Premenstrual Dysphoric Disorder

Premenstrual Dysphoric Disorder also called “PMDD” or PMS depression is a more severe form of premenstrual syndrome (PMS) characterized by extreme mood swings, anxiety, irritability, and depression, occurring in the week or two before your period starts (the luteal phase), most commonly in the days preceding menstruation ¹, ², ³, ⁴. And your symptoms usually go away two to three days after your period starts. Premenstrual Dysphoric Disorder (PMDD) is considered a mood disorder affecting young adult women that causes significant emotional, psychological, and physical symptoms, with significant distress or impairment in menstruating women during the the second half of a menstrual cycle occurring after ovulation and before the next period of your menstrual cycle. Premenstrual Dysphoric Disorder (PMDD) symptoms include mood swings, irritability, depression and fatigue are usually so severe that the young or adult woman misses school, work and/or avoids her regular social activities.

Symptoms of premenstrual dysphoric disorder (PMDD) include ⁵:

• Lasting irritability or anger that may affect other people
• Feelings of sadness or despair, or even thoughts of suicide
• Feelings of tension or anxiety
• Panic attacks
• Mood swings
• Sadness and crying often
• Lack of interest in daily activities and relationships
• Trouble thinking or focusing
• Tiredness or low energy
• Fatigue
• Food cravings or binge eating
• Trouble sleeping
• Feeling out of control
• Problems paying attention and concentrating
• Physical symptoms, such as cramps, bloating, breast tenderness, headaches, and joint or muscle pain

It is largely the emotional symptoms that are more severe when you have PMDD. You may have more severe depression symptoms, irritability, and tension ⁶. Premenstrual Dysphoric Disorder (PMDD) is diagnosed when women have 5 or more of the most common premenstrual syndrome (PMS) symptoms during the second half of her menstrual cycle for at least 2 menstrual cycles in a row, and symptoms are not due to a medical condition such as thyroid disease. According to the American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Premenstrual Dysphoric Disorder (PMDD) is recognized as a mental health condition ⁵.

To help diagnose PMDD, your doctor may ask you to chart your symptoms (see sample chart in Figure 2 below).

Premenstrual Dysphoric Disorder (PMDD) affects up to 5% of women of childbearing age ⁷. If you suspect you have Premenstrual Dysphoric Disorder (PMDD), it’s important to talk to your doctor. A thorough medical evaluation may determine if your symptoms are due to premenstrual dysphoric disorder or some other condition. If you’re diagnosed with premenstrual dysphoric disorder (PMDD), your doctor can recommend specific treatments to help minimize your symptoms. Premenstrual Dysphoric Disorder (PMDD) treatment options may include dietary and lifestyle changes, medications such as antidepressants or birth control pills or other therapies.

Treatments for PMDD include:

• Diet and lifestyle changes. Regular exercise often reduces premenstrual symptoms. Cutting back on caffeine, avoiding alcohol and stopping smoking may ease symptoms, too. Getting enough sleep and using relaxation techniques, such as mindfulness, meditation and yoga, also may help. Avoid stressful and emotional triggers, such as arguments over financial issues or relationship problems, whenever possible.
• Nutritional supplements. Consuming 1,200 milligrams of calcium daily may possibly reduce symptoms of PMS and PMDD. Vitamin B6 (pyridoxine), magnesium and L-tryptophan also may help, but talk with your doctor for advice before taking any supplements.
• Herbal remedies. Some research suggests that chasteberry (Vitex agnus-castus) may possibly reduce irritability, mood swings, breast tenderness, swelling, cramps and food cravings associated with PMDD, but more research is needed. The U.S. Food and Drug Administration doesn’t regulate herbal supplements, so talk with your doctor before trying one.
• Antidepressants called selective serotonin reuptake inhibitors (SSRIs). SSRIs change serotonin levels in your brain. The Food and Drug Administration (FDA) approved three SSRIs to treat PMDD:
  • Sertraline
  • Fluoxetine
  • Paroxetine
• Birth control pills. The FDA has approved a birth control pill containing drospirenone and ethinyl estradiol, to treat PMDD.
• Over-the-counter pain relievers may help relieve physical symptoms, such as cramps, joint pain, headaches, backaches, and breast tenderness. These include:
  • Ibuprofen
  • Naproxen
  • Aspirin
  • Stress management, such as relaxation techniques and spending time on activities you enjoy ⁸

Making healthy changes, such as eating a healthy combination of foods across the food groups, cutting back on salty and sugary foods, and getting more physical activity, may also help relieve some PMDD symptoms. But PMDD can be serious enough that some women should go to a doctor to discuss treatment options. According to a meta-analysis, women with PMDD have a fourfold higher risk of suicidal thoughts and a sevenfold higher risk of suicidal attempts ⁹. And, if you are thinking of hurting yourself or others, call your local emergency services number right away.

What is menstrual cycle?

Your menstrual cycle is the monthly hormonal cycle a female’s body goes through to prepare for pregnancy. Your menstrual cycle is counted from the first day of your period up to the first day of your next period. Your hormone levels (estrogen and progesterone) usually change throughout the menstrual cycle and can cause menstrual symptoms.

During your monthly menstrual cycle, your uterus lining builds up to prepare for pregnancy. If you do not get pregnant, estrogen and progesterone hormone levels begin falling. Very low levels of estrogen and progesterone tell your body to begin menstruation.

Periods usually start between age 11 and 14 (a girl’s first period is called menarche) and continue until menopause at about age 51 ¹⁰. In the United States, most girls start menstruating shortly after 12 years of age ¹¹. The average menstruation time in normally menstruating women is 3 to 5 days ¹² but a normal menstrual period can lasts up to 8 days ¹³. Besides bleeding from the vagina, you may have:

• Abdominal or pelvic cramping pain
• Lower back pain
• Bloating and sore breasts
• Food cravings
• Mood swings and irritability
• Headache and fatigue.

Regular menstrual periods in the years between puberty and menopause are usually a sign that your body is working normally. Irregular or heavy, painful periods are not normal. Many women also get premenstrual syndrome (PMS) symptoms.

Figure 1. Ovarian activity during the Menstrual cycle

Footnotes: Major events in the female menstrual cycle. (a) Plasma hormonal concentrations of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) affect follicle maturation in the ovaries. (b) Plasma hormonal concentrations of estrogen and progesterone influence changes in the uterine lining.

How long is a typical menstrual cycle?

The typical menstrual cycle is 28 days long, but each woman is different ¹⁴. Also, a woman’s menstrual cycle length might be different from month-to-month. Your periods are still “regular” if they usually come every 24 to 38 days ¹⁵. This means that the time from the first day of your last period up to the start of your next period is at least 24 days but not more than 38 days.

Some women’s periods are so regular that they can predict the day and time that their periods will start. Other women are regular but can only predict the start of their period within a few days.

What is ovulation?

Ovulation is when the ovary releases an egg so it can be fertilized by a sperm in order to make a baby. A woman is most likely to get pregnant if she has sex without birth control in the three days before and up to the day of ovulation (since the sperm are already in place and ready to fertilize the egg as soon as it is released). A man’s sperm can live for 3 to 5 days in a woman’s reproductive organs, but a woman’s egg lives for just 12 to 24 hours after ovulation.

Each woman’s cycle length may be different, and the time between ovulation and when the next period starts can be anywhere from one week (7 days) to more than 2 weeks (19 days) ¹⁶.

At different times in a woman’s life, ovulation may or may not happen:

• Women who are pregnant do not ovulate.
• Women who are breastfeeding may or may not ovulate. Women who are breastfeeding should talk to their doctor about birth control methods if they do not want to get pregnant.
• During perimenopause, the transition to menopause, you may not ovulate every month.
• After menopause you do not ovulate.

How can I keep track of my menstrual cycle?

You can keep track of your menstrual cycle by marking the day you start your period on a calendar. After a few months, you can begin to see if your periods are regular or if your cycles are different each month.

You may want to track:

• Premenstrual syndrome (PMS) symptoms: Did you have cramping, headaches, moodiness, forgetfulness, bloating, or breast tenderness?
• When your bleeding begins: Was it earlier or later than expected?
• How heavy the bleeding was on your heaviest days: Was the bleeding heavier or lighter than usual? How many pads or tampons did you use?
• Period symptoms: Did you have pain or bleeding on any days that caused you to miss work or school?
• How many days your period lasted: Was your period shorter or longer than the month before?

You can also download apps (sometimes for free) for your phone to track your periods. Some include features to track your PMS symptoms, energy and activity levels, and more.

Why should I keep track of my menstrual cycle?

If your periods are regular, tracking them will help you know when you ovulate, when you are most likely to get pregnant, and when to expect your next period to start.

If your periods are not regular, tracking them can help you share any problems with your doctor.

If you have period pain or bleeding that causes you to miss school or work, tracking these period symptoms will help you and your doctor or nurse find treatments that work for you. Severe pain or bleeding that causes you to miss regular activities is not normal and can be treated.

Who gets premenstrual dysphoric disorder?

Premenstrual Dysphoric Disorder (PMDD) affects up to 5% of women of childbearing age ⁷. Many women with PMDD may also have anxiety or depression ¹⁷.

Is premenstrual dysphoric disorder considered a mental illness?

Premenstrual dysphoric disorder (PMDD) is a mental health condition listed in the DSM-5 as a “depressive disorder” ⁵. The DSM-5 stands for Diagnostic and Statistical Manual of Mental Disorders and is a criteria for diagnosing mental health conditions.

Is premenstrual dysphoric disorder a form of bipolar disorder?

No. Premenstrual dysphoric disorder (PMDD) and bipolar disorder aren’t the same condition. They do, however, have similar symptoms. During a depressive episode in bipolar disorder, you may feel irritable or like you’re losing control. You may also have suicidal thoughts. It’s important to get support and seek help if you have symptoms of either condition.

Can I prevent premenstrual dysphoric disorder?

Treating existing depression or anxiety may make it less likely that PMS could become premenstrual dysphoric disorder (PMDD). But PMDD could be related to the way your hormones work, and you might not be able to prevent it. In that case, treatment can bring relief.

Many women with premenstrual dysphoric disorder (PMDD) have:

• Anxiety
• Severe depression
• Seasonal affective disorder (SAD)

Other factors that may play a role include:

• Alcohol or substance abuse
• Cigarette smoking
• Thyroid disorders
• Being overweight
• Having a mother with a history of the disorder
• Lack of exercise
• Family history of PMS or PMDD
• Personal or family history of depression, postpartum depression, or other mood disorders
• Less access to education about the management and treatment of PMDD.

Can you cure premenstrual dysphoric disorder naturally?

There are some ways to manage symptoms of premenstrual dysphoric disorder (PMDD) that don’t involve medication. For example, you can practice yoga, try meditation or find other ways to improve your mood. Regular exercise often reduces premenstrual symptoms. Cutting back on caffeine, avoiding alcohol and stopping smoking may ease symptoms, too. Getting enough sleep and changing certain aspects of your diet may also bring relief. Avoid stressful and emotional triggers, such as arguments over financial issues or relationship problems, whenever possible. Additionally, support groups or resources may help you.

PMDD vs PMS

Premenstrual dysphoric disorder (PMDD) can be considered a severe form of premenstrual syndrome (PMS) ¹, ¹⁸, ¹⁹. While both PMDD (Premenstrual Dysphoric Disorder) and PMS (Premenstrual Syndrome) involve physical and emotional symptoms that occur in the second half of a woman’s menstrual cycle, about 10-14 days before your period, PMS involves milder physical and emotional symptoms and PMDD is a more severe and disabling form of PMS, characterized by intense mood swings and emotional distress such as extreme depression, irritability, and anxiety that can be disabling significantly impacting your daily life. You may feel they are uncontrollable.

PMS (Premenstrual Syndrome)

Footnotes: Patients should record the score for each item on each day using the following scale: 1 = not at all, 2 = minimal, 3 = mild, 4 = moderate, 5 = severe, 6 = extreme. If during the mid-follicular phase (days 6 through 10; day 1 is first day of your period) the patient has an average daily score greater than 3 for any symptom, an alternative diagnosis should be sought. Excused symptoms include appetite for obese patients, insomnia with good reasons, or pain from physical illness. The week before menses, the patient should score at least 4 for at least two days on five symptoms that correlate with premenstrual dysphoric disorder diagnostic criteria (DSM-5). The week before menses, the patient should score at least 4 for at least two days on at least one impairment item. The patient must meet these criteria for two consecutive cycles or two out of three cycles. Clinical judgment should correlate with the assessment of daily ratings.

Premenstrual Dysphoric Disorder Assessment Scales

• Premenstrual Symptom Screening Tool (PSST): A questionnaire used to diagnose Premenstrual Dysphoric Disorder (PMDD) with 19 items that allow the patient to rate the severity of their symptoms ³⁹.
• Calendar of Premenstrual Experiences (COPE): Includes 22 symptoms grouped into 4 categories: mood reactivity, autonomic/ cognitive, appetitive, and related to fluid retention ⁴⁰.
• Visual Analogue Scale (VAS): Steiner et al ³⁹ used this scale in 1999 to rate each of the 4 core symptoms of PMDD: mood swings, irritability, tension, and depression. The scale consisted of a 100 mm vertical line labeled 0 or “no symptom” at the left end and 100 or “severe” at the right.
• Daily Record of Severity of Problems (DRSP): This scale consists of 24 items, out of which 21 items are grouped into 11 distinct symptoms and 3 functional impairment items. The items are rated from 1 (not at all) to 6 (extreme).
• Patient Reported Outcomes Measurement Information System (PROMIS): Junghaenel et al ⁴¹ used PROMIS computerized adaptive testing (PROMIS CAT) to detect premenstrual symptoms of depression, anxiety, and fatigue; the results of the study provided encouraging evidence for the utility of PROMIS instruments for the measurement of effective premenstrual symptoms.

Premenstrual Dysphoric Disorder Differential Diagnosis

The symptoms of premenstrual dysphoric disorder (PMDD) can overlap with other psychiatric disorders, most importantly major depression, and it is important to rule out another existing disorder before making the diagnosis of PMS or PMDD. The key factor in making the diagnosis of PMS and PMDD is the timing of your symptoms with your menstrual cycle ¹. Symptoms must occur during the luteal phase and resolve shortly after the onset of menstruation. Other conditions, such as depression or anxiety, may worsen during the luteal phase, but these can be distinguished from PMS because they persist throughout the menstrual cycle. Migraines, anemia, endometriosis, and hypothyroidism may produce symptoms similar to PMS or PMDD and should also be considered.

Some common premenstrual dysphoric disorder (PMDD) differentials include:

• Major depressive disorder: Depression symptoms include low mood, low energy, anhedonia, appetite change, sleep disturbance, difficulty concentrating, and thoughts of suicide. Roughly half the cases of PMS/Premenstrual Dysphoric Disorder (PMDD) can have a coexisting diagnosis of depression.[50] A diagnosis of PMS or Premenstrual Dysphoric Disorder (PMDD) may predate a diagnosis of depression or depression and Premenstrual Dysphoric Disorder (PMDD) may coexist. Criteria for the diagnosis of these disorders are different but not exclusive.
• Thyroid disease (hyperthyroid or hypothyroid):
  • Hypothyroid (underactive thyroid) symptoms and signs include weight gain, constipation, cold intolerance, depression, dry skin, and delayed deep tendon reflexes.
  • Hyperthyroid (hyperactive thyroid) signs and symptoms include weight loss, poor sleep, heat intolerance, heart rhythm disturbance such as atrial fibrillation, and hyperreflexia.
• Generalized anxiety disorder (GAD): Generalized Anxiety Disorder (GAD) is a mental health condition characterized by persistent and excessive worry and anxiety about everyday events, often interfering with daily life and accompanied by physical symptoms like restlessness or fatigue. Triggers may be identified for anxiety attacks, and the patient shows avoidance of these triggers. Chronic or situational anxiety does not vary with the menstrual cycle. Generalized anxiety disorder and premenstrual dysphoric disorder (PMDD) may coexist. Criteria are different but not exclusive.
• Mastalgia (breast pain): Mastalgia is breast pain. The pain can range from minor discomfort to severely disabling pain in some cases. Many people with breast pain are afraid they may have breast cancer. But breast pain is rarely linked to breast cancer. It should not be considered a possible symptom of breast cancer. There are 2 main types of mastalgia (breast pain):
  • Cyclical breast pain. The most common type of breast pain is linked to the menstrual cycle. It is nearly always hormonal. Some people begin to have pain around the time of ovulation. The pain continues until the start of their menstrual cycle. The pain may be barely noticeable. Or it may be so severe that you can’t wear tight-fitting clothing or handle close contact of any kind. The pain may be felt in only one breast. Or it may be felt as a radiating feeling in the underarm area.
  • Noncyclic breast pain. The pain may come from the breast. Or it may come from somewhere else, such as nearby muscles or joints, and may be felt in the breast.

Premenstrual Dysphoric Disorder treatment

There are 3 broad approaches to treating premenstrual dysphoric disorder (PMDD). While most experts recommend a combination of all 3, there have been no scientific studies to determine if combination treatment is really the best approach. It is likely that the best approach or combination of approaches will vary from woman to woman based on things like symptom severity and which symptoms are most troublesome.

Here are the 3 approaches with some examples of each:

1. Medications – including antidepressants, antianxiety drugs, analgesics, hormones and diuretics.
2. Psychobehavioral – including exercise and psychotherapies (cognitive-behavioral therapy, coping skills training, relaxation).
3. Nutritional – including diet modification, vitamins, minerals and herbal preparations.

Dietary and Lifestyle Changes

• Lifestyle changes. Regular exercise often reduces premenstrual symptoms. Getting enough sleep and using relaxation techniques, such as mindfulness, meditation and yoga, also may help. Avoid stressful and emotional triggers, such as arguments over financial issues or relationship problems, whenever possible.
• Dietary modifications: Increased intake of complex carbohydrates or proteins (“slow-burning fuels”) is believed to increase tryptophan availability, leading to increased serotonin levels. Cutting back caffeine, avoiding alcohol and stopping smoking may ease symptoms, too.
• Nutritional supplements. Consuming 1,200 milligrams of dietary and supplemental calcium daily may possibly reduce symptoms of PMS and premenstrual dysphoric disorder (PMDD) in some women, however the exact mechanism of action of calcium in PMS or PMDD is unknown ⁴². Randomized controlled trials have demonstrated the superiority of calcium in improving emotional and physical symptoms over placebo. A randomized controlled trial of 179 Tehran University students who met criteria for PMS without another psychiatric diagnosis found a 50% reduction in depression, appetite, and fatigue in women who received 500 mg of supplemental calcium carbonate twice daily for three months ⁴³. This result was also demonstrated in a U.S. study of more than 400 women who supplemented with 1,200 mg of calcium carbonate daily ⁴². Vitamin B6 (pyridoxine), vitamin D, magnesium and L-tryptophan also may help. Vitamin D supplementation for treatment of PMS and PMDD symptoms was reviewed in a cross-sectional analysis of a large study ⁴⁴. The cross-section analyzed was too small to make strong conclusions about the benefit of vitamin D ⁴⁴. A separate study followed 401 women for 16 years and compared those who developed PMS with those who did not ⁴⁵. The analysis concluded that low vitamin D levels were not associated with an increased risk of PMS ⁴⁵. Further studies are needed to support the use of vitamin D as a treatment for symptoms of PMS and PMDD. Vitamin B6 (Pyridoxine) at a dosage of 80 mg per day has also been studied and recommended as treatment for primarily psychological symptoms of PMS, but these studies are small and more data is needed to recommend it as first-line treatment ⁴⁶. Talk with your doctor for advice before taking any supplements.
• Herbal remedies. Some research suggests that Chaster-berry or Vitex agnus-castus (a herb also known as Chaste Tree and Monk’s Pepper) may possibly reduce irritability, mood swings, breast tenderness, swelling, cramps and food cravings associated with premenstrual dysphoric disorder (PMDD) by exerting some dopaminergic effect, but more research is needed ⁴⁷, ³. The Food and Drug Administration doesn’t regulate herbal supplements, so talk with your doctor before trying one.
• Stress management: Relaxation/ meditation/ yoga/ breathing techniques.
• Cognitive Behavioral Therapy (CBT). A 2009 meta-analysis analyzed seven trials, three of which were randomized controlled trials, and showed improvement in functioning and depression scores for patients with PMS or PMDD ⁴⁸. The frequency and duration of cogntive behavioral therapy (CBT) were not defined. However, the results suggest that mindfulness-based exercises and acceptance-based cognitive behavior therapy may be helpful for reducing symptoms. Further studies are needed to support the use of cognitive behavior therapy as first-line therapy.

Medications

Treatment of premenstrual dysphoric disorder is directed at preventing or minimizing symptoms and may include:

• Antidepressants. 
  • In the United States, selective serotonin reuptake inhibitors (SSRIs) are approved as first-line treatment for severe symptoms of PMS and PMDD. Although SSRIs are considered psychiatric medications, when used to treat premenstrual disorders they improve physical and psychiatric symptoms in most patients ⁴⁹. Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil) and sertraline (Zoloft), may reduce symptoms such as emotional symptoms, fatigue, food cravings and sleep problems ⁴⁹,  ⁵⁰, ⁵¹. You can reduce symptoms of premenstrual dysphoric disorder by taking SSRIs all month or only in the interval between ovulation and the start of your period. SSRI treatment probably increases your risk of adverse events, with the most common being nausea, weakness or lack of energy and drowsiness or excessive sleepiness ⁴⁹.
  • Antidepressants that predominantly affect noradrenergic transmission are not as effective for PMDD as SSRIs, which means that the effect of SSRIs in PMDD is not just an antidepressant effect ⁵², ⁵³. This is supported by the fact that the beneficial effect of SSRIs begins rapidly in PMDD, whereas antidepressant effect takes several weeks. Therefore, clinicians can use SSRIs intermittently from mid-cycle to menses to treat symptoms of PMDD as opposed to continuous treatment ⁵⁴. Side effects of SSRIs are usually mild. Nausea is the most common adverse effect, but it usually wears off in a couple of days after starting the therapy and doesn’t reappear even if the therapy is intermittent. Reduced libido and difficulty in achieving orgasm (anorgasmia) are other common side effects, but they are absent in drug-free intervals.
  • Other antidepressants that are linked with the relief of symptoms include a tricyclic antidepressant (TCA) called Clomipramine ⁵⁵, ⁵⁶ and serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine (Effexor).
  • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) such as venlafaxine (Effexor) have been used off-label to treat PMDD in women with predominantly psychological symptoms ⁵⁷. The effect is achieved over a relatively short period, three to four weeks, and sustained throughout subsequent menstrual cycles ⁵⁷.
• Benzodiazepines: Benzodiazepines like alprazolam have been found to be effective only in women with severe anxiety and premenstrual insomnia. However, since there is a risk of dependence, careful monitoring is required, especially in cases with reported prior substance abuse ⁵⁸, ⁵⁹.
• Hormonal therapies: For very severe symptoms, your doctor can use hormonal therapies to provide relief. The aim of hormonal therapy is to inhibit the hypothalamic-gonadal cycle; however, this causes medical menopause and leads to hot flashes and an increased risk of osteoporosis. Therefore, to prevent these adverse effects, women are also started back on estrogen and gestagen (a hormone with progesterone-like activity). Some patient reports suggesting recurrence of symptoms with the add-back gestagen (a hormone with progesterone-like activity) therapy. Hence, as an alternative, clinicians can combine gonadotropin hormone-releasing hormone (GnRH) agonist with tibolone (a synthetic steroid with weak estrogenic, progestogenic, and androgenic activity). Guidelines from the International Society of Premenstrual Disorders addressed gonadotropin-releasing hormone (GnRH) agonists as potential treatment of PMS and PMDD by eliminating luteal phase symptoms ⁶⁰. Although these medications have been used since the 1980s and are effective, they are not practical for long-term use because of the increased heart and blood vessels disease and osteoporosis risks associated with extended use ⁶⁰. Long-term users often need hormone add-back therapy to counteract many of their hypoestrogenic effects, which may cause a return of PMS symptoms ⁶¹.
• Birth control pills or oral contraceptive pills (OCPs). Taking birth control pills with no pill-free interval or with a shortened pill-free interval may reduce PMS and premenstrual dysphoric disorder (PMDD) symptoms for some women. Although oral birth control pills are widely used in clinical practice, their efficacy in treating PMDD has not been strongly supported by evidence. Studies have suggested that oral contraceptives provide benefit when treating physical and psychiatric symptoms of PMS or PMDD. Researchers analyzed four moderate-quality trials of continuous oral contraceptive use (90 mcg levonorgestrel/20 mcg ethinyl estradiol) in women who tracked their symptoms on the Daily Record of Severity of Problems ⁶². Although results were somewhat inconsistent, an improvement in depressive and physical symptoms (from 30% to 59%) was identified. A higher placebo response occurred in women with PMDD, which suggests that a greater improvement occurred in women with predominantly psychiatric symptoms at baseline ⁶², ⁶³. A separate PMDD trial found that continuous treatment for 112 days resulted in the most improvement in Daily Record of Severity of Problems scores ⁶³. Women on oral birth control pills experience more hormone-related symptoms on hormone-free days, and hence oral birth control pills treatment with fewer hormone-free days might be beneficial to these women.
• Drospirenone (a man-made progesterone) was particularly found to be effective in treating PMDD symptoms because of its anti-aldosterone and anti-androgenic effects. A 2023 Cochrane review of oral contraceptives containing drospirenone evaluated five trials with 858 women ⁶⁴. Combined oral contraceptives with drospirenone and ethinylestradiol 20 μg may improve premenstrual symptoms in women with premenstrual dysphoric disorder (PMDD) ⁶⁴. However, a powerful placebo effect was evident: in one trial, symptoms were reduced for 48% of the combined oral contraceptives containing drospirenone group versus 36% of the placebo group. The difference may not be clinically significant. Furthermore, combined oral contraceptives containing drospirenone may lead to more adverse effects compared to placebo. The effectiveness after three cycles is unknown. Little evidence exists for treating less severe symptoms, and determining whether combined oral contraceptives containing drospirenone work any better than other combined oral contraceptives that contain a different progestogen ⁶⁴.
• Danazol: This is a synthetic partial androgen agonist/antagonist and gonadotropin inhibitor that has also been shown to be efficacious in treating PMDD by inhibiting ovulation. However, it is associated with hirsutism and teratogenicity and thus not preferred as an initial agent.

Premenstrual Dysphoric Disorder prognosis

When undergoing treatment for premenstrual dysphoric disorder, symptoms tend to improve rapidly and you’re able to enjoy your life more fully. After cessation of treatment, symptoms recur rapidly, and their reemergence is more predictable than that with other mood disorders such as major depressive disorder. Symptoms do not usually recur after removal of the ovaries. Most women don’t have symptoms after menopause.

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