What is the first line of treatment for premenstrual dysphoric disorder (PMDD)?

First-Line Treatment for Premenstrual Dysphoric Disorder (PMDD)

Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacological treatment for premenstrual dysphoric disorder (PMDD), with sertraline, fluoxetine, and paroxetine being the preferred options. 1

Understanding PMDD

PMDD is a severe form of premenstrual syndrome affecting approximately 3-8% of menstruating women. It is characterized by:

• Irritability and anger
• Mood swings
• Sadness or depression
• Anxiety or tension
• Fatigue or lethargy
• Increased interpersonal conflicts
• Physical symptoms (bloating, breast tenderness)

These symptoms occur during the luteal phase (two weeks before menstruation) and typically resolve within a few days after the onset of menses.

Treatment Algorithm

First-Line Treatment: SSRIs

SSRIs have demonstrated significant efficacy in reducing PMDD symptoms with a moderate effect size (SMD -0.57) 1. They can be administered in two ways:

1. Continuous administration (daily dosing throughout the month)
2. Intermittent/luteal phase administration (dosing only during the 14 days before menses)

Research indicates continuous administration may be slightly more effective than luteal phase dosing (SMD -0.69 vs -0.39) 1, though intermittent dosing has the advantage of fewer side effects and may prevent tolerance development 2.

Recommended SSRI options:

• Sertraline (50-150 mg daily)
• Fluoxetine (20 mg daily)
• Paroxetine (20 mg daily)
• Escitalopram (10-20 mg daily)
• Citalopram (20 mg daily)

Alternative First-Line Option: Drospirenone-Containing Oral Contraceptives

For women who also desire contraception, drospirenone-containing oral contraceptives have FDA approval for PMDD treatment 3. Clinical trials have shown statistically significant improvement in Daily Record of Severity of Problems scores compared to placebo.

Second-Line Options:

• SNRIs (venlafaxine, duloxetine)
• Cognitive behavioral therapy (CBT)
• Lifestyle modifications

Monitoring and Side Effects

Common side effects of SSRIs include:

• Nausea (OR 3.30) 1
• Insomnia (OR 1.99) 1
• Sexual dysfunction (OR 2.32) 1
• Fatigue (OR 1.52) 1
• Dizziness (OR 1.96) 1

Important Clinical Considerations

1. Rapid onset of action: Unlike when treating depression, SSRIs for PMDD often work within days rather than weeks 2, making intermittent dosing feasible.

2. Treatment duration: For optimal results, treatment should continue for at least 2-3 menstrual cycles before assessing full efficacy.

3. Caution with paroxetine: If the patient is taking tamoxifen, paroxetine should be avoided due to CYP2D6 inhibition 4.

4. Dosing considerations: SSRI doses for PMDD are typically lower than those needed for depression 5.

Clinical Pitfalls to Avoid

1. Misdiagnosis: Ensure symptoms are confined to the luteal phase and resolve with menses; otherwise, consider other mood disorders.

2. Inadequate trial duration: Allow at least 2-3 menstrual cycles to assess efficacy.

3. Overlooking contraindications: Consider medical history, drug interactions, and pregnancy status before prescribing SSRIs.

4. Failure to discuss side effects: Patients should be informed about potential side effects, particularly nausea, insomnia, and sexual dysfunction.

By following this evidence-based approach, clinicians can effectively manage PMDD and significantly improve patients' quality of life.