Rarely, for very severe or refractory symptoms, a gonadotropin-releasing hormone (GnRH) agonist (eg, leuprolide 3.75 mg IM, goserelin 3.6 mg subcutaneously every month) with low-dose estrogen / progestin (eg, oral estradiol 0.5 mg once a day plus micronized progesterone 100 mg at bedtime) is given to minimize cyclic fluctuations.