What we know about its treatment

For people with premenstrual dysphoric disorder (PMDD), every month is a struggle: feeling down and hopeless, navigating a minefield of intrusive thoughts and emotions, feeling so tired and overwhelmed that they’re reduced to tears. The symptoms, which can also include depressed mood, anxiety, mood swings, irritability, sleep disturbances, difficulty concentrating and changes in appetite, disappear when their period starts, only to return the following month.

PMDD affects one in twenty menstruating women. It shares similarities with premenstrual syndrome (PMS), such as irritability or mood swings, but PMDD is debilitating. It can affect daily function in the luteal phase of the menstrual cycle (the two weeks before a period). During this time, there are fluctuations in the hormones estradiol and progesterone.

PMDD is a hormone sensitivity condition. Normal hormone changes in the luteal phase can cause symptoms including suicidal thoughtsThis is because PMDD brains respond differently to hormonal fluctuations.

PMDD was internationally recognized as a mental disorder in 2019. Awareness of PMDD treatments is still limited. Understanding evidence-based options can help navigate PMDD treatment.

Treatments and providers

Depending on the complexity of the symptoms, treatment may be supervised by general practitioners, mental health professionals such as psychiatrists or psychologists, or reproductive experts such as gynecologists.

If you suspect you have PMDD, Track your symptoms for at least two menstrual cycles. This can also help identify premenstrual exacerbation (PME)In PME, the symptoms of other conditions, such as a mood disorder or ADHD—may become more intense during the luteal phase. Recognizing symptom patterns can help you find treatments that work best for your condition.

Treatments that have performed well in high-quality, randomized controlled trials have the strongest evidence for effectiveness in treating PMDD. They require a prescription, so working with a health care provider is essential. They include:

Antidepressants

Selective serotonin reuptake inhibitors (SSRIs) are effective for approximately 60 percent of PMDD patients. They can help with emotional or psychological symptoms. For some, SSRIs also help with physical symptoms such as bloating or breast tenderness.

The SSRIs fluoxetine, sertraline, and paroxetine are first-line treatments for PMDD. These medications reduce symptoms faster with PMDD than other mood or anxiety disorders. There are several ways to take SSRIs to treat PMDD: taking SSRIs continuouslyonly during the luteal phase or with the onset of symptoms.

Discuss SSRI dosages with a healthcare provider. Trying SSRIs for two to three menstrual cycles is ideal to gauge their effects on reducing symptoms. If SSRIs don’t work, serotonin-norpinephrine reuptake inhibitors (SNRIs) could be another antidepressant option. But SNRIs have a higher risk of side effectsso make sure you discuss this with a provider.

Birth control pills

Most birth control pills are not effective in treating PMDD. This is because taking hormone pills for 21 days and then switching to sugar pills for seven days causes hormone fluctuations that can trigger PMDD symptoms.

However, there is a specific type of birth control pills that contain drospirenone (DCOCs). Helps reduce PMDD symptoms. Dropsirenone is a unique synthetic progestogen that is not found in other contraceptive pills.

Continuously taking DCOCs (skipping the sugar pills) or following a 24-4 regimen (24 days of hormones and four days of sugar pills) is recommended for PMDD. This regimen helps to better suppress ovulation and eliminates hormone fluctuations seen in the luteal phase. It reduces the chance of a negative brain response to hormone changes.

Examples of DCOCs include the brands Yaz, Angeliq, Beyaz, Gianvi, Loryna, Nikki, Ocella, Syeda, Vestura, Yaela, Yasmin, Zarah. Yaz is approved by the US Food and Drug Administration for PMDD treatment.

Other treatment options

Gonadotropin-releasing hormone analogues (GnRHa, also called chemical menopause) create a temporary, reversible menopausal state. It prevents the release of hormones that trigger ovulation. This in turn eliminates hormone fluctuations that cause PMDD symptoms.

Hormone replacement therapy (HRT) with ethinyl estradiol and synthetic progestogen is often used in GnRHa treatment to reduce side effects such as hot flashes, night sweats and bone loss. It helps maintain heart and brain health. Introducing HRT may cause an initial flare-up of PMDD symptoms, but these often resolve once hormone levels are stable.

Access to GnRHa and HRT can be difficult due to limited expertise. Using GnRHa for longer than six months is a new treatment and requires supervision by a gynaecologist, or sometimes a psychiatrist with expertise in reproductive mental health. If doctors are hesitant about prescribing GnRHa long-term, there are provider specific resourcesIt may help to initiate discussion about GnRHa treatment.

Ovarian removal with or without hysterectomy (surgical menopause) is a last-line treatment for PMDD. This is a surgical procedure in which the ovaries and fallopian tubes, or ovaries, fallopian tubes, and uterus are removed. It is invasive and irreversible. It also requires hormone replacement via HRT.

Many women with PMDD have progesterone intolerant. Removal of the uterus may help some people to continue taking estrogen-only HRT. Patients should discuss these options with a gynecologist. Consider surgical menopause only if all other treatments have failed to improve PMDD symptoms.

Possible treatments that require further research

Some people with PMDD do not experience relief with SSRIs or DCOCs. There are other medical options that show promise for PMDD symptoms, but more research is needed to understand their effectiveness.

The use of 5a-reductase inhibitors such as dutasteride and finasteride can help. They prevent the formation and flux of progesterone metabolites in the brain. They are approved for the treatment of conditions such as benign prostatic hyperplasia in men, but are an “off-label” treatment for PMDD. Only a few providers are willing to prescribe 5a-reductase inhibitors for PMDD because it adverse effects.

Mood stabilizers such as quetiapine in the luteal phase, along with an SSRI, it may help with PMDD, especially for those who have not benefited from taking SSRIs alone.

To take continuous estradiol plus progesterone is another option. This treatment uses natural formulations of estradiol and progesterone that are less potent than synthetic birth control pills.

This means that ovulation suppression can be inconsistent and dosages may need to be adjusted. Failure to suppress ovulation can cause PMDD symptoms, so patients require careful monitoring and supervision by a healthcare professional.

Non-medical treatments

Cognitive behavioral therapy (CBT) And Dialectical Behavior Therapy (DBT) can help with PMDD symptoms. They include learning techniques to control thoughts and emotions. DBT can also help deal with strong emotions and suicidal thoughts.

In addition, self-care skills can lay the foundation for healthy habits. This includes lifestyle changes such as maintaining sleep health And take up physical activity.

Getting enough rest during the premenstrual weeks helps manage symptoms. alcohol consumption, dealing with stress and a balanced diet can also help manage symptoms.

Anecdotally, some PMDD sufferers swear by supplements, but more research is needed to understand their effectiveness. For example, PMDD symptoms may improve with the use of vitex agnus castusBut the effects of using calcium carbonate And vitamin B6 for PMDD are unclear.

Taking supplements is risky because they are not well regulated. Talking to a healthcare provider can help address unique health situations.

Challenges in Identifying Treatment Options

PMDD symptoms are unique to each person. Tracking symptoms as you try new treatments can help you understand how treatment affects PMDD symptoms. Likewise, tracking symptoms as you make lifestyle changes can help you see which ones are helping.

Because PMDD is only recently recognized, many health care providers may also be new to understanding PMDD and its treatment. PMDD treatment should be a partnership between the provider and the patient, with both learning from each other.

For more information, please refer to “PMDD Treatment Options: A Patient Guide to Evidence-Based Treatment for Premenstrual Dysphoric Disorder“, published by the International Association for Premenstrual Disorders (IAPMD).

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