Premenstrual dysphoric disorder: How to alleviate her suffering
Accurate diagnosis, tailored treatments can greatly improve women’s quality of life
Antidepressants have been shown to effectively ameliorate affective and physical symptoms and improve quality of life and psychosocial function in patients with PMS and PMDD. The response rates for selective serotonin reuptake inhibitors (SSRIs) in PMDD treatment vary from 60% to 90%, vs 30% to 40% for placebo.32 A 2009 Cochrane review found SSRIs reduced premenstrual symptoms compared with placebo.33 However, a literature review suggested that the percentage of women with PMDD who respond to SSRIs or continuous oral contraceptives is lower than the percentage of women who do not respond at all, once the placebo effect is taken into account, and that approximately 40% of women with PMDD do not respond to SSRIs.34 A small study found that citalopram may be effective for women with PMDD who did not respond to a prior SSRI.35
However, only antidepressants that affect serotonergic—not noradrenergic—transmission are effective in PMDD.22 These include:
- the tricyclic antidepressant clomipramine
- the SSRIs citalopram, escitalopram, fluoxetine, paroxetine, and sertraline
- the serotonin-noradrenergic reuptake inhibitor venlafaxine.
It appears that in PMDD, serotonergic agents play a role other than their antidepressant effect.36 The effect of these agents is rapid in PMS/PMDD; women with PMDD who take antidepressants often experience reduced symptoms within the first menstrual cycle, whereas in MDD the onset of action can take weeks or months.37
Although why onset of antidepressant action is quick in PMDD is unclear, rapid onset allows for several dosing options. Some women prefer continuous dosing throughout the month because they do not have to keep track of ovulation. Dosing antidepressants only in the luteal phase (taking the antidepressant from ovulation onset to the start of menses) is an effective treatment strategy.38 Many women prefer to take medication for only 2 weeks per month, which can decrease side effects and lower treatment costs. Alternatively, symptom-onset dosing—initiating the antidepressant when PMDD symptoms begin and stopping at menses onset or within 3 days thereafter—has shown promising results.39,40 Paroxetine, sertraline, and fluoxetine are FDA-approved for PMDD as continuous or intermittent regimens, although using fluoxetine intermittently may not make sense because its biologically active metabolite has an extended half-life.37
Other treatments. Dietary interventions, psychotherapy, vitamins, bright light treatment, and spironolactone have been assessed for PMS/PMDD, although for many evidence-based findings are lacking (Box 3).
See the Bibliography below for studies that support using antidepressants to treat PMDD
Two reviews of 10 randomized controlled trials (RCTs) that evaluated 62 herbs, vitamins, and mineral treatments for premenstrual symptoms found efficacy for chasteberry (Vitex agnus-castus), calcium, and vitamin B6 but not for primrose oil, magnesium oxide, or St. John’s wort.a,b A study comparing fluoxetine with chasteberry found a similar percentage of patients responded to either agent (68% vs 58%, respectively).c Another study showed calcium resulted in a 48% reduction in premenstrual symptoms from baseline, compared with a 30% reduction with placebo.d Bright light treatment significantly reduced depression ratings in women with premenstrual dysphoric disorder (PMDD).e Compared with placebo, the aldosterone antagonist spironolactone improved irritability, depression, feelings of swelling, breast tenderness, and food craving in women with premenstrual syndrome (PMS).f
A recent systematic review of 7 trials of cognitive-behavioral therapy (CBT) for PMDD, including 3 RCTs, showed a lack of a statistically significant effect.g However, a separate review of RCTs of alternative treatments for PMDD—5 of which included CBT—suggested that CBT may be beneficial in reducing premenstrual symptoms, but the evidence was low quality.h
References
- Dante G, Facchinetti F. Herbal treatments for alleviating premenstrual symptoms: a systematic review. J Psychosom Obstet Gynaecol. 2011;32(1):42-51.
- Whelan AM, Jurgens TM, Naylor H. Herbs, vitamins and minerals in the treatment of premenstrual syndrome: a systematic review. Can J Clin Pharmacol. 2009;16(3):e407-e429.
- Atmaca M, Kumru S, Tezcan E. Fluoxetine versus Vitex agnus castus extract in the treatment of premenstrual dysphoric disorder. Hum Psychopharmacol. 2003;18(3):191-195.
- Thys-Jacobs S, Starkey P, Bernstein D, et al. Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. Premenstrual Syndrome Study Group. Am J Obstet Gynecol. 1998;179(2):444-452.
- Parry BL, Berga SL, Mostofi N, et al. Morning versus evening bright light treatment of late luteal phase dysphoric disorder. Am J Psychiatry. 1989;146(9):1215-1217.
- Wang M, Hammarbäck S, Lindhe BA, et al. Treatment of premenstrual syndrome by spironolactone: a double-blind, placebo-controlled study. Acta Obstet Gynecol Scand. 1995;74(10):803-808.
- Lustyk MK, Gerrish WG, Shaver S, et al. Cognitive-behavioral therapy for premenstrual syndrome and premenstrual dysphoric disorder: a systematic review. Arch Womens Ment Health. 2009;12(2):85-96.
- Busse JW, Montori VM, Krasnik C, et al. Psychological intervention for premenstrual syndrome: a meta-analysis of randomized controlled trials. Psychother Psychosom. 2009;78(1):6-15.
