What is the treatment for Premenstrual Dysphoric Disorder (PMDD) versus Premenstrual Syndrome (PMS)?

Treatment of PMDD vs PMS

For PMDD, start with SSRIs as first-line therapy (either continuous or luteal-phase dosing), while for milder PMS, begin with lifestyle modifications and calcium supplementation before escalating to pharmacologic treatment.

Distinguishing PMDD from PMS

The key difference lies in severity and functional impairment:

• PMS affects 20-40% of menstruating women with moderate physical and psychological symptoms (fatigue, irritability, bloating, breast tenderness) that cause some discomfort but limited functional impairment 1
• PMDD affects only 3-8% of women and represents a severe, disabling form classified as a depressive disorder in DSM-5, with marked functional impairment in work, relationships, or social activities 2, 3, 1

Both conditions occur during the luteal phase (last 2 weeks before menses) and resolve with menstruation onset 4, 3.

Treatment Algorithm for PMDD

First-Line: SSRIs

SSRIs are the established first-line treatment for PMDD and reduce overall premenstrual symptoms significantly 4, 2.

Dosing strategies:

• Continuous dosing (daily throughout the month) is more effective than luteal-phase-only dosing 2
• Luteal-phase dosing (14 days before expected menses) remains effective and allows women to take medication only half the month, reducing exposure and potentially improving adherence 5
• Both fluoxetine and paroxetine are FDA-approved for PMDD 6

Efficacy: SSRIs particularly improve psychological and behavioral symptoms, with moderate-certainty evidence showing significant symptom reduction 2.

Common Adverse Effects to Counsel Patients About

SSRIs in PMDD treatment cause predictable side effects 2:

• Nausea (most common)
• Sexual dysfunction or decreased libido
• Insomnia
• Fatigue/sedation
• Dizziness
• Dry mouth
• Asthenia (decreased energy)

Treatment Algorithm for PMS

First-Line: Non-Pharmacologic Interventions

For milder PMS without severe functional impairment:

• Calcium supplementation (1000-1200 mg daily) has demonstrated consistent therapeutic benefit and should be tried first 4
• Lifestyle modifications: Regular exercise, dietary changes (reducing caffeine, salt, alcohol), stress management 1
• Cognitive behavioral therapy (CBT) may provide additional benefit 1

Second-Line: Pharmacologic Treatment

If non-pharmacologic measures fail:

• SSRIs can be used for severe PMS using the same approach as PMDD 4, 2
• Oral contraceptive pills may help by suppressing ovulation and hormonal fluctuations 1

Alternative Pharmacologic Options (When SSRIs Fail or Are Contraindicated)

For both PMDD and severe PMS:

• Other antidepressants: Venlafaxine, duloxetine have demonstrated efficacy 4
• Anxiolytics: Alprazolam, buspirone may be useful 4
• Hormonal suppression: GnRH agonists, non-contraceptive estrogen formulations (though limited by side effects and cost) 1

Clinical Pitfalls to Avoid

• Don't diagnose without prospective symptom tracking: Both PMS and PMDD require prospective daily symptom charting for at least 2 consecutive menstrual cycles to confirm luteal-phase timing and symptom resolution with menses 3, 1
• Rule out premenstrual exacerbation of underlying mood disorders: Some women have depression or anxiety that worsens premenstrually rather than true PMDD—these require different treatment approaches 3
• Don't overlook the severity distinction: PMDD requires more aggressive initial treatment than PMS; starting with lifestyle changes alone in PMDD delays effective treatment 4, 3