Women, Wombs, Health, and Reason
Menstrual cycle-related symptoms have been recognized and treated by physicians for at least the past 3800 years. We know this because one of the oldest surviving medical texts, the Kahun Gynaecological Papyrus (c. 1800 BCE), describes some highly recognizable menstrual experiences (for example, period pain, heavy bleeding, lower back pain, and migraine) and ascribes them to ‘discharges . . . clenches . . . wrappings . . . or wandering . . . of the womb’ (Quirke 2002, 1:1–29). Interestingly, this Ancient Egyptian scroll also lists other (less directly associated) female symptoms and similarly associates them with the womb for example, leg pain and toothache (Quirke 2002, 1:15–20).
In this way, the Kahun Gynaecological Papyrus perhaps exemplifies a recurring theme that has helped shape constructions of female health throughout the history of Western medicine, namely, the attribution of any and all (otherwise unexplained) female-prevalent symptoms to the womb (or menstruation by association), as the defining feature of embodied femininity (Ussher 1989; King 1998). While a causal association between the female reproductive system and ill health is not necessarily ‘wrong’ or sexist, a widespread (yet incorrect) assumption that a generalized converse logical position also holds true, is much more problematic. That is, ‘if ill health is caused by the womb (in some women), then all women are ill (by virtue of having wombs).’ Indeed, it is this logical fallacy that underpins much of the myth of the irrational female.
Right up until the sixteenth century, descriptions of female-prevalent symptoms were always physical in nature (King 1998). From the seventeenth century onwards, however, they came to be seen as more emotional in origin, and experience. In particular, the work of Thomas Sydenham (1624–1689) was influential in the reclassification of ‘hysteria’ (a term adapted from Classical references to hysterikē pnix that is, ‘suffocation of the womb’) from a gynecological condition, to a female-prevalent nervous condition, caused by a weaker nervous constitution and subsequent emotional instability (Gilman et al. 1993, 143–46).
Sydenham’s new definition of ‘hysteria’ was in keeping with preexisting philosophical assumptions that women were inherently physically, spiritually, and intellectually inferior to men. Yet it meant that gender discrimination was thus now justified by a ‘scientific’ (that is, supposedly objective) medical claim that due to the pathological nature of the female (reproductive) body, women were also pathologically emotional (and, therefore, less capable of reason) and so inevitably subject to the control of men (Ussher 2005, 16).
By the late nineteenth century, the work of Sigmund Freud had firmly repositioned ‘hysteria’ as a type of psychological neurosis (Freud 1966). His work significantly influenced early twentieth century public discourse. Indeed, one of the main arguments used against women’s suffrage (the right to vote in parliamentary elections) was that (all) women were mentally unfit to make an informed and rational decision. Just such a belief was unambiguously conveyed by Sir Almroth Wright (1912), a famous physiologist and anti-suffragist; “[On] Militant Hysteria- No doctor . . . can ever lose sight of the fact that the mind of woman is always threatened with danger from the reverberations of her physiological emergencies.”
The Emergence of Premenstrual Conditions
The ‘myth of the irrational female’ is also a likely influence on the first formal medical description of ‘Premenstrual Tension’ (‘PMT’—the precursor to ‘PMS’) by Frank (1931), a US gynecologist. For although Frank’s paper initially documented cases of severe cyclical asthma, epilepsy, water retention, and cardiac irregularity, its main focus was on the experiences of a specific subset of patients, characterized by various signs of ‘nervous tension’ (Frank 1931, 1054). Astonishingly, in several cases, Frank’s symptom descriptions were simply value judgements on improper, or undesired, female behavior; and strikingly similar to contemporary descriptions of the ‘hysterical woman’ for example, “husband to be pitied,” “unbearable, shrew,” or “impossible to live with” (Frank 1931, 1055).
Frank was certainly not the first in the modern era to attribute changes in mood or emotions to the menstrual cycle. Various earlier sources describe apparently well-known expressions of cyclical emotional variability in a minority of menstruating women, although they were not previously considered to require medical intervention (for example, Hollick 1860, 91–92; Giles 1901, 27). Emily Martin (1987, 120) suggests that it is highly significant that Frank specifically discussed PMT in relation to women’s (supposed lesser) ability to work, since he was writing during the Great Depression, a time when women workers were being pressured to leave paid employment in favor of men.
Also, the first estrogen hormone was discovered just three years before Frank published his paper. The identification of the so-called ‘sex hormones’ provided a new scientific explanation to support existing ideas about the female reproductive system as the origin of female-prevalent ill health, and implied ‘natural’ susceptibility to irrational behaviors (Ussher 2011, 21). Correspondingly, Frank associated such overtly feminine symptoms (that is, those affecting behavior, mood, or emotions) with an excess of the ‘female’ hormone (now disproved) (Frank 1931, 1056):
It would thus appear that the continued circulation of an excessive amount of female sex hormone in the blood may in labile persons produce serious symptoms, some cardiovascular, but the most striking definitely psychic and nervous (autonomic). These periodic attacks . . . can be directly ascribed to the excessive hormonal stimulus.
During the 1950s, theories about Premenstrual Tension (PMT) continued to focus on the role of ‘female sex hormones,’ although symptoms were now attributed to a deficiency in progesterone (now disproved). PMT was renamed PMS (Premenstrual Syndrome), after Greene and Dalton (1953) argued that premenstrual symptoms were far more extensive than just ‘nervous tension.’ The most prominent ‘PMS expert’ at this time, Dr. Katharina Dalton, attempted to counter the undue emphasis on mood-based menstrual symptoms, and openly criticized what she called “the hijacking of PMS by psychologists” (Dalton and Holton 2000, 98). However, she also helped to perpetuate the myth of the irrational female by directly contributing to a somewhat dangerous (and unscientific) legal precedent for the mitigation of murder charges, if committed ‘under the influence of PMS’ (Laws, Hey, and Eagan 1985, 65–79; Chrisler 2002).
Over the past thirty years, clinical descriptions of PMS have remained predominantly psychological in focus, especially since the inclusion of premenstrual disorders in the American Psychiatric Association’s DSM (Diagnostic and Statistical Manual of mental disorders). First in the form of Late Luteal Phase Dysphoric Disorder (LLPDD) in 1987, and later its replacement, Premenstrual Dysphoric Disorder (PMDD), since 1994 (American Psychiatric Association 2000). Even reputable clinical sources sometimes refer to PMDD as ‘severe PMS’; implying that PMS is simply a less severe form of a mental health disorder (for example, Lopez, Kaptein, and Helmerhorst 2012; Maharaj and Trevino 2015; Naheed et al. 2017). In comparison, thyroid conditions, which are also ‘hormonal’ in origin and commonly cause severe mood changes, are not listed in the DSM.
So What? The Impact of Psychologising PMS
PMS research has, so far, been typified by contradictory, irreplicable, and usually highly contested, findings (Walker 1997; Knaapen and Weisz 2008; Halbreich 2007). This may partly be explained by the fact that for most of its history, it has been subject to a form of confirmation bias, or circular logic. By focussing on mood-based menstrual symptoms and neglecting those that are physical, PMS research unavoidably overlooks critical elements in the etiology (cause), prevalence, patient experiences, and treatments of menstrual cycle-related symptoms as a whole. For example, period pain is by far the most common menstrual cycle-related symptom, but it is not usually included in diagnostic criteria for PMS. This is despite the fact that period pain is known to have an effect on premenstrual mood, fatigue, and other symptoms (Balik et al. 2014; Smorgick et al. 2013).
Clinicians may struggle to identify menstrual cycle-related symptoms if PMS is understood to be essentially mood-based. For example, if certain physical symptoms are severe, a General Practitioner (GP) might simply diagnose a more chronic health condition, without first assessing if symptoms are cyclical in nature. Especially since even when PMS is suspected, many clinicians do not ask patients to record their symptoms over two cycles, as is required for formal diagnosis (Craner, Sigmon, and McGillicuddy 2014). (Menstrual migraine is an exception, since its high prevalence rate ensures that most clinicians are aware of a possible link to the menstrual cycle.)
Some clinicians may even question the validity of a PMS diagnosis, partly because symptoms are subjective and, therefore, difficult to qualify (for example, through clinical tests), but also because female-prevalent health issues in general, especially those that also affect mood (for example, fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome [IBS]), are more likely to be dismissed, or assumed to be psychosomatic in origin (see Hoffmann and Tarzian 2001; Asbring and Närvänen 2002; Letson and Dancey 1996). This troubling situation is also likely to be influenced by the myth of the irrational female, since hypochondria (imagined or pretend illness) was emphasized in nineteenth century descriptions of ‘female hysteria’ (Veith 1965, 144–45).
Systematic reviews of published clinical trials are felt to be the ‘gold standard for clarity, power, and precision’ in regard to the evidence-based management of PMS (O’Brien and Ismail 2007, 6). However, all five of the existing Cochrane systematic reviews of PMS treatments are based on clinical trials that almost universally selected participants using predominantly mood-based criteria (Jing et al. 2009; Lopez, Kaptein, and Helmerhorst 2012; Ford et al. 2012; Marjoribanks et al. 2013; Naheed et al. 2017). This is because the most widely used clinical tools for recording daily symptoms are either directly based on the diagnostic criteria for PMDD for example, the Daily Record of Severity of Problems (DRSP) (Endicott, Nee, and Harrison 2006), or otherwise over-emphasize emotional, behavioral, or psychological symptoms for example, variations of the Moos Menstrual Distress Questionnaire (MDQ) (Moos 1968). So, in effect, only a small subset of PMS patients/symptoms have ever been evaluated in the vast majority of clinical trials.
Some PMS researchers have focused on identifying cultural influences on clinical and scientific definitions of PMS. Their work is sometimes also limited by the assumption that menstrual changes are predominantly mood-based. For example, arguments put forward to oppose the unnecessary ‘medicalization’ of the menstrual cycle (while acknowledging the reality of the experiences of those who do experience distressing cyclical mood changes), may downplay, or neglect to mention physical menstrual cycle-related symptoms or conditions such as period pain, catamenial epilepsy, menstrual migraine, or cyclical asthma (for example, Chrisler and Gorman 2015). This omission might be seen to undermine their arguments (Kulkarni 2013), even though the point is still valid: The fact that a minority of people experience symptoms that are triggered by the menstrual cycle, does not justify the pathologisation of the cycle itself.
Research has found that people are more likely to report PMS if they have restricted access to social support (for example, Ussher, Perz, and Mooney-Somers 2007); an unequal share of household or childrearing responsibilities (for example, Coughlin 1990; Ussher 2003); or are experiencing relationship strain (for example, Kuczmierczyk, Labrum, and Johnson 1992). Any mention of ‘psychosomatic,’ or ‘psycho-social’ factors in relation to PMS, however, can trigger defensiveness on the part of the patient, their clinicians, or the wider public. Such terms are erroneously equated with hypochondria, even though this is not what is being described. Sadly, the resulting defensiveness can lead to the misinterpretation of clinical research findings. For example, a high-quality review that found inconclusive proof to support the existence of a ‘specific premenstrual negative mood syndrome’ in the general menstruating population (Romans et al. 2012) was misunderstood by some as denying the existence of severe cyclical mood symptoms, entirely (for example, Kulkarni 2013).