Contraceptive Options for Patients with Premenstrual Dysphoric Disorder (PMDD) and Migraines with Aura
Introduction to Contraceptive Options
- The American College of Obstetricians and Gynecologists recommends considering a progestin-only intrauterine device (levonorgestrel IUD) as the most appropriate contraceptive option for patients with PMDD, migraines with aura, and SSRI intolerance, due to its high effectiveness (>99%) and minimal systemic hormone exposure 2
- Migraines with aura significantly increase thrombosis risk when combined with estrogen, making estrogen-containing contraceptives contraindicated for these patients 1
Progestin-Only Contraceptive Options
- The levonorgestrel IUD is a highly effective (>99%) contraceptive option with low systemic hormone exposure, which may help with PMDD symptoms through partial suppression of ovulation, and is safe for patients with migraines with aura 2
- Progestin-only pills (POP) are an alternative option, but require strict adherence to timing and have lower efficacy (91-99%) compared to IUDs 2
- The progestin implant is a possible alternative, with high effectiveness (>99%), but limited data on thrombosis risk 2
- The DMPA injection is not recommended due to patient disinterest and potential higher thrombosis risk compared to other progestin-only methods 2
Non-Hormonal Contraceptive Options
- The copper IUD is a highly effective (>99%) alternative option with no hormonal side effects, but may increase menstrual bleeding and cramping, and potentially worsen PMDD symptoms in some patients 2
Management of PMDD Symptoms
- Cognitive Behavioral Therapy (CBT) is an effective treatment for PMDD symptoms and can be used alongside contraceptive methods 3
- Non-hormonal PMDD management strategies may need to be combined with contraceptive methods for symptom management, and patients should be monitored for changes in PMDD symptoms and assessed for the need for additional management strategies 3