Back to Search Results


Management of Premenstrual Dysphoric Disorder (PMDD)

Author: Vicky Mendiratta, MD

Mentor: Seine Chiang, MD
Editor: Katherine Rivlin, MD

Registered users can also download a PDF or listen to a podcast of this Pearl.
Log in now, or create a free account to access bonus Pearls features.

Premenstrual dysphoric disorder (PMDD) is a severe form of Premenstrual Syndrome (PMS) associated with marked behavioral, emotional, and 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 transitionAbout 15% to 20% of women of reproductive age have PMS with significantly impaired functioning, with  3% to 8% experiencing PMDD.

Treatment of PMDD includes lifestyle modifications, cognitive therapy, pharmacologic agents, and, rarely, surgery.

Lifestyle modifications for PMDD include engaging 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 also have evidence of benefit.  Some adjunct treatments have insufficient evidence to recommend routinely,  including massage, biofeedback, yoga, chiropractic manipulation, evening primrose oil, and Chinese herbal medicines. Bright light therapy, stress reduction, and adequate sleep are reasonable recommendations. Acupuncture may reduce symptoms of PMDD when compared to placebo therapy, but additional studies are needed.

Cognitive behavioral therapy and group psychoeducation and relaxation therapy may benefit patients with significant stress or anxiety components.

Pharmacologic therapies include Selective Serotonin Reuptake Inhibitors (SSRIs), which can be extremely effective as 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 another. First line therapy includes sertraline, paroxetine, citalopram, escitalopram and fluoxetine. Second line therapies to consider include venlafaxine and alprazolam.

Hormonal therapies include combined oral contraceptives (COC), which have mixed efficacy at treating PMDD in RCTs. Both cyclic and extended regimens inhibit ovulation and may reduce physical symptoms. For those who also desire contraception, COC is a reasonable first therapy, with the addition of an SSRI if needed. Drospirenone-containing COC formulations are specifically FDA approved for treatment of PMDD, with 48-60% of users reporting significant improvement.

An NSAID may be useful to manage systemic physical symptoms.

Gonadotropin-releasing hormone (GnRH) agonists (leuprolide) suppress ovulation and can manage the physical symptoms of PMDD.  Long term use should be approached cautiously and only after informed consent regarding side effects, including irreversible bone loss.

For those with disabling symptoms refractory to other medical therapies, oophorectomy may be considered. A 3 to 6-month trial of GnRH agonist demonstrating efficacy is advised in advance of surgical treatment.

Further Reading:

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


********** Notice Regarding Use ************

The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. (“SASGOG”) is committed to accuracy and will review and validate all Pearls on an ongoing basis to reflect current practice.

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.

Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. SASGOG reviews the articles regularly; however, its publications may not reflect the most recent evidence. While we make every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. SASGOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither SASGOG nor its respective officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

Copyright 2024 The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. All rights reserved. No re-print, duplication or posting allowed without prior written consent.


Back to Search Results