What is a woman to do who suffers from severe to disabling PMDD/PMS that is significantly affecting her ability to live her life and ALL of the more conservative treatment approaches have failed?
One possible therapeutic option is putting the woman into a postmenopausal, non-ovulating state. In this state, there will be a complete resolution of all of her symptoms related to her PMDD/PMS. Remember, PMDD/PMS, by definition, is a condition that some women experience due to the cyclic hormonal changes that are part of her ovulation cycle. If these cyclic hormonal changes are not occurring, neither will PMDD/PMS. Any symptoms that are still present in the postmenopausal hormonal state are due to another cause and a specific diagnosis with effective treatment can then be enacted.
Putting a woman into a non-cyclic, postmenopausal hormonal state is a treatment option that is not to be taken lightly. All other, more conservative treatments must have been explored and been unsuccessful prior to considering this option. It is truly the “Nuclear Option” in the treatment of PMDD/PMS.
Who should consider this option? In order for a hysterectomy with removal of the ovaries to be an option, a woman should have completed her family. This is NOT A TREATMENT FOR A DESPERATE WOMAN WHOSE PMDD/PMS IS SEEMINGLY FORCING HER TO GIVE UP HER DREAMS. This woman needs to consult a Reproductive Endocrinologist who specializes in PMDD/PMS treatment so that her overall life goals can be achieved.
A permanent, surgical menopause is a consideration only if it has been clearly demonstrated that all the PMDD/PMS symptoms have resolved when the woman is transiently placed in this hormonal state. This can easily be done with the medication, Lupron, a GnRH agonist whose effects are safe and temporary.
The once monthly, intramuscular dose of Lupron should be administered and the woman followed prospectively for a resolution of her PMDD/PMS symptoms when the full, therapeutic action of the medication is in effect. This can be assured by checking a serum FSH and estradiol one month after the first injection.
Once the postmenopausal hormonal effect of the Lupron is assured, the patient can be given supplemental estrogen to fully treat any postmenopausal symptoms, such as hot flashes, that may occur. If no such symptoms occur, or if they are mild and tolerable, then no estrogen needs to be given. If supplemental estrogen therapy is needed after a permanent, surgical menopause is created, this estrogen therapy would be weaned over the course of five years, in accordance with current medical guidelines, so that there is no increased risks of side effects, including cancer.
Only after one has clearly established that the woman’s PMDD/PMS symptoms have resolved in the postmenopausal hormonal state and that any symptoms she may be experiencing due to the postmenopausal hormonal state are acceptably treatable, will one consider creating a permanent, surgical menopause. If her emotional symptoms continue when the postmenopausal hormonal state is achieved, then the woman needs to be referred to or back to a psychiatrist to be evaluated for an underlying emotional/psychiatric disorder. This evaluation and treatment should be conducted while the woman is maintained, by the Reproductive Endocrinologist, in a postmenopausal hormonal state by continuing the Lupron injections. Only after the woman is clearly doing well emotionally should she consider proceeding to a permanent, surgical treatment.
Surgical menopause should consist of removal of the uterus, fallopian tubes and both ovaries. The cervix may either be retained or removed, based on discussions between the woman and her physician.
Why are the ovaries removed? Because they are the source of the cyclic hormone production that is triggering her PMDD/PMS symptoms.
Why is the uterus removed? Because the vast majority of women will feel best if they are maintained on the physiologic levels of natural estrogens that their bodies are used to until they would have gone through a natural menopause. (I stress physiologic levels, as opposed to pharmacologic levels, such as in birth control pills, because physiologic levels are meant to mimic the body’s natural hormone levels; pharmacologic levels are much higher and meant to override the body’s natural functions). If the uterus is present, continuous estrogen stimulation can cause the lining of the uterus, the endometrium, to undergo a series of changes that may eventually lead to cancer in this layer. This effect can be counteracted by the administration of progesterone. However, if progesterone is administered, then one will have artificially created the cyclic hormonal environment that led to the PMDD/PMS originally. With the uterus removed, a woman can receive the estrogen that her body craves without the risk of uterine cancer.
Again, hysterectomy with removal of both fallopian tube and ovaries is an end-stage treatment option and should only be considered when all other options have failed. For this reason, it should only be done under the guidance of a Reproductive Endocrinologist who specializes in PMDD/PMS treatment.