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, with sertraline 50-150 mg/day being an FDA-approved option that can be administered either daily throughout the menstrual cycle or only during the luteal phase. 1, 2

First-Line Pharmacologic Treatment

• SSRIs have been established as the most effective first-line treatment for PMDD with strong evidence supporting their use 2, 3
• FDA-approved sertraline dosing options include:
  • Daily dosing throughout the menstrual cycle (50-150 mg/day)
  • Luteal phase dosing (50-100 mg/day during the 2 weeks before menses) 1
• For luteal phase dosing with 100 mg/day, a 50 mg/day titration step for three days should be used at the beginning of each luteal phase 1
• Other effective SSRIs for PMDD include:
  • Fluoxetine (10-20 mg/day)
  • Escitalopram (10-20 mg/day)
  • Paroxetine (12.5-25 mg/day) 3, 4

Alternative Pharmacologic Options

• Serotonin and norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine and duloxetine have shown efficacy for PMDD 2
• Anxiolytics such as alprazolam and buspirone may be beneficial for anxiety-predominant PMDD symptoms 2
• Oral contraceptives containing drospirenone (3 mg with ethinyl estradiol 20 mg/day for 24 days, followed by 4 days inactive) have demonstrated effectiveness as first or second-line treatment 3

Dosing Strategies for SSRIs in PMDD

• Several dosing strategies have been studied:
  • Continuous daily dosing (every day of the menstrual cycle)
  • Luteal phase dosing (from ovulation to menses)
  • Symptom-onset dosing (starting when symptoms begin until the first few days of menses) 4, 5
• Unlike treatment for depression, SSRIs for PMDD can be effective when used intermittently during the luteal phase or limited to the duration of symptoms 6
• Symptom-onset dosing with sertraline has shown mixed results, with some symptom scales showing benefit while others do not 5
• Abrupt discontinuation of intermittent SSRI dosing has not been associated with withdrawal symptoms 4, 5

Non-Pharmacologic Treatment Options

• Cognitive Behavioral Therapy (CBT) has shown positive results in reducing the functional impact of PMDD and may be considered as a first-line treatment option 3
• CBT helps reduce:
  • Functional impairment
  • Depressed mood and feelings of hopelessness
  • Anxiety and mood swings
  • Irritability and conflict with others 3
• Calcium supplementation has demonstrated consistent therapeutic benefit among supplements 2
• Other complementary approaches with limited evidence include:
  • Agnus castus (chasteberry)
  • St. John's wort
  • Relaxation therapies 2, 6

Treatment Duration and Monitoring

• The effectiveness of sertraline for PMDD beyond 3 menstrual cycles has not been systematically evaluated in controlled trials 1
• Physicians should periodically re-evaluate the long-term usefulness of the medication for individual patients 1
• Monitor for common side effects of SSRIs including:
  • Gastrointestinal symptoms (nausea, diarrhea)
  • Sleep disturbances
  • Sexual dysfunction
  • Headache 2, 3

Clinical Considerations

• PMDD diagnosis requires symptoms during the luteal phase that remit within a few days following onset of menses 1
• Essential features include markedly depressed mood, anxiety, affective lability, and persistent anger or irritability 1
• Physical symptoms may include breast tenderness, headache, joint/muscle pain, and bloating 1
• Rule out other cyclical mood disorders that may be exacerbated by antidepressant treatment 1
• Consider patient preferences, contraindications, procreation plans, and symptom severity when selecting treatment 3