Which Medications Are Used to Treat Premenstrual Dysphoric Disorder (PMDD)?

The menstrual cycle has different phases. Hormones rise and fall throughout each phase. Shortly before a person’s menstrual period, these changes are thought to trigger both physical and mental health symptoms, such as fatigue or irritation. Many people know this as premenstrual syndrome (PMS). 

But for some people, these symptoms are much more intense. In fact, up to 10% of women experience a severe form of these symptoms. This is known as premenstrual dysphoric disorder (PMDD). For some, this condition can interfere with daily activities, cause depression and anxiety, or even lead to suicidal thoughts. For those with PMDD, there are various medications available that can help manage or lessen symptoms.

Below, we’ll discuss which PMDD medications are available, how well they work, and what to expect if you’re prescribed one.

What causes premenstrual dysphoric disorder, and how does medication help treat it?

Researchers don't know exactly what causes PMDD. But it’s thought to be linked to hormone changes that happen during the menstrual cycle. Serotonin may also play a part in the condition. Serotonin is a chemical found in the brain that’s involved in regulating mood and anxiety.

Regardless of why PMDD happens, researchers have found some medications that can treat it. Medications can help lessen the symptoms of PMDD and improve your quality of life. This means that with PMDD medication, you can focus more on the things that make you happy and less on your symptoms.

There are a few different types of PMDD medications. The most commonly prescribed medications work in one of two ways:

• They help balance serotonin levels.

• They change hormone levels.

Some medications are taken only during certain times of the menstrual cycle, when symptoms are most likely to be the worst. Other medications have to be taken every day. Your healthcare provider will work with you to find the medication(s) and dose schedule that work best for you.

Which medications are FDA approved to treat PMDD?

Some PMDD medications are approved by the FDA specifically to treat PMDD. Others have been found to work well but are used off-label. This is when a medication is prescribed for a reason other than what the FDA approved it for. 

Antidepressants for PMDD

Some antidepressants are helpful in treating PMDD. In particular, selective serotonin reuptake inhibitors (SSRIs) are quite effective. These medications focus on raising the serotonin levels in your brain. They can help relieve anxiety and depression symptoms often experienced with PMDD.

SSRIs are considered a first-choice option for treating PMDD. They can be used alone or along with other PMDD medications.

Most of the time, SSRIs are taken on a daily basis. But with PMDD, your healthcare provider may recommend that you take them only during the second half — or luteal phase — of your menstrual cycle. Both ways of taking these medications have been found to work well for PMDD symptoms.

The following SSRIs are FDA approved for PMDD:

• Fluoxetine (Sarafem)

• Paroxetine (Paxil)

• Sertraline (Zoloft)

Your healthcare provider may prescribe a different, off-label antidepressant to treat your PMDD. Several antidepressants have been shown to be effective in treating PMDD. If you’re not sure why you’re being prescribed a particular medication, always ask your provider.

Hormonal birth control medications for PMDD

Certain types of oral birth control containing a progestin called drospirenone have also been FDA approved to treat PMDD. Drospirenone is a unique type of progestin that can help get rid of excess water and lessen certain physical symptoms, such as breast pain and acne. These types of birth control are also considered first-choice treatment options for PMDD.

Birth control pills may help more with physical symptoms than mental health symptoms for some people. So you may need to take birth control with another PMDD medication, like an SSRI. However, other people also experience an improvement in mood symptoms from these medications.

The following oral birth control pills are FDA approved for PMDD: 

• Yaz (drospirenone/ethinyl estradiol)

• Beyaz (drospirenone/ethinyl estradiol/levomefolate)

Are there any other medications used to treat PMDD?

Over-the-counter (OTC) medications, like nonsteroidal anti-inflammatory drugs (NSAIDs), can help with some of the physical symptoms of PMDD, like cramps and headaches. Examples of NSAIDs include ibuprofen (Advil) and naproxen (Aleve). NSAIDs could be combined with both SSRIs and oral birth control pills. They wouldn’t be helpful, however, for treating mental health symptoms. 

Other medications that affect hormones may be tried if you haven't found relief with the above options. Using these medications would be considered off-label. Gonadotropin releasing hormone (GnRH) agonists might be used for short periods of time. These medications create a chemical menopause in the body while you use them. They can relieve symptoms by stopping the hormone changes that happen during the menstrual cycle. But due to their high cost and potential side effects, GnRH agonists are not a first choice.

Another possible option is extended-release (ER) quetiapine (Seroquel XR). This medication may be taken along with an SSRI if it’s not working well enough on its own. In a small study of 20 women, a low dose of quetiapine ER and an antidepressant helped improve PMDD symptoms. More research is needed to confirm quetiapine’s effectiveness. But the American Academy of Family Physicians recommends it as a possible off-label option if SSRIs aren’t working.

What side effects are associated with PMDD medications?

Everyone’s experience with medication side effects is different. Some people have no side effects while taking PMDD medications. Others experience many. Be sure to let your healthcare provider know if you have any side effects while taking medication for PMDD.

SSRIs

SSRIs are generally well tolerated and safe. In studies, side effects were similar for people taking SSRIs daily and those taking them only for the second half of their menstrual cycles.

The most common side effects that happen when taking SSRIs for PMDD include:

• Stomach upset

• Sexual problems, such as low sex drive

• Headaches

• Trouble sleeping

• Dry mouth

• Nausea

• Nightmares

Hormonal birth control pills

Hormonal birth control pills affect people in different ways. Generally, the most common birth control side effects include:

• Changes to your periods

• Breakthrough bleeding or spotting

• Nausea

• Breast tenderness

• Headaches

The birth control pills approved for PMDD carry a higher risk of blood clots than other birth control pills. This higher risk is linked to the progestin drospirenone. This risk is still very low for most people, though. Make sure to let your healthcare provider know if you have a history of blood clots.

How effective are PMDD medications?

This is a tricky question to answer. It depends on the symptoms you’re experiencing. Certain PMDD medications are better for mental health symptoms than others. And everyone responds to PMDD medications differently. 

SSRIs are usually tried first for PMDD. This is because they work well for most people with mental health symptoms, like depression or anxiety. Studies have shown SSRIs work for between 60% and 75% of people with PMDD who take them.

Some studies have shown drospirenone-containing birth control can help relieve the mental health symptoms of PMDD, like irritability and feelings of sadness. However, other studies have been unable to determine if drospirenone was more effective for PMDD than other oral contraceptives. It’s important to note these studies weren’t conducted for very long and didn’t include many people. Larger studies would be needed to say for sure if these types of oral birth control pills are effective for all people with PMDD. 

How long do you have to take PMDD medications?

PMDD is a chronic condition. The cyclic, severe symptoms may last until menopause. If you find a PMDD medication that is helpful, you and your healthcare provider may decide it’s best for you to take it until then. How long you continue your PMDD medications is a decision best made together with your provider.

What should you do if PMDD medications aren’t relieving your symptoms?

As discussed above, certain PMDD medications may work better for some symptoms than others. It can take some trial and error to find the right medication regimen that works for you. It may be helpful to keep a log or journal of the symptoms you experience. This can help your provider know if a medication is working.

Some people respond faster to PMDD medications than others. Your healthcare provider may want you to try a medication for a few cycles before switching to something else. They may schedule a follow-up appointment a few months after starting a medication to see if it’s working for you.

But if your symptoms worsen or you experience thoughts of harming yourself, you should contact your healthcare provider right away. Both SSRIs and hormonal birth control can negatively affect your mood or cause suicidal thoughts. Let your provider know if this happens, as your PMDD treatment may need to be adjusted.

Can lifestyle changes or supplements help with PMDD?

Possibly. There’s some evidence that changing your daily habits can help with PMDD, especially if your symptoms are mild. Here’s what studies show so far:

• Healthy lifestyle choices: Certain lifestyle choices can help with managing PMDD. This includes eating nutritious foods, cutting down alcohol, and getting 7 or more hours of sleep at night. 

• Exercise and stress reduction: Exercise and stress reduction are both good for your overall mental and physical health, and they may help with PMDD symptoms, too. Though there’s not a lot of research specifically on PMDD in this area yet, research shows that exercise and stress reduction are good for depression and anxiety — two of the biggest symptoms of PMDD. 

• Chasteberry (vitex agnus castus): This herbal supplement seems to work for mild PMS, and it may be helpful for PMDD, too. In some studies, it did a better job than placebo (sham medication) for treating PMDD, though more research is needed before we can say for sure how well it works. 

Scientists have also studied other vitamins and supplements for PMDD. But so far, they don’t seem to work very well — or at least not any better than placebo. These include:

• Primrose oil

• Vitamin B6

• Vitamin E

• Calcium

• Magnesium 

And remember: Before making any lifestyle changes, it’s always a great idea to check in with your healthcare provider. Even if a vitamin or supplement is “natural,” it can still cause side effects. And it may interfere with other medications you’re taking. 

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Written by:

Nicole E. Cieri-Hutcherson, PharmD, BCPS, NCMP

Nicole E. Cieri-Hutcherson, PharmD, BCPS, NCMP, has over a decade of experience as a pharmacist, professor, and researcher. She was a full-time clinical professor in the pharmacy practice department at D’Youville School of Pharmacy before subsequently joining the faculty of the pharmacy practice department at the University at Buffalo School of Pharmacy and Pharmaceutical Sciences.

Edited by:

Sophie Vergnaud, MD

Sophie Vergnaud, MD, is the Senior Medical Director for GoodRx Health. An experienced and dedicated pulmonologist and hospitalist, she spent a decade practicing and teaching clinical medicine at academic hospitals throughout London before transitioning to a career in health education and health technology.

Reviewed by:

Sarah Gupta, MD

Sarah Gupta, MD, is a licensed physician with a special interest in mental health, sex and gender, eating disorders, and the human microbiome. She is currently board certified by the American Board of Psychiatry and Neurology.

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