Blog of the Society for Menstrual Cycle Research

Is PMS Overblown? That’s What Research Shows

October 24th, 2012 by Elizabeth Kissling

If PMS is a myth, then what on earth can we blame for all the lady-rage?

Photo by Flickr user dearbarbie // CC 2.0

You may have seen the article in The Star or The Globe and Mail or The Atlantic about the recently published research review by a team of medical researchers who assert that “clear evidence for a specific premenstrual phase-related mood occurring in the general population is lacking.” Judging from the headlines and the online comments, this proposition is surprisingly controversial–probably because the headlines were frequently misleading, suggesting the findings are much broader than they are. Some online commenters are especially angry, insulting the intelligence and methods of the researchers, proclaiming that of course hormones affect moods, as does menstrual pain, citing examples of their own or their wives’ experience.

But Sarah Romans, MB, M.D.; Rose Clarkson, M.D.; Gillian Einstein, Ph.D.; Michele Petrovic, BSc and Donna Stewart, M.D., DPsych–the five medical scholars who reviewed all the extant studies of PMS based on prospective data–did not claim in the now-infamous Gender Medicine review study that PMS does not exist, or that hormones do not affect emotion or mood. The variety of research methods used in other studies prevented them from conducting a meta-analysis–a statistical technique that allows researchers to pool results of several studies, thus suggesting greater impact–so the authors instead looked at such study characteristics as sample size, whether the data was collected prospectively or retrospectively (that is, at the time of occurrence or recalled from memory), whether participants knew menstruation was the focus of the study and whether the study looked at only negative aspects of the menstrual cycle. Although their initial database searches yielded 646 research articles dealing with the menstrual cycle, PMS, emotions, mood and related keywords, only 47 studies met their criteria of daily prospective data collection for at least one full cycle.

When the authors scrutinized these studies, they found that, taken together, there is no basis for the widespread assumption in the U.S. that all (or even most) menstruating women experience PMS. In fact, only seven studies found “the classic premenstrual pattern” with negative mood symptoms experienced in the premenstrual phase only. Eighteen studies found no negative mood associations with any phase of the menstrual cycle at all, while another 18 found negative moods premenstrually and during another phase of the menstrual cycle. In other words, the symptoms these women experienced were not exclusively premenstrual, making the label inaccurate. Four other studies found negative moods only in the non-premenstrual phase of the cycle.

So let’s be fair, angry online commenters (and careless journalists): The researchers aren’t telling you menstrual pain is all in your head, or that your very real period pain won’t affect your mood. Sarah Romans did tell James Hamblin of The Atlantic,

The idea that any emotionality in women can be firstly attributed to their reproductive function—we’re skeptical about that.

Rightly so–feminists have been saying this for decades. Feminist critiques of PMS as a construct point to both the ever-increasing medicalization of women’s lives and the dismissal of women’s emotions, especially anger, by attributing them to biology.

Part of what makes PMS difficult to study, and difficult to talk about, is the multiple meanings of the term. In the research literature, there are more than 150 symptoms–ranging from psychological, cognitive and neurological to physical and behavioral–attributed to PMS. There is no medical or scientific consensus on its definition or its etiology, which also means there is no consensus on its treatment.

In everyday language, its meaning is even more amorphous. Some women and girls use PMS to mean any kind of menstrual pain or discomfort, as well as premenstrual moodiness. Some men and boys, as well as some girls and women, use it to diminish a woman’s or girl’s emotions when they disagree with her, or want to dismiss her opinions, or are embarrassed by her feelings.

Even researchers are influenced by entrenched cultural meanings. Romans and her colleagues observed that none of the 47 studies analyzed variability in positive mood changes, which they attribute to biases of the researchers. Many women have reported anecdotally that they feel more energetic, more inspired or other positive feelings during their premenstrual phase, but this is seldom studied or regarded as a “syndrome.” Romans and colleagues note that most measures of menstrual mood changes only assess negative changes, so even if positive changes are occurring, researchers are missing them. They also cite research indicating that both women and men tend to attribute negative experiences to the menstrual cycle, especially the premenstrual phase, and positive experiences during the premenstrual phase to external sources.

Romans and her colleagues do not deny the existence of menstrual pain, or even the existence of PMS. What their study shows is that very few women experience cyclic negative mood changes associated with the premenstrual phase of their ovulatory cycle. PMS is not widespread, and the authors are careful to distinguish it from premenstrual dysphoric disorder (PMDD), which is rarer still. As Gillian Einstein, one of the researchers, told the Toronto Star, “We have a menstrual cycle and we have moods, but they don’t necessarily correlate.” She did not add, but I will, that it it is unfair and unreasonable to assume that every woman’s moods should be attributed to her menstrual cycle and to refuse to take her feelings seriously.

Cross-posted at Ms. blog.

PMDD: No News Is News, for the APA

July 11th, 2012 by Elizabeth Kissling

Guest Post by Joan Chrisler, Connecticut College

I have to admit that I have not been closely following the news about the forthcoming edition (5th) of the Diagnostic and Statistical Manual of Mental Disorders, which is expected to be published by the American Psychiatric Association in May 2013.  So, when our blog editor Elizabeth Kissling asked me to take a look at a recent update on PMDD in Psychiatric News, I was intrigued.  As I read the article I found myself becoming irritable, very irritable, even angry – but, don’t worry about me; I couldn’t possibly have PMDD, as I no longer menstruate.  No, my emotional lability has more to do with the psychiatrists’ tendency to play fast and loose with facts than it does with my physiology.

Photo by Ben Husmann // CC 2.0

The “news” begins with a statement that PMDD has been “proposed” to be included in the section on depressive disorders rather than in the appendix, which is reserved for disorders that need more study and shouldn’t yet be used clinically.  This is a canard.  PMDD appears in both the appendix and the depressive disorders section of the current edition – the DSM-IV-TR, which was published in 2000.  As a result, it is already being used clinically.  Perhaps what they really mean to say is that it is being removed from the appendix because we already know enough about it.  Hmmm.

Next, we are told that there has been an “explosion” of research on PMDD in the “past 20 years.”  Why 20 years?  PMDD was originally named Late Luteal Phase Dysphoric Disorder and proposed for listing in the DSM-II-R (1987); early research that was intended to support the new diagnosis was not convincing, which probably factored into the decision to change its name. The current edition of the DSM was published 12 years ago, and the original DSM-IV in 1995 (17 years ago).  According to PsycINFO, the largest psychology database, there have only been 259 articles published since the most recent edition of the DSM appeared, which hardly seems like an explosion, especially if we consider that many of them are about PMS, not PMDD.  Others are not empirical reports of studies about PMDD; they are literature reviews, critiques of the diagnosis, and articles about psychotherapy for women with the diagnosis. The 259 even include random studies of migraines, schizophrenia, bipolar disorder, and menopause.  The psychiatrists believe that these studies provide “greater legitimacy” for the diagnosis.  Sorry, but I am not convinced.

The news report indicates that the criteria have been sharpened to require the presence of at least five of eleven symptoms during “most” menstrual cycles of the previous year.  Prospective daily ratings are recommended, but it seems unlikely to me that most patients would be willing to wait or that most doctors would really insist that women rate themselves daily for a year before prescribing medication for PMDD.  Another change is that the symptoms must produce “clinically significant distress” and “interference” with work, school, relationships, or social activities. These require judgment calls: “clinical significance” is the doctor’s call, and “interference” is the patient’s call.

I predict that these “sharper” descriptions are still vague enough to be overused. Example: A student in one of my classes told me in all seriousness that her menstrual cramps interfered with her daily life because she had to take an aspirin occasionally.  Did she have to skip class and lay down with a heating pad?  No, she took her pill and went about her business.  “Then, how is that interference?”, I asked. “I don’t usually have to take an aspirin!”, she insisted. Now, I hope that that young woman is unusual, but I ask you to consider that the youth culture seems to value anything “extreme” and consider much of their experience to be unusual. My students think that (almost) everything is “awesome”, “incredible”, and “amazing”. If they were asked if their irritability is “extreme”, I suspect they would be much more likely than I would be to say “yes”.

Perhaps the most interesting (well, in a bad way) part of the news is that symptoms have been reordered to give priority to emotional lability, irritability, and anger and to deemphasize depressed mood. Why? “The work group agreed that clinically depressed mood is not the first thing you think of when you think of PMDD”.  Perhaps the work group is thinking about cultural stereotypes of premenstrual women!  If depressed mood is no longer a key criterion for PMDD, why is it still called PMDD?  Shouldn’t the work group have proposed a name change that would drop “dysphoric disorder”?  Why will it be continue to be classified with depressive disorders if it isn’t one?

Finally, the news report notes that how much distress and/or interference premenstrual symptoms produce depends on women’s personality, coping style, and life circumstances. Well, of course. There are many studies in the literature that show this. Stress, trauma, and even frequency of perceived discrimination (Pilver et al., 2011) predict severity of premenstrual complaints. There is much that psychotherapists can do to help women to manage their symptoms, but all the DSM suggests is drug treatment: SSRIs (selective serotonin reuptake inhibitors — the most commonly prescribed anti-depressants in the U.S.).

In conclusion, I refer readers to the SMCR’s resolution dated June 2001.  Women should continue to be cautious about whether their premenstrual symptoms constitute a mental illness and whether they want to take a strong anti-depressant medication for the rest of their menstrual lives. Other types of help, without potentially serious side effects and the stigma of a psychiatric diagnosis, might be effective.

For more information about PMDD and the DSM, see:

Caplan, P. J. (1995).  They say you’re crazy: How the world’s most powerful psychiatrists decide who’s normal.  Reading, MA: Addison Wesley.

Chrisler, J. C., & Caplan, P. (2003).  The strange case of Dr. Jekyll and Ms. Hyde: How PMS became a cultural phenomenon and a psychiatric disorderAnnual Review of Sex Research, 13, 274-306.

 

Problems with YAZ making news again

November 5th, 2010 by Elizabeth Kissling

An Oklahoma City news program prepared this investigation about health risks of Bayer’s best-selling birth control pill, YAZ, with dramatic personal stories. The video cannot be embedded here, but you can watch it and read the news story here.

Previous commentary and reporting about YAZ at re:Cycling: The Next YAZ, What’s Up with YAZ?, and The Future of YAZ. For more about YAZ, see the reporting of our friend, Holly Grigg-Spall, at Sweetening the Pill.


Because women aren’t medicated enough?

September 19th, 2010 by Elizabeth Kissling

ProzacSome of you may recall that in my book, Capitalizing on the Curse, I argued that the addition of PMDD to the DSM-IV and the re-branding of fluoxetine HCI as Sarafem are linked. It was no coincidence that pharmaceutical manufacturer Eli Lilly sought a unique FDA approval for Sarafem as treatment for PMDD just as the patent on Prozac, also composed of fluoxetine HCI, was about to expire. Eli Lilly initially secured the patent for Sarafem until 2007, and it is no longer the only FDA-approved treatment for PMDD.

Lilly must be in need of a new way to keep milking the cash cow. How fortunate that new research suggests that Prozac can relieve garden-variety PMS as well. A neuroscientist at the University of Birmingham presented research last week at the British Science Festival that asserts a 2mg daily dose of fluoxetine in the week before menstruation could alleviate PMS. She tested it for three years on rats. Of course, rats don’t actually experience PMS, so they were “induced to have PMS-like symptoms”.

Every time I read another article about new treatments for PMS, I remember Joan Chrisler’s comments about over-diagnosis of PMS and PMDD (which are both associated with high levels of relationship and family stress): “We’re conditioned to want a pill. Instead of something you might need more, like a nap or a divorce, or the ERA.”

Is PMDD Genetic?

March 9th, 2010 by Elizabeth Kissling

White lab mouse sitting in a gloved palm.

Guest Post by Amber Steele, University of Cambridge

There have been a couple of stories in the press recently touting a study by Joanna Spencer and colleagues suggesting that PMDD may be genetic. I had a cursory look through the paper and read the article. Changes in dendritic branching of neurons in the limbic system across the menstrual cycle, owing to changes in estrogen, has been well documented in the female mice and rat. Additionally, changes in neuronal activity and accompanying receptor activity is also well document during periods of hormone change, again in the female mice and rat models. Individual differences in how this change occurs and the fact that it can be linked to differences in genes make sense. It seems that Spencer et al., have identified one of probably many genes that mediates these differences. This is not the first time that a gene of this kind has been identified or implicated. For example, Susan Girdler at Chapel Hill has done some interesting work on PMDD and suggests a genetic i.e., differing protein response to a hormone, difference in response to progesterone that might, in part, explain symptoms associated with PMDD.

The fact that Spencer et al., found a relationship to anxious behavior does not say anything conclusively about PMS or PMDD. It only states that if you have this variant then your levels of anxiety may change as estrogen fluctuates.

The news article is exploiting the findings from the Spencer study to construct a simplistic view of varying responses to hormone change within and across women. I suppose the author of the news article thought it might be interesting to examine the debate on whether or not there is a “clinically disordered” state during the luteal phase of the menstrual cycle in some women and whether it should be recognized officially. While it may do this, it also perpetuates misunderstandings and stereotypes about women’s hormones and their emotional states.

Amber Steele is a graduate student at the University of Cambridge with a biomedical background. She is writing a thesis is on wellbeing over the menstrual cycle and how it relates to hormonal “biomarkers” cortisol and progesterone.

Women, Men, and PMDD

October 15th, 2009 by Elizabeth Kissling

A new study published in a recent issue of Women & Therapy finds problems with the diagnostic criteria for PMDD. No surprise – feminist psychologists, researchers within the Society for Menstrual Cycle Research, and many others have repeatedly criticized the concept of PMDD as a mental illness related to menstruation for these and other reasons.

Supposedly, PMDD occurs in 3% to 8% of menstruating women. There is a host of problems with how this is determined, including varying means of defining and applying the DSM-IV criteria for PMDD across studies, but I’ll spare you that litany here. If PMDD is truly an illness related to the menstrual cycle, the criteria should be sex-specific; that is, only those capable of menstruating should meet the diagnosic criteria (the research implicitly assumes everyone is cissexual and that all non-pregnant women of reproductive age menstruate and no men do – let’s set that aside for now).

To test the sex-specificity of the criteria for PMDD, the researchers created two versions of the assessment tools they used to determine its presence: one version included sex-specific terms like menstruation, menstrual cycle, and premenstrual symptoms, while the other version substituted sex-neutral terms such as experiences and symptoms.

Lo and behold, women who completed the sex-specific diagnostic tools met the provisional criteria for PMDD at a significantly higher rate (20%) than women who completed the sex-neutral diagnostic assessment (8%). And 4.1% of men completing the sex-neutral assessment also met the criteria for PMDD. There was no statistically significant difference in the number of women and number of men meeting the criteria when sex-neutral language was used. The researchers tentatively conclude,

Therefore, these data suggest that PMDD may not be a premenstrual disorder per se. PMDD may instead reflect general cyclical changes in mood, and in women sometimes these changes occur during or near menstruation.

So this little study is far from being the last nail in the coffin PMDD deserves. But it’s a start.

Readers should note that statements published in re: Cycling are those of individual authors and do not necessarily reflect the positions of the Society as a whole.