What are the best treatments for Premenstrual Dysphoric Disorder (PMDD) symptoms?

Best Treatments for Premenstrual Dysphoric Disorder (PMDD)

Selective Serotonin Reuptake Inhibitors (SSRIs) and drospirenone-containing oral contraceptives are the first-line treatments for PMDD symptoms, with SSRIs showing the highest efficacy for most patients. 1, 2

First-Line Pharmacological Treatments

SSRIs

SSRIs are the most effective and well-established first-line treatment for PMDD:

• Recommended SSRIs and dosages:

  • Sertraline: 50-150 mg/day 1
  • Fluoxetine: 10-20 mg/day 1, 3
  • Escitalopram: 10-20 mg/day 1
  • Paroxetine: 12.5-25 mg/day 1

• Administration options:

  • Daily dosing throughout the menstrual cycle
  • Luteal phase dosing (only during the 2 weeks before menstruation) 3
  • Symptom-onset dosing (only during days when symptoms are present) 4

• Efficacy:

  • Approximately 60-70% of women respond to SSRIs 5
  • Effects are often seen within the first cycle of treatment 3

Drospirenone-Containing Oral Contraceptives

• FDA-approved for PMDD treatment: Drospirenone 3 mg with ethinyl estradiol 20 μg (24/4 regimen) 2
• Administration: 24 active hormone pills followed by 4 inactive pills 2, 1
• Mechanism: Suppresses ovulation and stabilizes hormonal fluctuations 2
• Best for: Women who also desire contraception 2

Second-Line and Adjunctive Treatments

Cognitive Behavioral Therapy (CBT)

• Effective for reducing functional impairment, depressed mood, anxiety, irritability, and conflict with others 1
• Helps with symptom management and coping strategies 4
• May be used as adjunctive therapy with pharmacological treatments 1

Lifestyle Modifications

• Regular exercise
• Stress management techniques
• Sleep hygiene practices
• Dietary changes (reducing caffeine, salt, and alcohol)
• These are recommended for all women with PMDD but may only be sufficient for mild symptoms 6

Calcium Supplementation

• May help reduce physical and emotional symptoms 4
• Can be used as an adjunctive treatment

Treatment Algorithm

1. Initial Assessment:

   • Confirm PMDD diagnosis (symptoms occur only during luteal phase)
   • Rule out other mood disorders that may worsen premenstrually
   • Assess symptom severity and impact on functioning

2. Treatment Selection:

   • For women not requiring contraception: Start with an SSRI (sertraline 50 mg/day or fluoxetine 10 mg/day)
   • For women desiring contraception: Consider drospirenone-containing oral contraceptive (3 mg drospirenone/20 μg ethinyl estradiol) 2

3. Monitoring and Adjustment:

   • Evaluate response after 1-2 menstrual cycles
   • If partial response to SSRI, increase dose
   • If no response after 2 cycles at adequate dose, switch to another SSRI

4. For Non-Responders to First-Line Treatment:

   • If SSRI failed, try drospirenone-containing oral contraceptive (or vice versa)
   • Consider adding CBT to pharmacological treatment 1
   • Evaluate for comorbid conditions that may be affecting treatment response

Important Considerations and Cautions

• SSRI side effects: Nausea, headache, insomnia, sexual dysfunction 3

• Drospirenone contraindications: 2

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

• Hyperkalemia risk with drospirenone: Monitor potassium levels in women taking medications that may increase serum potassium (NSAIDs, potassium-sparing diuretics, ACE inhibitors) 2

• Treatment limitations: Approximately 40% of women with PMDD do not respond adequately to current first-line treatments, highlighting the need for additional therapeutic options 5

Special Populations

• Women with comorbid depression or anxiety: Daily SSRI dosing may be more appropriate than intermittent dosing 4
• Women planning pregnancy: Consider non-pharmacological approaches or treatments that can be safely discontinued before conception

Remember that PMDD significantly impacts quality of life, and effective treatment can substantially improve functioning and well-being. A combination of pharmacological and non-pharmacological approaches often yields the best outcomes.