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Severe premenstrual syndrome — DFSRH MCQ

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EasyPremenstrual SyndromeSevere premenstrual syndromeDFSRH

A 38-year-old woman has severe premenstrual syndrome confirmed by prospective daily symptom recording over three menstrual cycles. She is well during the follicular phase but develops disabling irritability, anxiety and mastalgia during the late luteal phase. Cognitive behavioural therapy was insufficient, and luteal-phase sertraline was stopped because of persistent sexual dysfunction. She does not wish to use combined hormonal contraception and requires highly effective contraception. She has an intact uterus and no contraindication to intrauterine contraception. Following specialist review, transdermal estradiol is planned for symptom control. Which is the most appropriate treatment plan?

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Correct answer: E — Transdermal estradiol with a 52 mg levonorgestrel intrauterine device

Transdermal estradiol can improve both psychological and physical symptoms of PMS. Because this woman has an intact uterus, adequate progestogenic opposition is required to prevent estrogen-induced endometrial hyperplasia. Estradiol used for PMS is not itself contraceptive. A 52 mg levonorgestrel intrauterine device addresses both requirements: it provides highly effective contraception and can provide endometrial protection during systemic estrogen use. A copper intrauterine device provides effective contraception but no progestogenic endometrial protection, so option C is inadequate. An etonogestrel implant is contraceptive, but it is not the recommended method of providing endometrial protection with systemic estrogen, making C inappropriate. A 52 mg levonorgestrel intrauterine device alone provides contraception and local progestogen but is not an established treatment for the prospectively confirmed cyclical psychological and physical symptoms described; omitting the planned estradiol therefore makes D unsuitable. Barrier contraception does not provide the requested highly effective contraception and, like a copper device, does not oppose estrogen at the endometrium, so E is incorrect.

Reference: Managing premenstrual syndrome (PMS) (March 2018; current RCOG document accessed August 2026) — https://www.rcog.org.uk/media/mcreb5ix/pi-managing-premenstrual-syndrome-pms.pdf FSRH Guideline: Intrauterine Contraception (March 2023, amended version accessed August 2026) — https://www.fsrh.org/Common/Uploaded%20files/documents/fsrh-clinical-guideline-intrauterine-contraception-mar-23-amended.pdf Premenstrual Syndrome, Management (Green-top Guideline No. 48) (Second edition 2016; reviewed May 2023) — https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/premenstrual-syndrome-management-green-top-guideline-no-48/