Improving care experiences for premenstrual symptoms and disorders in the United Kingdom (UK): A mixed-methods approach

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L. Funnell, N. A. Martin-Key, S. Bahn This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4965274/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Jan, 2025 Read the published version in BMC Health Services Research → Version 1 posted 4 You are reading this latest preprint version Abstract Background Poor care experiences are reported for premenstrual disorders, which may result in negative outcomes such as distress, reduced healthcare engagement, and delays to diagnosis. Insights from those who have sought care for premenstrual symptoms previously are a valuable resource in identifying characteristics of poor care experiences as well as making recommendations for improvements based on their own experiences. Method An online survey was delivered, with participants recruited via social media. Data were explored using descriptive statistics and thematic analysis. Results The sample included 339 participants who completed at least 97% of the survey, endorsed premenstrual symptoms in consecutive menstrual cycles, and had sought formal help specifically for premenstrual symptoms. The mean age was 34.66 (SD = 5.88), with the majority identifying as women (n = 332, 97.94%) and white/Caucasian (n = 311, 91.74%). 75.22% (n = 255) felt that care was poor. 44.25% (n = 150) felt their symptoms were not taken seriously. 37.76% perceived a lack of HCP knowledge (n = 128). The majority did not receive recommendations of additional non-formal sources of help (i.e., websites, support groups; 84.96%, n = 288) or lifestyle changes (74.63%, n = 253). Better care experiences were associated with healthcare professionals taking symptoms seriously (U = 1383.00, p < .001), higher perceived healthcare professional knowledge (U = 1370.50, p < .001), and receiving recommendations of additional non-formal sources of help (X 2 = 48.251, df = 1, p < .001, Φc = .382) or lifestyle changes (X 2 = 7.849, df = 1, p = .005, Φc = .152). Thematic analysis revealed 8 aspects of care improvement: Empathetic care provision; HCP education, understanding, & research; Comprehensive symptom assessment and investigations; Diagnosis; Professional support and treatment provision; Signposting or referral to additional resources or sources of help; Wider healthcare system improvements; and, Patient role/voice and preferences. Conclusions Poor care experiences for premenstrual symptoms in the United Kingdom (UK) are characterized by dismissive attitudes and perceived lack of knowledge. Improved training provision for healthcare professionals is required. However, given the healthcare system constraints in the UK, research is needed to explore the feasibility and utility of informational toolkits for healthcare professionals. Utilization of standardized screening tools and patient-centered communication will likely ensure comprehensive assessments and reduce self-advocacy burdens. It is crucial to improve knowledge of therapeutic interventions to reduce barriers to treatment-seeking and enable shared decision-making. Premenstrual symptoms premenstrual disorders premenstrual dysphoric disorder Healthcare Figures Figure 1 Figure 2 Introduction Premenstrual symptoms are exceedingly common in women and other people assigned female at birth [ 1 ]. These encompass physical, psychological, and behavioural symptoms occurring in the luteal phase of the menstrual cycle. Premenstrual disorders such as premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are characterized by more severe symptoms and an accompanying impact on functioning. Such disorders are frequent, with PMS estimated to impact 50% of this population [ 2 ] and estimates of PMDD ranging from 3 to 8% [ 3 ], although these estimates may be inflated due to provisional diagnoses, with pooled point prevalence in community samples found to be 1.6% [ 4 ]. Despite the cyclical nature of the symptoms, they have wide-ranging impacts, including but not limited to, decreased productivity [ 5 ] and increased suicidality risk [ 6 , 7 ]. First-line treatment for premenstrual symptoms and disorders are lifestyle changes [ 8 ], with further treatments including psychological and pharmacological therapies [ 9 ] accessed through contact with healthcare services [ 10 ]. Unfortunately, dismissive healthcare professional (HCP) attitudes are extremely commonplace in women’s health [ 11 ]. Such dismissiveness necessitates long-term self-advocacy, as well as a reduced ability to engage in shared decision-making regarding treatment [ 11 ]. For premenstrual disorders, individuals report feeling as though they had to prove the severity of their symptoms to a clinician in order to be taken seriously [ 12 ]. Unfortunately, this dismissiveness of premenstrual symptoms can result in delays to diagnosis of PMDD [ 12 ], with additional risks of misdiagnosis [ 12 , 13 ]. Delays to diagnosis have wide-ranging impacts on the individual [ 14 ] and can result in the development of secondary mental health symptoms [ 15 ]. Previous work has investigated experiences of healthcare for PMDD in the United Kingdom (UK) [ 15 ] and the United States (US) [ 12 ], but to our knowledge, no recent research has investigated care experiences more generally for premenstrual symptoms. Additionally, given the risks associated with poor care experiences for premenstrual symptoms and disorders, it is important to determine how care can be improved. Methods The aims of the current study were two-fold. Firstly, to examine healthcare experiences of individuals in the UK who have specifically sought formal help for premenstrual symptoms. Secondly, to explore how healthcare experiences could be improved from the perspective of previous help-seekers. Participants Participants were recruited using free posts on Facebook and Twitter and paid advertisements on Facebook and Instagram between January 2024 and February 2024. Inclusion criteria were: (1) 18 years or older, (2) having a strong comprehension of the English language, (3) be assigned female at birth, (4) currently experiencing premenstrual symptoms, (5) not currently pregnant, in the perimenopause, or post-menopausal, and (6) not diagnosed with any gynecological conditions (e.g., endometriosis, polycystic ovary syndrome). Materials and procedures An online survey was generated and delivered using the survey software Qualtrics XM®. The survey took 10–20 minutes to complete, and was adaptive in nature so only relevant questions were displayed based on previous answers. The survey was designed in consultation with an experienced consultant psychiatrist (SB). All participants were asked about sociodemographic characteristics. Participants were asked about their formal care experiences including the type of HCPs they saw and the overall perceived quality of care they had received. Participants were also asked the open text question: “In your opinion, what could have improved your care experience?”. Participants were asked if they have received a formal diagnosis of PMDD. If yes, these participants were asked about their experience of receiving this diagnosis. Ethical approval The study was approved by the University of Cambridge Psychology Research Ethics Committee (approval number PRE.2023.117). All participants provided informed consent digitally before starting the survey. Data analysis Descriptive data analyses (i.e., means and standard deviations, frequencies and percentages) were analyzed and processed in Excel, version 2206 (Microsoft Office 365). Figures were created using Excel version 2206 and PowerPoint version 2206 (Microsoft Office 365). Group differences in care interaction characteristics between those who rated their formal care as “Good” or “Very good” and those who rated their formal care as “Poor” or “Very poor” were explored, with responses endorsed as “Not sure” excluded from group analyses. Group differences in ordinal data were explored using Mann-Whitney U tests. Group differences in categorical variables were explored using chi-square tests, and effect sizes were calculated as Cramer’s V (φc; small ≤ 0.10, medium ≤ 0.30, large ≤ 0.50; [16]). Tests for group differences were conducted in SPSS (version 29.0.1.1). Open text data was analyzed using thematic analysis against the Braun and Clarke framework [17]. One author read and re-read the open text data to establish data familiarization before writing a codebook (EF). This codebook was reviewed by a second author (NMK) to ensure all relevant codes were included and any necessary amendments were made. Open text data was coded against the code book under blinded conditions by two authors (EF and NMK). Following this, the data was unblinded and coding allocation was compared, with any discrepancies being discussed until agreement was reached. After coding was agreed, the codes were grouped into themes by two authors (EF and NMK) under blinded conditions. Again, following unblinding, themes were compared with any discrepancies being discussed until a final theme list was agreed. Any free text data which included “No” (or synonyms), “Not applicable” (or synonyms), or responses that were considered ambiguous or non-specific by both authors (e.g., “More options”) were labelled as not applicable and excluded from thematic analysis. Results Participants who had completed at least 97% of the survey, endorsed premenstrual symptoms in consecutive menstrual cycles, and had sought help from a HCP specifically for premenstrual symptoms (N=339) were included in the analyses. Sociodemographic data The mean age of the sample was 34.66 (SD=5.88). The majority of the sample identified as women (n=332, 97.94%) and were white/Caucasian (n=311, 91.74%). The majority held at least an undergraduate degree (n=276, 81.42%) and were in paid employment (n=285, 84.07%). See Supplementary Table A1 (Supplementary information) for full summary of the sociodemographic characteristics. Healthcare experiences The majority of those who had sought formal help had done so from a primary care provider (e.g., general practitioner, primary care physician, family physician, family doctor; 95.87%, n=325), with 65.49% (n=222) having only seen one HCP. Of those who had sought help from a HCP, 75.22% (n=255; Figure 1a) felt that the overall quality of their care was poor. 44.25% (n=150; Figure 1b) felt their symptoms were not taken seriously, and many perceived a lack of HCP knowledge regarding premenstrual disorders (37.76%, n=128; figure 1c). The majority did not receive referrals to or recommendations for additional non-formal sources of help (i.e., websites, support groups; 84.96%, n=288; figure 1d). The majority did not receive any recommendation of lifestyle changes which could be made to help manage premenstrual symptoms by a HCP (74.63%, n=253; Figure Xe). When comparing perceived care quality, the group that rated their overall care experience as "Good" or “Very good” felt that healthcare providers took their symptoms more seriously on a 4-point scale from “Not at all seriously” to “Very seriously” (mean=3.06, SD=0.77; U=1383.00, p<.001) compared to the group who rated their overall care as “Poor” or “Very poor” (mean=1.44, SD=0.56). Additionally, the group who rated their care “Good” or “Very good” also perceived the HCP to be more knowledgeable about premenstrual symptoms or disorders on a 4-point scale from “Not at all” to “Very” (mean=3.23, SD=0.69; U=1370.50, p<.001) compared to those with poorer care experiences (mean=1.60, SD=0.72). Moreover, individuals who rated their care as “Good” or “Very good” more often reported that they had received recommendations for or referrals to additional sources of help by a HCP (35.44%, n=28; X 2 =48.251, df=1, p<.001, Φc=.382) compared to those who reported poorer care experiences (5.58%, n=14). Furthermore, those who reported a “Good” or “Very good” care experience had more often been provided with recommendation for lifestyle changes to manage premenstrual symptoms by their HCP (36.90%, n=31; X 2 =7.849, df=1, p=.005, Φc=.152) compared to those with a poorer care experience (21.57%, n=55). Diagnosis of PMDD Of those who had seen a HCP specifically for premenstrual symptoms, 15.04% (n=51) reported that they have received a formal diagnosis of PMDD (Figure 2a). Of these, the majority waited at least 12 months for a diagnosis (41.18%, n=21; Figure 2b). The majority received a formal diagnosis of PMDD from a primary care provider (56.86%, n=29; Figure 2c). 16.81% (n=57) of those who sought formal help specifically for premenstrual symptoms reported currently monitoring their symptoms to assess whether they may have PMDD, with only 33.33% (n=7) doing this following the advice of a HCP, with the remaining deciding to do this themselves (Figure 2d). Thematic analysis 315 (92.92%) participants provided a response to the free text question regarding what could have improved their care experience. Of these, 16 (5.08%) were deemed not applicable and so removed for analysis and the remaining data (n=299, 88.20% of entire sample) was included for thematic analysis. Of these 299, 20.74% (n=62) characterized their care for premenstrual symptoms as “Good” or “Very good”, with the remaining 79.26% (n=237) of participants characterizing their care for premenstrual symptoms as “Poor” or “Very poor”. Thematic analysis revealed a total of 59 codes which were organized into 8 themes (table 1). Table 1. Themes, codes, and code frequencies. See Supplementary Table A2 for the codebook with code descriptions. Empathetic care provision Empathetic care provision was identified as a theme, with participants stating the importance of HCPs taking premenstrual symptoms seriously: “They could have at least made me feel as though they took me and my symptoms serious” “A health care professional that took my concerns seriously and didn't outright dismiss them” Further it was identified that receiving supportive care was important, with many participants seemingly perceiving supportive care as being compassionate: “Being more compassionate, more understanding” Further, emphatic care provision requires the HCP to engage in active listening (i.e., to be perceived by the patient as listening and paying attention to them and what they are saying): “Please listen to women! We don’t come to the GP for fun. We are usually embarrassed and desperate by the time we seek help so please don’t fob us off” “Being sincerely listened to” Active listening was often associated with a proactive approach, where the HCP is perceived as being proactive in their care: “…wanting to find a way to help/solution/cause” “Some curiosity.” This may include offering suggestions of other sources of support without the patient needing to ask: “For advice and guidance related specifically to the menstrual cycle - no medical professional has ever spoken to me about this without me specifically bringing it up” Proactively offering symptom investigations: “GP could have taken more interest in finding out why I was having issues” Or taking the time to do research and expand their knowledge if they were unfamiliar with premenstrual symptoms or disorders: “If he had said he didn’t know much about it but would look into it for me and come back to me with what he’d found so he could help me” “If the GP had said, I will look into PMDD and then we can make a follow up appointment to discuss options.” HCP accountability was also raised as a facet of empathetic care, with requests that HCPs provide an explanation of why they are unable to provide certain aspects care such as assessment, diagnosis, or treatment/management: “A better explanation of why they couldn't help with the issues” “…at least explaining why an assessment or diagnosis wasn't an option [that was offered]” One participant also reported feeling like they were a burden in previous care interactions: “I just felt like a nuisance” Participants also raised concerns about the potential risks associated with empathetic care not being delivered, particularly if help-seeking occurs in the luteal phase: “If they had spoken to me as disrespectfully and dismissively on that week when I was extremely vulnerable, I dread to think the outcome.” HCP(s) education, understanding, & research Many participants mentioned the importance of improved HCP knowledge of premenstrual symptoms and disorders, including potential symptoms and their treatment/management: “If my GP had had knowledge of PMDD in any form this would have helped.” Including awareness of how to manage complex premenstrual symptoms: “being willing to […] work with more complex cases that don't necessarily fit the flowchart.” Some participants stated the importance of including training about female health, hormones, and premenstrual symptoms and disorders in HCPs’ curriculum, with this training seemingly perceived as particular important for GPs: “Female health and hormones should be part of GPs training” “GP education about hormones and PMDD, so they believed me.” “Do GPs even know anything about women’s health or is the curriculum the same as in the times were clitoridectomy was used to treat mental illness in women? Educating the professionals would maybe have improved my care experience” Improved HCP knowledge likely includes improved recognition of the potential impacts of premenstrual symptoms and disorders on functioning: “…recognising the impact it has on my life which has been practically ruined.” “Some understanding of the impact that PMS can have, the danger of regularly feeling suicidal and the strength of symptoms.” And in general, improved recognition of the role of the menstrual cycle in mood and mental health: “Assumptions were made by a male doctor who put it down to depression. He had no intention of listening to the fact that just before my period I had thoughts of suicide but it was instantly relieved once my period has started.” “Them acknowledging the possibility of period related issues” Moreover, participants expressed the importance of HCPs recognising the association of the menstrual cycle, and premenstrual symptoms and disorders, on neurodevelopmental conditions such as autism spectrum disorders and attention deficit hyperactivity disorder (ADHD) “…more knowledge and education on PMDD and how it affects people especially those who are neurodivergent like myself as [it] affects every aspect of our being and destroys our lives.” Associated to this, one participant mentioned the importance of HCP awareness and communication with specific patient groups, such as patients with neurodevelopmental conditions or LGBTQ+ patients: “Better disability and LGBT awareness among staff.” Some participants expressed the need of seeing an experienced HCP or someone who specializes in premenstrual symptoms or disorders: “Having talked with a professional who is expert on PMS” “It was like they’d [HCPs] had no previous experience with the condition” Finally, there was a sentiment that there was a need for further research into premenstrual symptoms and disorders, including improved understanding of the causes and presentation: “More research and understanding about PMS - what range of symptoms are commonly experienced and for how long, what is considered usual, do hormone levels play a role and can we consider testing levels at different times if the cycle to see if there is any dysregulation that is causing extreme PMS?” As well as more evidence for the efficacy of available treatment/management options, in addition to the discovery of novel treatment/management options: “More research into what causes these issues and an effective treatment that deals with the acute problem rather than blanket long term medications for symptoms.” Participants also remarked that it is important that HCPs are aware of recent research to inform high-quality care practices: “Further knowledge and understanding of up to date research into appropriate care for PMDD” “Being able to speak to a practitioner with specialist knowledge and interest in PMS and PMDD, who was more up to date with the latest knowledge and treatments.” Comprehensive symptom assessment and investigations Participants raised the importance of comprehensive symptom assessment, which asks about a wide-range of possible premenstrual symptoms: “…a holistic assessment of my symptoms” “Discussing my symptoms in greater detail” “Asking more questions rather than writing it all off as ‘normal’.” “More holistic take/lifestyle questions” Some patients commented that comprehensive symptom assessment may be achieved by employing a structured screening tool to ensure all premenstrual symptoms are covered: “Maybe going through a questionnaire to guide questions about relevant symptoms” “There needs to be a new checklist for females with symptoms mental and physical with regards to periods.” This would also ensure high-risk symptoms and behaviors such as suicidality and self-harm are assessed, with many participants reporting that their HCP(s) had not specifically asked about suicidality and self-harm: “Asking the right questions so patient doesn't have to be the one to bridge topic of [suicidal ideation/self-harm] - it's understood that that can be a part of it” This is especially crucial as some patients may not feel able to disclose this information without prompting from a HCP: “I was too scared when my children were younger to admit that I felt suicidal every month.” Comprehensive symptom assessment, potentially with a structured screening tool, may also minimise the perception that HCPs are solely or primarily focused on physical symptoms, and overlooking psychological symptoms: “Male doctor said [he] was only interested in the dizziness and hot flashes” “More exploration of PMS symptoms rather than the bleeding itself” As part of a comprehensive symptom assessment, some participants expressed wanting to have tests/investigations such as blood tests or scans performed to rule out any underlying causes and identify potential hormonal imbalances: “If she has taken me seriously, done further tests, or even pretended to care.” “I would also have liked more conversations about ruling out other issues and investigating comorbidities like ADHD” “…maybe a suggestion of a blood test to make sure hormonally everything is ok.” However, many participants also noted that a crucial aspect of offering tests/investigations is ensuring there is an opportunity to discuss results from these tests/investigations with a HCP: “Follow up on test results, even though in normal range and discussion about what to consider next outside of basic tests” Some participants also suggested that the care record or patients’ medical history could be a useful supplement to appointments to contribute to a comprehensive assessment by streamlining and guiding the appointment: “If GPs who had looked through my history prior to calling and understood my situation had been more thoughtful and treated me with the respect I needed at the time.” And to reduce or remove the need for repeated information gathering: “…glancing through my history while we spoke so I wasn't going over the same points again and again each time” “Checking my medical records prior to or in my appointment, which would have shown a PMDD diagnosis, that I was in private talking therapy and that I was taking sertraline at a consistent dose. I had to tell the GP all of this so her suggestions weren't helpful or understanding.” As well as facilitating follow-up and monitoring over time, and between HCP(s): “…compare notes over my years & diff NHS [departments]” With HCP monitoring premenstrual symptoms and associated behaviors over time, in the context of the patient, to identify deterioration being deemed as important: “The previous GP could have looked into my symptoms better since it was a severe and unusual behavioural change, I started gaining weight very quickly and my overall appearance had rapidly declined. The mental health team should have noticed that I was a good student that hardly ever missed school and had severe increased anxiety, suicidal thoughts and depression and noticed that this was not ‘attention seeking behaviour’” The importance of HCPs suggesting monitoring over time by engaging in symptom tracking was also noted with the aim of supporting assessment: “It would have been better if the GP […] asked me to continue to register all my symptoms” “A plan on how we could investigate for PMDD - hormones fluctuate significantly during a cycle so some understanding of this along with the symptoms would have supported me to gather data so to speak” Some participants stated that in general there was a need to improve the speed of understanding. With earlier recognition of symptoms or understanding of experience by HCPs: “Better understanding early on and feeling validated that this isn't typical anxiety” “It took a long time/a few doctors for anyone to even mention PMDD” Diagnosis Participants expressed wanting to have received a diagnosis of PMDD, even if this was provisional (i.e., whilst tracking symptoms over two cycles) or “A formal diagnosis”: “A proper diagnosis instead of just being brushed off with ‘you are a woman that is just normal’” There were reports from some participants of previous experiences of premenstrual symptoms being misattributed to a different cause such as early onset menopause: “I think the GP immediately jumped to early menopause as an answer but I really don’t feel that’s the case” Or stress: “…often blamed on stress when women go seek help for it.” With other participants reporting their premenstrual symptoms had been attributed to a different condition: “Not being told I was ‘depressed’ which, for years, was a catch-all for my mental health.” Resulting in potential misdiagnosis: “Readily accepting my experience as truth rather than emotional instability due to an alleged personality disorder.” One participant also called for more professional support provision even if a provisional or official diagnosis of PMDD is not given: “Support for the physical and mental health symptoms, even in lieu of a diagnosis” Professional support and treatment provision The theme of professional support and treatment provision was mainly characterised by participants expressing the need of a wider treatment offering from HCPs, this includes offering alternative or a range of treatment options including hormonal, non-hormonal, and psychological treatments: “Improved variety of suggestions to help treat or manage symptoms.” “I would also like more non medication options for treatment and support.” This includes a perception that only hormonal treatment are an option: “…options for treatment (I was told to get the coil and that if I didn’t want this nothing could be done)” “Not being palmed off with the standard contraceptive options” “More options than just a pill would have been better.” Or antidepressants will be the only treatment offered by a HCPs: “Resources being available for more support options - not just antidepressants.” “[the HCP] didn't look into any alternative idea, just straight to antidepressants” With no “one size fits all” and it being important that the HCP(s) recognising the individual and delivering personalized care and treatment management: “…not given a one size fits all answer” “…individual treatment. It felt like they just have a one size fits all answer which doesn't work” Related to this, some participants reported a general sense of uncertainty about available treatment/management options: “Clearer management/treatment options.” “I'm not sure what other methods of support there are as the GP didn't speak about any - does the contraceptive pill help?” Participants reported it would have improved the care interaction if the HCPs had offered treatment or “Advice and care plan”: “I wish I had been offered some treatment” “Offering real help, trying treatments, actually trying to solve the problem.” With it being important that there is an improved speed of treatment initiation, with treatment being offered at the first instance of help-seeking: “Counselling should be absolutely offered straight away” “If they had prescribed [the contraceptive pill] straight away” There was a perception from some participants that they had received an inappropriate prescription: “Not been prescribed pain medication that I cannot take, and could have caused me more harm than good if I hadn't checked the label myself.” “I don’t think it’s appropriate to prescribe SSRIs for PMDD, when said SSRIs also come with unbearable side effects” With many participants having had previous negative experiences with medication available for management of premenstrual symptoms and disorders: “Hormonal treatments are the first and apparently only treatment for anything related to your cycle, I felt pushed towards that as the ‘best’ option even though I’ve had such bad experiences with them in the past.” Which in some cases resulted in reduced interest in further treatment seeking behaviour: “The feeling that if I do seek help it could be resolved without going back into contraceptives as they ruin my skin and give me vaginal dryness, lack of overall sex drive.” “But realistically other than medication to mask the symptoms of PMDD at the expense of worse side effects, there is nothing they can do for me.” Or reported treatment non-adherence: “I stopped taking [the contraceptive pill] because it was giving me so many side effects.” This also highlights the importance of HCPs providing a treatment follow-up to ensure treatment efficacy and optimization, as well as monitoring negative side-effects: “When put on the pill (especially after I told them it causes me to have low moods), a follow up of how I was finding it after 3 months.” “A follow up appointment booked in at the time of starting a month of treatment to be able to check in with the doctor” “Would have been good to have some follow up, as none since the initial appointment with GP.” And ensuring medication continuity to minimise the risk of deterioration whilst not receiving therapeutic intervention: “My GP […] hasn't always understood the importance of me always having access to the pill (despite it being written on my record it's for PMDD) - I can't just wait like everyone else or the symptoms return.” Aside from wanting to access therapeutic interventions, one participant mentioned wanting the HCP(s) to help them secure time off of work: “Discussion of PMDD and how it could allow time off work if necessary.” Signposting or referral to additional resources or sources of help Participants generally requested the provision of additional information from HCPs, either provided directly by the HCPs in an appointment setting: “It would have been better if the GP explained my symptoms to me and explained what is happening to me” Or the HCPs signposting to resources which can be independently accessed outside an appointment setting: “I was never made aware of any PMDD-specific resources.” “I wasn't signposted to any support networks or relevant information.” Some participants specifically mentioned that this information should include information about how common premenstrual symptoms are: “…what range of symptoms are commonly experienced” “I would have wanted more understanding of how widespread the symptoms are, how common among women they are, so I didn’t feel so alone.” Participants also stated that care experiences would be improved if the HCPs provided advice for symptom management: “Some advice on what could help during these two weeks.” For managing high-risk psychological symptoms: “Giving me practical coping strategies such as 'try sitting in A and E' (or better ones!) rather than leaving me to flounder alone at potential risk of suicide.” This would be particularly welcomed if advice was offered without prompting from the patient: “For advice and guidance related specifically to the menstrual cycle - no medical professional has ever spoken to me about this without me specifically bringing it up.” Many participants also mentioned wanting the HCPs to provide an onward referral to specialist care: “…to refer people to ACTUAL get help to treat their problems” “Let me see a gynecologist, someone specialized.” Participants mentioned that HCPs signposting to other sources of support would improve the care experience: “it might have been useful to be directed to other sources of support.” “…being signposted to charities or other specialized professionals” A participant also suggested that comprehensive patient information packs could be provided by the HCP which provide information, recommendations to other sources, and self-help advice: “Patient care packs - daily diary , helpline numbers and self-help book” Wider healthcare system improvements Some participants commented on factors which would improve the care experience which are relevant to wider healthcare system improvements. One such improvement is decreasing wait times, this included both reducing the speed of an onward referral: “Referral could be quicker” “…it was the referral to the psychiatrist and gynecologist when things slowed down/stopped” And the time between appointments decreasing: “Improved waiting times between appointments.” Related to this, it was mentioned by participants that it was important for access to HCPs to be improved: “Being easily able to access GP (or other appropriate primary care) for a 'non urgent' matter.” “It was near-impossible to get a doctor's appointment at my surgery, so more availability of appointments would have helped.” With it being crucial that there was continuity between HCPs seen between appointments, with a HCP acting as a single point-of-contact during the diagnostic and treatment process: “…to have the same female GP as a point of contact.” “Continuity of care - after I was referred for blood tests and they came back clear, there was no follow-up” Participants also noted it would be beneficial if appointment times were longer: “When I began to list the different symptoms I was told I'd need to book separate appointments to discuss them” “More time for appointments to really go through information. They often seem rushed.” Participants also commented on the referral process, with a suggestion of specific referral pathways designed for premenstrual symptoms/disorders: “A clear referral pathway to get a diagnosis” Which may facilitate a self-referral option: “Ability to self-refer to [obstetrics-gynecology]/consultant services.” It was also deemed important that referral decisions were transparent, particularly as to why a referral to a specialist service may be rejected: “The [gynecology] department taking the initial referral […] instead of pinging it back to my GP with no real reasoning as to why.” Patient role/voice and preferences The patient preferences was mainly characterized by preferences for face to face appointments with HCP: “More dialogue, face to face appointment” And a preference for seeing a female HCP: “Seeing a female consultant” “Maybe having a female practitioner to speak to instead of a male” In terms of patient role/voice, participants expressed interest in engaging in their healthcare experiences. Participants highlighted the importance of the HCPs encouraging shared decision making with the patient, particularly in regards to treatment: “Not been defensive when I questioned whether antidepressants were the best option.” “A dialogue about treatment options.” With it being crucial for the HCPs to respect the patient’s treatment decision: “More patience from the doctor, and respect for my choice not to want to get on the pill.” “Listened to my concerns about using anti-depressants and worked with me to discuss alternative solutions.” Participants also stated that they could also be involved in the healthcare interaction if the HCPs consider information gathered by the patient from informal sources (e.g., from online resources): “Sometimes I feel like having done some research is off putting to general practitioners and I have to play stupid in order to be advised. If I come in with some theory as to what may be the problem, I often get a bad look or the tone of the conversation completely changes (for the worse).” “Also not rolling their eyes when I’ve said I’ve looked on the internet when I’ve done that as I’ve felt unheard by the very people who should be listening” Additionally, a participants mentioned they thought it would be beneficial to provide information prior to an appointment to help prepare for the appointment and ensure the assessment is comprehensive: “Before when I had my first appointment, I sent in an email with all my symptoms so the Dr could read before I went in. That helped because I felt he guided the conversation and I kind of knew what we would discuss.” Finally, participants stated they wished to co-design a safety plan between themselves and the HCPs: “Next of kin/ trusted person patient and GP should do a safety plan also what can those do to help and keep patient safe.” Discussion The current study aimed to examine care experiences for premenstrual symptoms and disorders in the UK, while also seeking to identify potential strategies for care improvements. The study reflects previous findings [15], also demonstrating broadly poor care experiences. The sample generally perceived that HCPs held dismissive attitudes or acted dismissively. Moreover, there was a widely held perception that HCPs also lacked knowledge of premenstrual symptoms and disorders. The majority of the sample had not received advice on potential lifestyle changes which could be made to manage symptoms, despite this being a first line treatment recommendation [8, 9]. Further, such information would be a highly valuable resource as education on available lifestyle changes can empower individuals to self-manage premenstrual symptoms [18], which could be leveraged for therapeutic benefits either outside of or alongside other therapeutic interventions. Not receiving these recommendations directly from a HCP would likely necessitate individuals to find this information independently. With the majority of the sample also not receiving recommendations of or referrals to other sources of information from a HCP, the necessity of independent searching is further increased, with there being a risk of relying on poor quality information [19]. There was also an apparent delay to diagnosis of PMDD in the current sample, with the majority of those with a PMDD diagnosis reporting a wait of over a year. Delays to diagnosis of PMDD are common, with individuals often having to consult multiple HCPs with no continuity of HCPs [12] as also reported by participants in the current study. Delays to diagnosis of premenstrual disorders are associated with considerable challenges for the individual. Notably, previous qualitative research has revealed the high levels of emotional distress, reliance on maladaptive coping mechanisms, and unstable self-image experienced while awaiting a formal diagnosis of PMDD [15]. In contrast receiving a diagnosis results in a considerable sense of relief for the individual, providing an explanation for their symptoms [12]. Therefore, reducing delays to diagnosis is crucial to improve quality of life and reduce suffering. Interestingly however, the receipt of a provisional or official diagnosis was not frequently mentioned in the qualitative data as important for improving healthcare experiences. Instead, the qualitative data suggests that comprehensive symptom assessment is more frequently considered important for high-quality care experiences. In the current study GPs provided the majority of diagnoses of PMDD and so their ability to accurately identify symptoms when first consulted is critical. One approach to achieve this is through training for HCPs specifically on premenstrual symptoms and disorders, with a focus on symptom recognition. Another avenue for improved symptom identification is using a validated screening tool when patients present with a complaint of premenstrual symptoms, with qualitative data also demonstrating interest in such a tool from a patient perspective. Whilst prospective tracking of symptoms across two menstrual cycles is required to confirm a formal diagnosis of PMDD, screening would provide a provisional diagnosis [20] and identify individuals who require further assessment [21]. Comprehensive mental health screening could also be used to rule out other conditions with an overlapping symptom profile such as major depressive disorder [22], and to initially establish whether symptoms exclusively occur in the luteal phase. Perhaps crucially, use of a validated and standardized tool for the assessment of premenstrual symptoms in a clinical setting would also ensure that the HCP as standard practice asks about high-risk psychological symptoms which some participants reported difficulty in disclosing. Whilst these findings paint a disappointing picture of the current care provision for premenstrual symptoms in the UK, they should not be interpreted as criticism of HCPs working in the UK who are involved in the management of such symptoms. Instead, we intend them to be used as a call to action, highlighting the need to make improvements to healthcare experiences for premenstrual symptoms and disorders. As such, the current study also revealed factors which underpin more positive care experiences. Some participants raised suggestions of wider healthcare system improvements which they perceived to be required for better healthcare experiences. Core suggestions included faster referrals, ensuring continuity of care with a single point of contact between appointments, and longer appointment times. Whilst these are likely to be important for delivery of high quality care, they are not easily addressable, especially considering the current strains experienced by the national health service in the UK [23]. However, other findings from the current study may be more feasible to enact for service improvement. Firstly, participants who perceived their HCP as knowledgeable reported more positive care experiences, with qualitative data also indicating that consultation with a knowledgeable clinician would confer a better experience. In the current study, primary care providers were the most frequently, and in many cases the only HCP consulted and so are likely the sole source of formal management of premenstrual symptoms. Unfortunately, research has shown that globally primary care providers are the medical specialty perceived as the least knowledgeable about PMDD [24]. Going forward, the UK government has pledged to improve the provision of training in women’s health for incoming doctors [25]. However, this does not address potential lack in knowledge in currently practicing HCPs. Although specific training courses are available for HCPs, they are not mandatory and therefore uptake is likely limited to those clinicians with a special interest. Therefore, although we encourage currently practicing HCPs to engage with available training for premenstrual symptoms and disorders, an alternative is providing clinicians with “toolkits”. These toolkits could offer key information for identification and management of premenstrual symptoms and disorders. Toolkits have demonstrated some promise in communicating health information and research evidence in healthcare [26, 27], but further research is required to fully determine the impacts of implementation [26, 27]. Toolkits are perceived as particularly effective by clinicians and other allied health professionals when they are actionable, concise, and have a flexible delivery modality [28]. It is also vital that toolkits have a clear purpose, strong-evidence base, and are subject to evaluation in the setting of interest [27]. Therefore, future research may wish to explore the development of toolkits for premenstrual symptoms and disorders. The primary intended benefit of such tools would be to improve HCP knowledge, with a secondary intended benefit of improving care experiences. In future, if such toolkits for premenstrual symptoms and disorder are integrated into care settings to support HCPs in delivery of care, monitoring uptake and impact will be crucial. Secondly, attentive attitudes from HCPs were associated with better care experiences. The qualitative data also indicated the importance of supportive care for positive care experiences, with HCP active listening and taking symptoms seriously deemed to be key. This may be addressed by offering training to healthcare professionals to improve patient-centered communication skills [29]. Patient-centered communication uses varied strategies including active listening and use of layperson language in order to build a strong therapeutic relationship, gather and provide relevant information, and facilitate shared decision-making [30]. Taken together, this can improve the overall care experience and outcomes [30]. However, some clinicians report trepidation about utilizing patient-centered communication due to time constraints during consultations [30]. Given that GPs in the UK spend an average of under 10 minutes in consultation with patients [31], this is likely a restriction for comprehensive symptom assessment and creation of personalized care plans. Previous literature has also recommended that dismissive care interactions may be improved by training patients in effective health communication, with a focus on how to effectively ask for a preferred intervention [29], with participants also noting the importance of the HCP enabling opportunities for shared decision making. However, whilst this approach may empower the patient, it again places the burden of communication on them. Instead, a mixture of patient-centered communication and self-advocacy should be used to establish the patient’s circumstances, symptoms, needs, and preferences. Doing so will likely result not only in better care experiences, but also improved overall outcomes. Further, as recommendations of additional information sources and lifestyle changes from the HCP were found to confer a better care experience from both quantitative and qualitative data, it is vital that HCPs are empowered to provide these recommendations. Whilst improved training and toolkits can provide an increased knowledge of relevant recommendations, an additional offering may be a database of high-quality websites and support groups. This database would enable personalization of recommendations for additional information or support based on patient-specific factors. In addition to general information and advice, qualitative data revealed the perception that there would be, or previous experience of, a limited treatment offering from HCPs. This highlighted the importance of improved information provision about the full-range of treatments available for premenstrual symptoms and disorders. Such information would likely reduce hesitancy in treatment-seeking by addressing uncertainty around the availability and appropriateness of treatment options, whilst also increasing trust that the patient is able to refuse specific treatments in favor of others. It also further demonstrates the importance of improved HCP education to ensure they are aware of all therapeutic interventions available so they can offer comprehensive treatment options and enable the patient to be involved in the decision-making process. This also underscores the importance of amplifying patient voice and ensuring they are included in a participatory role in their care, which was deemed important for positive care experiences. Further, it was deemed highly important that treatment reviews were offered to monitor the treatment response and safety, as well as optimizing the therapeutic intervention as required. Limitations The results of the current study should be contextualized alongside some limitations. Firstly, there would have likely been a recruitment bias. Recruitment materials specified a focus on healthcare experiences for premenstrual symptoms, which may have motivated individuals with particularly positive or negative experiences to participate. Further, the majority of the sample were white and identified as women. Therefore, the results will not reflect the healthcare experiences of individuals from minority or other demographic groups who are likely to already experience poorer care [32] or be more easily dismissed by HCPs [29]. Finally, there are likely to be other determinants of positive healthcare experiences for premenstrual symptoms and disorders which were not considered in the current study. Previous research investigating factors influencing perceived quality of care identified a range of structural, interpersonal, and patient-level determinants [33, 34]. Therefore, whilst the current study reveals some factors, future research is required to identify further determinants of high-quality care. Conclusion To conclude, poor care experiences for premenstrual symptoms are pervasive in the UK characterized by dismissive attitudes and perceived lack of HCP knowledge of premenstrual symptoms and disorders. Thematic analysis revealed eight themes to improve healthcare experiences for premenstrual disorders: Empathetic care provision; HCP education, understanding, & research; Comprehensive symptom assessment and investigations; Diagnosis; Professional support and treatment provision; Signposting or referral to additional resources or sources of help; Wider healthcare system improvements; and, Patient role/voice and preferences. Improving the provision of training for HCP in the UK is required to deliver higher quality care for premenstrual symptoms and disorders. However, given the current constraints on the healthcare system in the UK, providing HCPs with easy to access, high-quality toolkits may deliver benefits in a faster timeframe. In tandem, the utilization of standardized screening tools for premenstrual symptoms and disorders in healthcare settings may be beneficial for delivering comprehensive assessments which includes high-risk psychological symptoms. Additionally, we encourage HCPs to engage in patient-centered communication, where feasible, to reduce the burden of self-advocacy on the help-seeking individual and improve the care experience. Further, it is crucial to improve knowledge of therapeutic interventions for both the public and HCPs to reduce barriers to treatment-seeking and enable shared decision making. Declarations Ethics approval and consent to participate The study was approved by the University of Cambridge Psychology Research Ethics Committee (approval number PRE.2023.117). Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests S.B. is co-founder of and holds shares in Psyomics Ltd but declares no non-financial competing interests. E.L.F. is a paid consultant for Psyomics Ltd but declares no non-financial competing interests. N.A.M-K. declares no financial or non-financial competing interests. Funding This work was supported by the Stanley Medical Research Institute (grant number 07R-1888). The funder was not involved in the conceptualization, design, data collection, analysis, decision to publish, or preparation of this manuscript. Authors' contributions E.L.F., N.A.M-K., and S.B. conceived the study focus and materials. E.L.F. coordinated and conducted participant recruitment. Data analysis was performed by E.L.F. and N.A.M-K. E.L.F. prepared the manuscript with revisions from N.A.M-K. and S.B. All authors read and approved the final manuscript. References Hantsoo L, Rangaswamy S, Voegtline K, Salimgaraev R, Zhaunova L, Payne JL. Premenstrual symptoms across the lifespan in an international sample: data from a mobile application. Arch Womens Ment Health. 2022 Oct 1;25(5):903–10. Direkvand-Moghadam A, Sayehmiri K, Delpisheh A, Kaikhavandi S. 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Opatowski M, Valdimarsdóttir UA, Oberg AS, Bertone-Johnson ER, Lu D. Mortality Risk Among Women With Premenstrual Disorders in Sweden. JAMA Network Open. 2024 May 28;7(5):e2413394. National Institute for Health and Care Excellence (NICE). Scenario: Management of premenstrual syndrome. [Internet]. 2019 [cited 2024 Aug 22]. Available from: https://cks.nice.org.uk/topics/premenstrual-syndrome/management/management/ Green LJ, O’Brien PMS, Panay N, Craig M on behalf of the Royal College of Obstetricians & Gynaecologists. Management of Premenstrual Syndrome. BJOG: An International Journal of Obstetrics & Gynaecology. 2017;124(3):e73–105. Carlini SV, Lanza Di Scalea T, McNally ST, Lester J, Deligiannidis KM. Management of Premenstrual Dysphoric Disorder: A Scoping Review. IJWH. 2022 Dec;Volume 14:1783–801. Department of Health & Social Care. Results of the ‘Women’s Health – Let’s talk about it’ survey. [Internet]. 2022 [cited 2024 Aug 22]. 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Arch Womens Ment Health. 2003 Aug 1;6(3):203–9. Freeman EW, Sondheimer SJ. Premenstrual Dysphoric Disorder: Recognition and Treatment. Prim Care Companion J Clin Psychiatry. 2003;5(1):30–9. The Health Foundation. Nine major challenges facing health and care in England. [Internet]. 2023 [cited 2024 Aug 22]. Available from: https://www.health.org.uk/publications/long-reads/nine-major-challenges-facing-health-and-care-in-england Hantsoo L, Sajid H, Murphy L, Buchert B, Barone J, Raja S, et al. Patient Experiences of Health Care Providers in Premenstrual Dysphoric Disorder: Examining the Role of Provider Specialty. J Womens Health (Larchmt). 2022 Jan 1;31(1):100–9. Department of Health and Social Care. First Women's Health Strategy for England to tackle gender health gap. [Internet]. 2022 [cited 2024 Aug 20]. Available from: https://www.gov.uk/government/news/first-womens-health-strategy-for-england-to-tackle-gender-health-gap Barac R, Stein S, Bruce B, Barwick M. Scoping review of toolkits as a knowledge translation strategy in health. BMC Med Inform Decis Mak. 2014 Dec 24;14(1):121. Yamada J, Shorkey A, Barwick M, Widger K, Stevens BJ. The effectiveness of toolkits as knowledge translation strategies for integrating evidence into care: a systematic review. BMJ Open. 2015; 5:e006808. Davis MM, Howk S, Spurlock M, McGinnis PB, Cohen DJ, Fagnan LJ. A qualitative study of clinic and community member perspectives on intervention toolkits: “Unless the toolkit is used it won’t help solve the problem.” BMC Health Serv Res. 2017 Jul 18;17(1):497. Hildenbrand GM, Perrault EK, Rnoh RH. Patients’ Perceptions of Health Care Providers’ Dismissive Communication. Health Promotion Practice. 2022 Sep 1;23(5):777–84. Naughton CA. Patient-Centered Communication. Pharmacy. 2018 Feb 13;6(1):18. Irving G, Neves AL, Dambha-Miller H, Oishi A, Tagashira H, Verho A, Holden J. International variations in primary care physician consultation time: a systematic review of 67 countries. BMJ Open. 2017; 7: e017902. Nuffield Trust. Poorest get worse quality of NHS care in England, new research finds. [Internet]. 2020 [cited 2024 Aug 22]. Available from: https://www.nuffieldtrust.org.uk/news-item/poorest-get-worse-quality-of-nhs-care-in-england-new-research-finds Taylor D, Postlewaite D, Desai S, James EA, Calhoun AW, Sheehan K, Weitz TA. Multiple Determinants of the Abortion Care Experience: From the Patient’s Perspective. American Journal of Medical Quality. 2013;28(6):510-518. Srivastava A, Avan BI, Rajbangshi P, Bhattacharyya, S. Determinants of women’s satisfaction with maternal health care: a review of literature from developing countries. BMC Pregnancy & Childbirth. 2015;15:97. Table 1 Table 1. Themes, codes, and code frequencies. See Supplementary Table A2 for the codebook with code descriptions. Theme Code Count % Empathetic care provision Taking symptoms seriously 75 25.08 Supportive care 65 21.74 Active listening 53 17.73 Proactive approach 23 7.69 HCP(s) accountability 2 0.67 Reduce feelings of burdensomeness 1 0.33 HCP(s) education, understanding, & research Improved HCP(s) knowledge and education 61 20.40 Recognition of impacts on functioning 15 5.02 Recognition of menstrual cycle role 13 4.35 Research need and awareness 8 2.68 Experienced HCP(s) 7 2.34 Improved education on hormone medications 7 2.34 Perceived focus on weight 2 0.67 Recognition of impacts on neurodevelopmental conditions 2 0.67 Communication with specific patient groups 2 0.67 Awareness of complex symptom management 1 0.33 Comprehensive symptom assessment and investigations Comprehensive symptom assessment 28 9.36 HCP(s) offers tests/investigations 20 6.69 Utilisation of care record/medical history 9 3.01 Improved speed of understanding 4 1.34 Structured screening 2 0.67 Asking about suicidality/self-harm 2 0.67 Tracking 2 0.67 Discuss test results 2 0.67 HCP(s) focus on physical 2 0.67 HCP(s) identify changes in symptoms and behaviour over time 1 0.33 Diagnosis Provisional/official diagnosis 10 3.34 Symptom misattribution/misdiagnosis 5 1.67 Support before diagnosis 1 0.33 Professional support and treatment provision Wider treatment offering from HCP(s) 42 14.05 Providing treatment review 19 6.35 Perceived inappropriate prescribing 8 2.68 Negative impacts of medication 8 2.68 HCP(s) providing treatment 6 2.01 "one size fits all" 4 1.34 Improved speed of treatment initiation 3 1.00 Treatment uncertainty 2 0.67 Ensure medication continuity 1 0.33 Securing time off work 1 0.33 Signposting or referral to additional resources or sources of help HCP(s) providing additional information 48 16.05 HCP(s) providing advice 35 11.71 HCP(s) providing an onward referral 31 10.37 HCP(s) signposting to sources of support 15 5.02 Info on symptom frequency 2 0.67 Patient packs 1 0.33 Wider healthcare system improvements Decreased wait time 9 3.01 Appointment time 8 2.68 Improve HCP(s) access 6 2.01 HCP(s) continuity 3 1.00 Specific treatment pathways 2 0.67 Self-referral to specialist care 1 0.33 Transparent referral decision making 1 0.33 Patient role/voice and preferences Preference for face to face appointments 8 2.68 Encouraging shared care decision making 6 2.01 Respect treatment decisions 5 1.67 Preference for female HCP(s) 4 1.34 Consider patient gathered information 3 1.00 Safety plan 1 0.33 Ability to provide information prior to appointment 1 0.33 Additional Declarations Competing interest reported. S.B. is co-founder of and holds shares in Psyomics Ltd but declares no non-financial competing interests. E.L.F. is a paid consultant for Psyomics Ltd but declares no non-financial competing interests. N.A.M-K. declares no financial or non-financial competing interests. Supplementary Files Additionalfile.docx Cite Share Download PDF Status: Published Journal Publication published 14 Jan, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 28 Aug, 2024 Editor assigned by journal 26 Aug, 2024 Submission checks completed at journal 26 Aug, 2024 First submitted to journal 23 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4965274","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":346145921,"identity":"6e28456e-fcf3-4d10-a8ba-cddbb1e8bd0f","order_by":0,"name":"E. L. 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Key. A) Overall perceived care quality, B) Perceived seriousness of symptom consideration, C) Perceived HCP knowledge about premenstrual symptoms and disorders, D) Whether alternative recommendations or referrals of non-formal sources of help were provided by HCP, E) Whether recommendations of lifestyle changes were provided by HCP\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4965274/v1/19237f187cee4a4ca57b6b37.png"},{"id":66840929,"identity":"733638cf-6608-4116-8e82-a7f887963976","added_by":"auto","created_at":"2024-10-17 05:05:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":136108,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eCharacteristics of PMDD diagnosis. Key. A) Proportion of individuals who have received a formal PMDD diagnosis among those who have sought formal help specifically for premenstrual symptoms (n=339), B) Time to receive a PMDD diagnosis (n=51), C) HCP who gave PMDD diagnosis (n=51), D) Initiation for premenstrual symptom monitoring (n=57)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4965274/v1/36e0b61f0ab0242eb8ba0542.png"},{"id":74285750,"identity":"7327d5a8-3d2c-4c64-889e-7ccf8171f6ff","added_by":"auto","created_at":"2025-01-20 16:14:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1480485,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4965274/v1/e9be1fd0-ade8-45a6-bc19-c8a461952a88.pdf"},{"id":66840927,"identity":"b4384202-4642-4092-94c8-d61a7795ae11","added_by":"auto","created_at":"2024-10-17 05:05:04","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":25460,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile.docx","url":"https://assets-eu.researchsquare.com/files/rs-4965274/v1/b28850d8d0da165a59470334.docx"}],"financialInterests":"Competing interest reported. S.B. is co-founder of and holds shares in Psyomics Ltd but declares no non-financial competing interests. E.L.F. is a paid consultant for Psyomics Ltd but declares no non-financial competing interests. N.A.M-K. declares no financial or non-financial competing interests.","formattedTitle":"Improving care experiences for premenstrual symptoms and disorders in the United Kingdom (UK): A mixed-methods approach","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePremenstrual symptoms are exceedingly common in women and other people assigned female at birth [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These encompass physical, psychological, and behavioural symptoms occurring in the luteal phase of the menstrual cycle. Premenstrual disorders such as premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are characterized by more severe symptoms and an accompanying impact on functioning. Such disorders are frequent, with PMS estimated to impact 50% of this population [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and estimates of PMDD ranging from 3 to 8% [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], although these estimates may be inflated due to provisional diagnoses, with pooled point prevalence in community samples found to be 1.6% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite the cyclical nature of the symptoms, they have wide-ranging impacts, including but not limited to, decreased productivity [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and increased suicidality risk [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFirst-line treatment for premenstrual symptoms and disorders are lifestyle changes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], with further treatments including psychological and pharmacological therapies [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] accessed through contact with healthcare services [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Unfortunately, dismissive healthcare professional (HCP) attitudes are extremely commonplace in women\u0026rsquo;s health [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Such dismissiveness necessitates long-term self-advocacy, as well as a reduced ability to engage in shared decision-making regarding treatment [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. For premenstrual disorders, individuals report feeling as though they had to prove the severity of their symptoms to a clinician in order to be taken seriously [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Unfortunately, this dismissiveness of premenstrual symptoms can result in delays to diagnosis of PMDD [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], with additional risks of misdiagnosis [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Delays to diagnosis have wide-ranging impacts on the individual [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] and can result in the development of secondary mental health symptoms [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevious work has investigated experiences of healthcare for PMDD in the United Kingdom (UK) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] and the United States (US) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], but to our knowledge, no recent research has investigated care experiences more generally for premenstrual symptoms. Additionally, given the risks associated with poor care experiences for premenstrual symptoms and disorders, it is important to determine how care can be improved.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe aims of the current study were two-fold. Firstly, to examine healthcare experiences of individuals in the UK who have specifically sought formal help for premenstrual symptoms. Secondly, to explore how healthcare experiences could be improved from the perspective of previous help-seekers.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eParticipants were recruited using free posts on Facebook and Twitter and paid advertisements on Facebook and Instagram between January 2024 and February 2024. Inclusion criteria were: (1) 18 years or older, (2) having a strong comprehension of the English language, (3) be assigned female at birth, (4) currently experiencing premenstrual symptoms, (5) not currently pregnant, in the perimenopause, or post-menopausal, and (6) not diagnosed with any gynecological conditions (e.g., endometriosis, polycystic ovary syndrome).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMaterials and procedures\u003c/h2\u003e \u003cp\u003eAn online survey was generated and delivered using the survey software Qualtrics XM\u0026reg;. The survey took 10\u0026ndash;20 minutes to complete, and was adaptive in nature so only relevant questions were displayed based on previous answers. The survey was designed in consultation with an experienced consultant psychiatrist (SB).\u003c/p\u003e \u003cp\u003eAll participants were asked about sociodemographic characteristics. Participants were asked about their formal care experiences including the type of HCPs they saw and the overall perceived quality of care they had received. Participants were also asked the open text question: \u0026ldquo;In your opinion, what could have improved your care experience?\u0026rdquo;. Participants were asked if they have received a formal diagnosis of PMDD. If yes, these participants were asked about their experience of receiving this diagnosis.\u003c/p\u003e \u003c/div\u003e\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the University of Cambridge Psychology Research Ethics Committee (approval number PRE.2023.117). All participants provided informed consent digitally before starting the survey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive data analyses (i.e., means and standard deviations, frequencies and percentages) were analyzed and processed in Excel, version 2206 (Microsoft Office 365). Figures were created using Excel version 2206 and PowerPoint version 2206 (Microsoft Office 365).\u003c/p\u003e\n\u003cp\u003eGroup differences in care interaction characteristics between those who rated their formal care as \u0026ldquo;Good\u0026rdquo; or \u0026ldquo;Very good\u0026rdquo; and those who rated their formal care as \u0026ldquo;Poor\u0026rdquo; or \u0026ldquo;Very poor\u0026rdquo; were explored, with responses endorsed as \u0026ldquo;Not sure\u0026rdquo; excluded from group analyses. Group differences in ordinal data were explored using Mann-Whitney U tests. Group differences in categorical variables were explored using chi-square tests, and effect sizes were calculated as Cramer\u0026rsquo;s V (\u0026phi;c; small\u0026thinsp;\u0026le;\u0026thinsp;0.10, medium\u0026thinsp;\u0026le;\u0026thinsp;0.30, large\u0026thinsp;\u0026le;\u0026thinsp;0.50; [16]). Tests for group differences were conducted in SPSS (version 29.0.1.1).\u003c/p\u003e\n\u003cp\u003eOpen text data was analyzed using thematic analysis against the Braun and Clarke framework [17]. One author read and re-read the open text data to establish data familiarization before writing a codebook (EF). This codebook was reviewed by a second author (NMK) to ensure all relevant codes were included and any necessary amendments were made. Open text data was coded against the code book under blinded conditions by two authors (EF and NMK). Following this, the data was unblinded and coding allocation was compared, with any discrepancies being discussed until agreement was reached. After coding was agreed, the codes were grouped into themes by two authors (EF and NMK) under blinded conditions. Again, following unblinding, themes were compared with any discrepancies being discussed until a final theme list was agreed. Any free text data which included \u0026ldquo;No\u0026rdquo; (or synonyms), \u0026ldquo;Not applicable\u0026rdquo; (or synonyms), or responses that were considered ambiguous or non-specific by both authors (e.g., \u0026ldquo;More options\u0026rdquo;) were labelled as not applicable and excluded from thematic analysis.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eParticipants who had completed at least 97% of the survey, endorsed premenstrual symptoms in consecutive menstrual cycles, and had sought help from a HCP specifically for premenstrual symptoms (N=339) were included in the analyses.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSociodemographic data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean age of the sample was 34.66 (SD=5.88). The majority of the sample identified as women (n=332, 97.94%) and were white/Caucasian (n=311, 91.74%). The majority held at least an undergraduate degree (n=276, 81.42%) and were in paid employment (n=285, 84.07%). See Supplementary Table A1 (Supplementary information) for full summary of the sociodemographic characteristics.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealthcare experiences\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe majority of those who had sought formal help had done so from a primary care provider (e.g., general practitioner, primary care physician, family physician, family doctor; 95.87%, n=325), with 65.49% (n=222) having only seen one HCP.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOf those who had sought help from a HCP, 75.22% (n=255; Figure 1a) felt that the overall quality of their care was poor. 44.25% (n=150; Figure 1b) felt their symptoms were not taken seriously, and many perceived a lack of HCP knowledge regarding premenstrual disorders (37.76%, n=128; figure 1c). The majority did not receive referrals to or recommendations for additional non-formal sources of help (i.e., websites, support groups; 84.96%, n=288; figure 1d). The majority did not receive any recommendation of lifestyle changes which could be made to help manage premenstrual symptoms by a HCP (74.63%, n=253; Figure Xe).\u003c/p\u003e\n\u003cp\u003eWhen comparing perceived care quality, the group that rated their overall care experience as \u0026quot;Good\u0026quot; or \u0026ldquo;Very good\u0026rdquo; felt that healthcare providers took their symptoms more seriously on a 4-point scale from \u0026ldquo;Not at all seriously\u0026rdquo; to \u0026ldquo;Very seriously\u0026rdquo; (mean=3.06, SD=0.77; U=1383.00, p\u0026lt;.001) compared to the \u0026nbsp; group who rated their overall care as \u0026ldquo;Poor\u0026rdquo; or \u0026ldquo;Very poor\u0026rdquo; (mean=1.44, SD=0.56).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdditionally, the group who rated their care \u0026ldquo;Good\u0026rdquo; or \u0026ldquo;Very good\u0026rdquo; also perceived the HCP to be more knowledgeable about premenstrual symptoms or disorders on a 4-point scale from \u0026ldquo;Not at all\u0026rdquo; to \u0026ldquo;Very\u0026rdquo; (mean=3.23, SD=0.69; U=1370.50, p\u0026lt;.001) compared to those with poorer care experiences (mean=1.60, SD=0.72).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMoreover, individuals who rated their care as \u0026ldquo;Good\u0026rdquo; or \u0026ldquo;Very good\u0026rdquo; more often reported that they had received recommendations for or referrals to additional sources of help by a HCP (35.44%, n=28; X\u003csup\u003e2\u003c/sup\u003e=48.251, df=1, p\u0026lt;.001, \u0026Phi;c=.382) compared to those who reported poorer care experiences (5.58%, n=14).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, those who reported a \u0026ldquo;Good\u0026rdquo; or \u0026ldquo;Very good\u0026rdquo; care experience had more often been provided with recommendation for lifestyle changes to manage premenstrual symptoms by their HCP (36.90%, n=31; X\u003csup\u003e2\u003c/sup\u003e=7.849, df=1, p=.005, \u0026Phi;c=.152) compared to those with a poorer care experience (21.57%, n=55).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnosis of PMDD\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf those who had seen a HCP specifically for premenstrual symptoms, 15.04% (n=51) reported that they have received a formal diagnosis of PMDD (Figure 2a). Of these, the majority waited at least 12 months for a diagnosis (41.18%, n=21; Figure 2b). The majority received a formal diagnosis of PMDD from a primary care provider (56.86%, n=29; Figure 2c). 16.81% (n=57) of those who sought formal help specifically for premenstrual symptoms reported currently monitoring their symptoms to assess whether they may have PMDD, with only 33.33% (n=7) doing this following the advice of a HCP, with the remaining deciding to do this themselves (Figure 2d).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThematic analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e315 (92.92%) participants provided a response to the free text question regarding what could have improved their care experience. Of these, 16 (5.08%) were deemed not applicable and so removed for analysis and the remaining data (n=299, 88.20% of entire sample) was included for thematic analysis. Of these 299, 20.74% (n=62) characterized their care for premenstrual symptoms as \u0026ldquo;Good\u0026rdquo; or \u0026ldquo;Very good\u0026rdquo;, with the remaining 79.26% (n=237) of participants characterizing their care for premenstrual symptoms as \u0026ldquo;Poor\u0026rdquo; or \u0026ldquo;Very poor\u0026rdquo;. Thematic analysis revealed a total of 59 codes which were organized into 8 themes (table 1).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 1. Themes, codes, and code frequencies. See Supplementary Table A2 for the codebook with code descriptions.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cstrong\u003eEmpathetic care provision\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEmpathetic care provision was identified as a theme, with participants stating the importance of HCPs taking premenstrual symptoms seriously:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;They could have at least made me feel as though they took me and my symptoms serious\u0026rdquo;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;A health care professional that took my concerns seriously and didn\u0026apos;t outright dismiss them\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eFurther it was identified that receiving supportive care was important, with many participants seemingly perceiving supportive care as being compassionate:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Being more compassionate, more understanding\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eFurther, emphatic care provision requires the HCP to engage in active listening (i.e., to be perceived by the patient as listening and paying attention to them and what they are saying):\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Please listen to women! We don\u0026rsquo;t come to the GP for fun. We are usually embarrassed and desperate by the time we seek help so please don\u0026rsquo;t fob us off\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Being sincerely listened to\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eActive listening was often associated with a proactive approach, where the HCP is perceived as being proactive in their care:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;\u0026hellip;wanting to find a way to help/solution/cause\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Some curiosity.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eThis may include offering suggestions of other sources of support without the patient needing to ask:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;For advice and guidance related specifically to the menstrual cycle - no medical professional has ever spoken to me about this without me specifically bringing it up\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eProactively offering symptom investigations:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;GP could have taken more interest in finding out why I was having issues\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eOr taking the time to do research and expand their knowledge if they were unfamiliar with premenstrual symptoms or disorders:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If he had said he didn\u0026rsquo;t know much about it but would look into it for me and come back to me with what he\u0026rsquo;d found so he could help me\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If the GP had said, I will look into PMDD and then we can make a follow up appointment to discuss options.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eHCP accountability was also raised as a facet of empathetic care, with requests that HCPs provide an explanation of why they are unable to provide certain aspects care such as assessment, diagnosis, or treatment/management:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;A better explanation of why they couldn\u0026apos;t help with the issues\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u0026hellip;at least explaining why an assessment or diagnosis wasn\u0026apos;t an option [that was offered]\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eOne participant also reported feeling like they were a burden in previous care interactions:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;I just felt like a nuisance\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eParticipants also raised concerns about the potential risks associated with empathetic care not being delivered, particularly if help-seeking occurs in the luteal phase:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If they had spoken to me as disrespectfully and dismissively on that week when I was extremely vulnerable, I dread to think the outcome.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHCP(s) education, understanding, \u0026amp; research\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMany participants mentioned the importance of improved HCP knowledge of premenstrual symptoms and disorders, including potential symptoms and their treatment/management:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If my GP had had knowledge of PMDD in any form this would have helped.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eIncluding awareness of how to manage complex premenstrual symptoms:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;being willing to [\u0026hellip;] work with more complex cases that don\u0026apos;t necessarily fit the flowchart.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eSome participants stated the importance of including training about female health, hormones, and premenstrual symptoms and disorders in HCPs\u0026rsquo; curriculum, with this training seemingly perceived as particular important for GPs:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Female health and hormones should be part of GPs training\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;GP education about hormones and PMDD, so they believed me.\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Do GPs even know anything about women\u0026rsquo;s health or is the curriculum the same as in the times were clitoridectomy was used to treat mental illness in women? Educating the professionals would maybe have improved my care experience\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eImproved HCP knowledge likely includes improved recognition of the potential impacts of premenstrual symptoms and disorders on functioning:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;\u0026hellip;recognising the impact it has on my life which has been practically ruined.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Some understanding of the impact that PMS can have, the danger of regularly feeling suicidal and the strength of symptoms.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eAnd in general, improved recognition of the role of the menstrual cycle in mood and mental health:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Assumptions were made by a male doctor who put it down to depression. He had no intention of listening to the fact that just before my period I had thoughts of suicide but it was instantly relieved once my period has started.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Them acknowledging the possibility of period related issues\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eMoreover, participants expressed the importance of HCPs recognising the association of the menstrual cycle, and premenstrual symptoms and disorders, on neurodevelopmental conditions such as autism spectrum disorders and attention deficit hyperactivity disorder (ADHD)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u0026hellip;more knowledge and education on PMDD and how it affects people especially those who are neurodivergent like myself as [it] affects every aspect of our being and destroys our lives.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eAssociated to this, one participant mentioned the importance of HCP awareness and communication with specific patient groups, such as patients with neurodevelopmental conditions or LGBTQ+ patients:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Better disability and LGBT awareness among staff.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eSome participants expressed the need of seeing an experienced HCP or someone who specializes in premenstrual symptoms or disorders:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Having talked with a professional who is expert on PMS\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;It was like they\u0026rsquo;d [HCPs] had no previous experience with the condition\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eFinally, there was a sentiment that there was a need for further research into premenstrual symptoms and disorders, including improved understanding of the causes and presentation:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;More research and understanding about PMS - what range of symptoms are commonly experienced and for how long, what is considered usual, do hormone levels play a role and can we consider testing levels at different times if the cycle to see if there is any dysregulation that is causing extreme PMS?\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eAs well as more evidence for the efficacy of available treatment/management options, in addition to the discovery of novel treatment/management options:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;More research into what causes these issues and an effective treatment that deals with the acute problem rather than blanket long term medications for symptoms.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eParticipants also remarked that it is important that HCPs are aware of recent research to inform high-quality care practices:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Further knowledge and understanding of up to date research into appropriate care for PMDD\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Being able to speak to a practitioner with specialist knowledge and interest in PMS and PMDD, who was more up to date with the latest knowledge and treatments.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComprehensive symptom assessment and investigations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants raised the importance of comprehensive symptom assessment, which\u0026nbsp;asks about a wide-range of possible premenstrual symptoms:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;\u0026hellip;a holistic assessment of my symptoms\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Discussing my symptoms in greater detail\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Asking more questions rather than writing it all off as \u0026lsquo;normal\u0026rsquo;.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;More holistic take/lifestyle questions\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eSome patients commented that comprehensive symptom assessment may be achieved by employing a structured screening tool to ensure all premenstrual symptoms are covered:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Maybe going through a questionnaire to guide questions about relevant symptoms\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;There needs to be a new checklist for females with symptoms mental and physical with regards to periods.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eThis would also ensure high-risk symptoms and behaviors such as suicidality and self-harm are assessed, with many participants reporting that their HCP(s) had not specifically asked about suicidality and self-harm:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Asking the right questions so patient doesn\u0026apos;t have to be the one to bridge topic of [suicidal ideation/self-harm] - it\u0026apos;s understood that that can be a part of it\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eThis is especially crucial as some patients may not feel able to disclose this information without prompting from a HCP:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I was too scared when my children were younger to admit that I felt suicidal every month.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eComprehensive symptom assessment, potentially with a structured screening tool, may also minimise the perception that HCPs are solely or primarily focused on physical symptoms, and overlooking psychological symptoms:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Male doctor said [he] was only interested in the dizziness and hot flashes\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;More exploration of PMS symptoms rather than the bleeding itself\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eAs part of a comprehensive symptom assessment, some participants expressed wanting to have tests/investigations such as blood tests or scans performed to rule out any underlying causes and identify potential hormonal imbalances:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If she has taken me seriously, done further tests, or even pretended to care.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I would also have liked more conversations about ruling out other issues and investigating comorbidities like ADHD\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u0026hellip;maybe a suggestion of a blood test to make sure hormonally everything is ok.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eHowever, many participants also noted that a crucial aspect of offering tests/investigations is ensuring there is an opportunity to discuss results from these tests/investigations with a HCP:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Follow up on test results, even though in normal range and discussion about what to consider next outside of basic tests\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eSome participants also suggested that the care record or patients\u0026rsquo; medical history could be a useful supplement to appointments to contribute to a comprehensive assessment by streamlining and guiding the appointment:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If GPs who had looked through my history prior to calling and understood my situation had been more thoughtful and treated me with the respect I needed at the time.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eAnd to reduce or remove the need for repeated information gathering:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u0026hellip;glancing through my history while we spoke so I wasn\u0026apos;t going over the same points again and again each time\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Checking my medical records prior to or in my appointment, which would have shown a PMDD diagnosis, that I was in private talking therapy and that I was taking sertraline at a consistent dose. I had to tell the GP all of this so her suggestions weren\u0026apos;t helpful or understanding.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eAs well as facilitating follow-up and monitoring over time, and between HCP(s):\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u0026hellip;compare notes over my years \u0026amp; diff NHS [departments]\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eWith HCP monitoring premenstrual symptoms and associated behaviors over time, in the context of the patient, to identify deterioration being deemed as important:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The previous GP could have looked into my symptoms better since it was a severe and unusual behavioural change, I started gaining weight very quickly and my overall appearance had rapidly declined. The mental health team should have noticed that I was a good student that hardly ever missed school and had severe increased anxiety, suicidal thoughts and depression and noticed that this was not \u0026lsquo;attention seeking behaviour\u0026rsquo;\u0026rdquo;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe importance of HCPs suggesting monitoring over time by engaging in symptom tracking was also noted with the aim of supporting assessment:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;It would have been better if the GP [\u0026hellip;] asked me to continue to register all my symptoms\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;A plan on how we could investigate for PMDD - hormones fluctuate significantly during a cycle so some understanding of this along with the symptoms would have supported me to gather data so to speak\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eSome participants stated that in general there was a need to improve the speed of understanding.\u0026nbsp;With earlier recognition of symptoms or understanding of experience by HCPs:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Better understanding early on and feeling validated that this isn\u0026apos;t typical anxiety\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;It took a long time/a few doctors for anyone to even mention PMDD\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnosis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants expressed wanting to have received a diagnosis of PMDD, even if this was provisional (i.e., whilst tracking symptoms over two cycles) or \u0026ldquo;A formal diagnosis\u0026rdquo;:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;A proper diagnosis instead of just being brushed off with \u0026lsquo;you are a woman that is just normal\u0026rsquo;\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eThere were reports from some participants of previous experiences of premenstrual symptoms being misattributed to a different cause such as early onset menopause:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I think the GP immediately jumped to early menopause as an answer but I really don\u0026rsquo;t feel that\u0026rsquo;s the case\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eOr stress:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u0026hellip;often blamed on stress when women go seek help for it.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eWith other participants reporting their premenstrual symptoms had been attributed to a different condition:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Not being told I was \u0026lsquo;depressed\u0026rsquo; which, for years, was a catch-all for my mental health.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eResulting in potential misdiagnosis:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Readily accepting my experience as truth rather than emotional instability due to an alleged personality disorder.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eOne participant also called for more professional support provision even if a provisional or official diagnosis of PMDD is not given:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Support for the physical and mental health symptoms, even in lieu of a diagnosis\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProfessional support and treatment provision\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe theme of professional support and treatment provision was mainly characterised by participants expressing the need of a wider treatment offering from HCPs, this includes offering alternative or a range of treatment options including hormonal, non-hormonal, and psychological treatments:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Improved variety of suggestions to help treat or manage symptoms.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;I would also like more non medication options for treatment and support.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eThis includes a perception that only hormonal treatment are an option:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u0026hellip;options for treatment (I was told to get the coil and that if I didn\u0026rsquo;t want this nothing could be done)\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Not being palmed off with the standard contraceptive options\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;More options than just a pill would have been better.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eOr antidepressants will be the only treatment offered by a HCPs:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Resources being available for more support options - not just antidepressants.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;[the HCP] didn\u0026apos;t look into any alternative idea, just straight to antidepressants\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eWith no \u0026ldquo;one size fits all\u0026rdquo; and it being important that the HCP(s) recognising the individual and delivering personalized care and treatment management:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;\u0026hellip;not given a one size fits all answer\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u0026hellip;individual treatment. It felt like they just have a one size fits all answer which doesn\u0026apos;t work\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eRelated to this,\u0026nbsp;some participants reported a general sense of uncertainty about available treatment/management options:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Clearer management/treatment options.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I\u0026apos;m not sure what other methods of support there are as the GP didn\u0026apos;t speak about any - does the contraceptive pill help?\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eParticipants reported it would have improved the care interaction if the HCPs had offered treatment or \u0026ldquo;Advice and care plan\u0026rdquo;:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;I wish I had been offered some treatment\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Offering real help, trying treatments, actually trying to solve the problem.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eWith it being important that there is an improved speed of treatment initiation, with treatment being offered at the first instance of help-seeking:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Counselling should be absolutely offered straight away\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;If they had prescribed [the contraceptive pill] straight away\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eThere was a perception from some participants that they had received an inappropriate prescription:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Not been prescribed pain medication that I cannot take, and could have caused me more harm than good if I hadn\u0026apos;t checked the label myself.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I don\u0026rsquo;t think it\u0026rsquo;s appropriate to prescribe SSRIs for PMDD, when said SSRIs also come with unbearable side effects\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eWith many participants having had previous negative experiences with medication available for management of premenstrual symptoms and disorders:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Hormonal treatments are the first and apparently only treatment for anything related to your cycle, I felt pushed towards that as the \u0026lsquo;best\u0026rsquo; option even though I\u0026rsquo;ve had such bad experiences with them in the past.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eWhich in some cases resulted in reduced interest in further treatment seeking behaviour:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The feeling that if I do seek help it could be resolved without going back into contraceptives as they ruin my skin and give me vaginal dryness, lack of overall sex drive.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;But realistically other than medication to mask the symptoms of PMDD at the expense of worse side effects, there is nothing they can do for me.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eOr reported treatment non-adherence:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I stopped taking [the contraceptive pill] because it was giving me so many side effects.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eThis also highlights the importance of HCPs providing a treatment follow-up to ensure treatment efficacy and optimization, as well as monitoring negative side-effects:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;When put on the pill (especially after I told them it causes me to have low moods), a follow up of how I was finding it after 3 months.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;A follow up appointment booked in at the time of starting a month of treatment to be able to check in with the doctor\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Would have been good to have some follow up, as none since the initial appointment with GP.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eAnd ensuring medication continuity to minimise the risk of deterioration whilst not receiving therapeutic intervention:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;My GP [\u0026hellip;] hasn\u0026apos;t always understood the importance of me always having access to the pill (despite it being written on my record it\u0026apos;s for PMDD) - I can\u0026apos;t just wait like everyone else or the symptoms return.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eAside from wanting to access therapeutic interventions, one participant mentioned wanting the HCP(s) to help them secure time off of work:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Discussion of PMDD and how it could allow time off work if necessary.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSignposting or referral to additional resources or sources of help\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants generally requested the provision of additional information from HCPs, either provided directly by the HCPs in an appointment setting:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;It would have been better if the GP explained my symptoms to me and explained what is happening to me\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eOr the HCPs signposting to resources which can be independently accessed outside an appointment setting:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;I was never made aware of any PMDD-specific resources.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;I wasn\u0026apos;t signposted to any support networks or relevant information.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eSome participants specifically mentioned that this information should include information about how common premenstrual symptoms are:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;\u0026hellip;what range of symptoms are commonly experienced\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I would have wanted more understanding of how widespread the symptoms are, how common among women they are, so I didn\u0026rsquo;t feel so alone.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eParticipants also stated that care experiences would be improved if the HCPs provided advice for symptom management:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Some advice on what could help during these two weeks.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eFor managing high-risk psychological symptoms:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Giving me practical coping strategies such as \u0026apos;try sitting in A and E\u0026apos; (or better ones!) rather than leaving me to flounder alone at potential risk of suicide.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eThis would be particularly welcomed if advice was offered without prompting from the patient:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;For advice and guidance related specifically to the menstrual cycle - no medical professional has ever spoken to me about this without me specifically bringing it up.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eMany participants also mentioned wanting the HCPs to provide an onward referral to specialist care:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;\u0026hellip;to refer people to ACTUAL get help to treat their problems\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Let me see a gynecologist, someone specialized.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eParticipants mentioned that HCPs signposting to other sources of support would improve the care experience:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;it might have been useful to be directed to other sources of support.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;\u0026hellip;being signposted to charities or other specialized professionals\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eA participant also suggested that comprehensive patient information packs could be provided by the HCP which provide information, recommendations to other sources, and self-help advice:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Patient care packs - daily diary , helpline numbers and self-help book\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWider healthcare system improvements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSome participants commented on factors which would improve the care experience which are relevant to wider healthcare system improvements. One such improvement is decreasing wait times, this included both reducing the speed of an onward referral:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Referral could be quicker\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u0026hellip;it was the referral to the psychiatrist and gynecologist when things slowed down/stopped\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eAnd the time between appointments decreasing:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Improved waiting times between appointments.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eRelated to this, it was mentioned by participants that it was important for access to HCPs to be improved:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Being easily able to access GP (or other appropriate primary care) for a \u0026apos;non urgent\u0026apos; matter.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;It was near-impossible to get a doctor\u0026apos;s appointment at my surgery, so more availability of appointments would have helped.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eWith it being crucial that there was continuity between HCPs seen between appointments, with a HCP acting as a single point-of-contact during the diagnostic and treatment process:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;\u0026hellip;to have the same female GP as a point of contact.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Continuity of care - after I was referred for blood tests and they came back clear, there was no follow-up\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eParticipants also noted it would be beneficial if appointment times were longer:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;When I began to list the different symptoms I was told I\u0026apos;d need to book separate appointments to discuss them\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;More time for appointments to really go through information. They often seem rushed.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eParticipants also commented on the referral process, with a suggestion of specific referral pathways designed for premenstrual symptoms/disorders:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;A clear referral pathway to get a diagnosis\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eWhich may facilitate a self-referral option:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Ability to self-refer to [obstetrics-gynecology]/consultant services.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eIt was also deemed important that referral decisions were transparent, particularly as to why a referral to a specialist service may be rejected:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The [gynecology] department taking the initial referral [\u0026hellip;] instead of pinging it back to my GP with no real reasoning as to why.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient role/voice and preferences\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient preferences was mainly characterized by preferences for face to face appointments with HCP:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;More dialogue, face to face appointment\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eAnd a preference for seeing a female HCP:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Seeing a female consultant\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026ldquo;Maybe having a female practitioner to speak to instead of a male\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eIn terms of patient role/voice, participants expressed interest in engaging in their healthcare experiences. Participants highlighted the importance of the HCPs encouraging shared decision making with the patient, particularly in regards to treatment:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Not been defensive when I questioned whether antidepressants were the best option.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;A dialogue about treatment options.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eWith it being crucial for the HCPs to respect the patient\u0026rsquo;s treatment decision:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;More patience from the doctor, and respect for my choice not to want to get on the pill.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Listened to my concerns about using anti-depressants and worked with me to discuss alternative solutions.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eParticipants also stated that they could also be involved in the healthcare interaction if the HCPs consider information gathered by the patient from informal sources (e.g., from online resources):\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Sometimes I feel like having done some research is off putting to general practitioners and I have to play stupid in order to be advised. If I come in with some theory as to what may be the problem, I often get a bad look or the tone of the conversation completely changes (for the worse).\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Also not rolling their eyes when I\u0026rsquo;ve said I\u0026rsquo;ve looked on the internet when I\u0026rsquo;ve done that as I\u0026rsquo;ve felt unheard by the very people who should be listening\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eAdditionally, a participants mentioned they thought it would be beneficial to provide information prior to an appointment to help prepare for the appointment and ensure the assessment is comprehensive:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Before when I had my first appointment, I sent in an email with all my symptoms so the Dr could read before I went in. That helped because I felt he guided the conversation and I kind of knew what we would discuss.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eFinally, participants stated they wished to co-design a safety plan between themselves and the HCPs:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Next of kin/ trusted person patient and GP should do a safety plan also what can those do to help and keep patient safe.\u0026rdquo;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe current study aimed to examine care experiences for premenstrual symptoms and disorders in the UK, while also seeking to identify potential strategies for care improvements. The study reflects previous findings [15], also demonstrating broadly poor care experiences. The sample generally perceived that HCPs held dismissive attitudes or acted dismissively. \u0026nbsp;Moreover, there was a widely held perception that HCPs also lacked knowledge of premenstrual symptoms and disorders. The majority of the sample had not received advice on potential lifestyle changes which could be made to manage symptoms, despite this being a first line treatment recommendation [8, 9]. Further, such information would be a highly valuable resource as education on available lifestyle changes can empower individuals to self-manage premenstrual symptoms [18], which could be leveraged for therapeutic benefits either outside of or alongside other therapeutic interventions. Not receiving these recommendations directly from a HCP would likely necessitate individuals to find this information independently. With the majority of the sample also not receiving recommendations of or referrals to other sources of information from a HCP, the necessity of independent searching is further increased, with there being a risk of relying on poor quality information [19].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere was also an apparent delay to diagnosis of PMDD in the current sample, with the majority of those with a PMDD diagnosis reporting a wait of over a year. Delays to diagnosis of PMDD are common, with individuals often having to consult multiple HCPs with no continuity of HCPs [12] as also reported by participants in the current study. Delays to diagnosis of premenstrual disorders are associated with considerable challenges for the individual. Notably, previous qualitative research has revealed the high levels of emotional distress, reliance on maladaptive coping mechanisms, and unstable self-image experienced while awaiting a formal diagnosis of PMDD [15]. In contrast receiving a diagnosis results in a considerable sense of relief for the individual, providing an explanation for their symptoms [12]. Therefore, reducing delays to diagnosis is crucial to improve quality of life and reduce suffering. Interestingly however, the receipt of a provisional or official diagnosis was not frequently mentioned in the qualitative data as important for improving healthcare experiences. Instead, the qualitative data suggests that comprehensive symptom assessment is more frequently considered important for high-quality care experiences. In the current study GPs provided the majority of diagnoses of PMDD and so their ability to accurately identify symptoms when first consulted is critical. One approach to achieve this is through training for HCPs specifically on premenstrual symptoms and disorders, with a focus on symptom recognition. Another avenue for improved symptom identification is using a validated screening tool when patients present with a complaint of premenstrual symptoms, with qualitative data also demonstrating interest in such a tool from a patient perspective. Whilst prospective tracking of symptoms across two menstrual cycles is required to confirm a formal diagnosis of PMDD, screening would provide a provisional diagnosis [20] and identify individuals who require further assessment [21]. Comprehensive mental health screening could also be used to rule out other conditions with an overlapping symptom profile such as major depressive disorder [22], and to initially establish whether symptoms exclusively occur in the luteal phase. Perhaps crucially, use of a validated and standardized tool for the assessment of premenstrual symptoms in a clinical setting would also ensure that the HCP as standard practice asks about high-risk psychological symptoms which some participants reported difficulty in disclosing. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWhilst these findings paint a disappointing picture of the current care provision for premenstrual symptoms in the UK, they should not be interpreted as criticism of HCPs working in the UK who are involved in the management of such symptoms. Instead, we intend them to be used as a call to action, highlighting the need to make improvements to healthcare experiences for premenstrual symptoms and disorders. As such, the current study also revealed factors which underpin more positive care experiences. Some participants raised suggestions of wider healthcare system improvements which they perceived to be required for better healthcare experiences. Core suggestions included faster referrals, ensuring continuity of care with a single point of contact between appointments, and longer appointment times. Whilst these are likely to be important for delivery of high quality care, they are not easily addressable, especially considering the current strains experienced by the national health service in the UK [23]. However, other findings from the current study may be more feasible to enact for service improvement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFirstly, \u0026nbsp;participants who perceived their HCP as knowledgeable reported more positive care experiences, with qualitative data also indicating that consultation with a knowledgeable clinician would confer a better experience. In the current study, primary care providers were the most frequently, and in many cases the only HCP consulted and so are likely the sole source of formal management of premenstrual symptoms. Unfortunately, research has shown that globally primary care providers are the medical specialty perceived as the least knowledgeable about PMDD [24]. Going forward, the UK government has pledged to improve the provision of training in women\u0026rsquo;s health for incoming doctors [25]. However, this does not address potential lack in knowledge in currently practicing HCPs. Although specific training courses are available for HCPs, they are not mandatory and therefore uptake is likely limited to those clinicians with a special interest. Therefore, although we encourage currently practicing HCPs to engage with available training for premenstrual symptoms and disorders, an alternative is providing clinicians with \u0026ldquo;toolkits\u0026rdquo;. These toolkits could offer key information for identification and management of premenstrual symptoms and disorders. Toolkits have demonstrated some promise in communicating health information and research evidence in healthcare [26, 27], but further research is required to fully determine the impacts of implementation [26, 27]. Toolkits are perceived as particularly effective by clinicians and other allied health professionals when they are actionable, concise, and have a flexible delivery modality [28]. It is also vital that toolkits have a clear purpose, strong-evidence base, and are subject to evaluation in the setting of interest [27]. Therefore, future research may wish to explore the development of toolkits for premenstrual symptoms and disorders. The primary intended benefit of such tools would be to improve HCP knowledge, with a secondary intended benefit of improving care experiences. In future, if such toolkits for premenstrual symptoms and disorder are integrated into care settings to support HCPs in delivery of care, monitoring uptake and impact will be crucial.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSecondly, attentive attitudes from HCPs were associated with better care experiences. The qualitative data also indicated the importance of supportive care for positive care experiences, with HCP active listening and taking symptoms seriously deemed to be key. This may be addressed by offering training to healthcare professionals to improve patient-centered communication skills [29]. Patient-centered communication uses varied strategies including active listening and use of layperson language in order to build a strong therapeutic relationship, gather and provide relevant information, and facilitate shared decision-making [30]. Taken together, this can improve the overall care experience and outcomes [30]. However, some clinicians report trepidation about utilizing patient-centered communication due to time constraints during consultations [30]. Given that GPs in the UK spend an average of under 10 minutes in consultation with patients [31], this is likely a restriction for comprehensive symptom assessment and creation of personalized care plans. Previous literature has also recommended that dismissive care interactions may be improved by training patients in effective health communication, with a focus on how to effectively ask for a preferred intervention [29], with participants also noting the importance of the HCP enabling opportunities for shared decision making. However, whilst this approach may empower the patient, it again places the burden of communication on them. Instead, a mixture of patient-centered communication and self-advocacy should be used to establish the patient\u0026rsquo;s circumstances, symptoms, needs, and preferences. Doing so will likely result not only in better care experiences, but also improved overall outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurther, \u0026nbsp;as recommendations of additional information sources and lifestyle changes from the HCP were found to confer a better care experience from both quantitative and qualitative data, it is vital that HCPs are empowered to provide these recommendations. Whilst improved training and toolkits can provide an increased knowledge of relevant recommendations, an additional offering may be a database of high-quality websites and support groups. This database would enable personalization of recommendations for additional information or support based on patient-specific factors. In addition to general information and advice, qualitative data revealed the perception that there would be, or previous experience of, a limited treatment offering from HCPs. This highlighted the importance of improved information provision about the full-range of treatments available for premenstrual symptoms and disorders. Such information would likely reduce hesitancy in treatment-seeking by addressing uncertainty around the availability and appropriateness of treatment options, whilst also increasing trust that the patient is able to refuse specific treatments in favor of others. It also further demonstrates the importance of improved HCP education to ensure they are aware of all therapeutic interventions available so they can offer comprehensive treatment options and enable the patient to be involved in the decision-making process. This also underscores the importance of amplifying patient voice and ensuring they are included in a participatory role in their care, which was deemed important for positive care experiences. Further, it was deemed highly important that treatment reviews were offered to monitor the treatment response and safety, as well as optimizing the therapeutic intervention as required.\u0026nbsp;\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThe results of the current study should be contextualized alongside some limitations. Firstly, there would have likely been a recruitment bias. Recruitment materials specified a focus on healthcare experiences for premenstrual symptoms, which may have motivated individuals with particularly positive or negative experiences to participate.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurther, the majority of the sample were white and identified as women. Therefore, the results will not reflect the healthcare experiences of individuals from minority or other demographic groups who are likely to already experience poorer care [32] or be more easily dismissed by HCPs [29].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, there are likely to be other determinants of positive healthcare experiences for premenstrual symptoms and disorders which were not considered in the current study. Previous research investigating factors influencing perceived quality of care identified a range of structural, interpersonal, and patient-level determinants [33, 34]. Therefore, whilst the current study reveals some factors, future research is required to identify further determinants of high-quality care.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTo conclude, poor care experiences for premenstrual symptoms are pervasive in the UK characterized by dismissive attitudes and perceived lack of HCP knowledge of premenstrual symptoms and disorders. Thematic analysis revealed eight themes to improve healthcare experiences for premenstrual disorders: Empathetic care provision; HCP education, understanding, \u0026amp; research; Comprehensive symptom assessment and investigations; Diagnosis; Professional support and treatment provision; Signposting or referral to additional resources or sources of help; Wider healthcare system improvements; and, Patient role/voice and preferences. Improving the provision of training for HCP in the UK is required to deliver higher quality care for premenstrual symptoms and disorders. However, given the current constraints on the healthcare system in the UK, providing HCPs with easy to access, high-quality toolkits may deliver benefits in a faster timeframe. In tandem, the utilization of standardized screening tools for premenstrual symptoms and disorders in healthcare settings may be beneficial for delivering comprehensive assessments which includes high-risk psychological symptoms. Additionally, we encourage HCPs to engage in patient-centered communication, where feasible, to reduce the burden of self-advocacy on the help-seeking individual and improve the care experience. Further, it is crucial to improve knowledge of therapeutic interventions for both the public and HCPs to reduce barriers to treatment-seeking and enable shared decision making.\u0026nbsp;\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the University of Cambridge Psychology Research Ethics Committee (approval number PRE.2023.117).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eS.B. is co-founder of and holds shares in Psyomics Ltd but declares no non-financial competing interests. E.L.F. is a paid consultant for Psyomics Ltd but declares no non-financial competing interests. N.A.M-K. declares no financial or non-financial competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Stanley Medical Research Institute (grant number 07R-1888). The funder was not involved in the conceptualization, design, data collection, analysis, decision to publish, or preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eE.L.F., N.A.M-K., and S.B. conceived the study focus and materials. E.L.F. coordinated and conducted participant recruitment. Data analysis was performed by E.L.F. and N.A.M-K. E.L.F. prepared the manuscript with revisions from N.A.M-K. and S.B. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHantsoo L, Rangaswamy S, Voegtline K, Salimgaraev R, Zhaunova L, Payne JL. Premenstrual symptoms across the lifespan in an international sample: data from a mobile application. Arch Womens Ment Health. 2022 Oct 1;25(5):903\u0026ndash;10.\u003c/li\u003e\n\u003cli\u003eDirekvand-Moghadam A, Sayehmiri K, Delpisheh A, Kaikhavandi S. Epidemiology of Premenstrual Syndrome (PMS)-A Systematic Review and Meta-Analysis Study. J Clin Diagn Res. 2014 Feb;8(2):106\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eHalbreich U, Borenstein J, Pearlstein T, Kahn LS. The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD). Psychoneuroendocrinology. 2003 Aug 1;28:1\u0026ndash;23.\u003c/li\u003e\n\u003cli\u003eReilly TJ, Patel S, Unachukwu IC, Knox CL, Wilson CA, Craig MC, et al. The prevalence of premenstrual dysphoric disorder: Systematic review and meta-analysis. Journal of Affective Disorders. 2024 Mar 15;349:534\u0026ndash;40.\u003c/li\u003e\n\u003cli\u003eHardy C, Hunter MS. Premenstrual Symptoms and Work: Exploring Female Staff Experiences and Recommendations for Workplaces. International Journal of Environmental Research and Public Health. 2021 Jan;18(7):3647.\u003c/li\u003e\n\u003cli\u003eOsborn E, Brooks J, O\u0026rsquo;Brien PMS, Wittkowski A. Suicidality in women with Premenstrual Dysphoric Disorder: a systematic literature review. Arch Womens Ment Health. 2021 Apr 1;24(2):173\u0026ndash;84.\u003c/li\u003e\n\u003cli\u003eOpatowski M, Valdimarsd\u0026oacute;ttir UA, Oberg AS, Bertone-Johnson ER, Lu D. Mortality Risk Among Women With Premenstrual Disorders in Sweden. JAMA Network Open. 2024 May 28;7(5):e2413394.\u003c/li\u003e\n\u003cli\u003eNational Institute for Health and Care Excellence (NICE). Scenario: Management of premenstrual syndrome. 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Available from: https://www.gov.uk/government/publications/our-vision-for-the-womens-health-strategy-for-england/our-vision-for-the-womens-health-strategy-for-england#priority-areas \u003c/li\u003e\n\u003cli\u003eOsborn E, Wittkowski A, Brooks J, Briggs PE, O\u0026rsquo;Brien PMS. Women\u0026rsquo;s experiences of receiving a diagnosis of premenstrual dysphoric disorder: a qualitative investigation. BMC Women\u0026rsquo;s Health. 2020 Oct 28;20(1):242.\u003c/li\u003e\n\u003cli\u003eCohen, J. Statistical Power Analysis for the Behavioral Sciences (2\u003csup\u003end\u003c/sup\u003e Edition). New York: Academic Press; 1988. 1\u0026ndash;978.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006 Jan;3(2):77\u0026ndash;101.\u003c/li\u003e\n\u003cli\u003eBastani F, Hashemi S. Effects of a Web Based Lifestyle Education on General Health and Severity of the Symptoms of Premenstrual Syndrome (PMS) among Female Students: A Randomized Controlled Trial. Procedia - Social and Behavioral Sciences. 2012 Jan 1;46:3356\u0026ndash;62.\u003c/li\u003e\n\u003cli\u003eHardy C, Sillence E. What Are Women Being Exposed to? A Review of the Quality, Content and Ownership of Websites on Premenstrual Dysphoric Disorder. Women\u0026rsquo;s Health Issues. 2016 Mar 1;26(2):183\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eAmerican Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5\u003csup\u003eth\u003c/sup\u003e Edition, text revision). American Psychiatric Publishing, Inc. 2022. \u003c/li\u003e\n\u003cli\u003eSteiner M, Macdougall M, Brown E. The premenstrual symptoms screening tool (PSST) for clinicians. Arch Womens Ment Health. 2003 Aug 1;6(3):203\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eFreeman EW, Sondheimer SJ. Premenstrual Dysphoric Disorder: Recognition and Treatment. Prim Care Companion J Clin Psychiatry. 2003;5(1):30\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eThe Health Foundation. Nine major challenges facing health and care in England. [Internet]. 2023 [cited 2024 Aug 22]. Available from: https://www.health.org.uk/publications/long-reads/nine-major-challenges-facing-health-and-care-in-england\u003c/li\u003e\n\u003cli\u003eHantsoo L, Sajid H, Murphy L, Buchert B, Barone J, Raja S, et al. Patient Experiences of Health Care Providers in Premenstrual Dysphoric Disorder: Examining the Role of Provider Specialty. J Womens Health (Larchmt). 2022 Jan 1;31(1):100\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eDepartment of Health and Social Care. First Women\u0026apos;s Health Strategy for England to tackle gender health gap. [Internet]. 2022 [cited 2024 Aug 20]. Available from: https://www.gov.uk/government/news/first-womens-health-strategy-for-england-to-tackle-gender-health-gap \u003c/li\u003e\n\u003cli\u003eBarac R, Stein S, Bruce B, Barwick M. Scoping review of toolkits as a knowledge translation strategy in health. BMC Med Inform Decis Mak. 2014 Dec 24;14(1):121.\u003c/li\u003e\n\u003cli\u003eYamada J, Shorkey A, Barwick M, Widger K, Stevens BJ. The effectiveness of toolkits as knowledge translation strategies for integrating evidence into care: a systematic review. BMJ Open. 2015; 5:e006808.\u003c/li\u003e\n\u003cli\u003eDavis MM, Howk S, Spurlock M, McGinnis PB, Cohen DJ, Fagnan LJ. A qualitative study of clinic and community member perspectives on intervention toolkits: \u0026ldquo;Unless the toolkit is used it won\u0026rsquo;t help solve the problem.\u0026rdquo; BMC Health Serv Res. 2017 Jul 18;17(1):497.\u003c/li\u003e\n\u003cli\u003eHildenbrand GM, Perrault EK, Rnoh RH. Patients\u0026rsquo; Perceptions of Health Care Providers\u0026rsquo; Dismissive Communication. Health Promotion Practice. 2022 Sep 1;23(5):777\u0026ndash;84.\u003c/li\u003e\n\u003cli\u003eNaughton CA. Patient-Centered Communication. Pharmacy. 2018 Feb 13;6(1):18.\u003c/li\u003e\n\u003cli\u003eIrving G, Neves AL, Dambha-Miller H, Oishi A, Tagashira H, Verho A, Holden J. International variations in primary care physician consultation time: a systematic review of 67 countries. BMJ Open. 2017; 7: e017902. \u003c/li\u003e\n\u003cli\u003eNuffield Trust. Poorest get worse quality of NHS care in England, new research finds. [Internet]. 2020 [cited 2024 Aug 22]. Available from: https://www.nuffieldtrust.org.uk/news-item/poorest-get-worse-quality-of-nhs-care-in-england-new-research-finds\u003c/li\u003e\n\u003cli\u003eTaylor D, Postlewaite D, Desai S, James EA, Calhoun AW, Sheehan K, Weitz TA. Multiple Determinants of the Abortion Care Experience: From the Patient\u0026rsquo;s Perspective. American Journal of Medical Quality. 2013;28(6):510-518.\u003c/li\u003e\n\u003cli\u003eSrivastava A, Avan BI, Rajbangshi P, Bhattacharyya, S. Determinants of women\u0026rsquo;s satisfaction with maternal health care: a review of literature from developing countries. BMC Pregnancy \u0026amp; Childbirth. 2015;15:97. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 1","content":"\u003cp\u003e\u003cem\u003eTable 1. Themes, codes, and code frequencies. See Supplementary Table A2 for the codebook with code descriptions.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"598\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCode\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCount\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmpathetic care provision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eTaking symptoms seriously\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e25.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eSupportive care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e21.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eActive listening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e17.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eProactive approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e7.69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eHCP(s) accountability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eReduce feelings of burdensomeness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"10\" valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHCP(s) education, understanding, \u0026amp; research\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eImproved HCP(s) knowledge and education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e20.40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eRecognition of impacts on functioning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e5.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eRecognition of menstrual cycle role\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e4.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eResearch need and awareness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eExperienced HCP(s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eImproved education on hormone medications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003ePerceived focus on weight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eRecognition of impacts on neurodevelopmental conditions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eCommunication with specific patient groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eAwareness of complex symptom management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"10\" valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComprehensive symptom assessment and investigations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eComprehensive symptom assessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e9.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eHCP(s) offers tests/investigations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e6.69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eUtilisation of care record/medical history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eImproved speed of understanding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eStructured screening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eAsking about suicidality/self-harm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eTracking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eDiscuss test results\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eHCP(s) focus on physical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eHCP(s) identify changes in symptoms and behaviour over time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiagnosis\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eProvisional/official diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eSymptom misattribution/misdiagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eSupport before diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"10\" valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProfessional support and treatment provision\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eWider treatment offering from HCP(s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e14.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eProviding treatment review\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e6.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003ePerceived inappropriate prescribing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eNegative impacts of medication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eHCP(s) providing treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003e\u0026quot;one size fits all\u0026quot;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eImproved speed of treatment initiation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eTreatment uncertainty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eEnsure medication continuity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eSecuring time off work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSignposting or referral to additional resources or sources of help\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eHCP(s) providing additional information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e16.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eHCP(s) providing advice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e11.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eHCP(s) providing an onward referral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e10.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eHCP(s) signposting to sources of support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e5.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eInfo on symptom frequency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003ePatient packs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWider healthcare system improvements\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eDecreased wait time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eAppointment time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eImprove HCP(s) access\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eHCP(s) continuity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eSpecific treatment pathways\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eSelf-referral to specialist care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eTransparent referral decision making\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\" valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient role/voice and preferences\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003ePreference for face to face appointments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eEncouraging shared care decision making\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eRespect treatment decisions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003ePreference for female HCP(s)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eConsider patient gathered information\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eSafety plan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 321px;\"\u003e\n \u003cp\u003eAbility to provide information prior to appointment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Premenstrual symptoms, premenstrual disorders, premenstrual dysphoric disorder, Healthcare","lastPublishedDoi":"10.21203/rs.3.rs-4965274/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4965274/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePoor care experiences are reported for premenstrual disorders, which may result in negative outcomes such as distress, reduced healthcare engagement, and delays to diagnosis. Insights from those who have sought care for premenstrual symptoms previously are a valuable resource in identifying characteristics of poor care experiences as well as making recommendations for improvements based on their own experiences.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eAn online survey was delivered, with participants recruited via social media. Data were explored using descriptive statistics and thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe sample included 339 participants who completed at least 97% of the survey, endorsed premenstrual symptoms in consecutive menstrual cycles, and had sought formal help specifically for premenstrual symptoms. The mean age was 34.66 (SD\u0026thinsp;=\u0026thinsp;5.88), with the majority identifying as women (n\u0026thinsp;=\u0026thinsp;332, 97.94%) and white/Caucasian (n\u0026thinsp;=\u0026thinsp;311, 91.74%). 75.22% (n\u0026thinsp;=\u0026thinsp;255) felt that care was poor. 44.25% (n\u0026thinsp;=\u0026thinsp;150) felt their symptoms were not taken seriously. 37.76% perceived a lack of HCP knowledge (n\u0026thinsp;=\u0026thinsp;128). The majority did not receive recommendations of additional non-formal sources of help (i.e., websites, support groups; 84.96%, n\u0026thinsp;=\u0026thinsp;288) or lifestyle changes (74.63%, n\u0026thinsp;=\u0026thinsp;253). Better care experiences were associated with healthcare professionals taking symptoms seriously (U\u0026thinsp;=\u0026thinsp;1383.00, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), higher perceived healthcare professional knowledge (U\u0026thinsp;=\u0026thinsp;1370.50, p\u0026thinsp;\u0026lt;\u0026thinsp;.001), and receiving recommendations of additional non-formal sources of help (X\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;48.251, df\u0026thinsp;=\u0026thinsp;1, p\u0026thinsp;\u0026lt;\u0026thinsp;.001, Φc\u0026thinsp;=\u0026thinsp;.382) or lifestyle changes (X\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;7.849, df\u0026thinsp;=\u0026thinsp;1, p\u0026thinsp;=\u0026thinsp;.005, Φc\u0026thinsp;=\u0026thinsp;.152). Thematic analysis revealed 8 aspects of care improvement: Empathetic care provision; HCP education, understanding, \u0026amp; research; Comprehensive symptom assessment and investigations; Diagnosis; Professional support and treatment provision; Signposting or referral to additional resources or sources of help; Wider healthcare system improvements; and, Patient role/voice and preferences.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePoor care experiences for premenstrual symptoms in the United Kingdom (UK) are characterized by dismissive attitudes and perceived lack of knowledge. Improved training provision for healthcare professionals is required. However, given the healthcare system constraints in the UK, research is needed to explore the feasibility and utility of informational toolkits for healthcare professionals. Utilization of standardized screening tools and patient-centered communication will likely ensure comprehensive assessments and reduce self-advocacy burdens. It is crucial to improve knowledge of therapeutic interventions to reduce barriers to treatment-seeking and enable shared decision-making.\u003c/p\u003e","manuscriptTitle":"Improving care experiences for premenstrual symptoms and disorders in the United Kingdom (UK): A mixed-methods approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-17 05:05:00","doi":"10.21203/rs.3.rs-4965274/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-28T07:40:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-27T00:16:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-27T00:15:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2024-08-23T15:31:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a54fe34c-1bb6-4a61-b734-d478c342a816","owner":[],"postedDate":"October 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-20T16:11:05+00:00","versionOfRecord":{"articleIdentity":"rs-4965274","link":"https://doi.org/10.1186/s12913-024-12140-3","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-01-14 15:57:57","publishedOnDateReadable":"January 14th, 2025"},"versionCreatedAt":"2024-10-17 05:05:00","video":"","vorDoi":"10.1186/s12913-024-12140-3","vorDoiUrl":"https://doi.org/10.1186/s12913-024-12140-3","workflowStages":[]},"version":"v1","identity":"rs-4965274","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4965274","identity":"rs-4965274","version":["v1"]},"buildId":"zQwnuV7TCBrMSSSToR1PI","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}