We’d Know More About PMS if Researchers Spent as Much Time on It as ED

Today I cried because I ran out of cheese, which means my period is imminent.

There are at least 200 known symptoms of premenstrual syndrome, aka PMS, separated out into physical (cramping, bloating) and psychological symptoms (irritability, anxiety, sadness). I’m sure "cheese breakdown" is included in that stupidly long list of symptoms.

Jokes aside, my PMS symptoms are relatively mild in comparison to Eden Church, a 22-year-old student from Toronto who was diagnosed with premenstrual dysphoric disorder (PMDD), sometimes referred to as PMS on steroids, when she was 20. "There are [days] where I will wake up and feel like a different person than I did the night before," Eden says. “It’s like coming home to your house three weeks out of the month and then one week of the month, you come home and all the furniture is on ceiling.”

Her body becomes almost foreign to her during the week before her period. Her depression—which she’s had since her last year of high school and took antidepressants for until this year—turns up a notch, and an impending sense of dread follows her around. The smallest inconveniences, which normally wouldn’t phase her, make her angry.

Around 75 percent of women experience PMS, while PMDD affects a much smaller (2-5) percent of the female population. And while both PMS and PMDD are widely accepted as real disorders on varying ends of a spectrum, some experts continue to cast doubt on their legitimacy.

Last year, writer Frank Bures questioned if PMS was real in his book, The Geography of Madness. In the above linked excerpt from Slate, he cites research that suggests that PMS—and its more brutal relative, PMDD—are culturally constructed rather than founded in biology. However, he recognizes that even if (and that’s a big “if”) something is a social construct, that doesn’t mean it’s not a real experience. He throws in examples of research that found women who endorsed stereotypical gender roles experience more “menstrual distress” and sheds light on the cultural differences between how eastern and western women experience their time of the month before coming to the conclusion that PMS and PMDD could be “cultural syndromes.”

It upsets my already agitated insides to tell you this, but furthering the argument that PMS might not be real is the fact that research has failed to show that it actually exists on several occasions. A review of the PMS literature in 2012 didn’t find any association between menstruation and negative mood. Another study, published in 2013, followed a random sample of women between the ages of 18 and 40 who tracked their mood over six months and found stress and social support were much better predictors of mood than the menstrual cycle.

However, associations of women’s menstrual cycle and moodiness go as far back as Hippocrates with women and the wandering womb theory, so surely centuries of anecdotal evidence and scientific research isn’t full of shit?

Unfortunately, between Hippocrates’ time and present day, there has been a long, sordid history of sexist and problematic research when it comes to that time of the month. So despite advancements in science, it’s still unclear if PMS and PMDD are a biological reactions to changes in hormones or if the idea of monthly moodiness is so culturally ingrained in the psyche of women that most of the female population are experiencing some form of hypochondria.

This isn’t a exactly a shocker, but part of the problem is that women are understudied. “Most of the problems that scientists study are problems and questions they feel would easily apply to both sexes,” says Gillian Einstein, director of University of Toronto’s collaborative program in women’s health, who confirms there hasn’t been much interest in PMS research. I don’t think we even know why we menstruate.” She tells me that not all mammals menstruate; some re-absorb their uterine lining, which sounds like a much better option.

Figuring out how to perfect the male boner, however, has been an area of prolific interest. ResearchGate found that there were five times as many studies on erectile dysfunction than there were on PMS, which helps explain why erectile dysfunction has a cure and PMS and PMDD do not. There was also trepidation of calling attention to these conditions, as that might further negative stereotypes about women, according to Hadine Joffe, psychiatrist and executive director at Connors Centre for Women’s Health and Women’s Biology.

“There was, historically, concern among women and feminists articulating this as a disorder to dismiss women as unstable subject to the whims of your hormones,” she says. That was also a reason why it took so long for PMDD to be classified as an official disorder, only making it into the Diagnostic and Statistical Manual in 2013. Further, there’s very little consensus on the specific symptoms of PMS and PMDD. And consider the amount of symptoms, diagnosis and subsequent research is tricky.

On top of this, I’m finding that a lot of the research on PMS and PMDD is kind of crappy (read: low budget and flawed). Einstein points out that the studies often have small sample sizes and most use women who are already in the clinic for their menstrual problems. There’s also recall bias, where participants naturally associate any little change in mood or temperament to their period because bleeding for five days straight has a tendency to stick out in one’s mind.

“Because the menstrual cycle is such a central phenomenon in a woman’s life…people tend to remember things in relation to the onset of menses. They start, kind of, linking the two,” explains Peter Schmidt, the chief of the National Institute of Mental Health's behavioral endocrinology branch.

Other flaws include: studies only following women for one menstrual cycle and telling participants that the study is about their periods so they’re already thinking about PMS before the study starts. Another reason this debate keeps cropping up is there aren’t any solid biological markers that can be used for diagnosis, Schmidt says.

Unlike endocrine disorders such as hypothyroidism, there isn’t too much or too little of a hormone when it comes to PMS and PMDD, Schmidt explains. That being said, research is slowly starting to show that there might be a biological basis to the feelings millions of women experience each month.

“Progress is being made,” Schmidt tells me. Earlier this year he and his colleagues published a study that found a gene that was sensitive to hormonal changes and was linked to PMDD In the study, women with PMDD had this gene and were more sensitive to hormone level changes throughout the menstrual cycle than women who didn’t have PMDD.

“[Women with] PMDD had an abnormal response to normal hormonal levels,” Schmidt says.
This was the first time there was evidence of a plausible biological cause for the disorder, but Schmidt cautions: “we’re still a long way from identifying the hub of the abnormalities in these women.”

There's also some evidence that estrogen and progesterone do affect the brain and indirect evidence that if you stop hormone fluctuations, PMS and PMDD symptoms go away. But Joffe says current technological limitations are preventing us from finding out what’s really happening in the brain. So while science is starting to make headway in solving this centuries-old mystery, there are still many fundamental questions that need answers.

For instance, what are the biological underpinnings of PMS and PMDD? Why are some people more sensitive than others? Why do symptoms disappear when the period starts? Would women still get cranky if you took away all the physical symptoms of PMS? Anyone who thinks humans are the superior species needs to tell me why we’re not smart enough to absorb our uterine linings instead of shedding it every month. As for the cheese-related tears, it doesn’t matter whether it’s linked to my period or what I’ve been conditioned to think my period wants from me. This mystery deserves boner-caliber research too.

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