PMS and the Wandering Womb

Research questions the prudence of attributing negative moods to the menstrual cycle.

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"Wombhouse" by Atelier van Lieshout has a bed in the uterus, a wet bar in one ovary, and a toilet in the other.  [spinster/flickr]

"The idea that any emotionality in women can be firstly attributed to their reproductive function -- we're skeptical about that," Dr. Sarah Romans told me, skeptical said with audible restraint. 

She and eight other researchers at the medical school at the University of Toronto published a review last week in the journal Gender Medicine that looked at all of the clinical research they could find to date on PMS with prospective data. Their conclusion was that the articles, in aggregate, "failed to provide clear evidence in support of the existence of a specific premenstrual negative mood syndrome."

Romans isn't saying that the mood symptoms we attribute to PMS aren't real and common. But she is saying that those symptoms are culturally over-attributed to the menstrual cycle, to the detriment of the medical community and those experiencing them -- and as a broader issue of gender equality.

The Diagnostic and Statistical Manual of Mental Disorders, which is the definitive text of U.S. psychiatrists, defines and outlines a diagnosis called premenstrual dysphoric disorder (PMDD). It's often casually defined as a severe version of PMS, which itself is not included in the DSM as a diagnosis. PMDD is characterized by physical and behavioral symptoms in the second half of the menstrual cycle.

"I do believe that PMDD exists," Dr. Romans told me. "I think we still don't know the prevalence. There was a good study recently that measured the prevalence rate down from 3-9 percent to around 1.5 percent." Still, "it's doing any woman a disservice to not let her have access to some of the effective treatments for PMDD." She describes how effective anti-depressant SSRIs like sertraline (Zoloft) can be, immediately, for PMDD.

Romans specifies, "Our interest was really in the wider premenstrual syndrome construct. I think most would assume that PMS is much more firmly evidence-based than in fact it is."

In their paper they note that the menstrual cycle has "historically been the focus of myth and misinformation, leading to ideas that constrain women's activities." An association between negative mood and the menstrual cycle has a long history, first noted in the scientific literature in 1931 by gynecologist Robert Frank and psychoanalyst Karen Horney. Long before that there was the wandering womb -- the notion, in the teachings of Hippocrates, that illness was due to the uterus moving around the body like a wild beast. The word hysteria is even derived from the Greek hystera, meaning uterus.

A broad mood-somatic premenstrual syndrome (PMS) was actively promoted by Katharina Dalton in the United Kingdom during the post-World War II years; she implicated progesterone deficiency as its cause. During the 1960s, PMS gradually supplanted Frank's earlier term of "premenstrual tension," and PMS continues to be the common term in the developed world. However, the definition of PMS, whether referring to mood alone or mood plus physical symptoms (e.g. bloating), is not clear when the term is used in both the scientific literature and in lay discussions.

The University of Toronto team systematically reviewed all the major English-language research that included daily mood reports that had been collected prospectively for at least one full menstrual cycle. There ended up being 41 that they considered large enough to be valid.

According to their review process, 15 studies (36.6 percent) "found no association" between mood and the phase of one's menstrual cycle. Another 17 (41.5 percent) "found an association of negative mood in the premenstrual phase, combined with another phase of the menstrual cycle." Six (13.5 percent) found an association between "negative mood and the premenstrual phase." The remaining 4 studies (8.5 percent) found an association between negative mood and a non-premenstrual phase. So, of the published research, several large studies have found associations between various phases of the menstrual cycle and moods. But they vary as to which phase. And sometimes no relationship exists at all. 

Presented by

James Hamblin, MD, is a senior editor at The Atlantic. He writes the health column for the monthly magazine and hosts the video series If Our Bodies Could Talk.

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