Surgery for PMDD/PME – The Basics

Surgery & Surgical Menopause for PMDD/PME

Surgery is the last line in treatment for premenstrual disorders reserved for those who have not gained relief through other evidence-based treatments. Surgery involves removal of the ovaries and often uterus, which induces menopause and is called surgical menopause. On this page we cover the basics on surgery for PMDD/PME and also surgical menopause.

Why do people have surgery for PMDD/PME?

What does the surgery do and how does it work for PMDD/PME?

What Is The Correct Surgery For PMDD?

What is Surgical Menopause?

What are the symptoms of surgical menopause?

Which Surgeries Result in Surgical Menopause?

How is surgical menopause different from the natural menopause?

For more in-depth information and answers to commonly asked questions you can visit our searchable FAQ.

Why do people have surgery for PMDD/PME?

Surgery for a premenstrual disorder is a big decision with life-long impacts on the body. Removing your ovaries is an invasive procedure that immediately causes surgical menopause and menopause symptoms. The decision to have surgery is not made lightly. However, when someone with PMDD/PME has ruled out all other evidence-based treatments, and still suffers severe symptoms that keep them from functioning in their normal life, surgery can be a life-changing, effective treatment.

“SSRIs worked quite well for me in my 20s and made my symptoms pretty manageable for a long time. However, in my 30s my symptoms severely worsened and despite working my way through the available treatment options, nothing worked (and often made me feel worse). It took me a while to get my head around the fact that surgery could be an option – I read lots of blogs and joined groups. At the end of the day, I felt like I was out of options and wanted my life back.” – Patient

Essentially, surgery for a premenstrual disorder is the last treatment option when your symptoms are severe, and no other interventions have worked.

Treatment guidelines for PMDD/PME

Having surgery at a younger age for severe PMDD? Listen to this podcast where IAPMD Volunteers, Rachel & Anna, share their experiences of having surgery in their early 20’s:

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What does surgery do and how does it work for PMDD/PME?

While many people refer to surgery for PMDD/PME as a ‘hysterectomy’ (removal of the uterus) – the essential part of the procedure is actually the removal of both ovaries (bilateral oophorectomy – or bilateral salpingo oophorectomy if the fallopian tubes are also removed). PMDD is a severe negative reaction in the brain to the natural rise and fall of estrogen and progesterone, triggered by ovulation, a process that takes place in the ovaries. By removing the ovaries (when all other forms of cycle suppression have not worked) you remove ovulation and thus, remove those fluctuations from happening.

Pre – surgery (fluctuations)

At a basic level – PMDD is caused by a sensitivity in the brain to the natural hormone fluctuations that occur as part of the menstrual cycle. The brain has a negative reaction to those ups and downs of the sex hormones.

Post – surgery (steady levels of hormones)

By removing the ovaries, and therefore removing ovulation/the menstrual cycle, and using estrogen therapy (HRT) to keep the hormone levels even and steady, you eliminate the fluctuations that trigger PMDD symptoms.

To learn more about the different types of surgery for PMDD/PME, visit considering surgery.

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What Is The Correct Surgery For PMDD?

When discussing surgery for PMDD, you will often hear people talking about having a ‘hysterectomy’ which can cause lots of confusion and misunderstanding. When surgical menopause is used as a final treatment for Premenstrual Dysphoric Disorder (PMDD), the removal of the ovaries is actually the critical part of treatment since the ovaries cause hormone fluctuations, and therefore trigger PMDD. The surgical removal of both ovaries is called a ‘Bilateral Oophorectomy.’

After removal of the ovaries, estrogen hormone replacement therapy (HRT) is used to reduce menopausal symptoms and bone and heart risks. Estrogen used alone can cause a buildup of the uterine lining, leading to hyperplasia, so a form of progesterone is often used as well to prevent this. However, since many individuals with PMDD have a sensitivity to progesterone (which can trigger PMDD-like symptoms), progesterone ‘add-back’ is not the preferred route. In many cases, the uterus is removed (a hysterectomy) in addition to the ovaries. 

When progesterone is well tolerated by the individual, the uterus can sometimes be kept, and combined HRT is used (i. e., estrogen and progesterone together).

Patient tolerates progestogen-based treatments

If you tolerate progestogen-based treatments, then you may only need a Bilateral Oophorectomy. This is the removal of both the ovaries. Your surgeon may also suggest BSO (Bilateral Salpingo – Oophorectomy) which means your fallopian tubes are removed as well.

Your uterus and cervix can remain in place (so no hysterectomy is needed, just ovary removal) and the progestin add-back HRT can be given in the form of the Mirena IUS or combined HRT (such as Tibolone) to protect from hyperplasia (monitoring is required).

Learn more about progestogen addback here.

Patient does not tolerate progestin-based treatments

If you do not tolerate progestogen-based treatments then you would need a Total Hysterectomy with Bilateral Oophorectomy (THBO). This is the removal of the uterus/womb, cervix and both ovaries. Your surgeon may also suggest to remove your fallopian tubes as well.

This means that you can use estrogen-only HRT and do not need to use progesterone add-back.

This is known as estrogen therapy (ET) – you can learn more here.

If you are unsure if you are progesterone intolerant, you can read more here.

A hysterectomy without ovary removal is not a treatment for PMDD.

Some surgeons will remove only the ovaries in special circumstances where physical risks are abnormally high due to other medical conditions; however, this is not standard practice for the treatment of PMDD.

download treatment guidelines

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What is Surgical Menopause?

Surgical menopause (sometimes called ‘surmeno’) is a surgically-induced menopause that refers to the menopausal (low) hormone state that occurs following surgical removal of both ovaries.  This procedure is called a bilateral oophorectomy and is the last line treatment for PMDD/PME, when less invasive treatments have not been effective. When both ovaries are removed, this removes the main source of estrogen, progesterone, and testosterone in your body. This means you will no longer have a menstrual cycle and you are in surgical menopause.

Removal of just one ovary (leaving the other) is called a unilateral oophorectomy. When just one ovary is removed, this does not result in surgical menopause and the remaining ovary continues to produce normal hormone cycling each month.

Often for treatment of a premenstrual disorder, (though not always), a surgical removal of the uterus (a hysterectomy) is performed at the same time as removal of your ovaries (oophorectomy) due to an intolerance to progestogen add-back. If you have a hysterectomy but keep your ovaries, you will not experience a surgical menopause – your hormones will continue to cycle as they normally would each month, even though your uterus is gone (and you will have no menstrual bleeding). A hysterectomy without ovary removal is not a treatment for PMDD.

Both ovaries must be removed for treatment of PMDD.

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What are the symptoms of surgical menopause?

Symptoms of surgical menopause are caused by estrogen deficiency. Following the surgical removal of the ovaries, you become post-menopausal immediately. As your hormone levels drop you may experience a sudden onset of menopausal symptoms. These may be mild, moderate, or severe, depending on your particular situation. These symptoms can be minimized by taking Hormone Replacement Therapy (HRT), or alternatives (see estrogen alternatives here) if hormones are not an option following surgery. 

Symptoms include, but are not limited to: 

• Vasomotor symptoms (e.g., hot flushes and sweats)

• Musculoskeletal symptoms (e. g., joint and muscle pain)

• Effects on mood or anxiety (e.g., feeling abnormally sad or worried)

• Urogenital symptoms (e.g., vaginal dryness, needing to urinate frequently)

• Sexual difficulties (e.g., low sexual desire, painful sex).

• Other – headaches, sleep issues, skin changes

Menopausal symptoms, as a result of estrogen deficiency, can also be long-term – but individual experiences vary. HRT can reduce these symptoms and can be safely taken long-term, except in some circumstances.

Long-term Health Risks

The ultra-low levels of estrogen in surgical menopause can cause bothersome menopausal symptoms, but more importantly, they can reduce the length and quality of your lifespan by increasing risk for various health conditions. We will address each below. 

For those under the age of 40 who enter surgical menopause, using HRT (Hormone Replacement Therapy) can reduce or eliminate the serious long-term health risks associated with surgical menopause, including:

• osteoporosis and broken bones

• cardiovascular disease (e. g., heart attack, stroke)

• dementia and Parkinson’s disease

• psychiatric disorders (e.g., mood or anxiety disorders)

• vulvar and vaginal atrophy

• sleep disorders (e.g., persistent and impairing insomnia)

• higher risk of death by any cause 

To summarize, surgical menopause is known to cause all of the above symptoms and health risks– but these problems can generally be reduced or eliminated by using estrogen therapy following surgery through to the typical age of menopause (51 years). Most individuals in surgical menopause choose to continue some level of estrogen through at least age 60 to maintain symptom relief.

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Which Surgeries Result in Surgical Menopause?

The following surgical procedures will result in surgical menopause:

*The cervix may also be removed depending on individuals reaction to HRT in both THBO and THBSO surgeries.

** A radical hysterectomy is typically performed when someone has cancer of the cervix, ovaries, fallopian tubes, or uterus. It is not a standard treatment for PMDD/PME.

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How is surgical menopause different from natural menopause?

Natural menopause occurs after a transition period (which can last from months to years) called perimenopause where the body gradually makes less estrogen to a point where the ovaries stop releasing eggs (menopause). Surgical menopause occurs instantly when you have both ovaries surgically removed.

Risks can be reduced by using transdermal estrogen (gels/patches which are absorbed through the skin)

Natural menopause 

A natural menopause occurs when the ovaries stop releasing eggs and, as a result, the levels of sex steroid hormones (estrogen, progesterone, and testosterone) fall. The average age of natural menopause is 51 years of age, but any time after 45 is considered ‘normal.’ The years during the menopausal transition are called perimenopause, which can last months or even up to years. Periods often become heavier and more sporadic during this time, and menopausal symptoms (e.g., night sweats, hot flashes, or vaginal dryness) begin to appear. If you are going through menopause naturally, you will be considered postmenopausal a year to the day of your last period. If menopause occurs between the ages of 40 and 45, this is referred to as early menopause. One in a hundred women will experience menopause under the age of 40 – this is referred to as premature menopause or premature ovarian insufficiency (POI).

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Surgical menopause

In those who undergo a bilateral oophorectomy (removal of both ovaries), the transition into menopause is immediate and known as surgical menopause. The symptoms can be sudden and may be more intense than those experienced in natural menopause, especially in younger individuals.

Following surgery to remove your ovaries, you will become postmenopausal instantly. 

Sudden symptoms of menopause often occur quickly following surgery, and can be unpleasant or distressing, so it is important to work with an experienced healthcare professional to look after both your short-term and long-term health during this rapid transition.

There is so much to learn when it comes to PMDs and surgery – check out our searchable knowledge base which is packed full of evidence-based answers for commonly asked questions. From considering surgery, right though to thriving in Surgical Menopause, this is your go-to source!

This project was financially assisted by The Patty Brisben Foundation for Women’s Sexual Health. The views expressed herein do not necessarily represent those of The Patty Brisben Foundation for Women’s Sexual Health.

Considering surgery for PMDD? | IAPMD

There are many factors to weigh when considering surgical menopause as a treatment for PMDD/PME, including medical eligibility, the likelihood of treatment success, and personal preferences. While living with a premenstrual disorder can make us feel desperate for relief – it needs to be a well considered decision. Surgery for PMDD/PME is the last line in treatment and is reserved for those who have not gained relief through the evidence-based treatments. 

Is surgical menopause the right treatment for my PMDD/PME?

How do I know if I am progesterone intolerant?

What are the known risks of surgical menopause?

What if I want to avoid hormone replacement therapy (HRT) due to a history of PMDD/PME (e.g., emotional hormone sensitivity)? 

Will surgical menopause change my bone health?

Can you still have PMDD after the surgery?

Read about the benefits and risks of HRT here

Have other questions? Don’t forget that our FAQ knowledge-base is packed full of your questions with answers from experts!

Watch this hour long webinar which is packed full of information and advice about surgery for PMDD:

Is surgical menopause the right treatment for my PMDD/PME?

Surgery/Surgical menopause is not an easy treatment to access for most people with PMDD/PME. 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 criteria (1 & 2) usually need to be met before they will consider moving forward with more invasive treatments. 

“Am I medically eligible? How do I know whether a doctor will consider referring me for surgery?”

These are discussed in more detail below:

1. 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 is detailed recordings/tracking of your symptoms alongside your cycle) that show a pattern consistent with PMDD before considering advanced treatments such as chemical or surgical menopause.

• 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 (tracking your symptoms daily) as noted above to document how symptoms change (or do not change) in response to these treatments. 

• Note that this requirement may be 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.

Learn more about non invasive treatments

3. If approved by your physician, you will also need to 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, and this needs to be evaluated during this process. 

4. Documentation of a chemical menopause trial using GnRH analogues. 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:

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 treatment option 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. 

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Other considerations

Your Personal Needs and Preferences

Of course, your own preferences and personal situation are very important in making a decision. We understand that many people with PMDD/PME are desperate to escape the relentless cycle of PMDD/PME, it is important to realize that this surgery is a big and irreversible decision. It will be life-changing. The decision to undergo such major surgery needs to be fully thought through by you and 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. 

If you would like to speak to others in the same situation, you can join our Facebook peer support group, ‘IAPMD – PMDD, Oophorectomy, Hysterectomy, & Life After Group’. You can also reach out to our peer support team who can help you talk you through your concerns. It’s free, confidential and manned by trained volunteers with lived experience of PMDD and/or PME.

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.

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How do I know if I am progesterone intolerant?

You will know you are progesterone intolerant if you have a negative psychological reaction (and in some cases, negative physical reactions also)  to taking progestin based medications. Examples of these medications are:

• Combined contraceptive pill 

• POP (progesterone only pill)

• Hormonal IUD/coil such as the Mirena/Jaydess. 

• Oral micronized progesterone

• Depo progesterone injection or the implanon.

Note that there is difference between progestins like the ones contained in hormonal birth control and naturally-occurring progesterone that is formed in the human body. 

“Within days of taking any type of progesterone product, the drop in mood and mood swings started. I came off it, and they went away. This was repeated several times with several different products” – Patient

Micronised progesterone (such as Prometrium or Utrogestan) is identical to the progesterone made in the human body, and, for many, has fewer side effects than the progestins found in birth control pills. 

In either case, studies have shown that it is often the change in progesterone– and not the level of progesterone itself– that triggers symptoms of “progesterone intolerance” in PMDD. It may be that, once the brain has had time to adjust to the new level of progesterone metabolites (typically one month), the symptoms will go away.

Manufactured progesterone is called progestogen in the UK and progestin in the US.

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What are the known risks of surgical menopause?

There are short-term and long-term risks associated with surgical menopause and you need to fully understand these before going ahead with surgery.

Surgical Risks

Any surgery has risks including, for example: a reaction to the anaesthetic, bleeding, infection or pain after the procedure. Your surgeon will explain these to you before your surgery, before you sign the consent form. It is important to understand that surgery will only go ahead if the benefits are believed to outweigh any risks.

Psychological Effects of Surgery

While everyone’s experience is different, some people may feel emotionally upset immediately following surgery. PMDD is a sensitivity to hormone fluctuations and after surgery your hormone levels drop significantly, thus making it a difficult time for many people. Ensuring those around  you understand why you are having the surgery, and having a good support network around you, are very important. 

Surgery and surgical menopause is a big physical and psychological adjustment for anyone, and this should not be underestimated. 

Estrogen Deficiency-Related Menopause Symptoms

Following surgical removal of the ovaries, you become post-menopausal immediately. As your hormone levels drop you may experience a sudden onset of menopausal symptoms. These may be mild, moderate, or severe depending on your particular situation. These symptoms can be minimized by taking Hormone Replacement Therapy (HRT), or alternatives [Link] if hormones are not an option following surgery. 

Symptoms of Surgical Menopause include, but are not limited to:

vasomotor symptoms

Hot flushes/flashes

Night sweats

musculoskeletal symptoms

Joint and muscle pain

effects on mood or anxiety

Feeling abnormally sad or worried

urogenital symptoms

Vaginal dryness

sexual difficulties

Low sexual desire

Menopausal symptoms, as a result of estrogen deficiency, can also be long-term – but everyone is individual. Hormone Replacement Therapy (HRT) can reduce these symptoms and can be taken long-term, quite safely, by the vast majority.

Read more about Hormone Replacement Therapy (HRT) here >>

Long-term Health Risks

If you enter into surgical menopause below the age of natural menopause (around 51 years of age), then there can be an increased risk of heart disease, osteoporosis, sexual dysfunction, and dementia as a result of estrogen deficiency. However, these risks are drastically reduced by taking Hormone Replacement Therapy (HRT). 

There are some studies reporting a correlation between surgical menopause and risk of early death; however, given that there are many shared risk factors between surgical menopause and early death (poorer overall health, experiences of severe stress in childhood), these, confounding factors currently make it impossible to know whether surgical menopause actually causes increased risk of early death.  

The ultra-low levels of estrogen in surgical menopause can cause bothersome menopausal symptoms, but more importantly, they can reduce the length and quality of your lifespan by increasing risk of various serious health conditions. We will address each below. 

For those under the age of 40 entering surgical menopause, using HRT (Hormonal Replacement Therapy) also reduces or eliminates the serious long-term health risks associated with surgical menopause, including:

• osteoporosis and broken bones

• cardiovascular disease (for example: heart attack, stroke)

• dementia and Parkison’s disease

• psychiatric disorders (for example: mood or anxiety disorders)

• vulvar and vaginal atrophy

• sleep disorders (for example: persistent and impairing insomnia)

• higher risk of death by any cause 

To summarize, surgical menopause is known to cause all of the above symptoms and health risks– but these problems can generally be reduced or eliminated by using estrogen therapy following surgery through to the typical age of menopause (51 years). Most individuals in surgical menopause choose to continue some level of estrogen through at least age 60 to maintain symptom relief.

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What if I want to avoid Hormone Replacement Therapy (HRT) due to a history of PMDD (e.g., emotional hormone sensitivity)? 

We totally understand the concerns that people have when starting HRT – especially if you have a history of reacting negatively to hormone based treatments. However, HRT can help reduce or eliminate many of the physical risks that come in surgical menopause, and so it is strongly recommended that HRT is used where possible. If you choose not to use HRT, it needs to be an informed decision.

Several studies show that people with PMDD experience abnormal negative emotional reactions during hormone changes. However, recent studies ALSO show that these negative emotional reactions usually go away about one month after starting HRT. Therefore, if you can tolerate the symptoms in the first month following the start of HRT (or any changes in HRT), symptoms usually subside.

So while it can be a difficult start, many people with PMDD/emotional hormonal sensitivities can take HRT during surgical menopause. 

 If you’re concerned about your ability to cope with initial symptoms in the first month of HRT, we encourage you to start with a low dose and build up slowly. It is wise to be aware that this can be a difficult time of increased symptoms, and plan ahead to increase support from family, friends, and healthcare providers during this time. For example, some people are able to start HRT during a “quiet month” where there is less stress in their life. Some may also choose to see a supportive health care provider more frequently during the first month of HRT, or ask those around them to provide additional support during this time. 

People in surgical menopause almost always need to take estrogen because surgical menopause causes very low levels of estrogen (lower than in natural menopause), which leads to major health risks without estrogen therapy.

If you are entering surgical menopause before the typical age of natural menopause (before age 51), experts from a variety of leading societies (linked below) strongly recommend taking estrogen at least until the age of 51, the average age of natural menopause, and to speak with your doctor to reevaluate the risks and benefits of estrogen use around that time. Most individuals in surgical menopause choose to continue estrogen therapy through age 60.

Expert Consensus indicating that estrogen is critical in surgical menopause:

• NICE guidelines on Menopause Diagnosis and Management (UK)

• NAMS 2017 Hormone Therapy Position Statement (North America)

Please note that these recommendations for estrogen in surgical menopause differ greatly from those in natural menopause, where estrogen is considered an optional method for controlling menopausal symptoms.

• Need for estrogen to control symptoms in surgical vs. natural menopause: Surgical menopause is similar to natural menopause in that it can cause bothersome menopausal symptoms (hot flashes, night sweats, joint or muscle pain, increased mood or anxiety symptoms, vaginal dryness, and sexual difficulties).

• Unique estrogen needs in surgical menopause (why it’s more important to take estrogen in surgical menopause): Estrogen in surgical menopause is about more than controlling the bothersome symptoms above– it is also needed to protect against the unique long-term health risks associated with oophorectomy/surgical menopause. Because surgical menopause causes a more severe estrogen deficiency, over time it is known to increase the risk of many long-term health problems, including osteoporosis, cardiovascular disease (heart attack, stroke), Parkison’s disease, impairing mood or anxiety disorders, sexual pain or discomfort, vulvar or vaginal atrophy, and dementia. In addition, surgical menopause is linked with greater risk of early death from all causes.

In sum, whereas most people undergoing natural menopause can avoid HRT without much consequence to their long-term health, this is not the cause in surgical menopause. Therefore, if you choose not to use HRT in surgical menopause, it needs to be a very informed decision with knowledge of potential long term risks, and we highly recommend that you discuss your decision with a trusted health care professional.

Some individuals in surgical menopause have a personal or family history of conditions that can be affected by hormones, and thus are more concerned about HRT risks. This is completely reasonable. Although the scientific research suggests that there are fewer risks of estrogen in surgical menopause than in natural menopause (because baseline levels are so much lower), it is important to speak with a knowledgeable provider about what is best for you. There are many adjustments that can be made (e.g., lower dose, slower titration, use of alternative medications, or supplemental use of local HRT) to ensure that you are both protected from long-term health risks while also avoiding or minimizing any possible HRT risks.

PMDD & Surgery group

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Will surgical menopause change my bone health?

Menopause is associated with a reduction in bone density due to falling levels of estrogen. Estrogen helps to protect bone strength. Therefore, estrogen replacement therapy (ERT) is used in those with premature menopause to maintain bone density and reduce the risk of osteoporosis.

What level of ERT (Estrogen Replacement Therapy) do I need to maintain bone health? 

In surgical menopause, the current recommendation is to maintain the level of ERT that keeps vasomotor symptoms (hot flashes, night sweats) at bay.  At the present time, there is no evidence supporting a “correct” or “optimal” level of ERT dosing (or blood level of estrogen) that protects bones in everyone; it appears that the optimal dosing of ERT is unique to each individual.  Therefore, experts recommend that ERT dose be adjusted on an individual basis to (1) achieve remission of menopausal symptoms (especially hot flashes and night sweats) while also (2) minimizing any risks of ERT (taking into consideration each woman’s individual risk profile).

There are lots of additional ways to protect your bone health, including staying active, weight bearing & high impact exercise, resistance exercise, and a healthy balanced diet rich in calcium and vitamin D. Quitting smoking and reducing alcohol intake are also important for reducing risk of osteoporosis. 

Should I have my bone mineral density tested? How often? 

Assessment of bone mineral density (DEXA scan) should be considered at the time of surgical treatment (start of surgical menopause) to evaluate your individual risk level for osteoporosis. The frequency of repeated bone density assessment should be guided by your individualized risk (e.g., not taking HRT, family history, smoking) for developing osteoporosis. Talk to your doctor about whether and how frequently your bone mineral density should be monitored.

More Information: 

www.thebms.org.uk/publications/consensus-statements

www.nhs.uk/live-well/healthy-body/menopause-and-your-bone-health/

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Can you still have PMDD after the surgery?

If you have just had a hysterectomy (and not a bilateral oophorectomy) you can still have PMDD post-surgery as the ovaries will still be functioning.

If you have had both ovaries removed, for those with underlying hormone sensitivities (e.g., PMDD), it is important to note that, although the removal of the ovaries prevents the monthly cyclical hormone fluctuations that may trigger brain reactions to hormones (e.g., emotional or cognitive changes), your brain will always be abnormally sensitive to hormone fluctuations, and surgical treatment will not change that. You are likely to still feel negative emotional reactions to any fluctuations caused by situations such as natural hormone depletion, HRT not absorbing properly, and changes in HRT levels/delivery methods. The aim is to get your levels steady with adequate HRT and keep them at that rate so there are no fluctuations to cause symptoms.

Since it may take quite some time to find the optimal dosages of HRT, many people with a history of hormone sensitivity still experience changes in their symptoms during this process. It does not mean that you still have PMDD – it just means that your brain is reacting to those fluctuations that are caused by a change in HRT, the natural depletion of hormones from your body, or the HRT not being correctly absorbed.

It should be noted that, in the case of PMDD, there is thought to be  a time lag of about 2 weeks between hormone changes and brain reactions; therefore, frequent changes to HRT levels should be avoided, and every change should be evaluated for about one month before deciding if it is effective and tolerable. 

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Have other questions? Don’t forget that our FAQ knowledge-base is packed full of your questions with answers from experts!

This project was financially assisted by The Patty Brisben Foundation for Women’s Sexual Health. The views expressed herein do not necessarily represent those of The Patty Brisben Foundation for Women’s Sexual Health.

“Why does my daughter want to have her uterus removed at 15?”

• Natasha Lipman and Kirsty Brewer
• BBC Stories

June 18, 2018

Ever since she started her period, Elizabeth* has had to struggle with suicidal thoughts. Only at 42, after a hysterectomy, did she finally feel better. Her 15-year-old daughter Grace* suffers from the same severe form of premenstrual syndrome. In this conversation, they explain why they want effective treatment for Grace so much – so as not to doom her to a life of hormonal hell.

At the age of 15, Grace made up her mind that she would not have children, and she was outraged that her mother had not made the same decision at the time.

They both suffer from the same severe form of premenstrual syndrome (PMS), which manifests itself in outbreaks of anxiety, rage, psychotic symptoms and unbearable physical pain.

“My mother gave me what I now have to live with for the next 40 years,” says a teenage girl. She wants to be the third in her family line to have a hysterectomy. But not in her 30s or 40s, like her mother and grandmother, but now.

After she began menstruating, Grace became much more restless and more anxious. She is often overcome by “longing, anger and great fatigue.”

Studying at school is difficult. Now she is coping, albeit with great difficulty, but she is looking forward to graduation.

“In the second half of the cycle, I can’t concentrate on the lessons. And when the rages start, it seems that no one understands me. After all, no one else is going through critical days like I do. I feel very lonely,” she says .

She only thinks about when her period will start – despite the fact that this is the worst time for her.

“I’m like a balloon going up and down. I need to burst,” explains Grace. “But when it does, I can barely breathe.”

Her menstruation can last almost half a month, or even more, and sometimes it is so strong that the girl is not able to sit through even one lesson without changing the pad.

“Blood seeps through eight layers of clothes. I change my pads and after 20 minutes the same thing,” she adds.

But even more than the bleeding, she is troubled by a deep sense of shame and humiliation that torments her after she loses control of herself and is filled with uncontrollable anger.

“I feel like I’ve ruined everything again. I’m so ashamed, I’m choking with tears. It’s a trauma for me.”

At the age of 13, she went to her family doctor with this problem, and he prescribed birth control pills with a high content of synthetic progesterone. She began to take them – and literally a day later she became very aggressive.

“It was unbearable for our whole family,” she says.

One day her younger brother – then he was five – saw how she raged, squealed, and then hit her mother. He then closed himself in the closet.

“I really hope he has already forgotten the time when Grace had a terrible crisis – says Elizabeth. – It looked very, very scary.”

She recalls another time when the whole family had dinner together and Grace was asked to move to a seat next to her. “It was like she was off the chain because of such a small thing,” says Elizabeth. A few seconds later, Grace was already running to destroy the bathroom.

She seemed to have been replaced, because her mother always knew her as a sweet, gentle, somewhat eccentric girl – “like from an Enid Blyton novel.”

The pills filled her with progesterone – according to Elizabeth, they are both hypersensitive to this hormone. It didn’t even occur to the doctor to consider in detail the possible side effects.

Grace was then referred to a psychiatrist, who put her on anti-psychotic medication so she wouldn’t be so violent and the family could “get through Christmas in peace,” says Elizabeth.

But everything was so bad that on the second day after Christmas, Elizabeth returned to the psychiatrist for a referral for hospital treatment for Grace.

“It’s not because we didn’t love her or didn’t want to take care of her, but purely for general safety,” the mother explains.

And she always felt that her daughter’s problems were related to the menstrual cycle. One day, she accidentally heard a story on the radio about premenstrual dysphoric disorder (PMDD) – and realized that Grace’s symptoms (as well as her own) exactly matched the description.

She found a doctor who specializes in hormonal treatment for PMDD. Grace is now receiving bioidentical hormone replacement therapy (HRT), which is considered a more natural form of hormone therapy because, as the name implies, hormones that are chemically identical to those produced by the human body are used for treatment.

This method works better. Grace is convinced that if her mother had not accidentally found out about him, she would have had to move from home to a psychiatric hospital.

“A person should feel completely safe when they cross the threshold of their house,” says Elisabeth. “When PMDD mines are planted under this house, it’s terrible. ”

• Severe PMS/PMDD occurs in 5-10% of menstruating women and is mainly caused by fluctuating hormone levels.

• Some women are genetically vulnerable to such fluctuations: studies show that PMS is often passed down from generation to generation.

• Although PMDD has physical manifestations, the most discomfort is associated with emotional symptoms such as depression, irritability and aggressiveness.

• PMS/PMDD can happen to anyone who is menstruating, but typically occurs in adolescence (with the onset of menstruation) and in women over 35 years of age.

• hysterectomy is considered a major operation and is used to treat PMS/PMDD only when other treatments have been exhausted but is usually effective; after surgery, patients should receive HRT so that problems associated with menopause do not appear instead of PMS.

Retrieved : Nick Panay and Anna Fenton

Elisabeth understands well what kind of life awaits her daughter with PMDD, because she went through it herself.

“From the age of 14, I was a hostage to my hormones,” she says.

She was also prescribed contraceptives in her early teens – they reduced bleeding, but not psychological problems. From the beginning of her period, Elizabeth suffered from suicidal tendencies.

“When I was in my 20s or 30s thinking that I had only lived half my life, it scared me a lot,” she says. “But now I see my daughter having all the same problems that I had.”

Elizabeth’s war on hormones ended only after a hysterectomy, which she had at 42: as menopause approached, she began to experience terrible pelvic pain. She also had her ovaries removed and was prescribed HRT.

“For some reason, it is believed that without a uterus, a woman will not feel complete – but I’m just glad that I got rid of it,” she says.

Elizabeth’s mother also had hormonal problems and had a hysterectomy at 35.

Although the bioidentical MH patches relieved Grace’s symptoms somewhat, they did not provide complete relief from her problems.

“I think Grace will continue to insist on a hysterectomy until she gets one – in her 20s, 30s or 40s,” says her mother.

Royal College of Obstetricians and Gynecologists guidelines indicate that hysterectomy may be an effective treatment for severe PMS; but in Grace’s case, no one takes her request for surgery seriously. According to her mother, doctors believe that she will grow up and change her mind.

But Grace looks at the situation differently: “I don’t want to have children because I don’t want them to suffer like me,” she says.

Elizabeth does not reproach her daughter for her aggressive behavior.

“Would I deliberately doom someone to suffer for life from hormones that cause depression and a desire to end everything? No, never!”

But voluntarily remain childless? It’s tantamount to wishing that Grace was never born, she says, which she would never want.

Even when Elizabeth was determined to have a hysterectomy, it was not easy for her to get permission from all medical authorities; now this battle is for her daughter.

Other family members are vehemently against the operation and say that Grace is too young for her; but Elizabeth understands how painful it is to face distrust, and knows how different life is before and after successful treatment. All this, according to her, gives her the strength to fully support her daughter and do everything that no one has ever done for her.

“I’m not going to ignore Grace,” she says. “Rejecting her attitude to hormones and their destructive effect on life is not to believe how bad she is.”

Elizabeth understands that even her daughter’s final test scores will depend on what phase of her cycle she is in.

She believes that her own life would have turned out differently if the hormones had been dealt with earlier.

“I think back to those emotional outbursts I had and shudder,” she says. hormones.”

When hormones dictate so much to you, there are many consequences – your potential for achievement is severely limited, she explains.

She remembers how she had to force a smile out of herself to hide her pain, and wondered how other people could move forward towards a goal when she did not have the strength to do so.

“I looked at my peers and thought that I was weak, lazy and had no ambitions, all this only played along with my low self-esteem,” she says.

She enjoys being a mother and a housewife – but once she wanted to be a writer. Perhaps if she had had a hysterectomy earlier, she would have succeeded.

“It took a long time for my hormonal problems to be taken seriously, which is sad. But in the end, everything turned out well for me,” says Elizabeth.

Monthly battles with hormones have also affected her relationships with men – and now she has been happily married for 10 years. Here is what she says about her rugby husband: “He is wonderful and knows how to support me – most importantly, he has learned to quietly wait out those times when my hormones are raging. ”

On Fridays, he kindly reminds: “Isn’t it time to change the hormonal patch, love?”

“Until I do that, I can yell at him – but then I calm down,” says Elizabeth.

She now focused on how to help Grace.

There are a little more good days in Grace’s life now than bad ones – it used to be the other way around.

“This is probably the best treatment I can hope for other than a hysterectomy. Please let me have a hysterectomy!” the girl pleads.

“I just want to live a normal life.”

Illustrations Emmy Russell

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Premenstrual syndrome: etiopathogenesis, classification, clinic, diagnosis and treatment | Unanyan A.L., Sidorova I.S., Kuzenkova N.N., Nikonets A.D., Elisavetskaya A.M., Nikitina N.A., Nesterenko Z.A., Soldatenkova N.

A., Baburin D. .IN.

An analytical review of international studies on the etiopathogenesis, classification, diagnosis, clinic and treatment of premenstrual syndrome is presented.

Etiopathogenesis

Premenstrual syndrome (PMS) is characterized by a high frequency of occurrence in the structure of gynecological morbidity – from 20 to 85% [1–3]. Cross-sectional (simultaneous) epidemiological study, which included 929 women, conducted on the basis of diaries filled out for 6 weeks, revealed the presence of premenstrual symptoms in 24% of the study [4]. According to other data, about 80% of women note the presence of at least one physical or psychological symptom of PMS in the luteal phase of the menstrual cycle [5].
The prevalence of PMS is not related to age, educational attainment or employment status, however, women who have had stressful events in the past are more likely to be diagnosed with PMS [6]. In a study examining the effect of being overweight on the development of PMS, it was found that for every 1 kg/m increase in body mass index (BMI) ² , there was a 3% increase in the risk of developing PMS (95% confidence interval (CI) 1 . 01–1.05), in connection with which the normalization of body weight may be useful for the prevention of PMS [7, 8]. Data from a cohort study show that light alcohol consumption is not associated with the development of PMS and premenstrual dysphoric disorder (PMDD), but early onset of alcoholism or prolonged alcohol use slightly increases the risk of developing premenstrual symptoms [9]. The results of another cohort study show that caffeine intake is not associated with PMS and current recommendations for women to reduce caffeine intake will not help prevent the development of PMS [10].
None of the existing theories of the origin of PMS fully explains the unambiguous cause of the disease [11]. One of the convincing points of view on the development of PMS is the concept that characterizes this disease as the result of an inadequate response of the central nervous system (CNS) and, above all, the hypothalamus to normal fluctuations in the level of sex hormones during the menstrual cycle [12].
Two interrelated theories prevail in the etiopathogenesis of PMS. The first suggests that some women are sensitive to progesterone and progestogens, because serum concentrations of estrogen and progesterone are the same in women with and without PMS. The second theory points to a specific role for the neurotransmitters serotonin and γ-aminobutyric acid (GABA) in key aspects of PMS pathogenesis. The level of GABA is regulated by one of the progesterone metabolites, allopregnanolone, and in women suffering from PMS, its level is usually reduced [13].

Classification, clinic, diagnostics

According to the II Consensus of the International Society for Premenstrual Disorders (ISPMD), which was proposed in Montreal (2012), premenstrual disorders (PMD) can be divided into two categories: primary and variant [14].
The main VUR is represented by typical somatic and / or psychological manifestations that are observed during the 2-week premenstrual phase and resolve during or immediately after menstruation. The number of symptoms, as well as their spectrum, are not significant in the specification of a diagnosis. The presence of symptoms during menstruation does not exclude the diagnosis of VUR, but there must be an asymptomatic period between menstruation and the approximate time of ovulation. In basic VUR, such cyclic state changes occur in most cycles (usually two out of three successive cycles).
Variant VUR includes 4 types: premenstrual exacerbation of the underlying disease, VUR with neoovulatory ovarian activity, VUR in the absence of
menstruation, progestogen-induced VUR [14, 15].
In the case of a premenstrual exacerbation of the underlying disease, the symptoms appear during the entire menstrual cycle, but they become more intense in the premenstrual phase. Diabetes mellitus, bronchial asthma, migraine, epilepsy, and depression can be examples of the underlying disease, the course of which, as a rule, tends to worsen in the second phase of the menstrual cycle [14–16].
VUR with neoovulatory ovarian activity occurs in women who do not ovulate but still report symptoms of VUR. The mechanism by which this type of variant VUR occurs is not well understood. It is possible that further studies of this condition will lead to its exclusion from the list of PMR [14, 15].
Women may experience symptoms of VUR despite not having a period. This occurs when ovulation and the ovarian cycle are preserved, and the absence of menstruation is associated with medical or surgical interventions at the level of the uterus and endometrium, leading to amenorrhea. VUR in the absence of menstruation is observed with ovarian-sparing hysterectomy, endometrial ablation, and with the use of a levonorgestrel-intrauterine system (LNG-IUD) [14, 15].
Progestogen-induced VUR is an iatrogenic form of VUR in which exogenous progestogen administration can provoke symptoms characteristic of VUR. Symptoms usually occur during the progesterone phase of the cycle. In such patients, ovulation is absent or suppressed, but the presence of progestogen provokes the appearance of VUR-like symptoms.

ISPMD systematized the variety of clinical manifestations of PMS, dividing them into typical physical and psychological/behavioral symptoms [14].
Typical physical symptoms include: back pain, joint and muscle pain, engorgement or tenderness in the mammary glands (mastodynia, mastalgia), bloating (flatulence), headaches, skin manifestations, and swelling of the extremities [14].
Psychological or behavioral symptoms include changes in appetite and eating habits, fatigue and fatigue, mood swings, irritability, anger, sleep disturbances, impatience, decreased concentration, social withdrawal, lack of control over one’s actions, decreased interest in daily activities, tension, anxiety, feeling of loneliness and despair, depressive mood [14].
3-8% of women have an extremely severe form of PMS with predominantly neuropsychiatric manifestations, called premenstrual dysphoric disorder (PMDD) [17]. PMDD is an additional term that was proposed by the American Psychiatric Society in 1994 [18]. In 2013, the fifth version of the Diagnostic and Statistical Manual of Mental Disorders, DSM V, was published, in which PMDD was moved from Appendix B to the main part [19], which strengthened the position of PMDD as an object of special interest not only for gynecologists, but also for psychiatrists.
Diagnostic criteria for PMDD according to DSM V include 11 symptoms, with 10 of them related to psycho-emotional and behavioral disorders. The symptoms are said to cause significant impairment. Symptoms characteristic of PMDD include: depressed mood, anxiety and tension, mood lability, irritability, decreased interest in daily activities, decreased concentration, fatigue and weakness, changes in appetite, sleep disturbance, impaired self-control, physical symptoms (mastalgia, joint pain, swelling, etc.). To establish the diagnosis of PMDD, at least five of the listed symptoms must be present, among which at least one is associated with mood [19].
PMS is an interdisciplinary problem. Various specialists should be involved in the examination of women with PMS: a psychiatrist, a therapist, a neuropathologist, etc.
For an accurate diagnosis of PMS, special attention should be paid to the time of onset of symptoms (regular manifestation in the luteal phase) and their negative impact on a woman’s daily life [20, 21].
Currently, the most reliable and effective method for diagnosing and quantifying PMS is the prospective daily assessment of symptoms by patients in a special diary or menstrual symptom calendar. A symptom diary should be completed by patients prior to initiating any therapy [11].
There are a large number of patient-centered questionnaires for identifying PMS. However, The Daily Record of Severity of Problems (DRSP) is the most commonly used and is simple and straightforward to use [15]. DRSP provides reliable and reliable information about the presence of symptoms and the deterioration of the patient’s condition [22].
Before starting any type of therapy, it is necessary for the patient to fill out a symptom diary for at least 2 consecutive menstrual cycles. If therapy is started early, treatment may improve symptoms but mask existing PMS [11].
Recently, electronic registration systems have appeared to assess the symptoms of PMS, taking into account the individual characteristics of the patient.

Treatment

Taking into account the polyetiology and multifactorial nature of PMS, various methods of therapy are offered. The tactics of therapy largely depend on the predominance of certain symptoms of PMS. But nevertheless, there are a number of drugs and areas of therapy, characterized by proven therapeutic efficacy in women with PMS.

First line therapy

Drospirenone-containing combined oral contraceptives (COCs) are effective in suppressing the symptoms of PMS and are used as the first line of pharmacological treatment [11]. According to a Cochrane systematic review that included 5 randomized clinical trials (RCTs) and 1920 participants, taking COCs (drospirenone (DRSP) 3 mg + ethinylestradiol (EE) 20 mcg) for 3 months, compared with taking placebo or alternative COCs ( 150 mcg desogestrel/150 mcg levonorgestrel), significantly reduced symptom severity in women with PMDD (RR 7. 92; 95% CI -11.16 to -4.67) [23].
Existing studies indicate the superiority of the continuous use of COCs over the cyclic regimen [11]. Continuous use of COCs (3 mg
DRSP + 20mcg EE) for 364 days was significantly more effective in suppressing PMS symptoms than the 21/7 regimen. During the first 6 months breakthrough bleeding was noted in 56% of patients, which could be controlled by a 3-day break in taking COCs [24].
Selective serotonin reuptake inhibitors (SSRIs) are the first line of pharmacological non-hormonal therapy for VUR [11]. According to the ISPMD Consensus IV recommendations, obstetricians and gynecologists treating women with PMS/PMDD should have professional knowledge of SSRIs, their mechanism of action and side effects [25]. A Cochrane systematic review of placebo-controlled trials showed that SSRIs (fluoxetine, paroxetine, sertalin) lead to an effective reduction in the severity of psychological and physical symptoms compared with placebo [26]. SSRIs in the treatment of women with PMS can be effective both when taken in the luteal phase of the cycle, and when taken continuously [26]. Women with VUR taking SSRIs should be advised of possible side effects such as nausea, drowsiness, insomnia, fatigue, and decreased libido [26]. The use of citalopram or escitalopram (10 mg/day) can lead to resolution of PMDD symptoms when other SSRIs may not be effective, their use in the luteal phase (15–28 days of the cycle) has been found to be the best [27]. At the planning stage and during pregnancy, SSRIs should be discontinued due to their possible teratogenicity, and also taking into account the regression of PMS during pregnancy [28]. When taking SSRIs in the luteal phase, they can be canceled on any day of the cycle, and when taken continuously, the dosage of SSRIs should be gradually reduced over 3–4 weeks to avoid withdrawal symptoms [26].

Second line therapy

The second line of therapy includes the use of transdermal estradiol in combination with cyclic progestogens, which have also shown to be effective in managing the physical and psychological manifestations of severe forms of PMS [11, 29]. Together with transdermal estradiol, a cyclic (10–12 days/cycle) course of oral or vaginal progesterone or LNG-IUD 52 mg should be used to prevent endometrial hyperplasia [11, 29]. When using transdermal estrogen, it is recommended to prescribe as low doses of progesterone or progestogen as possible in order to minimize their side effects. Micronized progesterone (100 mg) is the first line for progestogen opposition (10-12 days/cycle) when using transdermal estradiol, because it rarely leads to PMS-like manifestations [11]. Micronized progesterone can also be taken vaginally. This route of administration is better tolerated due to bypassing the hepatic metabolism of the drug and therefore preventing the formation of psychoactive metabolites such as allopregnanolone [30, 31]. It should be taken into account that LNG-IUD 52 mg as a progestogenic opposition at the initial stage of use can cause PMS-like side effects [32]. When using estradiol for PMS, women should be informed that there is currently not enough evidence on the long-term effects of such therapy on breast and endometrial tissue.
Higher doses of SSRIs, such as citalopram/escitalopram 20–40 mg continuously or only in the luteal phase of the cycle, are also considered second-line therapy for PMS [11].

Third line therapy

Gonadotropin-releasing hormone (GnRH) analogues inhibit the production of ovarian steroids and therefore cause radical improvement or complete resolution of symptoms in patients with underlying VUR. A meta-analysis of 7 studies showed the effectiveness of GnRH analogues in the treatment of VUR (RR 1.19; 95% CI –1.88–0.51) [33]. However, since they reduce bone density, they are mainly recommended for use only in severe cases or for clarifying the diagnosis of PMS [11].
The use of GnRH agonists for 6 months. and more require “return therapy” in the form of combined hormone replacement therapy or tibolone. Long-term combination therapy or tibolone, in contrast to sequential (cyclic) combination therapy, minimizes PMS-like progestogen side effects [34].
Long-term use of GnRH requires constant monitoring of bone density. Dual Energy X-Ray Absorptiometry (DEXA) is the “gold standard” for bone density testing
tissues [35]. It is recommended to conduct this study every 2 years and, in case of a significant decrease in bone density, stop taking GnRH analogs [36].

Fourth line therapy

Severe PMS in most cases successfully responds to drug therapy, but if it is ineffective, as well as in the presence of concomitant diseases of the uterus, hysterectomy with bilateral oophorectomy is justified [11].
Testosterone replacement should also be considered, as the ovaries are the main source of testosterone production (50%), and androgen deficiency can lead to libido suppression [37].
It is important to note that the cessation of drug treatment leads to the return of premenstrual symptoms. Treatment of PMS should be carried out for a long time, which dictates special requirements for the choice of safe therapy [11].
In the treatment of women with PMS, an integrated comprehensive approach to therapy is needed. Additional non-hormonal treatments are especially relevant if a woman has contraindications for taking hormonal drugs [11]. According to a cross-sectional study, cardio training and physical activity improve the course of PMS [8]. Exercise has been shown to reduce symptoms of PMS and lower late luteal phase hormone levels, so an exercise program may be useful as a component of complex therapy for progestogen-induced VUR [38].
The results of RCTs [39] testify to the effectiveness of cognitive-behavioral therapy, both individual and group forms. The British Royal College of Obstetricians and Gynecologists Guidelines for the Management of Women with PMS (2017) also indicate that cognitive behavioral therapy should be used as a routine treatment for severe PMS [11].
The polyunsaturated fatty acids in evening primrose oil (1 or 2 g/day) have been shown to be effective in improving premenstrual symptoms in a prospective randomized trial. Significant changes in blood cholesterol levels were not observed [40].
In a systematic review of the effectiveness of herbal medicines in the treatment of PMS, 4 studies (involving almost 600 women) supported the use of Vitex agnus castus [41]. According to 4 of 5 discrete placebo-controlled studies and 2 comparative studies, Vitex agnus castus is more effective than placebo, vitamin B ₆ (pyridoxine 200 mg/day) and magnesium in the treatment of PMS [42] . In another study in women with PMDD, Vitex agnus castus was comparable in therapeutic efficacy to fluoxetine [41]. The safety of use of Vitex agnus castus is rated as excellent, with rare and mild side effects [42, 43]. According to the latest meta-analysis in 2017, 13 of 14 placebo-controlled studies reported a positive effect of Vitex agnus castus in suppressing PMS symptoms. The authors emphasize the feasibility of further high-quality comparative efficacy studies Vitex agnus castus with SSRIs and COCs [44].
Currently, Vitex agnus castus is part of Mastodynon ^® , Cyclodinone ^® preparations, which are characterized by impeccable quality. The quality guarantor is the company Bionorica (Germany), which is the world leader in the manufacture of medicines from plant materials.

Conclusion

Approaches to the treatment of women with PMS may differ depending on the type of premenstrual disorder [11].
If the symptoms of PMS are cyclical and disappear with the onset of menstruation, after which there is an asymptomatic period, one should think about the main premenstrual disorder (PMS or PMDD). However, it is worth differentiating basic VUR from physiological (mild) VUR, in which a woman notes the presence of PMS symptoms, but they do not affect her quality of life. In this case, unlike the main VUR, specific therapy is not required [11]. In the treatment of mild VUR, which are classified as major, it makes sense to start treatment with herbal medicines containing Vitex agnus castus .
Some diseases (diabetes mellitus, bronchial asthma, migraine, epilepsy, depression) are characterized by an increase in symptoms in the luteal phase of the cycle – a premenstrual exacerbation of the underlying disease.