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, 3

First-Line Pharmacological Treatment

• SSRIs have demonstrated significant effectiveness in reducing overall premenstrual symptoms in women with PMDD (moderate-certainty evidence) 3
• Recommended SSRI options include:
  • Sertraline (50-150 mg/day)
  • Fluoxetine (10-20 mg/day)
  • Escitalopram (10-20 mg/day)
  • Paroxetine (12.5-25 mg/day) 1
• SSRIs can be administered in three different dosing regimens:
  • Continuous (daily throughout the month)
  • Luteal phase only (from ovulation to menstruation)
  • Semi-intermittent (with dosage increases during the luteal phase) 4
• Continuous SSRI administration appears more effective than luteal phase dosing for symptom reduction 3

Second-Line Pharmacological Options

• Drospirenone-containing oral contraceptives (3 mg drospirenone with 20 μg ethinyl estradiol in a 24/4 regimen) have shown efficacy for PMDD treatment 5
• Other antidepressants that may be effective include:
  • Venlafaxine (SNRI)
  • Duloxetine (SNRI)
  • Clomipramine (TCA) 2
• Anxiolytics such as alprazolam and buspirone have demonstrated some efficacy for PMDD symptoms 2

Common Side Effects of SSRIs

• Nausea (most common side effect) 3
• Insomnia 3
• Sexual dysfunction or decreased libido 3
• Fatigue or sedation 3
• Dizziness or vertigo 3
• Headache 3
• Dry mouth 3

Non-Pharmacological Approaches

• Cognitive Behavioral Therapy (CBT) has shown positive results in reducing the functional impact of PMDD symptoms 1
• CBT can help reduce:
  • Functional impairment
  • Depressed mood and feelings of hopelessness
  • Anxiety and mood swings
  • Irritability and conflict with others
  • Impact of symptoms on daily life 1
• Calcium supplementation has demonstrated consistent therapeutic benefit among supplements 2

Treatment Algorithm

1. Initial Assessment:

   • Confirm PMDD diagnosis using prospective symptom tracking over at least two menstrual cycles 1
   • Rule out other psychiatric disorders that may be exacerbated premenstrually 4

2. First-Line Treatment:

   • Begin with an SSRI (sertraline, fluoxetine, escitalopram, or paroxetine) 1, 3
   • Start with continuous dosing for maximum effectiveness 3
   • Allow 1-2 menstrual cycles to assess response 4

3. If inadequate response to first SSRI:

   • Switch to a different SSRI 2
   • Consider changing dosing strategy (continuous vs. luteal phase) 4

4. Second-Line Options (if SSRIs are ineffective or not tolerated):

   • Drospirenone-containing oral contraceptives (if contraception is also desired) 5
   • Other antidepressants (venlafaxine, duloxetine) 2
   • Add CBT to pharmacological treatment 1

5. Adjunctive Treatments:

   • Calcium supplementation 2
   • Lifestyle modifications (regular exercise, stress management) 1

Special Considerations

• For patients with comorbid depression or anxiety disorders, continuous SSRI treatment is preferred 4
• For patients with primarily physical symptoms, luteal phase dosing may be sufficient 4
• Drospirenone-containing contraceptives should be avoided in women with conditions that predispose to hyperkalemia 5
• Treatment should be reassessed periodically, as some women may experience symptom improvement over time 1

Monitoring and Follow-up

• Track symptoms using daily rating scales to assess treatment effectiveness 1
• Monitor for side effects, particularly during the first month of treatment 3
• For patients on drospirenone-containing contraceptives, consider potassium monitoring if taking other medications that may increase potassium levels 5

The evidence strongly supports SSRIs as the most effective treatment for PMDD, with drospirenone-containing oral contraceptives as an alternative option for women who also desire contraception. CBT provides additional benefits and should be considered as part of a comprehensive treatment plan.