Treatment of Premenstrual Dysphoric Disorder (PMDD)
Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacologic treatment for PMDD, and they can be administered either continuously throughout the menstrual cycle or intermittently during the luteal phase only, with both regimens showing efficacy. 1, 2, 3, 4, 5
First-Line Treatment: SSRIs
- SSRIs demonstrate rapid onset of symptom improvement in PMDD, typically within days rather than the weeks required for depression treatment. 1, 4
- Continuous daily dosing or luteal-phase-only administration (starting 14 days before expected menses) are both effective strategies. 1, 3
- Symptom-limited dosing (only during symptomatic days) has also shown efficacy, offering flexibility for patients who prefer minimal medication exposure. 1
- Common adverse effects including sexual dysfunction, gastrointestinal symptoms, and sedation may limit tolerability and should be discussed upfront. 4
Second-Line Treatment: Hormonal Suppression
- Combined oral contraceptives (COCs) containing drospirenone are effective for PMDD by suppressing ovulation and hormonal fluctuations. 2, 3
- Continuous or extended-cycle COC regimens (skipping placebo weeks) may provide superior symptom control compared to traditional cyclic dosing. 2
- GnRH agonists with add-back hormone therapy represent a more aggressive ovulation suppression strategy for refractory cases. 2, 3
Non-Pharmacologic Interventions
- Cognitive behavioral therapy (CBT) has demonstrated efficacy for PMDD symptom reduction and should be considered as monotherapy for mild-to-moderate cases or as adjunctive treatment. 2, 4, 5
- Regular aerobic exercise (minimum 150 minutes weekly of moderate-intensity activity) may reduce symptom severity. 6, 2
- Calcium supplementation (1200-1500 mg daily) has evidence supporting symptom improvement. 1, 5
- Vitex agnus castus (chasteberry) shows benefit in some studies and may be considered as adjunctive therapy. 1, 4
Diagnostic Confirmation Before Treatment
- Prospective symptom tracking for at least two consecutive menstrual cycles using a validated tool like the Daily Record of Severity of Problems is essential to confirm the luteal-phase timing of symptoms and distinguish PMDD from other mood disorders. 4, 5
- Symptoms must occur exclusively or predominantly during the luteal phase and resolve within days of menstruation onset to meet diagnostic criteria. 1, 2, 5
Treatment Algorithm
Start with an SSRI (either continuous or luteal-phase dosing based on patient preference and symptom severity). 1, 3, 4, 5
If SSRIs are not tolerated or contraindicated, initiate a drospirenone-containing COC with consideration for extended-cycle dosing. 2, 3
For patients with inadequate response to first-line treatments, consider combination therapy (SSRI plus COC) or referral to gynecology/psychiatry for GnRH agonist therapy. 2, 3
Incorporate CBT and lifestyle modifications (exercise, calcium supplementation) as adjunctive measures regardless of pharmacologic choice. 6, 2, 4, 5
Critical Caveats
- If symptoms persist throughout the entire menstrual cycle rather than resolving after menses, reassess for an underlying mood disorder (major depression, generalized anxiety) that may be premenstrually exacerbated rather than true PMDD. 4, 5
- Unlike depression treatment, SSRIs for PMDD work rapidly (within 1-2 cycles), so lack of response should prompt reconsideration of the diagnosis or switching to hormonal suppression strategies. 1, 3
- Avoid depot medroxyprogesterone acetate as it can worsen mood symptoms and adversely affect bone mineral density in reproductive-age women. 7
- Vitamin D and herbal remedies beyond Vitex agnus castus lack sufficient evidence for routine recommendation, though they are unlikely to cause harm. 5