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Treatment options, in the order doctors usually try them

PMDD treatment options in the order doctors usually try them, from the RCOG guideline and the Cochrane review.

Guidelines, such as the UK's RCOG guideline, describe a ladder. Your doctor will tailor it to you.

• For everyone: a clear explanation, support, regular exercise and cognitive behavioural therapy (CBT). These help on their own, and alongside medication.
• First line: SSRIs, a type of antidepressant. In PMDD they often work within days rather than weeks, so some people take them only in the second half of the cycle and others take them all month. Some newer combined contraceptive pills, often taken continuously, are another first-line option. Some supplements have modest evidence, such as vitamin B6 and calcium. Check with your doctor before starting anything.
• Second line: a higher SSRI dose, or hormone options such as oestrogen patches with progesterone.
• Third line: GnRH medicines that pause the cycle (a temporary, reversible medical menopause), with add-back hormone therapy, usually with a specialist.
• Last resort: surgery to remove the ovaries, often with the uterus, followed by hormone therapy. This is normally only considered after a GnRH trial shows that stopping the cycle works. In IAPMD's survey, over 80% of people who had surgery reported life-changing relief.

About 60% of people respond fully to SSRIs, and most people try more than one option. That is normal, not failure. Log every change under Treatment changes, and Jellybean shows the before and after for you.

Sources: RCOG Green-top Guideline 48, summarised on GPnotebook, IAPMD treatment options, Cochrane review: SSRIs for PMS and PMDD