What's the best treatment for Premenstrual Dysphoric Disorder (PMDD)?

Best Combined Oral Contraceptive for PMDD Treatment

For PMDD treatment, drospirenone 3 mg combined with ethinyl estradiol 20 mcg (24 days active/4 days inactive) is the only FDA-approved oral contraceptive specifically indicated for PMDD and should be your first-line hormonal option if the patient desires contraception. 1

When to Choose COCs for PMDD

Use drospirenone/ethinyl estradiol for PMDD only if:

• The patient has already decided to use oral contraceptives for birth control 1
• The patient has been formally diagnosed with PMDD by a healthcare provider (not just PMS) 1
• The patient does not have kidney, liver, or adrenal disease (drospirenone increases potassium and could cause serious cardiac complications) 1
• The patient is not on chronic daily therapy with NSAIDs, potassium-sparing diuretics, ACE inhibitors, ARBs, or aldosterone antagonists 1

Evidence for Drospirenone/Ethinyl Estradiol

Clinical trial data demonstrates significant efficacy:

• In two multicenter, double-blind, placebo-controlled trials with 384 and 64 women respectively, drospirenone/ethinyl estradiol showed statistically significant improvement in Daily Record of Severity of Problems scores 1
• The primary study showed an average decrease of 37.5 points versus 30.0 points with placebo over 3 menstrual cycles 1
• This formulation is recognized as either first-line or second-line treatment depending on patient contraceptive needs 2

First-Line Treatment Hierarchy for PMDD

SSRIs remain the established first-line pharmacologic treatment for PMDD regardless of contraceptive needs:

• Sertraline 50-150 mg/day, fluoxetine 10-20 mg/day, escitalopram 10-20 mg/day, or paroxetine 12.5-25 mg/day 2, 3, 4
• These can be dosed continuously or only during the luteal phase with similar efficacy 3, 4, 5
• SSRIs reduce emotional, cognitive-behavioral, and physical symptoms while improving psychosocial functioning 4

Drospirenone/ethinyl estradiol becomes first-line when:

• The patient specifically wants contraception as their primary goal 1, 2
• The patient prefers hormonal management over antidepressants 2

Critical Safety Monitoring

Before prescribing drospirenone/ethinyl estradiol, verify:

• Baseline serum potassium level (check again during first month of treatment) 1
• No contraindications to combined hormonal contraceptives (smoking >35 years old, VTE history, cardiovascular disease) 1
• Adequate renal, hepatic, and adrenal function 1

Alternative Hormonal Approaches

If drospirenone is contraindicated:

• Other anovulatory treatments have shown efficacy but are limited by side effects and cost 3, 6
• GnRH agonists or danazol may be considered only when other treatments fail, but serious side effects and cost limit use to short periods 4

Combination Strategy

If PMDD symptoms persist on drospirenone/ethinyl estradiol alone:

• Consider adding cognitive behavioral therapy (CBT), which reduces functional impairment, depressed mood, anxiety, mood swings, irritability, and symptom handicap 2
• CBT shows positive results in reducing the functional impact of PMDD and may become first-line as more evidence accumulates 2

Common Pitfalls to Avoid

• Do not prescribe drospirenone/ethinyl estradiol solely for PMDD treatment if the patient does not want contraception - SSRIs are more appropriate 1
• Do not confuse PMS with PMDD - they have different symptom severity, functional impairment, and potentially different etiologies; PMDD requires formal diagnosis 1, 2
• Do not overlook potassium monitoring - failure to check potassium levels in at-risk patients can lead to serious cardiac complications 1
• Do not use other COC formulations expecting similar PMDD efficacy - only drospirenone 3 mg/ethinyl estradiol 20 mcg has FDA approval and clinical trial evidence for PMDD 1