As the pathophysiology of PMS and PMDD suggests, symptoms are associated with the elevation and decline of sex hormones during ovulation. As symptoms are not found before menarche or after menopause, studies have focused on ovulation suppression to relieve these symptoms. If ovulation were suppressed, the rise and fall of these hormones would then be inhibited, resulting in a reduction or complete cessation of symptoms. Medical oophorectomy is the term used to describe using medications in the suppression of ovulation. GnRH agonists have been indicated to treat premenstrual dysphoric disorder and result in a hypoestrogenic state. Some GnRH agonists studied are leuprolide and buserelin, both found to be superior to placebo in reducing emotional and physical symptoms related to the menstrual cycle.

The disadvantages of using GnRH agonists include cost and negative side-effect profiles, being associated with menopausal symptoms, e.g., hot flashes, vaginal dryness, depression, headaches, and muscle aches. Also, long-term effects of these drugs may include osteoporosis or heart disease. GnRH agonists have yet to be further researched to understand the risks and benefits associated with this class of drugs. In addition to GnRH agonists, the synthetic androgen, danazol, has been studied in the treatment of PMDD. Doses of 200 mg a day of danazol were found to reduce many symptoms related to ovulation such as mastalgia (muscle pain) and migraines. Adverse effects to be aware of when prescribing danazol include estrogen deficiency side effects (e.g., menstrual irregularities and hot flashes), androgenic side effects (hirsutism, acne, and deepening voice), and lipid changes (decreased high-density lipoprotein cholesterol and increased low-density lipoprotein cholesterol).

As ovulation suppression has been shown to decrease symptoms associated with premenstrual dysphoric disorder, it is logical to consider the use of oral contraceptives. However, few studies have been conducted with conclusive evidence that specific contraceptives are advantageous in PMDD treatment. The most common concern is that the symptoms linked to birth control medications are often observed with those of the menstrual cycle (e.g., breast tenderness, headache, bloating, and depression). The challenge is to find the “right” birth control medication that provides relief from menstrual symptoms with minimal side effects. The new formulations of oral contraceptives attempt to achieve the right balance of estrogen and progestin to help decrease side effects. However, using oral contraceptives for premenstrual dysphoric disorder symptoms remains controversial, and no single oral contraceptive has been indicated as beneficial when side effects are considered.

Although emotional and psychological symptoms are often the focus of treatment in PMDD patients, it is important to remember that physical symptoms of premenstrual dysphoric disorder are similar to PMS. As a result, clinicians and health care providers have to be familiar with treatment options available for particular symptoms. The “symptom-based approach” is often the most successful when treating PMDD patients. Physical symptoms to be aware of include dysmenorrhea or cramps, headaches, weight gain and bloating, and mastodynia (breast tenderness).

Dysmenorrhea and Cramps and Headaches: Nonsteroidal anti-inflammatory drugs (NSAIDs) are often recommended to reduce menstrual pain. These include ibuprofen, ketoprofen, naproxen, or cyclooxygenase-2 inhibitors, such as celecoxib.

Weight Gain and Bloating: Sufficient clinical data supports the use of spironolactone, an aldosterone antagonist with potassium-sparing properties, to treat weight gain or bloating. The recommended dose of spironolactone is 25 mg two to four times a day during the luteal phase. Triamterene and hydrochlorothiazide have also been used, but little clinical data exist on their therapeutic effectiveness for these symptoms.

Mastodynia: Although NSAIDs are often used for the relief of breast tenderness related to premenstrual dysphoric disorder, vitamin E or primrose oil has also been used as a nutritional modality for this condition. Bromocriptine, at 1.25 to 7.5 mg per day, during the luteal phase has been clinically studied and supported.Danazol has also been studied for its antiestrogenic properties in the treatment of mastodynia, and studies have found positive results in its use. Additionally, using tamoxifen citrate in the luteal phase has also been studied, but conclusions regarding its use in PMDD are controversial.

Surgical Intervention and Management

Pharmacological and nonpharmacological treatments sometimes fail. In these instances, the option of bilateral oophorectomy (”removal of ovaries”) should be considered. However, this should only be a last resort because of its irreversible nature and because patients may experience menopausal symptoms or develop osteoporosis. The patient’s demographic information and medical history should be assessed carefully before considering surgery.

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