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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Premenstrual syndrome and premenstrual dysphoric disorder

Obstetrics and gynaecology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Premenstrual suicidality is an emergency

PMDD can include intense hopelessness, impulsivity, self-harm urges or suicidal thoughts, and cyclical timing does not reduce the immediate danger.

Action: Ask directly about intent, plan, means and protective factors, do not leave an unsafe person alone, and arrange urgent crisis or emergency assessment while involving trusted support with consent where possible.

Synopsis

Confirm a prospective cyclical symptom pattern, distinguish PMS and PMDD from premenstrual exacerbation, assess suicide risk, and use stepped psychological, serotonergic and ovulation-suppressing treatment safely.

  • PMS consists of distressing physical, behavioural or psychological symptoms recurring in the luteal phase and improving soon after menstruation begins, with a meaningful symptom-light interval.
PMDD is a severe predominantly mood-related premenstrual disorder causing major functional impairment; suicidal thoughts can occur and must be assessed directly at every relevant presentation.
  • Confirm timing prospectively with daily symptom ratings across at least two cycles before long-term treatment when safe; retrospective recall overestimates cyclicity.
  • Premenstrual exacerbation means an existing disorder worsens before menstruation but remains present at other times, and usually needs treatment of both the baseline condition and cyclical component.
  • Lifestyle support, sleep, regular activity and CBT can help, but severe symptoms should not be dismissed as a failure of self-care.
  • SSRIs are effective for severe PMS and PMDD and may be given continuously or during the luteal phase; screen for bipolar disorder, interactions and suicidality and review response.
  • A drospirenone-containing combined pill in a 24/4 regimen can be considered when contraception and ovulation suppression are wanted, after full combined-hormonal eligibility assessment.
  • Specialist ovarian suppression with transdermal oestrogen or a GnRH agonist plus add-back can test and treat refractory cyclical disease; irreversible surgery is a last option after response confirmation and fertility counselling.

    • Key red flags

    Current suicidal intent, a plan, access to means, recent self-harm or inability to remain safe requires urgent mental-health or emergency intervention.

    Mania, psychosis, severe agitation or marked sleep reduction suggests bipolar or another acute psychiatric disorder and needs urgent specialist assessment before antidepressant monotherapy.

    Symptoms present throughout the cycle without a clear symptom-free interval suggest an underlying mood, anxiety, trauma, neurodevelopmental or medical disorder rather than isolated PMS.

    New heavy, intermenstrual or postcoital bleeding, pelvic mass symptoms or severe non-cyclical pain requires a separate gynaecological pathway.

    Focal neurological symptoms, first severe migraine with aura or thromboembolic symptoms during hormonal treatment require urgent assessment and treatment review.

    Investigation priorities

    01
    Prospective daily symptom recordFirst step

    Confirm timing, severity, impairment and a symptom-light follicular interval over at least two cycles.

    Management branches

    ConfirmationProve the cycle relationship

    Recurrent premenstrual physical or mood symptoms affect daily life.

    1. Assess current safety, baseline psychiatric and medical disorders, contraception, medicines and the exact onset and offset of symptoms.
    2. Record daily symptoms, impairment and bleeding for at least two cycles using a validated tool, unless urgent care must proceed immediately.
    3. Classify PMS, PMDD or premenstrual exacerbation from prospective pattern and severity, then agree a measurable treatment goal.

    Key medicines

    FluoxetineGive 20 mg orally once daily either continuously or for 14 days during the luteal phase; the current PMDD SmPC advises reassessment after an initial six months.Screen for bipolar disorder and suicide risk; review nausea, insomnia, sexual dysfunction, bleeding, hyponatraemia, serotonin interactions and the long half-life when switching or planning pregnancy.
    Ethinylestradiol 20 micrograms with drospirenone 3 mgTake one active oral tablet daily for 24 days followed by one placebo tablet daily for four days, repeating without an extended hormone-free interval.The UK licence is contraception; assess blood pressure, migraine aura, smoking, venous or arterial thrombosis, liver or renal disease, potassium-raising medicines and interactions.
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    Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
    Sources

    Sources and review status

    National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

    • RCOG Green-top Guideline 48
    • RCOG managing premenstrual syndrome
    • NHS premenstrual dysphoric disorder
    • Fluoxetine 20 mg UK SmPC
    • Drospirenone 24/4 pill UK SmPC
    • Goserelin 3.6 mg UK SmPC

    Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

    Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom