can be used in lower doses and closer to the time symptoms begin. In women with premenstrual exacerbation(PME), medication is usually taken every day but the dose may be increased premenstrually. Adding estrogen can frequently be helpful. Since oral forms of estradiol significantly increase protein binding this can cause problems with decrease in estradiol, thyroid, and testosterone activity. Non oral forms of estrogen and conjugated forms of estrogen (Premarin, Cenestin) are less likely to increase protein binding.
Alprazolam, by enhancing GABA, helps premenstrual anxiety that is partly due to dropping progesterone. Progesterone increases GABA activity and this effect is lost premenstrually.
Side effects associated with SSRI’s that are short term include:
• Nausea
• Jitteriness
• Headache
• Sluggishness
• Dizziness
• Delayed orgasm
The short-term side effects usually go away in a few days, but if bothersome can be managed by changing the time medication is taken, taking after sex if delayed orgasm, splitting dose to lower peak levels, or decreasing the dose. Some side effects can be blocked with Trazodone. Wellbutrin XL can help with sexual side effects. Ginger is used to help alleviate nausea.
Long term side effects include “poop out,” sluggishness, loss of libido, and weight gain.
