Ovulation suppression

1. Less complex hormonal therapies include OCs and progestins. OCs (especially triphasic formulations) may decrease the cyclical symptoms of PMS, although they may worsen symptoms in a subset of patients.

2. Medroxyprogesterone acetate (Provera), 30 mg PO qd, may alleviate symptoms. Once the symptoms resolve, drug therapy may be switched to medroxyprogesterone acetate injections (Depot-Provera), 150 mg IM, every 3 months.

3. Ovarian suppression with GnRH agonists induces menopause. PMS symptoms will be relieved, but patients experience menopausal side effects, including irritability, insomnia, hot flashes, and vaginal dryness. To prevent osteoporosis, add-back therapy with estrogen and progesterone is required.

4. Leuprolide (Lupron Depot), 3.75 mg IM each month, or nafarelin (Synarel), 400-800 pg qd intranasally are effective. Conjugated equine estrogen, 0.625 mg, with medroxyprogesterone acetate, 2.5 mg given daily will provide adequate estrogen for cardioprotection and shield the bones from calcium breakdown.

5. Danazol, 200 mg qd-bid, is effective in decreasing the symptoms of PMS. Side effects include hirsutism, acne, and weight gain.

6. Surgery. Oophorectomy is reserved for patients whose symptoms have resolved completely for 4-6 months with GnRH agonists, who have completed child bearing, and who require more than 5 years of long-term suppression. References: See page 195.

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