How should I treat a 28‑year‑old woman with premenstrual dysphoric disorder, depression, anxiety and ADHD who has pill aversion and experiences worsening mood swings starting a week before menses that improve after bleeding begins?

Treatment Approach for PMDD with Pill Aversion

Given this patient's pill aversion, I recommend initiating an SSRI using luteal-phase dosing (starting at symptom onset approximately one week before menses and continuing through the first few days of bleeding), specifically sertraline 50-100 mg daily during symptomatic intervals, as this addresses her severe mood symptoms without requiring daily pill-taking year-round. 1, 2, 3

Primary Treatment: Intermittent SSRI Therapy

Why SSRIs Are First-Line for This Patient

• SSRIs specifically target the psychological and behavioral symptoms of PMDD, including the intense mood swings this patient describes, with significantly better efficacy than placebo 1, 4
• Luteal-phase dosing reduces pill burden from 365 pills yearly to approximately 168 pills (14 days × 12 cycles), which is critical given her documented pill aversion 2, 4
• Rapid onset of action occurs within several days of initiation, making intermittent dosing feasible 2
• No discontinuation syndrome has been reported with repeated cyclic stopping, unlike concerns with continuous SSRI use 2, 4

Specific Dosing Protocol

• Sertraline 50-100 mg daily starting at symptom onset (approximately 7 days before expected menses) and continuing through the first 2-3 days of menstrual flow 2, 3, 4
• Symptom-onset dosing (rather than fixed luteal-phase dosing) may improve adherence since she only takes medication when symptomatic 3
• Response rates of 50-67% have been demonstrated with this approach versus 26-52% with placebo 3, 4

Alternative Hormonal Approaches (Given Pill Aversion)

Non-Oral Contraceptive Options

Since this patient has pill aversion but may benefit from ovulation suppression:

• Contraceptive vaginal ring (NuvaRing) releases 15 μg ethinyl estradiol and 120 μg etonogestrel daily with once-monthly insertion, eliminating daily pill-taking 5
• Can be used continuously (skipping the hormone-free week) to eliminate menstrual cycles entirely and prevent PMDD symptoms 5, 6
• Extended or continuous regimens are particularly effective for severe dysmenorrhoria and mood symptoms associated with menstruation 5, 6

Injectable Option (Second-Line)

• DMPA (Depo-Provera) 150 mg intramuscularly every 12 weeks requires only four injections yearly, addressing pill aversion 7, 5
• Amenorrhea occurs in most women after ≥1 year of continuous use, which would eliminate cyclical PMDD symptoms 5
• For breakthrough bleeding, NSAIDs for 5-7 days can be used 5

Addressing Comorbid ADHD

Critical Consideration

• Her untreated ADHD may worsen PMDD symptoms and complicate treatment adherence 8
• Pill aversion must be addressed to enable ADHD treatment, as most stimulant medications require daily dosing
• Consider non-oral ADHD formulations such as methylphenidate transdermal patch or lisdexamfetamine (once-daily capsule that can be opened and mixed with food/liquid)

Treatment Algorithm

Step 1: Initiate Luteal-Phase Sertraline

• Start sertraline 50 mg at symptom onset (approximately 7 days pre-menses) 2, 3
• Continue through first 2-3 days of menstrual flow 2, 4
• Increase to 100 mg if inadequate response after 2-3 cycles 2, 4

Step 2: If Inadequate Response After 3 Cycles

• Add or switch to contraceptive vaginal ring used continuously (no hormone-free intervals) to suppress ovulation entirely 5, 6
• This eliminates the hormonal fluctuations driving PMDD 5

Step 3: If Hormonal Contraception Contraindicated or Refused

• Consider DMPA injections as they require minimal patient adherence (quarterly visits only) 7, 5

Common Pitfalls to Avoid

• Do not prescribe daily oral contraceptives given her documented pill aversion—this will result in non-adherence 5
• Do not use continuous daily SSRI dosing initially—intermittent luteal dosing is equally effective with better tolerability and reduced pill burden 1, 2, 8
• Do not delay ADHD treatment indefinitely—explore non-oral or once-daily formulations that minimize pill burden
• Rule out pregnancy before initiating any hormonal therapy 7, 5
• Counsel about expected side effects (headache, fatigue, sexual dysfunction with SSRIs; breakthrough bleeding with continuous hormonal methods) to prevent premature discontinuation 1, 5

Monitoring

• Assess response after 2-3 treatment cycles using validated tools like the Daily Record of Severity of Problems 3, 4
• No routine follow-up required for contraceptive methods unless side effects occur 5
• Blood pressure monitoring if hormonal contraception is used 5