What is the treatment for Premenstrual Dysphoric Disorder (PMDD)?

Treatment of Premenstrual Dysphoric Disorder (PMDD)

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line pharmacological treatment for PMDD, with continuous administration being more effective than luteal phase dosing. 1, 2

First-Line Treatment

Pharmacological Approach

• SSRIs:
  • First choice: Sertraline, fluoxetine, paroxetine, escitalopram, or citalopram 1, 2
  • Administration options:
    • Continuous daily dosing (more effective than luteal phase dosing) 2
    • Luteal phase dosing (only during the 2 weeks before menses) 1, 3
  • Fluoxetine is FDA-approved specifically for PMDD (marketed as Sarafem) 3

Non-Pharmacological Approach

• Cognitive Behavioral Therapy (CBT) is strongly recommended for managing mood symptoms 1

  • Focus on identifying negative thought patterns
  • Developing coping strategies
  • Stress reduction techniques

• Lifestyle modifications (recommended for all PMDD patients):

  • Regular aerobic exercise 4
  • Stress management techniques 4
  • Sleep hygiene improvements 1
  • Dietary modifications (reducing caffeine, salt, alcohol) 1

Second-Line Treatments

For Partial Response to SSRIs

• Switch to a different SSRI 1
• Augment with bupropion (more effective than buspirone for augmentation) 1

Alternative Pharmacological Options

• Venlafaxine, duloxetine, alprazolam, or buspirone 5
• Anxiolytics for anxiety-predominant symptoms 1
• Spironolactone for bloating/fluid retention 6
• NSAIDs for pain symptoms 6

Supplements and Complementary Approaches

• Calcium supplementation (demonstrated consistent therapeutic benefit) 5
• Other supplements (vitamin B6, magnesium) have limited evidence 7
• Chasteberry (Vitex agnus-castus) and St. John's wort have some supporting evidence but require further research 7

Treatment Algorithm

1. Initial Assessment:

   • Confirm PMDD diagnosis with prospective symptom tracking over 2 menstrual cycles
   • Identify predominant symptoms (psychological vs. physical)

2. Mild-to-Moderate Symptoms:

   • Start with lifestyle modifications and CBT
   • Add calcium supplementation

3. Moderate-to-Severe Symptoms:

   • Start SSRI (preferably continuous dosing)
   • Continue lifestyle modifications and CBT
   • Monitor for 2-3 cycles

4. Inadequate Response:

   • Switch to different SSRI or
   • Augment with bupropion or
   • Add targeted symptom treatment (anxiolytics, NSAIDs, spironolactone)

Common Side Effects of SSRIs

• Nausea (most common) 2
• Insomnia 2
• Sexual dysfunction 2
• Fatigue/sedation 2
• Dizziness 2

Important Considerations

• Treatment should be continued for at least 2-3 menstrual cycles to properly assess efficacy
• Regular monitoring of symptom improvement and side effects is necessary 1
• SSRIs work more quickly for PMDD than for depression, often showing benefits in the first cycle
• Be aware that pharmaceutical funding supported 68% of SSRI studies for PMDD, which may influence reported efficacy 2

Treatment Pitfalls to Avoid

• Failing to distinguish between PMDD and premenstrual exacerbation of underlying mood disorders
• Using hormonal contraceptives as first-line treatment (less evidence than SSRIs)
• Discontinuing SSRIs prematurely before adequate trial period
• Not addressing both psychological and physical symptoms