There are some studies showing that birth control pills (especially drospirenone-containing oral contraceptives (DCOC) – brand name “Yaz”) and birth control pills given with a shortened hormone-free interval (fewer sugar pills) are helpful for PMDD. However, not all studies show a benefit of DCOC over placebo, and they don’t appear to perform as well as SSRIs for treating PMDD.  Of note, all of these studies showing a benefit of DCOC use a 24-4 schedule (24 active pills, 4 inactive pills) or continuous schedule (where no inactive pills are taken). 

None of the studies using a 21-7 schedule show a benefit or oral contraceptives for PMDD. We suspect this is because patients experience more hormone flux during and after the 7 days of inactive pills on the 21-7 schedule, and therefore hormone flux and PMDD come back. So if you take oral contraceptives for PMDD, the evidence suggests you should start with a DCOC (such as “Yaz”) on a 24-4 or continuous dosing schedule.

However, many people cannot tolerate the progestins in hormonal contraceptives (pill, patch, shot, implant) at all. This progestin-sensitive syndrome has been recognized by the International Society for Premenstrual Disorders, and is an active area of investigation in several European laboratories. Unfortunately, however, we don’t yet understand who is at risk for a negative reaction to hormonal contraceptives, so it is a trial and error situation.

Although birth control pills might be more appealing because they impact the reproductive system, SSRIs are actually the first line medical treatment for PMDD— they probably work by helping to regulate serotonin in the brain and by regulating conversion of progesterone to neurosteroids, which improves neurosteroid stability and thereby reduces symptoms. 

So even though they are working in the brain and not the reproductive system, they do address the biological mechanisms of PMDD symptoms. It should also be noted that SSRIs seem to work faster in PMDD than in depression/anxiety-- they start to beat placebo (sugar pill) after about one day. So they might work differently in PMDD than they do in depression.

Updated 19 June, 2018 by Tory Eisenlohr-Moul, PhD

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