What are the medication options for Premenstrual Dysphoric Disorder (PMDD) in a patient with suspected Bipolar Disorder?

Medication Options for PMDD in Patients with Suspected Bipolar Disorder

For patients with PMDD and suspected bipolar disorder, mood stabilizers should be established first before addressing PMDD symptoms, with lamotrigine being particularly beneficial when depression and anxiety are predominant symptoms. 1

First-Line Approach: Stabilize Bipolar Symptoms

1. Establish mood stabilization first:

   • Begin with a mood stabilizer to control bipolar symptoms before addressing PMDD 2
   • Options include:
     • Lithium: FDA-approved for ages 12+ for acute mania and maintenance therapy 3, 1
     • Valproate: Effective for acute mania with 53% response rate, useful for rapid cycling and mixed episodes 3, 1
     • Lamotrigine: Particularly effective for bipolar depression with anxiety; consider as first choice when depression is predominant 1

2. Selection criteria for mood stabilizer:

   • For predominant mania with anxiety: Lithium or valproate
   • For predominant depression with anxiety: Lamotrigine
   • For mixed features: Valproate or combination therapy

Second-Line Approach: Addressing PMDD Symptoms

Once bipolar symptoms are stabilized:

1. For euthymic bipolar patients:

   • Estroprogestins (hormonal contraceptives) are first-line treatment for PMDD symptoms 2
   • Continuous rather than cyclic administration may provide better symptom control

2. For patients in acute bipolar phases:

   • During depressive episodes: Carefully consider add-on treatments to mood stabilizers
   • During manic episodes: Atypical antipsychotics or hormonal modulators as add-on to mood stabilizers 2

3. Antipsychotics as adjunctive therapy:

   • Quetiapine, aripiprazole, olanzapine may help with both bipolar symptoms and PMDD 1, 4
   • The combination of olanzapine and fluoxetine is FDA-approved for bipolar depression 3

Important Cautions

1. Antidepressant use requires extreme caution:

   • Never use antidepressants as monotherapy in bipolar patients 4
   • Only use SSRIs in combination with adequate mood stabilization 1
   • Monitor closely for treatment-emergent mania 2, 5
   • Antidepressants may destabilize mood or trigger manic episodes 3

2. Monitoring requirements:

   • For lithium: Monitor serum levels, thyroid function, renal function, and urinalysis every 3-6 months 3
   • For valproate: Monitor liver function, complete blood counts, and pregnancy tests 3
   • For atypical antipsychotics: Monitor BMI monthly for 3 months then quarterly; blood pressure, fasting glucose, and lipids at 3 months and then yearly 3

3. Special considerations:

   • Women with comorbid PMDD and bipolar disorder often have more complex illness course, including earlier onset of BD and greater number of mood episodes 5
   • Bipolar women susceptible to hormonal changes may experience more severe symptoms, more frequent relapses, and worse therapeutic response 6

Treatment-Resistant Cases

For patients with inadequate response to first- and second-line treatments:

1. Consider combination strategies:

   • Multiple mood stabilizers may be necessary 2
   • Add atypical antipsychotics if not already prescribed 1

2. Lifestyle modifications:

   • Regular exercise
   • Stress management techniques
   • Sleep hygiene
   • Dietary changes (reducing caffeine, alcohol, and sugar)

Clinical Pitfalls to Avoid

1. Misdiagnosis: Symptoms of PMDD may be confused with bipolar cycling; track symptoms in relation to menstrual cycle 6

2. Inadequate mood stabilization: Ensure bipolar symptoms are well-controlled before addressing PMDD symptoms 2

3. Premature antidepressant use: Adding antidepressants before adequate mood stabilization increases risk of cycling or mania 3, 4

4. Insufficient monitoring: Both conditions require close follow-up to assess treatment response and adjust medications as needed

5. Medication discontinuation: Any attempts to discontinue prophylactic therapy should be done gradually with close monitoring for relapse 3