Are antihistamines and Proton Pump Inhibitors (PPIs) effective for treating Premenstrual Dysphoric Disorder (PMDD)?

Antihistamines and PPIs for PMDD: Evidence-Based Assessment

Antihistamines and proton pump inhibitors (PPIs) are not recommended or effective treatments for Premenstrual Dysphoric Disorder (PMDD). The evidence does not support their use for this condition.

First-Line Treatment for PMDD

Based on the most recent and highest quality evidence, the following treatments are recommended for PMDD:

Selective Serotonin Reuptake Inhibitors (SSRIs)

• First-line pharmacological treatment with strong evidence of efficacy 1
• SSRIs significantly reduce premenstrual symptoms compared to placebo (moderate-certainty evidence)
• Options include:
  • Sertraline (50-150 mg/day)
  • Fluoxetine (10-20 mg/day)
  • Escitalopram (10-20 mg/day)
  • Paroxetine (12.5-25 mg/day)
• Administration can be either:
  • Continuous (more effective based on evidence)
  • Luteal phase only (from ovulation to menstruation)

Hormonal Contraceptives

• Combined hormonal contraceptives containing drospirenone are effective 2
• Specifically: 20 mcg ethinyl estradiol/3mg drospirenone in a 24/4 extended cycle regimen

Why Antihistamines and PPIs Are Not Indicated

1. No evidence for antihistamines in PMDD:

   • None of the guidelines or research studies mention antihistamines as a treatment for PMDD
   • Antihistamines are primarily indicated for allergic conditions, not mood disorders

2. No evidence for PPIs in PMDD:

   • PPIs are specifically indicated for acid-related disorders 3
   • PPIs are recommended for gastroesophageal reflux disease and prevention of esophageal ulcers 3, 4
   • No research supports their use in treating mood or hormonal disorders like PMDD

Treatment Algorithm for PMDD

1. Confirm diagnosis:

   • Symptoms must occur during luteal phase (2 weeks before menses)
   • Symptoms must resolve shortly after onset of menstruation
   • Symptoms must significantly interfere with daily functioning

2. First-line treatment options:

   • SSRIs (sertraline, fluoxetine, escitalopram, paroxetine)
   • Combined hormonal contraceptive with drospirenone (if contraception is also desired)

3. Second-line options if first-line treatments fail:

   • Other psychiatric medications with evidence of efficacy:
     • Venlafaxine
     • Duloxetine
     • Alprazolam
     • Buspirone 5

4. Non-pharmacological approaches:

   • Cognitive Behavioral Therapy (CBT) has demonstrated effectiveness 6
   • Regular aerobic exercise

Common Pitfalls to Avoid

1. Using medications without evidence: Prescribing antihistamines or PPIs for PMDD has no scientific basis and may delay effective treatment.

2. Overlooking side effects: SSRIs can cause adverse effects including nausea (OR 3.30), insomnia (OR 1.99), sexual dysfunction (OR 2.32), and fatigue (OR 1.52) 1.

3. Inadequate duration of treatment: Treatment should be continued for at least 2-3 menstrual cycles to properly evaluate efficacy.

4. Confusing PMDD with other conditions: PMDD must be differentiated from other mood disorders that may worsen premenstrually but are present throughout the cycle.

In conclusion, while several evidence-based treatments exist for PMDD, neither antihistamines nor PPIs are among them. Treatment should focus on medications with established efficacy, primarily SSRIs and specific hormonal contraceptives.