Radical hysterectomy or oophorectomy for severe PMDD

Hi,

I'm a 40 year old woman who has bipolar II disease. I've also got severe PMDD which makes life very difficult bipolar-wise two weeks out of every month. Basically my bipolar symptoms are uncontrollable on certain days of the month due to my cycle. I have to do everything within my power to keep my bipolar disease from ruining my life. The hormone cycling with my period has been directly responsible for missed days from work and partially responsible for one mental health hospitalization.

For the past 6 months I've been on Depot Lupron to see what it would be like if my hormones don't fluctuate, but rather just experience a steady state of estrogen with the Add Back. It's been heaven. I've never felt so good. The problem is that you're only supposed to be on Depot Lupron for 6 months. My gyno is willing to keep me on it longer, but I obviously can't stay on it indefinitely.

We talked about long term options yesterday. 1.) I could go on Depo Provera 2.) remove my ovaries 3.) LAVH.

I'm hesitant to go on Depo Provera. I have weight gain problems already with the drugs I take for my bipolar disease. Switching my bipolar drugs isn't an option because it's taken years to find a combination that works but doesn't leave me feeling dead inside. I know I don't gain weight on the Depot Lupron, which is why I'd like to stay on it a little longer.

I guess what I need help with is deciding between the two surgeries. I understand the physical difference between the two, but I don't understand the after effects of both. I've heard that with the LAVH I'd only have to take estrogen afterward, which would be similar to what I'm doing now. With the oophorectomy I've heard that I'd have to be on both progesterone and estrogen and that progesterone is the one that causes mood swings and irritability. Is this true?

The other thing to take into consideration is that my gyno thinks it'd be easier to get the LAVH through my insurance due to my history (heavy bleeding and pelvic pain). My insurance is pretty good for routine things, but I'm afraid saying I want surgery to help with a mood disorder won't fly with them.

Mostly, I'm looking for advice.

I know my reason for wanting this surgery is unusual, but I can't go through 10-15 more years of the monthly roller coaster ride.

Also, does an LAVH remove the ovaries? I'm confused about that.

Thanks!

First, the LAVH is a laparoscopic assisted vaginal hysterectomy. It has nothing to do with the ovaries. If you had only the LAVH, it would not solve your issue if the problem is ovarian fluctuation. Following the LAVH, you would not take estrogen as you would still have your ovaries. Your option to find a steady hormone level would then be the Lupron, Depo Provera, or some type of birth control.

If you have an oophorectomy only, retaining your uterus, then you would need to use both progesterone and estrogen because estrogen alone could allow the lining of the uterus to thicken and lead to uterine cancer.

If you had both the LAVH and BSO (removal of the complete uterus and both ovaries), then you could theoretically use a steady does of estrogen only.

One problem you need to consider is that some women find that how they felt on Lupron does NOT reflect surgical menopause. Some actually found that surgical menopause was worse and finding the right HRT balance was difficult. There is no way to know in advance if that would occur for you but you would want to keep it in mind because of the nature of your particular symptoms and circumstances.

Have you had a second opinion about what your options might be? I would suggest one before you make any final decisions.

Also, yes, there are risks with Lupron long term. However, I would recommend speaking to some specialists about the specific risks and if there were safe ways to combat them for you. Your pros for using Lupron long term might outweigh the cons of using it long term. There are doctors who are using it more long term in some patients with specific issues.

Additionally, talk to your doctors about options that might allow you to try the Depo Provera while combating the possible weight issues. As you are not experiencing all the symptoms some women do with Lupron, including weight gain, you might not experience all the symptoms some women do with Depo Provera, including weight gain.

I wonder if an aromatase inhibitor with add back therapy might be an out of the box option for you? It stops all estrogen production by the ovaries and fat cells. Just a thought that you might want to throw out there!

Finally, don't make any final decisions until you have sat down and talked to whomever helps you manage the bi-polar. That doctor may have some additional ideas and/or could make sure to help you though the entire process of figuring out what to do and keeping you as steady as possible through the recovery and finding the right hormonal balance.

I know this is not going to be easy and my goes out to you. I have male family members with bi-polar so I know that is difficult enough without throwing in PMDD!