Is PMS Overblown? That’s What Research Shows

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.

Dads, Daughters, and Menarche

httpv://youtu.be/wbmnUGhD42A

Oh, Mr. Dad! Is that the best you can do?

Mr. Dad is a syndicated parenting advice column in my local paper, and the September 26 edition featured a query from a dad worried that his 11-year-old daughter may begin menstruating while her mom is deployed overseas (she just left, and she’ll be gone for a year).

Mr. Dad’s first bit of advice is for the squeamish father to find an adult woman to talk to his daughter about puberty:

Your first assignment is to find an adult woman to run point. This could be a relative, friend, or even one of the female spouses whose husband is deployed with your wife’s unit. She’ll be able to walk your daughter through the basics and give you a list of supplies you’ll want to have on hand.

To his credit, Mr. Dad doesn’t let Nervous Dad off the hook, and does advise that he learn about female puberty “just in case things don’t go exactly according to plan”. But I’d rather see more dads embrace the possibility that they may well be the one their daughter turns to at menarche, like this dad.

Heck, they could even up being the helpful, available next-door neighbor in a time of need, like ol’ Hank Hill, in this video clip.

Menopause in the funny pages

Widely distributed U.S. comic strip “Zits” — the ongoing story of the life and times of 16-year-old Jeremy Duncan — began a storyline about menopause this week. Apparently, Jeremy’s mom has begun experiencing signs of perimenopause. So far, it’s not awful. The humor is based on the unpredictability of hot flashes and Jeremy’s apparent embarrassment at seeing his mother spontaneously remove her blouse.

© 2011 ZITS Partnership

It’s open to interpretation, of course, but so far (see yesterday’s strip), it seems to me that we’re invited to laugh at how easily the teenage boy is embarrassed, and to sympathize with the menopausal woman.

Sex, the Brain, and the Pill

Positron emission tomography image of a human brain

Does taking the Pill increase the size of your brain? According to this story in The Daily Mail, you betcha. And it makes women more talkative, too. That’s right – brain scans of 28 women PROVE it.

I know not to take too seriously such headlines in The Daily Mail (there’s a reason my British friends like to call it The Daily Fail), but if that story has you gnashing your teeth, consider this piece from The Guardian to be the antidote:

In fact, there are no major neurological differences between the sexes, says Cordelia Fine in her book Delusions of Gender, which will be published by Icon next month. There may be slight variations in the brains of women and men, added Fine, a researcher at Melbourne University, but the wiring is soft, not hard. “It is flexible, malleable and changeable,” she said.

In short, our intellects are not prisoners of our genders or our genes and those who claim otherwise are merely coating old-fashioned stereotypes with a veneer of scientific credibility. It is a case backed by Lise Eliot, an associate professor based at the Chicago Medical School. “All the mounting evidence indicates these ideas about hard-wired differences between male and female brains are wrong,” she told the Observer.

“Yes, there are basic behavioural differences between the sexes, but we should note that these differences increase with age because our children’s intellectual biases are being exaggerated and intensified by our gendered culture. Children don’t inherit intellectual differences. They learn them. They are a result of what we expect a boy or a girl to be.”

Now adding Delusions of Gender to my reading list; I’ve already read Lise Eliot’s Pink Brain, Blue Brain. (I also heard her present this work at a conference; it’s a very compelling presentation.)

The Leap from Younger Puberty to Fat-Shaming

'Puberty' by Edvard Munch. Photo courtesy of Flickr user independentman // CC 2.0

When the story that girls are reaching puberty earlier than ever began popping up everywhere this week, I did not doubt its veracity. It was no coincidence that I received an email from a friend yesterday, observing with mixed feelings that she had just purchased a first bra for her oldest daughter. Her daughter is 9.

News about girls reaching puberty earlier and earlier isn’t exactly new. We saw a flurry of stories in late 2009, when studies found an association between early menarche, late menopause and breast cancer. Additionally, the finding that African American girls often show signs of pubertal development earlier than other girls is well-established.

The study that triggered this new explosion of publicity, published this week in Pediatrics, assessed girls’ development by evaluating the size of breast buds (as breasts are called in early stages of development). The researchers evaluated an ethnically diverse population of 1,239 girls ages 6 to 8 across three research sites. They found that 10.4 percent of white, 23.4 percent of black and 14.9 percent of Hispanic 7-year-olds had reached “Sexual Maturation Stage 2.” Stage 2 is more typically reached at age 10, but may occur any time from age 8 to age 13. Menarche, the first menstrual period, occurs on average at age 12, in Stage 4, but it, too, varies, occurring as early as age 9 and as late as age 17.

The Pediatrics study does not, however, reveal what has caused the age of puberty to fall. Many are quick to blame the alleged obesity epidemic, as the study found that heavier girls were more likely to have more breast development. But Dr. Frank M. Biro, the first author of the study and the director of adolescent medicine at Cincinnati Children’s Hospital Medical Center, told the New York Times that it is unlikely that weight alone explains the findings. Instead, he speculates that environmental chemicals may influence early breast development, and he and his colleagues are presently running lab tests to assess the girls’ hormone levels and chemical exposure.

Fat is one of many factors affecting pubertal development. Others include:

• environmental toxins, including phthalates and Bisphenol A, commonly known as BPA, which can be found in nearly anything made of plastic: baby bottles, toys, plastic serving utensils, and more
• premature birth and low birth weight, which affect endocrine function
• psychosocial stressors, such as family dysfunction or abuse
• formula feeding, especially without breast feeding
• in-utero chemical exposure
• and, often neglected in these discussions, endocrine disruptors–the hormones used in raising beef and dairy cattle as well as chicken in this country. Almost all foods in a modern North American diet contains endocrine disruptors.

(For a more thorough analysis of causes of early puberty, see Sandra Steingraber’s report, The Falling Age of Puberty in U.S. Girls: What We Know, What We Need to Know, published in 2007 by the Breast Cancer Fund. Among other findings, Steingraber reports that new research has revealed that the amount of natural hormones a child’s body produces on its own is much lower than previously estimated; this means “safe levels” of exposure to synthetic hormones and endocrine disruptors must be recalibrated, and policy modified accordingly.)

Sadly, much of the public discussion of this research seems to be centering on the possible role of the alleged obesity crisis (or in fat activist Kate Harding’s preferred terminology, “the obesity crisis OOGA-BOOGA!”), despite a lack of concrete evidence. I’d hate to see this research lead to increased fat-shaming and body image issues for young girls, as there are far more serious consequences of a dramatic decline in age of puberty.

Why isn’t the focus on what can be done to help girls? Research published ten years ago by Girl Scouts, Inc., reported that 8- to 12-year-old girls are growing up in an increasingly stressful environment, as their cognitive and physical development occur at an accelerated pace, while emotional development does not. In other words, despite the budding breasts, a 10-year-old is still a 10-year-old psychologically. The resulting tension leads to young girls dealing with teen issues, such as sexuality and relationships, before they are ready.

Sandra Steingraber’s report for the Breast Cancer Action Fund lists numerous other possible outcomes of early puberty, including increased risk of mental illnesses such as depression, anxiety and eating disorders, as well as higher risk of PCOS and breast cancer later in life. Early puberty is also associated with greater risky behaviors in adolescence, such as smoking, drinking, drug use, and crime, as well as early and unprotected sex. Early-maturing girls also experience higher rates of violent victimization.

Of course, many early-maturing girls experience none of these negative outcomes. Some are like my friend’s little girl, whom she reports is walking a little taller today and wearing a quiet smile. What are we doing for the girls who don’t have her confidence and her support systems? The Breast Cancer Fund recommends advocating [PDF] for chemical policy reform, at state and federal levels, that will reduce our exposure to radiation and harmful chemicals in the environment and in the products we use, and increasing corporate accountability to eliminate environmental exposures to carcinogenic and endocrine-disrupting chemicals. All girls (and boys, too) should be able to approach puberty with a smile on their faces and pride in their steps.

[ Cross-posted at Ms. Magazine blog. ]

Hot Flashes: Now Especially for Fat Ladies

Photo of art by Czarnobyl by Flickr user urbanartcore.eu || CC 2.0

Since yesterday, although it seems longer, my RSS reader has been clogged with links to news reports about a UCSF study in which some women who lost weight found that their hot flashes diminished. Of course, that’s not what the headlines say. Here’s a sample of some of the titles of current stories about this study on Google news:

• Hot Flash Relief: Weight Loss Works, What Doesn’t? (US News & World Report)
• Bad hot flashes? Try dropping a few pounds (MSNBC.com)
• Losing weight may ease menopause symptoms (NBC13.com)
• Symptoms of Menopause Can Be Relieved by Weight Loss (Health News)
• Weight Loss Helped Overweight And Obese Women Reduce Hot Flushes (Medical News Today)

OK, that’s enough – see the trend? Suddenly weight loss is the cure for hot flashes. But in the actual study – which was about urinary incontinence, not menopause -141 women provided researchers with data about their hot flash symptoms six months after the study began. Sixty-five of the 141 women said they were less bothered by their hot flashes six months after participating in the weight loss program, 53 reported no change, and 23 women reported a worsening of symptoms.

Look at those numbers again, more slowly this time: 65 of 141 women who participated in a weight loss program were less bothered by hot flashes after six months. That’s 46% of the women – less than half – who found relief. Almost as many reported no change in symptoms, so why is this being touted as a successful intervention?

Because the women lost weight. Most of the news reports of this research stop just short of fat-shaming, but I submit that is exactly why this study is getting so much media attention. Even though it is well-established that diets do not work, even if you call them a “lifestyle change” or “a whole new way of eating”, and that the BMI (Body Mass Index) is useless as a gauge of health. In fact, fat is not a measure of health. But why pass up an opportunity to shame women about their bodies?

A New Blood Test to “Predict” “Menopause”? Is this What Women Really Want?

Collage by Merlinprincesse | Creative Commons 2.0

Guest Post by Heather Dillaway, Wayne State University

I keep seeing news articles about a “new Iranian study” that hopes to better predict “age at menopause” for women, and the authors of this study supposedly discovered a “blood test” that will be able to “predict menopause” within the next few years. It is touted as a way to judge when women will be “done” or be at the “end” of “menopause” and also to predict by default when they will be at the “end” of their “fertile” years (so that maybe they can know when they have to pop out that first or last baby). After seeing so many references to this study over the last week and having studied how women feel about the “beginning” and “end” of menopause for the last ten years myself, I can’t just sit back and not critique the underlying assumptions that are part of this study and air some of the concerns that I have about this impending blood test.

First, there is an assumption that the cessation of menstruation (as biomedical researchers define it) is the defining moment of “menopause.” Thus, what these scientists are trying to predict is the age when women might reach “menopause” (or 12 months past their last menstrual period). Yet, not all women judge the “end” of menstruation as the most important aspect of their menopause experience, in fact many women are much more concerned about when other signs and symptoms of “menopause” will begin and/or how long they will last, for instance, irregular bleeding or heavy bleeding in “perimenopause” or hot flashes, night sweats, etc. Can a test predict when irregular bleeding might start and how long it might last? And if a test predicts that a woman might reach her “age at menopause” right after her 54th birthday, will that make a 45-year-old woman with irregular bleeding feel assured that she has only 9 years left? In addition, can a test predict how soon a woman might start experiencing hot flashes and how long they might last, if that is instead to be her most worrisome sign or symptom?  If a test predicts that a woman’s age at menopause will be around age 49, will that woman feel assured about her hot flashes at age 48, having no idea how long those hot flashes will last but maybe hoping that they’ll end right alongside her last menstrual period? While the authors of this study (like most other biomedical studies) want to continue to uphold the definition of “menopause” as the official “end” of menstruation and ultimately the “end” of fertility, and hold this up as the most important part of menopause that we should know about, I beg to differ. Women want to know more than just their “age at menopause” or the final end to their fertility.

Second, continuing to define menopause primarily through the cessation of menstruation as this study does means that those women who do not menstruate regularly before menopause (e.g., pregnant women, breastfeeding women, women with amenorrhea before menopause, serious athletes, women with eating disorders and other health conditions, intersexed women, women on Depo-Provera or Seasonale, women with partial hysterectomies, women on hormone therapies, etc.) continue to be defined as abnormal and even infertile, if we follow through with the mindset of the authors of this study. In my mind, this study seems not to be written for those groups who haven’t been menstruating regularly before their “age at menopause” or who might even have been defined as “infertile” before menopause. The assumption is that all women menstruate regularly and are fertile before menopause and, therefore, menopause can mean the end of menstruation and fertility, but so many women’s experiences negate this assumption and reality. Even women who have simply been on the birth control pill for ten years or women who had a tubal ligation negate the idea that “menopause” is the end of fertility. There are so many factors that interrupt “normal” “menopause” or “normal” “fertility,” and this study does not explain any of that. If women have not been faced with a regular menstrual cycle earlier in their lives and have not been “fertile” before menopause, how are they supposed to interpret this study’s definition of “age at menopause” or fertility? Does this calculation still work for them? Presuming it does, what should they assume when they reach that predicted age at menopause? Should they just assume they’re done, and take the authority of the blood test as fact, that they are indeed “menopausal”? And should women who have experienced troubles with fertility before menopause wait to think that they are infertile until after the predicted age of menopause? This blood test leaves me with many questions and few answers, especially when I start to think about all of the supposed causes of age at menopause and infertility, and all of the women who are left with unexplained experiences if we rely on this blood test to give us the answers.

Third, the idea that this blood test essentially predicts time to failure/time to the “end” of fertility is problematic for those interested in promoting women’s health, in my opinion. The study is praised already for its potential ability to predict “early menopause” and allow women to know when (not if, but when) they should switch gears and begin to have those children they always wanted to have (assuming they wanted them, of course – there is no room for “childfree” women from the perspective of researchers touting this blood test).  As this study is praised for its ability to predict when women should start worrying about their fertility (and might want to have that baby before it’s “too late”), what does the predicted “age at menopause” do for a woman? Does it help her figure out when she might start having trouble getting pregnant, or when she should start trying to have that first or last baby? Does it help the woman trying to decide whether she really wants children or not?

If we are truly to promote positive gender identities, a healthy view of both menstruation and menopause, a healthy view of women who either decide to have children or decide to be child-free, and the women who delay childbearing until their forties, the idea that this study predicts the “end” of fertility (read: the end of women’s delay of childbearing now that she can plan “well”) could be problematic, if it is couched in terms of “time left” and (essentially) time to system failure. Ultimately, does that mean that, if you don’t plan well and end up childless that it’s your fault? Does that mean that if you are still concentrating on your career with only 5 years left until age at menopause that you are not scheduling your time well? Does that mean when you get to the “end,” you should maybe think of yourself in a different way? And should you worry if your blood test says you only have a year left of regular menstruation?

Or what happens if you get to your appointed cessation time and you don’t stop menstruating? And do we really want to let women think that if they reach their appointed age at menopause, then they don’t need to use birth control anymore? Furthermore, this study’s researchers admit that their new blood test can predict within a 4 month window but, from my calculations, that might leave women guessing whether they have hit their “age at menopause” within an 8-month period (4 months on either side of the predicted time, best case). And the authors of the study admit that the margin of error could be as much as 3-4 years off at the current time (but of course they’re hoping their estimations will be improved by the time that this blood test is approved and marketed).

How are women supposed to feel about all of this? I don’t know, but I worry about the extra anxiety that individual women might feel if they received this “simple blood test.”  I realize we all want to plan well and plan more, and that our entire society is geared towards planning when exactly that tornado will hit, that market will fall or recover, that housing market will get better, that weight will come off, that baby will be born, or that illness will be gone, but are we really truly better off and less anxious with all of this planning and prediction? And, at the bottom of it all, is this what women actually want? I’m left more anxious just thinking about the repercussions of this “simple blood test,” and I wonder what women really would rather know. And even if they did want to know their predicted age at menopause, is that the most important thing to them, and will this actually lessen their fertility concerns?

Should the pill be available over-the-counter?

The New York Times published an op-ed piece a few days ago about making the birth control pill available without a prescription. Kelly Blanchard, president of Ibis Reproductive Health, offers the following rationale:

Women don’t need a doctor to tell them whether they need the pill — they know when they are sexually active and want to avoid pregnancy. Pill instructions are easy to follow: Take one each day. There’s no chance of becoming addicted. Taking too many will make you nauseated, but won’t endanger your life, in contrast to some over-the-counter drugs, like analgesics.

I have mixed feelings, myself. I’m in favor of just about anything that makes contraceptives more accessible to the people who need them, but I fear that the likely increase in cost of OTC pills means the availability won’t benefit those who most the need them – the young and the poor. Also, there are some contraindications for pill use, such as high blood pressure, history of migraine, and use of certain anti-seizure drugs for epilepsy. And despite the happy, shiny images of Yaz and Seasonique commercials, some women just can’t tolerate the side effects, for any number of reasons.

What do you think, re:Cycling readers?