PMDD Treatment: Antidepressants, Birth Control & Therapy

PMDD treatment options at a glance

Premenstrual dysphoric disorder (PMDD) is treatable. ACOG's 2023 guideline on premenstrual disorders covers medicines, counseling, exercise and nutrition, complementary treatments, self-help and surgery, and notes that many patients may benefit from combining them.

Option	What the evidence shows	Who usually manages it
SSRI antidepressants	Moderate-certainty evidence that they reduce premenstrual symptoms	A psychiatric, primary care or OB-GYN clinician
Drospirenone birth control pill	FDA-approved for PMDD in people who want an oral contraceptive	An OB-GYN or primary care clinician
Cognitive behavioral therapy	Helpful in trials, though the evidence is lower quality	A licensed therapist
Exercise, diet and supplements	Limited or mixed	You, with your clinician's input
GnRH agonists	Effective in trials, used when other treatments fail	A gynecologist

What is PMDD, and how is it different from PMS?

PMDD is a severe, cyclical mood disorder. MedlinePlus describes severe depression symptoms, irritability and tension before menstruation, worse than premenstrual syndrome (PMS). The Office on Women's Health says symptoms start in the week or two before a period and usually ease two to three days after it begins.

Premenstrual symptoms treatment depends on severity. ACOG says PMS is diagnosed when symptoms appear in the 5 days before a period for at least three cycles in a row, end within 4 days after it starts, and interfere with some normal activities. Mild to moderate PMS often improves with lifestyle and diet changes.

	PMS	PMDD
Symptoms	Physical and emotional, often mild to moderate	Five or more, including at least one mood symptom such as irritability, depression, anxiety or mood swings
Impact	Interferes with some activities	Disrupts work, school or relationships
How it's confirmed	Symptoms in at least three cycles in a row	Daily symptom ratings over at least two cycles

How PMDD is diagnosed: two cycles of daily tracking

No physical exam or lab test can diagnose PMDD, MedlinePlus says. The FDA label for Yaz describes symptoms that recur in the luteal phase (the two weeks or so before your period) and lift within a few days of bleeding, rated prospectively over at least two menstrual cycles.

A 2024 meta-analysis of 44 studies found PMDD in 3.2% of participants when the diagnosis was confirmed by two cycles of tracking, and 7.7% when it wasn't. One validated tool, the Daily Record of Severity of Problems, has you rate each symptom daily and mark the days you bleed.

Tracking also separates PMDD from depression or anxiety, which ACOG notes are often present all month and can worsen before a period. If your low mood doesn't lift once your period starts, take our free depression test and bring the result to your visit.

Antidepressants for PMDD: SSRIs come first

The first option for PMDD is most often a selective serotonin reuptake inhibitor (what an SSRI is), MedlinePlus says. The FDA has approved three SSRIs for PMDD, per the Office on Women's Health: sertraline, fluoxetine and paroxetine (the controlled-release form, per the Paxil CR label).

The 2013 Cochrane review. Marjoribanks and colleagues pooled 31 randomized trials of five SSRIs. SSRIs reduced symptoms more than placebo, whether taken only in the luteal phase or every day, with no clear difference between the two.
The 2024 update. Jespersen and colleagues included 34 trials. SSRIs probably reduce premenstrual symptoms and are probably more effective taken every day than in the luteal phase only (moderate-certainty evidence). They urge caution because 68% of the trials were drug-company funded.

Luteal-phase vs. continuous dosing

Continuous dosing means every day. Luteal-phase (intermittent) dosing means starting about 14 days before your expected period and stopping when it begins. The Zoloft label allows either schedule for PMDD, and so does the Paxil CR label.

Part-month dosing can work because SSRIs can act within days in PMDD. In a small NIH study, 12 women with PMDD improved by the second day of luteal-phase fluoxetine. Your clinician helps choose the schedule.

Side effects and safety

In the 2013 Cochrane review, nausea and low energy were most common, and side effects rose with dose. The 2024 update adds insomnia, sexual side effects, dizziness and sweating. The Zoloft label adds:

A boxed warning for suicidal thoughts and behaviors in children and young adults.
Screening for bipolar disorder first, because an antidepressant can trigger mania in people who have it.
The sertraline PMDD trials excluded people on birth control pills, so how the two work together for PMDD is unknown.

Birth control for PMDD: drospirenone pills

A pill combining drospirenone (a progestin) and ethinyl estradiol (an estrogen), sold as Yaz, is FDA-approved to treat PMDD symptoms in people who choose an oral contraceptive for birth control. MedlinePlus says continuous-dosing pills, which can skip the monthly period, are most effective, especially ones with drospirenone.

The label sets limits:

Its PMDD benefit wasn't studied beyond three cycles, and it wasn't evaluated for ordinary PMS.
People over 35 who smoke shouldn't take it, because of the risk of serious cardiovascular events.
Drospirenone pills may carry a higher risk of blood clots than some other pills, and they can raise potassium.

An OB-GYN or primary care clinician usually prescribes it. With your consent, a psychiatric clinician can coordinate with them.

Therapy for PMDD: cognitive behavioral therapy

Cognitive behavioral therapy for PMDD builds coping skills for symptomatic days. MedlinePlus says CBT can be used with or instead of antidepressants, usually over about 10 visits.

CBT vs. fluoxetine. In a randomized trial, 108 women with confirmed PMDD received CBT, fluoxetine or both for six months. All three groups improved. Fluoxetine worked faster, CBT's gains held up better a year later, and combining them added no benefit.
Pooled trials. A 2009 meta-analysis found low-quality evidence that CBT reduces anxiety, depression and how much symptoms interfere with daily life.

Anywhere Clinic offers talk therapy with licensed therapists in some states, not all.

Lifestyle changes and natural remedies: the evidence is limited

Most of this research was done in PMS, not PMDD, and the quality is low. Treat these as additions to care, not replacements.

Exercise. ACOG suggests regular aerobic exercise. A 2020 meta-analysis found it may reduce PMS symptoms, but 87% of the trials were at high risk of bias.
Calcium. ACOG says 1,200 mg a day can help PMS symptoms. In a 1998 trial of 466 women, symptom scores fell 48% on calcium by the third cycle, against 30% on placebo. But MedlinePlus says most studies found calcium, magnesium and vitamin B6 unhelpful.
Vitamin B6. A 1999 review suggested a benefit at up to 100 mg a day but called most trials low quality. Large doses can cause numbness, per MedlinePlus.
Chasteberry. The NCCIH rates the studies low to moderate quality. It may be unsafe in pregnancy or with hormone-sensitive conditions.
Diet and sleep. ACOG suggests complex carbohydrates, less salt, sugar, caffeine and alcohol, and regular sleep times.

Ask your clinician before starting a supplement.

GnRH agonists for severe PMDD

When other treatments haven't helped, a gynecologist may try a gonadotropin-releasing hormone (GnRH) agonist such as leuprolide. These medicines suppress ovulation, and MedlinePlus notes side effects that resemble menopause. A 2022 scoping review found the strongest evidence for SSRIs and birth control pills, with GnRH agonists and surgery showing benefit in cases that don't respond. A 2004 meta-analysis found that low-dose "add-back" hormones, given to limit side effects, didn't reduce the benefit. This care happens with a gynecologist, not in a psychiatric telehealth visit.

When to get help right away

A 2021 meta-analysis found women with PMDD were almost four times as likely to have suicidal thoughts as women without premenstrual disorders. If you have thoughts of suicide or self-harm, call or text 988, or call 911. Book a visit if symptoms keep disrupting work or relationships, or if self-care hasn't helped.

PMDD treatment online at Anywhere Clinic

At Anywhere Clinic, a licensed psychiatric clinician (physician, nurse practitioner or physician assistant, depending on your state) meets with you by secure video. They review your tracking, check for depression, anxiety and bipolar disorder, and discuss options. Medication is the clinician's decision after an evaluation, and no medication is guaranteed. MedlinePlus also recommends a physical exam and thyroid testing to rule out other causes, done with your primary care clinician or OB-GYN.

See our PMDD and hormonal health care, or schedule a visit.

Insurance coverage depends on your state and plan; check yours on our accepted insurance page. Self-pay is $150 per visit, for new and follow-up visits. Georgia requires an in-person visit within 12 months. Visits before then can be by secure video. Call (702) 848-2256 to schedule.

This article is educational and isn't a substitute for medical advice, diagnosis or treatment.

Frequently Asked Questions

What is the best antidepressant for PMDD?

Research hasn't named one. The Cochrane reviews compared SSRIs with placebo, not with each other, and found them effective as a class. The FDA has approved sertraline, fluoxetine and controlled-release paroxetine for PMDD. The right fit depends on your history, side effects, other medicines and pregnancy plans, and your clinician decides after an evaluation.

What medications are used to treat PMDD?

The main drugs for PMDD are SSRI antidepressants and a drospirenone birth control pill. When those don't help, a gynecologist may use a GnRH agonist to suppress ovulation. Pain relievers such as ibuprofen can ease cramps, headaches and breast tenderness. Medication choice is made with your clinician.

Can PMDD be treated online?

Yes, for most people. A psychiatric clinician can evaluate PMDD by secure video, review your symptom tracking and manage SSRI treatment, and sertraline and paroxetine aren't controlled substances. Exams and lab work happen with your primary care clinician or OB-GYN, and GnRH agonists with a gynecologist.

Does insurance cover PMDD treatment?

Coverage depends on your state and plan; check yours on our accepted insurance page. Self-pay is $150 per visit, for new and follow-up visits. Medicaid can't be billed out of network, so a Medicaid plan works only where we're in network with it.

Is therapy or medication better for PMDD?

Both help, in different ways. In one randomized trial, CBT and fluoxetine worked about equally well after six months. Fluoxetine worked faster, and CBT's benefits lasted longer after treatment ended. ACOG's guideline notes that many patients may benefit from combining approaches.

What is the difference between PMS and PMDD?

PMDD is a severe form of PMS. PMS symptoms interfere with some activities. PMDD involves five or more symptoms, at least one of them a mood symptom, that disrupt work or relationships, confirmed with daily ratings over at least two cycles. Both ease within a few days after your period starts.