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 pharmacological treatment for PMDD, with sertraline and fluoxetine having FDA approval specifically for this condition. 1, 2

First-Line Pharmacological Treatment

SSRI Therapy Options

• Sertraline:

  • Initial dose: 50 mg/day 1
  • Can be administered in two different regimens:
    1. Daily throughout the menstrual cycle
    2. Luteal phase only (2 weeks prior to menses)
  • Dose may be increased to 100-150 mg/day based on response
  • For luteal phase dosing with 100 mg/day, start with 50 mg/day for first 3 days of luteal phase 1

• Fluoxetine:

  • FDA approved for PMDD 3
  • Effective at 20 mg/day with either continuous or luteal phase dosing 4
  • Lower doses (10 mg) may be effective for emotional symptoms with luteal phase dosing 4

Dosing Strategies

1. Continuous daily dosing (every day of the menstrual cycle)

   • More effective than luteal phase dosing according to meta-analyses 2
   • SMD -0.69 vs -0.39 for luteal phase dosing (P=0.03 for difference) 2

2. Luteal phase dosing (from ovulation to menses)

   • Still effective but slightly less than continuous dosing 2
   • Advantage: Fewer total medication days and potentially fewer side effects

3. Symptom-onset dosing (starting at symptom onset until first few days of menses)

   • Mixed evidence for efficacy 5
   • May be considered for women who prefer minimal medication exposure

Non-Pharmacological Approaches

Psychoeducation and Self-Management

• Education about the disorder, symptoms, and treatment options
• Stress management techniques
• Regular physical activity
• Nutritional counseling (regular meals, reduced caffeine, alcohol, and salt)

Cognitive Behavioral Therapy (CBT)

• Effective for managing emotional symptoms of PMDD
• Helps develop coping strategies for premenstrual symptoms
• Can be used alone for mild symptoms or in combination with medication for moderate-severe symptoms

Treatment Algorithm

1. Mild PMDD:

   • Start with non-pharmacological approaches
   • Consider luteal phase SSRI if symptoms persist

2. Moderate to Severe PMDD:

   • Begin SSRI (sertraline 50 mg/day or fluoxetine 20 mg/day)
   • Choose continuous dosing for more severe symptoms
   • Choose luteal phase dosing if patient prefers fewer medication days

3. If inadequate response after 2-3 cycles:

   • Increase SSRI dose (sertraline up to 150 mg/day)
   • Consider switching to another SSRI
   • Consider adding non-pharmacological approaches if not already implemented

Common Side Effects and Management

SSRIs commonly cause:

• Nausea (OR 3.30) 2
• Insomnia (OR 1.99) 2
• Sexual dysfunction (OR 2.32) 2
• Fatigue (OR 1.52) 2
• Dizziness (OR 1.96) 2

Important Considerations

• Approximately 60-70% of women respond to SSRI treatment for PMDD 6
• About 40% of women do not respond adequately to SSRIs, necessitating alternative approaches 6
• No evidence of discontinuation symptoms with intermittent dosing regimens 4, 7
• Continuous dosing is more effective than luteal phase dosing, but both are superior to placebo 2

Treatment Monitoring

• Use daily symptom tracking to assess treatment response
• Evaluate response after 2-3 menstrual cycles
• Consider treatment successful if there is significant reduction in symptom severity and functional impairment
• Periodically reassess need for continued treatment

Pitfalls to Avoid

1. Failing to distinguish PMDD from other mood disorders that may worsen premenstrually
2. Not providing adequate trial duration (at least 2-3 cycles)
3. Using inadequate dosing
4. Not considering alternative approaches for non-responders
5. Overlooking the impact of side effects on treatment adherence

Remember that while SSRIs are effective for many women with PMDD, a significant proportion will not respond adequately and may require alternative or additional treatment approaches.