There are several important considerations when you are deciding whether or not to seek surgical menopause as a treatment for PMDD, including medical eligibility for treatment, the likelihood of treatment success, as well as personal preferences.
Surgery for PMDD is the last line in treatment for PMDD and is reserved for those who have not gained relief through the evidence-based treatments.
Am I medically eligible? How do I know whether a doctor will consider referring me for surgery?
Surgical menopause is not an easy treatment to access for most people with PMDD. There are many reasons for this, not least of which is that PMDD is a relatively new diagnosis (created in 2013) and many providers have little experience working with the disorder. Among providers who do approve surgery for PMDD, the following two criteria usually need to be met before they will consider moving forward with more invasive treatments.
Documentation of PMDD diagnosis using two months of daily ratings. Physicians who make decisions about surgical eligibility generally require a PMDD patient to have two months of daily symptom ratings that show a pattern consistent with PMDD before considering advanced treatments such as chemical or surgical menopause. Click here to access resources for documenting your symptoms using daily ratings.
Note that in order to be eligible for more invasive treatments such as surgical menopause, symptoms should cause significant life impairment. It can be helpful to make notes in your daily ratings about how much your symptoms impact your ability to work, your ability to care for yourself, your ability to parent, and your ability to maintain relationships. It is also helpful to document any inpatient hospitalizations, and note if they have occurred due to PMDD.
2. Medical records showing that other, less invasive treatments didn’t work. All physicians take an oath to “do no harm” with their treatments-- they never want to expose people to greater physical risk as a result of their treatments. Since surgery brings greater physical risks than most other medical treatments, surgeons making decisions about surgical treatment of PMDD are often quite concerned about whether they might be “doing harm” to you by approving surgery, and about whether they will be held responsible if the surgery does not work for you . Because of this, they want to make sure that you have tried all other options before going under the knife. In order to document this, surgeons often require that you gather medical records showing that you’ve tried several of the less-invasive first-line treatments that have been shown to work better than a sugar pill in clinical trials for PMDD, such as SSRIs and drospirenone-containing oral contraceptives, and that you still experience unmanageable symptoms despite these treatments. It is also a good idea to continue to use daily ratings as noted above to document how symptoms change (or do not change) in response to these treatments. Click here to learn more about non-surgical treatments that have been found to be effective.
Note that this requirement is somewhat less extensive in the UK
As part of this process, doctors often also try to treat other co-occurring disorders that you may have in addition to PMDD, such as major depressive disorder (MDD) or generalized anxiety disorder (GAD). If they do this, rest assured that they are not saying that you don’t have PMDD-- they are trying to reduce your suffering overall by tending to these other, more chronic symptoms that may worsen or complicate PMDD.
3. Complete an assessment visit with the surgeon to review your other medical history and make sure that advanced treatments that cause a menopausal state are safe for you. Some individuals may be unable to safely undergo surgery, for example, and this needs to be evaluated during this process.
How likely is it that menopause will cure my PMDD?
Before a doctor decides to move forward with surgical intervention for PMDD, they usually want to use temporary medications to “test out” menopause moving on to surgery. This process is detailed below.
4. Documentation of a chemical menopause trial using GnRH analogues. The reason that surgical menopause is effective for PMDD is that it eliminates cyclical hormone changes, which prevents the hormone-sensitive (PMDD) brain from having adverse cyclical PMDD reactions. In order to test whether surgical menopause will be an effective treatment for you, it is wise to test out how you will respond to a menopausal hormone state. The best way to test out whether a menopausal state is right for you is to undergo a “reversible chemical menopause trial” in which medications called “GnRH analogues” are given to temporarily shut down your ovaries (which stops your hormones from fluctuating). It is fully reversible-- once you decide to stop the medication, your hormones will resume cycling as normal. If symptoms go away or improve vastly during this temporary “reversible chemical menopause trial”, this is a sign that surgical menopause may be a cure for you.
Note that not all doctors require this, but most do.
Note that if for some reason these medications do not successfully prevent ovulation and you continue to have hormone cycling (and symptoms), you and your doctor may still decide that surgery is the right option.
Generally speaking, surgeons become much more comfortable with the prospect of surgical treatment for PMDD once the four points above have been addressed.
Personal Needs and Preferences
Of course, your own preferences regarding surgery are very important. Having this surgery for PMDD is a big and irreversible decision. It will be life-changing. The decision to undergo such major surgery needs to be made in conjunction with your doctor/health-care provider. All risks and benefits of the surgery (and life following the surgery) should be explained to you in full.
Do not be afraid to ask questions.
It is important that you learn about the procedure/s and what it means for your health in the long term. This will allow you to make a decision based on your own personal situation.
For some, it can be helpful to arrange some talk therapy to discuss your options and give you time to come to a decision on your own terms and in your timeframe.
You should not agree to this surgery unless you understand the reasons for it, and understand the pros and cons of having your ovaries removed. If you are unsure about anything, ask your doctor/health-care provider for clarification or further information.
Accreditation: Dr Hannah Short, Dr Andrea Chisholm & Dr Tory Eisenlohr-Moul
Visit www.iapmd.org/surgery for lots of evidence-based information and resources for those considering, going through, or recovering from surgery for PMDD/PME.