There is no single option that works for all women with PMDD. You will want to work with your health care and support team to find the best treatment option for you.
Many women find it is a combination of several treatment options that help the most.
There are several options for treatment that are currently prescribed to manage symptoms of PMDD. Some have been proven to be effective and others have not. Some may lessen symptoms in the short term and others may have no effect or worsen symptoms over time. Always consult with your medical team before stopping or starting any medications or treatments.
- Oral Contraceptives
- Mood Stabilizers
- Progesterone Therapy
- Diet and Nutrition
- Alternative Medicine
- Complementary Medicine
- Homeopathic Medicine
- GnRH Agonists
Several members of the selective serotonin reuptake inhibitor (SSRI) class of medications have been approved by the FDA to treat the anxiety and depressive symptoms PMDD. These medications work by regulating the levels of the neurotransmitter serotonin in the brain and are often considered first-line treatment for this disorder. SSRIs that have shown to be effective in the treatment of PMDD include:
- fluoxetine (Prozac, Sarafem)
- sertraline (Zoloft)
- paroxetine (Paxil)
- citalopram (Celexa)
Up to 75% of women report relief of symptoms when treated with SSRI medications. Side effects can occur in up to 15% of women and include nausea, anxiety, and headache. SSRI medications to treat PMDD may be prescribed to be taken continuously or only during the 14-day luteal phase (second half) of the menstrual cycle. Other types of antidepressants (tricyclic antidepressants and monoamine oxidase inhibitors) and lithium (Lithobid) have not been shown to be effective in the treatment of PMDD. Finding the right dosage is key to the effectiveness of SSRIs. This form of treatment has been shown to improve irritability, depressed mood, dysphoria, bloating, breast tenderness, appetite changes, and psychosocial function. Studies show that most SSRI treatment studies are short-term, lasting only during 3 to 6 consecutive menstrual cycles and that data on the long-term benefits are extremely limited.1,2
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Oral contraceptives are also a first-line treatment option for PMDD. "The Pill" contains two forms of female hormones that include ethynyl estradiol (estrogen) and drospirenone (progestin/synthetic progesterone). Some pills may contain only progestin. When taken daily, these hormones travel through the bloodstream to the pituitary gland to prevent the release of LH and FSH which in turn prevents the growth of an egg at ovulation.3,4
These medications can offer symptom relief by regulating the fluctuation of hormones throughout a woman's menstrual cycle. Although, according to the American Academy of Family Physicians OCPs are not reported to be consistently effective in the treatment of PMDD.
OCPs may not suffice if mood symptoms are prominent and, in some patients, these drugs may worsen dysphoria (a known side effect of some birth control pills) in many women with and without PMDD.The increase in symptoms seems to be especially prevalent in women with progesterone-sensitive type PMDD. Recent studies point to a direct link between the female hormone progesterone and PMDD. All OCPs contain progesterone and may make symptoms worse.5
In randomized controlled trials, the only birth control pills that have shown improvement in PMDD symptoms are pills that consisted of a combination of ethynyl estradiol and drospirenone (like Yaz, Ocella, and Beyaz). These pills have been shown to offer relief from both physical and psychological PMDD symptoms with improvement in health-related quality of life. For women who choose the Pill for contraception, Yaz is the only birth control FDA-approved to treat PMDD.6,7
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Women with PMDD are most often misdiagnosed with bipolar disorder (rapid cycling or otherwise) due to the cyclical nature of both disorders. Because of this tragic confusion, women are often prescribed medications to treat bipolar disorder called mood stabilizers. These medications include:
- carbamazepine (Tegretol)
- Divalproex (Epival)
- lamotrigine (Lamictal)
- Gabapentin (Neurontin)
- topiramate (Topamax)
The last three listed above are classified as "anticonvulsants" and are typically used "off label" alone or in addition to other medications. These drugs are classified as anti-psychotic medications and have potential risks when used long-term and/or incorrectly in the wrong amounts or for the wrong disorders. In short, mood stabilizers are not approved nor appropriate for the treatment of PMDD. 8,9,10
It is recommended before starting or stopping any type of medication for the treatment of PMDD, to have baseline progesterone levels tested over a full menstrual cycle. A single hormone test is not sufficient in diagnosing a true progesterone deficiency as hormones naturally fluctuation throughout a monthly cycle.21,
Should progesterone levels prove to be too low, supplementing progesterone may be beneficial in relieving symptoms. For those without low progesterone, adding more of this hormone may increase the severity of symptoms including depression, rage, and anxiety.
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Homeopathy, or homeopathic medicine, is a medical philosophy and practice based on the idea that the body has the ability to heal itself. A homeopathic health practitioner (homeopath) uses pills or liquid mixtures (solutions) containing only a little of an active ingredient (usually a plant or mineral) for the treatment of disease. These are known as highly diluted or "potentiated" substances. There is some evidence to show that homeopathic medicines may have helpful effects.11
Folliculinum is a popular homeopathic medicine for PMS made from natural or synthetic oestrogen. In an observational study, 88% of 32 women with menstrual or premenstrual symptoms were satisfied with the overall effects of Folliculinum C97 in regards to breast pain and tension.12
Limited studies show that homeopathic therapies are well tolerated and beneficial for women with moderate PMS symptoms. There are few studies on the positive effect of homeopathy on PMDD but not enough evidence to support a consistent long-term benefit.
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Anybody will benefit from a whole and nutritious diet. Women with PMDD stand to benefit even more. Studies show a strong correlation between what we eat and emotional well-being. A common symptom of PMDD is an intense craving for food during the luteal phase, specifically foods high in carbohydrates and with good reason. Carbohydrates influence the production of serotonin which directly and indirectly control mood, sexual desire and function, appetite, sleep, memory, body temperature, and social behavior. While serotonin is produced in the brain, about 90% of our serotonin supply is in the digestive tract and blood platelets. The connection between mood and food is clear.13,14
The path from carbohydrate to serotonin looks like this: carbohydrate > insulin > tryptophan > serotonin. While high protein foods like chicken and beef contain a high amount of tryptophan, the brain is unable to efficiently absorb a small amount of this necessary nutrient. When a meal high in carbohydrates is consumed, the resulting insulin aids in getting more tryptophan to the brain and increasing levels of serotonin.15,16,17
It is important to choose the right kind of carbs, however, as choosing the wrong kind can make symptoms worse. Foods high in the carbohydrate sugar will have the opposite effect and reduce serotonin. While intense cravings may want otherwise, choosing whole grains will achieve the desired boost. Ultimately a diet rich in whole grains, fruits, vegetables, and calcium will benefit the most.18
In addition to a well-balanced diet, studies show great benefit from adding the following supplements:19
- Vitamin B6, up to 100 mg per day
- Vitamin E, up to 600 IU per day
- Calcium carbonate, 1,200 to 1,600 mg per day
- Magnesium, up to 500 mg per day
- Tryptophan, up to 6 g per day
A recent study reviewed efficacy and safety data on herbal supplements marketed for women. The author concluded that two herbal products, evening primrose oil and chaste tree berry, have been effective in treating breast tenderness and engorgement that typically accompanies PMS. There is no definitive evidence that these herbal supplements will have a positive effect on the emotional symptoms of PMDD.19,20
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Acupuncture has shown to have positive effects for physical pain and emotional symptoms including dysphoria and anxiety.
Gonadotropin-releasing hormone analogs (GnRH analogs or GnRH agonists) have also been used to treat PMDD. These drugs suppress estrogen production by the ovaries by inhibiting the secretion of regulatory hormones from the pituitary gland. As a result, menstrual periods stop, mimicking menopause. Nasal and injection forms of GnRH agonists are available. Examples of GnRH agonists include:
- leuprolide (Lupron)
- nafarelin (Synarel)
- and goserelin (Zoladex)
The side effects of GnRH agonist drugs are a result of the lack of estrogen and include hot flashes, vaginal dryness, irregular vaginal bleeding, mood changes, fatigue, and loss of bone density (osteoporosis). Adding back small amounts of estrogen and progesterone can help avoid or minimize many of the annoying side effects due to estrogen deficiency and help preserve bone density. PMDD may be driven by low levels of either progesterone or estrogen so some experimentation may be involved in discovering the appropriate level of these hormones.
Small studies reported relief of PMDD when a hysterectomy and bilateral oophorectomy were performed. Hysterectomy with oophorectomy should be considered a last-resort treatment option for women with severe PMDD that has not responded to standard treatments. In a 1990 study, fourteen women with severe, debilitating PMDD volunteered for a study of therapy by hysterectomy, oophorectomy, and continuous estrogen replacement. All had completed their families and had failed to benefit from previous medical treatments. Six months after surgery, PMDD symptom charting revealed that all of the women had complete relief of symptoms. 6 months after the operation, the women showed dramatic improvement in mood, general affect, well-being, life satisfaction, and overall quality of life. This study showed that surgical therapy, involving oophorectomy, hysterectomy, and continuous estrogen replacement, is effective in relieving the symptoms of PMDD.