Q. One of my middle-aged patients has a fairly long history of binge eating that I think may be related to her premenstrual dysphoric disorder. Now she is considering surgery for her premenstrual dysphoria. Is this common? (J. Anderson, Clearwater, FL)
A. Premenstrual dysphoric disorder is a depressive disorder described in the DSM-5, and the most severe form of premenstrual distress. Some 3% to 5% of premenstrual women are affected by it. A recent case study from Norway may provide some helpful information (J Eat Disord. 2018; 6:35). Drs. Camila Dahlgren and Eric Qvigstadt describe the case of a 39-year-old woman who was referred from a secondary heath center specializing in obstetrics and gynecology. She was seeking a second opinion about having bilateral oophorectomy to treat her symptoms; she and her husband had no children and did not wish to have any. The patient had struggled with symptoms for more than a decade, and reported affective lability, irritability, anger, and interregnal conflicts, as well as depressed mood and anxiety. These symptoms had not responded adequately to oral contraceptives, individual counseling, couple’s counseling, or antidepressants More conservative measures, including a 3-month trial of GnRH agonist injections (Procren®) had been unsuccessful, which led the couple to consider the surgically option. She also had a trial of estrogen replacement therapy.
The patient also reported having struggled with eating and weight problems since the onset of the premenopausal dysphoric disorder, although she had no history of a diagnosis of an eating disorder. Her cravings appeared as a marked increase in appetite and specific food cravings at about the time of ovulation, and increased exponentially until the onset of her menstrual period.
Her uncontrollable food intake nearly always took place when she was home alone, where she consumed large amounts of highly palatable foods; even a handful of nuts or a piece of chocolate could trigger overeating and the patient tried to avoid having such “trigger foods” at home. Her overeating was followed with a strong sense of shame and disgust and a need to restrict food intake.
After thorough consultation, the patient and her husband opted for bilateral salpingo-oophorectomy, or removal of both ovaries and both fallopian tubes, to induce surgical menopause.
After surgery, follow-up at 4, 8, and 12 weeks, as well as at 6-months post-surgery, the patient reported that all previous premenstrual dysphoric symptoms were gone, and she now had no adverse effects. In fact, she described the period after surgery as “a period of inner peace” she had not felt for years.
The authors believe this is the first study to document recovery from a long-standing eating disorder, according to the DSM-5, after bilateral salpo-oophorectomy. They also recommend that surgery be considered only as a last resort, when hormonal treatment fails.
This case highlights that premenopausal dysphoria disorder and disordered eating can co-occur. Some treatment approaches for the disorder may be of benefit for eating disorder symptoms, either through direct effects or via improving mood. The use of surgery should undoubtedly be reserved for rare cases.