How to Treat PMDD

What is PMDD?

Premenstrual dysphoric disorder (PMDD)is a significant disabling condition. It is the only form of premenstrual disorder currently classified in DSM V. Far fewer women suffer from PMDD than PMS estimates are that it is probably about 4-8 percent of women that suffer from it. 

PMDD often involves significant depression, anxiety, and mood swings and a host of other symptoms that begin 7-14 days before menstruation and usually resolve with its onset. PMDD symptoms interfere significantly with women's functioning. Click here to learn more about PMDD symptoms.

Where does PMDD come from?

Although there have been many theories about PMDD, what is currently believed is that women who suffer from PMDD are sensitive to the normal hormonal fluctuations of estrogen and progesterone in their bodies. How we treat PMDD is based on how we understand it.  

How is PMDD diagnosed?

The first step in how to treat PMDD is to get an accurate diagnosis. That isn't an easy feat. You and your health care provider should be working on this together, or you may want to begin the process of gathering data yourself so you can get a head start.

PMDD is diagnosed with the assistance of charting. Charting is a recording tool that can help the clinician both gather data and visually inspect a pattern to determine when women's symptoms occur and how severe women's symptoms are.

Charting should occur for at least two months, but preferably more due to the often dramatic variation in a women's pattern of symptoms over her menstrual cycles. It should then continue through treatment to determine if the chosen course is effective. 

PMDD can easily be confused with other disorders or minimized by your health care providers. Clarification can be important and finding a tool that accurately captures your symptoms and their severity is also important.  

Recommended tools for charting include the Calendar of Premenstrual Experiences (COPE), the  Prospective Record of the Severity of Menstruation (PRISM) and the Daily Record of Severity of Problems DRSP.

You can get a copy of the DRSP here. 

PRISM Calendar

COPE Calendar

Studies have shown women who believe they have PMDD often have another more continuous diagnosis exacerbated during their menstrual cycle. PMDD is cyclical and the mood is only present during the luteal phase of the menstrual cycle

If after looking at your chart your health care provider sees you have symptoms every day, but more on the days leading up to your period, he or she is likely to consider you as having premenstrual exacerbation (PME). PME is a worsening of another diagnosis like bipolar disorder or depression. That does not mean that it isn't treated.

Your health care provider is likely to consider you as having PMS if you don't have symptoms that are severe enough or include enough mood instability or meet enough criteria. That does not meet you shouldn't get treatment.

How to Treat PMDD: Medication

Your Doctor will help you make a decision based on all of your other medical conditions and medications but SSRIs are often considered one of the best choices for medications. At a recent workshop I attended on PMDD at Massachusettes General Hospital series given by Laura Fagioli Petrillo, M.D., I learned fluoxetine, sertraline, and controlled release paroxetine are FDA approved for PMDD. SSRI's are the first line of treatment. This means the best-accepted treatment that we have.

However, Dr Patrillo states, all SSRIs can be effective. They can work at a low dose, and have a rapid response. Also, SNRI's can be effective. They are:  clomipramine, venlafaxine, duloxetine. She states they have a 60 to 90 percent response rate.

Continous Dosing

You and your doctor might decide for you to take a  daily dose of your antidepressent at the same time every day.

Intermittent dosing

You and your doctor might decide to take your medicine in the luteal phase only with no other medication through the rest of the month. This is only likely if you have a very predictable period. Some women think that this might minimize the side effects of your antidepressant but this is not necessarily true. Additionally, the lack of regularity of taking a pill can make it difficult to remember to take the pill during the luteal phase so that can present challenges as well. 

Luteal phase bump up

Some doctors in certain circumstances will prescribe a bump up of meds when you during the luteal phase. This is likely if you have another condition being exacerbated during your luteal phase. 

Chronicity of PMDD

It's important to note that PMDD is chronic. Most women will relapse within one to two cycles after discontinuing their meds. Medication  is not curative. 

How to treat PMDD: Oral Contraceptives

Evidence from double-blind, randomized, placebo-controlled trials supports the use of some oral contraceptives for the treatment of PMDD. Some research suggests drosperinone based pills are more effective. Pills can be prescribed continuously or with a seven-day placebo break. Doctor Patrillo warns that there are risks with birth control pills that must be weighed with this option, that is not the first choice. One of the very serious risks includes increased suicide. 

How to treat PMDD : GNRH Agonists

Gonadotropin-Releasing Hormone Agonists ( GnRH agonists)

GnRH agonists prevent the production of hormones and induce medical menopause. This condition is reversible. This is an option in very severe cases but not a first choice. It is administered by nasal spray, and subcutaneously. If it is effective and it is reversed when the hormones are added back the symptoms of PMDD reappear. 

How to Treat PMDD: Natural Remedies

Mood charting

Mood charting can be an effective treatment because it helps you to practice awareness and acceptance of your symptoms and provides validation that you are not crazy. It also helps you to predict when your symptoms will be exacerbated thus planning for less stress. 

Lifestyle changes

  • Eliminating caffeine and sugar
  • Exercise
  • More sleep
  • Cognitive Behavioral Therapy. One study found it to be as effective as Antidepressants! 

Vitamin Supplements

  • Calcium 1200. Calcium has been suggested to be more effective than a placebo in reducing symptoms of PMDD. 

All of these supplements have been recommended to women who have PMS, although not shown specifically to alleviate symptoms of PMDD, they will likely assist in the more underlying somatic symptoms that also plague women with PMDD.

  • Vitamin b6 50- 100
  • magnesium 200- 460
  • Vitamin e 400 iu

How to Treat PMDD: Vitex agnus-castus (VAC) Chasteberry

Chasteberry can be taken in pill or liquid form. For women who have side effects that are undesirable or who are unable or unwilling to take antidepressants or birth control, it may be more desirable to try alternative methods of treatment. A recent review of the literature suggests that chaste berry has effectiveness when taken a week before menstruation in alleviating somatic symptoms of PMDD. Warnings because it may interact with hormones and cause side effects of nausea or headache. Some studies have suggested it may have a negative effect on hormone levels and may affect how antipsychotic medications work. 

Cerqueira, R., Frey, B., Leclerc, E., & Brietzke, E. (2017). Vitex agnus castus for premenstrual syndrome and premenstrual dysphoric disorder: a systematic review. Archives of Women's Mental Health, 20(6), 713-719.

Petrillo F. L.Psychiatric Disorders in Women: Diagnostic and Treatment Considerations Across the Female Lifespan (February 2020) PMDD

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