SSRIs
Based on all of the scientific evidence, the first-line conservative treatment for PMDD are SSRIs (selective serotonin reuptake inhibitors, for example: sertraline)— about 60% of cycling individuals with PMDD benefit from SSRIs. Although SSRIs are thought to take a while to “kick in” in depression or anxiety, SSRIs seem to work faster in PMDD (working better than a sugar pill after about a day!). This leads many experts to believe that they are working through a different pathway to reduce PMDD. Because they work so quickly in PMDD, SSRIs can be taken only in the luteal phase, between ovulation and menses—or, they can be taken the whole month long. SSRIs seem to help the most with emotional PMDD symptoms, and less with physical symptoms.
Drospirenone-containing oral contraceptive pills
The second conservative treatment is drospirenone-containing oral contraceptive pills (DCOCs) that contain estrogen (.02 mg of ethinyl estradiol) plus a new progestin (3mg drospirenone), taken on a 24-4 schedule (24 active pills, 4 inactive pills). The brand name for this pill is “Yaz”, but generic versions contain the same hormones. Some studies show that DCOCs can help PMDD, but they don’t help emotional symptoms as much as SSRIs do. Some studies show that DCOCs seem to work especially well for physical PMDD symptoms.
If neither SSRIs nor DCOCs have been effective for PMDD after a few cycles, and the cyclical symptoms are severe, a doctor can prescribe other, more intensive cycle suppression treatments to suppress the cyclical hormone changes that are known to trigger PMDD.
Second line treatments
Some doctors (especially in the UK) use estrogen patches (transdermal estradiol) with intermittent courses of progestin pills to prevent ovulation and therefore suppress hormone cycling. There are some possible physical risks of this approach, particularly for those with family histories of estrogen-sensitive cancers, that you should discuss with your doctor. This approach is easiest and most commonly used in those who are beginning the perimenopause.
Some doctors (especially in the UK) use estrogen patches (transdermal estradiol) with intermittent courses of progestin pills to prevent ovulation and therefore suppress hormone cycling. There are some possible physical risks of this approach, particularly for those with family histories of estrogen-sensitive cancers, that you should discuss with your doctor. This approach is easiest and most commonly used in those who are beginning the perimenopause.
However, the more typical and best-studied cycle suppression method is a monthly injection of something called a GnRH agonist (there are several of these, but the most-used example is called leuprolide or Lupron), which shut down hormone production by the ovaries, causing a reversible menopause in which your hormone levels stay very low and flat. However, because female bodies need some hormones to stay healthy, the doctor will usually need to prescribe stable continuous doses of estrogen (for bone and heart health) and progesterone (to prevent risks associated with estrogen-only treatment). The bad news is that, during the first month of this “hormone add back” of estrogen and progesterone on top of the GnRH agonist, you may experience your PMDD symptoms again. The good news is that a recent study has found that this hormone addback-triggered “PMDD” only lasts about a month, after which the brain is able to recover from the surge of hormones and the symptoms go away despite the same levels of stable hormones. This most recent study is encouraging because it suggests that GnRH agonist therapy with stable continuous addback of estrogen and progesterone is a viable long-term treatment that can be used until the patient is through natural menopause (and does not necessarily need to lead to surgical menopause).
Surgery
If the GnRH agonist plus hormone addback (often called a “menopause trial”) improves PMDD symptoms but the patient is unable or unwilling to continue with GnRH agonist treatments, patients may choose to request a total hysterectomy with bilateral oophorectomy (removal of the uterus and both ovaries) to once-and-for-all remove the hormonal flux that causes symptoms. Bilateral oophorectomy (removal of the ovaries) eliminates hormone cycling, and usually eliminates cyclical symptoms in those with PMDD.
Removal of the ovaries is the critical piece of this treatment—if either ovary remains in your body, so will your PMDD. Both ovaries must be removed for this surgical treatment to be effective. Add-back of transdermal estrogen is also usually necessary during surgical menopause, and should be introduced gradually to reduce the risk of PMDD symptoms returning.
Tory Eisenlohr-Moul, PhD, July 2, 2019