Hysterectomy and oophorectomy for PMS: does it work?

Removing the uterus can ease some premenstrual symptoms, but it doesn't stop the hormone swings that drive PMS unless the ovaries come out too. PMS tracks the rise and fall of estrogen and progesterone each cycle, not the uterus itself.

A hysterectomy that leaves the ovaries in place stops periods and period pain, but the ovaries keep cycling on their usual schedule. Without a period to mark the pattern, cyclical mood and physical symptoms can keep happening and go unrecognized (Menopause, 1998).

Removing the ovaries too (bilateral oophorectomy) stops that cycle completely, but it isn't a guaranteed fix either. It's a bigger step than hysterectomy alone, and it brings on immediate surgical menopause rather than targeting the diagnosis itself.

No trial has tested hysterectomy in women diagnosed with PMS specifically. What we have instead comes from trials of women having surgery for heavy periods, where premenstrual symptoms were tracked as a side finding, not the main question.

Most of the evidence comes from trials of hysterectomy for heavy periods (menorrhagia), with premenstrual symptoms tracked as a secondary outcome. Treat the numbers below as suggestive, not definitive for a PMS diagnosis.

In one trial of 200 women, satisfaction was about 9 percentage points higher after hysterectomy than after endometrial resection (95% CI 1.1 to 17.5%), and premenstrual symptoms like bloating and breast tenderness were less frequent after hysterectomy (BJOG, 1993). A larger trial of 196 women found 57% of those who'd had endometrial resection reported no improvement in premenstrual symptoms, compared with 23% of those who'd had hysterectomy (BJOG, 1996).

Not every trial agrees. A Finnish trial of 236 women randomised to hysterectomy or a hormone-releasing IUS found premenstrual symptoms eased by a similar amount in both groups by six months. The researchers concluded the effect of either treatment on premenstrual syndrome specifically 'remains unsettled' (Acta Obstet Gynecol Scand, 2012).

Recovery and symptom change run on different timelines. Recovery itself takes about two to three months after hysterectomy, compared with two to four weeks after endometrial ablation or resection (BMJ, 1994).

If the ovaries stay in place, the hormone cycle carries on as before, so any change in premenstrual symptoms shows up gradually, measured the same way trials measured it: at six and twelve months, with some improvements still visible four to five years later (BJOG, 1999).

If the ovaries come out too, the hormone drop is immediate. Surgical menopause starts within days, so hot flashes and other menopause symptoms can begin almost right away, while any easing of the premenstrual pattern happens because the cycle has stopped, not because it fades slowly.

Hysterectomy carries surgical risk on top of any hormone effects.

• Surgical risks: bleeding, infection, or injury to the bladder or bowel. One day-case vaginal hysterectomy study found a 1.4% intraoperative complication rate (BJOG, 2007).
• Recovery time: about two to three months before you're fully back to normal activity (BMJ, 1994).
• Surgical menopause, if the ovaries are removed too: hot flashes start almost immediately, and the long-term risk to heart, cognitive, sexual and mental health is higher than with the ovaries left in place (Hum Reprod Update, 2010).
• Mood: hysterectomy often lifts mood once the physical problem driving it is gone, but when the ovaries are also removed, the sudden hormone loss can bring on depressed mood, especially without hormone replacement (Menopause, 1998).

None of this makes hysterectomy the wrong choice for everyone. It means weighing these risks against how much PMS is affecting your life, with a doctor who can walk through both.

Hysterectomy is hard to reconsider once it's done, so a few things are worth ruling out first.

• You haven't tried reversible options yet, or haven't confirmed your symptoms actually track the hormone cycle.
• You want to keep the option of carrying a pregnancy.
• You're younger: removing the ovaries earlier means more years living with surgical menopause and its longer-term risks (Hum Reprod Update, 2010).
• You have other surgical risk factors a doctor hasn't assessed yet.

Tracking symptoms for two cycles on a Daily Record of Severity of Problems (DRSP) chart is the step most doctors want to see before surgery is even discussed.

Most women try reversible options long before surgery comes up. PMS treatment: what actually helps covers the usual first steps, from lifestyle changes to SSRIs taken only in the second half of the cycle.

If your pattern looks more like PMDD than PMS, the evidence picture is different. See hysterectomy and oophorectomy for PMDD for that version of this question, and what is PMS? Premenstrual syndrome, explained if you're not sure which one fits.

After hysterectomy with oophorectomy, estrogen replacement, sometimes combined with testosterone, can lower the risk of depressed mood that follows the sudden hormone drop (Menopause, 1998). A doctor decides whether that's right for you and for how long.

Finding a doctor who treats premenstrual conditions as the main problem, not a side note, makes the whole process easier. Finding a PMDD specialist is a place to start even if your diagnosis turns out to be PMS. For more of the evidence behind these options, see PMS and PMDD research, summarised.

Surgery, if it happens at all, is weeks or months away. Tonight you need something you can do now.

1. Leave the room if you're mid-argument, and say you'll be back in 20 minutes.
2. Breathe out for six counts, longer than you breathe in, until the edge comes off.
3. Write down what actually happened, not just how you feel about it, while it's fresh.

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