Management of Premenstrual Dysphoric Disorder (PMDD)
Author: Vicky Mendiratta, MD
Mentor: Seine Chiang, MD
Editor: Julie DeCesare, MD
Premenstrual dysphoric disorder (PMDD) is a severe form of Premenstrual Syndrome (PMS) associated with marked behavioral, emotional, and potentially physical symptoms. According to the American Psychiatric Association Diagnostic and Statistical Manual, fifth edition, PMDD differs from PMS in the severity of symptoms, requiring the presence of at least one severe affective symptom such as markedly depressed mood or hopelessness, anxiety, affective lability, or persistent anger which resolves around the onset of menses. The diagnosis of PMDD is diagnosed using a validated tool (e.g. Daily Record of Severity of Problems) that demonstrates a history of two consecutive menstrual cycles demonstrating luteal phase symptoms and the exclusion of other medical conditions. The differential diagnoses include primary mood or anxiety disorders, thyroid dysfunction, substance abuse and the menopausal transition. It has been estimated that 15% to 20% of women of reproductive age have PMS with significantly impaired functioning, and a further 3% to 8% have PMDD.
Treatment of PMDD includes lifestyle modifications, cognitive therapy, pharmacologic agents, and rarely surgery.
Patients with PMDD should engage in aerobic exercise most days of the week. Dietary changes, including reduction of sugar, salt, red meat, caffeine, and alcohol may reduce symptoms.
Calcium and Vitamin B6 having evidence of benefit.
Adjunct/alternative treatments have been studied without sufficient evidence to recommend routinely. These therapies include massage, biofeedback, yoga, chiropractic manipulation, evening primrose oil, and Chinese herbal medicines. Studies have shown that bright light therapy, stress reduction, and adequate sleep are reasonable recommendations. Low quality evidence suggests acupuncture may reduce symptoms of PMDD when compared to placebo therapy.
Cognitive behavioral therapy can effective. Group psychoeducation and relaxation therapy may benefit patients with significant stress or anxiety components.
Pharmacologic Therapy/Medications
Psychoactive therapy:
Selective Serotonin Reuptake Inhibitors (SSRIs) have been shown to be extremely effective and are a first-line treatment for PMDD. SSRIs result in a favorable response in 60-70% of patients. Both continuous and luteal phase SSRIs are effective, with no single agent superior to the other. First line therapy includes sertraline, paroxetine, citalopram, escitalopram and fluoxetine. Second line therapies to consider include venlafaxine and alprazolam.
Combined oral contraceptives (COC) have shown mixed efficacy in RCTs, but both cyclic and extended regimens inhibit ovulation and may reduce physical symptoms. For women who also desire contraception, COC is a reasonable first therapy, with addition of an SSRI if needed. Drospirenone-containing COC formulations are specifically FDA approved for treatment of PMDD, with 48-60% of women reporting significant improvement.
Nonsteroidal Anti-inflammatory Drugs
Trial with an NSAID may be useful to manage systemic physical symptoms.
GnRH agonists
Gonadotropin-releasing hormone (GnRH) agonists (leuprolide) have been shown to be effective for ovulation suppression and the physical symptoms of PMDD. Long term use should be approached cautiously and only after informed consent regarding side effects, including irreversible bone loss.
For women with disabling symptoms refractory to other medical therapies, oophorectomy may be considered. A 3 to 6-month trial of GnRH agonist demonstrating efficacy is a prerequisite to surgical treatment.
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Marjoribanks J, Brown J, O'Brien PM, Wyatt K. Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database Syst Rev. 2013 Jun 7;(6):CD001396. doi: 10.1002/14651858.CD001396.pub3.
Initial Approval January 2019; Revised January 2021. Revised July 2022