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

Treatment Options for Premenstrual Dysphoric Disorder (PMDD)

Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacological treatment for PMDD, with drospirenone-containing oral contraceptives being an effective alternative for women who also desire contraception. 1, 2

Understanding PMDD

PMDD is a severe form of premenstrual syndrome characterized by significant mood disturbances and physical symptoms that occur during the luteal phase of the menstrual cycle. Key symptoms include:

Psychological Symptoms:

• Markedly depressed mood
• Anxiety or tension
• Mood swings
• Persistent anger or irritability
• Decreased interest in usual activities
• Difficulty concentrating
• Lack of energy
• Feeling out of control

Physical Symptoms:

• Breast tenderness
• Headache
• Joint and muscle pain
• Bloating
• Weight gain

These symptoms typically begin 1-2 weeks before menstruation and resolve within a few days after the onset of menses. PMDD affects approximately 3-8% of menstruating women and significantly interferes with work, school, social activities, and relationships 2, 3.

Treatment Algorithm

First-Line Pharmacological Options:

1. SSRIs:

   • Most effective when administered continuously rather than only during the luteal phase 1
   • Recommended options:
     • Sertraline: 50-150 mg/day
     • Fluoxetine: 10-20 mg/day
     • Escitalopram: 10-20 mg/day
     • Paroxetine: 12.5-25 mg/day 4

2. Drospirenone-containing oral contraceptives:

   • Drospirenone 3 mg with ethinyl estradiol 20 μg (24/4 regimen)
   • Indicated for women who desire contraception and have been diagnosed with PMDD 2
   • Regimen: 24 days of active hormonal pills followed by 4 days of inactive pills 2

Second-Line Options:

1. Other antidepressants:

   • Venlafaxine
   • Duloxetine 5

2. Anxiolytics:

   • Buspirone
   • Alprazolam (use with caution due to addiction potential) 5

3. Hormonal interventions:

   • GnRH agonists (for severe cases unresponsive to other treatments) 6

Non-Pharmacological Approaches:

1. Cognitive Behavioral Therapy (CBT):

   • Shown to reduce functional impairment, depressed mood, anxiety, and conflict with others 4
   • Focuses on behavioral activation and cognitive restructuring

2. Lifestyle modifications:

   • Regular exercise
   • Stress management techniques
   • Dietary changes (reducing caffeine, salt, and alcohol)

3. Supplements (limited evidence):

   • Calcium supplementation (most consistent evidence) 5
   • Vitamin B6
   • Magnesium

Treatment Selection Considerations

1. For women desiring contraception:

   • Consider drospirenone-containing oral contraceptives 2
   • Note: Drospirenone may increase potassium levels; avoid in women with kidney, liver, or adrenal disease 2

2. For women with predominant mood symptoms:

   • SSRIs are most effective 1
   • Continuous dosing appears more effective than luteal phase dosing 1

3. For women with both physical and psychological symptoms:

   • Combined approach with SSRIs and supportive measures

Monitoring and Follow-up

• Evaluate response to treatment after 2-3 menstrual cycles

• Monitor for common SSRI side effects:

  • Nausea (most common)
  • Insomnia
  • Sexual dysfunction
  • Fatigue
  • Dizziness 1

• For women on drospirenone-containing contraceptives:

  • Monitor potassium levels during the first treatment cycle if also taking medications that may increase potassium 2

Important Considerations and Pitfalls

1. Distinguish PMDD from PMS: PMDD is more severe and requires at least 5 symptoms, including at least one mood symptom, that significantly impair functioning.

2. Rule out other conditions: Symptoms of other psychiatric disorders (depression, anxiety) may worsen premenstrually but require different management approaches.

3. Medication timing: Unlike treatment for major depression, SSRIs for PMDD can be effective when used only during the luteal phase, though continuous dosing appears more effective 1.

4. Contraindications for drospirenone-containing contraceptives:

   • Women over 35 who smoke
   • History of thromboembolism
   • Uncontrolled hypertension
   • Renal or adrenal insufficiency 2

5. Treatment duration: Continue effective treatment for at least 6-12 months before considering tapering.

PMDD is a serious condition that significantly impacts quality of life, but with proper diagnosis and treatment, most women experience substantial symptom relief and improved functioning.