Department of Obstetrics and Gynaecology, Westfries Gasthaus, 1620 AR Hoorn, Netherlands
Email: renckens{at}xs4all.nl
Sir,
A curious coincidence: the publication of the paper by Cronje et al. (2004) on hysterectomy and bilateral oophorectomy for severe premenstrual syndrome and the death of Katharina Dalton (19162004), a pioneer and populariser of the illness PMS on September 17 in Britain. In O'Connor's obituary in the New York Times of 28 September, Dr Shangold, a gynaecologist is quoted as saying Many people did not believe it was a real entity. She continued: She really brought it into the public eye, and eventually it became an accepted disorder for which we now have good treatments. She did not elaborate on these treatments, of which I am not aware at all, but I certainly do not think that the treatment as proposed by Cronje et al. could qualify in this respect.
I really thought that the old times in which women with psychiatric symptoms were operated upon by gynaecologists was long behind us, but I am wrong. In a retrospectively mortifying period in the history of our profession, from about the 1870s until 1910, many women were castrated by the so-called normal ovariotomy, which was called Battey's operation by J.Sims, as others underwent clitoridectomies for nymphomania. In Europe the German gynaecologist Hegar performed many of these operations, while in the US this role was performed by Battey. The details of this history can be found in the instructive chapter Gynaecological Surgery and the Desire for an Operation in Shorters excellent book (1992) on the history of psychosomatic illness.
We think that PMS is a psychosomatic illness in which the contribution of abnormal ovarian function has never been proven. Since 1983 it is called Late luteal dysphoric disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM). It is there that it belongs, and not in books on gynaecologic surgery. Treatment for this type of functional syndrome should be along psychosocial lines and not even the most severe symptoms should be taken as an indication for the removal of healthy organs.
In this kind of illness (cf Charcot's grande hysterie, chronic fatigue syndrome, postnatal depression, post-whiplash syndrome etc.) there is a striking contrast between the extreme visibility of the symptoms and the lack of objective findings. Although this category of patients do seek a medical solution for their problems, doctors should refrain from medical treatments, as the problem is incurable with conventional medical modalities such as surgery or medicines.
The apparently successful and sustained cures of PMS by hysterectomy and oophorectomy, as reported by Cronje et al. (2004) can be explained in other ways. It is well known that surgery does have strong placebo effects (Johnson, 1994
) and the PMS sufferer initially gets all the rewards that a sickness role in our society provokes. After recovering from surgery these women are converted into chronic patients, depending on hormone replacement therapy and this again will please most of them, because of the prolonged attention this entails. It should be possible to manage these women in other ways and medical treatmentespecially surgeryshould in my opinion be avoided in all cases.
References
Cronje WH, Vanisht A and Studd JWW (2004) Hysterectomy and bilateral oophorectomy for severe premenstrual syndrome. Hum Reprod 19, 21522155.
Johnson AG (1994) Surgery as a placebo. Lancet 344, 11401142.[ISI][Medline]
Shorter E (1992) Gynaecological Surgery and the Desire for an Operation. In: From Paralysis to Fatigue. A History of Psychosomatic Illness in the Modern Era. Free Press, New York, pp. 6994.