| Undertake a careful medical and psychiatric history.
Rule-out or treat any physical disorders (e.g. hypothyroidism). |
↓
| If premenstrual symptoms remain, obtain prospective mood ratings
for 2-3 months. Rule-out premenstrual exacerbation of other psychiatric
conditions. |
↓
| Diagnose with PMDD if the patient meets criteria after two consecutive
cycles. Encourage supportive counseling that advocates lifestyle
adjustments during vulnerable premenstrual times. Assess type and
severity of symptoms. |
↓
Mild symptoms: use vitamins, minerals,
evening primrose oil, or a diuretic
· May
be taken for only part of the cycle (midcycle to the onset of menses)
· Vitamin
B6: 25-100 mg per day (start with 25-50 mg per day; not
to exceed
100 mg per day)
· Optivite,
calcium, or magnesium may also have positive effects on mood
· Potassium-sparing
diuretics (e.g. hydrochlorothiazide 25 mg, triamterene 50 mg)
are appropriate if a woman has significant weight
gain premenstrually; monitor
electrolytes closely
· Bromocriptine
in dosages of 1.25-7.5 mg per day may be appropriate if breast
pain is a significant concomitant symptom |
↓
|
Moderate to severe symptoms: use psychotropic drugs or hormonal
therapy
· Improvement
typically requires 2-4 months of treatment
· SSRIs
(e.g. fluoxetine 20-40 mg per day starting at 20 mg for 2-3 cycles,
sertraline 50-100 mg per day,
clomipramine 25-75 mg per day, etc.) appear
to be effective; consider intermittent dosing
(e.g. from midcycle to the onset of
menses) with significant side effects
· Nortriptyline also may be beneficial
· Hormonal
options (e.g. GnRH agonists, danazol, and estradiol) may be effective
but are not recommended as there currently
is insufficent data about their safety
in long-term use; progesterone and oral contraceptives
do not appear to have a
beneficial effect on depressive symptoms
· Lithium
or other mood stabilizers may be effective for recurrent, suicidal
depression (check levels at different menstrual
cycle phases)
|
↓
|
Anxious
symptoms prominent with secondary dysphoria: use
anxiolytics
· Alprazolam
(start at .25 mg per day and increase as necessary; do not exceed
4 mg per day; taper at the onset of menses
by 25% per day) can be given
during days 12-28 of the cycle
· Clonazepam
may be helpful for patients who cannot tolerate the abrupt tapering
· Benzodiazepines may be used with caution during symptomatic days
· Buspirone
(start at 5 mg three times per day) may be used throughout the
cycle
or from midcycle to the onset of menses
|
|