Treatments for Managing Premenstrual Dysphoric Disorder (PMDD)

Premenstrual Dysphoric Disorder (PMDD) is a severe form of premenstrual syndrome (PMS) that significantly impacts the emotional and physical well-being of those affected. Characterized by intense mood swings, irritability, and depressive symptoms, PMDD disrupts daily life and poses a substantial challenge for those seeking relief. Affecting 5-8% of women, PMDD can significantly decrease their quality of life.

Despite the prevalence of PMDD, finding an effective treatment can be challenging. Many sufferers struggle to find relief that consistently addresses their symptoms, often leading to feelings of frustration and helplessness.

Fortunately, there are several promising PMDD treatment options available that can provide significant relief. Pharmacological treatments such as SSRIs and SNRIs, psychotherapies including CBT and MBCT, lifestyle modifications, and combined oral contraceptives (COCs) offer comprehensive approaches to managing PMDD symptoms. By exploring these treatments in consultation with healthcare professionals, women can find tailored solutions to improve their quality of life and regain control over their well-being.

1. Pharmacological Treatments

This overview explores various pharmacological treatments for PMDD, including Selective Serotonin Reuptake Inhibitors (SSRIs), Serotonin–Norepinephrine Reuptake Inhibitors (SNRIs), Gonadotropin-Releasing Hormone (GnRH) Agonists, and Anxiolytics.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are well-established as a primary PMDD treatment option. Multiple randomized controlled trials confirm that SSRIs, whether taken continuously or only during the luteal phase, significantly alleviate PMDD symptoms.

Their efficacy in treating PMDD involves mechanisms distinct from those used in other depressive and anxiety disorders, offering rapid symptom relief at lower doses. SSRIs are believed to modulate allopregnanolone synthesis, supported by findings from sertraline trials.

Previous research suggests SSRIs should be considered the gold standard for treating PMDD, with extensive evidence supporting their use. SSRIs such as sertraline, escitalopram, paroxetine, and fluoxetine have all been validated as effective treatments for PMDD.

Luteal phase dosing helps mitigate symptoms even after discontinuation at the onset of menstruation. Symptom-onset dosing, although effective, showed mixed results in some trials but remains a viable option for severe PMS. Both continuous and luteal phase dosing offer significant benefits tailored to patient needs.

Serotonin–Norepinephrine Reuptake Inhibitors (SNRIs)

SNRIs are considered promising second-line agents for PMDD when SSRIs are not well-tolerated, despite the limited evidence base. A scoping review on PMDD mentions venlafaxine and duloxetine as effective options for PMDD treatment.

Venlafaxine has shown positive results in both continuous and luteal phase dosing strategies. Duloxetine demonstrated efficacy in reducing PMDD symptoms in a small single-blind trial and an open-label study. Further placebo-controlled trials are needed to confirm these findings.

One particular study investigated the efficacy and tolerability of duloxetine, an SNRI, in treating PMDD. It found that continuous treatment with 60 mg/day of duloxetine significantly reduced premenstrual symptoms and improved functioning across three menstrual cycles.

The study showed a 52.62% reduction in premenstrual symptoms and significant improvements in functional impairment and quality of life. The study concluded that duloxetine could be a promising treatment for PMDD, though larger, controlled trials are needed for further validation.

In another open-label study, the effectiveness of venlafaxine, an SNRI, in treating PMDD among 30 Taiwanese women was evaluated. Over two menstrual cycles, the study found significant improvements in mood and behavior components.

Venlafaxine was administered at an average dose of 60.1 mg/day, and most patients experienced rapid symptom relief by the first cycle. The study concluded that venlafaxine is effective for treating PMDD, with common side effects including nausea, insomnia, and dizziness.

Gonadotropin Releasing Hormone (GnRH) Agonists

The GnRH agonists inhibit estrogen and androgen synthesis by initially increasing and then decreasing sex hormone levels. They are primarily used for advanced prostate cancer and also for conditions like endometriosis, uterine fibroids, and precocious puberty.

The versatility of GnRH agonists extends beyond their primary applications, offering potential benefits for other conditions. Research showed that depot leuprolide, a type of GnRH agonist, was significantly more effective than placebo in reducing PMS symptoms such as:

• Irritability
• Neurologic symptoms
• Breast tenderness
• Fatigue

The treatment brought symptoms to follicular phase levels in women without premenstrual depression and improved but did not fully alleviate symptoms in those with moderate depression. Leuprolide was generally well tolerated, and its differential effectiveness suggests it may help diagnose distinct PMS subtypes.

In a separate study, low dose GnRH agonist buserelin was found to significantly relieve premenstrual irritability and depression, while also improving positive mood symptoms and physical symptoms like swelling and headache in women with severe PMS. However, this treatment induced anovulation in 56% of patients, with older women being more prone to this effect. Notably, breast tenderness was not affected by the treatment.

Overall, low dose GnRH therapy effectively reduced key PMDD symptoms but may lead to anovulation, particularly in older women.

1. Anxiolytics

Anxiolytics are pharmacological agents specifically formulated to mitigate symptoms associated with anxiety and panic disorders. Among the most prevalent are benzodiazepines such as diazepam and alprazolam, which augment the activity of the neurotransmitter GABA. This augmentation serves to induce a pronounced calming effect within the central nervous system, thereby alleviating the distressing manifestations of anxiety and panic.

A previous study suggests that anxiolytics, such as alprazolam, may be effective in treating PMDD, particularly when taken during the luteal phase. However, evidence of their efficacy is mixed, with some studies showing no beneficial effect on mood.

Potential drawbacks include:

• Cognitive impairment
• Memory impairment
• Risk of dependence
• Risk of withdrawal

Buspirone, another anxiolytic with serotonergic action, shows possible efficacy but requires further confirmation. Both alprazolam and buspirone are considered second-line treatments for PMDD due to these limitations.

Similarly, another study discussed the use of anxiolytics for treating PMDD, particularly highlighting alprazolam and buspirone. Alprazolam, taken during the luteal phase, showed some benefits in alleviating PMDD symptoms. However, results were mixed and alprazolam use posed risks of sedation and dependency, making it a second-line treatment.

Buspirone, a 5-HT-1 partial agonist, has also shown potential efficacy for PMDD treatment, especially for patients who suffer from decreased libido or anorgasmia due to SSRIs, though it too is considered a second-line treatment.

2. Psychotherapies

This overview delves into three primary psychotherapeutic approaches: Cognitive Behavioral Therapy (CBT), Mindfulness-Based Cognitive Therapy (MBCT), and Psychoeducation. The following sections highlight the effectiveness and potential benefits of each approach, emphasizing the importance of tailored psychotherapeutic interventions for managing PMDD.

Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy (CBT) is an evidence-based therapeutic approach that focuses on identifying and altering negative thought patterns and behaviors to improve emotional well-being.

The core principle of CBT is the understanding that thoughts, feelings, and behaviors are interconnected and that changing negative thoughts can lead to positive changes in emotions and behaviors. CBT is highly effective in treating various mental health conditions, including PMDD, by addressing the specific symptoms and challenges associated with these disorders.

A systematic review of studies on CBT for PMS and PMDD revealed limited empirical evidence supporting its effectiveness. The review identified seven empirical reports, including three randomized controlled trials, which varied widely in methodology.

While CBT showed potential for treating PMS/PMDD, the evidence for statistically significant intervention effects was sparse. The review highlighted the need for methodologically rigorous research to establish a stronger evidence base, suggesting future studies should explore mindfulness- and acceptance-based CBT interventions for these conditions.

Another randomized clinical trial demonstrated that Internet-based cognitive-behavioral therapy (iCBT) is highly effective in managing PMDD. In the study, 174 women with PMDD were randomized to either an 8-week therapist-guided iCBT group or a waitlist control group.

The iCBT group showed significant improvements in functional and psychological impairment, impact on everyday life, symptom intensity, and symptom disability compared to the control group.

These treatment effects were stable for up to six months post-treatment. Additionally, coping styles and stress management were important moderators of treatment efficacy, with active coping and lower perceived stress associated with better outcomes.

Mindfulness-based CBT (MCBT)

MBCT is a form of cognitive behavioral therapy that integrates mindfulness practices such as yoga, meditation, deep breathing, and guided imagery. It emphasizes enhancing awareness and acceptance of negative thoughts, feelings, and sensations without judgment.

One study showed that MBCT effectively reduced symptoms of PMDD, significantly alleviating emotional symptoms like depression and anxiety and improving physical symptoms. This approach offers a promising treatment option for managing PMDD.

In a separate randomized controlled trial, participants who received MBCT showed significant improvements in depression, anxiety, and overall PMS symptoms compared to a control group that received no intervention.

Psychoeducation

Psychoeducation is an effective treatment approach for PMDD. A modularized treatment program, which includes comprehensive psychoeducation, cognitive interventions, and strategies for changing dysfunctional behaviors and lifestyle habits, was shown to help women better manage their PMDD symptoms.

The program focuses on educating women about their condition, identifying and altering negative thoughts, and promoting healthy lifestyle changes such as stress management, relaxation techniques, diet, and exercise. Initial results indicate that this structured approach can significantly improve symptoms and patient satisfaction, suggesting that psychoeducation should be considered a viable treatment option for PMDD.

Psychoeducation was also found effective in treating PMDD in young people. An intervention study showed that psychoeducation significantly improved symptoms in participants under 18 with PMS, indicating its potential benefit.

Although there is a lack of specific research on PMDD and psychoeducation in adolescents, evidence from studies on older women supports the positive impact of psychoeducation and CBT on PMDD symptoms. Developing high-quality psychoeducation materials can empower young people with PMDD and improve clinical outcomes.

3. Lifestyle Modifications

While pharmacological treatments exist, lifestyle modifications can also play a crucial role in managing PMDD. This discussion explores the impact of lifestyle factors on PMDD based on studies.

Adequate Sleep

Managing sleep patterns is essential for mitigating PMDD symptoms. Proper sleep hygiene and interventions can significantly affect the severity of PMDD.

A previous study indicated PMDD as significantly associated with sleep patterns. Their study found that medical students with PMDD reported fewer hours of sleep compared to those without the disorder.

This aligned with the findings of a recent study that demonstrated that a structured sleep schedule with consistent sleep and wake times improved mood in women with PMDD. Sleep disturbances, including insomnia and excessive sleepiness, are common in PMDD, and improving sleep quality can significantly reduce symptoms.

Physical Activity

Regular physical activity is another crucial aspect of managing PMDD. Exercise not only improves physical health but also has significant mental health benefits.

For instance, the American College of Obstetrics and Gynecology (ACOG) recommended regular aerobic exercise as a nonpharmacological measure to relieve PMS symptoms.

Additionally, a randomized controlled trial on the effects of yoga on women with PMS found that practicing yoga significantly reduced depression and diastolic blood pressure in participants. As a form of physical activity incorporating mindfulness and relaxation techniques, yoga can be particularly beneficial for managing PMDD by reducing stress and improving overall well-being.

Diet

Dietary habits can significantly influence PMDD symptoms. Modifying one's diet to reduce certain triggers and increase beneficial nutrients can help manage PMDD effectively.

A recent study explored the relationship between PMDD, stress, and emotional eating. This study found that women with PMDD had higher levels of negative perceived stress and emotional eating compared to those without the disorder. Managing stress through lifestyle modifications such as dietary changes, stress reduction techniques, and mindfulness can help control emotional eating and improve overall health.

4. Combined Oral Contraceptives (COC)

Combined oral contraceptives (COCs) are considered a beneficial option for managing PMDD. COCs prevent ovulation and stabilize hormonal fluctuations. Specifically, COCs containing drospirenone in a 24+4-day regimen have been approved by the US FDA for PMDD treatment.

Studies suggest that these COCs effectively reduce PMDD symptoms, potentially due to the anti-mineralocorticoid activity of drospirenone and its diuretic effects. Other COC formulations with different progestogens and regimens may also be effective, though the exact components contributing to the therapeutic effects still need to be fully understood. Continuous and extended COC regimens offer additional benefits by reducing hormonal fluctuations.

5. Acupuncture

Acupuncture significantly improves symptoms of PMS and PMDD. Various acupuncture techniques, including traditional acupuncture, hand acupuncture, and moxibustion, were analyzed, showing a 50% or better reduction in symptoms compared to the initial state. The treatments were found to be safe, with no serious adverse events reported, making acupuncture a viable complementary therapy for managing PMS and PMDD symptoms.

In a case review, patient symptoms improved during periods of acupuncture treatment and worsened when the treatment was not administered. This suggests that acupuncture may help alleviate the psychological symptoms of PMDD, which significantly affect the quality of life and work activities of patients. However, the study also highlighted the challenges in evaluating the effectiveness of acupuncture for PMDD and emphasized the need for further research.

Final Words

In summary, managing PMDD requires a multifaceted approach to effectively alleviate its severe emotional and physical symptoms. Effective PMDD treatments include SSRIs, CBT, lifestyle modifications, and COCs, each addressing different aspects of PMDD to improve overall quality of life.

It's crucial to consult with healthcare professionals to explore these PMDD treatment options and find the most suitable plan tailored to individual needs. Don't let PMDD control your life—take the first step towards relief by seeking professional advice and exploring the treatment options available.

FAQs about Premenstrual Dysphoric Disorder Treatments

What are the criteria for diagnosing PMDD?

The diagnosis of PMDD requires experiencing at least five PMDD related symptoms in the final week before the onset of menses, improving within a few days after the onset of menses, and becoming minimal or absent in the week post-menses. These symptoms must include one or more mood-related symptoms such as marked affective lability, irritability or anger, depressed mood, or anxiety and tension.

How is PMDD diagnosed?

Diagnosing PMDD involves a comprehensive assessment, including a health history, physical and pelvic exam, as well as a potential mental health evaluation given the nature of symptoms. Keeping a symptom journal over months may also be recommended.

What causes PMDD?

The exact cause of PMDD remains unclear to experts. However, symptoms may be triggered by the fluctuating levels of estrogen and progesterone following ovulation and before menstruation. Additionally, serotonin, a brain chemical that affects mood, appetite, and sleep, is believed to influence PMDD symptoms, with its levels fluctuating similarly to hormones throughout the menstrual cycle.