What counts as a premenstrual symptom? Patient and expert health professional perspectives on PMS (Premenstrual Syndrome)

Lead Research Organisation: King's College London
Department Name: Social Science, Health and Medicine

Abstract

PMS (Premenstrual Syndrome) diagnostic guidelines prioritise psychological symptoms, but the clinical reason for doing so remains unclear. Studies show that they are not necessarily the most commonly experienced, nor uniquely determining, nor most disruptive of the (100+) known premenstrual symptoms. Does such medical knowledge/ practice simply reflect and perpetuate the myth of the irrational female?

The main aim of this research is to explore how and why certain premenstrual symptoms achieve relative prominence over others, by examining 'expert' clinical constructions of PMS, alongside the experiences and perspectives of 'PMS sufferers'. It builds on the work of Prof. Jane M Ussher, in particular, whose research examines the gendered factors underlying the psychological symptoms of PMS, and identity in relation to the reproductive body.

Just as Ussher went on to develop an effective gender-centred psychological treatment for PMS, it is hoped that this research will also directly contribute to the integration of research and clinical practice. Especially in relation to the diagnosis and treatment of PMS, and associated female-prevalent conditions, such as; anxiety, asthma, chronic fatigue syndrome, depression, IBS (Irritable Bowel Syndrome), and migraine.

This study will address the following interrelated themes and questions:
- Premenstrual symptoms and identity. How do patients/clinicians (experience), explain, and categorise premenstrual changes/symptoms? How do patients associate PMS with their identity (or not), particularly in relation to gender, health, competence, rationality, and (reproductive) anatomy? In general terms, how do clinicians describe patients with PMS?

- Contested and stigmatised 'illnesses'. How do patients/clinicians compare PMS to other illnesses e.g. menstrual migraine, or Chronic Fatigue Syndrome? How do patients/clinicians account for the selective criteria used to diagnose PMS? How do patients/clinicians understand, or reveal, that PMS is a stigmatised or contested illness?

- Social influences in the construction of medical knowledge and practice. How do medical texts, training resources, and diagnostic/treatment guidelines define premenstrual symptoms, across a range of geographical and historical contexts? How does the gender, medical specialism, or age of a clinician affect the criteria used to diagnose PMS?

There is an inherent contradiction in arguments made about PMS: There is compelling evidence that positions it as a socially constructed 'illness' that serves to undermine the rational and political status of all 'women', but when some women (or transgender men) really do experience cyclical premenstrual symptoms, their experiences can in turn be undermined through medical/societal disbelief in their 'biological' validity (Martin, 1980).

By seeking to explore 'what counts' as a premenstrual symptom, and by asking this question of both expert medical professionals and 'PMS sufferers', this study hopes to examine this tension around what differentiates a menstrual cycle-related change from a symptom of ill health. As far as I am aware, this will be the first PMS study to include the perspectives of medical professionals, and to explicitly ask expert and lay participants to define, and explain, diagnostic criteria (from their personal perspective, rather than as defined elsewhere).

Feminist theorists have already shown how supposedly 'objective' scientific knowledge in this area can actually be highly subjective, and influenced by societal beliefs about gender roles. Likewise, this research project hopes to determine if the current clinical focus on the psychological elements of PMS is based on the lived experience of premenstrual symptoms, or simply reflects and perpetuates a societal myth - the 'naturally' irrational (or hysterical) female.

Publications

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Studentship Projects

Project Reference Relationship Related To Start End Student Name
ES/P000703/1 30/09/2017 29/09/2027
1916672 Studentship ES/P000703/1 30/09/2017 31/12/2020 Sally King
 
Description My doctoral research examined the way in which expert and lay accounts of PMS (Premenstrual Syndrome) described and explained premenstrual symptoms. I interviewed half of the world's top PMS experts and some self-identified PMS sufferers- and compared their descriptions with the available epidemiological data about the cause(s), type, severity, and prevalence of premenstrual symptoms in the general population. Participant descriptions overwhelmingly, albeit unintentionally, reproduced the myth of the 'hysterical' female rather than reflecting the available data. My research identified various discursive and practical factors as to why this myth is so difficult to recognise and counter, which I am now going to share with the participants and wider biomedical and academic audiences.

Main findings:
1. None of the participant group descriptions of premenstrual symptoms consistently reflected the available robust epidemiological data- but patients were better than the experts.
2. The participant descriptions seemed to reproduce three societal gender myths more than the available epidemiological data- 'femininity as debility', 'all in her mind' and 'the mysterious female (reproductive) body'.
3. Several interrelated discursive mechanisms and embodied, material, or institutional extra-discursive factors seemed to actively enable or constrain the participant discourses.
4. The third gender myth, 'the mysterious female (reproductive) body' appeared to substantially constrain the discourses available to the participant groups.
5. That 'good clinical intentions' may provide a more compelling explanation for the perpetuation of non-epidemiologically informed biomedical definitions of PMS and PMDD, than the 'material interests' previously identified in the critical PMS literature.
Exploitation Route A recent report on maternal mortality in the UK found that Black and other racialised ethnicity women were significantly more at risk of death during or after pregnancy and childbirth than White women (https://www.bmj.com/content/372/bmj.n152). Given that my study found that the symptom experiences of female patients were often dismissed or disbelieved (due to inaccurate assumptions based on the myth of the hysterical female) and that this was an even greater risk for Black and other racialised women, I am excited by the possibility of perhaps being able to make a real difference in the lives of patients by exposing the damaging effects of this gender/ race myth in clinical interactions.
Sectors Communities and Social Services/Policy,Education,Healthcare

 
Description There has been a significant increase in media and popular attention on the topic of menstrual health and associated human rights issues. While my work alone is not the sole reason why this topic is gaining more traction, I think my website (Menstrual Matters) and participation in five APPG All Party Parliamentary groups, UK and global research networks (I am a board member of the SMCR- Society for Menstrual Cycle Research) - and public engagement activites have contributed. The findings of my doctoral research are also directly helping to inform the Women's Equality Party's recommendations regarding maternal mortality in the UK (especially the racial myths involved). They are likely to influence medical school curricula and the way in which menstrual education is conducted in schools in the future.
First Year Of Impact 2021
Sector Education,Healthcare
Impact Types Societal,Policy & public services

 
Description APPG on Endometriosis
Geographic Reach National 
Policy Influence Type Membership of a guideline committee
Impact My inputs contributed to the recently updated NICE guidelines on Endometriosis and a UK governement public hearing/ debate regarding Endometriosis in the House of Commons.
URL https://www.endometriosis-uk.org/sites/endometriosis-uk.org/files/files/Endometriosis%20APPG%20Repor...
 
Description Invited member of UK government APPG (All Party Parliamentary Group) on Women's Health
Geographic Reach National 
Policy Influence Type Membership of a guideline committee
URL http://www.appgwomenshealth.org/about
 
Title Expert and patient descriptions of PMS (Premenstrual Syndrome) 
Description The raw data (interview transcripts and coding data) from my doctoral research. 
Type Of Material Database/Collection of data 
Year Produced 2022 
Provided To Others? Yes  
Impact None as yet- but I am sharing this data as per the ESRC funding policy. 
 
Description Cited in Health Affairs Journal blog 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Health Affairs Journal blog- 8 Oct 2020- Elizabeth Tobin-Tyler- 'How RBG's Voice Shaped The Courts'-And America's-Views On Women's Health For A Generation' - article about the late Supreme Court Justice, Ruth Bader Ginsburg's influence on female health research. Reference to my book chapter 'Premenstrual Syndrome (PMS) and the Myth of the Irrational Female'
Year(s) Of Engagement Activity 2020
URL https://www.healthaffairs.org/do/10.1377/hblog20201001.640025/full/
 
Description Feature interview- for BBC Science Focus magazine 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact BBC Science Focus Magazine- #347- 11th Mar 2020- Feature article 'A scientist's guide to periods'.
Year(s) Of Engagement Activity 2020
URL https://www.sciencefocus.com/magazine/the-age-of-rage/
 
Description Interview by Fortune Magazine 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Industry/Business
Results and Impact Interviewed for a feature article regarding menstrual leave policies (I wrote a book chapter on this topic during my PhD studies). My perspective provided much of the framework for the article.
Year(s) Of Engagement Activity 2021
URL https://fortune.com/2021/10/30/paid-menstrual-period-leave-us-companies/?n3yd8q
 
Description Interview for Lancet blog re Scottish period poverty policy 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The Lancet blog- 4 Dec 2020- Jacqui Thornton- 'Free period products in Scotland'- article about Scotland becoming the first country in the world to offer free period products to all who need them. Prominent quote and contribution to the tone of the blog.
Year(s) Of Engagement Activity 2020
URL https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32583-6/fulltext
 
Description Interview for Stylist Magazine article 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Stylist Magazine- 5 Oct 2019- Robyn Wilder- "Period leave: Would it help women in the workplace - or hold us back?" - Article about some of the pros and cons of the concept of 'menstrual leave'.
Year(s) Of Engagement Activity 2019
URL https://www.stylist.co.uk/life/period-leave-women-gender-equality-productivity/306025
 
Description Interview for The Times 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact The Times- 1 Nov 2020- Rosamund Unwin- 'Periods at work: should women get menstrual leave?'- article including an interview quotes regarding research on 'menstrual leave' policies.
Year(s) Of Engagement Activity 2020
URL https://www.thetimes.co.uk/article/periods-at-work-should-women-get-menstrual-leave-qlc2w6d0p
 
Description Interview for contribution to policy position paper- ODI (Overseas Development Institute) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact ODI- Overseas Development Institute- Align programme (Advancing Learning and Innovation on Gender Norms). I was interviewed in consultation for a policy position paper- 'Gender norms and the 'period revolution'' regarding the relationship between UK/ US period poverty campaigns and (some) positive shifts in gender norms. I was quoted several times and influenced the overall framing of the paper- as 'progress made but more research/ data required'.
Year(s) Of Engagement Activity 2021
URL https://www.alignplatform.org/sites/default/files/2021-08/gender_norms_and_the_period_revolution.pdf
 
Description Interview for online media content- MSN news and 'The Refinery' blogs 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Microsoft News and Refinery 29- 12 Sep 2020- Natasha Presky- 'How can we know more about erectile dysfunction than PMS?'- article about the relative lack of funding for female health research. Several quotes included and book chapter referenced.
Year(s) Of Engagement Activity 2020
URL https://www.msn.com/en-gb/health/mindandbody/how-can-we-know-more-about-erectile-dysfunction-than-pm...
 
Description Interview- World Service BBC podcast and radio show 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Interviewed for 2 hours for the 'Crowd Science' BBC world service podcast and radio programme. Although my quotes were ultimately edited down to just a few minutes, the overall framing of menstrual health that I provided was taken up by the programme presenters- who subsequently interviewed other researchers I had recommended. This is very important because my work reframes cyclical symptoms as due to immuno-inflammatory processes (rather than 'hormonal' changes)- which is my original contribution to the literatures/ clinical research and practice.
Year(s) Of Engagement Activity 2021
URL https://www.bbc.co.uk/programmes/w3ct1pqg
 
Description Keynote speaker at REBA (Rewards and Employee Benefits Association) London event (50+ major corporate firms) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Reward and Employee Benefits Association (REBA)- 05 Dec 2019- Coverage of keynote speech at 'Women's Health in the Workplace' event
Year(s) Of Engagement Activity 2019
URL https://reba.global/content/women-s-health-the-last-workplace-taboo
 
Description Media interview 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact I was interviewed for a feature article in Swiss Sunday magazine (similar to Sunday Times in the UK)- NZZ am Sonntag magazine. Again, I was heavily quoted and my critical perspective helped to frame the article.
Year(s) Of Engagement Activity 2021
URL https://www.menstrual-matters.com/wp-content/uploads/2021/06/NZZaS-Magazin-210425-Zyklus.pdf
 
Description Menstrual Matters website 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact I am the founder of the Menstrual Matters website- I write regular blogs and provide evidence-based information re menstrual health and associated human rights issues. THe website attracts approx 25K users per month. During the duration of my PhD over 500K people have accessed the website.
Year(s) Of Engagement Activity 2016,2017,2018,2019,2020,2021,2022
URL https://www.menstrual-matters.com/
 
Description Prominent quote in book review- Sunday Times 'Style' Magazine 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact The Sunday Times STYLE magazine- 12 Jan 2020- Direct quote in review of 'In the flo' book by Alisa Vitti. https://www.thetimes.co.uk/article/in-the-flo-is-this-new-book-the-key-to-understanding-your-period-wnpjqv7d5
Year(s) Of Engagement Activity 2020
URL https://www.thetimes.co.uk/article/in-the-flo-is-this-new-book-the-key-to-understanding-your-period-...
 
Description The Blobcast Podcast - live talk and recording 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact The Blobcast Podcast - 7 Nov 2018- "How Menstrual Myths and Taboos Help to Perpetuate Gender Inequalities" - live podcast event, recording now available on iTunes.
Year(s) Of Engagement Activity 2018
URL https://chartable.com/podcasts/the-blobcast-podcast/episodes/29811246-episode-1-the-menstural-moveme...
 
Description Vice Magazine article 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Vice - 27 Apr 2018- Natasha Preskey-"When the Rare Birth Control Pill Side Effect Happens to You"- Article about the lesser known side-effects of contraceptive medications.
Year(s) Of Engagement Activity 2018
URL https://www.vice.com/en/article/ywx9w7/birth-control-asthma-stomach-pain