Low-Dose Acetazolamide in the Treatment of Premenstrual Dysphoric Disorder: A Case Series
A 34-year-old single, childless Caucasian woman with a cyclothymic premorbid temperament, suffered from a severe form of PMDD since her adolescence. For more than 10 years she had abused substances (mainly cocaine) and alcohol. Her mood was consistently unstable, with bouts of self-inflicted injuries (self-cutting of the whole body), eating disorder (bulimia with self-induced vomiting) and impulsiveness, meeting DSM-IV-TR criteria for Borderline Personality Disorder. She had voluntarily interrupted a pregnancy when she was 32.\nIn the last two years, she had stopped drug and alcohol abuse, but her clinical picture remained as before. We instituted therapy with lithium up to 600 mg/day, maintaining lithium blood levels up to 0.6 mEq/L, while slowly titrating lamotrigine up to 200 mg/day.\nHer mood stabilized after six months of treatment, with the exception of the period before menses. According to the diary chart, during this period she experienced depressive feelings, severe anxiety, irritability, insomnia, binge eating, desperate crying spells, desire of self-cutting. Her Clinical Global Impressions severity scale score (CGIs) was 6. All symptoms lasted for 7-10 days and disappeared suddenly by the first day of menses. Three months later, we added 125 mg/day acetazolamide, with intermittent monthly intake limited from ten days before the menses to the first day of menses. Since the first month, PMDD symptoms improved significantly (CGIs, 2), while no significant adverse event occurred. However, blood pressure slightly decreased, from 110/80 mm Hg to 100/70 mm Hg. After one year of treatment, the patient continues on add-on acetazolamide and is free from premenstrual symptoms (CGIs=1).