How should you manage this case of pre-menstrual dysphoric disorder?
Clinical conundrum: In the next in our series, GP Dr Toni Hazell explores how to diagnose and manage a tricky case of pre-menstrual dysphoric disorder (PMDD)
You are seeing a 32-year-old woman who is newly registered with your practice. She has had to move house, into your practice area, because she lost her job and couldn’t pay the mortgage. She had been through several rounds of performance management, and she tells you that they were all related to errors that she made, and arguments that she had just before or during her period. Her last GP diagnosed pre-menstrual syndrome (PMS) and put her on the combined pill, but she tried three different brands and never got on with any of them – she has lost faith in hormones and wonders what else she can try.
1. The patient’s PMS seems to be on the more severe end of normal, and you wonder if she has PMDD. How would you go about confirming that?
PMDD is the most severe form of PMS – it has a prevalence of around 5-8%. For any type of PMS to be diagnosed, a prospective symptom diary should be kept, for at least two cycles, and the symptoms need to occur cyclically, during the luteal phase of the cycle. PMDD may be diagnosed when symptoms are more severe. The diagnostic criteria vary slightly between the ICD-11 and DSM-V, but the key features are similar. Symptoms must start in the luteal phase, improve with the start of the period and resolve within a week of the start of the period and must be very severe, causing significant distress and interfering with work/education and personal/family/social life. They must not be caused by the exacerbation of a psychiatric disorder.
You review the patient’s old notes – a prospective symptom diary was kept before her diagnosis of PMS and she explains that from the start the symptoms have severely affected her. This isn’t the first job that she has lost, and she has never been able to maintain a relationship, all of which she attributes to her PMS. There is no history of symptoms of anxiety or depression outside of her luteal phase, and no past history of any other diagnosed psychiatric illness and you suspect that she has undiagnosed PMDD. She visibly relaxes when you say this, saying that she has long thought this, but has always felt dismissed by healthcare professionals. It is not uncommon for women with PMS to feel that they are not being taken seriously and you reassure her that you will do your best to help.
2. The patient is adamant that she doesn’t want to try another contraceptive pill. What else could you prescribe?
PMS and PMDD are related to the menstrual cycle and so suppression of ovulation (via combined or progestogen-only hormonal contraception) is a logical, and often successful treatment. You take a further history and find that the patient has generally stopped each pill fairly quickly due to side-effects; knowing that side-effects often settle in the first few weeks of use, you wonder if she would do better if she could be persuaded to keep going for longer, but you suspect that you’ll have to build up some trust first before trying this.
Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) have evidence for use in PMS and PMDD, although this use is off-licence in the UK. They can be used continuously, or only in the luteal phase, with continuous use probably being more effective. The exact mechanism of action isn’t clear, but it’s possible that these medications may alter levels of allopregnanolone, a metabolite of progesterone, which is present at its highest levels in the luteal phase and is thought to be related to affective symptoms of PMS. The mechanism is thought to be different to that by which SSRIs/SNRIs has been theorised to treat depression, as the effect is faster and can be achieved at lower doses. SSRIs and SNRIs can be safely used in women who wish to conceive – women who want more information on the possible use during pregnancy might want to consult BUMPS (best use of medicines in pregnancy) for their information leaflets, and relevant information aimed at professionals can be found on the UK Teratology information Service (UKTIS) website.
Other future options, if she is willing to try a different form of hormone therapy, might include the use of transdermal oestradiol in the form of a patch (as usually used for HRT), used with a cyclical progesterone or levonorgestrel intrauterine device to prevent endometrial hyperplasia.
3. Are there any non-prescribed or lifestyle measures which have evidence for PMS?
There is some evidence for the use of CBT in the management of PMDD. In an ideal world all patients would have access to an MDT which included a psychologist who was familiar with the specific use of CBT in PMDD, but studies have shown that online CBT can also help women with PMDD. CBT can particularly improve symptoms such as feelings of hopelessness and anxiety, mood swings, impact of symptoms on daily life and conflict with others.
This patient might also find it useful to have some information about the effect of lifestyle on PMS. Caffeine, alcohol, smoking and recreational drugs can make mood fluctuations worse, and a low glycaemic-index diet, avoiding sugar where possible, should be advised. Usual sleep hygiene measures should be advised if sleep is an issue. If she asks about complementary therapies, you could advise that there is some evidence for the use of agnus castus, and it tends to be well tolerated. Complementary therapies come with the risks associated with a relative lack of regulation compared with prescribed drugs. However, the ‘traditional herbal registration’ mark from the Medicines and Healthcare Products Regulatory Agency (MHRA) indicates that the product meets similar standards to other regulated medications.
There are several agnus castus products on the list of herbal medicines granted registration, so you might steer the patient towards one of these. There is no evidence for the use of any vitamins, minerals or herbal products (previous advice to take high-dose vitamin B6 has been dropped due to the risk of toxicity) and sha should be made aware that some products, such as St. John’s Wort, can have interactions with other medication. There is also no evidence for therapies such as acupuncture, aromatherapy, massage or reflexology.
Dr Toni Hazell is a portfolio GP with an interest in women’s health based in north London
Sources and further reading
- Carlini S et al. Management of Premenstrual Dysphoric Disorder: A Scoping Review. Int J Womens Health 2022 Dec 21;14:1783–1801
- Funnell E et al. Improving care experiences for premenstrual symptoms and disorders in the United Kingdom (UK): a mixed-methods approach. BMC Health Serv Res 2025;14(25):70
- King S. Premenstrual Syndrome (PMS) and the Myth of the Irrational Female. Chapter 23 in: The Palgrave Handbook of Critical Menstruation Studies [Internet]. 2020
- Marais-Thomas H et al. [Premenstrual dysphoric disorder (PMDD): Drug and psychotherapeutique management, a literature review]. Encephale 2024 Apr;50(2):211-32
- NAPS. Guidelines on premenstrual syndrome. 2018
- UK MHRA. Herbal medicines granted a traditional herbal registration. 2014 (Last updated 2025)
- Weise C et al. Internet-Based Cognitive-Behavioural Intervention for Women with Premenstrual Dysphoric Disorder: A Randomized Controlled Trial. Psychother Psychosom 2019;88(1):16-29
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READERS' COMMENTS [1]
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Hmmm. so this patient who has self-diagnosed PMDD rather than severe PMS, has felt ‘dismissed’ by the female Practice Nurses, female GP Partners and salaried GPs, female GP VTS Registrars, and even female medical students, so has come to see me, the old white male GP. I wonder why she feels ‘dismissed’? Is it because they listened to her and offered her understanding and treatment options from paragraphs 2 and 3 above (It’s all in the mind, try some antidepressants, herbal treatments, CBT, whilst negating the suggestions for vitmins she has picked up from social media. ) One might even wonder if she is trying to manipulate me with reverse sympathy to ‘not dismiss her’ with those same suggestions. On the other hand, given that we do not have much besides CBT and SSRIs, with all those negative connotations, I was a little surprised that Implanon and Depoprovera, or, to the extreme, pregnancy, were not mentioned. I have specifically found considerable success, well worth the risks, as judged by the patients, of using Depoprovera in such situations (I am not a registered implanon inserter). Any trial of POPs tends to go really badly because the progeesterone levels fluctuate too wildly during the day, and bear no relation to how well the patients will respond to the Depo injection. I even had one patient who would come back at 11 weeks as she could feel the depo wearing off!