Hysterectomy and oophorectomy for PMDD: does it work?

Removing the ovaries (bilateral oophorectomy) can relieve PMDD, because it stops the monthly rise and fall of estrogen and progesterone that your brain reacts to. PMDD is a different reaction to normal hormone changes, not a sign of abnormal hormone levels. The surgery works by removing the hormone cycle itself, not by correcting a hormone level.

Hysterectomy on its own, removing only the uterus, leaves the ovaries in place and cycling. It stops your periods and any bleeding problems, but it doesn't stop the hormone pattern linked to PMDD, so it isn't expected to resolve PMDD symptoms by itself.

This comes down to two separate questions, and the answer depends on which one:

• Removing the uterus alone: usually doesn't help, since the ovaries keep cycling hormones.
• Removing the ovaries (oophorectomy): can help, since it stops the hormone cycle PMDD responds to.

Guidelines treat surgery as a last resort, used only after SSRIs, hormonal options and therapy haven't given enough relief, and usually after a reversible trial confirms it's likely to help. For more on those earlier options, see PMDD treatment: what actually helps.

The research specific to PMDD surgery is thin. Most of what's published is small, observational or decades old, not large trials built to test PMDD outcomes directly.

A 2010 review of oophorectomy at the time of hysterectomy found relatively little high-quality evidence either way for premenstrual syndrome, and noted that surgical menopause carries long-term risks to the heart, brain and mood that need weighing against the benefit (paper 1).

A randomized trial comparing hysterectomy with a less invasive procedure (endometrial resection) for heavy periods found premenstrual symptoms had improved in 77% of hysterectomy patients, versus 43% of those who'd had the resection, about three years on. That trial was about heavy bleeding, not diagnosed PMDD, and didn't separate out whether the ovaries were removed (paper 2).

One older study gave estrogen and progesterone back to nine women who'd already had hysterectomy and oophorectomy for severe PMS, to see if it brought symptoms back. Across the group, symptom scores didn't line up neatly with hormone levels, though a few individual women did show a clear link (paper 6).

For a broader look at the evidence base, see PMS and PMDD research, summarised.

Oophorectomy drops estrogen and progesterone within days, since the ovaries that produced them are gone. For most women, that's a fast, permanent end to the monthly hormone swing PMDD responds to.

But fast hormonal change isn't the same as fast symptom relief. The first weeks after surgery often bring surgical menopause symptoms of their own, hot flashes, sleep disruption, low mood, which can make it hard to tell what's PMDD easing and what's new.

Guidelines recommend starting hormone replacement therapy (HRT) around the time of surgery for most premenopausal women, both to manage surgical menopause and to protect long-term health. One review found this conversation often happened late or not at all: of 36 women who had bilateral oophorectomy for benign reasons including PMS, only 5.6% had HRT discussed with them before surgery, and 41.7% never had it discussed at all (paper 4).

There's no published timeline specific to PMDD symptom relief after oophorectomy. If you're considering it, ask your surgeon what to expect week by week, and how HRT will be timed.

This surgery ends fertility immediately and causes surgical menopause, which is more abrupt than a natural one. Side effects include:

• Hot flashes, night sweats and disrupted sleep
• Vaginal dryness and changes in sex drive
• Lower bone density over time without hormone replacement
• A higher long-term risk of cardiovascular disease
• Possible changes in mood, memory or thinking (paper 1)
• Needing hormone replacement therapy, with its own risks and benefits to weigh

Surgical risks apply too. A study of vaginal hysterectomy done as day surgery found a 1.4% rate of complications during the operation and a 6.2% rate of needing to return to hospital afterward (paper 5). Rates vary by surgical approach and whether the ovaries are removed at the same time.

The surgery can't be undone. If PMDD doesn't improve afterward, or another cause turns out to explain your symptoms, there's no way to restore ovarian function.

Oophorectomy for PMDD isn't right for everyone, and guidelines are cautious about it. Avoid or delay it if:

• PMDD hasn't been confirmed with daily symptom tracking over at least two cycles, since PMS, PMDD and other conditions that worsen before your period can look similar
• You haven't yet tried SSRIs, hormonal options or therapy, which help many women without surgery
• You're still considering pregnancy, since oophorectomy ends fertility
• You haven't had a reversible GnRH agonist trial to see whether stopping ovarian hormones actually helps your symptoms
• Your surgeon hasn't discussed hormone replacement therapy with you beforehand

A 2022 review of over 4,000 hysterectomies listed a preoperative PMDD diagnosis, without other supporting findings, as one of the criteria that made bilateral oophorectomy avoidable (paper 3). A PMDD specialist can help confirm the diagnosis properly first, and the DRSP chart is the daily tracking tool guidelines use to do that.

Even with surgery, most women benefit from some of the same supports used before it. CBT can help with the thought patterns and relationship strain PMDD brings, and that doesn't change once ovaries are gone.

If you've had a hysterectomy without oophorectomy, PMDD treatment still means treating the ovarian cycle: SSRIs (sometimes only in the days before symptoms would start), hormonal options, or a further conversation about oophorectomy if nothing else has worked.

After oophorectomy, hormone replacement therapy is usually part of ongoing care, both for surgical menopause symptoms and long-term health. Your dose and type are a decision for your doctor, based on your health history.

For the full range of non-surgical options and how they compare, see PMDD treatment: what actually helps. If you're earlier in working out whether what you have is PMDD or PMS, PMDD, explained covers how the diagnosis works, and hysterectomy and oophorectomy for PMS covers the related question for PMS rather than PMDD.

Surgery, if it happens at all, is likely months away. Tonight you need something for the wave in front of you.

Leave the room before you say something you can't take back. Tell whoever you're with that you need 20 minutes and that you'll come back, then set a timer.

Breathe out for six counts longer than you breathe in. That slows your heart rate even while the feeling is still loud.

Niyora is a PMS and PMDD support app. If you want somewhere to put a fight before you answer, Niyora's Moon lets you write down what happened, see it from another angle and draft a reply you can hold for 20 minutes. It's on iPhone, with Android coming soon.