How do you manage patients with PMDD when they are already on an SSRI and have an IUD?

Highlights

• As an initial step, consider increasing the patient's SSRI dosage if tolerated and supplementing with vitamin B6 and magnesium.
• Assess the patient's experience with their IUD, as a subgroup of women may experience acute depressive symptoms with it.
• Combined hormonal contraceptives, particularly those with drospirenone, are a recommended treatment option for suppressing the ovaries to manage mood symptoms.
• DMPA injections are presented as an alternative to combined hormonal contraception for the purpose of suppressing ovarian function.

Expert Insights

Optimizing Existing and Hormonal Therapies

For patients with Premenstrual Dysphoric Disorder (PMDD) who experience persistent symptoms despite treatment with an SSRI and placement of an IUD, clinicians can employ a multi-step approach. Dr. Kimberly Mangla suggests first optimizing the existing pharmacotherapy. She advocates for a "bump up dosing" strategy for the current SSRI, provided the patient can tolerate an increased dose. In addition to titrating the SSRI, Dr. Mangla recommends considering adjunctive supplements, specifically mentioning Vitamin B6 and Magnesium as potential additions to the treatment regimen.

Reassessing the Role of the IUD

A crucial next step involves evaluating the patient’s experience with their IUD. Dr. Kimberly Mangla points out that the IUD is not a first-line treatment for PMDD and notes the existence of data suggesting a subgroup of women may experience acute depressive symptoms with this device. This assessment of the IUD's potential impact on mood is a critical diagnostic consideration before proceeding with further management changes.

"...there is some data suggesting a subgroup of females experience acute depression symptoms." Dr. Kimberly Mangla

The Rationale for Ovarian Suppression

Both experts converge on the strategy of hormonal intervention to manage the cyclical mood symptoms of PMDD. Dr. Sarah Prager recommends combination hormonal contraception as a primary strategy for patients without contraindications to estrogen. She explains that the goal is to "suppress the ovaries," which directly addresses the hormonal fluctuations responsible for the mood component of PMDD. This remains a valid approach even when a levonorgestrel-releasing IUD is already managing any associated bleeding issues.

"This would hopefully address the mood component dependent on hormonal changes, even if the bleeding issues have been addressed with the LNG-IUD." Dr. Sarah Prager

Specific Hormonal Contraceptive Options

When selecting a method for ovarian suppression, clinicians have several options. Dr. Mangla highlights that there is "more data suggesting benefit of combined OCP, particularly those that contain drospirenone," for managing PMDD. Echoing the principle of ovarian suppression, Dr. Prager offers depot medroxyprogesterone acetate (DMPA) as an alternative for achieving the same therapeutic goal. The choice between these methods allows for tailoring the approach based on patient preference and clinical profile after a thorough discussion of risks and benefits.

"There is more data suggesting benefit of combined OCP, particularly those that contain drospirenone." Dr. Kimberly Mangla