Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
combined oral contraceptive (COC)
Used if contraception is desired. COCs containing drospirenone plus ethinyl estradiol may help treat premenstrual symptoms in women with severe symptoms.[77]
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Most research has focused on drospirenone-containing formulations and the only COC that is approved for the treatment of PMDD among patients seeking contraception is a drospirenone-containing preparation.[1] However, any COC is likely to improve symptoms; continuous administration is thought to be key to symptom relief (rather than the type of progestin used). Monophasic COCs may be better than mutiphasic COCs at improving mood symptoms.
Can be used cyclically or continuously. If initial treatment with cyclical COC fails then changing to a continuous regimen may be an appropriate next step. COCs can be prescribed continuously if a 4-day interval does not alleviate symptoms, although breakthrough bleeding can limit this option. This regimen has been shown to be superior to placebo with a levonorgestrel-containing pill.[79]
Women should be informed of the small increased risk of thromboembolic events with drospirenone, but this risk is not a contraindication to its use.[80]
Although the contraceptive patch and vaginal ring have the same mechanism of action as COCs, research is needed to confirm whether these methods are associated with a reduction in premenstrual symptoms.[1]
There are many different COCs available: consult product literature for guidance on dose.
combined oral contraceptive (COC)
There are no formal criteria available for defining moderate or severe PMS, and clinical judgement is usually used. Contributing factors include the patient's perception of symptom severity, impact on the patient's quality of life, and the presence or absence of distress or socioeconomic function. PMDD can be defined with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria.[5]
Used if contraception is desired. COCs containing drospirenone plus ethinyl estradiol may help treat premenstrual symptoms in women with severe symptoms.[77]
[ ]
Most research has focused on drospirenone-containing formulations and the only COC that is approved for the treatment of PMDD among patients seeking contraception is a drospirenone-containing preparation.[1] However, any COC will likely improve symptoms; continuous administration is thought to be key to symptom relief (rather than the type of progestin used). Monophasic COCs may be better than mutiphasic COCs at improving mood symptoms.
Can be used cyclically or continuously. If initial treatment with cyclical COC fails then changing to a continuous regimen may be an appropriate next step. COCs can be prescribed continuously if a 4-day interval does not alleviate symptoms, although breakthrough bleeding can limit this option. This regimen has been shown to be superior to placebo with a levonorgestrel-containing pill.[79]
Women should be informed of the small increased risk of thromboembolic events with drospirenone, but this risk is not a contraindication to its use.
May be used in combination with a selective serotonin-reuptake inhibitor in patients who do not respond to monotherapy.
Although the contraceptive patch and vaginal ring have the same mechanism of action as COCs, research is needed to confirm whether these methods are associated with a reduction in premenstrual symptoms.[1]
There are many different COCs available: consult product literature for guidance on dose.
low-dose selective serotonin-reuptake inhibitor (SSRI) or serotonin-noradrenaline reuptake inhibitor (SNRI)
There are no formal criteria available for defining moderate or severe PMS, and clinical judgement is usually used. Contributing factors include the patient's perception of symptom severity, impact on the patient's quality of life, and the presence or absence of distress or socioeconomic function. PMDD can be defined with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria.[5]
SSRIs can be used if COCs are contraindicated or if contraception is not desired. They inhibit reuptake of serotonin and address the neurotransmitter deficiency believed to underlie the pathogenesis of PMS or PMDD. They are considered to be more effective for behavioural symptoms than for physical symptoms of PMS/PMDD, although improvement in swelling/bloating and breast tenderness was reported in one review.[82] SSRIs have a rapid onset of action in the treatment of premenstrual symptoms and can start to improve symptoms within days.[1] Due to this quick treatment response, they are effective whether given continuously through the month or limited to the luteal phase. Limited evidence suggests that continuous and intermittent dosing regimens have comparable efficacy.[1]
Adverse effects include reduced libido, jitteriness, headache, dry mouth, and sleep disturbance.[81][83][100]
[ ]
Changes in sexual function and libido can be problematic in some women and typically last for as long as treatment is continued.[1]
A low starting dose is recommended; a higher dose may be prescribed if there is no response.[7]
Fluoxetine and sertraline are most frequently prescribed as first-line agents. Lack of response may necessitate an increased dose or a switch to a different drug. Switching from an intermittent to a continuous dosing regimen may be helpful, especially for patients who forget to take their medicine as directed.[1] In continuous users with persistent symptoms, increasing the dose during the luteal phase has been suggested.[1][83] Citalopram and escitalopram are well studied in PMS/PMDD.[81] Paroxetine is also effective, but may be more likely than other SSRIs to cause weight gain.
Relapse rate is high among patients who discontinue SSRI treatment for premenstrual disorders, and most patients will likely need to continue treatment until menopause.[1]
SNRIs, such as venlafaxine, have also been shown to be effective for PMS/PMDD. They may be a good choice for women with low energy symptoms. Withdrawal symptoms from SNRIs may be worse than those from SSRIs.
May be used in combination with a combined oral contraceptive in patients who do not respond to monotherapy.
Primary options
fluoxetine: 20 mg orally once daily
OR
sertraline: 50 mg orally once daily
OR
citalopram: 10 mg orally once daily
OR
paroxetine: 5-10 mg orally (immediate-release) once daily; 12.5 mg orally (controlled-release) once daily
OR
escitalopram: 10 mg orally once daily
Secondary options
venlafaxine: 25 mg orally (immediate-release) twice daily
higher-dose selective serotonin-reuptake inhibitor (SSRI) or serotonin-noradrenaline reuptake inhibitor (SNRI)
SSRIs inhibit reuptake of serotonin and address the neurotransmitter deficiency believed to underlie the pathogenesis of PMS or PMDD. They are considered to be more effective for behavioural symptoms than for physical symptoms of PMS/PMDD, although improvement in swelling/bloating and breast tenderness was reported in one review.[82] SSRIs have a rapid onset of action in the treatment of premenstrual symptoms and can start to improve symptoms within days.[1] Due to this quick treatment response, they are effective whether given continuously through the month or limited to the luteal phase. Limited evidence suggests that continuous and intermittent dosing regimens have comparable efficacy.[1]
Adverse effects include reduced libido, jitteriness, headache, dry mouth, and sleep disturbance.[81][83][100]
[ ]
Changes in sexual function and libido can be problematic in some women and typically last for as long as treatment is continued.[1]
About 30% to 40% of women do not respond to this treatment and there are no strong predictors of response.[84]
Fluoxetine and sertraline are most frequently prescribed first. Lack of response may necessitate a switch to a different drug. Switching from an intermittent to a continuous dosing regimen may be helpful, especially for patients who forget to take their medicine as directed.[1] In continuous users with persistent symptoms, increasing the dose during the luteal phase has been suggested.[1][83] Citalopram and escitalopram are well studied in PMS/PMDD.[81] Paroxetine is also effective, but may be more likely than other SSRIs to cause weight gain.
Relapse rate is high among patients who discontinue SSRI treatment for premenstrual disorders, and most patients will likely need to continue treatment until menopause.[1]
SNRIs, such as venlafaxine, have also been shown to be effective for PMS/PMDD. They may be a good choice for women with low energy symptoms. Withdrawal symptoms from SNRIs may be worse than those from SSRIs.
May be used in combination with a combined oral contraceptive in patients who do not respond to monotherapy.
Primary options
fluoxetine: 20-60 mg orally once daily
OR
sertraline: 50-150 mg orally once daily
OR
citalopram: 20-40 mg orally once daily
OR
paroxetine: 10-30 mg orally (immediate-release) once daily; 12.5 to 25 mg orally (controlled-release) once daily
OR
escitalopram: 20 mg orally once daily
Secondary options
venlafaxine: 25-100 mg orally (immediate-release) twice daily
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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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