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

Management Options for Premenstrual Dysphoric Disorder (PMDD)

Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for PMDD, with continuous administration being more effective than luteal phase dosing. 1

First-Line Pharmacological Treatment

SSRIs

• SSRIs have demonstrated the most consistent therapeutic benefit for PMDD 2, 1

• Administration options:

  • Continuous daily dosing (more effective than luteal phase dosing) 1
  • Luteal phase dosing (starting 14 days before menses)
  • Symptom-onset dosing

• FDA-approved options:

  • Fluoxetine (Prozac) 3
  • Sertraline (Zoloft)
  • Paroxetine controlled-release

• Dosing considerations:

  • Start with lower doses than those used for depression
  • Monitor for common side effects: nausea (NNTH = 3.3), insomnia (NNTH = 2.0), sexual dysfunction (NNTH = 2.3), fatigue (NNTH = 1.5) 1

Second-Line Pharmacological Options

Other Antidepressants

• Venlafaxine (SNRI) 2
• Duloxetine (SNRI) 2

Anxiolytics

• Alprazolam (for severe anxiety symptoms) 2
• Buspirone 2

Hormonal Interventions

• Oral contraceptives (especially those containing drospirenone) 4
• GnRH agonists (for severe cases unresponsive to other treatments) 5
  • Note: Limited by side effects and need for add-back hormone therapy

Non-Pharmacological Approaches

Supplements

• Calcium supplementation (1000-1200 mg/day) - most evidence-supported supplement 2, 4
• Insufficient evidence for:
  • Vitamin D
  • Omega-3 fatty acids
  • St. John's wort
  • Agnus castus (chasteberry) 5, 6

Psychological Interventions

• Cognitive Behavioral Therapy (CBT) 6
  • Particularly effective for addressing negative thought patterns
  • Comparable efficacy to SSRIs for depression symptoms 7
• Mindfulness-based stress reduction 7

Lifestyle Modifications

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

Treatment Algorithm

1. Mild PMDD:

   • Start with lifestyle modifications and calcium supplementation
   • Consider CBT or mindfulness-based interventions

2. Moderate PMDD:

   • SSRI (first choice: sertraline 50-150 mg daily or fluoxetine 20 mg daily)
   • Consider continuous rather than luteal phase dosing 1
   • Add calcium supplementation

3. Severe PMDD:

   • SSRI at therapeutic doses (continuous dosing)
   • Consider combination therapy with CBT
   • For inadequate response, consider:
     • Switching to another SSRI
     • Adding hormonal therapy
     • Consultation with psychiatry and/or gynecology

Important Clinical Considerations

• Distinguish PMDD from other mood disorders by confirming symptom cyclicity with prospective daily symptom tracking over 2-3 menstrual cycles 6
• Symptoms must be present in the luteal phase and resolve shortly after menstruation begins
• Evaluate for comorbid psychiatric conditions that may be exacerbated premenstrually
• SSRIs work more rapidly for PMDD than for depression, often within the first cycle of treatment 5
• Treatment should continue for at least 6-12 months before considering discontinuation
• For patients with contraindications to SSRIs, consider hormonal interventions or non-pharmacological approaches as first-line

Common Pitfalls to Avoid

1. Failing to distinguish PMDD from premenstrual exacerbation of another psychiatric disorder
2. Inadequate symptom tracking before diagnosis
3. Using subtherapeutic doses of SSRIs
4. Discontinuing treatment prematurely
5. Not addressing comorbid conditions that may worsen PMDD symptoms
6. Relying solely on unproven supplements or alternative therapies

By following this evidence-based approach to PMDD management, clinicians can significantly improve patients' quality of life and reduce the substantial functional impairment associated with this disorder.