Premenstrual Syndromes : PMS and PMDD - Rutuja :: The site ...

ultimately be followed by severe medical problems.
Misplaced overenthusiasm for the surgery removed any
sense of good clinical judgment and usually more harm
was done than good.
More recent data
Although total abdominal hysterectomy and bilateral
salpingo-oophorectomy (TAH/BSO) is a common operation
for many indications, there are very few data concerning
PMDD. Casson et al 27 found it to be effective
in 14 patients for physical and psychological symptoms
as well as having a favorable effect on lifestyle, after first
suppressing ovarian steroidogenesis with danazol. Casper
and Hearn 28 also showed a dramatic improvement in
mood, general affect, well-being, life satisfaction and
quality of life in another small study of 14 women.
Cronje et al (Figure 14.4) 29 subsequently published the
results of 49 such women collected over 10 years from
two busy PMDD clinics, with all but one being symptomfree
and enthusiastic about the treatment. Such surgery
is rarely required but is very effective and indeed curative.
However, it is significant that some disapproving
correspondence following the Cronje publication 29
referred to the 19th century scandal of Battey’s operation.
All but one of these women had tried various ineffective
medical treatments for a mean of 3.6 years
before referral to the specialist PMS clinic. They were
treated with anovulatory doses of estradiol patches or
implants for a mean of 3 years before problems with
bleeding or progestogen intolerance made surgical
treatment necessary. One patient, the one who refused
any medical therapy, regretted the operation but all
Very satisfied
Very dissatisfied
Dissatisfied
Satisfied
Figure 14.4 Total abdominal hysterectomy and
bilateral salpingo-oophorectomy for premenstrual
syndrome. (Adapted from Cronje et al, 29 with
permission.)
MANAGEMENT BY OVARIAN CYCLE SUPPRESSION 127
others were very satisfied with a complete resolution of
symptoms.
The importance of ovarian function in the causation
and treatment of PMS should be a factor for discussion
with a patient concerning prophylactic oophorectomy
at the time of consenting for hysterectomy. 30 Conservation
of ovaries does not cure the symptoms of PMDD,
for the patient will still have cyclical symptoms of
depression, irritability, irrational behavior, etc., as well
as cyclical headaches that may be the equivalent of menstrual
migraine before surgery. The psycho-protective
value of estrogens compared with progesterone can be
seen in the beneficial response of women with postnatal
depression and perimenopausal depression, the other
components of ‘reproductive depression’. 31,32
Practical aspects
Total abdominal hysterectomy and bilateral salpingooophorectomy
is the ultimate form of ovulation suppression
and the only true cure for PMS, as this
operation removes the ovarian cycle completely. The
procedure is not commonly performed for this indication,
as a lesser alternative can usually be found. However,
data suggest a highly beneficial effect in the selected
women undergoing TAH/BSO, the majority of which
are highly satisfied following this procedure and, as
such, it should be offered as a therapeutic option.
Preoperative GnRH analogues, although not mandatory,
are a useful test of whether bilateral oophorectomy
(with or without hysterectomy) would be successful in
treating symptoms. This appears to be such a valuable
approach in gynecological practice that it is disappointing
that research has not been conducted to provide the
evidence for the value of this ‘GnRH test’. It is essential
that adequate hormone therapy is given (including,
possibly, testosterone replacement) to prevent simply
replacing one set of symptoms with another. Women
who have had a hysterectomy with ovarian conservation
will often continue to have cyclical symptoms in the
absence of menstruation (ovarian cycle syndrome). 30
Women who undergo bilateral oophorectomy laparoscopically,
with conservation of the uterus, can expect a
much less-invasive procedure. But the persistence of the
uterus and therefore, of course, the endometrium,
entails protection of the endometrium and all that that
entails regarding progestogenic restimulation of symptoms.
There are no research studies in this area.
CONCLUSIONS
Although the genesis of PMS/PMDD is probably multifactorial,
it is likely that through polygenic inheritance