26 June 2006
Have We Got PMS All Wrong?
by Angie Rankman
Throughout history, the definition, diagnosis and treatment of premenstrual tension (PMT), also known as premenstrual syndrome (PMS), has been rocky to say the least. Despite impressive sounding scientific reports into PMT, the studies are, more often than not, vague and amorphous, and based on little more than anecdotal evidence. This has led Professor Jane Ussher, a psychologist at the University of Western Sydney, to question the science that defines PMT and post-natal depression as hormonal problems. In her new book, Managing the Monstrous Feminine, Ussher claims that far from being the result of dysfunctional biological processes allegedly associated with PMT, the anger, stress and depression that women feel is the result of them absorbing and suppressing extreme societal pressures. Others, too, have argued that the "medicalization" of the female body has led to no more than the creation and continuation of a dedicated pharmaceutical market. So who are we to believe, and what lessons are we meant to learn from these opposing views?
For women experiencing PMT, it may seem somewhat of a stretch to believe that the emotional turmoil they suffer is somehow not hormone related. But this is exactly what critics of the hormonal explanation are saying; that PMT is a social construct. To ensure that PMT is normalized as a biological dysfunction, says Ussher: "Premenstrual symptomatology is now enshrined as a psychiatric illness, called 'Premenstrual Dysphoric Disorder' [PMDD], in the Diagnostic and Statistical Manual of the American Psychiatric Association [DSMIV]."
The inclusion of a new "disorder" into the DSMIV had its opponents, but their protests fell on deaf ears. Pulitzer Prize winning journalist Susan Faludi, relates the frustrations of one senior female AMA board member, Dr Teresa Bernardez, who opposed the inclusion. Dr Bernardez describes the atmosphere among AMA board members at the time of the vote as one where throwing out the new disorder was "giving in to the women." Bernardez finally got the chance to make an appeal before the board took a final vote, but was less than satisfied with the outcome. "I began to speak and they would not let me continue," said Bernardez, "I had to fight to be heard." When Bernardez's term on the board expired she was not invited back.
The DSMIV's definition of PMDD reads as follows: "This syndrome of physical symptoms associated with depressed or irritable mood, labile affect, loss of interest, impaired concentration and other symptoms occurs regularly prior to menses, remits shortly before menses, and is absent during the week after menses. It is often considered a severe form of normal premenstrual syndrome (PMS) in women." A quick glance at the DSMIV's definition of PMDD and PMS reveals a problem almost immediately. Namely, what is PMDD? That it is "considered a severe form of normal PMS" is vague in the extreme when you take into consideration the fact that health professionals cannot even agree on any real definition of PMS itself. All we can take away from such definitions is that women feel angry, depressed and generally crappy around menses. But even more interesting, is Ussher's observation that despite the symptoms of PMS and PMDD having the same "magnitude as major psychological disorders such as depression," PMS and PMDD go under-recognized in large-scale epidemiological studies or burden of health assessments.
The lack of any real definition or diagnosis criteria that sits comfortably outside of other forms of depression or anger adds additional weight to Ussher's argument. In a 2004 essay, Ussher explains that: "Despite research across several disciplines, efforts to understand and ameliorate premenstrual symptomatology have not succeeded. Rather, this is a field riddled by contradictory discourses and perspectives, with biomedical and psychological researchers offering numerous competing etiological theories and treatments." Such a situation means that any competing explanations for the depression and anger that a woman may suffer go largely unnoticed, as they are lumped under the psychological "disorders" of PMS and PMDD, and abstracted to such an extent that they become treatable by drugs alone (which we'll come to later). As such, any underlying cause of a woman's anger or depression need never be addressed.
Ussher has argued over the years in various papers and in her new book, that PMT and PMDD both represent the dislocation of women's anger and depression from its real source. "Women are using psychiatric terminology - 'anxiety', 'depression,' 'PMS' - in describing the reactions they experience to their own needs not being recognized," says Ussher. "Their anger or depression is pathologized - positioned as a symptom of PMS - rather than being positioned as an understandable response to 'having to get up and clean up after everybody', and deny their own needs, every day of the year." Ussher put it more bluntly in a recent media interview regarding her new book, saying: "The tags pre-menstrual syndrome, post-natal depression and menopause have become catch-all diagnostic categories that attribute women's unhappiness to their reproductive bodies and legitimize medical management of their condition." It is a controversial and unpopular viewpoint, but she is not alone in this assessment, or of the troubles that have beset a society that has medicalized the female body.
The fallout from PMS and PMDD being diagnosed as, says Ussher, an "internal pathology," is that drugs are used to alleviate the symptoms instead of the cause, which remains, according to Ussher, veiled and unacknowledged. "Following controlled clinical trials, the most widely advocated theories at the current time are serotonin imbalance, leading to the prescription of selective serotonin reuptake inhibitors (SSRIs)," says Ussher. The uptake of SSRIs, such as Fluoxetine, has been mixed from country to country, as methods of diagnosing PMDD have been problematic. In an article in PloS Medicine, Barbara Mintzes wrote: "The European Medicines Evaluation Agency refused to approve drugs for PMDD, raising concerns that women 'with less severe pre-menstrual symptoms might erroneously receive a diagnosis of PMDD resulting in widespread inappropriate short and long-term use of Fluoxetine'." Many of the studies into PMDD and PMS are based on recall from the women themselves, or interviews with relevant family members. This not only exposes the subjective nature of diagnosis, but also, says Mintzes, reveals the deliberate attempts of pharmaceutical companies to broaden the scope of PMDD definitions for the sake of boosting profits.
Rather than a medical "disorder" as a direct result of biological dysfunction, Ussher considers PMS and PMDD a form of self-censorship on the part of the woman. "It's a form of self-censoring. Women feel that they are expected to cope with the gamut of responsibilities - including their job, partner, children, extended family, housework etc - without complaint. They become distressed about the state of their lives and seek help only to be told that it is likely to be the result of these three diagnostic tags." Ussher adds that this is also true of women in their later years who are postmenopausal, and who have been prescribed HRT treatments. "The rates of depression in women actually fall with age, with only 7 per cent of women aged 45-54 experiencing depression. The notion of the menopausal body causing upheaval and depression is nothing more than fiction," she says. The fairytale images that permeate throughout our society, where a woman can have everything from raising a family, taking time out for herself and be sexy to boot, says Ussher, are no more than a mirage. "From our research it appears that for many women they only reach a position of equilibrium and peace when they can leave these myths behind, or realize they can't sustain them any more, or feel they have paid their dues, and can now turn to their own needs for the first time in their lives." In short, Ussher is suggesting that society needs to stop viewing women's bodies as the source of all their distress in life.
Ussher's is an interesting and confronting perspective for women. In a world where, on average, women do the bulk of housework; a little more care, understanding and appreciation would be a welcome change. What remains to be seen is if women can adopt this new life-path where they are in the driver's seat. "Women need to understand that it is okay to be vulnerable at certain times without letting it overwhelm them. It's also okay to say no - for many women, this is the most difficult technique to master of all."
Further reading: Disease Mongering in Drug Promotion: Do Governments Have a Regulatory Role?