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.

 

The woman, the serpent and the cycle

March 13th, 2012 by Chris Hitchcock

According to a recent study, women are best at picking out a picture with a snake during the days immediately before their period. You might think this would be a surprise, given the general idea of premenstrual compromise in women. Mind you, there isn’t much data to support poorer thinking or performance for women during the premenstrual period.

However, the authors were able to salvage the idea of premenstrual compromise here. They argue that about 30% of women have premenstrual syndrome, and most of the rest of us show some kind of cyclicity. And so they attribute the 200 millisecond (1/5 of a second) faster response to anxiety and fear. Either that, or it is maternal instinct, protecting the small cluster of cells that might possibly be an impending pregnancy.

Media has picked this up, with headlines about PMS being good for something after all.

Sometimes it seems that women can’t win for losing.

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.