What is the recommended management for premenstrual dysphoric disorder (PMDD)?

Management of Premenstrual Dysphoric Disorder (PMDD)

Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for premenstrual dysphoric disorder, with fluoxetine 20 mg daily being the most extensively studied and effective option for reducing both emotional and physical symptoms. 1

Diagnosis and Clinical Features

PMDD is characterized by severe emotional and physical symptoms that occur during the luteal phase of the menstrual cycle (two weeks before menstruation) and resolve shortly after the onset of menses. Key symptoms include:

• Mood swings, irritability, and depressed mood
• Anxiety and tension
• Decreased interest in usual activities
• Difficulty concentrating
• Fatigue and lethargy
• Changes in appetite or food cravings
• Sleep disturbances
• Physical symptoms (breast tenderness, bloating, headaches)

Treatment Algorithm

First-Line Treatment: SSRIs

SSRIs have demonstrated moderate-quality evidence for effectiveness in PMDD 1:

1. Fluoxetine 20 mg daily - Most extensively studied and FDA-approved for PMDD 2, 3
2. Sertraline 50-150 mg daily
3. Paroxetine 12.5-25 mg daily
4. Escitalopram 10-20 mg daily

Administration Options:

• Continuous dosing (every day of the menstrual cycle) - More effective than luteal phase dosing 1
• Luteal phase dosing (from ovulation to menses) - Still effective but less so than continuous dosing 3

Second-Line Treatments

If SSRIs are ineffective or poorly tolerated:

1. Combined Oral Contraceptives (COCs) - Particularly those containing drospirenone 3 mg with ethinyl estradiol 20 mg daily for 24 days followed by 4 days of inactive pills 4

2. Cognitive Behavioral Therapy (CBT) - Effective for:

   • Reducing functional impairment
   • Improving depressed mood and anxiety
   • Managing irritability and interpersonal conflicts
   • Reducing symptom intensity 4

Treatment-Resistant PMDD

For patients who don't respond to first- and second-line treatments:

1. GnRH analogues - Consider for severe cases with cyclic symptoms, particularly when initiated during days 1-3 of the menstrual cycle 5

2. Combination therapy - SSRI plus CBT may provide additional benefit for some patients 4

Important Considerations

Adverse Effects of SSRIs

Common side effects to monitor and discuss with patients 1:

• Nausea (most common)
• Insomnia
• Sexual dysfunction
• Fatigue or sedation
• Dizziness
• Decreased concentration

Treatment Duration

• Initial trial of 2-3 menstrual cycles to assess effectiveness
• For responders, continue treatment for 6-12 months, then reassess need for ongoing therapy
• Some patients may benefit from long-term treatment

Pitfalls to Avoid

1. Misdiagnosis - Ensure symptoms are cyclical and related to the luteal phase through prospective daily symptom charting for at least two menstrual cycles

2. Inadequate dosing - Starting with too low a dose may result in treatment failure

3. Insufficient treatment duration - Allow adequate time (2-3 cycles) before concluding treatment is ineffective

4. Overlooking comorbidities - PMDD may coexist with other mood disorders that require separate treatment

5. Ignoring non-pharmacological approaches - Lifestyle modifications (regular exercise, stress management, dietary changes) should complement pharmacological treatment

Special Considerations

• Pregnancy planning - Discuss contraception needs if prescribing SSRIs
• Existing mood disorders - Continuous rather than intermittent SSRI dosing may be preferred
• Adolescents - Consider starting with lower SSRI doses and titrating as needed

By following this evidence-based approach to PMDD management, clinicians can significantly improve symptoms and quality of life for affected patients.