Doctors have turned period problems into a 'syndrome', requiring an armament of potent drugs, when many symptoms are either normal or the result of nutritional deficiencies.
Menstruation was among the Victorian's greatest obsessions. The term gynecology was coined early in the Victorian era to define the medical speciality of female disorders. Although we like to think that today's medicine is a million miles from those days, in fact we have not progressed at all. Although we no longer diagnose "moon madness", in terms of helping the majority of women who suffer from mild to moderate menstrual difficulties we have not come much farther than the "female corrective pills" of old.
When a problem isn't a problem
The list of symptoms of pre menstrual syndrome (PMS) includes 100 different emotional and physical states (J Rep Med, 1983; 28: 509-15). Both PMS and painful periods (dysmenorrhea) are experienced in varying degrees by up to 90 per cent of women a figure large enough to suggest that with mild symptoms, it is not their presence, but their absence which is "abnormal" (Acta Ob Gyn Scand, 1959; 38 (sup 2): 7-8; Brit J Psychatri, 1963; 109: 711-21). Although many of the more severe symptoms of PMS appear due to nutritional deficiencies (see box, p 4), some of the less tangible symptoms, such as hunger or anger, may be normal.
Only a minuscule percentage of sufferers have the kind of headline grabbing problems committing murder, burning down buildings which fascinate the media.
While the "normal" menstrual cycle is 28 days, this is just an average a simple scatter graph with cycles ranging from 15 to 41 days would produce such a figure.
Some women do get significantly more hungry before their periods. Since the metabolism speeds up when estrogen is dominant (briefly before ovulation and again in the week before menstruation) this too is normal and only perceived as a problem in cultures which worship thinness.
Sociological research suggests that menstruation does not induce uncontrollable emotions, but simply lowers a woman's ability to repress genuine, often difficult, emotions which are already there.
As Jane Usher, a psychologist at University College, London, has commented: "PMS is most common in women in the 30 to 35 age group. This is most likely to be the time in a woman's life when she is coping with small children. She may be holding down a job and coming home to the exhausting prospect of cooking and cleaning. She will have very little time to see her friends and so her social support network will be very thin. Women with lives like this come to me and complain that it all gets on top of them once a month. My question is how do they survive the rest of the month? How do they even manage to stay alive under such difficult circumstances?"
PMS is still not well understood, but current consensus is that it is a complex interaction of mind and body triggered by the normal events of the ovulatory cycle, rather than a hormonal imbalance. Because of this, current practice is to destroy a woman's normal cycle, either chemically or surgically, in the hopes that this will remove whatever it is that is causing the problems. Methods include removing both ovaries or suppressing ovulation with the Pill or gonadotrophin releasing hormones (GnRH) or by altering the nervous and endocrine system responses to the ovary with selective serotonin reuptake inhibitors (SSRIs).
Beginning in the late 1970s, it was discovered that women with cramps have high levels of the hormone prostaglandin F2 (PGF2 alpha) in their menstrual blood. When this hormone is released into the blood stream as the endometrial lining breaks down, it causes the uterus to go into spasm, resulting in cramping pain (Br J Ob Gyn, 1984; 91: 673). What we still don't know is what causes the body to release high levels of this hormone in the first place. The most likely explanation is that it is a reaction to some stimulus directly or indirectly related to menstruation, stress, tiredness, or, in some women, even fear and anxiety at their approaching periods. Painful periods and PMS are often experienced together.
When a cure isn't a cure
Treatment for menstrual difficulties is often eclectic and research is almost entirely led by the pharmaceutical industry. So it's no surprise that many of the "solutions" on offer are pills, patches and injections.
GnRH can't be given for long term use since they cause menopause like symptoms and increase the risk of osteoporosis and heart disease. Symptoms usually return once the therapy has stopped. Attempts have been made to "protect" the heart and bones while on GnRH by giving women conventional hormone replacement therapy (J Endocrin Metab, 1991; 72: 252A-F; Ob Gyn, 1993; 82: 104-7). But with the addition of HRT the women's symptoms often return and she is also then exposed to the well documented risks of long term HRT use. HRT can reactivate endometriosis in women with a history of the disease (BMJ, 1996; 312: 1221-2).
Danazol, a synthetic steriod, can produce masculinization of the woman and also of her female fetus should she fall pregnant while on the drug. Trials have been unconvincing since there are often high drop out rates among participants (Drug Ther Bulletin, 1990; 28: 22-4).
Fluoxetine (Prozac), a serotonin reuptake inhibitor, does not help around 40 per cent of those who take it (N Eng J Med, 1995; 332: 1574-5). When a trial of the drug was conducted to study its efficacy in PMS, some doctors questioned whether the drug was tested because investigators truly believed that serotonin levels were altered during the menstrual cycle or "because a pharmaceutical company paid clinical investigators to develop a new indication for the drug". (N Eng J Med, 1995; 333: 1152-3). In this particular trial one third of the women, women who were after all highly motivated to find a "cure" for their PMS dropped out because of unpleasant side effects (N Eng J Med, 1995; 332: 1529-34).
The dopamine agonist bromocriptine is often used to treat a range of problems from breast pain to amenorrhea absence of periods since it suppresses prolactin production. Opinion is divided as to its usefulness (Ob Gyn, 1980; 56: 723-6; Br J Ob Gyn, 1977; 84: 370-4; BMJ, 1977; 1: 147-8). However it has a number of undesirable side effects, including nausea, dizziness, headache and low blood pressure (Clin Endocrinol, 1990; 32: 565-71; Eur J Ob Gyn Reprod Biol, 1991; 40: 111-8). As many as 10 per cent of individuals cannot tolerate the drug.
Hormones are often given on a cross your fingers for luck basis: prosta glandin in case there is a deficiency in the late luteal phase of the menstral cycle; estrogen to suppress ovulation. In general, estrogens stimulate immunity, increasing antibody production, while progesterone and testosterone cause immunosuppression at many points on the immune pathways (J of Immunol 1988; 1491: 1-8). In fact, progesterone is a more powerful immunosupressant than the adrenal steroids. Progesterone also can act as a co-carcinogen with viruses and chemicals (Potential Carcinogenic Hazards from Drugs, 1967; 7: 162-71). It is now believed among some quarters that breast cancer can be caused by increased levels of progesterone (Fertil Steril, March 1992; BMJ, March 4, 1995). Several well controlled trials have shown no benefit from progesterone given vaginally or rectally in doses up to 800 mg daily (Br J Psychiatry, 1979; 135: 209-15; Am J Ob Gyn, 1986; 154: 573-81; JAMA, 1990; 264: 349-53; JAMA, July 5, 1995).
Combined oral contraceptives are often freely prescribed, but studies of large groups of women show only a slight improvement in PMS symptoms (Br J Psychiatry, 1970; 116: 161-4), and some women report a worsening of symptoms (J Psycosom Res, 1976; 20: 169-77).
When researchers compared 43 women with asymptomatic endometriosis and 111 controls with symptomatic pelvic inflammatory disease and endometriosis, the women with asymptomatic endometriosis were 4.3 times more likely to use oral contraceptives than those with overt endometriosis. The authors speculate that contraceptive use may effect the endometrium, and so cause the disease (Am J Ob Gyn, 1997; 176: 580-5).
Long term use of the Pill increases the risk of breast cancer in older women (JAMA, 1996; 276: 1404-8).
Deep vein thrombosis risk is also greater for women on the new "third generation" pills which contain gestodene and desogestrel. It doubles the risk of thrombosis from 15 to 30 cases per 100,000 per year (Lancet, 1995; 346: 1570). The study of groups of women from 21 hospitals around the world confirms this result. The risk was highest within the first four months of taking the Pill, and disappeared within three months of coming off the drug.
Giving the Pill will not help 10-20 per cent of women with painful periods and may be contraindicated or simply unsuitable for others (Clin OB Gyn, 1990; 33: 168-78). At any rate, it seems that using drugs which seek to alter hormonal or endocrine response may even be on the wrong track, if the results of one study are to be believed. When women were given the progesterone antagonist mifepristone to shorten the late luteal phase and induce menstruation, PMS symptoms appeared with even greater severity after treatment (N Eng J Med, 1991; 324: 1174-9).
Dysfunctional menstrual bleeding (either too light, too heavy or absent) can be caused by fibroids, endometriosis or ovarian cysts. Often the proposed solution to these problems is surgical, either removal of the ovary or ovaries (oophorectomy), the uterus (hysterectomy) or endometrial ablation (where the lining of the womb is removed). Fibroids and endometriosis account for around half of all hysterectomies performed (N Eng J Med, 1993; 328: 856-60), and in some 40 per cent of hysterectomies, one or both ovaries are removed as a matter of course.
Several studies appear to show that removal of the ovaries will end menstrual problems (Psychol Med, 1993; Supple 24: 1-47; Gyn Endocrinol 1992; 6: 57-64; Fertil Steril, 1994; 62: 932-7; Ob Gyn, 1994; 84: 779-86). However these results only look at short term gains. The removal of the ovaries has serious implications for future health and should be considered aggressive rather than therapeutic.
Preservation of the ovaries is important. With an ovary removed a woman will have greater difficulty getting pregnant. Removal of the ovaries is associated with an increased risk of osteoporosis and heart disease, as well as many menopausal symptoms, including decreased skin thickness and greater susceptibility to bruising and injury (Ann Gyn, 1977; 66: 241; Am J Ob Gyn, 1981; 139: 38; Am J Ob Gyn, 1993; 168: 765-71). To prevent these menopausal symptoms the woman will need to use hormone replacement therapy and expose herself to all the risks that entails (see WDDTY's Guide to the Menopause).
Oophorectomy is rarely necessary a surgeon should be able to remove a large cyst and save the ovary. However, this requires a certain surgical finesse which many of today's surgeons do not have. Taking the whole organ out and this is true with ovaries with cysts or a uterus with fibroids is much simpler for doctors than the kind of reconstructive surgery needed to preserve it. When the problem is fibroids, this reconstructive surgery is called myomectomy.
If the cysts in the ovaries are small, often the best advice is to watch and wait. In a study of 278 women which compared surgical intervention versus observation over a six month period, cysts cleared up to the same extent in both groups. The clear up rate was higher among younger women (BMJ, 1996; 313: 1110-13).
The same applies to fibroids, which are not in themselves dangerous less than two in 1000 fibroids turn into uterine cancer (N Eng J Med, 1993; 328: 856-60). How a woman approaches the treatment of her fibroids depends on the size and site of the fibroid and whether or not it is interfering with her fertility (WDDTY, 1996; 7(1): 1-3).
Finally, endometrial ablation or resection (ER) is often touted as an effective way to relieve heavy bleeding. However, when researchers in Bristol compared ER to hysterectomy, ER fared badly. Endometrial resection leads to vaginal bleeding, often quite heavy, in about 87 per cent of cases the very thing which the operation is supposed to treat. ER patients suffer pain and in 11 per cent of cases worse pain than before the operation. PMS is worse in 18 per cent, and 23 per cent of ER patients took more time off work (Br J Ob Gyn, 1996; 103: 142-9).
For the majority of women with mild to moderate menstrual problems, a visit to the doctor may only be in the nature of seeking some reassurance of the normality of these symptoms and some acknowledgement of their situation. This is reflected in the the high placebo response rate of around 50 per cent in many treatments of PMS. In one trial of hormone implants, 94 per cent improved on placebo (BMJ, 1986; 292: 1629-33).
For those whose symptoms are caused by genuine nutritional deficiencies or hormonal imbalances, it's important to find a doctor who can tailor individual treatment programmes which take into account the woman's lifestyle and social context in order to help restore function and well being. The vast majority of women respond well to lifestyle modifications and counselling.
The fact that there is no concurrent medical speciality for "men's" problems should also give us pause for thought. The focus on women's (ill) health is disproportionate, often inappropriate and sometimes more pathological than the disorders themselves. We still seek to "normalize" women and to this end, during her 35 or so childbearing years, a woman can expect to be on the receiving end of the "best" which medical science has to offer.