Executive Summary
A comprehensive review of the evidence on premenstrual dysphoric disorder, including specific treatment guidelines, has just been published.
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Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are marked by the cyclic nature of symptoms that begin in the late luteal phase of the menstrual cycle and remit shortly after the onset of menstruation. PMDD is distinguished from PMS by the severity of symptoms, predominance of mood symptoms, and role dysfunction, particularly in personal relationships and marital/family relationships.
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It is estimated that 3-9% of women of reproductive age meet the criteria for PMDD. Approximately two million to five million women have severe PMDD symptoms. Selective serotonin reuptake inhibitors have emerged as a first-line treatment option for PMDD.
The patient in front of you says she has dealt with depression, marked anxiety, sudden mood shifts, persistent irritability, and bloating. While the symptoms disappear with the onset of her menstrual cycle, when they are present, they are severe enough to interfere with her relationships and work activities. What is your diagnosis?
Look at premenstrual dysphoric disorder (PMDD). Both premenstrual syndrome (PMS) and PMDD are marked by the cyclic nature of symptoms that begin in the late luteal phase of the menstrual cycle and remit shortly after the onset of menstruation. PMDD is distinguished from PMS by the severity of symptoms, predominance of mood symptoms, and role dysfunction, particularly in personal relationships and marital/family relationships.1
There are many proposed treatment options for premenstrual dysphoric disorder, but which are most effective? A comprehensive review of the evidence, including specific treatment guidelines, has just been published.2
Given the debilitating symptoms and impact associated with PMDD, healthcare professionals need to be able to identify and effectively treat patients with PMDD, says Shalini Maharaj, MPAS, PA-C, and Kenneth Trevino, PhD, both formerly affiliated with the University of Texas Southwestern Medical Center in Dallas. Maharaj, now a hospitalist physician assistant at Parkland Health and Hospital System in Dallas, and Trevino, now in private practice in Dallas, conducted an in-depth review of the safety and efficacy of proposed treatments as an aid to clinical decision-making.
It is estimated that 3-9% of women of reproductive age meet the criteria for PMDD.3 Approximately two million to five million women have severe PMDD symptoms.4 The following symptoms might occur during days 14-28 in a 28-day menstrual cycle, and they notably subside within 2-3 days after menses begins:
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markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts;
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marked anxiety, tension, feelings of being “keyed up” or “on the edge”;
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marked affective lability;
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persistent and marked anger or irritability or increased interpersonal conflicts;
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decreased interest in usual activities;
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subjective sense of difficulty in concentrating;
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lethargy, easy fatigability, or marked lack of energy;
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marked change in appetite, overeating, or specific food cravings;
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hypersomnia or insomnia;
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subjective sense of being overwhelmed or out of control;
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other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of bloating, or weight gain.5
Obtaining prospective charting symptom information for a two-month period can help with diagnosis and treatment.
Selective serotonin reuptake inhibitors (SSRIs) such as sertraline, fluoxetine, and escitalopram have emerged as a first-line treatment option for PMDD, says Trevino. They have established efficacy and safety, which makes them an ideal treatment option, he says.
Although treatment with SSRIs might be continuous, semi-intermittent, or administered at the start of symptoms, further research is needed to determine which of these treatment schedules provide the best balance between effectiveness and side effects, according to the current analysis.
Clinicians also should be aware of the many other treatment options for PMDD, states Trevino. Such treatments offer an alternative option to women who are unable to achieve an adequate response to an SSRI.
Different types of antidepressants can be useful in treating PMDD, while some anti-anxiety drugs, such as alprazolam, are helpful for managing specific PMDD-related symptoms, the analysis states. Oral contraceptives containing drospirenone/ethinyl estradiol are an effective and recommended treatment option for women with PMDD who also are seeking contraception. Beyaz (Bayer HealthCare Pharmaceuticals, Wayne, NJ) carries a Food and Drug Administration indication for treatment of PMDD symptoms for women who choose an oral contraceptive for birth control. Research indicates continuous contraception with a combination levonorgestrel/ethinyl estradiol formulation might reduce the symptoms of PMDD, which provides an option for women who are appropriate candidates for a continuous pill as a contraceptive.6
When these options fail, various anovulatory treatments that decrease ovarian hormone production are effective, the analysis notes. Due to potential side effects and high cost, these are considered “third-line” alternatives, it states.2 Some types of supplements and herbal-related treatments have been proposed, with some warranting further research, the analysis states. Only calcium supplementation has shown a consistent therapeutic benefit so far, it notes.2
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Steiner M, Pearlstein T, Cohen LS, et al. Expert guidelines for the treatment of severe PMS, PMDD, and comorbidities: The role of SSRIs. J Womens Health (Larchmt) 2006; 15:57-69.
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Maharaj S, Trevino K. A comprehen-sive review of treatment options for premenstrual syndrome and premenstrual dysphoric disorder. J Psychiatr Pract 2015; 21(5):334-350.
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Halbreich U, Borenstein J, Pearlstein T, et al. The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD). Psychoneuroendocrinology 2003; 28(Suppl 3):1-23.
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Ginsberg KA, Dinsay R. In: Ransom SB, ed. Practical Strategies in Obstetrics and Gynecology. Philadelphia: W.B. Saunders; 2000.
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American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, fourth ed. Text Revision. Washington, DC: American Psychiatric Association; 2000.
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Freeman EW, Halbreich U, Grubb GS, et al. An overview of four studies of a continuous oral contraceptive (levonorgestrel 90 mcg/ethinyl estradiol 20 mcg) on premenstrual dysphoric disorder and premenstrual syndrome. Contraception 2012; 85(5):437-445.
