📋 Key Information Summary
- Premenstrual syndrome (PMS) affects up to 75% of reproductive-age women; premenstrual dysphoric disorder (PMDD) affects 3–8% and is classified as a depressive disorder in DSM-5-TR.
- Diagnosis requires prospective daily symptom charting for at least two symptomatic cycles, confirming symptom presence in the luteal phase and absence in the follicular phase.
- PMDD requires ≥5 of 11 DSM-5-TR criteria in the final week before menses, improving within a few days of onset, with at least one of four key affective symptoms (marked affective lability, irritability, depressed mood, or anxiety/tension).
- Common differential diagnoses include major depressive disorder, generalised anxiety disorder, thyroid dysfunction, endometriosis, perimenopause, and iron deficiency — all must be excluded.
- First-line pharmacotherapy for PMDD is an SSRI (fluoxetine 20 mg/day or sertraline 50 mg/day), which may be given continuously or only during the luteal phase.
- SSRIs are effective in PMS/PMDD within the first treatment cycle — a markedly faster onset than for major depression.
- Combined oral contraceptives containing drospirenone in a 24/4 extended regimen (Yaz®) have specific evidence for PMDD; standard COCs have variable benefit.
- Calcium 1,200 mg daily and cognitive behavioural therapy (CBT) have robust evidence as non-pharmacological interventions.
- Mefenamic acid 500 mg TDS during the luteal phase is effective for PMS with prominent physical symptoms (headache, breast pain, pelvic pain).
- GnRH agonists with add-back HRT are reserved for severe, treatment-refractory PMDD and require specialist initiation and monitoring.
- Aboriginal and Torres Strait Islander women may face barriers including remote access to specialist care, cultural stigma around menstrual health, and reduced availability of allied health services for CBT.
- Suicidal ideation may be a feature of severe PMDD; all patients should be screened for suicidality and safety-planned accordingly.
Introduction & Australian Epidemiology
Premenstrual syndrome (PMS) is a recurrent luteal-phase disorder characterised by a constellation of physical, emotional, and behavioural symptoms that significantly impair quality of life and resolve within a few days of menstruation. At the severe end of the spectrum, premenstrual dysphoric disorder (PMDD) represents a distinct psychiatric diagnosis classified under Depressive Disorders in the DSM-5-TR, requiring prominent mood disturbance and functional impairment.
PMS is one of the most common gynaecological conditions encountered in Australian general practice. Community-based surveys estimate that 75–80% of reproductive-age women experience at least mild premenstrual symptoms, with approximately 20–40% reporting moderate-to-severe PMS and 3–8% meeting criteria for PMDD. The condition accounts for significant absenteeism and presenteeism in the Australian workforce, with an estimated annual cost exceeding AUD 500 million in lost productivity and healthcare utilisation.
In Australia, PMS/PMDD is frequently under-recognised and under-treated in primary care. Many women self-manage with over-the-counter supplements for years before seeking medical attention. General practitioners play a pivotal role in early identification through structured symptom assessment, initiating evidence-based management, and facilitating specialist referral when needed.
This guideline covers the classification, diagnostic approach, differential diagnosis, non-pharmacological management, and pharmacological therapy of PMS and PMDD within the Australian clinical context, referencing current DSM-5-TR criteria, Therapeutic Guidelines, PBS-listed medications, and Australian primary care pathways.
Pathophysiology
PMS and PMDD are not caused by abnormal hormone levels per se, but rather by an abnormal central nervous system response to normal cyclical fluctuations in ovarian steroids, particularly the metabolites of progesterone (allopregnanolone). The key pathophysiological mechanisms include:
- GABAergic dysfunction: Allopregnanolone is a potent positive allosteric modulator of GABA-A receptors. In women with PMDD, there appears to be altered sensitivity of the GABA-A receptor complex, with paradoxical anxiogenic responses to allopregnanolone rather than the expected anxiolytic effect.
- Serotonergic dysregulation: Oestrogen and progesterone modulate serotonin synthesis, receptor density, and reuptake. The rapid efficacy of SSRIs in PMDD (often within one cycle) supports a direct serotonergic mechanism rather than conventional antidepressant neuroplasticity effects.
- HPA axis reactivity: Women with PMDD show blunted cortisol responses and altered stress reactivity in the luteal phase, suggesting hypothalamic-pituitary-adrenal axis involvement.
- Genetic predisposition: Twin studies indicate a heritability of approximately 40–50% for PMS/PMDD. Polymorphisms in the oestrogen receptor alpha gene (ESR1) and serotonergic transporter gene (5-HTTLPR) have been implicated.
- Neuroinflammation: Emerging evidence suggests elevated inflammatory markers (IL-6, TNF-α, CRP) in the luteal phase of symptomatic women, potentially contributing to mood and physical symptoms.
- Calcium and micronutrient dysregulation: Altered intracellular calcium signalling and low serum calcium levels have been documented in women with PMS, supporting the evidence for calcium supplementation.
Key concept: PMS/PMDD is a disorder of the response to normal hormonal fluctuations, not of hormone levels themselves. Routine serum hormone testing is not diagnostically useful.
Classification of PMS & PMDD Criteria
PMS Spectrum
PMS is not a single diagnostic entity in DSM-5-TR but is clinically recognised on a severity spectrum:
Mild
Mild PMS
Symptoms present but do not significantly impair social, occupational, or interpersonal functioning. Usually self-managed with lifestyle measures and OTC analgesics.
Setting: Self-management, GP review if persistent
Moderate
Moderate-to-Severe PMS
Multiple somatic and/or mood symptoms causing moderate functional impairment. Relationships, work, or daily activities are affected. Prospective charting confirms luteal phase pattern.
Setting: GP management with structured assessment
Severe
PMDD (DSM-5-TR)
≥5 of 11 DSM-5-TR criteria with prominent affective symptoms causing marked functional impairment. At least one core mood symptom must be present. Classified as a Depressive Disorder in DSM-5-TR.
Setting: GP initiation of SSRI ± referral to gynaecology or psychiatry
DSM-5-TR Diagnostic Criteria for PMDD (296.3 / F32.81)
Mandatory requirement: Diagnosis of PMDD requires prospective daily symptom charting for at least two consecutive symptomatic cycles. Retrospective reporting alone is insufficient due to recall bias.
In the majority of menstrual cycles during the past year, ≥5 of the following 11 symptoms must have been present in the final week before menses, with onset improving within a few days of menses onset, and becoming minimal or absent in the week post-menses:
| Category | Symptom (≥1 required marked) |
|---|---|
| Affective (≥1 must be marked) | 1. Marked affective lability (mood swings, crying, increased sensitivity to rejection) 2. Marked irritability, anger, or increased interpersonal conflicts 3. Marked depressed mood, hopelessness, or self-deprecating thoughts 4. Marked anxiety, tension, or feeling keyed up / on edge |
| Behavioural / Cognitive | 5. Decreased interest in usual activities (work, school, social) 6. Difficulty concentrating 7. Fatigue or marked lack of energy 8. Marked change in appetite, overeating, or specific food cravings |
| Somatic | 9. Hypersomnia or insomnia 10. Feeling overwhelmed or out of control 11. Physical symptoms: breast tenderness, bloating, joint/muscle pain, weight gain |
Additional required criteria:
- Symptoms must be associated with clinically significant distress or interference with work, school, social activities, or relationships.
- The disturbance is not merely an exacerbation of another disorder (e.g., MDD, panic disorder, dysthymia, personality disorder), although it may be superimposed on these conditions.
- Criterion A and B must be confirmed by prospective daily ratings during at least two symptomatic cycles (use of validated tools such as the Daily Record of Severity of Problems [DRSP] or Penn Daily Symptom Report).
- The symptoms are not attributable to the physiological effects of a substance or another medical condition.
Validated Symptom Assessment Tools for Australia
| Tool | Description | Clinical Use |
|---|---|---|
| Daily Record of Severity of Problems (DRSP) | 24-item daily diary; gold standard for PMDD diagnosis | Prospective confirmation — download from IAPMD.org |
| Penn Daily Symptom Report (DSR) | 17-item daily rating; validated and widely used | Alternative to DRSP; simpler for GP use |
| Premenstrual Symptoms Screening Tool (PSST) | Retrospective screening tool; useful for initial consultation | Screening only — cannot confirm diagnosis |
| Visual Analogue Scales (VAS) | Simple single-symptom severity ratings | Monitoring treatment response |
Differential Diagnosis
Accurate diagnosis of PMS/PMDD requires exclusion of conditions that may mimic, exacerbate, or coexist with premenstrual symptoms. Prospective charting is the critical differentiating tool — in true PMS/PMDD, symptoms are absent or minimal during the follicular phase.
Red flag: If symptoms persist throughout the entire cycle without a symptom-free follicular interval, consider primary psychiatric disorders, thyroid dysfunction, or other systemic conditions rather than PMS/PMDD.
| Condition | Key Distinguishing Features | Initial Investigations |
|---|---|---|
| Major Depressive Disorder (MDD) | Symptoms persist throughout cycle; no symptom-free follicular phase. May premenstrually worsen but not remit post-menses. | PHQ-9; psychiatric assessment |
| Generalised Anxiety Disorder | Chronic, persistent worry; not confined to luteal phase. | GAD-7; prospective charting |
| Thyroid dysfunction | Fatigue, mood change, weight change, menstrual irregularity. Hypothyroidism particularly common in women of reproductive age. | TSH, free T4 ± thyroid antibodies |
| Endometriosis | Chronic pelvic pain, dysmenorrhoea, dyspareunia; pain may worsen premenstrually but persists beyond menses onset. | Pelvic USS; referral to gynaecology if suspected |
| Iron deficiency / Anaemia | Fatigue, cognitive symptoms; associated with heavy menstrual bleeding. Not cycle-dependent in pattern. | FBC, ferritin, transferrin saturation |
| Perimenopause | Cycle irregularity, vasomotor symptoms; overlap with PMS in transitional period. Age typically >40 years. | FSH (if >40 years and oligomenorrhoea); clinical assessment |
| Chronic fatigue syndrome | Persistent fatigue >6 months with post-exertional malaise; not cycle-dependent. | Exclusionary workup per RACGP guidelines |
| Borderline personality disorder | Affective instability and interpersonal difficulties may worsen premenstrually; baseline symptoms persist throughout cycle. | Psychiatric assessment |
| Hyperprolactinaemia | Amenorrhoea or oligomenorrhoea, galactorrhoea, mood disturbance. | Serum prolactin |
Overlap syndromes: Up to 50% of women with PMDD have a comorbid psychiatric disorder. Prospective charting helps distinguish PMS/PMDD from premenstrual exacerbation of an underlying condition (PME). Both may require simultaneous treatment.
Investigations
There is no laboratory test that confirms PMS or PMDD. The diagnosis is clinical, supported by prospective symptom charting. Investigations are directed at excluding differential diagnoses.
Recommended Baseline Investigations
Essential
Full Blood Count (FBC)
Exclude iron deficiency anaemia, which may mimic or worsen PMS fatigue and cognitive symptoms. MBS Item 66512.
Essential
Serum Ferritin
Evaluate iron stores, especially in women with heavy menstrual bleeding. Target ferritin >30 µg/L. MBS Item 66503.
Essential
Thyroid Function Tests (TSH, fT4)
Exclude hypothyroidism/hyperthyroidism. MBS Item 66716.
Available
Serum Prolactin
If amenorrhoea, oligomenorrhoea, or galactorrhoea present. MBS Item 66656.
Available
FSH / Oestradiol
If perimenopause suspected (age >40, cycle irregularity). MBS Item 66654.
Available
Pelvic Ultrasound
If endometriosis, fibroids, or structural pathology suspected. MBS Item 55062 (transvaginal) / 55053 (transabdominal).
Specialist
Laparoscopy
Definitive diagnosis of endometriosis; referral to gynaecology if pelvic USS normal but clinical suspicion high.
Do not order: Serum progesterone, oestradiol, or salivary hormone panels for PMS/PMDD diagnosis. Hormone levels in PMS/PMDD are within normal physiological ranges — the pathology is in the central nervous system response, not in circulating hormone levels.
Non-Pharmacological Management
Non-pharmacological strategies are recommended as first-line for mild PMS and as adjunctive therapy for moderate-to-severe PMS/PMDD. Many women prefer lifestyle and psychological interventions before commencing medication.
Prospective Symptom Charting
Symptom charting is both a diagnostic tool and a therapeutic intervention. The process of self-monitoring enhances insight, validates the woman's experience, and often produces a modest symptom reduction through self-awareness. Recommend charting for 2–3 cycles before initiating pharmacotherapy.
Dietary Modifications
1
Calcium Supplementation
Calcium carbonate 1,200 mg daily (elemental calcium) — reduces overall symptom severity by 48% in RCTs (Thys-Jacobs, 1998). Available OTC in Australia (e.g., Caltrate®, Blackmores Calcium). Evidence level: A.
2
Vitamin D
Maintain serum 25(OH)D ≥75 nmol/L. Many Australian women are vitamin D insufficient, particularly those who are dark-skinned, veiled, or reside in southern states. Supplement with cholecalciferol 1,000 IU daily if deficient.
3
Magnesium
Magnesium glycinate or citrate 250–400 mg daily. Evidence is moderate for reduction of mood symptoms, water retention, and migraine. May cause loose stools — start at lower dose.
4
Vitamin B6 (Pyridoxine)
50–100 mg daily. Some evidence for mood and irritability symptoms. Do not exceed 100 mg/day (peripheral neuropathy risk). Available OTC. Evidence level: B.
5
Dietary Adjustments
Regular balanced meals (every 3–4 hours), complex carbohydrates, reduced refined sugar, caffeine (≤200 mg/day), alcohol, and salt during the luteal phase. Omega-3 fatty acids from oily fish or supplements may reduce inflammatory symptoms.
Exercise
Regular aerobic exercise (150 minutes/week moderate intensity per Australian Physical Activity Guidelines) has demonstrated efficacy for mood-related PMS symptoms. Exercise stimulates endorphin release, reduces cortisol, and improves sleep quality. Even moderate walking programmes show benefit.
Cognitive Behavioural Therapy (CBT)
CBT is an evidence-based psychological treatment for PMDD, with RCT evidence showing efficacy comparable to SSRIs for mood symptoms. CBT for PMS/PMDD specifically targets:
- Cognitive restructuring of negative automatic thoughts in the luteal phase
- Behavioural activation and scheduling of pleasurable activities
- Stress management and relaxation techniques
- Communication skills training (to address interpersonal conflicts)
- Psychoeducation about the biological basis of PMS (reduces self-blame)
In Australia, CBT for PMS/PMDD may be accessed through a Mental Health Treatment Plan (MBS Item 80110), which provides Medicare rebates for up to 10 sessions per calendar year (plus 10 additional sessions under certain conditions). Referral to a clinical psychologist with experience in women's health is recommended. Online CBT programmes (e.g., mindspot.org.au) may be suitable for women in rural/remote areas.
Sleep Hygiene
Address insomnia and hypersomnia with structured sleep hygiene: consistent wake time, screen curfew 60 minutes before bed, cool dark bedroom, avoidance of caffeine after midday. Refer for CBT for insomnia (CBT-I) if persistent.
Other Complementary Approaches
| Intervention | Evidence | Recommendation |
|---|---|---|
| Chasteberry (Vitex agnus-castus) | Moderate RCT evidence for PMS symptom reduction; likely dopaminergic mechanism | May consider for mild PMS; 20–40 mg standardised extract daily. Not PBS-listed. Avoid if on dopamine-related medications. |
| Evening primrose oil | Weak/insufficient evidence; no better than placebo in most RCTs | Not routinely recommended. May consider for isolated breast pain (3–4 g/day). |
| Saffron (Crocus sativus) | Emerging evidence; small RCTs suggest benefit for mood symptoms | Insufficient evidence for routine recommendation. 30 mg/day studied. |
| Acupuncture | Small studies with mixed results; some benefit for pain and mood | May be considered as adjunct; safe; no PBS rebate. |
| St John's Wort (Hypericum perforatum) | Some evidence for PMS symptoms; significant drug interactions | Avoid with SSRIs, COCs, anticoagulants, anticonvulsants. Risk of serotonin syndrome. |
Pharmacological Management
First-Line: SSRIs
First-line for PMDD: SSRIs are the most extensively studied and effective pharmacotherapy for PMDD. They are effective when given continuously or in luteal-phase-only dosing, with response typically within the first treatment cycle — much faster than for major depression.
Fluoxetine
Prozac®, Lovan® · SSRI · First-line
Adult dose
20 mg PO daily (continuous) or 20 mg PO daily from day 14 of cycle to menses onset (luteal phase dosing). May increase to 40 mg/day in non-responders after 2 cycles.
Paediatric dose
Not routinely used <18 years for PMDD; specialist supervision if considered.
Renal adjustment
No adjustment required.
Hepatic adjustment
Reduce dose or extend interval in significant hepatic impairment.
Key interactions
MAOIs (contraindicated), tamoxifen (inhibits CYP2D6 — use sertraline instead), serotonergic drugs. Long half-life (4–6 days) — caution with switching.
PBS status
✔ PBS General Benefit (for depression; off-label for PMDD)
Sertraline
Zoloft® · SSRI · First-line alternative
Adult dose
50 mg PO daily (continuous or luteal phase). May increase to 100 mg/day after 1–2 cycles if incomplete response.
Paediatric dose
Not routinely indicated for PMDD <18 years.
Renal adjustment
No adjustment required.
Hepatic adjustment
Reduce dose in hepatic impairment.
Key advantage
Safe with tamoxifen (does not inhibit CYP2D6). Shorter half-life than fluoxetine — easier switching. Preferred in women with breast cancer on tamoxifen.
PBS status
✔ PBS General Benefit (for depression; off-label for PMDD)
Escitalopram
Lexapro® · SSRI · Second-line SSRI
Adult dose
10–20 mg PO daily (continuous or luteal phase).
Renal adjustment
Caution in severe renal impairment (CrCl <20 mL/min).
Note
Less PMDD-specific trial data than fluoxetine/sertraline but similar pharmacology. QTc prolongation risk at higher doses — caution in cardiac patients.
PBS status
✔ PBS General Benefit
Luteal-phase dosing note: SSRIs can be given only during the luteal phase (typically day 14 to menses onset) with comparable efficacy to continuous dosing. This approach may reduce total drug exposure and side effects. If symptoms recur, switch to continuous dosing.
Second-Line: Combined Oral Contraceptives
Drospirenone / Ethinylestradiol (24/4 regimen)
Yaz® · COC · Progestin with anti-mineralocorticoid activity
Adult dose
Drospirenone 3 mg / ethinylestradiol 20 µg. 24 active tablets + 4 placebo tablets per cycle (extended regimen). Requires TGA-approved indication for PMDD.
Mechanism
Suppresses ovulation, eliminates hormonal fluctuations. Drospirenone has anti-androgenic and anti-mineralocorticoid properties (spironolactone analogue).
Key precautions
Do NOT use with potassium-sparing diuretics or potassium supplements (hyperkalaemia risk). Contraindicated in renal impairment, adrenal insufficiency, hepatic dysfunction. Standard VTE risk assessment required.
PBS status
⚠ PBS Authority Required (contraception indication; PMDD indication may require private prescription)
Other COCs: Standard monophasic or triphasic COCs have inconsistent evidence for PMS/PMDD. Some women with PMS report benefit, particularly with continuous or extended-cycle regimens that reduce the hormone-free interval. However, only the drospirenone 24/4 regimen has specific PMDD indication evidence.
Adjunctive / Symptom-Specific Therapy
Mefenamic Acid
Ponstan® · NSAID · For physical symptoms
Adult dose
500 mg PO TDS, taken during the luteal phase (from symptom onset to day 2 of menses).
Indication
PMS with predominant physical symptoms: headache, pelvic pain, breast pain, bloating, menorrhagia.
Key precautions
Avoid in renal impairment, GI ulceration, asthma (aspirin-sensitive). Short-course luteal phase use minimises GI risk.
PBS status
✔ PBS General Benefit
Spironolactone
Aldactone® · K-sparing diuretic · For fluid/breast symptoms
Adult dose
25–100 mg PO daily, taken continuously or during the luteal phase only.
Indication
Predominant fluid retention, bloating, and breast tenderness symptoms of PMS.
Key precautions
Monitor potassium — risk of hyperkalaemia (especially with ACE inhibitors, ARBs, potassium supplements). Avoid in renal impairment. Anti-androgenic effects (menstrual irregularity, breast tenderness). Contraindicated in pregnancy.
PBS status
✔ PBS General Benefit
Third-Line / Specialist Therapies (Severe, Refractory PMDD)
Leuprorelin (GnRH Agonist)
Lucrin® · GnRH agonist · Specialist-only
Adult dose
3.75 mg IM monthly or 11.25 mg IM every 3 months. Must use with add-back HRT (norethisterone 5 mg + conjugated oestrogen 0.625 mg daily, or tibolone 2.5 mg daily).
Indication
Severe, treatment-refractory PMDD. Creates medical menopause to eliminate cycle. Response to GnRH agonist confirms diagnosis and predicts response to surgical oophorectomy.
Key precautions
Bone density loss with prolonged use (>6 months without add-back). Vasomotor symptoms. Cardiovascular risk. Maximal 6 months without add-back. Specialist initiation and BMD monitoring (DEXA at baseline and 6 months).
PBS status
✖ Authority Required (Specialist)
Danazol
Danocrine® · Androgen · Specialist-only
Adult dose
200 mg PO daily during the luteal phase only, for breast tenderness predominant symptoms.
Key precautions
Virilisation risk (acne, hirsutism, voice deepening) — use lowest effective dose. Hepatotoxicity. Contraindicated in pregnancy (Category D). Reliable contraception mandatory.
PBS status
✖ Authority Required (Specialist)
Treatment Algorithm
1
Diagnose & Assess
Prospective charting for 2–3 cycles. Classify as mild PMS, moderate PMS, or PMDD. Exclude differentials.
2
Mild PMS
Lifestyle advice, calcium + vitamin D, dietary changes, exercise, symptom charting. Reassess in 3 months.
3
Moderate PMS / PMDD
SSRI (fluoxetine 20 mg or sertraline 50 mg) — luteal or continuous dosing. Add CBT if access available. Mefenamic acid for physical symptoms. Reassess at 3 cycles.
4
Inadequate Response
Optimise SSRI dose, switch SSRI, or trial drospirenone/EE COC (Yaz®). Combine SSRI + COC if needed. Reassess at 3 cycles.
5
Refractory PMDD
Refer to gynaecology or reproductive endocrinology. GnRH agonist with add-back HRT. If effective, discuss bilateral oophorectomy + hysterectomy as definitive treatment (requires multidisciplinary discussion).
Monitoring
Pharmacotherapy Monitoring
| Therapy | Monitoring | Frequency |
|---|---|---|
| SSRIs | Symptom response (DRSP/VAS), side effects, suicidality (especially <25 years), sexual function | Review at 4–6 weeks, then 3-monthly. Screen for suicidality at each visit in first 6 months. |
| Drospirenone/EE COC | Blood pressure, VTE risk reassessment, potassium (if concurrent medications), cycle control | 3-monthly for first year, then 6-monthly. BP check at 3 months. |
| Spironolactone | Serum potassium, renal function (eGFR) | 1 week after initiation, then at 1 and 3 months, then 6-monthly. |
| GnRH agonists | Bone mineral density (DEXA), symptoms of hypo-oestrogenism, lipid profile, liver function | DEXA at baseline and 6-monthly. Specialist-led monitoring only. |
| Calcium supplementation | Symptom diary; serum calcium if renal impairment or concurrent medications affecting calcium | Review response at 3 months. |
Ongoing Review
- Continue prospective symptom charting during treatment to objectively assess response.
- Review the need for ongoing pharmacotherapy annually — some women improve after 6–12 months and can trial discontinuation.
- SSRIs should be tapered gradually if discontinued (dose reduction over 2–4 weeks) to avoid discontinuation symptoms.
- Screen for comorbid mental health conditions at every review — depression and anxiety are common comorbidities.
Special Populations
Pregnancy
SSRIs: PMS/PMDD resolves during pregnancy due to anovulation. SSRIs should be tapered before or early in pregnancy if possible. If continued, sertraline is preferred (most safety data). Paroxetine is Category D — avoid. Neonatal adaptation syndrome may occur with third-trimester SSRI exposure.
COCs: Contraindicated in pregnancy.
Spironolactone: Contraindicated in pregnancy — anti-androgenic effects may feminise a male fetus.
Mefenamic acid: Avoid in third trimester (premature ductus arteriosus closure). First/second trimester: short course acceptable if benefits outweigh risks.
PMS/PMDD typically remits in pregnancy; pre-conception counselling is important for women planning pregnancy.
Adolescents
Diagnosis: PMS is common in adolescents but PMDD diagnosis requires careful assessment. Cycles may be anovulatory and irregular in the first 1–2 years post-menarche, making prospective charting more challenging.
First-line: Non-pharmacological management (lifestyle, CBT, calcium). SSRIs may be used with caution — increased suicidality monitoring required in <25 years (TGA black box warning). Start at lower doses.
COCs: May be considered for adolescents with concurrent contraceptive need. Counselling on VTE risk in younger users.
School counsellors and Headspace centres can provide accessible psychological support for adolescents with PMS/PMDD.
Perimenopause & Older Women
Transition: PMS symptoms may worsen in the perimenopausal transition (ages 40–55) due to more erratic hormonal fluctuations and anovulatory cycles. Symptoms resolve with menopause.
Differential: Vasomotor symptoms, sleep disturbance, and mood changes of perimenopause may overlap with or mimic PMS. FSH and cycle pattern assessment may help.
Management: SSRIs remain effective. MHT (menopausal hormone therapy) may be considered if perimenopausal symptoms predominate. Avoid GnRH agonists close to natural menopause age.
Renal Impairment
Spironolactone: Contraindicated if eGFR <30 mL/min — high hyperkalaemia risk.
Mefenamic acid: Avoid if eGFR <30 mL/min — risk of further renal deterioration.
SSRIs: Fluoxetine and sertraline generally require no dose adjustment. Use caution with escitalopram in severe renal impairment.
Calcium: Use with caution — monitor for hypercalcaemia in CKD. Discuss with nephrologist.
Hepatic Impairment
SSRIs: Reduce dose and extend interval in significant hepatic impairment. Fluoxetine's long half-life may result in accumulation.
COCs: Contraindicated in active liver disease, hepatic adenoma, or decompensated cirrhosis.
Danazol: Contraindicated in hepatic impairment — hepatotoxic.
Liver function tests should be monitored if hepatic impairment is present and SSRIs or other hepatically-metabolised medications are prescribed.
Women with Breast Cancer on Tamoxifen
SSRI selection: Fluoxetine and paroxetine are potent CYP2D6 inhibitors and reduce conversion of tamoxifen to its active metabolite endoxifen — AVOID. Use sertraline or escitalopram instead (minimal CYP2D6 inhibition).
COCs: Generally contraindicated in hormone receptor-positive breast cancer.
Consult oncologist before initiating any hormonal manipulation. Non-pharmacological approaches should be maximised.
Aboriginal and Torres Strait Islander Health
Aboriginal and Torres Strait Islander women experience higher rates of chronic disease, mental health conditions, and social disadvantage — all of which may exacerbate the impact of PMS/PMDD. Culturally safe, trauma-informed care is essential.
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