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.
So happy to see some good prospective data reported on premenstrual mood changes. We’ve known since a population-based study in Calgary almost 20 years ago that emotional symptoms before flow that were sufficient to cause distress were very rare (in a study that disguised its intent to study PMS).
However, as an endocrinologist who believes in the potential of hormones to interact with EVERYTHING, and as a woman who (barely) survived perimenopausal symptoms (including very definite increased negative moods prior to flow), I think that women in the transition to menopause are most likely to object to these data. Which doesn’t make what they say or what these authors found untrue.
First of all, the answer is not in about premenstrual mood symptoms in symptomatic perimenopause because we don’t have the prospective daily data that we need. In addition we don’t have actual blood hormone levels to compare with those women’s reports. But what I do know is that the average age of women going to “PMS Clinics” is in the late 30s-late 40s which spans early perimenopause for most women.
The other important thing to keep in mind is that other menstrual cycle-related experiences (like cramps, sore breasts or night sweats) and common women’s situations (like being a single parent, or being expected to do all the grunt work on the job and at home) also influence our mood and ability to cope around the time of our flow.
I also know that, during my dreadful perimenopause, oral micronized progesterone helped me with cramps, sore breasts and night sweats when I was precribed it for the 14 days before flow.
The good news is that we at CeMCOR have obtained Canadian Institutes of Health Research funding to do a randomized controlled three-month trial of progesterone for hot flushes and night sweats in symptomatic perimenopausal women. We will capture feelings of frustration, depression and anxiety as part of that study. We’ve just gotten ethical approval to allow eligible women across Canada to participate in this study. For more information visit http://www.cemcor.ubc.ca.
So, one day, we will have an answer about whether negative mood symptoms increase before flow in perimenopause or not, and whether progesterone helps.
I’m going to go out on a limb here so, those with scientific minds, please be open to what I am about to say. I am a member of the society who has a more spiritual viewpoint of the menstrual cycle. Those of us in the society who do have this viewpoint come from a simple construct: the luteal phase of the cycle is when women are called inward to look at what is not working in their lives. Both (but I will not claim all just yet) physical and emotional pain can be attributed to what is coming up for them in this phase. We live in a culture that not only doesn’t honor or understand the physical and emotional lives of women, but essentially abhors it as we have seen over and over in the media, in science, (Is Menstruation Obsolete?, for example – if you want to call that science) and from the very minds and mouths of men and women themselves. So is it any surprise that women experience both physical and emotional pain? The severity of premenstrual issues can impact other phases of the cycle (follicular and ovulatory phases) if the issues are severe enough. And yes, this has been my experience. My own self research in learning to honor and respect my body and its hormonal function, and yes charting my cycle and using cloth pads, obliterated my premenstrual symptoms in less that one year. My husband will attest to that. I have witnessed other women heal these issues also. Our Native American sisters had the right idea, where women gathered to learn from the experience of, and be nurtured by, older women who knew and understood these unwritten ideals. If women go through life without finding a way to honor their cyclic time then perimenopause and menopause will kick into high gear to accomplish all the inner work that has not been done over the years. This, my dear friends, is the short of it, and there is “the long” of it but there’s too much to share in this one reply.
My greatest desire is to see research designed around the spiritual lives of women. I did see research from our Australian members last year at the Pittsburgh meeting who addressed one aspect of this. While I do not have at my finger tips the researchers names or the name of their research, there was a study conducted along the idea that women wanted to be alone premenstrually. This is one of the truths of the luteal phase of the cycle. I am not in a position to do psychological or nursing research on this subject but would be happy to assist in anyway I can those that want to. There is so much to share on this subject and I am certain other members of the society agree with my comments. As you can see I feel strongly about this and in no way want to insult the sensibilities of other members of the society, but possibly digging into the scientific research with the mind, body, spirit aspect of the premenstrual phase of the cycle would be beneficial overall.
Maybe we can explain the ‘lady rage’ over why women are constantly written off over their health concerns. That is not hormonal – it is fact.
I call it the ‘Take Two Valium and Go Home, Honey Syndrome.’
Perhaps this is part of the issue: the ‘widespread belief needs challenging, as it perpetuates negative concepts linking female reproduction with negative emotionality.’
The fluctuation in moods is not about ‘female reproduction’ but more about cyclical hormone health. There is a whole segment of women’s health not being acknowledged.
Do you know who the sponsors of the study were?
Thanks for clarifying what this study actually determined. I’m constantly amazed at how poorly research results are reported or explained by journalists. Always going for the one idea that will attract the most attention. Liz, I know this piece appeared on the Ms. blog but I’d love to see it on one of the major news sites that reported the study, maybe the one that had the most vociferous comments.
What this research seems to be telling us is that PMS is wildly misunderstood by everyone – researchers, women, men, the public, etc – but used over and over again to explain (sometimes explain away) and/or dismiss women’s feelings and experiences. One might say PMS has become a meme without meaning – an idea that exists differently in everyone’s mind but one we keep talking about as if we all agree what it is we are talking about, when we obviously don’t. I’d like to coin the term PMSism and start using it to call out anyone who uses PMS to dismiss, discredit or ridicule women for having strong emotions and opinions they have the audacity to voice.
I have one question about the studies reviewed by these researchers. Was there any specification as to whether study participants were using or not using hormonal birth control? It’s a variable that must be considered when talking about PMS.
One final thought. A nursing student told me several years ago that one of her female instructors told her class that they would all be better nurses if they used hormonal birth control. You know, to even out that emotionality that so obviously would impair their ability to be good nurses. It made me sick to hear this, but this is how little value is given to women’s emotional lives in many realms. Those troublesome women who dare to say what they think and feel. Must be PMS.
Cindy, As one who charted her cycles for 27 years, I learned to recognize and appreciate the variations in my creativity, energy, outgoingness, tolerance, sensitivity, anger and emotional tone throughout the various phases of my cycle. Charting for me was like having a touchstone for my inner life, and a guide to both the physical and emotional changes I experienced.
I’ve been thinking a lot lately about how much deeper our culture’s understanding and appreciation of menstruation would be if we strove to understand that it is a cycle, with phases, not just the obvious event – the period.
You aren’t the first to note that paying attention to one’s cycle can have a mitigating effect on menstrual problems. If I’m not mistaken, Jerilynn Prior reported this in one of her studies where women were taught to use menstrual cycle diaries. Inga Muscio, in her book Cunt, shares her intriguing story on what happened when she started “hanging with the moon” and how it changed her experience of menstruation. I love this quote: “The negativity surrounding menstruation is an illusion that falls, falls, falls away the instant perspective shifts.”
When I started to chart, my perspective shifted to ovulation. It became the focal point of my cycle observations, not just because I was using FAM for contraception, but because I loved how I felt during the ovulation phase. It’s what I remember the most about my pre-menopause cycling years, and the only thing I miss about being menopausal.
I also remember experiencing more intense mood swings and sleep disturbances in the 10 years leading up to menopause, though not always pre-menstrually. Life circumstances do matter. These symptoms faded dramatically when I quit a demanding job I had come to dislike immensely.
I keep thinking about this study and its implications. On one hand is it possible that hormone balance has broken down to such a degree that women are experiencing anxiety, depression and negative moods throughout the month. The study does mention ‘an association between negative mood and a non-premenstrual phase.’ That could be pre-ovulatory.
I am still interested in know the sponsors of the study or where the University receives its funding. I did research Sara Roman’s ares of interest:
Women’s mental health
Mood disorders
Social determinants of health
Social networks
Childhood and adult abuse
Psychiatric epidemiology
Sleep
My concern is this study could be used as part of the agenda to put women on synthetic hormones to control their moods. It certainly opens the door for prescribing psychotropics for depression, anxiety etc – that are no longer PMS related – but are found throughout the entire month.
I had 5 comments that came in over night on my blog on hormone imbalance. I think we are standing at the top of a very slippery slope into the rabbit hole.
Leslie, the study was partially supported by a Canadian Institutes of Health Research Grant. The authors’ publication statement declares no conflicts of interest. There is no indication that any pharmaceutical company had any influence or provided any financial backing of the study.
Thank you Elizabeth. It is always good to know the source of the study.
Leslie, Canadian Institutes of Health Research Grant should not be interpreted as the source of the study. They provided some funding to support it. The idea originated with Dr. Romans, and she was the Principal Investigator on the grant proposal. The study was conducted primarily by researchers at University of Toronto, and the findings were published in Gender Medicine.
I’d like to know where researchers found so many women who were not on birth control pills, or confirm that none were since you do not have a menstrual cycle on the pill.
Mayo Clinic sez: Traditional birth control pills are designed to mimic a natural menstrual cycle. A traditional pill pack contains 28 pills, but only 21 are active — containing hormones to suppress your fertility. The other seven pills are inactive. The bleeding that occurs during the week you take the inactive pills is withdrawal bleeding, which looks like a period. This is your body’s response to stopping the hormones. If you skip the inactive pills and start a new pack of active pills right away, you won’t have this withdrawal bleeding.