Psych · General adult psychiatry — mood disorders / women's mental health
Premenstrual dysphoric disorder
Also known as PMDD · Premenstrual dysphoric disorder · Late luteal phase dysphoric disorder · Severe premenstrual syndrome · Premenstrual syndrome severe
Exam-exhaustive fellowship reference on premenstrual dysphoric disorder — DSM-5-TR/ICD-11 criteria, prospective diary diagnosis, PMS vs PMDD vs premenstrual exacerbation, allopregnanolone/GABA hormone-sensitivity model, SSRI continuous and luteal-phase dosing, drospirenone/EE contraception, CBT, GnRH with add-back, surgical pathways, suicide risk, and guideline deltas. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Luteal-phase suicidal ideation, plan or attempt — treat as psychiatric emergency; cycle-linkage does not reduce risk intensity
- Severe rage, intimate-partner violence risk, or inability to care for dependants during symptomatic weeks
- Presumed 'PMDD' with inter-episode depressive/anxiety symptoms still present mid-follicular phase — reframe as premenstrual exacerbation and treat the baseline disorder
- Combined oral contraceptive in migraine with aura, prior VTE, smoking age 35+, or uncontrolled hypertension — absolute/relative contraindications
- Long-term GnRH agonist without oestrogen/progestogen add-back — iatrogenic bone loss and menopausal morbidity
- Surgical oophorectomy proposed without prior chemical menopause confirmation that symptoms are ovary-driven
Meet the patient
She is 31 and brings a phone. On it is a note titled "the bad week," started eighteen months ago because her partner said she was "two different people." Every entry lands in the seven days before her period: rage at her children, tears in the car park, certainty that everyone would be better off without her.[1][19]
Then she bleeds, and by day two she is fine. She has been told she is hormonal by a GP, a gynaecologist, and — she adds, carefully — a psychiatrist.[14][19]
The examiner's question is not "is this PMDD?" It is "how would you prove it, and what would change your answer?"[2][14]
References20ShowHide
- [1]Yonkers KA, O'Brien PM, Eriksson E Premenstrual syndrome Lancet, 2008.PMID 18395582
- [2]Epperson CN, Steiner M, Hartlage SA, et al. Premenstrual dysphoric disorder: evidence for a new category for DSM-5 Am J Psychiatry, 2012.PMID 22764360
- [3]Steiner M, Steinberg S, Stewart D, et al. Fluoxetine in the treatment of premenstrual dysphoria. Canadian Fluoxetine/Premenstrual Dysphoria Collaborative Study Group N Engl J Med, 1995.PMID 7739706
- [4]Yonkers KA, Halbreich U, Freeman E, et al. Symptomatic improvement of premenstrual dysphoric disorder with sertraline treatment. A randomized controlled trial. Sertraline Premenstrual Dysphoric Collaborative Study Group JAMA, 1997.PMID 9307345
- [5]Freeman EW, Rickels K, Sondheimer SJ, et al. Continuous or intermittent dosing with sertraline for patients with severe premenstrual syndrome or premenstrual dysphoric disorder Am J Psychiatry, 2004.PMID 14754784
- [6]Yonkers KA, Kornstein SG, Gueorguieva R, et al. Symptom-Onset Dosing of Sertraline for the Treatment of Premenstrual Dysphoric Disorder: A Randomized Clinical Trial JAMA Psychiatry, 2015.PMID 26351969
- [7]Marjoribanks J, Brown J, O'Brien PM, Wyatt K Selective serotonin reuptake inhibitors for premenstrual syndrome Cochrane Database Syst Rev, 2013.PMID 23744611
- [8]Jespersen C, Lauritsen MP, Frokjaer VG, Schroll JB Selective serotonin reuptake inhibitors for premenstrual syndrome and premenstrual dysphoric disorder Cochrane Database Syst Rev, 2024.PMID 39140320
- [9]Yonkers KA, Brown C, Pearlstein TB, et al. Efficacy of a new low-dose oral contraceptive with drospirenone in premenstrual dysphoric disorder Obstet Gynecol, 2005.PMID 16135578
- [10]Lopez LM, Kaptein AA, Helmerhorst FM Oral contraceptives containing drospirenone for premenstrual syndrome Cochrane Database Syst Rev, 2012.PMID 22336820
- [11]Ma S, Song SJ, et al. Oral contraceptives containing drospirenone for premenstrual syndrome Cochrane Database Syst Rev, 2023.PMID 37365881
- [12]Schmidt PJ, Nieman LK, Danaceau MA, et al. Differential behavioral effects of gonadal steroids in women with and in those without premenstrual syndrome N Engl J Med, 1998.PMID 9435325
- [13]Hantsoo L, Epperson CN Allopregnanolone in premenstrual dysphoric disorder (PMDD): Evidence for dysregulated sensitivity to GABA-A receptor modulating neuroactive steroids across the menstrual cycle Neurobiol Stress, 2020.PMID 32435664
- [14]Hantsoo L, Epperson CN Premenstrual Dysphoric Disorder: Epidemiology and Treatment Curr Psychiatry Rep, 2015.PMID 26377947
- [15]Steinberg EM, Cardoso GMP, Martinez PE, et al. Rapid response to fluoxetine in women with premenstrual dysphoric disorder Depress Anxiety, 2012.PMID 22565858
- [16]Wyatt KM, Dimmock PW, Ismail KM, et al. The effectiveness of GnRHa with and without 'add-back' therapy in treating premenstrual syndrome: a meta analysis BJOG, 2004.PMID 15198787
- [17]Segebladh B, Borgström A, Nyberg S, et al. Evaluation of different add-back estradiol and progesterone treatments to gonadotropin-releasing hormone agonist treatment in patients with premenstrual dysphoric disorder Am J Obstet Gynecol, 2009.PMID 19398092
- [18]Weise C, Kaiser G, Janda C, et al. Internet-Based Cognitive-Behavioural Intervention for Women with Premenstrual Dysphoric Disorder: A Randomized Controlled Trial Psychother Psychosom, 2019.PMID 30783069
- [19]Pearlstein T, Steiner M Premenstrual dysphoric disorder: burden of illness and treatment update J Psychiatry Neurosci, 2008.PMID 18592027
- [20]Malhi GS, Bell E, Bassett D, et al. The 2020 Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders Aust N Z J Psychiatry, 2021.PMID 33353391