Endocrine Abstracts

A 41-year-old lady presented with a long history of very severe premenstrual dysphoria, commencing 2 weeks prior menstruation. Her symptoms included behavioural problems and in particular aggression, impaired memory, palpitation, bloating and diarrhoea. She also experience cyclical left head and left eye pain without visual symptoms. She was para 3+0 with a past medical history of polycystic ovary syndrome, eventually treated by ovarian diathermy. During pregnancy her symptoms resolved, but subsequently they did not improve during three cycles of subcutaneous goserelin acetate implant.

Previous unsuccessful treatments included tricyclic antidepressants, serotonin uptake inhibitors, vitamin B complex, Gamolenic acid and various ‘natural’ remedies. On Dianette and other combined oral contraceptive pills, both with and without a pill free week, she felt worse. Treatment with continuous oestrogen following insertion of a Mirena intrauterine device was unsuccessful as she was unable to tolerate the device.

Family history included primary hyperparathyroidism, primary thyroid failure, type 1 diabetes, stroke and depression. Investigations showed a normal short synactin test, bone profile, renal function, thyroid function, prolactin, ESR, full blood count and CT brain.

As her symptoms had become increasingly intolerable, she was treated with Nafarelin 200 μg intranasally bd, followed 2 months later by the addition of continuous combined hormone replacement therapy, using oestradiol hemihydrate 1 mg and dydrogesterone 5 mg. She did not menstruate for the first 2 months and felt tired and lethargic. However, following the addition of HRT her symptoms completely resolved.

After 8 months she experienced some menstrual bleeding and recurrence of her dysphoric symptoms. Nafarelin was therefore increased to 400 μg bd and her add back changed to Tibolone 2.5 mg daily. This was followed by a complete and persistent resolution of symptoms.