Premenstrual change is experienced by up to 90 per cent of women, with up to 40 per cent experiencing moderate distress, categorised as premenstrual syndrome (PMS) and two to five per cent experiencing severe distress and disruption to their lives, categorised as premenstrual dysphoric disorder (PMDD) (Hartlage, Freels, Gotman, & Yonkers, 2012). Recognition of the continuum of premenstrual distress, and overlap between the diagnostic categories PMS and PMDD, has led to the adoption of the term ‘premenstrual disorders’ (PMDs). PMDs includes emotional and behavioural symptoms that have a significant impact on a woman’s quality of life during the premenstrual phase of the cycle, but are absent after menstruation and before ovulation. The symptoms most commonly reported include irritability, depression, mood swings, anxiety, concentration difficulties, feelings of loss of control, and tiredness, often combined with physical symptoms such as bloating, breast tenderness, headache and general body aches (Rapkin & Lewis, 2013).
The costs of PMDs in terms of impact upon women’s quality of life and economic functioning are estimated to be considerable (Halbreich, Borenstein, Pearlstein, & Kahn, 2003). This has led to the development of a range of biomedical interventions, including the use of antidepressants of the serotonin reuptake inhibitor (SSRI) class, anxiolytics and hormone treatments to suppress ovulation, and oophorectomy (the surgical removal of the ovaries) (Nevatte, et al., 2013; Rapkin & Lewis, 2013). Although these approaches may be effective in reducing premenstrual symptoms, they do not take account of the complex mechanisms underlying premenstrual distress which are not adequately accounted for by physiology alone (Ussher & Perz, 2013a). Furthermore, many women express a preference for non-medical treatment options for their premenstrual symptoms, due to side effects or contraindications to drug treatments (Lustyk, Gerrish, Shaver, & Keys, 2009). Consequently, there has been a development of psychological approaches to treat PMDs (Blake, 1995) that take into account the interaction of embodied, cognitive and sociocultural factors in the development of symptoms (Ussher, 2006).
The results of systematic review and meta-analysis of randomised controlled trials suggest that cognitive behaviour therapy (CBT) can reduce anxiety, have a beneficial impact on behavioural change, and reduce interference of premenstrual symptoms on daily living (Busse, Montori, Krasnik, Patelis-Siotis, & Guyatt, 2009; Lustyk, et al., 2009). Such interventions involve a combination of behavioural strategies such as relaxation training, coping skills, social support and anger management, combined with facilitation of cognitive restructuring to overcome the sense of helplessness associated with premenstrual symptoms and reframe self-defeating cognitions (Ussher, Hunter, & Cariss, 2002). CBT has been demonstrated to be as effective as SSRIs in reducing premenstrual distress in the short-term and to be more effective at long-term follow-up (Hunter et al., 2002).
Women’s negotiation of premenstrual change in a cultural and relational context
One limitation of existing psychological and biomedical research is that it positions PMDs as ‘disorders’, implicitly conceptualising them as static or fixed entities, with the occurrence (or non-occurrence) of symptoms as the end point of analysis. The cultural construction of premenstrual change as ‘PMS’ or ‘PMDD’, women’s ongoing appraisal and negotiation of changes in emotion, behaviour, or bodily sensations, the meaning of premenstrual distress in their lives, and the role of relationships in the development of premenstrual symptoms are issues that are often marginalised or negated.
The bodily functions we understand as a sign of ‘illness’ vary across culture and across time. Women’s interpretation of psychological and bodily changes as being ‘symptoms’ of PMS cannot be understood outside of the social and historical context in which they live, influenced by the meaning ascribed to these changes in a particular cultural context. In cultures where PMS is not understood as a discursive category, women don’t take up the position of PMS sufferer, and don’t blame PMS or the premenstrual body for psychological distress (Chrisler, 2004). This has led feminist critics to argue that PMS and PMDD are merely the latest in a line of diagnostic categories that act to pathologise the reproductive body (Nash & Chrisler, 1997; Ussher, 2006). However, we also need to acknowledge the vulnerability experienced by women premenstrually, the role of the body or social stressors in premenstrual experiences, and women’s subjective evaluation and negotiation of psychological and bodily changes (Ussher, 2011).
Psychological research has demonstrated that the development of premenstrual symptoms, and the construction of these symptoms as ‘PMS’, is a shifting process of negotiation and coping. For example, in research conducted in the UK and Australia, three interrelated processes of appraisal and coping were found to be central to the experience and construction of ‘PMS’. These were, awareness of premenstrual changes in emotion, ability to cope, or reactivity to others, expectations and perceptions of these changes, and mode of response or coping (Ussher, 2002; Ussher & Perz, 2013b). At each stage in this process, women could resist or take up the position of ‘PMS sufferer’ – the construction of premenstrual change as PMS was not inevitable.
Relational issues were a major predictor of self-diagnosis and coping with premenstrual distress developing, and being positioned as ‘PMS’, within the context of interactions with partners or children (Ussher & Perz, 2008). Using a ‘short fuse’ metaphor, women report greater reactivity to family stresses and altered perception of daily life stresses premenstrually (Fontana & Palfaib, 1994; Ussher & Perz, 2013b). Women and their families may also attribute premenstrual expression of negative emotion to PMS, even when alternative explanations can be found, which leads to women’s emotions being positioned as a hormonal pathology (Ussher, 2006). Direct expression of emotion has been reported to be lower in families where women report PMDs (Kuczmierczyka, Labrumb, & Johnson, 1992), which increases the likelihood of premenstrual emotion being positioned as problematic.
Many women who report PMDs also report higher levels of relationship dissatisfaction or difficulties. There is evidence that both women and their partners evaluate the relationship more negatively in the premenstrual phase, suggesting that some couples are not simply distressed, but rather are distressed in the premenstrual phase of the cycle (Brown & Zimmer, 1986; Ryser & Feinauer, 1992). It has also been reported that premenstrual anger and irritation is associated with legitimate relationship conflicts, with feelings of dissatisfaction being openly expressed during the premenstrual phase of the cycle, in contrast to women self-silencing during the remainder of the month (Ussher & Perz, 2010). This suggests that relational factors, and relational communication, may underlie premenstrual distress for some women. The coping responses of men have been found to be a strong predictor of women’s symptom severity, with high levels of premenstrual distress associated with a partner’s avoidance, fear, and anger, and low levels of distress associated with reassurance and support (Rundle, 2005; Ussher & Perz, 2013a).
Taking the relational context of PMDs into account, a recent study examined the efficacy of a couple-based CBT intervention, in comparison with a one-to-one CBT therapy, and a waitlist control group. Post-intervention, women in the two active CBT conditions reported significantly lower premenstrual distress and higher cognitive coping than women in the waitlist control. In addition, women in the couple condition reported significantly higher active behavioural coping post-intervention in comparison to the one-to-one and waitlist control groups. Based on these findings, CBT should be available for women reporting moderate-severe PMDs, with couple-based CBT offering some additional benefits to a one-to-one modality.