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5/1/2019

Management of Premenstrual Dysphoric Disorder (PMDD)

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. 

 

Lifestyle Modifications

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

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.

 

Hormonal therapies

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.

 

Surgical Therapy

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.

Further Reading:

Armour M, Ee CC, Hao J, Wilson TMarie, Yao SS, Smith CA. Acupuncture and acupressure for premenstrual syndrome (PMS). Cochrane Database syst Rev. 2018 Aug 14; ( 8): CD005290. DOI: 10.1002/14651858.CD005290.pub2

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.

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

 

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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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