There are times when PMDD symptoms are so severe that they dramatically alter a woman’s ability to lead her life. There are also times when these symptoms will not adequately respond to even maximal medical therapies. These women have been through the spectrum of conservative treatment options and have hit a dead end. Is there any way to “cure” this woman’s PMDD?
The answer to this is a resounding “YES” if her symptoms are truly due to PMDD. A hysterectomy with removal of both ovaries and fallopian tubes will cure her disease. However, this is an aggressive therapy that should only be undertaken in specific situations when specific conditions are met. There is no “going back” once surgery is performed.
When should one consider the option of hysterectomy with removal of the fallopian tubes and ovaries to treat PMDD?
- Symptoms should be severe to disabling, causing major disruption to the woman’s ability to conduct her life.
- All other forms of medical therapy should have been tried and failed to restore reasonable functionality to the woman’s life during the PMDD affected time periods. This presumes appropriate use of maximal doses of each treatment option, sometimes in combination.
- Prior to determining that a hysterectomy with removal of the fallopian tubes and ovaries is a viable option, an adequate trial of a Gonadotropin Releasing Hormone Agonist (GnRHa) such as Depot Lupron has to be conducted. This trial will put the woman into a reversible postmenopausal hormonal state. Once confirmed by laboratory testing that the postmenopausal hormonal state has been achieved, her PMDD symptoms should completely resolve (as there will be no progesterone present in her system to trigger her PMDD). If she continues with any of the PMDD symptoms, then these symptoms are not PMDD. Instead, they are manifestations of an underlying psychiatric condition that requires the evaluation and treatment of a psychiatrist. Surgery as treatment of the “PMDD” would be inappropriate and unhelpful. (Often times, the patient should stay on the GnRHa until she has been diagnosed and treatment started by the psychiatrist so as not to confuse issues).
This GnRHa treatment will both confirm the diagnosis of PMDD and give one the opportunity to determine if the lady will experience significant postmenopausal symptoms. These postmenopausal symptoms may include hot flashes, night sweats, palpitations, insomnia, increased anxiety and mental fogginess. All such symptoms should all be treated prior to definitive surgery to assure that they can be successfully treated. We do not want to exchange one set of debilitating symptoms for another. If one cannot adequately relieve the symptoms that may occur from the postmenopausal hormonal state, then the patient and the physician have to balance the risks and benefits of each treatment in determining their future course.
However, when the trial of a GnRHa results in the alleviation of the disabling PMDD symptoms, a hysterectomy with removal of the uterus, fallopian tubes and both ovaries and estrogen replacement therapy, if needed, can be life altering.
Another hysterectomy with removal of the ovaries is a consideration is when a woman, who suffers from moderate or worse PMDD symptoms, is also suffering from a gynecologic problem that requires a hysterectomy. Frequently the ovaries will not be removed for purely gynecologic indications at the time of surgery, attempting avoid the postmenopausal hormonal state. However, this is an ideal time to resolve significant PMDD by removing the ovaries at the time of the hysterectomy. Any significant menopausal symptoms can be eliminated after surgery by administering estrogen replacement therapy.
In all of these cases, if the estrogen replacement therapy is needed, it can be safely weaned within 5 years of the surgery. In this case, there are no increased long-term complications, including breast cancer.
If you find yourself in any of the situations described above, discuss them with your gynecologist or contact Dr. Burke at drburke@geraldburkemd.com. Hysterectomy with removal of both fallopian tubes and ovaries is an important treatment modality for those who suffer from severe to disabling PMDD that is refractory to all more conservative, medical forms of therapy. Hysterectomy is an indicated treatment for severe PMDD, uterine fibroids, pelvic pain and vaginal bleeding that will not respond to more conservative measures.
Gerald V. Burke, M.D.