What are the treatment options for Premenstrual Dysphoric Disorder (PMDD)?

Treatment Options for Premenstrual Dysphoric Disorder (PMDD)

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line treatment for PMDD, with sertraline being particularly effective when administered either continuously or during the luteal phase of the menstrual cycle. 1, 2

First-Line Pharmacological Treatment

SSRIs

• Sertraline (Zoloft): FDA-approved specifically for PMDD

  • Dosing: Start at 50 mg/day, can be administered either:
    • Daily throughout the menstrual cycle, or
    • Limited to the luteal phase (2 weeks before menses)
  • Can increase dose up to 150 mg/day if needed 3
  • For luteal phase dosing with 100 mg/day, use a 50 mg/day titration step for first 3 days of each luteal phase 3

• Other effective SSRIs:

  • Fluoxetine
  • Paroxetine
  • Escitalopram
  • Citalopram 2

• Administration approaches:

  • Continuous dosing is probably more effective than luteal phase dosing (SMD -0.69 vs -0.39) 2
  • Unlike depression treatment, SSRIs for PMDD can be effective when used cyclically 4

Common Side Effects of SSRIs

SSRIs are associated with several side effects that patients should be aware of:

• Nausea (most common)
• Insomnia
• Sexual dysfunction/decreased libido
• Fatigue/sedation
• Dizziness/vertigo
• Dry mouth
• Decreased energy 2

Second-Line Pharmacological Options

If SSRIs are ineffective or poorly tolerated, consider:

• Other antidepressants:

  • Venlafaxine (SNRI)
  • Duloxetine (SNRI) 1

• Anxiolytics:

  • Alprazolam
  • Buspirone 1, 5

• Hormonal treatments (for those not responding to first-line options):

  • Ovulation suppression therapies
  • Note: These have more side effects and limitations compared to SSRIs 4, 5

Non-Pharmacological Approaches

For mild to moderate PMDD symptoms, or as adjuncts to medication:

1. Cognitive Behavioral Therapy (CBT)

   • Strong evidence for effectiveness in managing mood symptoms 6

2. Lifestyle modifications:

   • Regular aerobic exercise
   • Stress management techniques
   • Healthy diet with regular meals 7

3. Supplements with evidence:

   • Calcium supplementation - most consistent therapeutic benefit among supplements 1
   • Other supplements (limited evidence):
     • Vitamin B6
     • Magnesium 5

4. Herbal remedies (limited evidence):

   • Chasteberry (Agnus castus)
   • St. John's wort (caution: interacts with many medications) 4

Treatment Algorithm

1. Assess symptom severity:

   • Mild to moderate: Start with lifestyle modifications and CBT
   • Moderate to severe: Consider pharmacotherapy alongside non-pharmacological approaches

2. First-line pharmacotherapy:

   • Start with sertraline 50 mg/day (either continuous or luteal phase)
   • If inadequate response after 1-2 cycles, increase dose (up to 150 mg/day)
   • If still inadequate, try another SSRI

3. Second-line options (if SSRIs fail or are not tolerated):

   • Try SNRIs (venlafaxine or duloxetine)
   • Consider anxiolytics for predominant anxiety symptoms
   • Add calcium supplementation

4. Third-line options:

   • Hormonal treatments for ovulation suppression
   • Combination therapies (medication + CBT)

Important Considerations

• PMDD symptoms occur during the luteal phase (7-14 days before menses) and resolve within 1-2 days after menses begins 7
• True PMDD requires a symptom-free period during the follicular phase 7
• Accurate diagnosis requires prospective symptom tracking across at least two menstrual cycles
• Long-term use of SSRIs for PMDD beyond 3 menstrual cycles has not been systematically evaluated in controlled trials 3
• Periodic reassessment of treatment effectiveness and necessity is recommended 3

Monitoring and Follow-up

• Track symptoms using a daily rating scale to assess treatment effectiveness
• Monitor for side effects, particularly in the first few weeks of SSRI treatment
• Reassess the need for continued treatment periodically, especially for long-term use
• For luteal phase dosing, ensure proper timing with menstrual cycle

Remember that PMDD is a severe form of premenstrual syndrome that significantly impacts quality of life, and effective treatment can substantially improve functioning and well-being.