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 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) |
| 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？」 | |
| 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) |
| Suicidal ideation in PMDD | Active suicidal thoughts in luteal phase | 「有冇諗過傷害自己或者唔想活？」 | |
| Ectopic pregnancy / early pregnancy | Missed period, pelvic pain, positive pregnancy test | 「最後一次M幾時？有冇可能懷孕？」 | |
| 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？」 |
| 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？」 | |
| 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？」 | |
| Masquerades | Hypothyroidism | Fatigue, weight gain, constipation, cold intolerance; elevated TSH | 「有冇怕凍、便秘、體重增加？」 |
| 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？」 | |
| Drug side-effects (OCP, psychotropics) | Temporal correlation with drug initiation/change | 「最近有冇轉藥或者開始食新藥？」 | |
| 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？」 |
| 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)
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