Hi readers, my name is Hannah (she/they) and I am the author of this piece. I want to acknowledge my position as a white-passing, Indigenous women who currently experiences premenstrual syndrome (PMS) every cycle. While I have lived PMS experiences, I recognize that these do not encapsulate the full spectrum of lived experiences and through research, I wish to incorporate as many realities as possible. I am committed to growth as a researcher and a human being, and am open to feedback if perspectives are missed or have been done a disservice. Through a lateral communication approach, I hope to utilize my access to postsecondary education to share and promote knowledge of topics related to women’s health. I have a personal interest in PMS and my goal of this work is to communicate the hormonal changes associated with PMS and promote an increased bodily awareness and connection. Finally, I hope to reduce the negative stereotypes and myths that menstruators are taught to believe from a young age that can lead to bodily contempt and confusion.
Menstruators are defined as any person, regardless of gender, who menstruates/has periods. To be clear, menstruating does not mean someone is a woman and being a woman does not mean the person menstruates (or ovulates). All menstruators can experience premenstrual syndrome (PMS).
In this FAQ, we will discuss the causes of PMS. We will go over:
What is PMS?
PMS is a cyclical condition with symptoms arising during the luteal phase (after ovulation) and ceasing within the first couple days after menstruation. The cyclical pattern of symptoms is what defines PMS and rules out different mental or physical health diagnosis. In their lifetime, 90-95% of menstruators who are in the reproductive age range (from 15 to 49 years of age) experience PMS, with 3-8% of them experiencing symptoms so severe that the symptoms negatively impact the quality of their daily life. This is diagnosed as Premenstrual Dysphoric Disorder (PMDD). (1*-6*). Reproductive age refers to an age range that people who ovulate are fertile and can become pregnant within.
PMS can be confusing because it encompasses such a diverse range of physical, emotional and behavioural symptoms that are unique to individuals, with no definitive lab tests to diagnose (1*-8*). These symptoms include, but are not limited to:
Breast tenderness
Severe headaches and migraines
Sugar cravings
Cramps
Irritability
Depressed mood
Severe and intense mood fluctuations
Bloating
Acne
Fatigue
PMS - Hormonal Causes
Research is inconclusive about the fundamental cause of PMS as it can often be multifactorial (1*, 8*, 10*). At its core, it is believed that PMS is due to the hormonal changes menstruators experience during the mid- to late-luteal phase. Importantly, it is an individual’s sensitivity to the fluctuations and the biological effects of progesterone and estrogen that trigger PMS symptoms (5*, 11*-14*). Menstruators with PMS have similar levels of hormones as menstruators who do not experience PMS. This means that PMS is not caused by hormonal dysregulation or abnormal levels of hormones, but rather an abnormal response to normal changes in hormones. Simply, some menstruators may have a lower tolerance to both the hormonal changes and the pain associated with the luteal phase of the MC compared to those who do not experience PMS (5*, 11*-14*). Hormonal birth control often reduces the intensity of hormonal fluctuations, and this is likely the mechanism that relieves some PMS symptoms. This evidence further suggests that the fluctuation of hormones is more likely the cause of PMS rather than the absolute levels.
Estrogen (also referred to as oestrogen) and progesterone ‘take turns’ throughout the MC. Estrogen takes centre stage during the first half of the MC, the follicular phase. After ovulation, estrogen and progesterone drop off briefly followed by a large, steady increase in progesterone and a much smaller rise in estrogen in the mid- to late-luteal phase. Directly after ovulation and the few days before menstruation can be very challenging for menstruators. This is when both ovarian hormones dramatically fluctuate and are at their lowest levels, leaving those with a lower tolerance to fluctuations more vulnerable (5*, 8*, 11*, 15*). For a more in-depth description of all phases of the MC, Clue, a website and app with information on menstrual and reproductive health, has a detailed article about MC phases.
Often estrogen, progesterone and the MC itself is vilified and thought to be a negative consequence of ‘womanhood’ because of the negative symptoms one can experience.
However, estrogen and progesterone are not inherent brats running the MC amuck; both hormones are involved in various essential functions within the body. Progesterone and estrogen are important neurosteroids, meaning they can influence brain chemistry and signaling. They can alter metabolic rate, hormones associated with sleep, the uterus, and cognitive function... and those are just the beginning (4*, 8*, 11*, 16*-18)! Ovarian hormone interactions in the body are highly complex and can be a challenge for those with PMS. For example, while progesterone promotes a state of relaxation and calmness, it is also a precursor to the stress hormone, cortisol (11*). Those sensitive to the effects of hormones and the fluctuations may experience an increase in baseline cortisol levels, which can then affect sleep (specifically melatonin) and feelings of anxiety (12*).
Due to the multifactorial nature of PMS, there are a wide variety of treatment options. These options are beyond the scope of this article. It is important to speak to a trusted healthcare professional about individual symptoms and experiences to decide the best course for treatment and relief.
PMS - Sociological Causes
While your doctor will likely only discuss the hormonal causes of PMS with you, we also think it is important to discuss the more widespread socio-cultural understandings of menstruation which have an impact on PMS.
In the last decade, research has suggested that PMS is a Western disorder and is partly dependent on how menstruation is described and discussed in a culture (1*, 19*-21*). Sociocultural norms and values influence what and how information is communicated and whether it is at all appropriate to talk about specific topics (1*, 22). In the west, because attitudes about menstruation are largely negative, women’s perceptions of themselves during menstruation and their MC in general, are negatively influenced by these attitudes (22).
Misinformation and negative stereotypes are spread through many routes including public spaces (peers and school) and familial relationships (23*). One study compared a small group of young (19-24 year old), female-identifying college students in America and India and asked where they received information about menstruation and the general tone of the messaging (23*). Indian women reported receiving mostly positive or neutral information about periods, with the only negative information coming from magazines. This is in direct contrast to American women, who reported receiving negative information from multiple sources such as magazines, popular culture, school and parents. Notably, American college students reported that the majority of their negative sources were male relatives, including their fathers (23*). More generally, men and women alike often believe that the positive experiences in a women’s life are from external sources such as their lifestyle and environment, compared to negative ones being blamed on their internal hormonal environment and specifically the premenstrual phase (22).
Despite cultural differences in the understanding of menstruation, more recent studies show that PMS is a global experience for menstruators (9*, 22-25*). Different cultures may not have defined medical diagnoses for PMS (and PMDD) or a label for the collection of symptoms, but subjective premenstrual distress is felt globally (26*). Further, the presence of specific symptoms may occur more or less frequently depending on cultural context (19*, 26*). Many non-Western cultures report an increased experience of physical symptoms including bloating and abdominal pain (i.e. cramping) (19*, 24*, 26*). In a study of Pakistani women from three different cities, 98.8% had no knowledge of PMS or PMDD, but up to 79% of participants reported at least one recurring symptom. 69% of the women who did report symptoms experienced a negative effect in work performance, social interactions and daily housekeeping activities, with 8% of them reporting severe impairment in daily activities (24*).
Studies suggest that those who lack knowledge about the disorder are often more likely to accept symptoms as normal and not report or show concern, and ultimately, not seek treatment or relief (24*, 25*). Thus, it is important for physicians to acknowledge how an individual's culture may affect their understanding of symptoms, and take a holistic approach to healthcare. This means physicians should work with their patients to first understand their level of knowledge and any preconceived perceptions of menstruation and symptoms related to menstrual discomfort. This is a critical aspect of patient-centred care that should be prioritized.
Historically, in the Western world, PMS has been dismissed and normalized for menstruators, with many youth being taught experiencing this range of uncomfortable symptoms before menstruation was to be expected, tolerated, and even hidden (19*). The first literature published that acknowledged PMS in 1931 remarks on how “it is remarkable that so little attention has been paid to the fact that these disturbances occur not only during menstruation but even more frequently, though less obtrusively, in the days before the onset of menstrual flow” (27*). It wasn’t until the twentieth century that PMS was recognized as a condition deserving medical attention rather than an inherent “hysterical” characteristic of women that should be suppressed and hidden. The paper concludes that there has been a failure in promoting positive images of menstruation. Menstrual symbolism is in many cultures, but often focuses on how periods can be dangerous, dirty and make menstruators less competent or less sexually appealing (22). Indeed, there is an inherent bias to label menstruators as overly emotional due to their reproductive organs (19*, 22). This understanding and rhetoric removes important social and cultural contexts.
Epidemiological studies show that white women across multiple countries are more likely to experience PMS and PMDD compared to racialized women, including East Asian, South Asian, Afro-Caribbean and African-American women (19*, 28*-31*). This finding contradicts current research which shows that Black patients often report greater pain in general than white patients, which is not reflected in the level of appropriate treatment that racialized minorities receive in health care (32*-34*). In this case, the epidemiological statistics are likely misleading. Are white women truly at an increased risk of PMS and PMDD or, are they more likely to be diagnosed with and/or report PMS symptoms compared to racialized counterparts? There is a large body of evidence that shows racialized and Indigenous folks are underdiagnosed and undertreated for a variety of pain-related conditions due to racial discrimination within medicine. For example, Black women in the U.S. are underdiagnosed and left without proper treatment for endometriosis because of the incorrect stereotype that this condition is more common in white women (35*). Because of this, many Black women have not received adequate treatment for a chronic pain condition that has been shown to negatively impact quality of life (35*, 36*).
Therefore, it is important to remember that while objective reporting may show increased incidence of PMS and PMDD and associated symptoms in white women, this information and bias can easily lead to mistreatment and inadequate healthcare for racialized menstruators who are already at an increased risk for negative health outcomes.
*These sources do not specify the gender identity of the women included. Historical representation leads us to believe only cisgender women were included.
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Research Disclaimer
The majority of research on PMS does not collect information on gender. Transgender and gender-diverse folks may experience PMS differently than cis-gender counterparts. Transgender and gender-diverse people experience systemic oppression and violence daily which contributes to an increased risk of poor health outcomes, including mental illness and cardiovascular disease. The menstrual cycle (MC) is often considered a fifth vital sign, meaning it is an important health indicator in those who menstruate. Approaching ovarian hormone health with an intersectional framework is critical to understanding and representing this unique health experience of these vulnerable groups. Applying an intersectional approach would show how inequities in healthcare and unique environmental stressors can impact PMS experiences in different populations.
Human beings, especially those within the scientific community, have a tendency to categorize and create boundaries and labels. Labels can be helpful in diagnosing PMS and MC abnormalities; however, we need to recognize that the MC is a complex phenomenon with various challenges and celebrations, and PMS itself encapsulates a range of symptoms and experiences that will be unique to individuals. PMS looks different for everyone. Menstruators deserve more holistic attention to this condition as it is experienced globally and can have significant impacts on quality of life and general health outcomes.
A Note on Current Research and PMS
Some researchers use the term perimenstrual as opposed to premenstrual as this encompasses symptoms, especially mood disruptions, experienced during menses as well as the premenstrual phase. As an example, a group of researchers across Canada concluded that negative mood was not confined to the premenstrual phase and more often continued or began through menstruation when analyzing data from 47 studies (37). This is likely validating to many menstruators who feel negative mood, among other symptoms, during menstruation.
However, to the disappointment of many, studies are also more likely to include more negative mood items to report on compared to positive. When participants are asked to report symptoms, there are usually more negative options and few positive options. This assumes from the beginning that phases of the MC are specifically associated with discomfort and negativity. This does not show the entire picture of mood fluctuation and variability throughout the MC and perpetuates the idea that the MC is generally a negative experience and invalidates those who feel connected to their MC and have positive perceptions and experiences.
Another issue in research about the MC is that true random samples of the population are rarely used. Instead, convenience samples of post-secondary women and nurses are the go-to. Convenience sampling is when researchers take data from a specific population (i.e. women from a specific university or institution) because it is easier to collect and/or access this data. This skews the data and it is not representative of many groups of people; therefore, the results cannot be confidently generalized. For example, college and university is often closely correlated to socioeconomic status which can further be stratified based on race and gender identity. These groups of women are likely to have very different PMS experiences as was noted above due to cultural and social contexts.
Find out here on how to access gynecological care near you.
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