What are the treatment options for Premenstrual Dysphoric Disorder (PMDD)?

Treatment Options for Premenstrual Dysphoric Disorder (PMDD)

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line treatment for PMDD due to their proven efficacy in reducing both emotional and physical symptoms with fewer adverse effects compared to other interventions.

First-Line Pharmacological Treatment

SSRIs

• Sertraline: 50-150 mg/day (start at 25-50 mg and titrate) 1
• Fluoxetine: 10-20 mg/day 1
• Escitalopram: 10-20 mg/day 1
• Paroxetine: 12.5-25 mg/day 1

SSRI Dosing Strategies

1. Continuous daily dosing: Taking medication every day of the menstrual cycle
2. Luteal phase dosing: Starting at ovulation and continuing until menses
3. Symptom-onset dosing: Starting when symptoms begin and continuing through the first few days of menses 2

Second-Line Pharmacological Options

Hormonal Treatments

• Drospirenone-containing oral contraceptives: Drospirenone 3 mg with ethinyl estradiol 20 mg daily for 24 days followed by 4 days of inactive pills 3, 1
  • FDA-approved for PMDD in women who choose to use oral contraceptives for contraception
  • Should only be used if patient has already decided to use oral contraceptives for birth control and has been diagnosed with PMDD by a healthcare provider 3

Other Antidepressants

• SNRIs: Venlafaxine, duloxetine 4
• Other psychiatric medications: Alprazolam, buspirone 4

Non-Pharmacological Approaches

Cognitive Behavioral Therapy (CBT)

• Demonstrated effectiveness in reducing functional impairment, depressed mood, anxiety, mood swings, irritability, and conflict with others 1
• Should be strongly considered as an alternative to medication where available 5
• Particularly beneficial for addressing psychosocial stressors that may contribute to symptoms 6

Lifestyle Modifications

• Regular exercise
• Stress management techniques
• Sleep hygiene

Supplements

• Calcium supplementation: Only supplement with consistent evidence of benefit 4

Treatment Algorithm

1. Initial Assessment:

   • Confirm PMDD diagnosis (symptoms present only during luteal phase)
   • Distinguish from premenstrual syndrome (PMS), which is less severe

2. First-line Treatment:

   • Start with an SSRI (sertraline 50 mg/day or fluoxetine 20 mg/day)
   • Choose dosing strategy based on symptom pattern:
     • For severe symptoms: Continuous daily dosing
     • For moderate symptoms: Luteal phase dosing
     • For mild symptoms: Symptom-onset dosing

3. If inadequate response after 2-3 cycles:

   • Increase SSRI dose within therapeutic range
   • OR switch to another SSRI

4. If still inadequate response:

   • Consider drospirenone-containing oral contraceptive (if contraception is also desired)
   • OR try an SNRI (venlafaxine or duloxetine)

5. For patients who cannot tolerate or prefer not to take medications:

   • Refer for CBT
   • Consider calcium supplementation

Important Clinical Considerations

• Monitoring: Assess response after 2-3 menstrual cycles
• Duration: Continue effective treatment for at least 6-12 months before considering tapering
• Discontinuation: No withdrawal symptoms reported with intermittent SSRI dosing regimens 7
• Caution with St. John's Wort: While potentially effective, it has significant drug interactions and is not FDA-regulated for consistent potency 5

Special Populations

• Women with comorbid depression or anxiety: Prefer continuous daily dosing of SSRIs
• Women planning pregnancy: Discuss risks/benefits of medication continuation
• Women with contraindications to SSRIs: Consider CBT as primary treatment

Remember that PMDD significantly impacts quality of life, and effective treatment can substantially improve functioning across personal, social, family, and professional domains 1.