Premenstrual dysphoric disorder (PMDD) is a serious condition that impairs your daily life, affecting everything from your job to your relationships. You feel irritable or have mood swings. You don’t enjoy the activities you normally enjoy. You have a tough time focusing on work or really anything. You feel tense or anxious. Your energy takes a nosedive, and your sleep and appetite shift, too.
Maybe you feel incredibly overwhelmed, or completely out of control. Maybe you feel hopeless and on edge. And, of course, on top of these emotional and cognitive symptoms, you also experience physical symptoms, such as bloating, breast tenderness, and cramps.
The good news is that PMDD is absolutely treatable. The first-line treatment is medication. Psychotherapy also may be beneficial. In some severe cases, surgery may help.
Some research has suggested that cognitive behavioral therapy (CBT) might be helpful for dealing with the emotional symptoms of premenstrual dysphoric disorder (PMDD). In CBT, therapists teach clients to challenge and change negative thoughts and develop effective, healthy coping skills.
Preliminary research has suggested that mindfulness-based therapies also might be helpful for emotional symptoms. For instance, after participating in mindfulness-based stress reduction (MBSR) in a pilot study, women experienced decreases in depression, hopelessness, anxiety, mood swings, sensitivity, irritability, and conflict with others. MBSR is an 8-week, evidence-based program that teaches various mindfulness practices, including sitting meditation, body scan, walking meditation, and gentle, mindful yoga movements.
Medications for PMDD
Three medications have been approved by the U.S. Food and Drug Administration (FDA) to treat PMDD: sertraline (Zoloft), fluoxetine (Prozac), and paroxetine HCI (Paxil). All three are selective serotonin reuptake inhibitors (SSRIs), which are considered the first-line treatment for PMDD.
Some women with PMDD take medication every day, while others take medication during the luteal phase (which starts after ovulation and ends when your period begins). (It normally takes weeks to feel the full benefits of SSRIs, but in women with PMDD, SSRIs work within hours or days.)
Some women also might take a lower dose of medication on a daily basis and then take a higher dose of the same medication during the luteal phase. The first two dosing regimens have been well-studied, and appear to be equally effective. The data on the third dosing schedule has been limited.
The type of dosage regimen you use will depend on several factors, such as whether your symptoms are present throughout your menstrual cycle and whether they’re predictable, along with your personal preference. For instance, if your periods are irregular, and thereby the onset of your symptoms is inconsistent, you’d likely benefit from continuous, daily treatment.
Side effects of SSRIs include nausea, headaches, insomnia, decreased energy, drowsiness, fatigue, sweating, and sexual dysfunction. Some of these side effects are short term. For instance, nausea ends within 4 or 5 days of starting the medication, and doesn’t come back at all with intermittent dosing (i.e., taking medication during the luteal phase). The most problematic side effect that does persist is sexual dysfunction, which includes decreased sex drive, delayed orgasm, and difficulty having an orgasm. Only taking an SSRI during the luteal phase might diminish these side effects.
About 60 to 70 percent of women with PMDD will get better with an SSRI, which means that about 30 to 40 percent will not. Unfortunately, we don’t know why some women respond and others don’t.
In some cases, switching to a different SSRI can help. In other cases, switching the dosing regimen can help. That is, if you started taking an SSRI during the luteal phase but didn’t get better, you might benefit from taking the medication every day—and vice versa.
Oral contraceptives are considered a second-line treatment intervention. They can be especially helpful for women who have painful or irregular periods. A birth control pill containing drospirenone and ethinyl estradiol (Yaz and Yasmin) has been approved by the FDA to treat PMDD. In 2012, the FDA issued a warning that Yaz and other oral contraceptives containing drospirenone increase the risk of blood clots.
The FDA, however, doesn’t recommend stopping these oral contraceptives. It does advise doctors to assess a woman’s risk for blood clots before starting the medication. The warning also states that the risk for blood clots is very small, and actually lower than the risk of blood clots during pregnancy.
A gonadotropin-releasing hormone (GnRH) agonist is typically used as a third-line treatment for women with severe PMDD symptoms who don’t respond to SSRIs or oral contraceptives. GnRH suppresses ovulation by causing the ovaries to stop producing estrogen and progesterone. A common form of GnRH is a monthly injection of leuprolide acetate at 3.75 mg.
Because GnRH induces menopause symptoms, it’s also given to women considering a hysterectomy and bilateral salpingo-oophrectomy (removal of the uterus and ovaries) to make sure they can tolerate and benefit from such a permanent solution. (Surgery is considered as a last resort for severe, disabling symptoms.)
Because it mimics menopause, GnRH has significant side effects, including: hot flashes, vaginitis, and a decrease in bone density. To prevent bone loss, doctors typically initiate add-back therapy, which involves prescribing progestin or a combination of estrogen and progestin.
When talking with your doctor about your treatment, be sure to express any questions or concerns that you have. Ask about possible side effects, so you’re well-aware of what to expect, and fully understand the specific intervention. Speak up, and always advocate for yourself.
- Seek support. We don’t hear much about premenstrual dysphoric disorder (PMDD), so it’s understandable if you feel like you’re the only one who has this illness. The International Association for Premenstrual Disorders (IAPMD) offers a variety of resources, including peer support. Reach out, and know you’re absolutely not alone.
- Exercise. Stress can exacerbate PMDD, so incorporating exercise—which lowers stress and anxiety—into your routine can be helpful. Exercise can be anything from a dance class to a walk around the block. The key is to engage in physical activities you genuinely like.
- Practice relaxation techniques. This is also helpful in managing stress and anxiety. For instance, you might listen to guided meditations, practice progressive muscle relaxation, and start an at-home yoga practice.
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