LAUSR

O NE OF THE characteristic symptoms of premenstrual dysphoric disorder (PMDD) is sleep disturbance before menstruation, mainly involving hypersomnia, and insomnia can occur in some cases. In most PMDD patients, the administration of selective serotonin reuptake inhibitors (SSRI) leads to rapid resolution of symptoms such as depressed mood, anxiety, and affective lability. However, premenstrual sleep disturbances, such as hypersomnia and insomnia, may persist. I encountered a case in which ramelteon was effective for the treatment of residual sleep disturbances (hypersomnia) that persisted in a patient with PMDD even after SSRI therapy. Herein, I present my experience with this patient. The patient was a 29-year-old woman with a 4-year history of PMDD and no physical complications. Her menstrual cycle was 28 days in length. For 10 days before menstruation, she experienced symptoms such as marked affective lability, marked irritability and anger, marked depressed mood, marked anxiety and tension, decreased interest in usual activities, lethargy, marked lack of energy, cravings for sweet foods, excessive daytime sleepiness, and frequent nocturnal awakenings. Although most of her premenstrual symptoms showed resolution with an intermittent dosing regimen of escitalopram at 20 mg/day, the excessive daytime sleepiness and frequent nocturnal awakenings persisted from days 7 to 1 before menstruation began, disrupting her daily activities during this period. She expressed a strong desire for improvement in these premenstrual sleep problems. With the aim of ameliorating the frequent nocturnal awakenings, ramelteon was additionally administered at a dose of 8 mg/day at bedtime during the luteal phase only, which resulted in complete resolution of not only the frequent nocturnal awakenings, but also the excessive daytime sleepiness during her subsequent menstrual cycle. She gave informed consent for the publication of this description, and her anonymity has been preserved. I experienced a case of PMDD that responded favorably to additional administration of ramelteon. Many patients with PMDD experience premenstrual hypersomnia and insomnia, and they often do not respond adequately to SSRI. Ramelteon is a selective melatonin MT1/MT2 receptor agonist. Some studies have shown that melatonin function is lower during the luteal phase in patients with PMDD than during the follicular phase in patients with PMDD or during the luteal phase in healthy women. As a melatonin receptor agonist, ramelteon compensated for the decrease in melatonin function during the luteal phase in the present patient with PMDD, ameliorating both her frequent nocturnal awakenings and excessive daytime sleepiness. Although the symptoms of PMDD are thought to be associated with abnormal functioning of the serotonergic system, my experience suggests that melatonin may also play a role in sleep-related symptoms such as hypersomnia and insomnia.