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Abstract

This paper deals with Premenstrual Syndrome and Premenstrual Dysphoric Disorder in the context of their discussion with stigma. In order to answer the question, Does the medicalisation of Premenstrual syndrome and Premenstrual Dysphoric disorder reinforce stigma? This paper has highlighted the concepts of Premenstrual Syndrome and Premenstrual Dysphoric Disorder, considering their symptoms, causes, diagnosis and treatment.

According to the results, Premenstrual Syndrome is a group of behavioral and physical symptoms that develop during the luteal phase of the menstrual cycle and in a cyclic pattern. Premenstrual Dysphoric Disorder is considered a severe form of Premenstrual Syndrome. With respect to answering the question, it is revealed that women experiencing Premenstrual Dysphoric Disorder and seeking treatment are often abused. Therefore, in order to treat Premenstrual Syndrome or Premenstrual Dysphoric Disorder, the physicians and clinicians must be supportive. It must not be taken as a hormonal change only, and the physicians need to treat it with some effective treatment.

Introduction

This assignment is based on answering an important question, “Does the medicalisation of Premenstrual Syndrome and Premenstrual Dysphoric Disorder reinforce stigma?” discussed on many platforms. In order to answer this, it is essential to have a detailed review of the specific terminologies of Premenstrual syndrome and Premenstrual Dysphoric Disorder.

This paper comprises many sections; for instance, in the first section, an overview of Premenstrual Syndrome – PMS and Premenstrual Dysphoric Disorder – PMDD is presented, followed by the causes of these conditions, symptoms, diagnosis and treatment methods. Further, the medication for PMS and PMDD reinforces stigma and is being discussed considering the point of view of different psychologists and physicians. The last section deals with a summary of the entire document.

An Overview of Premenstrual Syndrome and Premenstrual Dysphoric Disorder

Premenstrual Syndrome is referred to as a group of behavioural and physical symptoms that develop during the luteal phase of the menstrual cycle and in a cyclic pattern. On the other hand, Premenstrual Dysphoric Disorder is considered a severe form of PMS (Dell and Svec, 2019). The common symptoms in this cyclic pattern include irritability, anger, depression and internal tension. These symptoms accumulatively interfere with daily activities. A study conducted by Freeman (2013) demonstrated that mild Premenstrual Syndrome is common and is found to be affecting up to 75% of women with normal hormones level and regular menstrual cycles, whereas Premenstrual Dysphoric Disorder influences 3% to 8% of women. However, this condition can have influences women of any cultural, socioeconomic or ethnic background. On the other hand, the study by Dell (2014) revealed that Premenstrual Dysphoric Disorder is usually developed as a chronic condition and can have more serious effects on the quality of a woman’s life. Fortunately, various self-care measures and treatments can effectively control the symptoms in most women.

Causes of Premenstrual Syndrome and Premenstrual Dysphoric Disorder

According to Parker and Parker (2014), tissues that change throughout a woman’s menstrual cycle are very sensitive to hormone levels. In this scenario, the increasing and decreasing levels of hormones such as progesterone and estrogen may affect chemicals in the brain, including serotonin, a substance that affects mood. However, no significant studies reveal Premenstrual Syndrome or Premenstrual Dysphoric Disorder is developed by some women and others are not affected by it. This is because, in women, progesterone and estrogen levels are similar with and without these symptoms. However, a recent study by Durairaj and Ramamurthi (2019) demonstrated that some women’s most likely explanation for the development of Premenstrual Dysphoric Disorder is their high sensitivity towards regular or normal changes in hormones levels.

Symptoms of Premenstrual Syndrome and Premenstrual Dysphoric Disorder

The study of Mikacich (2008) explored that the most common symptoms of both conditions include bloating, fatigue, irritability, anxiety and depression. On the other hand, clinical manifestations explain the following series of symptoms of Premenstrual Syndrome and PMDD:

• Hopelessness, sadness and the feeling of worthlessness
• Variable mood swings with frequent tearfulness
• Anxiety, depression and tension
• Persistent conflict with coworkers, family members or friends
• Persistent anger and irritability
• Difficulty in concentration and decrease of interest in daily activities
• Lethargic, fatigue or lack of energy levels
• Difficulty in sleeping or excessive sleeping
• Changes in appetite and incline towards eating specific foods
• Feeling out of control or overwhelmed
• Headaches, breast swelling, muscle and joint pains and weight gains.

Other conditions have symptoms likewise to Premenstrual Syndrome and PMDD like anxiety, depression, perimenopause and bipolar disorder. Therefore doctors and practitioners need to distinguish between underlying depression and the actual occurrence of PMS and Premenstrual Dysphoric Disorder because the treatments are quite different (F. Casper, 2022). However, Durairaj and Ramamurthi (2019) explained that women with underlying depression often feel comfortable and better during and after periods, whereas their symptoms are not resolved completely. However, women diagnosed with Premenstrual Syndrome and Premenstrual Dysphoric Disorder were found to have a complete resolution of symptoms with the start of their menses.

It is essential to mention here that there other medical disorders that are found to be different from Premenstrual Syndrome and Premenstrual Dysphoric Disorder and worsen before and during menses with similar symptoms of PMS and PMDD. These medical disorders include Myalgic Encephalomyelitis Fatigue Syndrome, Pelvic and Bladder Pain and Irritable Bowel Syndrome. Therefore, it is essential to conduct a careful medical history to distinguish between these disorders, Premenstrual Syndrome and Premenstrual Dysphoric Disorder. This is because it is possible that women can have PMS and Premenstrual Dysphoric Disorder with other medical conditions (Premenstrual syndrome (PMS) – Symptoms and causes, 2022).

Diagnosis of Premenstrual Syndrome and Premenstrual Dysphoric Disorder

Regarding the diagnosis of Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD), no single test is evidenced. The symptoms must occur during the luteal phase – the second phase of the menstrual cycle only and most often during 5 to 7 days before the menses. There should be physical and behavioural symptoms development for the diagnosis of PMS and PMDD. Moreover, the occurrence of symptoms of Premenstrual Syndrome and PMDD should not be present between days 4 to days 12 in a 28 days menstrual cycle. However, the doctors recommended the following procedures for the diagnosis of Premenstrual Syndrome and Premenstrual Dysphoric Disorder(F. Casper, 2022).

Blood test: A blood test is essential for the diagnosis of Premenstrual Syndrome and Premenstrual Dysphoric Disorder and is only recommended for additional conditions prevailing in a woman that causes depression, anxiety and fatigue, such as anaemia. On the other hand, thyroid tests can detect hyperthyroidism and hypothyroidism, both of which have similar symptoms to Premenstrual Syndrome (PMS) and PMDD – Premenstrual Dysphoric Disorder.

Recording symptoms: The prevailing PMS and Premenstrual Dysphoric Disorder is most often diagnosed with the monitoring of woman’s symptoms with these conditions. A clinician or doctor may suggest a woman carefully monitor and record her symptoms for two complete menstrual cycles daily (Tiranini and Nappi, 2022).

Treatment of Premenstrual Syndrome and Premenstrual Dysphoric Disorder

Clinicians recommend the following treatments for Premenstrual Syndrome and Premenstrual Dysphoric Disorder:

Conservative Treatment

These treatments are recommended first for Premenstrual Syndrome conditions, including relaxation techniques, regular exercises, and supplementing certain minerals and vitamins. The symptoms of Premenstrual Syndrome are relieved by these therapies in some women with no side effects. However, if these therapies provide no significant relief, the clinicians consider prescribed medications as a second option (Born and Steiner, 2014).

On the other hand, these treatments are also suggested for patients with Premenstrual Dysphoric Disorder with prescribed medication. The following conservative therapies are suggested for women with PMDD:

Relaxation therapy: relaxation therapy can assist women in easing their stress, anxiety and depression of daily activities, and these may include techniques like self-hypnosis, medication, biofeedback and progressive muscle relaxation

Exercise and yoga: these may help women with Premenstrual Dysphoric Disorder to reduce tension, stress and anxiety

Mineral and vitamin supplements: it is recommended that Vitamin B6 and certain mineral supplements can have smaller benefits for women with PMDD; however, the consumption of no more than 100 is prescribed on a daily basis (Daw, 2022).

Selective Serotonin Reuptake Inhibitors: these are considered to be highly effective treatments for the conditions of Premenstrual Syndrome and Premenstrual Dysphoric Disorder. In a study conducted by Koren and Ornoy (2018), these treatments include Zoloft, Prozac and Sarafem, Paxil and Celexa, which reduce Premenstrual Dysphoric Disorder significantly as compared to other treatments. Studies revealed that 60% and 75% of women diagnosed with Premenstrual Dysphoric Disorder improve their condition with Selective Serotonin Reuptake Inhibitors. However, it is not essential to take medication on a daily basis but taking the medication prescribed under these treatments only during the luteal phase of the menstrual cycle is sufficient.

However, it is also evidenced that some women may pose to certain sexual side effects with these medical treatments. For instance, the most common sexual side effect reported is difficulty in having an orgasm; in this scenario, doctors prescribe having a lower dose or an alternative drug with a similar formula. On the other hand, it is recommended by a few clinicians that Selective Serotonin Reuptake Inhibitors must not be taken more than two menstrual cycles to measure their benefit (Durairaj and Ramamurthi, 2019).

Birth Control Pills

Several studies revealed that some women diagnosed with Premenstrual Syndrome and Premenstrual Dysphoric Disorder get relief when they start taking birth control pills. On the other hand, few studies also reported that taking birth control pills only aggravates their Premenstrual Syndrome symptoms, and therefore doctors prescribe them to move to an alternative and more effective treatment (Rott 2019; Durairaj and Ramamurthi, 2019).

In the United States of America, Yaz – a birth control pill, is medically approved to treat the symptoms of Premenstrual Dysphoric Disorder. One packet of Yaz includes 24 tablets of 20 mcg Ethinyl estradiol and 3 mg drospirenone. With these medicines, it is believed that mood symptoms are improved; however, with certain concerns, women taking Yaz are more likely to have blood clots in the lungs and legs. Therefore, it is only prescribed in case of severe symptoms of Premenstrual Dysphoric Disorder (F. Casper, 2022).

Gonadotropin-releasing Hormone Agonists

These medications temporarily cause the ovaries to stop making estrogen and progesterone, which eventually improves physical symptoms of bloating and irritability while developing temporary menopause. However, this medication has several side effects, such as causing bone loss over time and severe hot flashes. Therefore, women are also treated with low doses of progesterone and estrogen in addition to the Gonadotropin-releasing Hormone Agonists to prevent bone loss and stop hot flashes. Although this treatment is considered very effective, it should be essentially used in case other treatments do not work. However, it is also too much expensive (Chang, 2014).

Ineffective Treatments

Moreover, it is evidenced that there are several treatments often prescribed to women with symptoms of Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD). These treatments include antidepressant drugs, progesterone and lithium. Moreover, several popular dietary supplements such as free fatty acids, primrose oil and ginkgo piloba that are often prescribed to patients by some clinicians have also no proven benefits in treating PMS and Premenstrual Dysphoric Disorder.

Medication of Premenstrual Syndrome and Premenstrual Dysphoric Disorder reinforces stigma

The medical conditions and symptoms related to the menstrual cycle have been diagnosed and treated by clinicians and physicians for the last 3800 years. In this regard, theKahun Gynaecological Papyrus, which is recognised as one of the pioneer in medical testing, explains a few commonly known and recognised menstrual experiences; for instance, heavy bleeding, period pain, migraine and lower back pain, and assigns these experiences to clenches, or wandering of the womb. On the other hand, Egyptian physicians also listed other female symptoms such as toothache and leg pain and associated them with the menstrual cycle (Smith, 2011).

In this scenario, a recurring theme is exemplified by theKahun Gynaecological Papyrus,which has assisted the physicians in shaping constructions of female health and prevalent symptoms of the menstrual cycle and explaining features of embodied femininity. Although a causal relationship between ill-health and the female reproductive system is not essentially sexist or wrong, a widespread assumption generalising converse logical position is also prevailing and is becoming more problematic. The assumption is that if ill-health in women is caused by the menstrual cycle or the womb, then all women having monthly menses are ill demonstrating the myth of the irrational female.

The myth of irrational females is also associated with the first formal medical explanation of Premenstrual Tension, which is now recognised as Premenstrual Syndrome. In this regard, the first description was provided by Frank in 1931, who was a US gynaecologist. Initially, in his research, he documented different cases of severe epilepsy, asthma, and cardiac irregularity; however, categorising these conditions in specific subsets of patients, various signs of nervous tension were developed (Severino, 2012). In several cases, the symptoms described by Frank were simply valued as improper, judgmental, or undesired because he linked those with female behaviours and strikingly related with a contemporary explanation of the hysterical woman; for instance, impossible to live with, unbearable or shrew or husband to be pitied.

Certainly, there are several sources earlier available that explain apparently recognised expressions of menstrual cyclical variability in emotions (Browne, 2014). They were not previously recognised to demand medical interventions because they have appeared in a minority of menstruating women.

During the 1950s, the researchers focused on the role of the female sex hormone associated with Premenstrual Tension. Later as it was renamed Premenstrual Syndrome, it is argued by Browne (2014) that the symptoms of this condition are far more extensive as compared to nervous tension. Dr Katharina Dalton, the most prominent Premenstrual Syndrome at that time, started openly criticising the hijacking of Premenstrual Syndrome by psychologists and attempted to encounter the undue influence of mood-based menstrual symptoms. She also assisted in perpetuating the myth of irrational females under the influence of Premenstrual Syndrome (Standen, 2019). The Premenstrual Dysphoric Disorder is referred to as severe Premenstrual Syndrome from every reputable clinical source, implying that Premenstrual Syndrome is simply less severe than mental health disorder (Farming, Nasrudin and Budu, 2019).

In the context of reinforcing stigma, it is demonstrated by Yang et al. (2012) that PMS and Premenstrual Dysphoric Disorder are both considered a cultural-bound syndrome. There is no evidence of Premenstrual Dysphoric Disorder, but people tend to find such evidence. According to his study, women who want recognition for discomfort are diagnosed as having Premenstrual Dysphoric Disorder. For women, the controversy of Premenstrual Dysphoric Disorder as the myth of ill-heath is frustrating and confusing, and they want some relief from Premenstrual Dysphoric Disorder. On the other hand, it is believed by some feminist psychologists that the language surrounding Premenstrual Dysphoric Disorder is misleading, and its categorisation as a psychiatric disorder denounces women as mentally ill.

Moreover, the real reasons for women’s suffering are covered up by the psychological conditions associated with Premenstrual Dysphoric Disorder. According to those feminist psychologists, Premenstrual Syndrome and Premenstrual Dysphoric Disorder are labels that can be utilised by a sexist society that believes women are going crazy on a monthly basis. Premenstrual Dysphoric Disorder is though emotional displays and is seen as a mental disorder in women; likewise, symptoms of emotional displays are normal in men. They demonstrate that any hormonal changes in people, even if they are related to sex, can exacerbate thyroid issues, anxiety and migraines are considered to be normal for men and are not called hormonal changes kinds of mental illness, but symptoms of Premenstrual Dysphoric Disorder in women is considered as mental illness (OBGYNs, 2022).

In this regard, Tiranini and Nappi (2022) explain that PMDD is not only the diagnostic aspect of “blacklash against feminism”, but it undermines the self-confidence of women experiencing its symptoms and feeds into stereotypes about women. Cohen (2017) said that it is highly convenient for a woman to use to explain her condition. However, O’Brien, Rapkin and Schmidt (2018) demonstrated that the Premenstrual Syndrome and PMDD category is not helpful as well as valid for women and several studies declared Premenstrual Dysphoric Disorder as a mental disorder “unjustified”. This is because many health professionals have already diagnosed Premenstrual Syndrome and Premenstrual Dysphoric Disorder, and therefore their overextension of diagnosis is now changing the condition into cultural-bound issues and reinforcing stigma (Premenstrual Dysphoric Disorder | Deconstructing stigma, 2022). On the other hand, according to some research, women experiencing Premenstrual Dysphoric Disorder and seeking treatment are often abused. In some societies, in the condition of Premenstrual Dysphoric Disorder, a woman who wants a pill or other treatment is often divorced (Rapkin, 2019).

Entering into the Drug Treatments

The food and Drug Administration has approved two medications for treating Premenstrual Dysphoric Disorder: Sarafem and Zoloft. The Sarafem Eli Lilly manufacturer heavily marketed this medicine to treat Premenstrual Dysphoric Disorder. However, it was acquired by Prozac due to the expiry of Sarafem’s patent. It is reported that more than $33 million was spent by Lilly to promote this drug to its customers, and its success can be judged by the fact that after its approval in the 7th month of its manufacturing, more than 200,000 prescriptions were doled out by the physicians for Sarafem (Bonnice, 2020).

Recently, Pfizer, the manufacturer of Zoloft, came forward with this medicine for treating Premenstrual Dysphoric Disorder. In this regard, it has been suggested by a few research studies that both these medicines are considered to be more effective in treating PMDD than placebos (Rott, 2019; Durairaj and Ramamurthi, 2019). However, the drug treatment is not free from controversy. For instance, it is believed by its critics that a significant advantage is being taken by drug manufacturers of health concerns of women and their fears to increase this stigma. It is also mentioned by Bonnice (2020) some psychologist experts that the decision to accept Sarafem as a treatment for Premenstrual Dysphoric Disorder is nothing but a dangerous and misleading assumption that the condition exists whereas anxiety and depression actually go untreated. On the other hand, they assert that many drug manufacturers are actually funding and enforcing physicians and clinicians to prescribe their medicines to treat Premenstrual Dysphoric Disorder.

However, it is also believed by some psychologists and after considering a review of those women who were involved in clinical trials, that the treatment of these medicines actually works and women experiencing Premenstrual Dysphoric Disorder find relief to some extent (Farming, Nasrudin and Budu, 2019). In response to the criticism against these medications, it is mentioned by Bonnice (2020) that the studies conducted by drug manufacturers are not based on hundreds of women experiencing Premenstrual Dysphoric Disorder but based on some smaller studies conducted by independent researchers. Their studies indicated that these particular treatments could achieve a sizeable therapeutic benefit. On the other hand, some notified that women who are actually suffering from Premenstrual Dysphoric Disorder could be discounted without the psychiatric-disorder classification, and it is more helpful for women to receive some kind of diagnosis.

According to Farming, Nasrudin and Budu (2019), many women with Premenstrual Dysphoric Disorder are relieved when they find someone who takes their symptoms seriously and recognises their experience. He believes that the critics of Premenstrual Dysphoric Disorder belittle women and reinforce the stigma of mental disorders where behavioural changes and problems with moods are common characteristics and therefore discourage women from seeking help. Regardless of their perspectives on Premenstrual Dysphoric Disorder, it is stated by many psychologists that it is very important not to jump to the conclusion and call Premenstrual Dysphoric Disorder nothing, but if a woman says that she has Premenstrual Syndrome or Premenstrual Dysphoric Disorder, the physicians and clinicians must be supportive. It must not be taken as a hormonal change only, and the physicians need to treat it with some effective treatment.

Conclusion

Premenstrual Syndrome is referred to as a group of behavioural and physical symptoms that develop during the second half of the menstrual cycle and in a cyclic pattern. On the other hand, Premenstrual Dysphoric Disorder is considered a severe form of Premenstrual Syndrome. No significant studies reveal Premenstrual Syndrome or Premenstrual Dysphoric Disorder is developed by some women, and others are not affected by it. However, the most likely explanation for some women’s development of Premenstrual Dysphoric Disorder is that they are highly sensitive to normal changes in hormone levels.

The following series of symptoms of Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD) is concluded from the above discussion.

• Hopelessness, sadness and the feeling of worthlessness
• Variable mood swings with frequent tearfulness
• Anxiety, depression and tension
• Persistent conflict with coworkers, family members or friends
• Persistent anger and irritability
• Difficulty in concentration and decrease of interest in daily activities
• Lethargic, fatigue or lack of energy levels
• Difficulty in sleeping or excessive sleeping
• Changes in appetite and inclined toward eating specific foods
• Feeling out of control or overwhelmed
• Headaches, breast swelling, muscle and joint pains and weight gains.

Regarding the diagnosis of Premenstrual Syndrome and Premenstrual Dysphoric Disorder, no single test is evidenced. The symptoms must occur during the luteal phase – the second phase of the menstrual cycle only and most often during 5 to 7 days before the menses. There should be physical and behavioural symptoms development for the diagnosis of both conditions.

With respect to the treatment of Premenstrual Syndrome and Premenstrual Dysphoric Disorder, the conservative treatments include relaxation therapy, exercise and yoga, and mineral and vitamin supplements. On the other hand, selective Serotonin Reuptake Inhibitors and birth control pills are also considered to be highly effective in treating Premenstrual Syndrome and Premenstrual Dysphoric Disorder. However, Gonadotropin-releasing Hormone Agonists are used in case of intense severity of the symptoms.

It is concluded that the assumption of ill-health in women is caused by the menstrual cycle or the womb and that all women having monthly menses are ill demonstrating the myth of the irrational female. The myth of irrational females is also associated with the first formal medical explanation of Premenstrual Tension, which is now recognised as Premenstrual Syndrome.

However, it is believed by some psychologists and after considering a review of those women who were involved in clinical trials that the treatment of these medicines actually works and women experiencing Premenstrual Dysphoric Disorder find relief to some extent. Therefore, it is very important not to jump to the conclusion and call Premenstrual Dysphoric Disorder nothing, but if a woman says that she has Premenstrual Syndrome or Premenstrual Dysphoric Disorder, the physicians and clinicians must be supportive. It must not be taken as a hormonal change only, and the physicians need to treat it with some effective treatment.

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