PMS: Biology or Culture?

Image: http://www.slate.com/articles/health_and_science/medical_examiner/2016/11/pms_might_be_a_cultural_syndrome_not_a_biologic_one.html

In Frank Bures’ article “Is PMS Real?: Or is it Just a Figment of Our Menstruation-Fearing Culture?”, Bures challenges the common belief that PMS has solely biological causes and raises the idea of PMS as being one of many “cultural syndromes” — syndromes in one culture that don’t appear in others — in the U.S. He states,“our beliefs about PMS can become part of its cause in a kind of feedback loop feeding off, exacerbating, even initiating the physiological sides of the syndrome.”

He references several studies in the article that supports the idea of PMS as a “cultural syndrome.” In one study, researchers found that “women who endorsed traditional gender roles experienced more menstrual distress” while another study found that women who were led to believe they were premenstrual, when in reality they were not, experienced more symptoms of PMS than those who were premenstrual but were told that they were not.

In keeping with his message that PMS is at least partially based on culture, Bures cites World Health Organization surveys that show that menstrual cycle-related symptoms were most likely to be reported by women who lived in Western Europe, Australia, and North America; and that a common PMS ailment reported by women in Hong Kong and China — increased sensitivity to cold — was not one reported by American women. Likewise, Chinese women rarely reported negative moods.

He mentions Robert Frank, an American gynecologist who in 1931 published the article “The Hormonal Causes of Premenstrual Tension” which listed “irritability, bloating, fatigue, depression, attacks of pain, nervousness, restlessness, and the impulse for ‘foolish and ill considered actions’” as symptoms that occurred a week before menstruation due to ovarian activity.

In 1953, British doctor Katherina Dalton expanded on this idea, added more symptoms, such as anxiety, moodiness, anger, poor judgement, lack of physical coordination, decreased efficiency, arguments with family or friends, seizures, increased personal strength or power, feelings of connection to nature or to other women, migraines, poor judgment, decreased efficiency, and food cravings. She coined the condition these symptoms fell under as premenstrual syndrome, and argued that it arose from fluctuations in the hormones estrogen and progesterone. People who had one of these symptoms during the second half of their menstrual cycle could be diagnosed with PMS.

But PMS did not get “medicalized” until the 1980s, when in the U.K., three convicted women (tried for arson, assault, and manslaughter) in the U.K. received hormone treatments as part of their sentence. They had blamed their actions on PMS. After these convictions, the idea of PMS as a medical condition became more widespread in America. Groups, such as PMS Action, organized to promote recognition and treatment of PMS. Private PMS clinics appeared, and progesterone therapy was adopted to treat PMS. This spurred the inclusion of premenstrual-related disorders in several editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), culminating in its appearance in the DSM-5 as premenstrual dysphoric disorder (PMDD) — a severe form of PMS. The DSM-5 even states that PMDD is not a cultural syndrome, yet “‘frequency, intensity, and expressivity of symptoms and help-seeking patterns may be significantly influenced by cultural factors.’”

Bures ends the article by citing another study that noted,

“The more time that women of ethnic minorities spend living in the United States, the more likely they are to report PMDD…we must also accept exposure to U.S. culture as a risk factor for contracting PMDD.”

Bures had an interesting point to make about PMS. As we know from the placebo effect, our beliefs and expectations about something can impact our experiences of it, so the idea that the experience of PMS is influenced by cultural beliefs of PMS makes sense. Though he never pulls out actual numerical data, Bures effectively argues his point using his references of studies that are from reputable journals. However, I’m a bit skeptical of how much emphasis he places on the effects of culture on PMS.

While not really surprised by some of the symptoms Dalton included in her definition of PMS (moodiness, anger), I was taken aback at some of the symptoms she included. Symptoms such as increased personal strength or power, and feelings of connection to nature or to other women. Apparently I am missing something, because I do not see those two symptoms as problematic. But other than that, I can understand why the notion that women who argue with others, or who show strong emotions in general are seen as PMSing, as the symptoms of PMS as described by Dalton include arguments with family or friends, anger, anxiety, sadness, and moodiness.

In Hamblin’s article, Dr. Romans’ review suggested that the association between hormone fluctuation and PMS-attributed moods is not as strong or definitive as it had been portrayed in the past — which calls into question Dalton’s argument of the role of hormones in PMS.

Dr. Romans would probably agree with the influence of culture on PMS to an extent — but she would also acknowledge that these mood symptoms are culturally over-attributed to the menstrual cycle, and could be indicative of other issues — such as lack of social support, stress, declining health.

PMS, like the “wandering womb” and “uterine suffocation”, blames the female reproductive organs for negative conditions associated with those who have a uterus. But what differs between PMS, the “wandering womb,” and “uterine “suffocation” is that the cause is not directly associated with the uterus, but rather, hormone fluctuations related to menstruation. However, the underlying theme remains the same: that those born with a uterus are controlled by it.