Snapshot A 29-year-old female patient complains of depression, poor sleep quality, and breast tenderness. These symptoms occur on a monthly basis, about 2 weeks before menstruation. Her symptoms greatly improve with menses. Introduction Recurrent physical and behavioral symptoms manifesting during the luteal phase of the menstrual cycle resolve with menstruation absence of secondary causes severe: premenstrual dysphoric disorder (PMDD) Presentation Physical and behavioral symptoms physical abdominal bloating, breast pain, cramps behavioral anger, irritability, changes in appetite Evaluation Diary of symptoms for >2 cycles temporal relationship of symptoms to cycle is important Treatment Selective serotonin re-uptake inhibitors (SSRIs) severe PMS, PMDD paroxetine is contraindicated in pregnancy first trimester exposure may lead to congenital heart disease Drospirenone + ethinyl estradiol (Yaz; Yasmin) drospirenone is a spironolactone analog antiandrogen and antimineralocorticoid effects Gonadotropin-releasing hormone agonist (GnRH agonist) A 29-year-old female patient complains of depression, poor sleep quality, breast tenderness and abdominal bloating. These symptoms occur on a monthly basis, about 2 weeks before menstruation. Her symptoms greatly improve with menses.