What are the best recommended anxiolytics for a perimenopausal female who did not tolerate Wellbutrin (bupropion) or Effexor (venlafaxine)?

Best Anxiolytics for Perimenopausal Women Who Did Not Tolerate Wellbutrin or Effexor

For perimenopausal women who did not tolerate bupropion (Wellbutrin) or venlafaxine (Effexor), selective serotonin reuptake inhibitors (SSRIs) such as sertraline or citalopram are the recommended first-line anxiolytics, with buspirone as an excellent alternative for those concerned about sexual side effects or dependency.

First-Line Options

SSRIs

• Sertraline (Zoloft)

  • Dosage: Start at 25-50 mg daily, gradually increase to 50-200 mg daily as needed 1
  • Benefits: FDA-approved for multiple anxiety disorders, well-studied in women
  • Advantages: Less likely to interact with tamoxifen compared to some other SSRIs 2

• Citalopram

  • Dosage: 20-40 mg daily
  • Benefits: Shown to be effective for anxiety in perimenopausal women 2
  • Consideration: May provide additional benefit for those who didn't respond to venlafaxine 2

Non-SSRI Alternative

• Buspirone
  • Dosage: 15-30 mg daily (divided doses)
  • Benefits: Non-benzodiazepine anxiolytic with minimal risk of dependency 3, 4
  • Particularly suitable for: Elderly patients and those with chronic anxiety 5, 6
  • Advantages: No sexual dysfunction, no sedation, no withdrawal syndrome 3, 4

Rationale for Recommendations

When selecting anxiolytics for perimenopausal women who failed to tolerate bupropion or venlafaxine, it's important to consider:

1. Previous Medication Failures:

   • Bupropion (Wellbutrin) is a dopamine-norepinephrine reuptake inhibitor that can sometimes increase anxiety 2, 7
   • Venlafaxine (Effexor) is an SNRI that, while effective for both anxiety and vasomotor symptoms 8, may have intolerable side effects for some patients

2. Perimenopausal Considerations:

   • The Women's Preventive Services Initiative recommends screening and treating anxiety in women during perimenopause due to its high prevalence during this transition 2
   • Perimenopausal women often experience both anxiety and vasomotor symptoms concurrently

3. Evidence for SSRIs:

   • The American Cancer Society/American Society of Clinical Oncology specifically recommends SNRIs and SSRIs for managing vasomotor symptoms in perimenopausal women 2
   • SSRIs have demonstrated effectiveness for anxiety with moderate to high strength of evidence 2

Implementation Considerations

Monitoring

• Schedule follow-up within 2-4 weeks of starting medication
• Assess for side effects: nausea, headache, insomnia, sexual dysfunction
• Evaluate improvement in anxiety symptoms using validated scales

Potential Side Effects

• SSRIs: Headache, nausea, sexual dysfunction, insomnia 2
• Buspirone: Dizziness, headache, nervousness (generally milder than SSRIs) 4

Important Cautions

• If the patient is taking tamoxifen, avoid paroxetine and fluoxetine due to CYP2D6 inhibition 2
• Start at lower doses and titrate slowly in perimenopausal women who may be more sensitive to side effects
• Consider potential interactions with other medications

Non-Pharmacological Approaches to Use Concurrently

• Cognitive Behavioral Therapy (CBT) - first-line psychological treatment with strong evidence 2
• Regular exercise and stress reduction techniques
• Sleep hygiene practices
• Avoidance of caffeine, alcohol, and spicy foods that may trigger hot flashes 2

When to Consider Alternative Approaches

If the patient fails to respond to or cannot tolerate the recommended medications:

• Consider referral to psychiatry for more specialized management
• Evaluate for comorbid conditions that may be complicating treatment
• Consider gabapentin as an alternative, which can help with both anxiety and vasomotor symptoms 2

Remember that treatment duration should be at least 4-12 months after symptom resolution for a first episode of anxiety, with longer treatment for recurrent episodes 2.