What are the treatment options for a patient with Premenstrual Dysphoric Disorder (PMDD)?

Treatment Options for Premenstrual Dysphoric Disorder (PMDD)

Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for PMDD, with fluoxetine (10-20 mg/d), sertraline (50-150 mg/d), escitalopram (10-20 mg/d), or paroxetine (12.5-25 mg/d) as the most effective options. 1, 2, 3

First-Line Pharmacologic Treatment: SSRIs

SSRIs demonstrate superior efficacy for both mood and physical symptoms of PMDD and can be dosed either continuously or intermittently during the luteal phase only. 1, 4, 3

Dosing Strategies

• Continuous daily dosing throughout the menstrual cycle is effective and well-established 1, 3
• Luteal phase-only dosing (starting 14 days before expected menses) is equally effective and may reduce side effects 1, 3
• Symptom-onset dosing (starting when symptoms begin) can also be effective, though more research is needed to compare these approaches directly 1

Specific SSRI Options

• Fluoxetine 10-20 mg/d is FDA-approved for PMDD (marketed as Sarafem) 5, 2
• Sertraline 50-150 mg/d 1, 2
• Escitalopram 10-20 mg/d 1, 2
• Paroxetine 12.5-25 mg/d 1, 2

Second-Line Pharmacologic Options

Other Antidepressants

• Venlafaxine (SNRI) has demonstrated efficacy for PMDD when SSRIs are not tolerated or ineffective 1
• Duloxetine (SNRI) may be considered as an alternative 1

Anxiolytics

• Alprazolam can be used for severe anxiety symptoms, though carries risk of dependence 1
• Buspirone may help with anxiety-related PMDD symptoms 1

Hormonal Treatments

• Drospirenone-containing oral contraceptives (3 mg drospirenone + 20 mcg ethinyl estradiol, 24 days active/4 days inactive) are effective as first- or second-line treatment 2
• GnRH agonists can suppress ovulation but are limited by side effects and cost 1, 6

Non-Pharmacologic Treatments

Cognitive Behavioral Therapy (CBT)

CBT effectively reduces functional impairment, depressed mood, anxiety, mood swings, irritability, and conflict in PMDD patients. 2

• CBT targets the psychological and behavioral components of PMDD 2
• Can be used as monotherapy for mild-to-moderate PMDD or combined with SSRIs for severe cases 2
• Reduces symptom severity and improves daily functioning 2

Lifestyle Modifications

Implement these as foundational interventions for all PMDD patients: 6, 4

• Regular aerobic exercise (at least 30 minutes, 3-5 times weekly) 6
• Stress management techniques including relaxation strategies 6
• Dietary modifications: reduce caffeine, alcohol, salt, and refined sugars 6

Supplements

• Calcium supplementation (1200 mg/d) has consistent evidence for reducing PMDD symptoms 1
• Chasteberry (Vitex agnus castus) may provide modest benefit 4, 3
• St. John's wort shows some efficacy but has significant drug interactions 3

Treatment Algorithm

Step 1: Initial Assessment and Diagnosis

• Confirm diagnosis using Daily Record of Severity of Problems (DRSP) for at least 2 consecutive menstrual cycles 4
• Verify symptoms occur only during luteal phase (7-14 days before menses) and resolve within 1-2 days after menses onset 6, 4
• Rule out premenstrual exacerbation of underlying mood disorders 3

Step 2: First-Line Treatment Selection

Start with an SSRI (fluoxetine 10-20 mg/d, sertraline 50-150 mg/d, escitalopram 10-20 mg/d, or paroxetine 12.5-25 mg/d) 1, 2

• Choose luteal phase dosing if patient prefers to minimize medication exposure or has concerns about side effects 1, 3
• Choose continuous dosing if patient has comorbid depression or anxiety, or if luteal phase dosing proves difficult to manage 1, 3
• Add lifestyle modifications and calcium supplementation (1200 mg/d) to all patients 1, 6

Step 3: If Inadequate Response After 2-3 Cycles

• Switch to a different SSRI if partial response or intolerable side effects 1
• Increase dose to maximum recommended range if partial response with good tolerability 1
• Add CBT if predominantly psychological symptoms persist 2

Step 4: If SSRIs Fail or Are Contraindicated

• Try drospirenone-containing oral contraceptive (3 mg/20 mcg, 24/4 regimen) 2
• Consider venlafaxine or duloxetine as alternative antidepressants 1
• Add anxiolytic (buspirone or alprazolam) for severe anxiety symptoms 1

Step 5: Refractory Cases

• Refer to psychiatry or gynecology for consideration of GnRH agonists or other hormonal suppression 1, 6
• Intensify CBT with specialized PMDD-focused therapy 2

Common Pitfalls and Caveats

• Do not diagnose PMDD without prospective symptom tracking for at least 2 cycles, as retrospective recall is unreliable 4
• SSRIs work faster in PMDD than in depression, often showing benefit within days rather than weeks 3
• Sexual dysfunction is common with SSRIs (>60% experience side effects), which may affect treatment adherence 7
• Distinguish PMDD from premenstrual exacerbation of major depressive disorder or anxiety disorders, which require continuous treatment 3
• Combined oral contraceptives primarily improve physical symptoms rather than mood symptoms, unlike SSRIs which address both 4
• Calcium supplementation is the only supplement with consistent evidence, while other supplements have limited or conflicting data 1