Are progesterone Intrauterine Devices (IUDs) beneficial for Premenstrual Dysphoric Disorder (PMDD)?

Progesterone IUDs for Premenstrual Dysphoric Disorder (PMDD)

Progesterone IUDs are generally not recommended as first-line treatment for PMDD as they may potentially worsen mood symptoms in women with this condition. Progestin-only methods, including levonorgestrel IUDs, have the potential to negatively affect mood symptoms for women with baseline mood disorders, including PMDD 1.

Understanding PMDD and Contraceptive Options

PMDD is a severe form of premenstrual syndrome affecting up to 7% of reproductive-age women. It develops in predisposed individuals after exposure to progesterone at ovulation, with symptoms beginning up to two weeks before menses and resolving shortly after menstruation begins 1.

The pathophysiology of PMDD involves:

• Luteal phase abnormalities in serotonergic activity
• Altered configuration of GABA-A receptors triggered by progesterone metabolites 1
• Maladaptive neural reactivity to gonadal hormone fluctuations 2

Evidence Against Progesterone IUDs for PMDD

Progestin-only contraceptive methods, including levonorgestrel IUDs, may:

• Negatively impact mood symptoms in women with or without baseline mood disorders 1
• Potentially worsen PMDD symptoms due to continuous progestin exposure
• Require careful counseling and close follow-up if used in patients with PMDD 1

The paradoxical, unfavorable effect of progestins on mood can be explained by:

• Suppression of ovulation
• Disturbance of endocrine function in the luteal phase
• Chemical structure preventing metabolism to neuroactive, mood-improving derivatives 3

Recommended Contraceptive Options for PMDD

First-line options:

1. Combined hormonal contraceptives (CHCs) - specifically 20mcg ethinyl estradiol/3mg drospirenone in a 24/4 extended cycle regimen has been shown to significantly improve emotional and physical symptoms of PMDD 1, 4

   • This is the only FDA-approved hormonal contraceptive for PMDD treatment
   • Other monophasic, extended cycle CHCs with less androgenic progestins may also help

2. Copper IUD - recommended for those not seeking hormonal contraceptives 1

   • No hormonal impact on mood
   • Highly effective contraception (>99%) 5

Cautions with other methods:

• Progestin-only pills (POPs) - potential to negatively affect mood 1
• Levonorgestrel IUD - may worsen mood symptoms 1
• Etonogestrel implant - potential negative mood effects 1
• Depot medroxyprogesterone acetate (DMPA) - may negatively impact mood and has higher VTE risk compared to other progestin-only methods 5, 1

Treatment Approach for PMDD

For women with PMDD requiring contraception, consider:

1. First-line pharmacological treatment: Selective serotonin reuptake inhibitors (SSRIs) have strong evidence for effectiveness 2

2. Contraceptive recommendations:

   • For women who need both contraception and PMDD treatment: Consider combined hormonal contraceptives with drospirenone in 24/4 regimen
   • For women who cannot use estrogen-containing methods: Copper IUD is preferred over progesterone IUDs

3. Newer approaches:

   • Selective progesterone receptor modulators (SPRMs) like ulipristal acetate have shown promise in reducing PMDD symptoms 2
   • These create stable and low progesterone levels with maintained low-medium estradiol levels

Special Considerations

• Women with thrombotic risk factors should avoid estrogen-containing contraceptives 5
• For these women, copper IUD would be the safest option for contraception
• If hormonal treatment for PMDD is needed alongside contraception in women with thrombotic risk, consider non-contraceptive treatments like SSRIs

Monitoring and Follow-up

If a progesterone IUD must be used in a woman with PMDD (e.g., for treatment of heavy menstrual bleeding):

• Provide thorough counseling about potential mood effects
• Schedule close follow-up to monitor mood symptoms
• Be prepared to remove the IUD if mood symptoms worsen significantly
• Consider concurrent SSRI therapy to manage PMDD symptoms

Remember that PMDD treatment should prioritize both effective symptom management and appropriate contraception based on individual risk factors and needs.