Treatment of Premenstrual Disorder
Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacologic treatment for premenstrual dysphoric disorder (PMDD) and moderate-to-severe premenstrual syndrome (PMS), with fluoxetine being FDA-approved specifically for this indication. 1, 2, 3
Initial Assessment and Diagnosis
Before initiating treatment, confirm the diagnosis by documenting symptom timing:
- True premenstrual disorders occur only during the luteal phase (7-14 days before menses) with complete resolution within 1-2 days after menstruation begins 4
- Use the Daily Record of Severity of Problems for prospective symptom tracking over at least two menstrual cycles 5
- Rule out underlying psychiatric conditions that may worsen premenstrually but persist throughout the cycle 4
Treatment Algorithm
Step 1: Lifestyle Modifications (Mild Symptoms)
For women with mild PMS symptoms, begin with non-pharmacologic interventions:
- Regular aerobic exercise, stress management techniques, and dietary modifications (reducing caffeine, salt, and refined sugars) 4, 3
- Calcium supplementation (1200 mg daily) is the only supplement with consistent evidence of therapeutic benefit 2
- Cognitive-behavioral therapy can address maladaptive thought patterns and coping strategies 5, 4
Step 2: First-Line Pharmacologic Treatment (Moderate-to-Severe Symptoms/PMDD)
SSRIs are superior to other treatments for both emotional and physical symptoms:
- Fluoxetine is FDA-approved for PMDD and can be dosed continuously (20 mg daily) or intermittently during the luteal phase only 1, 3
- Other effective SSRIs include sertraline and citalopram, which demonstrate efficacy with luteal-phase dosing 3
- Luteal-phase dosing (starting 14 days before expected menses) reduces cost and long-term side effects while maintaining efficacy 3
- Symptom improvement typically occurs within the first treatment cycle, unlike depression treatment which requires 4-6 weeks 2
Step 3: Alternative SSRI or Second-Line Options
If the initial SSRI fails after 2-3 menstrual cycles:
- Switch to a different SSRI before abandoning this drug class 3
- Consider venlafaxine or duloxetine as alternative serotonergic agents 2
- Low-dose alprazolam (0.25 mg 2-3 times daily) during the luteal phase only is a second-line option, though carries risk of dependence 3
Step 4: Hormonal Suppression (Refractory Cases)
For women who fail multiple serotonergic trials:
- Combined oral contraceptives containing ethinyl estradiol with drospirenone or other progestogens primarily improve physical symptoms rather than mood symptoms 6, 5
- COCs may be considered for women requiring both contraception and PMS treatment 6
- GnRH agonists or danazol achieve ovulation suppression but are limited to short-term use (3-6 months) due to significant side effects and cost 3
Critical Considerations
Distinguish between treatment goals: SSRIs address both mood and physical symptoms effectively, while hormonal contraceptives predominantly target physical manifestations 5. This distinction should guide initial treatment selection based on the patient's primary symptom burden.
Dosing strategy matters: Luteal-phase dosing of SSRIs reduces the risk of discontinuation syndrome, long-term side effects, and overall cost compared to continuous dosing, while maintaining equivalent efficacy 3. Start medication 14 days before expected menses and discontinue 1-2 days after menstruation begins.
Avoid common pitfalls: Do not diagnose PMS/PMDD based on retrospective recall alone, as this leads to overdiagnosis 5. Prospective daily symptom charting is essential. Additionally, buspirone requires continuous dosing and takes longer to achieve effect compared to SSRIs, making it less practical for intermittent luteal-phase treatment 2.
Herbal supplements lack robust evidence: While chasteberry and other herbal remedies are commonly used, only calcium supplementation has demonstrated consistent benefit in controlled trials 2. Other supplements should not replace evidence-based treatments.