Skip to main content

Main menu

  • Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Info for
    • Authors
    • Reviewers
  • About Us
    • About the Ochsner Journal
    • Editorial Board
  • More
    • Alerts
    • Feedback
  • Other Publications
    • Ochsner Journal Blog

User menu

  • My alerts
  • Log in

Search

  • Advanced search
Ochsner Journal
  • Other Publications
    • Ochsner Journal Blog
  • My alerts
  • Log in
Ochsner Journal

Advanced Search

  • Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Info for
    • Authors
    • Reviewers
  • About Us
    • About the Ochsner Journal
    • Editorial Board
  • More
    • Alerts
    • Feedback
Case ReportCase Reports and Clinical Observations

Combined Oral Contraceptive Pill Initiation in a Patient With Major Depressive Disorder, Premenstrual Dysphoric Disorder, Social Anxiety, Panic Disorder, and Histrionic Personality Disorder

Cody Roi and Erich J. Conrad
Ochsner Journal June 2017, 17 (2) 181-183;
Cody Roi
Department of Psychiatry, Louisiana State University Health Sciences Center, New Orleans, LA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Erich J. Conrad
Department of Psychiatry, Louisiana State University Health Sciences Center, New Orleans, LA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • References
  • Info & Metrics
  • PDF
Loading

Abstract

Background: Comorbid psychiatric conditions present an added layer of challenge in managing patients, as each condition and associated set of symptoms exacerbate the complexity of the overall presentation. Premenopausal women may be at particular risk for inadequate care, as their comorbid conditions may present overlapping symptoms and mask independent premenstrual symptoms. The prevalence of premenstrual dysphoric disorder and associated conditions can be as high as 8% in women of reproductive age. Recognizing and assessing premenstrual symptoms that are comorbid with other psychiatric conditions can help contribute to a comprehensive treatment strategy and potentially improve the treatment response for the comorbid conditions. Combined oral contraceptive pills (COCPs) have been approved for premenstrual conditions and should be considered by the psychiatrist as an available treatment option.

Case Report: A 34-year-old Caucasian female patient with comorbid major depressive disorder, premenstrual dysphoric disorder, social anxiety, panic disorder, and histrionic personality disorder, with persistent suicidal ideation and distress intolerance, was treated with norgestimate-ethinyl estradiol with improvement in mood, anxiety, and menstrual cramping and with associated diminished suicidal ideation and improved distress tolerance.

Conclusion: In this case, Beck Depression Inventory and Beck Anxiety Inventory scores, as well as self- and peer-reported functionality, all suggested improvement in symptoms following the introduction of COCPs. The neurohormonal contribution to psychiatric conditions continues to be studied and is becoming increasingly important. An understanding of the presence and etiology of premenstrual symptoms should be part of a comprehensive psychiatric assessment of female patients, and consideration of COCPs in the treatment plan adds a potentially potent option for symptom mitigation and remission.

Keywords
  • Contraceptives–oral–combined
  • depressive disorder
  • panic disorder
  • premenstrual dysphoric disorder
  • stress–psychological

INTRODUCTION

Comorbid psychiatric conditions present an added layer of challenge in managing patients, as each condition and associated set of symptoms exacerbate the complexity of the overall presentation. Premenopausal women may be at particular risk for inadequate care, as their comorbid conditions may present overlapping symptoms and mask independent premenstrual symptoms. The prevalence of premenstrual dysphoric disorder (PMDD) and associated conditions can be as high as 8% in women of reproductive age.1 Recognizing and assessing premenstrual symptoms that are comorbid with psychiatric conditions can help contribute to a comprehensive treatment strategy and potentially improve the treatment response for the comorbid conditions. Combined oral contraceptive pills (COCPs) have been approved for premenstrual conditions and should be considered by the psychiatrist as an available treatment option.

We present the case of a patient with comorbid major depressive disorder, PMDD, social anxiety, panic disorder, and histrionic personality disorder, with persistent suicidal ideation and distress intolerance, who was treated with norgestimate-ethinyl estradiol.

CASE REPORT

A 34-year-old Caucasian female presented to psychiatry for treatment of mood and anxiety symptoms. The patient was unemployed owing to debilitating social anxiety and panic attacks. She lived at home with her boyfriend and husband and practiced a polyamorous lifestyle that included cyber relationships. She was heavily involved with the online gaming community for recreation and admitted that she had left the house only sparingly in the past 3 years owing to her refractory depression and poorly managed anxiety. Her medication treatments during the past 5 years had produced only mild improvement in mood and anxiety symptoms and included various medications from the selective serotonin reuptake inhibitor (SSRI), selective norepinephrine reuptake inhibitor, benzodiazepine, and atypical neuroleptic classes, as well as lithium. At the time of her presentation, however, she was only taking risperidone and sertraline. Throughout the course of her management, psychotherapy had been recommended on various occasions, as she had struggled with significant interpersonal issues in her romantic relationships. While she was open to considering therapy, cost was a considerable limitation. In addition to the associated mood symptoms of depression, anhedonia, fatigue, insomnia, and chronic feelings of worthlessness, she experienced frequent crying episodes and chronic suicidal ideation. Upon a more detailed assessment, the patient reported that her symptoms were qualitatively worse for the 8-10 days preceding her menstrual cycle, and that for a number of years her mood and anxiety symptoms had been less tolerable owing to severe menstrual cramping. She had been diagnosed with PMDD the previous year. A previous provider had attempted to ameliorate the patient's premenstrual symptoms by adding 10 mg of citalopram during the week preceding her menstrual cycle to the 40 mg she was taking daily. This approach did not improve symptoms.

COCP options were discussed with the patient who agreed to a trial. She was not currently using nor had she ever used any form of hormonal contraception. At the time of COCP initiation, the patient was taking 200 mg of sertraline daily and 1 mg of risperidone nightly. The medications were continued at these doses without any changes throughout the course of the COCP trial. The COCP norgestimate-ethinyl estradiol 0.25 mg/35 mcg was initiated and was chosen on the basis of formulation and concerns for cost. Two weeks preceding COCP initiation, the patient's Beck Depression Inventory (BDI-II) score was 35, and her Beck Anxiety Inventory (BAI) score was 19. At 1-month follow-up post-COCP initiation, her BDI-II and BAI scores were 11 and 21, respectively. She reported that she felt more capable of managing her emotions, was having reduced frequency and duration of crying spells, reduced insomnia, and no further suicidal ideation. She also reported only mild menstrual cramps that did not interfere with her functionality. Behaviorally, she began leaving the house to spend time with friends and began working independently through a cognitive behavior therapy workbook that had been provided to her. The patient's roommate who accompanied her for follow-up visits confirmed the patient's report of improved mood and functionality. At 13 weeks' follow-up from COCP initiation, her mood continued to remain improved, anxiety diminished, and gains in functionality were maintained. BDI-II and BAI scores were 17 and 9, respectively (Figure). At 28 weeks' follow-up, the patient continued to report diminished anxiety, improved mood, and controlled cramping.

Figure.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure.

Changes in the Beck Depression Inventory (BDI-II) and Beck Anxiety Inventory (BAI) scores over time after combined oral contraceptive pill (COCP) initiation. The BDI-II is rated on a 4-point scale ranging from 0 to 3 based on the severity of each item. The maximum total score is 63. The higher the score, the higher the depression severity. The BAI is also rated on a 4-point scale ranging from 0 to 3 based on the severity of each item. The maximum total score is 63. The higher the score, the higher the anxiety severity.

DISCUSSION

Premenstrual conditions refer to symptoms surrounding the luteal phase of menstruation and include premenstrual syndrome and PMDD. Symptoms can be both psychological (tearfulness, irritability, anxiety, depressed mood, and lability) and physiological (bloating, breast tenderness, insomnia, fatigue, weight gain, and skin changes). PMDD is a more severe condition in which these symptoms interfere with the quality of life and may affect occupational functionality and interpersonal relationships. PMDD has been associated with an increased risk of nonfatal suicidal ideation, plans, and attempts.2 PMDD is estimated to affect 3%-8% of premenopausal women.1 The major feature that distinguishes PMDD from other depressive disorders is the presence of symptoms or marked exacerbation of symptoms only during the luteal phase of the menstrual cycle.

The pathophysiology of PMDD is not well understood; social, genetic, biologic, environmental, and psychologic factors are all thought to contribute to the development.3 Various mechanisms have been proposed. Studies of hormonal mechanisms suggest that women with PMDD have a higher vulnerability to fluctuations in gonadal hormones associated with the menstrual cycle; in particular, susceptibility to changing levels of the centrally acting progesterone metabolite allopregnanolone may have a role in PMDD.4,5 Estrogen receptors have interactions with serotonin pathways that may affect mood and anxiety.6 Symptomatic women have been reported to have a lower density of serotonin transporter receptors compared to controls7 and higher levels of serotonin responsiveness during the follicular phase compared to the luteal phase.8

Other possible mechanisms include alterations in responsiveness to vitamin D [1,25 (OH)2D] metabolism as a trigger for PMDD,9 and alterations in intercellular magnesium levels have also been reported.10 Magnetic resonance imaging studies of the anterior cingulate cortex suggest low gamma-aminobutyric acid (GABA) receptor density in women with PMDD compared to controls,11 and allopregnanolone may influence mood symptoms by positive modulation of GABAA receptors.4 Genetic vulnerabilities associated with the 5-HT1A and estrogen receptor alpha gene (ESR1), as well as high body mass index, stress, and trauma exposure, have been suggested as risk factors.1

Treatment options for PMDD continue to be developed as the pathophysiology becomes better understood. Lifestyle factors, including regular exercise and healthy diet, as well as supplementation with calcium and vitamin B6 (pyridoxine), may be of benefit.12 Pharmacologic agents that have shown some benefit include SSRIs,13 COCPs (particularly those containing ethinyl estradiol and drospirenone3,14,15), and gonadotropin-releasing hormone (GnRH) agonists.

In this case, our patient reported improvements in mood, anxiety, social function, and the physical symptoms of bloating and cramping associated with PMDD. Consequently, further interventions were not required.

In this case, BDI-II and BAI scores, as well as self- and peer-reported functionality, all suggested improvement in symptoms following introduction of COCPs. BDI-II and BAI scores trended generally downward over a 13-week period. Other authors have suggested that the greatest gains with COCPs might be seen during the first cycle with less improvement over subsequent cycles.15

The treatment of PMDD is primarily based on expert opinion. Many authors recommend beginning with an SSRI as first-line treatment for severe PMDD.3 Various SSRIs have been studied and may be prescribed either daily or during the luteal phase only beginning on day 14. When SSRI management fails to produce a resolution of symptoms, as in this patient's case, a trial of COCPs has been recommended. Drospirenone/ethinyl estradiol contraceptive formulations are approved for management of PMDD. GnRH agonists such as leuprolide have been used and may be efficacious by inducing anovulation and amenorrhea.3 Others have suggested beginning with an integrated approach to symptom mitigation that includes lifestyle modifications, psychoeducation, and dietary supplements in addition to psychopharmacology.12 The efficacy of COCPs for PMDD has had mixed results, with some studies showing benefits, while others have not.16

CONCLUSION

The neurohormonal contribution to psychiatric conditions continues to be studied and is becoming increasingly important. An understanding of the presence and etiology of premenstrual symptoms should be part of a comprehensive psychiatric assessment of female patients, and consideration of COCPs in the treatment plan adds a potentially potent option for symptom mitigation and remission.

This article meets the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties Maintenance of Certification competencies for Patient Care and Medical Knowledge.

ACKNOWLEDGMENTS

The authors have no financial or proprietary interests in the subject matter of this article.

  • © Academic Division of Ochsner Clinic Foundation

REFERENCES

  1. ↵
    1. Cunningham J,
    2. Yonkers KA,
    3. O'Brien S,
    4. Eriksson E
    Update on research and treatment of premenstrual dysphoric disorder. Harv Rev Psychiatry. 2009; 17 2: 120- 137. pmid:19373620
    OpenUrlCrossRefPubMed
  2. ↵
    1. Pilver CE,
    2. Libby DJ,
    3. Hoff RA
    Premenstrual dysphoric disorder as a correlate of suicidal ideation, plans, and attempts among a nationally representative sample. Soc Psychiatry Psychiatr Epidemiol. 2013 3; 48 3: 437- 446. pmid:22752111
    OpenUrlCrossRefPubMed
  3. ↵
    1. Bhatia SC,
    2. Bhatia SK
    Diagnosis and treatment of premenstrual dysphoric disorder. Am Fam Physician. 2002 10 1; 66 7: 1239- 1249. pmid:12387436
    OpenUrlPubMed
  4. ↵
    1. Andréen, L,
    2. Nyberg S,
    3. Turkmen S,
    4. van Wingen G,
    5. Fernández G,
    6. Bäckström T
    Sex steroid induced negative mood may be explained by the paradoxical effect mediated by GABAA modulators. Psychoneuroendocrinology. 2009 9; 34 8: 1121- 1132. pmid:19272715
    OpenUrlCrossRefPubMed
  5. ↵
    1. Freeman EW,
    2. Frye CA,
    3. Rickels K,
    4. Martin PA,
    5. Smith SS
    Allopregnanolone levels and symptom improvement in severe premenstrual syndrome. J Clin Psychopharmacol. 2002 10; 22 5: 516- 520. pmid:12352277
    OpenUrlCrossRefPubMed
  6. ↵
    1. Borrow AP,
    2. Cameron NM
    Estrogenic mediation of serotonergic and neurotrophic systems: implications for female mood disorders. Prog Neuropsychopharmacol Biol Psychiatry. 2014 10 3; 54: 13- 25. pmid:24865152
    OpenUrlPubMed
  7. ↵
    1. Rojansky N,
    2. Halbreich U,
    3. Zander K,
    4. Barkai A,
    5. Goldstein S
    Imipramine receptor binding and serotonin uptake in platelets of women with premenstrual changes. Gynecol Obstet Invest. 1991; 31 3: 146- 152. pmid:1649111
    OpenUrlCrossRefPubMed
  8. ↵
    1. Inoue Y,
    2. Terao T,
    3. Iwata N,
    4. et al.
    Fluctuating serotonergic function in premenstrual dysphoric disorder and premenstrual syndrome: findings from neuroendocrine challenge tests. Psychopharmacology (Berl). 2007 2; 190 2: 213- 219. pmid:17072588
    OpenUrlPubMed
  9. ↵
    1. Thys-Jacobs S,
    2. McMahon D,
    3. Bilezikian JP
    Cyclical changes in calcium metabolism across the menstrual cycle in women with premenstrual dysphoric disorder. J Clin Endocrinol Metab. 2007 8; 92 8: 2952- 2959. pmid:17488795
    OpenUrlCrossRefPubMed
  10. ↵
    1. Rosenstein DL,
    2. Elin RJ,
    3. Hosseini JM,
    4. Grover G,
    5. Rubinow DR
    Magnesium measures across the menstrual cycle in premenstrual syndrome. Biol Psychiatry. 1994 4 15; 35 8: 5575- 5561.
    OpenUrl
  11. ↵
    1. Liu B,
    2. Wang G,
    3. Gao D,
    4. et al.
    Alterations of GABA and glutamate-glutamine levels in premenstrual dysphoric disorder: a 3T proton magnetic resonance spectroscopy study. Psychiatry Res. 2015 1 30; 231 1: 64- 70. pmid:25465316
    OpenUrlPubMed
  12. ↵
    1. Vigod SN,
    2. Frey BN,
    3. Soares CN,
    4. Steiner M
    Approach to premenstrual dysphoria for the mental health practitioner. Psychiatr Clin North Am. 2010 6; 33 2: 257- 272. pmid:20385336
    OpenUrlCrossRefPubMed
  13. ↵
    1. Wyatt KM,
    2. Dimmock PW,
    3. O'Brien PM
    Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database Syst Rev. 2002; (4):CD001396.
    1. Halbreich U,
    2. Freeman EW,
    3. Rapkin AJ,
    4. et al.
    Continuous oral levonorgestrel/ethinyl estradiol for treating premenstrual dysphoric disorder. Contraception. 2012 1; 85 1: 19- 27. pmid:22067793
    OpenUrlPubMed
  14. ↵
    1. Marr J,
    2. Niknian M,
    3. Shulman LP,
    4. Lynen R
    Premenstrual dysphoric disorder symptom cluster improvement by cycle with the combined oral contraceptive ethinylestradiol 20 mcg plus drospirenone 3 mg administered in a 24/4 regimen. Contraception. 2011 7; 84 1: 81- 86. doi:10.1016/j.contraception.2011.10.010. pmid:21664515
    OpenUrlCrossRefPubMed
  15. ↵
    1. Freeman EW,
    2. Halbreich U,
    3. Grubb GS,
    4. et al.
    An overview of four studies of a continuous oral contraceptive (levonorgestrel 90 mcg/ethinyl estradiol 20 mcg) on premenstrual dysphoric disorder and premenstrual syndrome. Contraception. 2012 5; 85 5: 437- 445. doi:10.1016/j.contraception.2011.09.010. pmid:22152588
    OpenUrlCrossRefPubMed
View Abstract
PreviousNext
Back to top

In this issue

Ochsner Journal
Vol. 17, Issue 2
Jun 2017
  • Table of Contents
  • Index by author
Print
Download PDF
Article Alerts
Sign up with your email address
Email Article

Thank you for your interest in spreading the word on Ochsner Journal.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Combined Oral Contraceptive Pill Initiation in a Patient With Major Depressive Disorder, Premenstrual Dysphoric Disorder, Social Anxiety, Panic Disorder, and Histrionic Personality Disorder
(Your Name) has sent you a message from Ochsner Journal
(Your Name) thought you would like to see the Ochsner Journal web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Combined Oral Contraceptive Pill Initiation in a Patient With Major Depressive Disorder, Premenstrual Dysphoric Disorder, Social Anxiety, Panic Disorder, and Histrionic Personality Disorder
Cody Roi, Erich J. Conrad
Ochsner Journal Jun 2017, 17 (2) 181-183;

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Combined Oral Contraceptive Pill Initiation in a Patient With Major Depressive Disorder, Premenstrual Dysphoric Disorder, Social Anxiety, Panic Disorder, and Histrionic Personality Disorder
Cody Roi, Erich J. Conrad
Ochsner Journal Jun 2017, 17 (2) 181-183;
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Abstract
    • INTRODUCTION
    • CASE REPORT
    • DISCUSSION
    • CONCLUSION
    • ACKNOWLEDGMENTS
    • REFERENCES
  • Figures & Data
  • Info & Metrics
  • References
  • PDF

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Conservative Management of a Second-Trimester Cervical Ectopic Pregnancy
  • Intravaginal Application of Topical Black Salve for High-Grade Cervical Intraepithelial Neoplasia
  • Cesarean Scar Pregnancy Management: Minimally Invasive Suction of the Gestational Sac Content Combined With Local and Intramuscular Methotrexate Injection
Show more CASE REPORTS AND CLINICAL OBSERVATIONS

Similar Articles

Keywords

  • Contraceptives–oral–combined
  • depressive disorder
  • panic disorder
  • premenstrual dysphoric disorder
  • stress–psychological

Current Post at the Blog

COPE Provides a Framework for Ethical Peer Review

Our Content

  • Home
  • Current Issue
  • Ahead of Print
  • Archive
  • Featured Contributors
  • Ochsner Journal Blog
  • Archive at PubMed Central

Information & Forms

  • Instructions for Authors
  • Instructions for Reviewers
  • Submission Checklist
  • FAQ
  • License for Publishing-Author Attestation
  • Patient Consent Form
  • Submit a Manuscript

Services & Contacts

  • Permissions
  • Sign up for our electronic table of contents
  • Feedback Form
  • Contact Us

About Us

  • Editorial Board
  • About the Ochsner Journal
  • Ochsner Health
  • University of Queensland-Ochsner Clinical School
  • Alliance of Independent Academic Medical Centers

© 2021 Ochsner Clinic Foundation

Powered by HighWire