Role of Oral Contraceptive Pills in Treating Premenstrual Dysphoric Disorder (PMDD)
Combined oral contraceptives containing drospirenone and ethinyl estradiol are FDA-approved and effective for treating symptoms of premenstrual dysphoric disorder (PMDD) in women who desire contraception. 1
Understanding PMDD
PMDD is a severe form of premenstrual syndrome characterized by:
- Markedly depressed mood, anxiety or tension
- Affective lability and persistent anger/irritability
- Decreased interest in usual activities
- Difficulty concentrating and lack of energy
- Changes in appetite or sleep patterns
- Physical symptoms: breast tenderness, headache, joint/muscle pain, bloating, weight gain
These symptoms occur regularly during the luteal phase, remit within days after menses onset, and significantly interfere with daily functioning. Diagnosis requires prospective symptom assessment over at least two menstrual cycles. 1
Evidence for OCPs in PMDD Treatment
Drospirenone-Containing OCPs
- FDA Approval: Drospirenone 3mg/ethinyl estradiol 0.02mg tablets are specifically indicated for PMDD treatment in women who choose OCPs for contraception 1
- Mechanism: Drospirenone is a fourth-generation progestin with anti-mineralocorticoid and anti-androgenic properties that may help address PMDD symptoms 2
- Efficacy: Low to moderate quality evidence shows drospirenone-containing OCPs may improve overall premenstrual symptoms with a small to moderate effect size 3
- Administration: Most effective when given in a 24/4 regimen (24 active pills, 4 placebo) rather than the traditional 21/7 regimen 4
Clinical Evidence
A randomized, double-blind, placebo-controlled study showed that drospirenone/ethinyl estradiol in a 24/4 regimen was superior to placebo for improving PMDD symptoms, with 61.7% of subjects showing positive response versus 31.8% with placebo 4. Another study found improved symptoms compared to placebo, though without statistical significance 5.
Treatment Algorithm for PMDD
First-line approach for women desiring contraception:
Alternative approaches if OCPs are contraindicated or ineffective:
Safety Considerations and Monitoring
Potential Adverse Effects
- Intermenstrual bleeding (13% vs 3% with placebo)
- Menorrhagia (9% vs 1% with placebo)
- Nausea (5% vs 4% with placebo)
- Skin rash (4% vs 2% with placebo) 5
Contraindications
- Women over 35 who smoke
- History of or high risk for arterial/venous thrombotic events
- Uncontrolled hypertension
- Liver tumors or disease
- Renal impairment
- Adrenal insufficiency 1
Monitoring
- Evaluate changes in mood and PMDD symptoms after 2-3 cycles
- Monitor blood pressure
- Assess for signs of thromboembolism
- Check serum potassium in women on medications that may increase potassium levels 1
Important Caveats
OCPs do not protect against sexually transmitted infections; condoms should be recommended if STI protection is needed 7
The effectiveness of drospirenone-containing OCPs for PMDD beyond three menstrual cycles has not been well evaluated 1, 3
While drospirenone-containing OCPs are FDA-approved for PMDD, there is limited evidence comparing them to other combined hormonal contraceptives 3
Drospirenone has anti-mineralocorticoid activity that may cause hyperkalemia in susceptible individuals 1
Combined OCPs containing drospirenone may be associated with a higher risk of venous thromboembolism than those containing levonorgestrel or some other progestins 1
By following this evidence-based approach, clinicians can effectively use OCPs containing drospirenone to address both contraceptive needs and PMDD symptoms in appropriate patients.