Combined oral contraceptives (COCs) containing estrogen and progesterone are considered secondline treatment for PMDD—specifically, COCs containing 20 µg of ethinyl estradiol and 3 mg of drospirenone administered as a 24/4 regimen.2,3,5,6 This combination has been approved by the FDA for women with PMDD who seek oral contraception.3 Although drospirenone-containing products have been associated with increased risk for venous thromboembolism (VTE), this risk is lower than that for VTE during pregnancy or in the postpartum period.3 Currently, no strong evidence exists regarding the effectiveness of other oral contraceptives for PMDD.6
Gonadotropin-releasing hormone agonists are the thirdline treatment for PMDD.6 They eliminate symptoms of the luteal phase by suppressing ovarian release of estrogen and ovulation.6 However, use of these agents is not recommended for more than one year due to the increased risk for cardiovascular events.5,6 In addition, long-term users need add-back therapy (adding back small amounts of the hormone) to counteract the effects of low estrogen, such as bone loss; providers should be aware that this may lead to the recurrence of PMDD.3,5,6 The use of estrogen and progesterone formulations for PMDD is currently not strongly supported by research.6
Complementary treatment
Cognitive behavioral therapy has been shown to improve functioning and reduce depression in women with PMDD and may be a useful adjunct.2,20 Regular aerobic exercise, a diet high in protein and complex carbohydrates to increase tryptophan (serotonin precursor) levels, and reduced intake of caffeine, sugar, and alcohol are some commonly recommended lifestyle changes.2
Calcium carbonate supplementation (500 mg/d) has demonstrated effectiveness in alleviating premenstrual mood and physical symptoms.21 There is currently no strong evidence regarding the benefits of acupuncture, Qi therapy, reflexology, and herbal preparations for managing PMDD.22
Surgery
Bilateral oophorectomy, usually with concomitant hysterectomy, is the last resort for women with severe PMDD who do not respond to or cannot tolerate the standard treatments.6 This surgical procedure results in premature menopause, which may lead to complications related to a hypoestrogenic state—including vasomotor symptoms (flushes/flashes), vaginal atrophy, osteopenia, osteoporosis, and cardiovascular disease.2 Therefore, it is important to implement estrogen replacement therapy after surgery until the age of natural menopause is reached.2 If hysterectomy is not performed, the administration of progesterone is necessary to prevent endometrial hyperplasia and therefore reduce the risk for endometrial cancer.2 However, the addition of progesterone may lead to recurrence of symptoms.2
Continue to: Treatment challenges