Medication Options for PMS and PMDD

PMDD
Written By Georgina Standen

Understanding PMS and PMDD

Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD) are real, biological conditions caused by sensitivity to hormonal fluctuations rather than abnormal hormone levels. PMS can affect up to 40% of women, while PMDD — the most severe form — impacts 3–8% of women and can cause disabling mood changes, fatigue, and physical symptoms. In fact, research shows that over 80% of women with PMDD have thought about suicide at some point, with up to 30% making an attempt. These conditions are serious, but effective treatments exist.

To explore just how common these conditions are, what those symptoms look like, and the key differences between PMS and PMDD, you can read my dedicated articles: How common are PMS and PMDD?, The 200+ symptoms of PMS, and PMS vs PMDD: Understanding the Difference.

Antidepressants (SSRIs and SNRIs)

The most widely used medications for PMDD are antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, and escitalopram. They can be taken either continuously or just during the luteal phase (the two weeks before menstruation). This is unique to PMDD — antidepressants often work rapidly, improving mood and physical symptoms within the first cycle.

Some women who don’t tolerate SSRIs may benefit from serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine or desvenlafaxine, especially in perimenopausal women who also experience hot flushes.

Hormone Therapy (HRT)

Many women with PMS or PMDD, particularly those approaching perimenopause, respond well to hormone therapy. This is because the root problem is often sensitivity to hormonal changes, not low hormone levels.

Transdermal oestrogen, given as a patch or gel, can suppress ovulation and stabilise mood. Evidence suggests higher doses (such as 100 mcg patches twice weekly) may be particularly effective. Adding testosterone in very low doses can also help with low energy and libido in selected cases.

Women with a uterus also need a progestogen for endometrial protection. However, many women with PMS or PMDD are progesterone-intolerant. In these cases, using the lowest effective dose for the shortest time (7–10 days per month) or opting for micronised progesterone (Utrogestan®), sometimes via the vaginal route, may reduce side effects.

Combined Oral Contraceptives (COCs)

By suppressing ovulation, COCs can help stabilise hormone fluctuations. Drospirenone-containing pills (e.g., Yaz®, Yasmin®) may reduce bloating and breast tenderness and are often more effective than older preparations. Continuous or extended-cycle use — taking pills back-to-back to minimise or eliminate withdrawal bleeds — is sometimes more beneficial than traditional 21/7 regimes.

There is a newer generation pill, which includes natural oestrogen, which is showing promise for the treatment of PMS and you can read more about that here.

However, some women notice mood worsening on the pill, so careful monitoring is essential.

While combined hormonal contraception (CHC) is sometimes contraindicated, a newer progestogen-only pill, Slynd®, may be beneficial as it contains drospirenone and suppresses ovulation in most women.

GnRH Analogues

For the most severe and treatment-resistant cases, GnRH analogues can effectively “switch off” ovarian hormone production, inducing a temporary menopause. This usually leads to dramatic improvement in PMS/PMDD symptoms.

Because they reduce bone density and cause menopausal symptoms, GnRH analogues are usually combined with “add-back” HRT to protect long-term health. They are generally considered when other treatments haven’t worked, or when lives are significantly at risk from severe PMDD.

The Role of Progestogens

Progestogens can be both part of the solution and part of the problem. Many women with PMS/PMDD experience mood worsening with synthetic progestins, whether in contraceptives or HRT. Micronised progesterone (Utrogestan®) is often better tolerated because it is bioidentical and can be given orally or vaginally, influencing the GABA pathway through its metabolite allopregnanolone.

The levonorgestrel intrauterine system (LNG-IUS, Mirena®) can sometimes help reduce physical symptoms but has been linked in some studies to increased depression risk in sensitive women. This highlights the importance of tailoring treatment individually.

I have written a dedicated blog all about progesterones and progestins.

Other Medications

Other drugs may be considered when standard therapies are unsuitable. Spironolactone, a diuretic with anti-androgen effects, can help with fluid retention, bloating, and mastalgia. Short-term use of other diuretics may also bring relief in selected cases. In very severe situations, anxiolytics or other classes of antidepressants may be added, ideally under specialist supervision.

Screening and Diagnosis

Accurate diagnosis is key. Prospective symptom diaries over at least two cycles remain the gold standard, but tools such as the Premenstrual Symptoms Screening Tool (PSST) can provide a quick and effective way to identify women likely to benefit from treatment. Misdiagnosis is common — for example, PMDD is sometimes mistaken for bipolar disorder — so recognising the cyclical pattern of symptoms is essential. You can read my blog on how PMS and PMDD are diagnosed for a more in depth view.

Taking the Next Step

The choice of treatment depends on your symptoms, medical history, and preferences. Some women find relief with SSRIs, others with the pill or HRT, and in the most severe cases, GnRH analogues may be appropriate. The key is that help is available, and you don’t have to go through this alone.

About the Author

Dr Georgina Standen is a Women’s Health GP and Medical Director of Sirona Health. She specialises in the diagnosis and treatment of PMS (premenstrual syndrome) and PMDD (premenstrual dysphoric disorder), as well as broader hormonal health and menopause care. Her approach blends evidence-based medicine with personalised, compassionate support to help women regain control of their health and wellbeing.

Sirona Health offers PMS and PMDD consultations in Stroud, Cirencester, Tetbury, Fairford, Lechlade, Calne, Corsham, Chippenham, Malmesbury and Bath, along with nationwide secure online appointments.

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FAQ

  • PMS is common, but PMDD is a severe form that causes disabling emotional and physical symptoms. It affects around 5–8% of women.

  • Yes. SSRIs and SNRIs work in PMDD even without depression because they act on serotonin pathways affected by hormone changes.

  • No. Transdermal oestrogen, sometimes combined with micronised progesterone, can be very effective for PMS and PMDD, particularly in perimenopausal women.

  • Certain contraceptives, especially those with drospirenone, can improve symptoms. Continuous regimes often work best.

  • GnRH analogues may be considered in severe, resistant cases. Psychological support is also important alongside medical treatment.

  • There’s no blood test. Diagnosis relies on symptom history, prospective charting, or screening tools like the PSST.