Premenstrual Syndrome
Premenstrual syndrome is a cyclical condition occurring during the luteal phase of the menstrual cycle, characterized by a combination of physical, emotional, and behavioral symptoms that resolve with the onset of menstruation.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Premenstrual syndrome (PMS) | Cyclical physical + mood Sx in luteal phase, symptom-free follicular phase, functional impairment, ≥2 cycles [1] | 「嚟完M之後到下次排卵之前，你係咪完全冇呢啲症狀？」(symptom-free interval) | ~60% |
| Premenstrual dysphoric disorder (PMDD) | ≥5 symptoms with ≥1 marked affective symptom (anger/irritability/depression/anxiety), severe functional impairment [1] | 「呢啲情緒症狀有冇嚴重到你做唔到嘢或者同人嘈交？」 | ~5% | |
| Serious Not To Miss | Major depressive disorder | Persistent low mood/anhedonia > 2 weeks WITHOUT symptom-free interval | 「過去兩個星期，有冇成日覺得好冇精神或者做咩都冇興趣？」(PHQ-2) | ~10% |
| Ectopic pregnancy / early pregnancy | Missed period, pelvic pain, positive pregnancy test | 「最後一次M幾時？有冇可能懷孕？」 | ~3% | |
| Suicidal ideation in PMDD | Active suicidal thoughts in luteal phase | 「有冇諗過傷害自己或者唔想活？」 | < 1% | |
| Pitfalls | Premenstrual exacerbation of underlying psychiatric disorder (depression/GAD/bipolar) | Symptoms present throughout cycle but worsen premenstrually; NO true symptom-free interval | 「係嚟M之前先出現，定係成個月都有，只係嚟M之前嚴重啲？」 | ~15% |
| Endometriosis/dysmenorrhoea overlap | Dominant pain during menses (not before); deep dyspareunia, infertility | 「經痛係嚟M時痛定係嚟M之前已經開始痛？有冇性交痛？」 | ~5% | |
| Perimenopause | Age > 40, irregular cycles, vasomotor symptoms | 「你幾多歲？月經週期有冇開始唔規律？有冇潮熱、出汗？」 | ~5% | |
| Masquerades | Hypothyroidism | Fatigue, weight gain, constipation, cold intolerance; elevated TSH | 「有冇怕凍、便秘、體重增加？」 | ~5% |
| Anaemia | Fatigue, pallor, dizziness; low Hb (heavy menstrual loss) | 「有冇頭暈、面色蒼白、好攰？月經量多唔多？」 | ~5% | |
| Drug side-effects (OCP, psychotropics) | Temporal correlation with drug initiation/change | 「最近有冇轉藥或者開始食新藥？」 | ~3% | |
| Trying to Tell Me Something? | Relationship/domestic stress; work/school burnout; sexual concerns; health anxiety about hormonal/gynaecological disease | Symptoms contextualised within psychosocial distress; patient focuses on impact on relationships/work | 「其實你最擔心嘅係咩？呢啲症狀對你同伴侶/同事嘅關係有冇影響？」 | ~20% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好呀！我係X醫生。今日想同你傾吓，了解吓你嘅情況，大約傾六分鐘，有咩唔明隨時講。」 | Warm greeting + signposting = interpersonal marks |
| 0:30–1:30 | Chief complaint & HPI – open question, then LIQORAAA | 「你今日嚟想睇啲咩呀？」→「可唔可以講多啲畀我聽？」→「通常喺嚟M之前幾耐開始唔舒服？」「最困擾你嘅症狀係邊樣？」 | Establishes CC and symptom timeline; examiners check completeness |
| 1:30–2:30 | Symptom analysis – PMS domains (mood, physical, functional) + red flags | 「有冇覺得好down或者好燥？」「有冇頭痛、谷脹、乳房脹痛？」「有冇影響返工/返學/同人相處？」「月經有冇唔正常出血？」 | Differentiates PMS severity (PMDD vs PMS), excludes serious pathology |
| 2:30–3:30 | ICE + hidden agenda | 「你自己覺得可能係咩原因？」(Idea)「你最擔心係咩？」(Concern)「你今日嚟最希望我幫到你啲咩？」(Expectation) | Direct marks on CRF; uncovers hidden agenda (e.g. relationship stress, fear of hormonal disease) |
| 3:30–4:30 | PMHx, drug Hx (OCP, SSRIs), FHx, Menstrual Hx, Social Hx | 「你有冇食緊藥或者避孕藥？」「屋企人有冇情緒病或者月經問題？」「你月經幾時開始、幾日嚟一次、嚟幾多日？」「工作/讀書壓力大唔大？」 | Rules out drug side-effects, depression, thyroid, and psychosocial masquerade |
| 4:30–5:15 | Brief targeted systems review – thyroid Sx, mood screen (PHQ-2), functional impact | 「有冇怕凍/怕熱、體重變化？」「過去兩個星期有冇成日覺得好冇精神或者做咩都冇興趣？」「症狀有冇嚴重到影響日常生活？」 | Excludes masquerades; assesses severity for PMDD |
| 5:15–5:45 | Summarise back + check understanding | 「我總結吓，你主要係每個月嚟M之前一個禮拜左右會覺得…你覺得啱唔啱？有冇嘢我漏咗？」 | Scores summarising & checking marks |
| 5:45–6:00 | Close with empathy + safety-net | 「你嘅情況好常見，我哋可以一齊搵方法幫你。如果症狀突然嚴重好多或者出現好低落嘅情緒，記得隨時返嚟睇。」 | Empathy + safety net = marks for closure |
Uncovering the hidden agenda: The patient may present with "period discomfort" but actually be worried about PMDD/depression, relationship difficulties, inability to function at work/school, or fear of a hormonal or gynaecological disease. Ask 「其實你最擔心嘅係咩？」 early in the ICE section. The hidden agenda is often psychological or relational.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive → Think Of |
|---|---|---|---|---|
| Onset/pattern | When do symptoms start relative to menses? Do they resolve within a few days of menses? | 「症狀通常喺嚟M之前幾耐開始？嚟咗M之後幾耐消失？」 | PMS requires symptoms in the luteal phase that resolve within a few days of menses [1] | PMS/PMDD if strictly luteal; if persistent → consider depression or thyroid |
| Core affective Sx | Do you feel depressed, anxious, irritable, or have mood swings before your period? | 「嚟M之前會唔會覺得好煩躁、好緊張、或者情緒好低落？」 | Mood symptoms are core to PMDD diagnosis [1] | PMDD if ≥5 symptoms with ≥1 affective; major depression if persistent |
| Core physical Sx | Breast tenderness, bloating, headache, fatigue, appetite changes? | 「有冇乳房脹痛、肚谷脹、頭痛、好攰、或者食慾大變？」 | Physical symptoms common in PMS [1] | If isolated breast pain → consider breast pathology |
| Severity/function | Do symptoms interfere with work, school, or relationships? | 「呢啲症狀有冇影響你返工/返學或者同家人朋友相處？」 | Functional impairment required for PMS/PMDD diagnosis [1] | PMDD if marked impairment |
| Duration | How many cycles has this been going on? | 「呢個情況持續咗幾多個月經週期？」 | Needs ≥2 consecutive cycles for diagnosis [1] | New onset → exclude pregnancy, thyroid change |
| Symptom-free interval | Are you completely fine in the follicular phase (after period ends)? | 「嚟完M之後到下次排卵之前，你係咪完全冇症狀？」 | Key discriminator: PMS has a symptom-free interval; depression/GAD do not | If no free interval → depression, GAD, personality disorder |
| Menstrual Hx | Age of menarche, cycle regularity, LMP, flow, dysmenorrhoea | 「你幾歲開始嚟M？週期規唔規律？最後一次M幾時？有冇經痛？」 | Baseline menstrual data; dysmenorrhoea may overlap | Endometriosis if severe dysmenorrhoea; PCOS if irregular |
| Red flag – suicidality | Any thoughts of self-harm or not wanting to live? | 「有冇諗過傷害自己或者唔想活落去？」 | PMDD can cause suicidal ideation in luteal phase | Urgent psych referral if active suicidal intent |
| Pregnancy/sexual Hx | Could you be pregnant? Are you sexually active? Contraception? | 「有冇可能懷孕？有冇性生活？有冇用避孕措施？」 | Pregnancy mimics PMS symptoms; OCP is both Rx and DDx | Pregnancy; OCP side-effects |
| Drug Hx | Any medications, supplements, OCP, hormonal treatment? | 「有冇食緊任何藥、補充劑、或者避孕藥？」 | OCP can worsen or improve PMS; SSRIs may already be tried | Drug-induced mood change |
| Thyroid Sx | Weight change, heat/cold intolerance, palpitations? | 「有冇體重變化、怕凍怕熱、心跳快？」 | Hypothyroidism mimics PMS (fatigue, mood, bloating) [2] | Hypothyroidism |
| PMHx | Any psychiatric history, chronic illness? | 「以前有冇睇過精神科或者有冇長期病？」 | Pre-existing depression/anxiety may be exacerbated premenstrually | Premenstrual exacerbation of underlying psychiatric disorder |
| FHx | Family history of PMS, depression, thyroid disease? | 「屋企人有冇月經前問題、情緒病、或者甲狀腺病？」 | Genetic predisposition for PMDD; family psych Hx | PMDD, depression |
| Social Hx | Work/study stress, relationship quality, caffeine/alcohol/smoking | 「工作/讀書壓力點？同伴侶/家人關係點？有冇飲酒、飲好多咖啡、或者食煙？」 | Psychosocial stressors worsen PMS; caffeine/alcohol exacerbate symptoms | Hidden agenda: relationship/work stress |
| Health-seeking | What have you tried so far? Why come today specifically? | 「你之前有冇試過咩方法？點解揀今日嚟睇？」 | Reveals expectations and triggers for consultation | May reveal recent crisis episode or functional failure |
Case Report Form Answer Builder
- CC: "Recurrent mood and physical symptoms before menstruation for __ months/years"
- HPI must capture:
- Symptom timing: starts in luteal phase (typically 5–10 days before menses), resolves within a few days of onset of menses
- Nature of symptoms: affective (irritability, low mood, anxiety, mood lability) AND physical (breast tenderness, bloating, headache, fatigue)
- Severity and functional impact (work/school/relationships)
- Duration: ≥2 consecutive symptomatic cycles
- Symptom-free interval in follicular phase (the key diagnostic criterion) [1]
- Menstrual history: cycle regularity, LMP, flow
- Negative pregnancy test if relevant
- Examples: "Premenstrual mood symptoms affecting work performance" / "Worsening irritability before periods causing relationship difficulties" / "Seeking treatment for recurrent premenstrual symptoms"
- Choose the ONE reason that best captures WHY the patient came TODAY, not just the symptom. Often the reason is functional impairment or a specific concern.
| Component | Example Wording |
|---|---|
| Idea | "Patient thinks her symptoms may be hormonal / related to her menstrual cycle" |
| Concern | "Worried that symptoms are getting worse / affecting her marriage / concerned she may have depression or a hormonal imbalance" |
| Expectation | "Hopes for medication or supplement to relieve symptoms / wants to know if this is normal / wants referral to gynaecologist" |
- Premenstrual Syndrome (PMS)
- Minimum supporting evidence: (1) cyclical symptoms confined to the luteal phase, (2) symptom-free follicular phase, (3) ≥2 consecutive cycles, (4) functional impairment [1]
- If affective symptoms are predominant and severe with ≥5 total symptoms → consider writing PMDD as the most likely diagnosis
| DDx | Key Discriminator |
|---|---|
| Premenstrual dysphoric disorder (PMDD) | More severe affective symptoms (≥1 of: marked mood lability, irritability, depressed mood, anxiety); ≥5 total symptoms; marked functional impairment |
| Major depressive disorder / Generalised anxiety disorder | Symptoms persist throughout the cycle with NO true symptom-free interval |
| Hypothyroidism | Persistent fatigue, weight gain, cold intolerance, constipation; no cyclical pattern; elevated TSH |
(Alternative DDx to consider: perimenopause, premenstrual exacerbation of psychiatric disorder, endometriosis-related symptoms)
| Domain | Problem |
|---|---|
| Biological | Recurrent cyclical luteal-phase symptoms (breast tenderness, bloating, headache) causing physical discomfort |
| Psychological | Premenstrual mood disturbance (irritability, low mood, anxiety) ± self-esteem issues |
| Social/Functional | Impaired occupational/academic performance and/or interpersonal relationship difficulties due to premenstrual symptoms |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| PMS (most likely) | No reliable specific physical sign in a brief FM station. Best exam clue: prospective symptom diary showing luteal-phase clustering. On exam day, may find breast tenderness on palpation if in luteal phase | Gentle bilateral breast palpation; abdominal palpation for bloating | Breast tenderness / abdominal distension present in luteal phase and absent in follicular phase supports cyclical PMS |
| PMDD | No specific sign; diagnosed by prospective daily symptom charting over ≥2 cycles. Mental state exam may show dysphoria/lability if in luteal phase | Mental state examination during luteal phase | Marked affective disturbance confined to luteal phase |
| Major depression | Psychomotor retardation, flat affect, poor eye contact, tearfulness — present throughout cycle | Mental state examination at ANY point in cycle | Persistent findings regardless of cycle phase distinguishes from PMS |
| Hypothyroidism | Dry skin, periorbital oedema, bradycardia, delayed ankle reflex relaxation, goitre | Palpate thyroid; check pulse rate; examine skin; test ankle jerks | Non-cyclical physical signs + elevated TSH |
| Anaemia | Conjunctival pallor | Pull down lower eyelid, inspect palpebral conjunctiva | Suggests chronic blood loss (heavy menses) contributing to fatigue symptoms |
Exam Tip: Physical Exam for PMS
PMS/PMDD is primarily a clinical diagnosis based on history and prospective symptom charting. In the OSCE, the examiners know there may be no definitive sign. State: "There is no pathognomonic physical sign for PMS. The best supporting evidence is a prospective daily symptom diary confirming luteal-phase symptom clustering. On examination today, breast tenderness on palpation is consistent with the luteal phase." This shows you understand the diagnosis.
Top Traps That Lose Marks
- Forgetting to confirm the symptom-free interval — If symptoms are present throughout the cycle, it is NOT PMS; it is likely depression/GAD or premenstrual exacerbation of an underlying disorder.
- Confusing PMS with PMDD — PMS can be mild-moderate; PMDD requires ≥5 symptoms including ≥1 core affective symptom (marked mood lability, irritability, depressed mood, or anxiety) with significant functional impairment [1].
- Missing suicidal ideation screen — PMDD patients have increased suicide risk in the luteal phase. Always ask.
- Not asking about pregnancy — Early pregnancy symptoms overlap with PMS.
- Not asking about drug history — OCP, hormonal therapy, and psychotropics can mimic or mask PMS.
- Writing "hormonal imbalance" as a diagnosis — PMS is not caused by abnormal hormone levels; it is due to abnormal sensitivity to normal cyclical hormonal changes. Examiners will mark this down.
- Forgetting ICE — Direct CRF marks. Must explore all three explicitly.
Must-not-miss red flags → urgent referral:
- Active suicidal ideation/plan → urgent psychiatric referral
- Symptoms suggestive of ectopic pregnancy (missed period + pelvic pain + vaginal bleeding)
- New neurological symptoms (severe headache with focal signs) → exclude intracranial pathology
Shortest safe management/safety-net line: 「如果你嘅情緒突然差到好想傷害自己，請即刻去急症室或者打撒瑪利亞防止自殺會熱線。我會安排你做個症狀日記，記錄兩個月經週期，下次覆診再一齊睇。」
Key GC lecture point [1]: PMS management options include lifestyle modification (regular exercise, balanced diet, reduce caffeine/alcohol/salt), cognitive behavioural therapy, and pharmacotherapy. First-line pharmacotherapy for moderate-severe PMS/PMDD is SSRIs (can be given continuously or only in the luteal phase). Second-line includes combined OCP (especially drospirenone-containing) and GnRH agonists for refractory cases.
High Yield Summary
What to ASK: Luteal-phase timing, symptom-free follicular interval, specific affective + physical symptoms, functional impact, ≥2 cycles, pregnancy status, drug history, thyroid symptoms, PHQ-2 depression screen, suicidal ideation, ICE.
What to WRITE on CRF: CC with temporal pattern; RFC = functional/relational impact of cyclical symptoms; ICE explicitly; Dx = PMS (or PMDD if severe); DDx = PMDD, depression, hypothyroidism; BPS problems = physical symptoms / mood disturbance / work-relationship impairment; Physical sign = breast tenderness in luteal phase (acknowledge PMS is mainly a clinical/diary-based diagnosis).
What NOT to MISS: Symptom-free interval (the discriminator), suicidal ideation screen, pregnancy exclusion, depression masquerading as PMS.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: CFB (OG04) Menstrual Disorders.pdf (PMS/PMDD definition, diagnostic criteria, luteal-phase pattern, management options including SSRIs and OCP) [2] Lecture slides: GC 114. Climacteric symptoms menopause and related illness; amenorrhoea.pdf (perimenopause as differential, thyroid screening)
Postcoital Bleeding
Postcoital bleeding is vaginal bleeding that occurs during or after sexual intercourse, most commonly caused by cervical pathology such as ectropion, cervicitis, polyps, or cervical carcinoma.
Pruritus Ani
Pruritus ani is a dermatologic condition characterized by intense itching of the perianal skin, often caused by local irritants, infections, dermatologic disorders, or systemic conditions.