What medications are used to treat Premenstrual Dysphoric Disorder (PMDD)?

Medications for Premenstrual Dysphoric Disorder (PMDD)

Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line treatment for PMDD, with continuous dosing being more effective than luteal phase dosing for reducing symptoms and improving quality of life. 1

First-Line Medications

SSRIs have demonstrated the strongest evidence for PMDD treatment:

• Sertraline (Zoloft): 50-150 mg/day 2
• Fluoxetine (Prozac): 10-20 mg/day 2
• Escitalopram (Lexapro): 10-20 mg/day 2
• Paroxetine (Paxil): 12.5-25 mg/day 2
• Citalopram (Celexa): Standard dosing (evidence supports efficacy) 3

Dosing Strategies for SSRIs

1. Continuous dosing (daily throughout the month) - most effective approach 1
2. Luteal phase dosing (from ovulation to menses) - less effective but still beneficial 1
3. Symptom-onset dosing - taking medication only when symptoms begin 3

Second-Line Medications

When SSRIs are ineffective or not tolerated:

Other Antidepressants

• Venlafaxine (SNRI) - effective for PMDD with anxiety symptoms 4
• Duloxetine (SNRI) - shown efficacy for PMDD 5

Anxiolytics

• Alprazolam - short-term use for severe anxiety symptoms 5
• Buspirone - may help with irritability and anxiety 5

Hormonal Options

• Drospirenone-containing oral contraceptives (with ethinyl estradiol) - FDA-approved for PMDD 6
  • Drospirenone 3 mg with ethinyl estradiol 20 μg in a 24/4 regimen 6
  • Should only be used if patient also desires contraception 6

Medication Selection Algorithm

1. Start with an SSRI (sertraline or fluoxetine preferred due to extensive evidence)

   • Begin with continuous dosing
   • If side effects are problematic, try luteal phase dosing

2. If inadequate response after 2-3 cycles:

   • Try a different SSRI
   • Consider dose adjustment

3. If SSRIs fail or are contraindicated:

   • Try SNRIs (venlafaxine or duloxetine)
   • Consider drospirenone-containing oral contraceptives if contraception is also desired

4. For specific symptom management:

   • Add anxiolytics for severe anxiety (short-term use only)

Important Considerations

Efficacy Monitoring

• Evaluate response after 1-2 menstrual cycles
• Use symptom tracking to assess improvement

Common Side Effects of SSRIs

• Nausea (NNTH: approximately 10) 1
• Insomnia (NNTH: approximately 17) 1
• Sexual dysfunction (NNTH: approximately 15) 1
• Fatigue/sedation (NNTH: approximately 30) 1

Cautions and Contraindications

• Avoid SSRIs in patients with bipolar disorder (may trigger mania)
• Use caution with drospirenone in patients with conditions that predispose to hyperkalemia 6
• Monitor potassium levels when using drospirenone with medications that may increase potassium (NSAIDs, ACE inhibitors, potassium-sparing diuretics) 6

Clinical Pearls

• PMDD affects 3-8% of menstruating women and represents the severe end of premenstrual disorders 7
• Unlike depression treatment, SSRIs for PMDD can be effective with intermittent dosing 7
• Continuous dosing of SSRIs shows greater efficacy than luteal phase dosing (SMD -0.69 vs -0.39) 1
• Drospirenone-containing oral contraceptives should only be used for PMDD if the patient has already decided to use contraception 6
• Response to SSRI treatment is typically more rapid for PMDD than for major depression 3

By following this evidence-based approach to medication selection for PMDD, clinicians can help patients achieve significant symptom relief and improved quality of life.