6 General adult psychiatry6.2 Pregnancy, childbirth and the menstrual cycle
6.2.6 Menstrual and menopausal psychiatric presentations
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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.
Start with the timing
The first question is when symptoms happen in relation to the menstrual cycle. Three patterns matter.
Premenstrual symptoms come back in the luteal phase, the part of the cycle between ovulation and the next period. They ease once the period starts, and there is a fairly symptom-free gap afterwards.
Premenstrual dysphoric disorder needs at least five symptoms, including a marked mood symptom. The symptoms must cause substantial distress or impairment. The cyclical pattern must be confirmed prospectively, by recording symptoms as they happen rather than from memory.
Premenstrual exacerbation means an existing disorder gets worse before a period. The symptoms carry on at other times of the month too.
Telling the presentations apart
Presentation | How to tell it apart |
|---|---|
Premenstrual disorder | Daily symptom ratings over at least two cycles |
Worsening of depression or bipolar disorder | Check for symptoms throughout the cycle and ask about previous episodes |
Menopausal transition | Assess menstrual change, vasomotor symptoms (hot flushes and night sweats), sleep and mood together |
Independent psychiatric or physical illness | Full assessment of the syndrome, with targeted examination or tests |
Menopause
Hot flushes, night sweats and broken sleep can lower mood, concentration and day-to-day function. Even so, do not automatically put depression or mania down to hormones.
Perimenopause is usually diagnosed clinically. In an otherwise healthy person aged 45 or over with new vasomotor symptoms and a change in their periods, routine hormone tests are not needed.
Menopause is diagnosed after at least 12 months without a period in someone not using hormonal contraception. Other situations need assessment under the relevant guidance.
Earlier onset or diagnostic doubt may justify targeted tests under the relevant guidance. Look for thyroid disease, anaemia or other causes when the history points to them.
History
Ask about medicines, contraception, whether pregnancy is possible, substance use, relationships and work. Find out how the symptoms affect daily life.
Management
Plan treatment together with the patient. Base the plan on the symptom pattern, severity, their preferences, contraception needs and any medical contraindications.
Premenstrual symptoms may be treated with cognitive behavioural therapy (CBT), selective serotonin reuptake inhibitors (SSRIs) or hormonal options. Ask for specialist review if symptoms are severe or do not respond to treatment.
Menopausal symptoms may respond to hormone replacement therapy (HRT) or menopause-specific CBT, after individual assessment.
A depressive disorder needs proper depression treatment. Some people need both treatment for menopausal symptoms and psychiatric care.
Practical changes can help with sleep, workload, caring demands and support. Do not present lifestyle changes as a substitute for treatment that is indicated.
Review
Keep using prospective ratings to judge whether treatment has changed the cyclical pattern. Do not rely on a single good or bad week.
Check safety: suicidality, bipolar symptoms and treatment interactions. Involve gynaecology or a menopause specialist when needed.