Premenstrual dysphoric disorder — assessment and management (MEQ)

(i) Working diagnosis and differentials. Working diagnosis: premenstrual dysphoric disorder (provisional until two-cycle prospective ratings). Justify with multi-year luteal core affective symptoms (irritability, lability, anxiety, hopelessness), marked impairment, and near-complete post-menstrual resolution with mid-follicular PHQ-9 of 3. Differentials: premenstrual exacerbation of MDD (against: follicular remission); bipolar irritability (screen elevated periods); trauma-related or personality-pattern rage without cycle lock; medical mimics (thyroid, anaemia, endometriosis); substance-related luteal worsening. Discriminators: mid-follicular MSE/function, mania history, gynaecological pain history, diary confirmation.[1][6]

(ii) Assessment. Start prospective daily ratings (e.g. DRSP) for two cycles while not delaying care for current risk. Expand passive death wishes into full suicide risk assessment timed to late luteal week; safety plan; means access. Bipolar screen; substance screen; contraception and pregnancy plans (wants pregnancy in ~2 years — avoid long-term teratogenic strategies and counsel SSRI pregnancy risk–benefit if still needed). Trauma and relationship violence risk; collateral if available; baseline TSH/FBC/pregnancy test as indicated; do not use a random progesterone level to diagnose PMDD.[1][6]

(iii) First-line plan. Psychoeducation: abnormal CNS sensitivity to normal hormone fluctuations, not character flaw. SSRI first-line: e.g. fluoxetine 20 mg orally once daily continuous, or luteal-phase only from ~day 14 until menses (rapid onset of benefit enables intermittent use); alternative sertraline 50 mg orally daily (titrate toward 50–150 mg as needed). Cochrane supports SSRI efficacy; continuous may be slightly more effective overall than luteal-only. Early review for activation/suicidality; sexual side-effect counselling. Offer CBT (including protocolised/internet-based CBT) for cycle-linked appraisals and coping. Measurement-based follow-up across cycles.[2][3]

(iv) COC and surgery. If she also wants contraception now: discuss drospirenone 3 mg / ethinyl estradiol 20 microg 24/4 COC with RCT support for PMDD, VTE and migraine-with-aura screening, and limited long-cycle outcome data. Given pregnancy desire in two years, COC is optional and time-limited, not mandatory. Oophorectomy is not appropriate now — last resort only after failed optimised medical care and a positive chemical menopause trial (GnRH agonist with add-back planning) proving ovary-driven symptoms; irreversible infertility conflicts with her reproductive goals.[4][5]

(v) Pitfalls. Calling it "just PMS"; skipping diary; treating as continuous MDD without noting follicular remission (or the reverse — missing PME); inventing low-progesterone therapy; offering surgery first; no suicide plan; starting COC despite contraindications; ignoring pregnancy timeline.[1][5][6]