The Waco Guide

Present
Inadequate
Response
Absent
Moderate/Severe
Desired and appropriate Not desired / not appropriate
Adequate
response
Inadequate
response
Inadequate
response
Mild
Inadequate
response
Inadequate
response
Discontinue prior ineffective
SSRI/SNRI
Inadequate
response
Adequate
response
Adequate response
Inadequate
response
Adequate response
Premenstrual Dysphoric
Symptoms
Evaluate for underlying
mood disorder
See corresponding
decision support and
treat appropriately
Premenstrual Exacerbation:
consider dose increase
of primary pharmacotherapy
during luteal phase
Premenstrual Dysphoric
Disorder (PMDD)
Evaluate symptom
severity
Combination Lifestyle interventions
psychotherapy, pharmacotherapy
Cognitive behavioral
therapy (if available)
SSRI or Hormonal Contraception
(evaluate patient's desire and CDC Medical Eligibility
Criteria for Hormonal Contraception)
Continuous hormonal
contraception for 3 months
Drospirenone containing
Combined oral contraception
(COC) most studied
Drospirenone only option if
progesterone only
contraception (POC) desired
POC
Consider addition of
estrogen if eligible or
augment with SSRI
SSRI
Fluoxetine
Sertraline
Increase dose as needed
each cycle
Continue SSRI/SNRI
minimum one year
Inadequate response
at max recommend/tolerable dose
Change to different
SSRI/SNRI
Escitalopram
Fluoxetine
Sertraline
Duloxetine
Increase dose as
needed each cycle
Consider third SSRI/SNRI trial and
reconsider OCP desire/appropriateness in
combination with SSRI/SNRI
Lifestyle
interventions
Exercise
Relaxation
techniques
Diagnosed by documentation of symptoms
prospectively over 2 cycles using
Daily Record of Severity of Problems (DRSP)
COC
Continue
Increase estrogen
dose of COC to 30mcg
equivalent
Evaluate
response
Augment with SSRI:
Combination
OCP/SSRI therapy
(see SSRI arm)
Continued inadequate response
despite multiple SSRI's and
OCP (if desired/appropriate)
GnRH agonist
consider low dose estrogen-progesterone "add back" therapy
Assess patients guideline defined appropriateness
for last resort surigical bilateral salpingo-oopherectomy
Symptom targeted
augmentation
See corresponding decision
support tool (e.g. MDD, GAD)
SSRIs may be administer continuously,
during luteal phase, or in a symptom
triggered manner
Continuous and luteal
phase have equivalent efficacy
Continuous: convenient/simple, benefit
for non-premenstrual symptoms
Luteal phase: Potentially more affordable
and fewer side effect potential, start day
14 of cycle and end at onset of menses or
few days after
Symptom triggered: Preferred if
symptoms are brief and predictable

Diagnosis confirmed by documentation of symptoms prospectively over 2 cycles using Daily Record of Severity of Problems (DRSP)

Is there an underlying mood disorder?