New Guidelines for Severe PMS, PMDD Advise Antidepressants, CBT and Birth Control

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  • ACOG has released a new set of guidelines for the treatment of PMS and PMDD (Premenstrual dysphoric disorder).
  • Treatments that are recommended include antidepressants and cognitive behavioral therapy.
  • Removal of the ovaries with or without the uterus is not advised.
  • Experts say this will help women with PMS or PMDD get the best care.

The American College of Obstetricians and Gynecologists (ACOG) has announced the release of its Clinical Practice Guideline for the management of premenstrual disorders.

This document, which appears in the December 2023 issue of Obstetrics & Gynecology, is meant to provide recommendations for physicians in treating premenstrual disorders like premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD).

The Office on Women’s Health states that PMS is very common with over 90% of women saying that they have physical and emotional symptoms such as bloating, headaches, and moodiness around the time of their periods.

Symptoms tend to begin a week or two before and usually end within two to three days after it begins.

They add that PMDD is similar to PMS, but is considered to be more serious and severe. It may require treatment with medication.

It includes emotional symptoms such as anxiety, depression, and irritability which can be severe enough to interfere with a woman’s day-to-day life.

These updated recommendations are based on the currently available evidence of what works best and is safest for patients when it comes to treating these conditions.

Dr. Greg J. Marchand, who is dual board-certified in OBGYN and MIGS (Practice Focus) and is the Director of Marchand Institute for Minimally Invasive Surgery, said that publications like this one are “very important” because they indicate what the standard of care is in the U.S.

Marchand further noted that premenstrual syndrome “is a serious disease that does not get enough attention.

“ACOG is making the point that all OBGYNs need to be thinking more about diagnosing and treating PMS more often, as women are suffering in silence,” he said.

Better treatment for PMS, PMDD include antidepressants, talk therapy

Marchand said the guidelines discuss what treatments have the most evidence behind them as well as those that are not recommended.

The three most effective treatments advised by the guidelines include antidepressants known as selective serotonin reuptake inhibitors (SSRIs), combined oral contraceptives, and cognitive behavioral therapy (CBT).

Marchand went on to explain that SSRIs are used to treat both anxiety and depression. They are believed to work by making more of the neurotransmitter serotonin available in the brain.

Oral contraceptives, on the other hand, are birth control pills containing estrogen and progesterone. They can prevent pregnancy as well as regulate periods.

Finally, according to Marchand, CBT is what is often referred to as “talk therapy” and is done by a mental health professional. CBT is the most studied and scientifically validated form of psychotherapy for depression.

“The guideline gives no preference as to which therapy is best,” he added, “but lists them all as being strongly recommended.”  

In addition, the guidelines discuss therapies that are less recommended, although Marchand notes that the guidelines do not advise that you shouldn’t use them.

These treatments include gonadotropin-releasing hormone (GnRH) agonists, exercise, calcium supplements, and types of common pain relievers called nonsteroidal anti-inflammatory drugs (NSAIDs).

“GnRH agonist medications are powerful hormonal medications that work by bringing on a partial or complete menopausal state temporarily… ” Marchand explained. A study published in 2023 in Neuropharmacology reports that GnRH agonists produced “antidepressant-like effects” in male mice.

Additionally, a number of studies have found that exercise can have beneficial effects on both depression and anxiety, according to a 2023 systematic review published in the British Journal of Sports Medicine.

However, there is only limited evidence of a link between calcium and depression, per a 2023 study found in Frontiers in Nutrition.

NSAIDs have also been proposed to help depression due to their anti-inflammatory effects, according to a 2016 article in Current Neuropharmacology.

Finally, Marchand said that the document advises against bilateral oophorectomy (removing the ovaries) with or without hysterectomy (removing the uterus) as a first-line treatment for PMS or PMDD.

“This is pretty much common sense as removing these organs is a very serious surgery that will cause menopause, sterility, and may increase the chance of heart attack and stroke in some women,” said Marchand.

Why these new guidelines for PMS and PMDD are important

Dr. Ankita Langan, an OBGYN with Novant Health in Charlotte, North Carolina, said, “These new guidelines provide some direction as far as what women can do at home to help with premenstrual symptoms as well as information on what may be helpful to do discuss with an OBGYN.”

Robin Davis, MSN, ARNP, FNP-BC, a board-certified Family Nurse Practitioner with The Fountain at West Palm Beach, Florida, added that the guidelines are important because many women simply ignore their symptoms.

“The reality is most people, not only women, lack the necessary knowledge when it comes to the symptoms of PMS and PMDD, as well as how to properly manage them,” she said.

Davis further noted that both conditions may require lifelong management.

“Unfortunately, medical professionals often overlook the symptoms of PMDD or incorrectly diagnose PMDD,” she said.

Additionally, according to Davis, there are negative social and cultural connotations linked to these conditions so women tend to suffer in silence.

“With proper and comprehensive guidelines, people are more likely to understand how debilitating PMS and PMDD are,” she said, adding that women would benefit from these guidelines because they would better understand their reproductive health.

“Medical professionals also benefit from the guidelines because they’d be able to provide an accurate diagnosis and better care,” she concluded.

Takeaway

The latest guidance from experts on treating PMS and PMDD indicates that antidepressants, oral birth control, and CBT have the most evidence behind them.

Other options including hormone agonists, exercise, calcium supplements, and certain types of pain relievers are less recommended although they are not actively discouraging their use.

Finally, the organization states that bilateral oophorectomy (removing the ovaries) with or without hysterectomy should not be used as a first-line treatment for these disorders.

Experts say these guidelines will help both women and their doctors to better understand these conditions so that women can get the healthcare that they need.

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