5/1/2019

Management of Premenstrual Dysphoric Disorder (PMDD)

Author: Vicky Mendiratta, MD

Mentor: Seine Chiang, MD

Editor: Daniel Martingano, DO, PhD, FACOG

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Premenstrual dysphoric disorder (PMDD) is a severe form of Premenstrual Syndrome (PMS) associated with marked behavioral, emotional, and somatic physical symptoms strongly associated with suicidality confined to the premenstrual phase affecting between 1.8% - 5.8% of menstrual women.

The DSM-5 and ICD-11 differentiate PMDD from PMS by requiring luteal phase confinement of at least one of the following core emotional symptoms including

affective lability
irritability or anger
depressed mood
or anxiety

DSM-5 additionally includes symptoms of decreased interest in activities and a sense of being overwhelmed, while ICD-11 includes the additional cognitive symptom of forgetfulness. A total of five or more symptoms are needed for DSM-5 diagnosis. Both require either significant distress or impairment in various spheres of functioning, as well as exclusion of other medical causes or exacerbation of another mental disorder. Further, these symptoms must be present in the luteal phase of most menstrual cycles in the prior year and must result in clinically significant distress or interference in daily life.

To confirm the diagnosis of PMDD, DSM-5 requires ratings of symptoms over two months taken prospectively prior to the initiation of any treatment using a validated tool such as the Daily Record of Severity of Problems. While ICD-11 advises that prospective symptom ratings should be done, it does not stipulate this as a diagnostic requirement. Nevertheless, prospective symptom monitoring remains the gold standard of diagnosis.

Treatment of PMDD focuses on reducing symptom severity and improving patient functioning and quality of life. Combinations of treatments modalities are effective than a single approach, but studies assessing the superiority of combined approaches are lacking. Treatment modalities include:

Medical managements such as SSRIs, hormonal medications, etc.
Psychological treatments such as cognitive behavioral therapy (CBT)
Complementary and alternative medications/practices (CAM)
Surgical management with total hysterectomy with BSO in rare or refractory cases

For mild symptoms or patients who decline pharmacotherapy, evidence supports psychological treatments and CAM such as exercise, yoga, and acupuncture. For more severe symptoms, treatments with the most robust evidence, namely SSRIs and COC, should be prioritized.

SSRIs are an effective medication class and is considered first-line therapy, specifically including sertraline, escitalopram, paroxetine, and fluoxetine. SNRIs, specifically venlafaxine, also have demonstrated efficacy yet with weaker evidence than SSRIs.

COC medications are effective treatments for somatic symptoms of the menstrual cycle, yet data concerning the effect of COC on affective premenstrual symptoms have been inconsistent given the heterogeneity of COC options. Overall, drospirenone-containing COC provide the most consistent benefit when used for management of PMDD compared with other COC formulations, where drospirenone-containing COC formulations are specifically FDA approved for treatment of PMDD and associated with 48-60% of users reporting significant improvement.

Continuous exposure to GnRH receptor agonists, specifically leuprolide injection and PO danazol, act to suppress ovulation through downregulation of GnRH receptors. Suppression of ovulation has been shown to treat PMS, with generalized benefits to PMDD. Long term use should be approached cautiously and only after informed consent regarding side effects, including irreversible bone loss.

Several psychotherapeutic modalities have been shown to be efficacious in the treatment of PMS and PMDD, although CBT has the strongest evidence of benefit. CBT demonstrates a benefit for PMDD alone when compared to SSRIs monotherapy, making it a reasonable option although both treatments approaches are usually performed together.

Hysterectomy with BSO has been successfully utilized as a definitive treatment option for women with PMDD refractory to other interventions, but is rarely required.

Further Reading:

Naik SS, Nidhi Y, Kumar K, Grover S. Diagnostic validity of premenstrual dysphoric disorder: revisited. Front Glob Womens Health. 2023 Nov 27;4:1181583. doi: 10.3389/fgwh.2023.1181583. PMID: 38090047; PMCID: PMC10711063.

Management of Premenstrual Disorders: ACOG Clinical Practice Guideline No. 7. Obstet Gynecol. 2023 Dec 1;142(6):1516-1533. doi: 10.1097/AOG.0000000000005426. PMID: 37973069.

Lopez LM, Kaptein AA, Helmerhorst FM. Oral contraceptives containing drospirenone for premenstrual syndrome. Cochrane Database Syst Rev. 2012 Feb 15;(2):CD006586. doi: 10.1002/14651858.CD006586.pub4. Update in: Cochrane Database Syst Rev. 2023 Jun 23;6:CD006586. PMID: 22336820.

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. Revised May 2024. Revised February 2026.

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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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