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 20 mg/day being FDA-approved and demonstrably effective for both emotional and physical symptoms. 1, 2

First-Line Pharmacologic Treatment: SSRIs

SSRIs are the cornerstone of PMDD treatment, with robust evidence supporting their efficacy:

• Fluoxetine 20 mg/day is FDA-approved specifically for PMDD and reduces overall premenstrual symptoms with moderate-certainty evidence 1, 2
• Alternative SSRIs with demonstrated efficacy include sertraline (50-150 mg/d), escitalopram (10-20 mg/d), and paroxetine (12.5-25 mg/d) 3
• SSRIs reduce premenstrual symptoms with a standardized mean difference of -0.57, representing clinically meaningful improvement 2

Dosing Strategy: Continuous vs. Luteal Phase

Continuous daily dosing is more effective than luteal-phase-only administration:

• Continuous administration shows greater symptom reduction (SMD -0.69) compared to luteal phase dosing (SMD -0.39), with statistically significant superiority 2
• However, luteal phase dosing remains a viable option for women preferring intermittent treatment, as fluoxetine 20 mg during the luteal phase (ovulation to menses) demonstrates efficacy without discontinuation effects 4, 5
• Intermittent dosing may reduce cumulative adverse event exposure while maintaining therapeutic benefit 4

Non-Pharmacologic First-Line Options

Regular aerobic exercise is recommended as a first-line treatment for mild-to-moderate PMDD symptoms by the American College of Sports Medicine 6

Cognitive Behavioral Therapy (CBT) shows positive results in reducing:

• Functional impairment, depressed mood, anxiety, mood swings, irritability 3
• Intensity of symptoms and their impact on daily life 3
• CBT can be considered first-line or adjunctive therapy, though more comparative research is needed 3

Adjunctive Treatments for Specific Symptoms

For physical pain symptoms (cramping, breast tenderness, headache):

• NSAIDs are recommended by the American Academy of Family Physicians 6

For severe anxiety symptoms:

• Alprazolam may be used cautiously due to dependence risk, per American College of Physicians recommendations 6
• This should be reserved for refractory cases given benzodiazepine addiction potential 6

Common Adverse Effects of SSRIs

Patients should be counseled about expected side effects, which are generally transient:

• Most common: Nausea (OR 3.30), asthenia/decreased energy (OR 3.28), somnolence/decreased concentration (OR 3.26) 2
• Sexual dysfunction occurs with OR 2.32, which may be particularly relevant for reproductive-age women 2
• Other frequent effects: Insomnia (OR 1.99), dizziness (OR 1.96), dry mouth (OR 2.70), sweating (OR 2.17) 2
• These adverse events rarely cause discontinuation and are consistent with the known SSRI safety profile 5

Critical Safety Monitoring

Monitor for treatment-emergent suicidality, particularly in adolescents and young adults, as SSRIs carry black box warnings for this population per the American College of Obstetricians and Gynecologists 6

Treatment Algorithm

1. Confirm diagnosis with prospective daily symptom charting over 2 menstrual cycles showing luteal phase symptoms with follicular phase remission
2. Initiate SSRI therapy (fluoxetine 20 mg/day continuously as first choice) 1, 2
3. Add aerobic exercise as adjunctive therapy for all patients with mild-to-moderate symptoms 6
4. Consider CBT as monotherapy for mild cases or adjunctive therapy for moderate-to-severe cases 3
5. Add NSAIDs for prominent physical symptoms (dysmenorrhea, mastalgia) 6
6. If inadequate response after 2-3 cycles: Increase SSRI dose or switch to alternative SSRI 3
7. For refractory cases: Consider hormonal contraceptives with drospirenone as second-line option 3

Important Caveats

• Unlike major depressive disorder, SSRIs work rapidly in PMDD, often within the first treatment cycle, and do not require 4-6 weeks for efficacy 4
• Luteal phase dosing eliminates the need for continuous medication exposure but requires patient adherence to cycle-timed administration 4
• The evidence base consists primarily of pharmaceutical company-funded trials, which should temper interpretation, though effect sizes remain clinically meaningful 2