Hormonal SSRIs

If treatment with an SSRI or another antidepressant such as clomipramine is not successful, hormonal treatment with a GnRH agonist, such as leuprolide, maybe considered. The use of leuprolide improves premenstrual emotional symptoms as well as some physical symptoms such as bloating and breast tenderness. Cost, the need for intramuscular administration, and the side effects of hypoestrogenism (e.g., vaginal dryness and hot flashes) limit its use. 

A number of non-hormonal therapies have been studied for symptomatic management of vasomotor symptoms, including antidepressants [e.g., selective serotonin reuptake inhibitors (SSRIs) and venlafaxine], herbal products (e.g., soy, black cohosh, and dong quai), and a group of miscellaneous agents (e.g., gabapentin, clonidine, and megestrol). The choice of therapy depends on the patient s concomitant disease states, such as depression and hypertension, and the risk for potential adverse effects. 

SSRIs are theorized to reduce the frequency of hot flashes by increasing serotonin in the central nervous system and by decreasing LH. Of the SSRIs, citalopram, paroxetine, and sertraline all have been studied and have demonstrated a reduction in hot flashes while treating other symptomatic complaints such as depression and anxiety.33 Venlafaxine, which blocks the reuptake of serotonin and norepinephrine, has demonstrated a reduction in hot flashes primarily in the oncology population.34 Overall, these antidepressant medications offer a reasonable option for women who are unwilling or cannot take hormonal therapies, particularly those who suffer from depression or anxiety. These agents should be prescribed at the lowest effective dose to treat symptoms and may be titrated based on individual response. 

Consider augmentation ) (non-SSRI antidepressant, lithium, thyroid hormone,... 

Bouman WP Pinner G, lohnson H. Incidence of selective serotonin reuptake inhibitor (SSRI) induced hyponatraemia due to the syndrome of inappropriate antidiuretic hormone (SIADH) secretion in the elderly. Int 1 Geriatr Psychiatry 1998,13 12-15. 

Case reports have indicated an association between SSRIs and the syndrome of inappropriate secretion of antidiuretic hormone. Symptoms include lethargy, headache, hyponatremia, increased urinary sodium excretion, and hyperosmotic urine. Acute treatment of this syndrome should consist of discontinuation of the drug as well as restriction of fluid intake. Patients experiencing severe confusion, convulsions, or coma should receive intravenous sodium chloride. Elderly persons may he at a higher risk for developing this syndrome. 

There have been other reports of hyponatremia with SSRIs (38,39). Hyponatremia is probably more common with SSRIs than with tricyclic antidepressants and predominantly but not exclusively affects older patients. Most reports involve fluoxetine, but this might represent greater patient exposure. All SSRIs and venlafaxine can produce this adverse effect (SEDA-23,21 SEDA-25,14). According to published reports, the median time to the onset of hyponatremia is 13 days (range 3-120) and the presentation is of inappropriate secretion of antidiuretic hormone (38). Symptoms, such as lethargy and confusion, can be non-specific, so awareness of the possibility of SSRI-induced hyponatremia, particularly in elderly people, is needed. 

The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a possible adverse effect of the SSRIs (SEDA-14, 14) (SEDA-18, 20) (SEDA 21, 11) (40). The mechanism is not known. Several of the affected patients have been elderly, and old people may be at greater risk. 

Since SSRIs can sometimes also reduce sodium due to SIADH (syndrome of inappropriate antidiuretic hormone production), patients treated with combinations of oxcarbazepine and SSRIs should be carefully monitored, especially in the early stages of treatment... 

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