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

Treatment Options for Premenstrual Dysphoric Disorder (PMDD)

Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for PMDD due to their proven efficacy in reducing symptoms and improving quality of life. 1, 2

First-Line Pharmacological Treatments

SSRIs

• SSRIs demonstrate moderate-certainty evidence for reducing overall premenstrual symptoms in women with PMDD 2
• Continuous administration (daily throughout the month) is more effective than luteal phase dosing (taking medication only during the two weeks before menstruation) 2
• Recommended SSRI options and dosages:
  • Sertraline 50-150 mg/day 3
  • Fluoxetine 10-20 mg/day 3
  • Escitalopram 10-20 mg/day 3
  • Paroxetine 12.5-25 mg/day 3

Oral Contraceptives with Drospirenone

• Drospirenone-containing oral contraceptives are effective for PMDD treatment 3
• Recommended regimen: Drospirenone 3 mg with ethinyl estradiol 20 μg daily for 24 days followed by 4 days of inactive pills 4
• Only use for PMDD if the patient has already decided to use oral contraceptives for birth control 4
• Not effective for premenstrual syndrome (PMS), which is a less severe form of premenstrual symptoms 4

Second-Line Pharmacological Options

Other Antidepressants

• Venlafaxine (SNRI) shows efficacy for PMDD symptoms 1
• Duloxetine (SNRI) has demonstrated usefulness in treating PMDD 1
• Clomipramine (tricyclic antidepressant) can be used as an off-label treatment 2

Anxiolytics

• Alprazolam has shown efficacy for PMDD but should be used cautiously due to addiction potential 1
• Buspirone may be helpful for PMDD symptoms, particularly anxiety 1

Adverse Effects of Pharmacological Treatments

SSRI Side Effects (moderate-certainty evidence)

• Common side effects include:
  • Nausea (NNTH = 7) 2
  • Insomnia 2
  • Sexual dysfunction or decreased libido 2
  • Fatigue or sedation 2
  • Dizziness 2
  • Dry mouth 2

Drospirenone Considerations

• May increase potassium levels; contraindicated in patients with kidney, liver, or adrenal disease 4
• Requires potassium monitoring if used with medications that can increase potassium levels (NSAIDs, potassium-sparing diuretics, ACE inhibitors) 4
• Increased risk of blood clots compared to some other contraceptives 4

Non-Pharmacological Approaches

Cognitive Behavioral Therapy (CBT)

• CBT shows positive results in reducing the functional impact of PMDD 3
• Helps reduce depressed mood, anxiety, irritability, and conflict with others 3
• Could potentially become a first-line treatment with more research evidence 3

Calcium Supplementation

• Among supplements, calcium has shown the most consistent therapeutic benefit 1

Treatment Algorithm

1. Initial Assessment:

   • Confirm PMDD diagnosis with prospective symptom tracking over at least two menstrual cycles 4
   • Distinguish from PMS (less severe) and other mood disorders 3

2. First-line Treatment:

   • For patients not using contraception: Start with an SSRI (preferably continuous dosing) 2
   • For patients desiring contraception: Consider drospirenone-containing oral contraceptive 4, 3

3. If inadequate response to first-line treatment:

   • Switch to a different SSRI 1
   • Consider adding CBT 3
   • Try a different class of antidepressant (SNRI) 1

4. For partial response:

   • Consider augmentation strategies:
     • Combine SSRI with drospirenone-containing oral contraceptive if appropriate 1
     • Add calcium supplementation 1

5. Treatment-resistant cases:

   • Consider anxiolytics for short-term use 1
   • Evaluate for comorbid conditions that may complicate treatment 5

Special Considerations

• Treatment should continue for at least 2-3 menstrual cycles to adequately assess efficacy 2
• Patients with comorbid mood or anxiety disorders may benefit from continuous rather than intermittent SSRI dosing 5
• Monitor for improvement in quality of life and functioning, not just symptom reduction 6
• Discontinuation rates for some treatments can be high (up to 90% at 2 years for drospirenone), often due to cost or disappointment with efficacy 7