Treatments

What Are the Treatment Options for Premenstrual Exacerbation (PME)?

For many women, the days leading up to their periods aren’t just about bloating or cramps. They also come with emotional instability, mood swings, and a resurgence of psychiatric symptoms.

Today, we'll be exploring the possible treatments for conditions impacted by Premenstrual Exacerbation (PME), which worsens existing mental health conditions in the luteal (premenstrual) phase of your cycle.

Major depressive disorder

• Antidepressant dose adjustment (e.g., increasing sertraline premenstrually) may help, but evidence is still emerging¹.

• Hormonal treatments, like oral contraceptives or gonadotropin-releasing hormone (GnRH) agonists (responsible for releasing the luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which support estrogen and progesterone production), show mixed results².

Bipolar disorder

• GABA-A receptor modulators (like lamotrigine) combined with hormonal contraceptives may help stabilize mood³.

• Selective Serotonin Reuptake Inhibitors (SSRIs), which increase serotonin levels in the brain, aren't generally recommended for PME in bipolar cases.

Anxiety disorder

• Rumination-focused cognitive behavioral therapy (CBT) may benefit those with generalized anxiety disorder (GAD), particularly during the luteal phase, when repetitive negative thinking tends to spike.

Trauma/stress-related disorder

• Cognitive behavioral therapy (CBT) may benefit those with post-traumatic stress disorder.

• Hormone stabilization may support mood regulation. However, research is required in this space.

Personality disorder

• SSRIs (during the luteal phase) may help with high-arousal symptoms, like anger^{4 5}.

• Hormone stabilization may support mood regulation and shows promise for low-arousal symptoms^{4 5}.

• Non-pharmacological approaches are also effective. These include cycle-tracking and Dialectical Behavior Therapy (DBT)⁶.

• Oral contraceptives may worsen symptoms in borderline personality disorder.

Obsessive-compulsive disorder (OCD)

• PSSRIs and mood stabilizers are commonly prescribed. However, there’s still a big research gap when it comes to adequately managing OCD symptoms specifically in relation to the menstrual cycle.

Psychotic disorder

• Adjunctive estrogen therapies (like estradiol or ethinyl estradiol) may help, as estrogen appears to play a protective role in schizophrenia. However, results are inconsistent⁷.

• Newer treatments, like selective estrogen receptor modulators, may be worth exploring.

• Antipsychotic medication adjustment around hormonal changes is a possibility, but results remain complex.

Note

Struggling with PME each month? You’re not alone! Reach out to your nearest healthcare professional or gynaecologist for clarity and support.

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Medically reviewed by

Dr Yash Bahuguna, MBBS, MS, DNB, ISGE Certified Practitioner for PCOS

Medical Advisor, Cranberry.Fit

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Researched by

Dr Inara Isani, BDS

Health Researcher & Writer

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Written by

Avantika Sukhia, BA (Hons), MLitt

Health Writer

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References

1. Miller MN, Newell CL, Miller BE, Frizzell PG, Kayser RA, Ferslew KE. Variable dosing of sertraline for premenstrual exacerbation of depression: a pilot study. Journal of Women's Health. 2008 Jul 1;17(6):993-7.

2. Freeman EW, Sondheimer SJ, Rickels K. Gonadotropin-releasing hormone agonist in the treatment of premenstrual symptoms with and without ongoing dysphoria: a controlled study. Psychopharmacology Bulletin. 1997;33(2):303.

3. Robakis TK, Holtzman J, Stemmle PG, Reynolds-May MF, Kenna HA, Rasgon NL. Lamotrigine and GABAA receptor modulators interact with menstrual cycle phase and oral contraceptives to regulate mood in women with bipolar disorder. Journal of affective disorders. 2015 Apr 1;175:108-15.

4. Peters JR, Eisenlohr-Moul TA. Ovarian hormones as a source of fluctuating biological vulnerability in borderline personality disorder. Current psychiatry reports. 2019 Nov;21(11):109.

5. Peters JR, Owens SA, Schmalenberger KM, Eisenlohr‐Moul TA. Differential effects of the menstrual cycle on reactive and proactive aggression in borderline personality disorder. Aggressive behavior. 2020 Mar;46(2):151-61.

6. Eisenlohr-Moul TA, Schmalenberger KM, Owens SA, Peters JR, Dawson DN, Girdler SS. Perimenstrual exacerbation of symptoms in borderline personality disorder: evidence from multilevel models and the Carolina Premenstrual Assessment Scoring System. Psychological Medicine. 2018 Sep;48(12):2085-95.

7. Kulkarni J, de Castella A, Fitzgerald PB, Gurvich CT, Bailey M, Bartholomeusz C, Burger H. Estrogen in severe mental illness: a potential new treatment approach. Archives of General Psychiatry. 2008 Aug 4;65(8):955-60.