Women's Health · Full case

Premenstrual Disorder (PMDD)

RCOG / NICE CKSSymptom diarySuicide-risk screen

It's the timing that defines itPremenstrual disorders are defined by the cyclical, luteal-phase pattern: symptoms appear in the 1–2 weeks before menstruation and resolve within a few days of bleeding starting, with a symptom-free week. The character of symptoms matters less than the timing

PMS vs PMDDPremenstrual syndrome (PMS) = distressing physical/psychological symptoms in the luteal phase. PMDD (premenstrual dysphoric disorder) is the severe form with prominent mood symptoms (marked irritability, depression, anxiety, lability) causing significant impairment — a recognised psychiatric diagnosis

Diary = the diagnosisDiagnosis rests on a prospective symptom diary over at least 2 menstrual cycles (e.g. the DRSP) — confirming the luteal-phase pattern with a symptom-free follicular phase. Retrospective recall is unreliable and over-diagnoses

Rule out the mimicThe key differential is an underlying mood disorder (depression, anxiety, bipolar) with PREMENSTRUAL EXACERBATION — here symptoms are present all month and worsen premenstrually. The diary distinguishes a symptom-free week (PMDD) from year-round symptoms (mood disorder)

Ask about suicidePMDD carries a significantly increased risk of suicidal thoughts and self-harm, concentrated in the luteal phase. A risk assessment is mandatory — these symptoms can be severe and dangerous even though they remit each month

SSRI works fast hereSSRIs are highly effective for PMDD and can be taken continuously OR only in the luteal phase (they work within days for premenstrual symptoms, unlike in depression). First-line pharmacological options alongside a combined pill

Ovulation suppressionSuppressing ovulation helps: a combined oral contraceptive (continuous/extended, drospirenone-containing often preferred) is a first-line hormonal option; severe refractory cases may need GnRH analogues (with add-back HRT) under specialist care

Stepped & specialistStepwise: lifestyle/CBT → SSRI and/or COCP → higher-dose/continuous → GnRH analogues → (rarely) surgery. Severe, refractory or diagnostically uncertain cases warrant gynaecology / a specialist premenstrual-disorder service

📋 Clinical Stem — Premenstrual Disorder (PMDD)

A 34-year-old woman who feels "like a different person — almost unhinged" for a week or two before every period, with rage, despair and fleeting thoughts she'd be better off gone, then is "completely fine again"

Leila Hassan, 34, describes a pattern she's lived with for years but never named: for about 10–14 days before each period she becomes intensely irritable, tearful and anxious, snaps at her partner and children, feels hopeless, and has had fleeting thoughts that her family "would be better off without me" — then within a day or two of her period starting it lifts and she feels "completely normal, like myself again." She functions well the rest of the month. She is frightened by the intensity and the dark thoughts, ashamed of how she behaves toward her family, and wonders if she is "going mad" or bipolar. She has no symptoms in the week after her period. She is not on hormonal contraception and is otherwise well.

This stem tests the ability to: recognise the cyclical, luteal-phase pattern with a symptom-free follicular phase as premenstrual dysphoric disorder (PMDD) rather than a primary mood disorder; distinguish it from an underlying depression/anxiety/bipolar disorder with premenstrual exacerbation (symptoms all month, worse premenstrually) — using a prospective 2-cycle symptom diary to confirm; perform a mandatory risk assessment for the luteal-phase suicidal thoughts and validate the experience without pathologising her as a "bad mother"; explain the diagnosis and the stepped management (lifestyle/CBT, SSRI continuous or luteal, combined pill/ovulation suppression, GnRH analogues for refractory cases under specialist care); and know when to involve gynaecology/specialist services. The SCA challenge is taking the dark thoughts seriously and confirming the diagnosis with a diary, while relieving her shame and fear of being "mad".

Scenario A — PMDD (this stem) Severe luteal mood symptoms with a symptom-free week and impairment ± luteal suicidal thoughts. Confirm with a 2-cycle diary; risk assess; SSRI (continuous/luteal) ± COCP; lifestyle/CBT; review.

Scenario B — Mood disorder with premenstrual exacerbation (the mimic) Depression/anxiety present all month, worse premenstrually; no symptom-free week on the diary. Treat the underlying disorder; SSRI continuously; mental-health input.

Scenario C — PMS (non-severe) Luteal physical/psychological symptoms that are distressing but not severely impairing. Lifestyle, simple measures, consider COCP/SSRI if needed.

Scenario D — Bipolar disorder History of elevated/manic episodes; premenstrual worsening can occur. Caution with antidepressants; mental-health/specialist input; do not miss bipolarity.

Scenario E — Severe / refractory PMDD Failed first-line treatments, profound impairment, high risk. Specialist premenstrual-disorder service; GnRH analogues with add-back HRT; rarely surgical options.

Key variables to adapt for The luteal pattern + symptom-free week (PMDD) vs all-month symptoms (mood disorder); severity/impairment (PMS vs PMDD); suicide/self-harm risk in the luteal phase; the prospective diary; bipolar history (antidepressant caution); contraceptive needs/desires; previous treatments; perimenopause overlap; the shame and relationship impact.

Steps:

Step 1

History — The Cyclical Pattern · The Mimic · Risk · Impact · ICE

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The history is built around one defining feature — timing. Premenstrual disorders are confirmed by symptoms in the luteal phase that resolve with menstruation and a symptom-free week afterwards; the crucial distinction is from an underlying mood disorder that is present all month and merely worsens premenstrually. Two things must happen alongside: a risk assessment for the luteal suicidal thoughts, and the relief of Leila's shame and fear that she is "going mad".

🎓 SCA framing — name it, validate it, assess the risk

"What you're describing — feeling like a completely different person for a week or two before your period, then yourself again — is a recognised condition with a name and effective treatments. You're not going mad, and you're not a bad mother. Can I ask some questions to be sure we've got the pattern right, including some about how dark those thoughts get?"

Leila is ashamed and frightened. Naming PMDD as real and treatable, validating her, and then gently assessing the risk are the moves that make this consultation both safe and therapeutic.

1A — Pattern, mimic, risk and impact

Question	Why it matters	Changes what?
🟢 OPEN QUESTION"Tell me about the pattern — when in the month it happens, and what you're like in between."	The open question lets the cyclical pattern emerge. The hallmark of a premenstrual disorder is luteal-phase symptoms (the 1–2 weeks before the period) that resolve within a few days of bleeding, with a genuinely symptom-free week. Leila's "completely normal in between" is the key feature that points to PMDD rather than a mood disorder.In SCA: asking what she's like between episodes is the single most diagnostic question — it tests for the symptom-free follicular phase.	Luteal symptoms + symptom-free week → PMDD
🚩 The mimic — mood disorder with premenstrual exacerbation"Are there low days or anxious days at other times of the month too, even if they're worse before your period?"	The pivotal differential. If symptoms are present throughout the month and merely worsen premenstrually, this is an underlying depression/anxiety (or bipolar) disorder with premenstrual exacerbation — managed as the primary disorder, not as PMDD. A true symptom-free follicular phase is what defines a premenstrual disorder. The prospective diary settles it.	All-month symptoms → primary mood disorder (treat as such). Symptom-free week → PMDD.	Defines PMDD vs mood disorder2-cycle symptom diary
🚩 Risk assessment"You mentioned thoughts that your family would be better off without you — can you tell me more? How dark do those thoughts get, and have you ever thought about acting on them?"	Mandatory. PMDD significantly raises suicidal ideation and self-harm risk, concentrated in the luteal phase. Explore the nature, intensity, plans, intent and protective factors of Leila's thoughts, and how she is during the worst days. The cyclical, remitting nature does NOT make the risk trivial.	Active intent/plan → urgent mental-health assessment + safety plan; luteal-phase safety planning.	Active risk → urgent assessment
Bipolar & psychiatric history"Have you ever had periods of feeling unusually high, sped up, or not needing sleep? Any past depression or mental-health treatment?"	A history of elevated/manic episodes raises bipolar disorder — important because antidepressants need caution and the management differs. Past depression/anxiety also shapes the differential and treatment.	Bipolar features → caution with SSRIs; mental-health/specialist input.	Bipolar → antidepressant caution
Impact & relationships"How is this affecting your relationship, your children, your work?"	Severity is defined by impairment. The impact on Leila's family — and her shame about it — is central both to the PMDD (vs PMS) classification and to the therapeutic relationship. Naming that the behaviour is driven by a treatable condition relieves guilt and supports engagement.	Significant impairment → PMDD; treat actively; address relationship impact/guilt.	Impairment defines severity; address guilt
Reproductive & treatment history"Where are you with contraception and family plans? What have you already tried for this?"	Contraceptive needs and plans shape hormonal options (a combined pill can both treat PMDD and provide contraception); previous treatments and their effect guide the next step. Perimenopause can overlap and alter the picture.	Contraceptive need → COCP option; previous treatments → tailor next step.	Align treatment with contraception/plans

1B — Red flags

🚨

Red Flags — the cyclical illness that can still be dangerous

Red flag	Why dangerous	Action
Active suicidal ideation / self-harm (often luteal-phase)	PMDD substantially increases suicide risk; intense luteal-phase despair can lead to acts even though it remits.	Risk assessment; urgent mental-health/crisis input if intent/plan; luteal safety plan
Underlying mood disorder with premenstrual exacerbation	Misdiagnosing a year-round depression/anxiety as PMDD leads to under-treatment of the primary illness.	Prospective diary; treat the primary disorder; mental-health input
Bipolar disorder	Antidepressants can destabilise mood; bipolarity is easily missed.	Screen for mania/hypomania; caution with SSRIs; specialist/mental-health input
Severe functional collapse / safeguarding concern	Severe PMDD can endanger the woman and affect care of children.	Urgent support; consider safeguarding; specialist referral
Postpartum / perimenopausal overlap	Other hormonal mood disorders can coexist or confuse the picture.	Clarify with history/diary; treat appropriately
Refractory severe symptoms	High morbidity; needs escalation beyond primary care.	Specialist premenstrual-disorder service / gynaecology

1C — ICE

💭 Ideas

"What do you think is happening to you — you mentioned wondering if you're bipolar or 'going mad'?"

Leila fears she is mentally ill in a frightening, permanent way. Surfacing this lets you name PMDD as a recognised, hormone-linked, treatable condition — and to explain how it differs from bipolar disorder — which is profoundly reassuring and reframes her self-blame.

😟 Concerns

"What worries you most — the dark thoughts, or how you are with your family?"

Her concerns are the suicidal thoughts and the shame about her behaviour toward her children. Naming both lets you assess the risk properly and relieve the guilt by attributing the behaviour to a treatable condition rather than to her character.

🎯 Expectations

"What were you hoping for from coming today?"

She may want an instant fix or fear being dismissed as "hormonal". Naming this lets you set out the plan — confirm with a diary, assess safety, and start effective treatment (often quickly with an SSRI) — so she leaves with hope and a concrete path.

1D — Psychosocial context

Premenstrual disorders sit at a painful intersection of stigma: women are told it's "just PMS" and dismissed, while privately they experience symptoms severe enough to threaten relationships and, at the extreme, life. Many carry deep shame about how they behave during the luteal phase and blame themselves. The transformative clinical act is to take it seriously — to name PMDD as a genuine, hormone-linked condition with effective treatments, to separate the woman's worth from her premenstrual symptoms, and to assess the very real luteal-phase risk that the cyclical remission can hide.

🙎 "Am I a bad mother?"

Attribute the behaviour to a treatable condition; separate it from her character.

"The way you are with your family in those two weeks isn't who you are — it's a symptom of a hormone-driven condition. That you feel so awful about it tells me how much you love them. We can treat this."

🧠 "Am I going mad / bipolar?"

Reassure and differentiate clearly from bipolar disorder.

"You're not going mad. Because it comes and goes with your cycle and you're completely well in between, this is premenstrual dysphoric disorder rather than bipolar — and that distinction matters, because it's very treatable."

🆘 Taking the dark thoughts seriously

The remitting nature doesn't reduce the risk; assess and safety-plan.

"I'm really glad you told me about those thoughts — they're part of how severe this can get, and I take them seriously even though they lift after your period. Let's make a plan for the worst days and get you treatment so they ease."

🚫 Undoing dismissal

Counter the "just PMS" message she may have internalised.

"This isn't something to just put up with or be embarrassed about. It's a recognised condition, and there are treatments that genuinely work — you deserve to feel like yourself all month."

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"What are you like in the week AFTER your period?" — tests for the symptom-free phase that defines PMDD.

"Tell me more about the thoughts that your family would be better off without you — have you thought about acting on them?" — mandatory risk assessment.

"This is a recognised, treatable condition — you're not going mad or a bad mother." — validates and reframes.

Deductions

Not assessing suicide/self-harm risk
Not distinguishing PMDD from a year-round mood disorder (no diary)
Dismissing it as "just PMS"; not screening bipolar
Leaving her shame and fear unaddressed

🔴 Red

No risk assessment; PMDD vs mood disorder not distinguished; "just PMS" dismissal; bipolar not screened; shame unaddressed

🟠 Amber

Cyclical pattern recognised; some risk assessment; diary not arranged; validation partial; ICE partial

🟢 Green

Luteal pattern + symptom-free week established; mimic excluded via diary; full risk assessment; bipolar screened; validated & de-shamed; ICE all three

Step 2

Triage — Acute Risk · Specialist · Routine Primary Care

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The triage hinge is risk: active suicidality needs urgent mental-health input; severe/refractory or diagnostically uncertain disease needs specialist services; and most PMS/PMDD is diagnosed (via diary) and treated in primary care.

🔴 Urgent

Same day / soon

Risk

Active suicidal intent / planUrgent mental-health/crisis assessment; safety plan
Severe functional collapse / safeguardingUrgent support; safeguarding if children at risk
Suspected bipolar disorderMental-health input; SSRI caution

🟠 Specialist

Refer

Gynae / PMD service

Severe / refractory PMDDSpecialist premenstrual-disorder service; GnRH analogues
Diagnostic uncertaintyAfter diary; specialist review
Considering ovulation suppression escalationGynaecology

🟢 Routine

Primary care

Diagnose & treat

Suspected PMS/PMDD2-cycle diary; lifestyle/CBT; SSRI ± COCP
Mood disorder w/ premenstrual exacerbationTreat primary disorder
Established PMDD on treatmentReview, optimise, monitor risk

🎓 SCA Checkpoint — Step 2Tasks

Triage rationale

"We can confirm and treat this here. The one thing I want to be sure about today is your safety on the worst days — and if the dark thoughts ever feel like more than passing thoughts, here's exactly who to contact."

Deductions

Not escalating active suicidality
Not recognising when specialist/GnRH escalation is needed

Step 3

Assessment — Mental State · Risk Formulation · Exclude Other Causes

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"Examination" is a mental state assessment and a risk formulation, plus consideration of physical contributors. There is no physical sign of PMDD — the assessment confirms the mood picture, quantifies risk, and excludes mimics.

🧠 Mental state & risk

Domain	What to assess
Mood / affect	Current state (may be follicular and well); reactivity; lability.
Cyclical history corroboration	Pattern, symptom-free week, impairment.
Risk	Suicidal ideation/plan/intent, self-harm, protective factors — including how she is on the worst luteal days.
Bipolar screen	Past mania/hypomania; family history.

🩺 Physical / other

Check	Why
Thyroid / anaemia consideration	Can contribute to mood/fatigue if clinically indicated.
Perimenopausal features	Overlap of hormonal mood symptoms in older women.
BP / suitability for COCP	If a combined pill is being considered.
Pregnancy status	Relevant to treatment choice.

🎓 SCA Checkpoint — Step 3TasksGlobal Skills

Demonstrating the formulation

"From what you've told me, the picture is severe mood symptoms confined to the two weeks before your period, with a clear well week afterwards, and some dark thoughts at the worst point — that's a premenstrual disorder, and I want to confirm it with a diary and keep you safe in the meantime."

Deductions

No explicit risk formulation
Not screening bipolar / excluding mimics

Step 4

Investigations — The Prospective Diary · Selective Bloods

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The single most important "investigation" is a prospective symptom diary over at least two cycles — it confirms the luteal pattern with a symptom-free follicular phase and separates PMDD from a year-round mood disorder. Bloods are selective.

📓 Symptom diary

Element	Detail
Prospective ≥2 cycles	Daily rating (e.g. DRSP — Daily Record of Severity of Problems); confirms timing and severity.
Looks for	Luteal symptoms resolving with menses + a symptom-free week → PMDD/PMS. Symptoms all month → mood disorder.
Why prospective	Retrospective recall over-diagnoses; the diary is the diagnostic standard.
Safety alongside	Don't delay risk management while the diary is collected; safety-plan now.

🧪 Bloods (selective)

Test	When
TFTs	If thyroid disease suspected (mood/fatigue).
FBC / ferritin	If anaemia contributing to fatigue.
FSH (older women)	Only if perimenopause is genuinely in question — not for routine PMDD.
No hormone "test" for PMDD	There is no blood test that diagnoses PMDD — it is clinical + diary.

🎓 SCA Checkpoint — Step 4Tasks

Key reasoning

"I'd like you to keep a daily symptom diary over the next two cycles — it confirms the pattern and rules out a year-round low mood. We won't wait for it to keep you safe, though, and if you're severe we can start treatment now."

Deductions

Diagnosing PMDD on retrospective recall alone
Ordering hormone profiles to "diagnose" PMDD

Step 5

Diagnosis — PMS · PMDD · Mood Disorder w/ Exacerbation · Bipolar

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Name the disorder by the diary-confirmed pattern and severity — and explicitly separate PMDD from the year-round mood disorder it mimics, because the treatments and risks differ.

Diagnosis	Discriminating features
PMDD	Severe luteal mood symptoms (marked irritability, depression, anxiety, lability) with significant impairment and a symptom-free week (Leila).
PMS	Distressing luteal physical/psychological symptoms, less severe impairment.
Mood disorder + premenstrual exacerbation	Depression/anxiety present all month, worse premenstrually; no symptom-free week on the diary.
Bipolar disorder	History of mania/hypomania; premenstrual worsening can occur; antidepressant caution.
Perimenopausal mood symptoms	Hormonal mood change around the menopause transition.

🚩 The symptom-free week is the whole game

The defining discrimination is whether there is a genuine symptom-free follicular phase. If yes (Leila), the diagnosis is a premenstrual disorder — PMDD given the severity, mood predominance, impairment and luteal suicidal thoughts. If symptoms persist throughout the month, it is a primary mood disorder with premenstrual exacerbation, treated as such. The prospective diary makes the call. For Leila: likely PMDD, with a mandatory ongoing risk plan and bipolar screened out.

🎓 SCA Checkpoint — Step 5Tasks

Explaining it plainly

"This looks like premenstrual dysphoric disorder — a severe, hormone-linked mood condition tied to the two weeks before your period. We'll confirm it with the diary, but because you're so clearly well in between, this isn't a constant depression or bipolar — and it's very treatable."

Deductions

Labelling PMDD without the symptom-free-week criterion
Missing an underlying mood/bipolar disorder

Step 6

Referral — Mental Health · Gynaecology · Specialist PMD Service

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Most PMS/PMDD is managed in primary care. Referral is for acute risk (mental health), refractory or severe disease and ovulation-suppression escalation (gynaecology / specialist premenstrual-disorder service), and diagnostic uncertainty.

Referral	Who / when	Urgency
🔴 Mental health / crisis	Active suicidality, self-harm, suspected bipolar disorder.	Urgent / same day
Gynaecology	Considering ovulation suppression escalation (GnRH analogues with add-back HRT); refractory hormonal management.	Soon
Specialist premenstrual-disorder service	Severe / refractory PMDD; diagnostic uncertainty after diary; complex cases.	Routine / soon
Psychology / CBT	CBT is effective for PMDD — first-line psychological option.	Routine
Mental-health team	Comorbid depression/anxiety needing input.	As needed

🎓 SCA Checkpoint — Step 6Tasks

Knowing the thresholds

"We'll start treatment here. If it doesn't settle things, there's a specialist service and stronger hormonal options through gynaecology — and if your safety were ever a concern, I'd involve the mental-health team straight away."

Deductions

Not escalating active risk to mental health
Not knowing the specialist/GnRH route for refractory disease

Step 7

Management — Lifestyle/CBT · SSRI · COCP · Escalation · Safety-Net

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Management is stepped: lifestyle and CBT, then SSRIs (continuous or luteal-phase only) and/or a combined pill to suppress ovulation, escalating to GnRH analogues under specialist care for refractory disease — with a luteal-phase safety plan running throughout given the suicide risk.

7A — The stepped plan

💊 Treatment ladder

Step	Detail
Lifestyle & CBT	Exercise, sleep, stress reduction; CBT is effective; psychoeducation reduces shame.
SSRI	First-line pharmacological — continuous OR luteal-phase only (works within days for PMDD); e.g. sertraline, fluoxetine, citalopram. Counsel on use and side effects.
Combined pill (ovulation suppression)	Continuous/extended COCP, drospirenone-containing often preferred; also provides contraception. Assess COCP suitability.
Escalation (specialist)	Higher-dose/combination; GnRH analogues with add-back HRT for severe refractory; rarely surgical (oophorectomy) as a last resort under specialist care.
Other	Some use of certain supplements is reported; evidence varies — don't oversell.

🛡️ Safety, support & follow-up

Element	Detail
Luteal safety plan	Explicit plan for the worst days; crisis contacts; involve partner with consent; remove means if relevant.
Relationship support	Help her and (with consent) her partner understand the condition; reduce guilt.
Diary & review	Confirm diagnosis on the diary; review response and risk early; adjust the ladder.
Bipolar caution	If any bipolar features emerge, reassess before/with antidepressants.
Validate & instil hope	Emphasise that effective treatment exists and most improve.

🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills

A plan that scores

"Here's the plan: a symptom diary to confirm it, and we can start an SSRI now — which you can take all the time or just in the two weeks before your period, and it works quickly for this. A combined pill is another option that also covers contraception. Let's make a clear plan for the worst days, and here's who to call. We'll review soon."

Deductions

No safety plan despite luteal suicidal thoughts
Treating "depression" with no regard to the cyclical pattern; missing the luteal-SSRI option
Not offering ovulation suppression / not knowing escalation

"I don't really know how to explain it… for a week or two before my period I turn into someone I don't recognise — furious, crying, hopeless. I've even thought my family would be better off without me. Then my period comes and I'm completely fine again. I think I might be bipolar, or just a terrible person."

Who you are

Leila Hassan, 34, two children. For years, in the 10–14 days before each period you become intensely irritable, tearful, anxious and hopeless — you snap at your partner and kids and have had fleeting thoughts that they'd be better off without you. Within a day or two of your period starting it lifts and you feel completely normal — "like myself" — and you function well the rest of the month. You're frightened by the intensity and the dark thoughts, deeply ashamed of how you treat your family, and you wonder if you're "going mad" or bipolar. You have no symptoms in the week after your period. You're not on hormonal contraception and are otherwise well.

Hidden concerns (reveal if explored)

The dark thoughts (main): they frighten you; they're fleeting and you've never had a plan, but you've never told anyone. If asked gently, you'll disclose.

Shame: you feel like a bad mother. Being told it's a condition, not your character, is a huge relief.

Fear of being "mad"/bipolar: reassurance that this is cyclical and treatable helps enormously.

Contraception: you're open to the pill if it might help.

Clinical details if asked

Symptoms 10–14 days premenstrually; resolve within 1–2 days of bleeding; genuinely well the week after
Mood predominant: irritability/rage, tearfulness, anxiety, hopelessness; some bloating/breast tenderness
Fleeting luteal thoughts "they'd be better off without me"; no plan, no intent, never acted; some protective factors (your children)
No periods of feeling high/sped up/not needing sleep (no mania); no year-round low mood
No past psychiatric diagnosis; not on contraception; no medical problems; not pregnant
Significant impact on your relationship and your guilt about the children

Reactions at key moments

On being told it's PMDD, not bipolar: visibly relieved — "so there's a name for it?"
On the risk questions: hesitant but discloses if asked kindly; relieved to be taken seriously.
On the diary: happy to keep one.
On the SSRI working quickly / luteal option: surprised and encouraged.
Challenge line: "Be honest — does this mean there's something seriously wrong with me? Am I bipolar?"

"Please be honest with me — is something seriously wrong? Am I bipolar, or am I just a bad mother who can't control herself?"

Resolution: Leila is helped if the GP: (1) recognises the cyclical luteal pattern with a symptom-free week as PMDD, distinguishing it from a year-round mood disorder/bipolar, and arranges a prospective 2-cycle diary to confirm; (2) conducts a sensitive, thorough risk assessment of the luteal suicidal thoughts and makes a safety plan; (3) validates her and relieves her guilt, attributing the behaviour to a treatable condition; (4) offers effective treatment — an SSRI (continuous or luteal-phase) and/or a combined pill, plus lifestyle/CBT — and knows the specialist/GnRH escalation route; (5) reviews early. She stays frightened and ashamed if dismissed as "just PMS", if the risk and diagnosis aren't taken seriously, or if no clear treatment plan is offered.

🏥

Clinic Quick Reference

Premenstrual Disorder (PMDD) — Clinical Decision Framework

RCOG/CKS · Luteal pattern + diary · SSRI/COCP · Risk

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🔍 1 — Diagnose

Pattern: luteal-phase symptoms resolving with menses + a symptom-free week. PMDD = severe mood-predominant form with impairment. Confirm with a prospective ≥2-cycle diary (DRSP). Differentiate from a mood disorder with premenstrual exacerbation (symptoms all month) and bipolar. Always assess suicide/self-harm risk (luteal phase).

💊 2 — Treat (stepped)

1. Lifestyle + CBT. 2. SSRI — continuous OR luteal-phase (works within days); and/or combined pill (continuous/drospirenone-containing) to suppress ovulation. 3. Escalate (specialist): GnRH analogues + add-back HRT; rarely surgery. Safety plan throughout; review early; specialist/gynae for severe/refractory.

🎓

SCA Quick Reference

PMDD — Consultation Playbook

Timing defines it · screen risk · diary confirms · treat & validate

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🎯 The three pivots that pass this case

1 · Assess the risk

PMDD raises luteal-phase suicide risk — a thorough risk assessment and safety plan are mandatory, despite monthly remission.

2 · Timing & the mimic

Symptom-free week = PMDD; symptoms all month = mood disorder with premenstrual exacerbation. Confirm with a 2-cycle diary.

3 · Treat & validate

SSRI (continuous/luteal — works fast) ± combined pill + CBT; relieve shame; know the GnRH/specialist escalation.

⛔ Don't skip the suicide-risk assessment · Don't diagnose on retrospective recall — use a prospective 2-cycle diary · Don't miss a year-round mood disorder or bipolar · Don't dismiss it as "just PMS" · Remember the luteal-only SSRI option and ovulation-suppression / GnRH escalation

Premenstrual Disorder (PMS / PMDD) · GP Clinical Reasoning Framework v2 · RCOG Green-top Guideline (Premenstrual Syndrome) · NICE CKS Premenstrual syndrome · DSM-5 (PMDD) · ISPMD

Defined by the luteal-phase timing with a symptom-free week; PMDD = severe mood-predominant form with impairment · Confirm with a prospective ≥2-cycle symptom diary (DRSP) · Differentiate from a mood disorder with premenstrual exacerbation (symptoms all month) and bipolar · Always assess suicide/self-harm risk (concentrated in the luteal phase) · SSRIs are effective and can be continuous or luteal-phase only; combined pill (continuous/drospirenone) suppresses ovulation; CBT/lifestyle first-line · Escalate refractory cases to specialist services (GnRH analogues + add-back HRT)

Teaching clinicians why each step matters — not just what to do · Always consult current RCOG and NICE CKS guidance · Clinical judgement takes precedence over any framework

Premenstrual Disorder (PMDD)

Red Flags — the cyclical illness that can still be dangerous

🙎 "Am I a bad mother?"

🧠 "Am I going mad / bipolar?"

🆘 Taking the dark thoughts seriously

🚫 Undoing dismissal

Same day / soon

Refer

Primary care

🚩 The symptom-free week is the whole game

🎭 Patient actor brief — click to practise

Who you are

Hidden concerns (reveal if explored)

Clinical details if asked

Reactions at key moments