A 23-year-old woman attends her GP. She says she has been struggling with her periods recently and would like some help to make them more manageable. She says that in the days leading up to her period she becomes very irritable and has poor concentration. This gradually resolves once menstruation occurs. She says her periods are also heavy. She is concerned about the impact of her condition on her relationship, although her partner is very supportive. Her past medical history includes migraine without aura. She has no drug allergies. She is keen to start a medication that will help with her symptoms.

What is the next most suitable step in management?

Options:
explanation: The intrauterine device is a copper-based system that provides contraception but does not deliver any hormones either systemically or locally. As such, it does not influence the hormonal variations that are thought to cause premenstrual syndrome and are of no benefit in managing this condition.
name: Intrauterine device
label: c
answer: no
explanation: This patient describes symptoms in keeping with premenstrual syndrome (PMS). She experiences mood swings, cognitive issues and irritability during the luteal phase of her cycle, with symptom cessation with the onset of menses. All women are advised to keep a period diary to document the frequency and severity of their symptoms, although this patient already provides an adequate history. The severity of PMS is based on clinical judgement without any scoring criteria; features indicating more severe symptoms include impact on quality of life, mood disturbance or impact on function. Lifestyle changes are an important first-line measure in all women, such as exercise, regular sleep, good diet and restricting alcohol intake. However, this patient reports that the symptoms are affecting her day-to-day life and she is also seeking pharmacological therapy. She most likely has moderate disease, in the absence of more severe features such as depression and loss of function. The first-line treatment as per National Institute for Health and Care Excellence (NICE) guidelines for moderate PMS is the combined oral contraceptive. This will also help her periods, which she says are heavy. A selective serotonin reuptake inhibitor (SSRI) is an alternative, for example, where this may be indicated, or first-line for severe disease.
name: Combined oral contraceptive
label: a
answer: yes
explanation: Although this patient suffers from irritability, she does not report any symptoms indicative of psychosis, such as hallucinations or delusions. If she were experiencing these, then specialist input would be appropriate to rule out any alternative diagnoses.
name: Antipsychotic agent
label: d
answer: no
explanation: As per the NICE guidelines, progesterone-only treatments do not have adequate evidence and are not recommended in the management of premenstrual syndrome. Moderate disease is treated with the combined oral contraceptive pill, and severe disease with SSRIs.
name: Progesterone-only pill
label: b
answer: no
explanation: An SSRI would be first-line for severe PMS, for example, if she were experiencing low mood and disabling emotional lability affecting her daily function. However, for moderate disease, the first-line agent is the combined oral contraceptive pill. This will also help her periods, which she reports are heavy.
name: Selective serotonin reuptake inhibitor
label: e
answer: no

Correct answer: a


Learning point: Combined oral contraceptives are first-line treatment for moderate premenstrual syndrome, alleviating both mood symptoms and heavy menstrual bleeding.