Treatment of PMDD in Patients Already on SSRIs
For patients already on an SSRI for another condition who develop PMDD, the most effective approach is to increase the SSRI dose during the luteal phase (14 days before menses) while maintaining the baseline dose during the follicular phase.
Understanding PMDD in the Context of Existing SSRI Treatment
PMDD is a severe form of premenstrual syndrome affecting 3-8% of menstruating women, characterized by significant mood symptoms that can lead to functional impairment 1. When a patient is already taking an SSRI for another condition (such as depression or anxiety) but experiences PMDD symptoms, this presents a unique treatment challenge.
Treatment Algorithm for PMDD in Patients Already on SSRIs
Step 1: Optimize Current SSRI Treatment
- Assess current SSRI dosing: Determine if the patient is on an optimal dose for their primary condition
- Consider luteal phase dosing increase: Increase the SSRI dose by 50-100% during the luteal phase (14 days before menses) while maintaining the baseline dose during the rest of the cycle 2
- Medication options: Sertraline, fluoxetine, and extended-release paroxetine are FDA-approved for luteal phase dosing 3
Step 2: If Inadequate Response to Dose Adjustment
- Switch to a different SSRI: Consider changing to sertraline (50-150 mg/day), fluoxetine (10-20 mg/day), escitalopram (10-20 mg/day), or paroxetine (12.5-25 mg/day) 1
- Consider intermittent dosing: If the primary condition allows, switch to luteal phase-only dosing (taking the SSRI only during the 14 days before menses) 4
Step 3: If Still Inadequate Response
- Add hormonal treatment: Consider adding an oral contraceptive containing drospirenone (3 mg with ethinyl estradiol 20 mg/day for 24 days, followed by 4 days inactive) 1
- Add cognitive behavioral therapy (CBT): CBT has shown effectiveness in reducing functional impairment, depressed mood, anxiety, and irritability associated with PMDD 1
Evidence and Efficacy
Multiple studies support the efficacy of SSRIs for PMDD treatment, with symptom reduction similar between continuous and intermittent administration regimens 5, 3. A randomized clinical trial demonstrated that symptom-onset dosing with sertraline was effective for PMDD treatment 2.
Intermittent SSRI therapy allows women to take the medication for only 14 days each month, reducing overall medication exposure and potential side effects 4. This approach has not been associated with discontinuation symptoms despite the intermittent nature of the treatment 2.
Important Considerations and Potential Pitfalls
- Side effects: Monitor for SSRI-related side effects including headache, fatigue, insomnia, anxiety, and sexual dysfunction 4
- Avoid paroxetine in certain cases: Evidence suggests paroxetine may exacerbate REM sleep behavior disorder and should be used cautiously 6
- Augmentation strategies: For patients with treatment-resistant symptoms, consider augmentation strategies such as adding atypical antipsychotics or glutamatergic agents 7
- Withdrawal symptoms: When using intermittent dosing, monitor for potential SSRI discontinuation symptoms, although these have not been commonly reported with luteal phase dosing 2
Treatment Monitoring
- Assess response after 2-3 menstrual cycles
- Use symptom diaries to track improvement
- Monitor for side effects, particularly sexual dysfunction which is more common with paroxetine than other SSRIs 6
- Evaluate functional improvement in personal, social, family, and professional domains
By following this approach, most women with PMDD who are already on an SSRI can achieve significant symptom improvement with minimal additional medication burden or side effects.