Abstract：
Objective: Despite the documented success of gonadotropin-releasing hormone analogs (GnRHa) for the treatment of treatment-resistant premenstrual dysphoric disorder (PMDD), many patients struggle to find providers who have sufficient knowledge of PMDD and its evidence-based treatments and/or who are comfortable treating PMDD after first-line treatment options have failed. Here, we discuss the barriers to initiating GnRHa for treatment-resistant premenstrual dysphoric disorder (PMDD) and offer practical solutions to address these barriers for providers who encounter patients with treatment-resistant PMDD but may not have the necessary expertise or comfort with providing evidence-based treatments (ie, gynecologists, general psychiatrists). We have included supplementary materials including patient and provider handouts, screening tools, and treatment algorithms with the hope that this review may serve as a primer on PMDD and the use of GnRHa with hormonal addback as a treatment, as well as a guideline for clinicians delivering this treatment to patients in need.
Options: In addition to offering practical treatment guidelines for first and second lines of treatment for PMDD, this review offers an in-depth discussion of GnRHa for treatment-resistant PMDD.
Outcomes: The burden of illness in PMDD is estimated to be similar to that of other mood disorders, and those suffering from PMDD are at a high risk for suicide.
Evidence: We present a selective review of relevant clinical trials evidence supporting the use of GnRHa with addback hormones in treatment-resistant PMDD (the most recent evidence cited was published in 2021), highlighting the rationale for addback hormones and presenting the different possible hormonal addback approaches.
Values: The PMDD community has and continues to suffer from debilitating symptoms despite the known interventions. This article provides guidance for implementing GnRHa into practice among a broader scope of clinicians including general psychiatrists.
Benefits, Harms, and Costs: The primary benefit of implementing this guideline is that a broad range of clinicians beyond reproductive psychiatrists who encounter patients with PMDD will have a template for assessing and treating PMDD and implementing GnRHa treatment when first-line treatments fail. Harms are expected to be minimal; however, some patients may have side effects or adverse reactions to the treatment or may not respond as they had hoped. Costs of GnRHa can be high depending on insurance coverage. We provide information within the guideline to help navigate this barrier.
Recommendations: (1) Prospective symptom rating in evaluating for PMDD is necessary for diagnosis and evaluating treatment response. (2) SSRIs and oral contraceptives should be trialed as the first- and second-line treatments for PMDD. (3) When first- and second-line treatments have failed to yield symptom relief, the use of GnRHa with hormone addback should be considered. Risks and benefits of GnRHa should be weighed among clinicians and patients, and potential barriers to access should be discussed.
Validation: This article adds to the available systematic reviews on the effectiveness of GnRHa in the treatment of PMDD and Royal College of Obstetrics and Gynecology\'s guidelines on the treatment of PMDD.
Options: In addition to offering practical treatment guidelines for first and second lines of treatment for PMDD, this review offers an in-depth discussion of GnRHa for treatment-resistant PMDD.
Outcomes: The burden of illness in PMDD is estimated to be similar to that of other mood disorders, and those suffering from PMDD are at a high risk for suicide.
Evidence: We present a selective review of relevant clinical trials evidence supporting the use of GnRHa with addback hormones in treatment-resistant PMDD (the most recent evidence cited was published in 2021), highlighting the rationale for addback hormones and presenting the different possible hormonal addback approaches.
Values: The PMDD community has and continues to suffer from debilitating symptoms despite the known interventions. This article provides guidance for implementing GnRHa into practice among a broader scope of clinicians including general psychiatrists.
Benefits, Harms, and Costs: The primary benefit of implementing this guideline is that a broad range of clinicians beyond reproductive psychiatrists who encounter patients with PMDD will have a template for assessing and treating PMDD and implementing GnRHa treatment when first-line treatments fail. Harms are expected to be minimal; however, some patients may have side effects or adverse reactions to the treatment or may not respond as they had hoped. Costs of GnRHa can be high depending on insurance coverage. We provide information within the guideline to help navigate this barrier.
Recommendations: (1) Prospective symptom rating in evaluating for PMDD is necessary for diagnosis and evaluating treatment response. (2) SSRIs and oral contraceptives should be trialed as the first- and second-line treatments for PMDD. (3) When first- and second-line treatments have failed to yield symptom relief, the use of GnRHa with hormone addback should be considered. Risks and benefits of GnRHa should be weighed among clinicians and patients, and potential barriers to access should be discussed.
Validation: This article adds to the available systematic reviews on the effectiveness of GnRHa in the treatment of PMDD and Royal College of Obstetrics and Gynecology\'s guidelines on the treatment of PMDD.
摘要：
目的：尽管促性腺激素释放激素类似物（GnRHa）在治疗难治性经前烦躁不安症（PMDD）方面取得了成功，许多患者很难找到对PMDD及其循证治疗有足够了解的提供者和/或在一线治疗方案失败后愿意接受PMDD治疗的提供者.这里,我们讨论了启动GnRHa治疗难治性经前烦躁不安症（PMDD）的障碍，并为遇到难治性PMDD患者但可能没有必要的专业知识或舒适提供循证治疗的提供者提供解决这些障碍的实用解决方案（即，妇科医生,一般精神科医生)。我们已经包括了补充材料，包括患者和提供者的讲义，筛选工具,和治疗算法，希望这篇综述可以作为PMDD的入门和使用GnRHa和激素回补作为治疗，以及临床医生为有需要的患者提供这种治疗的指南。
选项：除了为PMDD的一线和二线治疗提供实用的治疗指南外，这篇综述对GnRHa用于治疗耐药的PMDD进行了深入的讨论。
结果：估计PMDD的疾病负担与其他情绪障碍相似，那些患有PMDD的人自杀的风险很高。
证据：我们对相关临床试验证据进行了选择性审查，这些试验证据支持在治疗耐药的PMDD中使用GnRHa和减排激素（引用的最新证据发表于2021年）。强调背补激素的基本原理，并提出不同的可能的激素背补方法。
价值观：尽管采取了已知的干预措施，但PMDD社区已经并继续遭受衰弱症状的困扰。本文为在包括普通精神科医生在内的更广泛的临床医生中实施GnRHa提供了指导。
好处，危害,和费用：实施本指南的主要好处是，除了遇到PMDD患者的生殖精神病医生之外，广泛的临床医生将有一个模板来评估和治疗PMDD，并在一线治疗失败时实施GnRHa治疗。预计危害最小；然而，一些患者可能对治疗有副作用或不良反应，或者可能没有他们希望的反应。GnRHa的成本可能很高，具体取决于保险范围。我们在指南中提供信息以帮助浏览此障碍。
建议：（1）评估PMDD的前瞻性症状评级对于诊断和评估治疗反应是必要的。（2）SSRIs和口服避孕药应作为PMDD的一线和二线治疗方法进行试验。（3）当一线和二线治疗未能缓解症状时，应考虑使用GnRHa和激素回拨。应在临床医生和患者中权衡GnRHa的风险和收益，应该讨论潜在的准入障碍。
验证：本文增加了关于GnRHa治疗PMDD有效性的系统评价和皇家妇产科学院关于PMDD治疗的指南。
目的：尽管促性腺激素释放激素类似物（GnRHa）在治疗难治性经前烦躁不安症（PMDD）方面取得了成功，许多患者很难找到对PMDD及其循证治疗有足够了解的提供者和/或在一线治疗方案失败后愿意接受PMDD治疗的提供者.这里,我们讨论了启动GnRHa治疗难治性经前烦躁不安症（PMDD）的障碍，并为遇到难治性PMDD患者但可能没有必要的专业知识或舒适提供循证治疗的提供者提供解决这些障碍的实用解决方案（即，妇科医生,一般精神科医生)。我们已经包括了补充材料，包括患者和提供者的讲义，筛选工具,和治疗算法，希望这篇综述可以作为PMDD的入门和使用GnRHa和激素回补作为治疗，以及临床医生为有需要的患者提供这种治疗的指南。
选项：除了为PMDD的一线和二线治疗提供实用的治疗指南外，这篇综述对GnRHa用于治疗耐药的PMDD进行了深入的讨论。
结果：估计PMDD的疾病负担与其他情绪障碍相似，那些患有PMDD的人自杀的风险很高。
证据：我们对相关临床试验证据进行了选择性审查，这些试验证据支持在治疗耐药的PMDD中使用GnRHa和减排激素（引用的最新证据发表于2021年）。强调背补激素的基本原理，并提出不同的可能的激素背补方法。
价值观：尽管采取了已知的干预措施，但PMDD社区已经并继续遭受衰弱症状的困扰。本文为在包括普通精神科医生在内的更广泛的临床医生中实施GnRHa提供了指导。
好处，危害,和费用：实施本指南的主要好处是，除了遇到PMDD患者的生殖精神病医生之外，广泛的临床医生将有一个模板来评估和治疗PMDD，并在一线治疗失败时实施GnRHa治疗。预计危害最小；然而，一些患者可能对治疗有副作用或不良反应，或者可能没有他们希望的反应。GnRHa的成本可能很高，具体取决于保险范围。我们在指南中提供信息以帮助浏览此障碍。
建议：（1）评估PMDD的前瞻性症状评级对于诊断和评估治疗反应是必要的。（2）SSRIs和口服避孕药应作为PMDD的一线和二线治疗方法进行试验。（3）当一线和二线治疗未能缓解症状时，应考虑使用GnRHa和激素回拨。应在临床医生和患者中权衡GnRHa的风险和收益，应该讨论潜在的准入障碍。
验证：本文增加了关于GnRHa治疗PMDD有效性的系统评价和皇家妇产科学院关于PMDD治疗的指南。
