What is the recommended treatment for premenstrual dysphoric disorder (PMDD)?

Treatment of Premenstrual Dysphoric Disorder (PMDD)

SSRIs are the first-line pharmacologic treatment for PMDD, with fluoxetine (10-20 mg/day), sertraline (50-150 mg/day), escitalopram (10-20 mg/day), or paroxetine (12.5-25 mg/day) as the recommended agents, which can be dosed either continuously throughout the cycle or intermittently during the luteal phase only. 1, 2

First-Line Treatment Approach

Mild-to-Moderate Symptoms

• Regular aerobic exercise should be initiated as first-line treatment for mild-to-moderate PMDD symptoms before considering pharmacotherapy 3
• NSAIDs can be added for physical pain symptoms (cramping, breast tenderness, headaches) 3

Moderate-to-Severe Symptoms Requiring Pharmacotherapy

SSRI Antidepressants (First-Line Pharmacologic Treatment):

• Fluoxetine is FDA-approved specifically for PMDD treatment (marketed as Sarafem) and has the most extensive evidence base 1, 4
• Dosing flexibility is a unique advantage of SSRIs in PMDD: unlike depression treatment, SSRIs can be effective when used only during the luteal phase (from ovulation to menses) or even symptom-onset dosing, not requiring daily continuous administration 5, 6, 4
• Fluoxetine 20 mg daily (continuous or luteal phase) is effective for both emotional and physical symptoms 4
• Fluoxetine 10 mg luteal phase dosing is effective for emotional symptoms 4
• Alternative SSRIs include sertraline 50-150 mg/day, escitalopram 10-20 mg/day, or paroxetine 12.5-25 mg/day 2
• Critical safety consideration: Monitor for treatment-emergent suicidality, particularly in adolescents and young adults, as SSRIs carry black box warnings for this population 3

Second-Line Treatment Options

When SSRIs are ineffective or not tolerated:

• Other serotonergic antidepressants: venlafaxine or duloxetine 5
• Anxiolytics: alprazolam (use cautiously due to dependence risk) or buspirone 3, 5
• Hormonal ovulation suppression with drospirenone-containing oral contraceptives (ethinyl estradiol 20 mcg + drospirenone 3 mg, 24 days active/4 days inactive) 2

Dosing Strategy Algorithm

Choose between three SSRI dosing approaches based on patient preference and symptom pattern:

1. Luteal phase dosing (approximately 14 days before expected menses until menstruation starts): Lower total drug exposure, no discontinuation effects reported, effective for most patients 6, 4

2. Continuous daily dosing (every day of the menstrual cycle): May be preferred if luteal phase timing is difficult to predict or if patient has comorbid depression 4

3. Symptom-onset dosing: Starting medication only when symptoms begin each cycle 5, 6

Adjunctive and Supportive Treatments

• Calcium supplementation is the only supplement with consistent demonstrated benefit 5, 6
• Spironolactone for bloating and fluid retention symptoms 7
• Cognitive behavioral therapy (CBT) shows effectiveness in reducing functional impairment, depressed mood, anxiety, mood swings, irritability, and conflict 2

Common Pitfalls to Avoid

• Do not confuse PMS with PMDD: PMDD requires specific DSM-5 criteria with marked functional impairment and predominantly affective symptoms 2, 6
• Do not assume daily dosing is necessary: Unlike depression treatment, intermittent luteal-phase SSRI dosing is equally effective for PMDD and reduces total drug exposure 6, 4
• Do not overlook the dependence risk with alprazolam: While effective, benzodiazepines should be used cautiously given addiction potential 3
• Fluoxetine is well-tolerated in PMDD treatment and discontinuation effects have not been reported with intermittent dosing regimens 4