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PMDD, part II: How Is Premenstrual Dysphoric Disorder Treated?

PMDD, part II: How Is Premenstrual Dysphoric Disorder Treated?

Teena Merlan | April 25, 2020 | Women's Health
Medically reviewed by: Dr. Don Aptekar, MD, FACOG

In the first part of this premenstrual dysphoric disorder (PMDD) series, we covered what PMDD is and how it’s diagnosed. Now we’ll dive into how PMDD is treated with prescription medication and natural remedies.

Research on the effectiveness of PMDD treatment approaches is limited and primarily based on PMS treatment. Though PMDD and PMS are different, there is some overlap with symptoms and treatment recommendations. The effectiveness of treatment for PMDD symptoms has not been widely studied.  

The treatment goals for PMDD are to reduce symptoms and improve your ability to function in both work and personal life, which would in turn enhance your overall quality of life (1). Treatment is as individual as you are, which means that finding what works may require a bit of trial and error (2), and a multidisciplinary approach may be needed (3). Always speak with your doctor before making any changes to your health routine. Though the approaches below have not been studied extensively, lifestyle changes like eating a healthier diet and getting more exercise are beneficial in many ways and are always worth the effort (4). 

Here are some treatments your healthcare provider may suggest or prescribe to alleviate your symptoms (in no particular order): 

Medications

A wide variety of prescription and over-the-counter medications may be  used to treat PMDD symptoms, including hormone-altering medications like hormonal birth control and ovulation suppressors (5), antidepressants (1), anti-anxiety medications, and non-steroidal anti-inflammatory drugs (NSAIDs) (3). Doctors usually recommend using medications for at least 3 cycles before deciding whether or not the treatment is effective (3).

Birth control pills specifically formulated with drospirenone and ethinyl estradiol (brand name Yaz®) are approved by the FDA to treat PMDD (3), but as with any medication, they also have a list of side effects to consider. Specifically, Yaz® was recalled by the FDA to add warnings to the label: Some studies found birth control containing drospirenone to increase the risk of blood clots as much as three times compared to those containing levonorgestrel (another hormone commonly found in birth control) — yet other studies found no additional risk (6). Additionally, treatment with hormonal birth control has mixed results, causing some patients to feel better while causing other patients’ symptoms to worsen. (5). 

A specific class of antidepressants called selective serotonin reuptake inhibitors (SSRIs) are usually the first medication prescribed and are the only class of antidepressant that is approved by the FDA to treat PMDD (7) because serotonin is affected by estrogen and progesterone, and is suspected to play a part in causing mood-related symptoms of PMDD (50). Fluoxetine (Prozac®), sertraline (Zoloft®), and paroxetine (Paxil) are the only SSRIs approved by the FDA for specifically treating PMDD and have been shown to be effective if they’re only taken during the luteal phase or throughout the cycle (1, 7). SSRIs have been found to improve all symptoms of PMDD, not just those that are mood related (1), but they have also been found to be effective in only 60% to 75% of cases (5) and may also cause nausea, jitteriness, headaches, decreased sexual interest, and may interfere with the ability to orgasm (8). These sexual side effects may persist even when the dosing is intermittent (4). 

Alprazolam (Xanax®) is an anti-anxiety medication that has been shown to reduce premenstrual anxiety and other premenstrual symptoms (9). Due to the high potential for dependence and abuse of this type of medication, the American Academy of Family Physicians recommends this treatment in low doses during the luteal phase and only for patients who do not have a history of substance abuse and do not respond to SSRIs (1).  

Over-the-counter NSAIDs such as ibuprofen (Advil®) may improve headaches and back, breast, and other pain symptoms, but effects on mood-related symptoms are limited (1). NSAIDs also have side effects, including increasing your risk of heart attack and stroke; experts recommend that you only take enough to be effective and for a short amount of time (10).

Diet and Lifestyle Changes

Sufficient studies have not been conducted on how dietary changes affect PMDD, but diet changes during the luteal phase may result in relief for certain symptoms (11). Reducing or eliminating nicotine use is commonly recommended (9), especially if one of your symptoms is insomnia. Reducing caffeine intake and alcohol consumption is also recommended, since these can also disrupt sleep (12). 

Preliminary studies suggest that eating more protein (4) and complex carbohydrates during the luteal phase may improve mood, control carbohydrate cravings (12), and improve memory (3, 11). Complex carbohydrates can be found in beans, peas, whole grains, and vegetables (13). These dietary changes may also improve overall symptoms by increasing tryptophan, a precursor to serotonin (4). Low serotonin levels have been associated with decreased physical and mental health, and evidence suggests that tryptophan increases brain serotonin and acts as an effective antidepressant in mild or moderate cases of depression (14).

Increasing water intake is also advised, as staying hydrated decreases bloating and improves digestion. Decreasing salt intake may also reduce swelling, bloating, and breast tenderness (12).

Exercise

Regular exercise can improve premenstrual symptoms (3) and relieve stress (15) that may produce or exacerbate symptoms (16); therefore, increasing physical activity is recommended as a potential treatment for PMDD (5). One study found that yoga improved physical premenstrual symptoms and decreased the use of over-the-counter pain medications (17). Though not studied for PMDD specifically, many studies have found that aerobic exercise improves mood and energy levels (4). The greatest benefits are associated with exercising 5 days per week for 30 minutes each day, but a few days per week of exercise is better than none (5).

Meditation 

Stress and anxiety may exacerbate symptoms of PMDD (16), and PMDD itself can cause stress and anxiety (14); thus, using stress-reducing and relaxation techniques like meditation and mindfulness may be beneficial in easing certain symptoms of PMDD (5, 18). Look for a meditation center or group in your area if you want to meditate with others. If you prefer to meditate at home, try your phone’s app store for an app (Headspace is popular for both Apple and Android devices), check out this How to Meditate article for helpful tips for beginners, or for a longer sit, try Dharma Seed for free guided meditations

If you’re interested in meditation, I recommend trying both group and solo meditation sessions, even if you suspect that you’d prefer one or the other. I am a private, introverted person and meditated alone for several years; but, I was pleasantly surprised by my experience in group meditation. Being in a group of like-minded people provided a sense of community and support that was helpful in times of stress, and I found myself benefiting from and enjoying meditation with others as much as meditation by myself. 

Therapy

Cognitive-behavioral therapy (CBT) has been shown to improve symptoms as well as provide tools to handle psychological or emotional symptoms as they arise (3). One study compared the efficacy of treatments among three groups: one group received fluoxetine (an antidepressant), the second group received CBT, and the third group received both medication and therapy. After 6 months, the efficacy rates were comparable, but after 1 year, participants who had received CBT were coping better than those who only received fluoxetine. (19). Another study showed that CBT was as effective as 20 milligrams daily of fluoxetine in treating symptoms of PMDD (9). Because PMDD symptoms are present until after menopause (9), developing the proper tools to handle the emotional and psychological symptoms is absolutely essential to living well with this disorder (20).

People often have misconceptions about therapy, and as mentioned previously, figuring out the treatment or combination of treatments that works for you may take some trial and error. Additionally, finding a therapist or counselor who is right for you is critical, but that may not be the first or even second therapist you visit. Ask your doctor if therapy is a good approach for you, and if so, ask who they’d recommend. Also check out the APA’s How to Choose a Psychologist Guide for some tips on finding the right practitioner. 

I was fortunate to not only find a therapist who specializes in treating PMDD, but also one I was able to really connect with and feel comfortable with immediately, despite some initial generalized anxiety about therapy. Her office is over 2 hours away by car, but she also meets patients online, which many therapists offer. This might be a good option for you and may be less expensive (check out what you should know about online therapy or find an online therapist). If cost is a concern, see if your insurance covers therapy and check out this list of what you can do if you can’t afford therapy.

Vitamins and Supplements 

The vitamins and supplements below have been shown to, or are suspected to be effective in reducing premenstrual symptoms during the luteal phase, but few quality studies have been conducted on specifically treating PMDD. Always speak with your healthcare provider before starting any new supplements or medications, especially since some of these supplements may be toxic at incorrect doses or could interact with other medications.

Of the supplements below, calcium is the only one with strong evidence to support that it improves premenstrual symptoms, such as fatigue, depression, insomnia, bloating, and food cravings (7, 21). One study showed that calcium with vitamin D had a similar effect on PMS symptoms as dydrogesterone, a progestin medication (22), and another study showed that calcium with vitamin D provided significant symptom improvement when paired with CBT (23). Because calcium supplements have potential risks and side effects, some of which are listed in the table below, you may want to consider increasing calcium intake via diet and food sources instead of supplements. 

Supplement

Purported Effect

Warnings/Possible Side Effects

Food Sources

Calcium

Strong evidence suggests calcium improves pain, fatigue, depression, insomnia, bloating, food cravings (7, 19, 24, 21)

Kidney stones at high doses (7, 25) increased risk of heart disease (26, 27), acid rebound, constipation, drug interactions (27)

Milk, cheese, yogurt, soy products, sardines, canned salmon, and dark leafy greens such as kale and collard greens (26, 25)

Vitamin D

Necessary for calcium absorption (28)

May reduce premenstrual symptoms (12)

Nausea, vomiting, poor appetite, constipation, weakness, weight loss, confusion, disorientation, heart rhythm problems, kidney damage (29)


May interact with certain medications and decrease efficacy of hormonal birth control. Only take this under the supervision of your healthcare provider. (29)

Through skin from sunlight, egg yolks, saltwater fish, liver, and fortified milk (28)

 

All other vitamins, minerals, and supplements below have anecdotal or limited research and need further study (7). For example, one study suggested that low levels of both calcium and magnesium may be related to PMS symptoms, but this study only included 46 participants, and they experienced PMS, not PMDD (30). 

Supplement

Purported Effect

Warnings/Possible Side Effects

Food Sources

Magnesium 

May reduce bloating, mood changes, pain (7), fluid retention, and breast tenderness (31)

Diarrhea (7)

Pumpkin seeds, almonds, spinach, cashews, peanuts, soymilk, black beans, edamame, 60-69% cacao dark chocolate, smooth peanut butter, avocado, baked potato with skin (32)

Chasteberry

May reduce irritability, mood swings, anger, headache, breast fullness (31), and overall symptoms (7)

Should not use with  certain medications; consult your doctor before taking chasteberry (33)

Only available in liquid extract, capsules, tablets, essential oil (33)

Vitamin E 

May reduce breast tenderness (31), nervous tension, anxiety, fatigue, depression, headaches, insomnia (24)

Bleeding (hemorrhagic stroke), nausea, fatigue (7)

Vegetable oils (wheat germ, sunflower, safflower, corn, and soybean oils), nuts (almonds, peanuts, and hazelnuts/filberts), seeds, green leafy vegetables (34)

Evening primrose oil

May reduces breast tenderness (31) or overall symptoms (24)

None (7)

Difficult to obtain in food sources, most efficient in concentrated oil form (35)

Vitamin B6 

May ward off fatigue (1, 12), depression, and overall symptoms (7

High doses are toxic. Only take this under the supervision of your healthcare provider. (7

Chickpeas, beef liver, yellowfin tuna, sockeye salmon, chicken breast, potatoes, turkey, bananas, 85% lean ground beef (36)

St. John’s Wort

May improve mood (7, 37, 38) or physical symptoms (9), though research is conflicted and anecdotal

Photosensitivity (7), anxiety, dry mouth, dizziness, gastrointestinal symptoms, fatigue, headache, or sexual dysfunction (39)


May interact with certain medications and decrease efficacy of hormonal birth control. Only take this under the supervision of your healthcare provider.

Available as teas, tablets, capsules, liquid extracts, and topical applications (39)

Ginkgo biloba

May improve psychological premenstrual symptoms (40), breast pain, fluid retention (9), and mood changes (7)

Increased risk of bleeding (7)

Sole source is the ginkgo tree; supplements are generally derived from leaves (41)

Aromatherapy

Effects of aromatherapy on PMDD specifically have not been studied, but one small study suggests that lavender aromatherapy could potentially relieve premenstrual symptoms (42), and another small study conducted in Japan suggests that fragrance of yuzu, a Japanese citrus fruit, may have the same effect (43). In another study, aromatherapy with an essential oil blend of lemon, eucalyptus, tea tree, and peppermint was found to decrease perceived stress and depression as well as improve sleep but didn’t actually alter the physiological measurements of stress (44). Another study confirmed that physiological markers of stress were not affected by aromatherapy but suggested that aromatherapy could be more beneficial if the user was told that it would be effective (45).

Acupuncture

Studies on the effectiveness of acupuncture in treating PMS and PMDD suggest that these methods may be helpful, but more research is needed. One anecdotal study found that symptoms decreased with regular acupuncture treatments, but resurfaced as soon as treatments stopped (7). Common side effects may include soreness and minor bleeding or bruising where the needles were inserted. Since risks of acupuncture are low as long as your practitioner is licensed, experienced, and using sterile single-use needles (46), acupuncture may be worth trying for yourself to see how you respond to this kind of treatment (46, 47). Consult with a doctor before receiving acupuncture treatment, especially if you have a bleeding disorder, a pacemaker, or are pregnant (46). 

Plan Ahead

A little planning can go a long way in preventing lasting relationship, lifestyle or work issues associated with PMDD symptoms. Rather than canceling plans, try to avoid accepting invitations to big parties and social events, dates, or other outings that may have increased opportunities for emotional distress when you’re feeling especially sensitive (20). Take that one step further and plan self-care activities when you know you’ll be in the thick of PMDD. Do something that makes you happy or comforts you like getting a massage or mani/pedi, soaking in a warm bath, exercising outdoors, writing, crafting or spending time with someone you care about. 

Be aware of certain counter-productive activities and behaviors that masquerade as self-care. Retail therapy, eating a box of cookies, or having some wine might be considered self-care if it truly makes you happy and calm, but if it ends up making you feel out of control or crazy, it can be self-destructive (48). If you continue with the activity despite it worsening your symptoms or causing financial difficulty, it could be a sign of addiction (49). One woman shared her story about how she used drugs and alcohol to cope with her PMDD before her diagnosis. Women with PMDD are more likely to abuse alcohol (50) and are more sensitive to its effects (51). 

If you think you need help with substance use, check out the Substance Abuse and Mental Health Services Administration’s national hotline. It’s free, confidential, and always available.

Support

Trusted family members and friends can provide an excellent support system when you feel like you need help with day-to-day tasks or emotional support. Confide in people who won’t judge or shame you, and with whom you feel safe, even during times of extreme vulnerability. 

The International Association for Premenstrual Disorders is a great resource that also offers peer support and online group support for those with PMDD. It is a great way to connect with people who can relate to what you’re going through. 

The good news

In 2017, a research team found a gene complex that seems to be responsible for the increased hormone sensitivity associated with PMDD. One of the researchers, David Goldman, M.D., of the NIH’s National Institute on Alcohol Abuse and Alcoholism said, “This is a big moment for women’s health, because it establishes that women with PMDD have an intrinsic difference in their molecular apparatus for response to sex hormones – not just emotional behaviors they should be able to voluntarily control.” The team hopes that the discovery will lead to more effective treatment of the disorder (52).

Living with PMDD may be challenging, but you’re not alone! The symptoms are difficult to live with, but recognition by national and international organizations is an important step for PMDD. Even though PMDD cannot be cured, plenty of treatments are available; one or a combination of them may work for you. Speak with your doctor about your symptoms and options.

More Resources

International Association for Premenstrual Disorders

National Suicide Prevention Lifeline

Substance Abuse and Mental Health Services Administration

APA’s How to Choose a Psychologist Guide

Psychology Today’s Online Therapist Search

Dharma Seed for guided meditations


Photo of author by Anthony Nielsen

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