Patients need counseling on options
Reproductive health patients often describe having unpleasant symptoms related to their menstrual cycle. Premenstrual syndrome, for example, refers to any mood symptoms in the days or weeks before their period begins.
Some patients may receive a psychiatric diagnosis of premenstrual dysphoric disorder (PMDD), which also refers to symptoms women may experience in the luteal phase of their menstrual cycle and resolves with menses. But diagnosis depends on someone having five specific symptoms from different categories, including mood changes; cognitive symptoms such as difficulty concentrating; and physical symptoms, including being tired and having a change in appetite and sleep patterns, says Sara V. Carlini, MD, director of perinatal psychiatry in the department of psychiatry at the Maimonides Medical Center in Brooklyn, NY.1
PMDD is underrecognized by clinicians, and patients can feel invalidated when they are told they have to just deal with it, she notes.
“Someone may have some of these premenstrual symptoms but not meet criteria for full diagnosis of premenstrual dysphoric disorder,” she notes. “PMDD may be overly strict in terms of diagnosis, and it’s been proposed it should be relaxed to include more people who have symptoms but don’t meet all criteria.”
The benefit of an official diagnosis is that physicians are more likely to recognize a patient’s disorder and prescribe treatment. Payers also may be more likely to cover treatment.
“It’s frustrating for a patient, who has symptoms that are debilitating, to be told, ‘If you had one more symptom, you could technically be diagnosed with PMDD,’” Carlini says. “It’s a strict set of symptoms to have a diagnosis with PMDD, but it’s not to say that folks who have premenstrual syndrome symptoms don’t need treatment.”
OB/GYNs can definitely make a diagnosis of PMDD without having to refer a patient to a psychiatrist, she adds.
“They can follow treatment algorithms and treat a patient if they’re able and empowered to do that,” Carlini explains. “If they have a case where they really need psychiatric input and consultations, then OB/GYNs and psychiatrists can work together to enhance patient outcomes and make sure all avenues are being followed.”
If a patient does not respond to combined hormonal contraceptives or adjunct therapy approaches and they want to shut down their menstrual cycle, then a psychiatrist would refer them to an OB/GYN.
There are some patients who experience very severe symptoms and who may ask for surgery, such as a total hysterectomy or bilateral removal of the ovaries. These cases require an OB/GYN consult, she says.
Another treatment involves prescription for a selective serotonin reuptake inhibitor (SSRI). These drugs are considered the gold standard of treatment for PMDD because of the volume of clinical trial evidence that demonstrates their effectiveness, Carlini says.
The way SSRIs are prescribed for PMDD is different from the way they are prescribed for other psychiatric conditions, where they are prescribed for daily use and the medication’s effect is built up over time, she notes.
For PMDD patients, an SSRI medication is effective if dosed only in the luteal phase, 14 days prior to menses, she says.
Some early research suggests that an SSRI could be effective for an even shorter interval if they are taken when symptoms start, Carlini adds.
“There is little evidence looking at that type of dosing, but it’s a potential option for folks who want to take a little medication for the least amount of time possible,” she explains. “It is interesting because it shows that SSRIs, when used to treat PMDD, work in a different way than how they treat depression and anxiety, where the medication has to be taken over time, and the benefits are seen after four to six weeks.”
SSRIs appear to work instantly for patients with PMDD symptoms.
Oral contraceptives that contain ethinyl estradiol and drospirenone can help improve some of the mood and physical symptoms of PMDD. The only one of these combination pills that is approved by the Food and Drug Administration for this use is Yaz.2
“The bottom line with research into combined oral contraceptives is there is a meta-analysis of these studies, looking for patterns, and it seems to suggest they’re quite good for physical symptoms,” Carlini says.
But they appear to be less efficacious in treatment of mood dimensions of premenstrual dysphoric disorder, she adds.
“It’s reasonable to try combined oral contraception as a primary treatment for PMDD,” Carlini says.
Clinicians who prescribe this treatment should ask for feedback from patients about how they are responding to the medication and work to adjust treatment as necessary, she adds.
For patients who ask for natural remedies, there is some literature about the use of B6 and B1 vitamins, calcium, and herbal preparations and mineral supplementation, Carlini notes.
“The pitfalls of herbal supplementation is the FDA does not regulate the supplement industry,” she adds. “There is no way of knowing if the preparations contain what they say they contain when you buy them off the shelf, and that’s what I warn my patients about.”
REFERENCES
- Carlini SV, di Scalea TL, McNally ST, et al. Management of premenstrual dysphoric disorder: A scoping review. Focus 2024;22:81-96.
- Ghoshal M. Can birth control help with PMDD? Healthline. June 22, 2021. https://www.healthline.com/health/birth-control/birth-control-for-pmdd
