3 Clinical psychopharmacology3.4 Therapeutics

3.4.5.6 Prescribing for premenstrual symptoms and menopause

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Written by Resident Doctor Committee · Published

New in the 2027 syllabus

The College added this topic for exams from January 2027.

Establishing the pattern

Before you prescribe, work out how the symptoms relate to the menstrual cycle.

  • Premenstrual dysphoric disorder causes marked mood symptoms that come and go with the cycle and impair functioning. They usually improve soon after menstruation begins.

  • Prospective daily symptom ratings mean the patient records symptoms each day, as they happen, for at least two cycles. This separates a premenstrual disorder from persistent depression or from another illness that gets worse before a period.

  • Around menopause, depressive symptoms linked to the menopause can overlap with a depressive disorder. They do not automatically need the same treatment.

Illustrative symptom patterns, not diagnostic cut-offs or patient recordings. A premenstrual disorder includes a relatively symptom-free interval; premenstrual exacerbation adds cyclical worsening to ongoing symptoms. Real cycle lengths vary, and prospective daily ratings are needed. Original illustration drawn in Python for MRCPsychiatrist; see images/ATTRIBUTION.md

Treating premenstrual symptoms

Option

Use

What to assess

Selective serotonin reuptake inhibitor (SSRI)

Severe cyclical symptoms, given continuously or only in the luteal phase

Side effects, the patient's preference and any coexisting persistent illness

Combined hormonal contraception

Stops ovulation in suitable patients

Contraceptive needs, contraindications and effect on mood

Cognitive behavioural therapy (CBT)

Helps the patient cope with symptoms and the problems they cause

Whether it is available and whether the patient wants it

Gonadotrophin-releasing hormone analogue

Specialist treatment of severe symptoms that have not responded to other options

Effects of low oestrogen, and the need for protective add-back treatment

  • Luteal-phase prescribing means taking the drug only in the second half of the cycle, when symptoms occur. If depression persists through the whole cycle, continuous treatment may be needed instead.

  • A treatment diary shows whether symptoms and functioning actually improve. Do not assume a change of prescription has helped.

Around menopause

  • Hormone replacement therapy (HRT) can be considered for depressive symptoms linked to the menopause that do not meet criteria for a depressive disorder. Assess menopausal symptoms and the risks of treatment at the same time.

  • A depressive disorder needs its own assessment and treatment, as well as appropriate menopause care.

  • Menopause-specific CBT can help with mood, sleep and vasomotor symptoms (hot flushes and night sweats) where these are relevant.

  • Antidepressants should be chosen for their indication and side-effect profile. They are not a substitute for HRT across all menopausal symptoms.

Reviewing combinations

  • Oestrogen-containing treatment can lower lamotrigine levels. When oestrogen is started, check for worse seizure or mood control. When it is stopped, lamotrigine levels can rise, so watch for toxicity.

  • Sleep disruption, hot flushes and sexual side effects affect whether people keep taking treatment. Ask about them directly.

  • In bipolar disorder, review any history of mood elevation before starting an antidepressant for cyclical or menopausal mood symptoms.

  • Shared care between psychiatry, primary care and gynaecology helps coordinate symptom monitoring and medication changes.

Revision material for the MRCPsych examinations. Not clinical guidance, and not for use in patient care.