Many treatments have been proposed for a severe form of premenstrual syndrome called premenstrual dysphoric disorder, but until now, it has not been clear which are the most effective.

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The authors note that severe premenstrual dysphoric disorder can lead to suicidal thoughts.

Researchers from the University of Texas Southwestern Medical Center in Dallas hope their comprehensive review of the available evidence and treatment guidelines will help health professionals decide the best treatments for patients with premenstrual dysphoric disorder.

They report their findings in the Journal of Psychiatric Practice.

Between 50-80% of women experience mild to severe symptoms in the days before their menstrual period. These include tension, irritability, bloating, headache, breast pain (mastalgia) and depression.

While most women suffer only mild or occasional symptoms, around 3-8% experience premenstrual dysphoric disorder (PMDD) – a severe form of premenstrual syndrome (PMS) with a combination of emotional and physical symptoms that cause major disruption to women’s home, work and social lives.

The authors note that severe PMDD symptoms may also lead to suicidal thoughts; one study they reviewed found that 15% of women affected by the disorder reported at least one suicide attempt.

Co-author Shalini Maharaj, of the department of physician assistant studies, says:

“Given the debilitating symptoms and impact associated with PMDD, health care professionals need to be able to identify and effectively treat patients with PMDD.”

For their review, Maharaj and co-author Dr. Kenneth Trevino, of the department of psychiatry, examined studies covering psychiatric, anovulatory, supplements, herbal, nonpharmacological and other treatments.

They note that while nobody has yet discovered what causes PMDD, there is some agreement that it involves disruption to levels of certain neurotransmitters such as serotonin, an imbalance in which is linked to depression.

This appears to be corroborated by studies that show a widely used class of antidepressant drugs known as selective serotonin reuptake inhibitors (SSRIs) may help relieve symptoms of PMDD.

In their paper, the authors discuss a review of 31 randomized trials that looked at the effect of SSRIs on PMDD. Altogether, the trials included nearly 4,400 women.

The authors suggest the evidence from the trials makes a strong case for considering SSRIs as a “first-line” treatment for PMDD, but they call for further research to examine and recommend treatment schedules that balance the drugs’ effectiveness against side effects during the various phases of the menstrual cycle, as they explain:

“In the treatment of PMDD, SSRIs, specifically sertraline, fluoxetine, and escitalopram, have been established as first-line treatment options prescribed either for just the luteal phase or with continuous dosing. Further research is needed comparing the efficacy of continuous, semi-intermittent, luteal phase, and symptoms-onset dosing.”

However, SSRIs do not suit everybody, so other treatment options should also be considered for PMDD. The authors put the other treatments into two categories: second-line and third-line alternatives to SSRIs.

Among the second-line alternatives, they say some antidepressants can help with PMDD, and certain anti-anxiety drugs may help with specific symptoms. The evidence is insufficiently clear to give specific advice.

For example, they class the anti-anxiety drug alprazolam (used in luteal phase) as a second-line treatment option but note “more research with larger samples is needed regarding discontinuation symptoms.”

They also note that more robust research is needed that compares second-line drugs like alprazolam against SSRIs.

For women with PMDD who also need contraception, then those containing drosperinone/ethinyl estradiol may be a recommended option, they note.

If none of the second-line options works, then third-line options such as anovulatory treatments may be effective. These decrease hormones that promote egg production, inducing a state of “medical menopause.” These are classed as third-line options because of their side effects and high cost, say the authors.

In reviewing the case for supplements and herbal treatments, the reviewers say while several have been proposed, more evidence is needed. So far, only calcium supplements appear to show any benefit, they add.

There were similar conclusions about psychotherapy, exercise and dietary treatments for PMDD. The reviewers note that studies on the effect of cognitive behavioral therapy do not show it benefits women with PMDD, but they call for more studies that compare different psychotherapies.

Regarding exercise – such as strength training or aerobic – the reviewers note it has been proposed as an “adjunctive therapy for PMDD, although there are no evidence-based guidelines concerning its use.” Similarly, on dietary treatments, they comment:

There are no evidence-based dietary guidelines, but associations have been reported between increased PMS symptoms and caffeine, smoke exposure, refined sugars, and alcohol. Dietary soy isoflavones, as well as fats and carbohydrates, may be of some benefit, although more research is needed.”

In their conclusion, the reviewers say overall, there is a need for larger, placebo-controlled studies that use a consistent definition of PMDD and a more rigorous diagnosis. They also call for standard outcomes measures so results can be compared more easily.

Meanwhile, from a recent study that investigates the benefits and risks of SSRIs used during pregnancy, Medical News Today learned that while they may reduce risk of some birth complications, they can also increase risk of problems affecting newborns.