Comprehensive review looks at safety, efficacy of treatment options for premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome that causes major disruption in several areas of life for many women. Many treatment options have been proposed, but which are most effective? A comprehensive review of the evidence, including specific treatment guidelines, is presented in the September Journal of Psychiatric Practice, published by Wolters Kluwer.

"Given the debilitating symptoms and impact associated with PMDD, health care professionals need to be able to identify and effectively treat patients with PMDD," write Shalini Maharaj, MPAS, and Kenneth Trevino, PhD, of the University of Texas Southwestern Medical Center. As an aid to clinical decision making, they conducted an in-depth review of the safety and efficacy of proposed treatments for PMDD.

Treatment for PMDD--SSRIs Are First Choice, but Other Options Exist

About three to eight percent of premenopausal women suffer from PMDD: a severe form of premenstrual syndrome with a combination of emotional and physical symptoms, causing significant impairment in home, work, and social life. Severe PMDD symptoms may also lead to suicidal thoughts--one study found that 15 percent of women with PMDD reported at least one suicide attempt.

In their review, Maharaj and Trevino identify a wide range of proposed PMDD treatments--classified as psychiatric, anovulatory, supplements, herbal, and non-pharmacologic. While the cause of PMDD is not entirely understood, one contributing factor seems to be negative effects of changing hormone levels on certain neurotransmitters, including serotonin.

This has been supported by studies showing a rapid response to selective serotonin reuptake inhibitors (SSRIs), a widely used class of antidepressant drugs. Based on the results of 31 randomized trials including nearly 4,400 women, SSRIs are considered the "first-line" treatment for PMDD. Although treatment with SSRIs may be continuous, semi-intermittent, or administered at the start of symptoms, further research is needed to determine which of these treatment schedules provide the best balance between effectiveness and side effects.

For women who experience an inadequate response to SSRIs, other treatment options should be considered. Different types of antidepressants are useful in treating PMDD, while some anti-anxiety drugs are helpful for managing specific PMDD-related symptoms. Oral contraceptives containing drosperinone/ethinyl estradiol are an effective and recommended treatment option for women with PMDD who are also seeking contraception.

When these options fail, various anovulatory treatments--which decrease ovarian hormone production resulting in a state of medical menopause--are effective. However, because of potential side effects and high cost, these are considered "third-line" alternatives.

Various supplements and herbal-related treatments have been proposed as well, with some warranting further research. However, so far, only calcium supplementation has shown a consistent therapeutic benefit.

Maharaj and Trevino call for larger, placebo-controlled studies of potential treatments for PMDD. Such studies should use a consistent definition for PMDD and a placebo screening period to confirm the diagnosis. The authors also stress the need to use or adopt standardized outcome measures in PMDD research, due to the difficulty comparing results from PMDD studies that use different outcome measures.