What medications are used to manage increased anxiety before and during a menstrual period?

Medication Management for Menstrual-Related Anxiety

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line treatment for managing increased anxiety before and during menstrual periods, and can be administered either continuously or intermittently during the luteal phase (2 weeks before menstruation) depending on symptom pattern. 1, 2

First-Line Pharmacological Options

SSRIs/SNRIs

• Continuous dosing: Daily administration throughout the menstrual cycle
  • Fluoxetine: Start 10-20mg daily
  • Sertraline: Start 25-50mg daily, target dose up to 200mg
  • Escitalopram: 10-20mg daily
  • Paroxetine: 12.5-25mg daily
  • Citalopram: 10-20mg daily
  • Venlafaxine (SNRI): Start at lower doses and titrate gradually 3, 4

Intermittent (Luteal Phase) Dosing

• Begin medication 14 days before expected menstruation and discontinue at onset of menses
• Particularly effective for women with symptoms confined to the premenstrual period
• Fluoxetine 20mg/day has shown 75% response rate with fewer side effects when used intermittently 2

Efficacy Considerations

• SSRIs demonstrate moderate effect sizes for reducing premenstrual symptoms (SMD -0.65,95% CI -0.46 to -0.84) 1
• Both continuous and luteal phase administration are effective, with no clear evidence of superiority for either approach 1
• Response typically occurs within the first treatment cycle, unlike the delayed response seen when treating major depression 3

Side Effect Management

• Common side effects include:
  • Nausea (NNH = 7)
  • Asthenia/decreased energy (NNH = 9)
  • Somnolence (NNH = 13)
  • Fatigue (NNH = 14)
  • Decreased libido (NNH = 14)
  • Sweating (NNH = 14) 1
• Side effects are dose-dependent; start with lower doses and titrate gradually to minimize anxiety exacerbation 4
• Sexual dysfunction may be particularly problematic for some women

Special Considerations

For Women with Comorbid Conditions

• For women with concurrent depression or anxiety disorders, continuous dosing is preferred 3
• For women with premenstrual symptoms only, intermittent dosing may offer fewer side effects while maintaining efficacy 2

Benzodiazepines

• Should be reserved for short-term use only or treatment-resistant cases
• Risk of dependence limits their utility as a long-term solution
• May be used briefly in combination with SSRIs during initial weeks of treatment before SSRIs take effect 5

Treatment Duration and Monitoring

• Evaluate response after 2-3 menstrual cycles
• For responders with isolated premenstrual symptoms, consider continuing treatment for 6-12 months before reassessment
• Monitor for emergence of depression or suicidal ideation, particularly in younger patients 4
• Use standardized screening tools to assess symptom improvement

Clinical Pearls

• Starting SSRIs at lower doses may prevent initial anxiety exacerbation
• Intermittent dosing may be preferable for women concerned about daily medication or side effects
• Treatment should continue for at least 2-3 cycles before determining efficacy
• If one SSRI is ineffective or poorly tolerated, another SSRI may still be effective

SSRIs have demonstrated consistent efficacy for menstrual-related anxiety with a favorable risk-benefit profile compared to other medication classes. The option of intermittent dosing provides flexibility that aligns with the cyclical nature of symptoms while potentially minimizing side effects.