What is the best treatment for premenstrual dysphoric disorder (PMDD)?

Best Treatment for Premenstrual Dysphoric Disorder (PMDD)

Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for premenstrual dysphoric disorder, with sertraline, fluoxetine, and controlled-release paroxetine being FDA-approved options that can be administered either continuously or during the luteal phase only. 1, 2, 3

Treatment Algorithm

First-Line Treatment: SSRIs

• Sertraline: Start with 50 mg/day, can be administered daily throughout the menstrual cycle or limited to the luteal phase (last 2 weeks before menses) 1
• Fluoxetine: FDA-approved for PMDD
• Paroxetine (controlled-release): FDA-approved for PMDD

SSRIs demonstrate significant efficacy in reducing overall premenstrual symptoms compared to placebo. Continuous administration appears more effective than luteal phase administration, though both are viable options 3. The efficacy of SSRIs for PMDD is well-established through multiple randomized controlled trials, making them the clear first-line choice.

Administration Options

1. Continuous dosing: Taking medication daily throughout the entire menstrual cycle
2. Luteal phase dosing: Taking medication only during the 2 weeks before menses begins
   • For luteal phase dosing with sertraline: Start with 50 mg/day; if using 100 mg/day, use a 50 mg/day titration step for the first 3 days of each luteal phase 1

Second-Line Options

If SSRIs are ineffective or poorly tolerated:

1. Other psychiatric medications:

   • Venlafaxine (SNRI)
   • Duloxetine (SNRI)
   • Alprazolam (benzodiazepine) - modest efficacy 4
   • Buspirone - modest efficacy 4

2. Hormonal interventions:

   • Hormonal contraceptives (though evidence is limited)
   • Ovulation suppression therapies

Common Side Effects of SSRIs

Most common adverse effects include:

• Nausea (most common)
• Insomnia
• Sexual dysfunction
• Fatigue
• Dizziness
• Dry mouth
• Decreased energy

Supplement Options

• Calcium supplementation: The only supplement with consistent therapeutic benefit 2
• Other supplements like vitamin E, omega-3 fatty acids, and herbal remedies (such as St. John's wort, chasteberry) have limited or conflicting evidence 5, 6

Important Clinical Considerations

Diagnostic Confirmation

Ensure proper diagnosis of PMDD using DSM criteria, which requires:

• Symptoms occurring during the luteal phase
• Resolution within a few days of menses onset
• Significant functional impairment
• Prospective symptom tracking for at least two menstrual cycles

Treatment Duration

For long-term use (beyond 3 menstrual cycles), periodic reevaluation is necessary to determine continued need for medication 1.

Monitoring

Regular follow-up to assess:

• Treatment response
• Side effects
• Need for dose adjustments
• Functional improvement

Special Populations

For women using oral contraceptives, the efficacy of SSRIs for PMDD in combination with oral contraceptives is unknown, as these patients were excluded from clinical trials 1.

Pitfalls to Avoid

1. Misdiagnosis: Failing to differentiate PMDD from other mood disorders that may worsen premenstrually
2. Inadequate trial duration: Not allowing sufficient time for SSRIs to demonstrate efficacy
3. Overlooking non-pharmacological approaches: Lifestyle modifications and exercise should be recommended for all women with PMDD
4. Inappropriate medication timing: When using luteal phase dosing, timing is critical for efficacy

The evidence strongly supports SSRIs as the most effective treatment for PMDD, with the flexibility of either continuous or luteal phase administration based on symptom pattern and patient preference.