Treating Premenstrual Dysphoric Disorder - Harvard Health Publishing

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Most women experience some degree of premenstrual syndrome (PMS) symptoms - bloating, breast tenderness, food cravings, irritability, mood swings - a few days before and just after their menstrual periods begin.

However, some women experience at least five premenstrual symptoms so severe that they cause significant mental distress and interfere with work, school, or relationships - thereby meeting the criteria for premenstrual dysphoric disorder, or PMDD.

PMDD risk factors and diagnosis

Risk factors for PMDD include:

personal diagnosis of a mood disorder (anxiety, depression, bipolar disorder)
a family history of mood disorders
changes in mood during other hormonal transitions, such as after giving birth, or when stopping or starting hormone-based contraception
exposure to chronic stress or trauma (including abuse).

Women with PMDD appear to have a heightened sensitivity to the hormonal changes that occur during the menstrual cycle. Differences in certain genes and neurotransmitter systems may affect how the brain responds to these changes. Studies also have reported higher levels of inflammation in women with PMDD, which may cause or contribute to this sensitivity.

Some lifestyle factors may worsen PMDD symptoms but are not considered causes. These include smoking, sleep deprivation, alcohol use, caffeine use, a sedentary lifestyle, and high levels of perceived daily stress.

A key challenge in PMDD diagnosis is differentiating between mild premenstrual symptoms, which may be annoying but are not disabling, and those severe enough to interfere with daily life. Also, it's important to rule out other conditions that cause symptoms similar to PMDD such as depression, dysthymia, anxiety, and hypothyroidism.

However, it also is possible to have both PMDD and another similar condition at the same time. For example, one study found that women with generalized anxiety disorder were more than seven times as likely to have PMDD, compared with women who did not have this disorder. To further complicate the picture, symptoms of mood disorders may worsen in the days before a woman's menstrual period begins; this is called premenstrual exacerbation and is not considered PMDD.

Symptoms that may indicate PMDD

There's no one constellation of symptoms that means you definitely have PMDD. Medical teams typically base a diagnosis on several factors.

whether you experienced five or more of the following symptoms (at least one must be related to mood) for most menstrual cycles in the past year:
- depression, feelings of hopelessness
- anxiety or tension
- mood swings, feeling unusually sad, sensitive to rejection
- irritability, anger, increased conflict with others
- loss of interest in daily activities
- difficulty concentrating
- decreased energy
- food cravings and appetite changes
- insomnia or sleepiness
- a sense of being overwhelmed or out of control
- physical symptoms such as breast tenderness or bloating
your symptoms interfere with activities, work, school, or relationships
your symptoms are not due to a cyclical worsening of another disorder such as an anxiety disorder.

Your doctor may ask you to take notes during at least two menstrual cycles, keeping track of your daily symptoms and how severe they are.

Antidepressants for treating PMDD

Antidepressants that slow the reuptake of serotonin are effective for many women with PMDD. Usually, the first choice is one of the selective serotonin reuptake inhibitors (SSRIs) such as sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), or fluoxetine (Prozac). If SSRIs are not effective, another option is venlafaxine (Effexor), a serotonin and norepinephrine reuptake inhibitor (SNRI).

Antidepressants that target neurotransmitters other than serotonin have not proven effective in treating PMDD. This suggests that SSRIs work in some way independent of their antidepressant effect - but their mechanism of action in PMDD remains unclear.

SSRIs work faster for PMDD than they do for depression, which means that women don't necessarily have to take the drugs every day. Instead, women can take them on an intermittent basis, also known as luteal-phase dosing because it coincides with the roughly 14-day phase that begins just after ovulation and ends when menstruation starts.

The decision about whether to take an SSRI every day or on an intermittent basis depends on the type of symptoms you experience and if you experience more persistent depression. Intermittent dosing is sufficient for treating irritability or mood swings, but daily medication may be necessary to control symptoms such as fatigue and physical discomfort.

Most side effects of SSRIs are usually relatively mild and don't last long. Nausea, for example, typically subsides within several days of starting an SSRI - and the problem tends not to recur even when the drug is taken intermittently.

Sexual side effects, such as reduced libido and inability to reach orgasm, can be troubling and persistent, even when dosing is intermittent. Of course, PMDD also can lessen sexual desire, so taking an SSRI on an intermittent basis may still be an acceptable strategy.

Other treatments for PMDD

Hormonal contraceptives may be helpful for some women. Yaz (drosperinone/ethinyl estradiol) is FDA-approved for treating PMDD. It works by helping to reduce hormone fluctuations throughout the menstrual cycle. Yaz is an oral contraceptive pill taken once daily. It begins working during the first menstrual cycle, with studies showing continued symptom improvement in later cycles.

For severe PMDD that does not respond to antidepressants, treatment with GnRH analogues may be an option. These compounds block the ovaries from producing hormones, chemically simulating menopause. Because they stop estrogen production, GnRH agonists can have serious side effects. They usually are used only for six months or less.

Cognitive behavioral therapy is a nonpharmacologic approach to PMDD. Studies have shown that this type of therapy can be effective, with one study finding it as effective as an antidepressant.

Finally, surgical treatment may be an option. The surgery includes removal of the uterus, fallopian tubes, and ovaries, with long-term hormone therapy needed. Because it is major surgery, it is appropriate only in select cases.

Lifestyle changes for PMDD

Most research on lifestyle changes has focused on PMS symptoms and not PMDD specifically, but your medical team may recommend lifestyle changes to try to lessen PMDD symptoms.

Diet. Medical teams generally recommend dietary changes that promote health benefits, such as limiting sugar, caffeine, and alcohol, as well as consuming more whole foods (such as whole grains, vegetables, and fruits).

Aerobic exercise. A wealth of evidence shows that aerobic physical activity, such as walking, swimming, or biking, tends to improve mood and energy levels in the general population. Studies also have found that regular physical activity - which can include aerobic activities, weight training, and yoga- lessens PMS symptoms.

Supplements. Some studies have suggested benefits to specific vitamins and minerals. Calcium and vitamin D have been associated with a reduction in PMS symptoms, and vitamin B₆ is commonly recommended for mild to moderate PMS symptoms, though there is little research related to PMDD.