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5/1/2019

Management of Premenstrual Dysphoric Disorder (PMDD)

Author: Vicky Mendiratta, MD

Mentor: Seine Chiang, MD
Editor: Regan Theiler, MD

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Premenstrual dysphoric disorder (PMDD) is a severe form of Premenstrual syndrome (PMS) associated with marked behavioral and emotional symptoms, in addition to physical symptoms According to the American Psychiatric Association Diagnostic Statistic 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. Patients prospectively record symptoms, utilizing the Daily Record of Severity of Problems (DRSP) form, which is a validated, reliable inventory. The diagnosis of PMDD is based on 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.  Approximately 2% of women will meet criteria for 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.

Extensive reviews reveal mixed efficacy for numerous supplements, with only 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, acupuncture, chiropractic ma-nipulation, evening primrose oil, and Chinese herbal medicines. However, bright light therapy, stress reduction, and adequate sleep are reasonable recommendations.

 

Cognitive Behavioral Therapy

Cognitive behavioral therapy can be an effective treatment.  Group psychoeducation and re-laxation 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, first-line treatment for PMDD. SSRIs result in a favorable response in 60-70% of patients.  In 2013, a Cochrane review including 31 RCTs concluded that both continuous and luteal phase SSRIs were effective treatment, with no single agent superior to the other. First line therapy includes sertraline, paroxetine, citalopram, escitalopram and fluoxetine. Second line thepaties 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. Because of their diuretic effect, Drospirenone-containing COC formulations are specifically FDA approved for treatment of PMDD, with 48-60% of women reporting sig-nificant improvement.

Nonsteroidal Anti-inflammatory Drugs

Trial with an NSAID may be useful to manage systemic physical symptoms.

GnRH agonists

GnRH agonists (leuprolide) have been shown to be effective for ovulation suppression and treatment of refractory 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 3-6 month trial of GnRH agonist demonstrating efficacy is a prerequisite to surgical treatment.

 

Further Reading:

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.

 

Mendiratta V. Primary and Secondary Dysmenorrhea, Premenstrual Syndrome, and Premen-strual Dysphoric Disorder.  In Lentz, G (Ed.), Comprehensive Gynecology (Chapter 37). Phila-delphia, PA: Elsevier/Mosby. August, 2016.

Initial Approval January 2019

 

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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.

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. The Foundation 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. The Foundation does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither the Foundation, the ABOG, SASGOG nor their 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.

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