The correct answer is A. This patient has a presentation that is consistent with premenstrual dysphoric disorder (PMDD). This disorder is described in the Diagnostic and Statistical Manual of Mental Disorders, and is considered a form of premenstrual syndrome (PMS) with more severe emotional symptoms. Selective serotonin reuptake inhibitors (SSRIs) are the initial drugs of choice for PMDD or severe PMS. Fluoxetine (Prozac) and sertraline (Zoloft) are both approved for the management of this disorder. Patients who have severe PMS may be placed on a daily dose. Another approach that has been shown to be effective is intermittent therapy, in which the SSRI is administered only during the symptomatic phase. This method reduces the overall rate of side effects and is less expensive. Fluoxetine (Prozac) has the longest half-life of all the SSRIs, thus may be especially helpful in this disorder as missed doses are not as impactful.
Oophorectomy (choice B) as a treatment for PMS is controversial because the surgery is irreversible, there is morbidity and mortality associated with the surgery, and the resulting loss of hormones is also associated with health risks. The most appropriate management for this patient is fluoxetine.
Primrose oil (choice C) has been studied as a treatment for the symptoms of PMS and has not been found to be effective. There may be some benefit for the use of this agent in treating the soreness of the breasts that this patient is experiencing.
Like primrose oil, progesterone (choice D) also has been evaluated as a possible treatment for PMS. In several trials it was not shown to be more effective than placebo, although there is some evidence that it may help for specific symptoms such as breast tenderness and bloating.
Vitamin B6 (choice E) is considered to be of limited benefit for the treatment of PMS. High doses (>100 mg/day) are associated with peripheral neuropathy.
PEARL: Premenstrual dysphoric disorder (PMDD) is associated with the cyclic occurrence of depression, anxiety, and emotional lability that occurs 1 week prior to menses and dissipates within 1 week after the completion of menses. These symptoms are most pronounced in the luteal phase of the menstrual cycle and may also include anger, irritability, and internal tension. Physical symptoms include breast tenderness, abdominal bloating, and headaches. To meet the DSM criteria, the patient must have ≥5 of the above signs or symptoms. Approximately 3-8% of menstruating women meet the criteria for this condition. SSRIs are the medication class of choice for PMDD. Alternative options include calcium supplementation, pyridoxine, magnesium, and vitamin E.
