Flow: The Cultural Story of Menstruation (11 page)

Not surprisingly, due to such incredibly fuzzy boundaries, PMS tends to be self-reported or, more spookily, reported by one’s partner or colleagues. There are upward of 115 “PMS clinics” around the country; at those clinics, as well as in online groups, women are frequently urged to self-diagnose. Yet how can a woman really say if she has PMS when even the experts can’t agree on what it is?

At the very least, a formal evaluation of PMS includes a thorough physical and gynecological exam, as well as a psychiatric assessment and medical history. Further psychological and lab testing may be done, as well. Even so, PMS is only officially diagnosed when a doctor can then confirm a pattern of symptoms that occur in the five days before the period for at least three cycles in a row; that the symptoms end within four days after the period stops; and, perhaps most crucially, that the symptoms interfere with at least some aspects of the woman’s normal life.

That being said, other conditions can be and frequently are mistaken for PMS. Clinical depression and anxiety disorders, not surprisingly, are often confused with PMS, because many of their symptoms are, well, kinda sorta exactly the same. To make things even more bewildering, conditions like manic depression and anxiety disorders often get worse during the premenstrual time; an otherwise dormant mental problem can suddenly flourish, as well. (In fact, one theory suggests that the word “lunatic” came about when it was observed that mental crises tended to follow the lunar/menstrual cycle of twenty-eight days.) So who the heck knows what’s actually going on with that monthly tantrum of yours?

What’s more, women who are entering menopause can also experience PMS-esque symptoms, like fatigue and mood swings. This is pretty normal, but there are also serious medical conditions that can eerily resemble PMS, problems you definitely wouldn’t want to mess around with. These include irritable bowel syndrome, lupus, and chronic fatigue syndrome, as well as endocrine and thyroid problems—all of which can regularly flare up in the premenstrual time.

But don’t get us wrong, here.

Just because PMS is clearly a strangely blurry, hard-to-define occurrence doesn’t mean that unpleasant premenstrual symptoms are just in a woman’s head. Mood swings, painful breasts, and fatigue before one’s period are definitely real, a monthly physiological fact of life for many, if not most, women. And despite being one of the most wildly over- and misdiagnosed conditions in the Western world, PMS is still a genuine problem for millions. According to the American College of Obstetricians and Gynecologists, something like 85 percent of all women suffer from at least one of the typical symptoms, to varying degrees.

We ourselves have yet to meet a girl or woman who didn’t sprout at least one pimple, gorge out on at least one pan of brownies, or feel truly, utterly convinced that she didn’t have any real friends in the world the week before her period. The fact is, certain cyclical fluctuations in mood and the monthly reappearance of certain physical symptoms are clearly totally normal for most, if not all, healthy women of reproductive age. Only when the premenstrual symptoms become such a problem that they significantly interfere with our normal lives can a woman really be said to suffer from PMS.

For a small percentage, the premenstrual time looms as a monthly menace, one fraught with genuine concern. When a woman finds herself truly debilitated by not only horrible physical symptoms, but psycho mood swings, the kind that every month threaten to leave her home, work, and all relationships around her in smoldering ashes, she is said to suffer from Premenstrual Dysphoric Disorder, or PMDD.

PMDD is the super-duper, bad-ass-mother version of PMS that is said to affect anywhere from 3 to 8 percent of all women. Symptoms generally kick in from one to two weeks before flow starts, and subside several days after. For women who suffer from PMDD, this can therefore mean more than half of each month is spent feeling like Snow White’s evil stepmother, smoking crack, on steroids.

For years, the supposed gold standard for treating PMDD was the hormone progesterone. This idea was touted by Dr. Katharina Dalton, the person who coined the term in the first place, and was much ballyhooed in her 1978 bestseller, Once a Month, and in PMS clinics around the country. Yet not only did critics point out attractive side effects such as depression, swelling, bleeding, and possibly increased rates of cancer, it turned out progesterone worked no better than placebos and was basically snake oil with a pedigree.

Since 2001, the single most popular way to treat women who suffer from PMDD has been a prescription drug called Sarafem (aka fluoxetine), first manufactured by Eli Lilly and Company, and now by Warner Chilcott. Sarafem (a drug whose name is clearly meant to evoke the “seraphim,” the highest-ranked, most divine form of angel in the Christian celestial pecking order and something we should obviously be aspiring to be each month) is an antidepressant from the selective serotonin reuptake inhibitor class, a chemical twin to Prozac.

Do you remember Prozac? Sure you do. If you’re old enough to wax fondly about the 1990s, you probably remember the insanely successful, green-and-white antidepressant manufactured by Eli Lilly, the one that spawned all those books and magazine articles and jokes on late-night television. Prozac went along its wildly profitable way until 2001, when the patent expired and fluoxetine went generic. Prices for the capsule immediately plummeted by about 80 percent.

Yet by then, the FDA had already quietly approved Sarafem. Sarafem costs three and a half times more than Prozac, even though it still has the exact same active ingredient, only now presented in girlish shades of yellow (and previously pink and lavender) rather than androgynous green and white. And if you’re wondering darkly if the FDA knows about any of this, keep in mind that this is pharmaceutical business as usual.

What makes this especially galling is that while fluoxetine is now available generically for three and a half times less than Sarafem, doctors were forbidden for years to substitute the generic when writing a prescription to treat PMDD. This is because the FDA “Orange Book,” which routinely lists drugs and their generic equivalents, claimed that Sarafem has no generic, because Warner Chilcott is the exclusive patent holder. Sarafem capsules only became available as a generic in May 2008.

Wild, no?

And so, back to the underlying question: what are PMS and PMDD, exactly? And how are we supposed to deal with them?

Most women clearly do have emotional and physical symptoms in the week before their period. And while we hate to be the ones who say it, since the condition itself is so poorly understood, there doesn’t appear to be a single panacea or magic bullet that can handle them. Some studies show that regular exercise reduces anxiety; and many women we know swear by cutting down on salt, sugar, and caffeine, taking diuretics, and practicing stress-reduction techniques like yoga and meditation. Therapy or even talking about your symptoms to female friends can be a help, as well. We ourselves find that taking daily calcium and vitamin E supplements seems to help markedly with both the Cruella De Vil-esque temper swings and breast tenderness. Unfortunately, very few studies of these treatments have involved double-blind evaluations that would truly prove just what’s effective and what isn’t.

It’s worth keeping another tidbit in mind. Even the underlying assumption that conditions like PMS and PMDD actually exist is by no means universal, even though both are widely accepted as medical fact across the United States. Many countries have never heard of either; while it’s accepted worldwide that most women are indeed affected by their premenstrual cycles, the bloating, tears, and temper that seem to freak Americans out so much don’t seem to be viewed in such a negative, pathologized way elsewhere. In 1987, medical anthropologist Thomas Johns made the point that even though premenstrual symptoms have long been universally recognized, PMS only appears in Western industrial cultures, and then only starting in the late twentieth century. In other words, the rock-solid faith that PMS is an actual condition is pretty much a Western idea, and it’s only in America that PMDD has been officially recognized as an illness. Whereas the Food and Drug Administration accepts PMDD as a disease, the World Health Organization does not.

Speaking of anger: while any premenstrual outburst may be upsetting to us and to those around us, for other women, those few days may actually give them a welcome opportunity to express frustrations that they may not otherwise feel free in venting. Sarafem’s slogan is “More like the woman you are.” But, excuse us … who’s to say that “the women we are” don’t get incredibly pissed off once in a while, especially if we’ve been holding it in all month? As Roseanne Barr once said, “Women complain about PMS, but I think of it as the only time of the month when I can be myself.”

One thing rarely mentioned by anyone is the fact that for many women, the premenstrual week isn’t just a time of nasty mood swings and unexplained tears; it can be a time of great energy, creativity, and focus. It can also be a time of reflection and inwardness. Biologists in Kenya discovered that in their premenstrual days, female baboons regularly seek solitude. Funnily enough, the male baboons don’t seem to care or even notice.

And who knows, maybe being cyclically moody is part of our human nature. In 1996, two researchers named Heather Nash and Joan Crisler came up with a study in which they listed classic symptoms of PMS, but replaced the term with the gender-neutral Episodic Dysphoric Disorder. A surprising number of men felt that they suffered from it, and their female friends agreed with them.

In her book Periods, Sharon Golub makes the point that we as a culture don’t think that being variable is normal; we cling instead to the belief that being the same all the time is normal.

But is it?

Chapter 6

SEX AND RELIGION

I
N 1953, A SMALL, HARD-COVERED BOMB WITH a dust jacket went off in bookstores across America. It was the publication of Sexual Behavior in the Human Female, the wildly controversial sex study written by Dr. Alfred Kinsey, Wardell Pomeroy, and their colleagues. Sure, Kinsey & Co. had published Sexual Behavior in the Human Male five years earlier, but heck, that was no big news; men were supposed to like sex! Yet in the very same year that Patti Paige was scoring jukebox gold with “How Much Is That Doggie in the Window?” and Disney’s Peter Pan was raking in big bucks at the box office, Kinsey’s study of actual female sexual practices rocked the horrified country with its candid revelations about sexual fantasies, sadomasochism, lesbianism and bisexuality, childhood sexual urges and experiences, masturbation, and pre-and extra-marital affairs.

Yet for all the unprecedented candor and open-mindedness as its authors traipsed dutifully from one forbidden topic to another, Sexual Behavior in the Human Female had virtually nothing to say about menstruation. The interviewers didn’t ask their subjects about sex during their periods, nor did any of the women questioned offer any of their own opinions or experiences: how they felt about it, how they dealt with it, or whether or not it was a problem, an excuse, something that was repellent or even a turn-on in the bedroom.

Similarly, The Hite Report on Female Sexuality (1976), the first research project about women’s sexuality that was conducted by women, was also eerily silent on the subject. In interviewing a hundred thousand women and girls, author Shere Hite uncovered fundamental societal misconceptions about the nature of female sexuality involving frigidity, masturbation, and that whole clitoral-versus-vaginal-stimulation-during-intercourse debate. Yet as progressive and revelatory as it still is today, The Hite Report didn’t mention sex during menstruation either. Not even once.

And this strikes us as kind of weird. s menstruate approximately four to After all, every female of childbearing age does menstruate approximately four to five days every four weeks. What’s more, people do have sex, so would it be so crazy to predict that the two events might occasionally overlap? So what are we to make of these two highly regarded sex studies avoiding the subject altogether, either consciously or unconsciously? Does that leave us to assume that all Americans share the notion that sex is a total nonstarter during a woman’s period? Or perhaps that it’s one of the deepest sexual taboos of all … so deep, it wouldn’t occur to either interviewer or subject to even give it a passing mention?

We know that most ancient cultures around the world and throughout history have held negative views about menstruation, to put it mildly. The mysterious, cyclical bleeding of women that arose from neither injury or illness was considered totally freakish even in relatively enlightened times and was more often than not routinely used to demonize women and remind them of their lowly, inferior (yet oddly dangerous) status.

Not surprisingly, men in ancient times had an especially hard time wrapping their minds around the very idea of sex with a menstruating woman. The aversion and fears were so incredibly deeply rooted, the act is referred to in ancient religious and mythology texts—and yet invariably as the source of dire, cosmic mischief.