Karen Ward was convinced she was going mad. "I was in floods of tears," she says. "I had terrible mood swings, had become very clumsy and my memory seemed to be going." Her mother eventually persuaded her to go to the doctor. "I told him I needed someone to help me," recalls Karen, now 45. "He just stared at me. Then he told me he'd had a bad day, too." After a year of suffering, Karen, a social worker from Shropshire, realised that she was fine for two weeks every month, but a different person for the other two. "I finally clicked that it must be premenstrual syndrome. But the doctor's reaction made me feel I was making a fuss about nothing."
Most women suffer to some degree from premenstrual tension. Far more severe, however, is premenstrual syndrome (PMS), which affects around 5% of women. It can incapacitate them for days. The concept of PMS has long been difficult for the medical profession to deal with. The lack of sympathy that Karen received is common, although Dr Mayur Lakhani, vice-chairman of the Royal College of General Practitioners, has grounds for optimism.
"It's difficult, because there's no diagnostic test," he says. "A lot of our efforts have been directed at things like recommending the pill, which evidence now suggests doesn't help. We need to rethink." This rethink is reflected by a recent report in the Lancet that PMS sufferers can be helped, both emotionally and physically, by Prozac. But now some women are worried they will be given the antidepressant just to get them out of the doctor's surgery.
Dr Paul Dimmock, one of those responsible for the report, says that won't happen. He and colleagues from Keele University and North Staffordshire Hospital reviewed a number of studies of a group of drugs called selective serotonin-reuptake inhibitors (SSRIs) and their effectiveness in treating PMS. Prozac is one of these drugs. "There's no doubt that these SSRIs helped women with PMS," he says. "That's because, for a few days a month, the hormonal cycle causes an imbalance of serotonin in the brain. Taking SSRIs addresses that imbalance. It is not acting as an antidepressant."
Karen Ward agrees. "I'd tried everything," she says. "I honestly thought there was nothing that could control it. Then I tried Prozac and it worked almost instantly. It gave me a quality of life I hadn't had for years."
Dr Dimmock says the SSRIs work on physical as well as mental symptoms because the brain chemicals control general well-being. But what's particularly interesting about his work is how it appears to question whether traditional ways of dealing with the syndrome are correct. "The licensed drugs for PMS, such as progesterone or oestrogen, are not very effective," says Dr Dimmock.
The reason for this, says Dr Maurice Katz, who runs a specialist PMS clinic at London's Elizabeth Garret Anderson Hospital, is that most women with PMS have normal hormones. This means there's no reason for hormone treatment. "In the past, it was often found that giving a patient progesterone made them feel better," says Dr Katz. "But that's because progesterone acts as a sedative. Oestrogen was also given, but it's rare for women to have an oestrogen deficiency."
Karen Ward was given progesterone pessaries and oestrogen patches. Neither helped. This would have been no surprise to Katz. He has no doubt that Prozac can help PMS sufferers, but says this is most common when their dominant symptoms are depression or aggression. "It must be targeted at specific patients," he says. "If a patient's main symptom is bloating or migraines, Prozac is not the answer. Diet is important, as are lifestyle and stress. Counselling is often overlooked, too. Many patients have problems with psychological causes."
In the past, this suggestion of psychological causes has caused some to conclude that the illness does not exist. That is not what Katz and colleagues are suggesting, but hints that PMS may have psychological foundations have been used by some, including doctors, to accuse women of malingering.
Jemma Taylor noticed her symptoms four years ago. It was soon after a divorce and she initially thought that her constant anger and irritability reflected those difficult times. Then she realised they weren't going away, and that she only felt this way at certain times of the month. "The doctor just palmed me off," she says. "He told me I'd have to live with it. I had to fight to be treated." Jemma went to another doctor who suggested she try the pill (for its hormonal effects). It made no difference, so she was prescribed Prozac. But her experience was quite different from Karen's. "It was awful. I needed to be calmed down, not lifted up. I couldn't focus. I couldn't sleep. I was sweating. It was like drinking lots of cups of coffee."
Eventually Jemma found a specialist PMS clinic in Leeds and now has her illness under control. "I changed my diet," she says. "It was things I hadn't thought of, like eating little and often and trying to stay calm. Prozac definitely didn't help and I don't like the idea of it being given out to anyone with a problem."
This should not happen. Prozac is licensed only for severe cases and the doses given are small. However, the Medicines Control Agency recently warned that Prozac can make people feel suicidal and there is concern about putting another swathe of people on to the drug. "We would certainly applaud the use of Prozac for those who benefit," says Christine Baker from the National Association for Premenstrual Syndrome. "But we would like to stress that diet and a healthy lifestyle should be looked at first. We have had calls from women who don't want to take it but whose doctors are trying to persuade them to, and we have had calls from women who say it's changed their lives.
"There don't seem to be any adverse effects in the long term. But if the symptoms return when someone comes off it, they might have to take it for years. There's no one treatment for PMS. We're keen for women to know there are different approaches."
"We're not suggesting just throwing pills at women," says Dr Dimmock. "We've looked at other things, like vitamin B6, and there's evidence that works too, but not as forcefully. PMS has to be taken more seriously. We still don't know its cause, but we're moving on when it comes to treatment."