NANO QUIRKE-BAKRADZE
To the Chief Executive of Health Education England,
Dr Navina Evans
4 Stewart House
32 Russell Square
WC1B 5DN
2nd April 2023
Dear Dr Navina Evans,
I am writing to you to address my concern on the attitudes and approach to pre-menstrual syndrome (PMS).
PMS is a syndrome where women experience a range of symptoms from mood fluctuations and irritability to depression and muscle fatigue, usually within the week before or during menstruation (NHS 2019). As you are aware, it is treated with a range of medical services, from painkillers to talking therapy (2019). Yet, despite establishing PMS’ profound effect, why have we reduced it to a couple of ‘mood swings’ and ‘rage’ – why have we attributed the complexity and humanity of women’s moods down to PMS? And how, despite PMS becoming much more widely known and accepted (in the Western context), has it barely been touched on in medical research?
This attitude to PMS, and the general approach to treatment, concerns me.
With this letter, I aim to show the problems with over-medicalising PMS as a condition, the cultural understandings of PMS through the Western context and compare this with other cultural interpretations. Finally, I shall present solutions that I believe are actionable and will foster better awareness of the complexity of PMS, which can improve its subsequent treatment.
I want to demonstrate the importance of understanding PMS and its effects through the social and environmental context, rather than focusing on the purely biomedical, which I believe is a flaw within the current medical approach that the NHS adopts. I hope by writing this letter that I can show you the value of different perspectives in informing both the education on PMS and approach to its care.
PMS first started getting recognised as a short phase of ‘tension’ in the 1930s, its first appearance in the medical world (Frank 1931 as cited in Johnson 1987). However, it was only from 1970 onwards that this became known as PMS (Johnson 1987). A court-case in the 1980s propelled it to the international stage, as two women who had committed crimes were defended because of severe PMS (Johnson 1987). This was arguably the start of PMS’ medicalisation. It is interesting to me how, after all this, the concept of PMS has now been used to describe almost any ill-tempered behaviour in women, this being propagated most through media (Roberts 2011).
First, I will present to you the implications of the medicalised approach to PMS, and why it is an issue. PMDD is one example of this, showing how medicalisation has impacted treatment for women’s menstrual health. PMDD – ‘a severe form of PMS’ (Mind UK 2021), was first added to the DSM – IV in 2000, (formerly late luteal phase dysphoric disorder) (Chrisler and Gorman 2016). This was largely to acknowledge the profound impact this severe PMS had on women’s lives, and therefore advocate for more effective treatment of these symptoms. Whilst this does validate people’s experiences, I believe it also takes one step closer towards entirely relying on medicine to treat this condition and thus neglects any social element of the experience of pain. It is no coincidence that after PMDD became an official part of the DSM-5 manual for diagnostic mental illness, pharmaceutical companies started paying more attention, marketing their products for sufferers of PMDD (Roberts 2011, 2). In fact, it was right after the change to PMDD in 2000 when the FDA approved Sarafem, a drug manufactured by Eli Lilly, thus promoting the condition so that ‘more women could self-present with PMDD and put more pressure on doctors to prescribe it’ (Fauber 2016). This is a huge problem for PMS and women’s menstrual health, because it normalises the administration of drugs to people who may be wrongly diagnosed, and thus subjects them to potent drugs that could cause more harm than good. Furthermore, many drug companies fund studies of conditions like PMS (Daw 2021). This is not to diminish the consequences of these symptoms on women, but rather draw attention to the fact that these companies are capitalising off this vulnerability, rather than treating people for their symptoms. Big pharma do not have patients’ best interests at heart, but GPs and doctors around the UK are still having to rely on them for alleviation of PMS/PMDD pain. The advertisement of Sarafem with a pink pill, despite being a version of Prozac (treated for depression) rebranded the pill as exclusive to PMDD (Roberts 2011), further encouraging uptake by those suffering from PMDD, and forming their response to pain through the ‘meaning and culture’ that shapes illness (Kleinman 1988). Another example of how pharma controls the conceptualisation of illness. This is not to argue that medication is ultimately bad; rather, I am merely highlighting the importance of looking at intersectional factors such as culture, class etc., as a way of conceptualising something as complex as PMS, and not over-attribute the influence of biology over a women’s mental state. Some argue that having PMDD as a diagnosis encourages stigmatisation of women’s mood fluctuations as being mentally ill, when in fact it is part of being human. But this does not mean it should be dismissed, but rather treated with consideration of these nuances. Thus, you can see how medicalisation is a problem for the treatment and understanding of PMS/PMDD, as it focuses solely on the biological experience and so neglects the ‘social and systemic frameworks’ that contribute to this experience (Scully 2004).
Recognising the social importance of PMS and society’s impact on our understanding of PMS is important to consider. For example, a study showed that more cases of PMS are reported in places such as Europe, North America, while most common symptoms reported in Hong Kong and China were increased sensitivity to cold (Bures 2016). This goes to show that there is some cultural variation in PMS. It could even be considered a ‘culture bound syndrome’, seeing as studies such as Browne’s show that women of ethnic minorities who spend time living in the US are more likely to report PMDD (Browne 2014).
Martin posits that the symptoms of PMS as we know them now are a product of a Western post-industrial society, where everything is viewed in relation to labour. One such example includes women conceptualising their PMS as a loss of ability ‘to carry on activities involving mental and physical disciplines’ (Martin 1988, 3). Because capitalist society demands jobs that ’require and reward discipline’ (Martin 1988), any experience that takes away from that productivity is viewed as negative and detrimental not only to society but also to oneself – thus it is counted as something to be fixed and out of the norm. Johnson encapsulates this perfectly, saying that women are expected to be both ‘reproductive and productive, have both careers and family’ (1987). This is a pressing issue in women’s health, as because of these societal expectations to serve under labour, we end up having to deal with our struggles by getting our hormones balanced, when the environment around us should be adapted to our needs and demand less productivity. I believe there needs to be more accommodations made to help women deal with their PMS/PMDD, which can only happen once we start to look at these conditions not as biological entities, but as interconnected structures. Consequently, you can see how the social environment interacts with our biology to shape our understanding of PMS, hence the importance of re-evaluating the current approach to PMS.
There are other cultural understandings of PMS – the UK has a largely Western-centric idea of PMS management, which is adapting oneself rather than the environment. However, the Beng women – an ethnic group in Ivory Coast – view their menstruation as an opportunity to reduce their usual workload (Gottlieb 1988). Perhaps it would be better if we did the same, and view our usually negative symptoms, such as lack of concentration, as a chance to focus our energies broader? This shows us the influence of capitalist values in framing our own experience of PMS. Thus, an understanding of different PMS perspectives and a reframing our own experience, can ultimately help us better manage our struggles.
All this is to say that our attitudes to PMS and how we approach its care must change. I believe the road to this lies in improving education on women’s health, starting from secondary school. In Hong Kong, the introduction of educational programs in schools helped marginally reduce students’ PMS symptoms (Chau and Chang 1999), such as anxiety. The writers discuss this as being in part due to their better understanding of PMS’ biology and its impact on social relationships, school performance and general wellbeing. However, Chau and Chang report that students lacked ‘trusting relationships’ with their teachers and parents, which may have impacted their accessibility to information on women’s health. This highlights the responsibility of authorities, such as teachers and health professionals, in shaping our perceptions of PMS. Thus, I posit the need to implement a continuous education program on women’s health issues in schools, to bring awareness of this and enable students to become better equipped to manage PMS into adulthood, as well as understand when to visit the doctor for more severe variations such as PMDD. Education should also situate PMS in local and cultural contexts, pointing out the importance of cultural factors such as language used to describe pain (as mentioned above with Scully 2004) in moulding individual PMS experiences. This will help shape the treatment of PMS as a human condition first and foremost, rather than universalising it as something everyone experiences equally.
I really believe that better education will lead to better care, not only through highlighting the nuances and variations of PMS, but also through empowering the next generation to advocate for their health and their bodies.
After all, you said it yourself:
‘Focus on people and the rest will follow’, (Evans, 2012).
Yours sincerely,
Nano Quirke-Bakradze
References
Browne, Tamara Kayali. 2014. “Is Premenstrual Dysphoric Disorder Really a Disorder?” Journal of Bioethical Inquiry 12 (2): 313–30. https://doi.org/10.1007/s11673-014-9567-7.
Bures, Frank. 2016. “Got PMS? Thank Our Menstruation-Fearing Culture, Not Biology.” Slate Magazine. November 28, 2016. https://slate.com/technology/2016/11/pms-might-be-a-cultural-syndrome-not-a-biologic-one.html.
Chau, J. P. C., and Anne Chang. 1999. “Effects of an Educational Programme on Adolescents with Premenstrual Syndrome.” Health Education Research 14 (6): 817–30. https://doi.org/10.1093/her/14.6.817.
Chrisler, J. C., and J. A. Gorman. 2016. “Menstruation.” Edited by Howard S. Friedman. ScienceDirect. Oxford: Academic Press. January 1, 2016. https://www.sciencedirect.com/science/article/pii/B9780123970459002548.
Daw, Jennifer. 2021. “Is PMDD Real?” Apa.org. 2021. https://www.apa.org/monitor/oct02/pmdd.
Evans, Navina. 2012. Twitter post. https://twitter.com/navinaevans?lang=en
Fauber, John. 2016. “Lowering the Bar: How PMDD Went from an Idea to a Diagnosis.” Www.medpagetoday.com. November 16, 2016. https://www.medpagetoday.com/special-reports/loweringthebar/61457#:~:text=While%20the%20FDA%20approved%20Sarafem.
Gottlieb, Alma. 1988. “Menstrual Cosmology among the Beng of Ivory Coast.” In Blood Magic the Anthropology of Menstruation, edited by Alma Gottlieb and Thomas Buckley. 55-75: University of California Press.
Johnson, Thomas M. 1987. “Premenstrual Syndrome as a Western Culture-Specific Disorder.” Culture, Medicine and Psychiatry 11 (3): 337–56. https://doi.org/10.1007/bf00048518.
Kleinman, A. (1988). The Illness Narratives: Suffering, healing and the Human Condition, Basic Books.
Martin, Emily. 1988. “Premenstrual Syndrome: Discipline, Work, and Anger in Late Industrial Societies.” In Blood Magic: The Anthropology of Menstruation, edited by Alma Gottlieb and Thomas Buckley, 161–87. Berkeley: University of California Press. https://www-degruyter-com.libproxy.ucl.ac.uk/document/doi/10.1525/9780520340565/html.
Mind UK. 2021. “What Is PMDD?” Www.mind.org.uk. 2021. https://www.mind.org.uk/information-support/types-of-mental-health-problems/premenstrual-dysphoric-disorder-pmdd/about-pmdd/#:~:text=Premenstrual%20dysphoric%20disorder%20(PMDD)%20is.
NHS Choices. 2019. “PMS (Premenstrual Syndrome).” NHS. 2019. https://www.nhs.uk/conditions/pre-menstrual-syndrome/.
Roberts, Jane. 2011. “Dispensing Knowledge and Shaping Experience: The Role of Popular Media in the Lives of Women with Pre Menstrual Dysphoric Disorder.” MSc Dissertation, UCL. https://www.ucl.ac.uk/anthropology/sites/anthropology/files/102012.pdf.
Scully, Jackie Leach. 2004. “What Is a Disease?” EMBO Reports 5 (7): 650–53. https://doi.org/10.1038/sj.embor.7400195
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