Treatment of Premenstrual Dysphoric Disorder (PMDD)
Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for Premenstrual Dysphoric Disorder (PMDD), with continuous administration being more effective than luteal phase dosing. 1
First-Line Pharmacological Treatment
SSRIs
- SSRIs have the strongest evidence for PMDD treatment and are recommended as first-line therapy
- Specific SSRI options with proven efficacy:
Administration Options
- Continuous daily dosing (every day of the menstrual cycle) is more effective than luteal phase dosing 1
- Continuous administration showed greater symptom reduction (SMD -0.69) compared to luteal phase administration (SMD -0.39) 1
- Luteal phase dosing (from ovulation to menses) is still effective and may be considered for patients concerned about side effects 4
Second-Line Pharmacological Treatment
Hormonal Therapy
- Drospirenone-containing oral contraceptives are FDA-approved for PMDD treatment 5
- Specifically, drospirenone 3 mg with ethinyl estradiol 20 μg daily for 24 days followed by 4 days of inactive pills 5, 3
- In clinical trials, women taking drospirenone and ethinyl estradiol had significantly greater improvement in Daily Record of Severity of Problems scores compared to placebo (37.5 points vs. 30.0 points) 5
Non-Pharmacological Approaches
Cognitive Behavioral Therapy (CBT)
- CBT shows effectiveness for PMDD, particularly for:
- Reducing functional impairment
- Improving depressed mood, anxiety, and irritability
- Decreasing conflict with others
- Reducing the impact of premenstrual symptoms on daily life 3
Treatment Algorithm
Diagnosis confirmation:
- Ensure proper diagnosis using DSM-5 criteria
- Differentiate PMDD from premenstrual syndrome (PMS) and other mood disorders
- Require prospective symptom tracking for at least two menstrual cycles
Initial treatment:
- Start with an SSRI (sertraline, fluoxetine, escitalopram, or paroxetine)
- Begin with continuous daily dosing for maximum effectiveness
- Consider starting at lower doses and titrating up if needed
If inadequate response after 2-3 cycles:
- Increase SSRI dose to maximum recommended
- If still inadequate, switch to a different SSRI
If SSRIs are contraindicated or not tolerated:
- Consider drospirenone-containing oral contraceptives (if contraception is also desired)
- Add CBT as adjunctive treatment
Important Considerations and Potential Side Effects
SSRI Side Effects
- Common adverse effects include:
- Nausea (3.3 times more likely than placebo)
- Insomnia (1.99 times more likely)
- Sexual dysfunction (2.32 times more likely)
- Fatigue (1.52 times more likely)
- Dizziness (1.96 times more likely) 1
Drospirenone Considerations
- Drospirenone may increase potassium levels
- Avoid in patients with kidney, liver, or adrenal disease
- Monitor potassium levels in patients on medications that may increase potassium:
- NSAIDs (when taken long-term)
- Potassium-sparing diuretics
- ACE inhibitors
- Angiotensin-II receptor antagonists 5
Clinical Pearls and Pitfalls
- Important distinction: PMDD is different from PMS, requiring more severe mood symptoms that significantly interfere with functioning 3
- Timing matters: PMDD symptoms occur regularly before menstruation and resolve within a few days after the period starts 5
- Avoid misdiagnosis: Ensure symptoms are not just an exacerbation of another disorder
- Treatment duration: Unlike depression treatment, SSRIs for PMDD can be effective when used cyclically or intermittently 6
- Monitoring: Track symptom improvement using standardized tools like the Daily Record of Severity of Problems scale 5
By following this evidence-based approach, most women with PMDD can achieve significant symptom relief and improved quality of life.