Premenstrual Syndromes and Nursing Care
What Is Premenstrual Syndromes
Until the 1970s, misogynist views of menstrual related experiences
prevailed. Notably, an article written by a Johns Hopkins University physician,
Erle Henrikson , in 1948 described premenstrual tension as the “Bitch
Syndrome.”
After “carefully observing” many nurses and other
“perfectionistic” women, Henrikson declared in his study that women
who were both high achievers and “not satisfied” with their work or
roles had more severe symptoms ( Speroff , 1988).
With the advent of the 1970s,
critique and counterpoint arguments to negative classification of perimenstrual
experiences were beginning to be published. Feminist scholars recommended the
use of the word “change” over “symptom,” as in “premenstrual changes” (Delaney,
Lupton, & Toth, 1976; Parlee , 1973).
In 1979, feminist epidemiologist and
nurse researcher Nancy Woods first used the term “premenstrual symptoms or
experiences” (Woods &Hulka , 1979). In the mid-1980s, professional medical
organizations in the United States and United Kingdom met to define
premenstrual syndrome (PMS) for clinical trials and scientific research.
The
published proceedings established the medical basis for the presentation and
clinical existence of PMS as a disease classification (Dawood, McGuire, &
Demers, 1985; Halbreich , 1997).
From this point forward, misogynist labeling
shifted to medical diagnosis. Notably, psychiatry and the Biological Psychiatry
Branch of the National Institute of Mental Health provided the leadership in
biomedical research ( Rubinow & Schmidt, 1995).
In 1986, the Board of
Trustees of the American Psychiatric Association (APA) voted to include a PMS
label as a diagnosis in the research appendix of the Diagnostic and Statistical
Manual, 3rd edition (DSM-IIIR) (American Psychiatric Association, 1986).
Although the diagnostic term, Late Luteal Phase Dysphoric Disorder (LLPDD), was
included in the 1987 DSM-IIIR in the “category requiring further study” (or
research appendix), it was given a diagnostic code, title, list of symptoms ,
and cutoff points exactly like diagnostic categories in the main text of the
DSM that is supported by scientific evidence.
In spite of the recommendation of
its own subcommittee that there was little substantive science to support a
diagnosis of premenstrual mental illness, the APA included a revised label of
premenstrual dysphoric disorder (PMDD) in the DSM-IV research appendix and in
the main text under Depressive disorders.
While symptom assessment requires one
of four mood symptoms and four physical or somatic symptoms to qualify for the
PMDD diagnosis, only antidepressant drugs were recommended for psychiatric
treatment.
Premenstrual Syndrome and Feminists
It has been argued that the controversy over the labeling and treatment
of PMS and its symptoms was not restricted to conflict between feminists and
the APA, nor was it a natural result of scientific progress. Rather, using
terms such as PMS or PMDD gives a diagnostic (dysfunctional) label to
premenstrual experiences and ignores the underlying social causes, allowing the
status quo to be maintained.
Furthermore, women internalize patriarchal beliefs
about femininity and pathology and blame their individual biology for their
feelings of dissatisfaction, rather than challenge the cultural traditions by
looking for a political or social solution.
Health Classification of Premenstrual Syndrome
So what’s all of the fuss about a label? More than an issue of
semantics, the terminology we use to describe women’s experiences influences
social, political, and medical institutions. Classification of health related
signs and symptoms generally leads to the identification of diagnostic criteria
but is ultimately a social process, and as such it is influenced by multiple
social forces.
Unfortunately, biomedical language has predominated with little
attention paid to alternative perspectives from other disciplines and, more
importantly, from a woman’s perspective.
Nursing Research on Premenstrual Syndrome
Nursing research has been done independently and collectively, with
colleagues in the Society for Menstrual Cycle Research (SMCR), at the forefront
of a woman centered agenda for understanding menstrual cycle experiences as
both normative and illness processes.
One early example of an outcome of the
cross disciplinary SMCR conferences was the 1981 Guidelines for Non-Sexist Research
(Psychology of Women Division).
These guidelines, sponsored by the SMCR, were a
result of 2 years of effort by a national task force of psychologists appointed
by Division 35 (Psychology of Women Division of the American Psychological
Association, 1981) of the American Psychological Association and endorsed by
them in 1981.
A long history of funded research programs also demonstrates the
scope, sophistication, and scientific rig or of nursing research in these
areas. Since 1986, the National Institute for Nursing Research has been
actively supportive of research addressing the cause and consequences of
menstrual cycle and menopause related health conditions (Reame, 2001).
Nurse
researchers have focused on comorbidities related to menstruation or menstrual
cycle phase, such as sleep function and disturbance, fatigue, fibromyalgia,
gastrointestinal function and irritable bowel syndrome, brain function and
neurocognition, depression, mood states, stress responsivity, circadian
rhythms, pain and analgesic responses, bone biomarkers and osteoporosis, HIV
and AIDS, violence and post-traumatic stress syndrome.
As well as chronic
diseases such as heart disease variability, diabetes, epilepsy, cancer, and
arthritis (Golding, Taylor, Menard, & King, 2000; Taylor, D., 1999; Woods,
Lentz, Mitchell, & Kogan, 1994; Shaver, Giblin, Lentz, & Lee, 1988;
Heitkemper et al., 1995; Reame, 2001; Williams, 2003 ).
Social Impact of Menstrual and Nursing Research
Attention to the context in which menstruation occurs has been an
important part of nursing research into the menstrual cycle. Studies have
documented the importance of stressful life circumstances in association with
symptoms, as well as the importance of socialization for menstruation.
Nurse
researchers have made clear the consequences for women of a social context in
which menstrual symptoms such as PMS are invalidated or used to invalidate
women’s complaints and abilities.
Nancy Woods with her team, first at the
University of North Carolina and later at the University of Washington,
developed and tested multivariate models of “perimenstrual symptoms and
experiences”.
It included sex role orientation, socialization, social
context, stress, well-being, health status, health practices, and health
seeking (Brown, MA, & Woods, 1986; Brown, MA, & Zimmer, 1987a, 1987b;
Macdougall , 2000; Mitchell, E., Woods, Lentz, & Taylor, 1991; Mitchell,
1999; Mitchell, ES, Woods, & Lentz, 1987, 1993; Mitchell, ES, Woods, Lentz,
Taylor, & Lee, 1992; Mitchell, ES, Woods, & Mariella, 2003; Oleson
& Woods, 1986; Taylor, DT , & Woods, 1991; Taylor, D., Woods, Mitchell,
& Lentz, 1987; Woods, 1985).
Other nurse investigators have looked beyond
negative mood and personal variables to consider positive feelings and
experiences, generational differences of mood and physical experiences across
social, monthly and seasonal cycles, and development of biopsy.
Cho social
conceptual models that clarify the limitations of the biomedical model and
provide a basis for hypothesis testing (Cahill, 1998; Costos & Gleason,
1995; Lee, S., 2001; Taylor, D., 1990; Taylor, D., & Woods, 1991).
Premenstrual Syndrome and Treatment
As a normative experience, nurses have carefully described the
experience of women across menstrual cycle phases and transitions. Patterns of
perimenstrual symptoms, including Premenstrual Syndrome (PMS), Premenstrual
Magnification (PMM), and dysmenorrhea symptoms, have been described carefully
as the basis for treatment.
The existence of a symptom pattern consistent with
definitions of PMS has been described, and the possibility for its
idiosyncratic experience has been theoretically developed and tested.
Definitions and criteria for clinical assessment based on daily recordings as
well as retrospective assessment have been established.
One of the first
epidemiologic studies of premenstrual mood change in a healthy, community based
sample was conducted by Woods in which women’s daily experience of feelings,
cognitions, and physical changes were assessed across three menstrual cycles
using prospective daily diaries in multiple, non clinical samples of regularly
menstruating women (Woods, Most, &Dery , 1982; Woods &Hulka , 1979;
Woods, Mitchell, Lentz, Taylor, & Lee, 1987).
An important contribution by
Nancy Woods to understanding what is and is not PMS is the redesign of the
epidemiologic approach to estimating the prevalence of PMS. Instead of assuming
a set of a priori symptoms or signs attributed to the label of PMS, she turned
the epidemiologic model on his head by asking women about their daily
experiences across multiple menstrual cycles.
Factor and cluster analysis
methods allowed classification of these data based on women’s lives across all
menstrual cycle phases rather than only the premenstrual or menstrual phase.
Measuring Premenstrual Experiences
The measurement of perimenstrual experiences has become
increasingly sophisticated as well as reflecting its complex, nonlinear nature.
Ellen Mitchell and colleagues (Mitchell, ES, et al., 1991; Mitchell, ES, et
al., 1987, 1993; Mitchell, ES, et al., 1992) have made important contributions
to advancing the definition of PMS through their data-based models of perimenstrual
experience classification (perception, evaluation, response patterns).
Research
methods that go beyond the traditional quantitative approaches are now better
able to capture the women’s subjectivity (lived experience) and diversity, such
as the interview method, cross-cultural research, ethnography, and feminist
experimental methods.
A number of studies. have compared views and experiences
of menstrual cyclicity, including PMS. of women from other cultures (Berg, J.,
1999; Beyene , Taylor, & Lee, 2001; Brown, M., & Zimmer, 1986; Dan
& Al- Gasseer , 1991).
Social and physical environmental effects on the
menstrual cycle and PMS experience have been explored, examining the effects of
perimenstrual symptoms on work, marital relationships, mother-daughter
relationships, and family functioning (Brown, M., & Zimmer, 1986; Roberts,
SJ , &Garling , 1980; Robinson, K., 1997).
Nursing Research Outcomes for Premenstrual Syndrome
Nursing research has been influential in expanding therapeutic
studies beyond the context-free clinical drug trials while maintaining the
“gold-standard” experimental methods-placebo controlled, randomized
clinical trial designs.
The earliest studies included nonrandomized trials of
the effectiveness of biofeedback and autogenic training for menstrual pain,
feminist self-help groups, community education strategies, combined self-help
and professional support groups, and behavioral (transpersonal approach,
relaxation training, telephone counseling, and exercise) therapies (Amato,
1987; Heczey , 1980; Heinz, 1986; Miota , Yahle , &Bartz , 1991; Morse C,
Dennerstein , Farrell, &Varnavides , 1991; G Morse, 1999; Taylor , D.,
& Bledsoe, 1986).
In the 1990s, well-designed, controlled clinical trials
of complementary therapies and cognitive-behavioural therapies were reported
(Cohen, SM, 1989; Groer, 1993; Morse, G., 1999). The first NIH-funded,
randomized clinical trial of a pilot-tested, non-pharmacologic treatment
included personal symptom management strategies as well as strategies for
controlling social stress (Taylor, D., 1996, 1999, 2000).
This clinical trial
demonstrated how environmental stress management was as important as personal
stress management strategies for coping with mood and physical symptoms.
Scientific Rationalized Care for Premenstrual Syndrome
Putting the science back into self-care has been a major
contribution to menstrual cycle research by nurse scientists, resulting in
research dissemination to consumers. In 2002, Diana Taylor published one of the
first science-based self-help books for women that described effective,
non-drug remedies for relieving PMS (Taylor, D., &Colino , 2002).
Progress
has also been made within professional and clinical communities to translate
research into practice, using both empirical research as well as women’s
experiences as an important aspect of the base of evidence. A national
organization of women’s health nurses has implemented a model of clinical
guideline development the Association of Women’s Health, Obstetric and Neonatal
Nursing (2003).
This professional organization of women’s health care providers
developed an innovative clinical practice guideline (Association of Women’s
Health, Obstetrical & Neonatal Nursing) based on a broad range of clinical,
empirical, and theoretical evidence and subsequently evaluated the guideline in
nursing practice through a research- based practice project (Collins-Sharp,
Taylor, Kelly-Thomas, Killeen, & Dawood, 2002).
In this guideline, they
recommend the term Cyclic Perimenstrual Pain and Discomfort (CPPD) to
differentiate normal cyclic changes associated with menstruation from the
severe, debilitating menstrual and premenstrual symptom experiences that
require professional or pharmacologic intervention.
Albeit the label references
the negative end of the perimenstrual experience spectrum, it is based on a
range of empirical studies using quantitative and qualitative methods of
women’s experiences, not just hypothetical pigeonholing.
As more nurses assume roles as primary care providers for women,
the need for this evidence based therapeutic models is critically important.
Clinical trials of treatment models, coupled with interventions to promote the
understanding of menstruation, symptoms, and self-care options, should be
aggressively pursued.