Premenstrual dysphoric disorder — structured clinical viva

Diagnosis. PMDD is a DSM-5-TR depressive disorder defined by luteal clustering of core affective and additional symptoms with follicular remission and impairment. Prospective diaries confirm timing; normal peripheral hormone levels do not exclude the diagnosis.[1]

Why hormones are "normal". Pathophysiology is CNS sensitivity to normal cyclic oestradiol/progesterone and the neurosteroid allopregnanolone acting at GABA-A receptors. Schmidt’s paradigm showed GnRH suppression remits symptoms and hormone add-back re-triggers them in susceptible women only — proving sensitivity, not excess hormone production.[2][3]

Intermittent sertraline is real medicine. SSRIs are first-line with Cochrane-level support. Benefit often appears within days in PMDD, enabling continuous, luteal-phase, or symptom-onset schedules. Example: sertraline 50–150 mg orally daily continuous, or from ovulation/symptom onset through early menses. Continuous dosing may be slightly more effective overall; choose by cycle regularity, comorbidity, and preference. Counsel sexual side-effects, early activation, and suicide safety-netting.[4][7]

Not any pill. The COC with dedicated PMDD RCT signal is drospirenone 3 mg / ethinyl estradiol 20 microg (24/4 regimen) for women who also want contraception, with VTE and migraine-with-aura screening. Other pills lack equivalent PMDD-specific evidence strength.[5]

Chemical menopause. GnRH agonists suppress ovarian cyclicity for refractory disease; meta-analytic support exists, but add-back HRT is required to mitigate bone and vasomotor harm. A positive chemical menopause response informs rare consideration of surgical oophorectomy after full counselling — not a first-line step.[2][6]