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

Non-Hormonal Treatment Options for Premenstrual Dysphoric Disorder (PMDD)

Selective serotonin reuptake inhibitors (SSRIs) are the first-line non-hormonal pharmacological treatment for PMDD, with cognitive behavioral therapy (CBT) as an effective non-pharmacological option. 1, 2

First-Line Pharmacological Treatment: SSRIs

Efficacy and Administration

• SSRIs have demonstrated effectiveness in reducing premenstrual symptoms in women with PMDD 3
• Administration options:
  1. Continuous administration (daily dosing throughout the menstrual cycle)
     • More effective than luteal phase dosing 3
  2. Luteal phase dosing (taken only during the 2 weeks before menses)
  3. Symptom-onset dosing (taken from symptom onset through the first few days of menses) 4

Recommended SSRIs and Dosages

• Sertraline: 50-150 mg/day 2
• Fluoxetine: 10-20 mg/day 2
• Escitalopram: 10-20 mg/day 2
• Paroxetine: 12.5-25 mg/day 2

Important Considerations

• Response rates: Approximately 60% of women respond to SSRIs for PMDD 5
• Approximately 40% of women with PMDD do not respond to SSRIs, highlighting the need for alternative treatments 5
• Common adverse effects include:
  • Nausea (most common)
  • Insomnia
  • Sexual dysfunction
  • Fatigue/sedation
  • Dizziness 3

First-Line Non-Pharmacological Treatment: Cognitive Behavioral Therapy (CBT)

Efficacy

• CBT is strongly recommended for managing mood symptoms in PMDD 1
• Demonstrated effectiveness in reducing:
  • Functional impairment
  • Depressed mood and feelings of hopelessness
  • Anxiety and mood swings
  • Irritability and sensitivity
  • Insomnia
  • Interpersonal conflicts 2

Implementation

• CBT should focus on:
  • Identifying and challenging negative thought patterns related to premenstrual symptoms
  • Developing coping strategies for symptom management
  • Stress reduction techniques
  • Behavioral activation during symptomatic phases

Second-Line Pharmacological Options

Augmentation Strategies

• For patients with partial response to SSRIs, consider:
  • Switching to a different SSRI
  • Augmenting with bupropion (shown to be more effective than buspirone for augmentation) 6

Alternative Non-Hormonal Medications

• Anxiolytics: For acute management of severe anxiety symptoms 7
• Spironolactone: May help with physical symptoms like bloating 7
• NSAIDs: For management of physical pain symptoms 7

Lifestyle Modifications

• Despite limited specific evidence, lifestyle modifications are recommended for all women with PMDD 7
• May be sufficient for mild-to-moderate symptoms 7
• Key components:
  • Regular exercise
  • Stress management techniques
  • Sleep hygiene
  • Dietary modifications (reducing caffeine, alcohol, and salt)

Treatment Algorithm

1. Initial Assessment:

   • Confirm PMDD diagnosis with prospective symptom tracking over 2 menstrual cycles
   • Assess symptom severity and impact on functioning

2. First-Line Treatment:

   • For mild-moderate symptoms: Start with CBT and lifestyle modifications
   • For moderate-severe symptoms: Initiate SSRI (preferably continuous dosing) AND recommend CBT

3. Evaluate Response After 2-3 Cycles:

   • If good response: Continue treatment
   • If partial response: Consider increasing SSRI dose or switching to another SSRI
   • If minimal/no response: Move to second-line options

4. Second-Line Options:

   • Try a different SSRI
   • Consider augmentation strategies
   • Evaluate for adjunctive treatments (anxiolytics, NSAIDs) for specific symptoms

Important Clinical Considerations

• Monitoring: Regular assessment of symptom improvement and side effects
• Duration of treatment: Long-term treatment may be necessary; discuss risks/benefits
• Discontinuation: Monitor for withdrawal symptoms if discontinuing SSRIs
• Comorbidities: Assess and treat comorbid conditions that may exacerbate PMDD symptoms

Pitfalls to Avoid

1. Underestimating severity: PMDD significantly impacts quality of life and requires active treatment
2. Inadequate trial duration: Allow at least 2-3 menstrual cycles to assess treatment efficacy
3. Overlooking non-pharmacological options: CBT has strong evidence and should be offered alongside or before pharmacotherapy when appropriate
4. Failure to consider symptom patterns: Tailor treatment approach based on predominant symptoms (psychological vs. physical)
5. Not addressing partial response: Many patients require combination therapy or treatment adjustments