What are the hormone-free treatment options for Premenstrual Dysphoric Disorder (PMDD)?

Hormone-Free Treatment for PMDD

Selective serotonin reuptake inhibitors (SSRIs) are the established first-line hormone-free treatment for PMDD, with sertraline being FDA-approved and demonstrating significant efficacy in reducing both emotional and physical symptoms. 1

First-Line Pharmacologic Treatment: SSRIs

SSRIs should be initiated as the primary hormone-free treatment for PMDD, with the following FDA-approved and evidence-based options 1, 2:

Dosing Strategies

SSRIs can be administered in two effective regimens 1, 2, 3:

• Continuous daily dosing: Sertraline 50-150 mg/day, fluoxetine 10-20 mg/day, escitalopram 10-20 mg/day, or paroxetine 12.5-25 mg/day throughout the entire menstrual cycle 2, 4
• Luteal phase dosing: Administered only during the 2 weeks prior to menses onset, then discontinued 1, 3

Sertraline is specifically FDA-approved for PMDD and demonstrated significantly greater efficacy than placebo on the Daily Record of Severity of Problems (DRSP) total score, Hamilton Depression Rating Scale, and Clinical Global Impression scores in controlled trials 1.

Key Advantages of SSRIs for PMDD

Unlike depression treatment, SSRIs for PMDD 3, 5:

• Work rapidly, often within the first cycle
• Require lower doses than those used for depression
• Can be effective with intermittent (luteal phase only) dosing without discontinuation effects
• Address both emotional symptoms (depressed mood, anxiety, irritability) and physical symptoms (bloating, breast tenderness, pain)

Alternative Pharmacologic Options

If SSRIs are contraindicated or ineffective 2, 3:

• Venlafaxine (SNRI): Demonstrated efficacy for PMDD symptoms 2
• Duloxetine (SNRI): Useful alternative serotonergic agent 2
• Buspirone: Anxiolytic option for predominant anxiety symptoms 2
• Alprazolam: May be considered but carries dependency risk 2

Evidence-Based Non-Pharmacologic Treatments

Calcium Supplementation

Calcium supplementation is the only non-prescription treatment with consistent demonstrated therapeutic benefit for PMDD 2, 3. This represents the most reliable over-the-counter hormone-free option.

Cognitive Behavioral Therapy (CBT)

CBT should be considered as an adjunctive or alternative treatment, particularly for patients preferring non-pharmacologic approaches 2, 4, 3. CBT has shown effectiveness in reducing:

• Functional impairment
• Depressed mood and hopelessness
• Anxiety and mood swings
• Irritability and interpersonal conflict
• Impact of premenstrual symptoms on daily life 4

Other Complementary Options

The following have limited but suggestive evidence 2, 3:

• Agnus castus (chasteberry): May be useful as adjunct
• Hypericum perforatum (St. John's wort): Some supportive data
• Omega-3 fatty acids: Lacks strong PMDD-specific evidence and is not recommended as standalone treatment 6

Clinical Approach Algorithm

1. Confirm PMDD diagnosis using DSM-5 criteria with prospective daily symptom charting for at least 2 menstrual cycles 1

2. Initiate SSRI therapy as first-line treatment 2, 4:

   • Start with sertraline 50 mg/day (FDA-approved) or fluoxetine 10-20 mg/day
   • Choose between continuous or luteal phase dosing based on patient preference
   • Titrate dose based on response (sertraline up to 150 mg/day, fluoxetine up to 20 mg/day)

3. Add calcium supplementation as adjunctive therapy 2, 3

4. Consider CBT for patients preferring psychotherapy or as augmentation to pharmacotherapy 4, 3

5. If inadequate response after 2-3 cycles, consider:

   • Switching to alternative SSRI
   • Trying SNRI (venlafaxine or duloxetine)
   • Augmenting with buspirone for anxiety symptoms 2

Important Clinical Caveats

Approximately 40% of women with PMDD do not respond adequately to SSRIs 7. When initial SSRI treatment fails, systematic trials of alternative serotonergic agents should be pursued before concluding treatment failure 2, 7.

Distinguish PMDD from premenstrual exacerbation of underlying mood disorders, as the latter requires different treatment approaches targeting the primary psychiatric condition 2, 3.

Luteal phase dosing offers advantages including lower total medication exposure, reduced side effects, and no discontinuation syndrome, while maintaining comparable efficacy to continuous dosing 3, 5.