It started with a seething rage that had me clenching my jaw at every mundane irritation. Then the fury would subside and be replaced by a despair so profound that there aren’t words to describe it. My mind would race with increasingly disturbing thoughts – paranoia about loved ones, morbid accident scenarios, vivid memories of every ill-conceived thing I’d ever done, self-destructive fantasies on how to silence the weird, achy feeling in the pit of my stomach. All this mental and emotional turmoil was accompanied by extreme fatigue, joint and muscle pain, indigestion, insomnia and severe headaches that could stretch out over an entire week. It took all my energy during these times just to stay functional, and many days I would have to leave work early if I made it in at all, unable to stand more than a few seconds of clipped, cold conversation with anyone. And then, just like that, it would be over, and I would curse myself for being so weak and lazy that I couldn’t even deal with a few “feelings”. As obvious as it seems now, it took me a long time to accept that these monthly disruptions were caused by a real, medical issue. Though I recognized the cyclical nature of my symptoms, I initially refused to succumb to stereotypes about “that time of the month.” I thought that recognizing the pattern would be enough to induce change, that it was simply an issue of “mind over matter.”
“Women are so emotional”
Despite its long history as a scapegoat for the physical and psychiatric complaints of menstruating individuals (taking over from hysteria in the mid-20th century), the legitimacy of premenstrual syndrome (PMS) remains a contentious subject. Some feminists feel that, in light of the ongoing stigma around all things menstrual and the frequent dismissal of women’s medical concerns, recognition of real symptoms is a positive step towards accepting and treating female-specific disorders. Others, however, argue that embracing the concept of a medical syndrome that affects the majority of women risks pathologizing traits perceived as feminine and legitimizing sexist behaviours, both from men seeking to discredit women’s experiences and from women seeking to “blame” their actions on clinically-recognized impairment.
“She’s just on her period”
While a quick search of the scientific literature on PMS yields results almost as varied and conflicting as the myriad social opinions on the subject, there is increasing evidence of a link between hormonal sensitivities and PMS. However, this is not the whole story.
First, let’s clear up some misconceptions. While “PMS” is used colloquially to describe the time right before or even during menstruation, the menstrual cycle is actually broken up into two phases: the follicular phase, which lasts from the start of menstruation to ovulation; and the luteal phase, which lasts from ovulation to the start of the next period. Physical or psychiatric symptoms related to PMS can start anytime during the luteal phase (up to 2 weeks before menstruation); however, these symptoms recede once the period starts. Studies have shown that some of these changes may be linked to levels of the hormone progesterone, which peaks around ovulation and returns to baseline levels by menstruation.
This is where it gets complicated. Since all regular menstrual cycles involve this drop in progesterone during the luteal phase, scientists have had difficulty pinpointing the exact mechanism behind differing severities of PMS. A recent study by Lovick et al. (2017) found that it was the kinetics of progesterone decline, rather than the levels themselves, that correlated with premenstrual symptoms, whereby women who maintained steady levels of the hormone until just before menstruation reported significantly more severe symptoms than those who showed a gradual decline in progesterone throughout the entire luteal phase. There have also been studies linking the occurrence of severe PMS to differences in the GABA neurological pathway, which interacts with the progesterone metabolite allopregnanolone and has been shown to have a role in anxiety. However, the details of this mechanism remain unclear.
“It’s just an excuse”
Given all this sound scientific evidence, why is the concept of a menstrual mental illness still so controversial? The main problem is not with the science, but with the cultural context in which it operates. Right out of the gate, there is the observation that women in Western societies report more severe PMS than in other parts of the world. While this may in part be due to differing social norms surrounding menstruation, it may also reflect real physiological differences between women from different cultures, as the high-fat, low-activity Western lifestyle is associated with higher overall levels of progesterone. Furthermore, in both social and medical settings, PMS is often too broadly or poorly defined. While many women (as high as 90%) report physical symptoms such as bloating or breast tenderness during the luteal phase of the menstrual cycle, only about 30% report the type of mood disturbances – irritation, fatigue, anger – that are stereotypically associated with PMS. The proportion of women who experience physical and psychiatric symptoms so severe that they actually interfere with regular functioning is even smaller, and many of these individuals do not suffer directly from premenstrual syndrome, but from exacerbation of an existing mental illness (such as major depressive disorder) during the luteal phase. Only women who experience severe physical and emotional symptoms with impaired functioning in the absence of confounding disorders fit the criteria for premenstrual dysphoric disorder (PMDD), which was officially recognized by the American Psychiatric Association in 2013 through inclusion in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V). With all these factors taken into consideration, estimates for the prevalence of PMDD range from 3-9%, although some scientists believe that even this is an overestimate.
“Some people have real problems”
In the end, the real problem with the demonization and dismissal of PMS, whether as a clinical condition or a social one, is that it dissuades individuals from seeking medical or psychiatric help that could significantly improve their quality of life. It wasn’t until after a year of therapy had failed to help me deal with worsening cyclical depression that I considered a medical solution and turned (as any good graduate student would) to PubMed for answers. And even now, I consider myself incredibly fortunate. Fortunate that I had a background allowing me to research and understand the science behind my symptoms. Fortunate that I had a doctor who listened to my experiences and supported my desire for a medical solution. And fortunate that when I did finally start medication (sertraline, at the lowest clinical dose), my monthly mood disturbances disappeared almost completely. Many women aren’t so lucky.
“It’s all in your head”
The following anecdotes are from individuals who wish to remain anonymous.
“The first time I thought it was food poisoning, it was 8 hours of pretty constant vomiting and diarrhea. I started getting worried that this meant something was very wrong so I went to the doctor. He shrugged and said something like ‘some women get bad cramps’. I left the doctor’s office feeling like I’d wasted his time.”
• • •
“Once a month, without fail, I’ll have a terrible day…. I go to sleep in the throes of depression, wake up around 4am with period cramps and I realize that it was all the hormones talking.”
• • •
“I am very blessed to only have mild period pain. Although twice I have gone in for UTI [and] the doctors didn’t really believe me, only to call me two days later from the lab saying I should start taking the antibiotics.”
• • •
“Every once in awhile… it takes me out of commission entirely. I know a good number of women that have that experience every single month. Ultimately, that is the thing I want people to remember and understand…. [F]or many women, they fight tooth and nail to show up….”
- Bäckström et al. GABAA receptor-modulating steroids in relation to women’s behavioral health. Current Psychiatry Reports (2015). 17(11): 92.
- Birch K. The McArdle Disease Handbook: A guide to the scientific and medical research into McArdle Disease, explained in plain English. (2011). AGSD-UK.
- Daw J. Is PMDD real? Researchers, physicians and psychologists fall on various sides of the debate over premenstrual dysphoric disorder. American Psychological Association (2002). 33(9): 58.
- DeRubeis RJ and Strunk DR. The Oxford Handbook of Mood Disorders. (2017). Oxford University Press.
- Epperson CN and Hantsoo LV. Making strides to simplify diagnosis of premenstrual dysphoric disorder. American Journal of Psychiatry (2017). 174 (1): 6-7.
- Hamblin J. PMS and the wandering womb. The Atlantic. Published online Oct 16, 2012.
- Lovick et al. A specific profile of luteal phase progesterone is associated with the development of premenstrual symptoms. Psychoneuroendocrinology (2017). 75: 83-90.
- Neurobiology: Baby blues. Nature (2008). 454: 671.
- Taylor D. From “It’s All in Your Head” to “Taking Back the Month”: Premenstrual syndrome (PMS) research and the contributions of the Society for Menstrual Cycle Research. Sex Roles (2006). 54:377–391.
- Timby et al. Women with premenstrual dysphoric disorder have altered sensitivity to allopregnanolone over the menstrual cycle compared to controls—a pilot study. Psychopharmacology (2016). 233:2109–2117.
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