Premenstrual Syndrome (PMS)

By Oleg Nekrassovski

Introduction

The present paper will start by arguing that PMS is a medicalization of normal female emotions

and feelings surrounding menstruation, rather than a real psychological/physical disorder

rooted in female physiology. This position will first be supported by evidence gleaned from

feminist sources on the subject, before being challenged by evidence found in medical,

scientific sources. Next, an attempt will be made to respond to the objections raised by the

medical and scientific experts. And finally, the paper will be concluded by a delineation of the

outcomes of the debate that has taken place in this paper.

Feminist Views

Women’s feelings and experiences, that the Western medical establishment has labeled as a

premenstrual syndrome (PMS), have been experienced by women from all over the world since

times immemorial. However, according to Kissling (2006), only in those societies, where the

Western medical establishment holds great power, do these feelings and experiences

constitute a syndrome or a disease.

Moreover, a prominent gynecologist, famous for being one of the founders of the PMS concept,

currently attributes PMS to various pathological variations in hormone levels. However, there is

no evidence that hormones cause PMS (Kissling, 2006). In fact, women who claim to be

suffering from PMS have hormonal cycles indistinguishable from those of women who do not

report any PMS symptoms (Kissling, 2006).

Also, the medical professionals have not managed to come up with a blood test or any other

objective diagnostic test which would enable them to distinguish between PMS, PMDD, and

normal ovulation. This may seem somewhat surprising if we consider the fact that PMS has

been researched by Western scientists for more than seventy years; a time span which also

turned out to be insufficient for reaching a consensus on PMS’s definition, etiology, or

treatment (Kissling, 2006).

However, because of their belief that PMS is an objectively definable and measurable

pathological state, rather than a social construct, the medical experts have developed clear

guidelines (with little room for individual interpretation) for diagnosing PMS (Ussher, 2003).

One of the results of such a move is that many women, who seek help for premenstrual

symptoms, are dismissed as hyper vigilant and are not given any treatment, for the simple

reason that they do not meet the diagnostic criteria set out by the experts (Ussher, 2003).

Conversely, one of the diagnostic criteria for PMS, developed by the experts, is the presence of

a range of negative emotions during the premenstrual phase of the cycle. These emotions

include anger, irritation, depression, loss of confidence, lack of concentration, sadness,

tearfulness, desire to be alone, desire for comfort or security, among other feelings (Ussher,

2003). And, according to Ussher (2003), what the experts are measuring women against here is

not arbitrary. Instead, it is an idealized woman, what every woman in our society is expected to

be. Such a woman is never needy, angry or irrational. Instead, “She is calm, in control, always

able to look after others, and never loses her temper or breaks down in tears” (Ussher, 2003, p.

137). Consequently, according to Ussher (2003), it is clear that based on such diagnostic criteria,

the PMS sufferers are simply those women who cannot live up to the idealized construction of

femininity during the premenstrual phase of their cycle, rather than women who are suffering

from some physiological disorder.

In a similar vein, several medical anthropologists point out that only Western biomedical

healers recognize, define, and treat a specific set of bizarre behaviours which they call PMS

(Kissling, 2006). According to these anthropologists, not only do manifestations of premenstrual

symptoms get treated only in the West, but only in the West do premenstrual symptoms get

manifested through such bizarre behaviours (Kissling, 2006). These anthropologists also point

out that PMS appeared in the industrialized West, only in the second half of the twentieth

century. Consequently, they theorize that the bizarre behaviours that manifest PMS, in the

West, is a dramatic act which women unconsciously put on in order to temporarily escape

responsibilities of paid work and motherhood, when they feel overwhelmed by them (Kissling,

2006). Moreover, such an act always goes through smoothly because PMS, instead of being

blamed on the woman’s self, is blamed on her body. This way PMS becomes a socially approved

way for a modern Western woman to take a break from overwhelming responsibilities (Kissling,

2006).

According to Ussher (2003), nearly all current medical and psychological studies of PMS employ

single variable, correlative models of cause and effect. In other words when it is found that the

reduction in particular premenstrual symptoms strongly correlates with a particular treatment,

it is immediately proposed that the physiological factors manipulated by the treatment are

responsible for the occurrence of observed symptoms (Ussher, 2003). However, such proposals

regarding the etiology of PMS are essentially flawed, for the simple reason that correlation

does not imply causation. In other words, there are few if any reasons to believe that the

physiological variables manipulated by the treatment cause the observed symptoms of PMS

(Ussher, 2003).

According to Ussher (2003), within the positivist/realist research methodology, the

physiological factors of health are considered to be more objective and more “real” than the

social and psychological factors. Consequently, there is a strong tendency among medical

researchers to follow a purely physiological approach in the study of etiology and treatment of

medical conditions such as PMS (Ussher, 2003). The inevitable result of such an approach is that

many illnesses, which may be caused by psychosocial factors, are deemed, by medical experts,

to be caused by pathological processes within the body and are treated through the

administration of pharmacological agents (Ussher, 2003).

However, according to Ussher (2006), PMS is not a mere social construct, or a fiction framed as

fact by self-proclaimed experts. In fact, many women do experience depression, anger, and a

strong desire for social isolation during the premenstrual phase of their cycle. Moreover, there

is convincing evidence that these “PMS symptoms” are caused by a combination of hormonal

changes, increased arousal of the autonomic nervous system, and increased perception of

stress, which occur during this phase of the menstrual cycle (Ussher, 2006).

Medical/Scientific Objections

There is considerable evidence to suggest that the bizarre behaviours of Western PMS sufferers

are found in women from many other cultures. In fact, severe PMS or PMDD (a severe form of

PMS with pronounced psychiatric symptoms) has been reported in 2.4% of an Indian population

cohort consisting of 83 women, 6.4% of 52 Indian volunteer women, 12% of the 150 women

from a Taiwanese PMS clinic, and 18.2% of 384 Pakistani college students (Pearlstein, 2007).

This data clearly suggests that PMS is a worldwide rather than a Western culture-bound

syndrome. Moreover, it is clear that if PMS diagnosis simply singled out only those women who

failed to display Western ideals of feminine virtue during the premenstrual phase of their cycle,

nearly all non-Western women would be categorized as PMS sufferers because the ideals of

femininity found in their cultures are different from those in the West. As it stands however,

the documented prevalence of severe PMS is comparable to that found in the West.

Assuming that current etiological studies of PMS solely utilize correlative models is also clearly

wrong. For example, the experiment used to determine the endocrine differences between

PMS sufferers and asymptomatic women involved suppressing the natural production of

gonadal steroids in both groups of women, and then artificially administering equal amounts of

gonadal steroids to both groups (Eriksson, 2007). The suppression of gonadal steroid

production in PMS sufferers led to the disappearance of PMS symptoms, while artificial

administration of gonadal steroids led to their reoccurrence, but only in PMS sufferers.

Normally asymptomatic women remained asymptomatic even though they were injected with

a dose of gonadal steroids exactly equal to that given to habitual PMS sufferers (Eriksson,

2007). Hence, this experiment conclusively demonstrated that PMS sufferers and asymptomatic

women differ not in the levels of gonadal steroids but in how responsive the target organs are

to the influences of relevant gonadal steroids (Eriksson, 2007). The theoretical value of the

experiment was doubtlessly due to the fact that it relied on direct manipulation of potentially

causative factors, on top of simple observations of correlation.

The way the general public and clinicians use the term PMS is imprecise, generic, and covers a

wide variety of symptoms, ranging from severe symptoms that limit or impair normal

functioning (and hence are termed “clinically significant”) to mild physiological changes

characteristic of a normal menstrual cycle (Freeman, 2007). In fact “when the severity of the

symptoms is not identified, up to 90% of menstruating women report PMS symptoms”

(Freeman, 2007, p. 55). On the other hand, only about 20% of menstruating women suffer from

a clinically significant disorder (Freeman, 2007). Thus, not all premenstrual feelings and

experiences constitute a syndrome or a disease in the eyes of the Western medical

establishment. In fact it is clear that most women who experience premenstrual symptoms are

not classified as PMS sufferers in need of medical intervention. Consequently, it is no wonder

that many women who are annoyed by their premenstrual symptoms and want to eliminate

them through medical intervention, get dismissed as hyper vigilant and are not given any

treatment for the simple reason that their premenstrual experiences are a normal part of

female physiological function which does not constitute a disease.

Gynecologists, when presented with a patient complaining about her premenstrual symptoms,

in virtue of their training, often choose to focus on the physical symptoms, while psychiatrists,

for the same reasons, often prefer to focus on mood and behavioural symptoms (Freeman,

2007). Consequently, PMS patients who suffer from severe psychological problems often

choose to go to a gynecologist instead of a psychiatrist in order to avoid the stress and anxiety

which they believe they will experience if they get labeled as mentally ill (Freeman, 2007). Thus,

the claim that the physiological factors of health are considered, by the Western medical

establishment, to be more “real” than the psychosocial factors, is misguided. PMS, for example,

as can be seen from the above, gets studied and treated by at least two specialists:

gynecologists and psychiatrists. The first group of experts is trained to deal with physiological

aspects of PMS (and thus perhaps may be said to consider them more “real” than psychosocial

factors), while the second group may perhaps be said to disregard physiological factors, and

instead deals with the psychosocial factors of PMS because that’s what its members were

trained to do best. Moreover, it can be seen from the above information that the alleged bias of

the health care system in favour of dealing only with physiological factors, if it exists at all, is

due to PMS patients who preferentially see gynecologists instead of psychiatrists even though

they are in need of psychiatric help.

Response to Medical/Scientific Objections

Comparisons of severe PMS sufferers from different cultures showed that women of European

descent displayed predominantly emotional symptoms of PMS, while women of non-Western

origins were more likely to have primarily somatic symptoms (Pearlstein, 2007). This points

back to the theory proposed by medical anthropologists that the observable symptoms of PMS

in Western women are unconscious dramatic acts rather than signs of an underlying

physiological illness. Also, even though PMS has often been regarded as a primarily endocrine

condition, all attempts to explain it in terms of hormonal differences between PMS sufferers

and asymptomatic women, have consistently failed (Eriksson, 2007). Responding to the rest of

the medical/scientific objections, however, doesn’t appear to be feasible or even possible. In

fact, the author of the present paper found them to be more convincing than the evidence used

to support the initial feminist position on this issue.

Conclusion

The above debate has demonstrated, at least to the author of the present paper, that PMS, at

least when manifested by clinically significant symptoms, is a real psychological/physical

disorder rooted in female physiology, rather than a medicalization of normal female emotions

and feelings surrounding menstruation, as initially proposed. However, the studies regarding

the physiological etiology of clinically significant PMS, while being a great step forward, remain

inconclusive and hence need to continue. Determining the physiological causes of clinically

significant PMS will be a key next step, as it will enable the formulation of objective diagnostic

criteria which in turn will enable medical professionals to distinguish between clinically

significant PMS and other physiological and psychiatric disorders with similar symptoms.

Moreover, a definite establishment of physiological etiology of clinically significant PMS will

inevitably lead to effective treatment of this widespread, debilitating condition.

References

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