We’ve all blamed PMS on hormones but, despite popular belief, no direct causal link between female sex hormones and PMS has ever been proven. So why does the ‘hormonal woman’ stereotype persist? And how does it fuel outdated, sexist narratives about female health?
In this episode, Jess Miles speaks to Sally King, a visiting fellow in menstrual physiology at King’s College London, about the myths and sexist tropes that blame the healthy reproductive body for the female-prevalence of emotional distress and physical pain.
They discuss why so much of menstrual health focuses on hormones while overlooking the inflammatory nature of the cycle and what needs to change in healthcare, education and everyday conversations.
Listen to the podcast here, or on your favourite podcast platform:
Scroll down for shownotes and transcript.
Sally King is a visiting fellow in menstrual physiology at King’s College London who specialises in integrating biological and sociological research and data concerning menstrual health.
Menstrual Myth Busting by Sally King is available on the Policy Press website. Order here for £19.99.
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SHOWNOTES
For evidence-based information on this topic, Sally’s website, Menstrual Matters, is an essential resource.
Timestamps:
1:27 – What’s your background?
5:29 – Who have you written the book for?
6:33 – What’s the problem with focusing on hormones?
9:18 – What is spontaneous decidualisation?
15:30 – What are the myths around menstruation that you challenge?
26:21 – Can you tell the analogy with Dwayne the Rock Johnson?
29:06 – Can you talk about how these myths are perpetuated?
48:18 – What suggestions would you make for improving clinical practice and teaching?
50:35 – Can you tell us about Menstrual Matters?
Transcript:
(Please note this transcript is autogenerated and may have minor inaccuracies.)
Jess Miles: Have you ever said you feel a bit hormonal in the run up to your period, and attributed your mood to estrogens and progestogens? I have, so I was shocked to read in ‘Menstrual Myth Busting’ by Sally King, that there’s no direct causal relationship between female sex hormones and premenstrual symptoms that has ever been demonstrated. The only thing the science proves is an association between the timing of symptoms and changes in the hormones average circulating levels.
Meanwhile, the well-established inflammatory nature of the menstrual cycle and associated symptoms has been almost entirely overlooked by those working in this field. When we talk about PMS, it seems that we’ve been working with myths rather than scientific information. What’s worse is that this concept of the hormonal premenstrual woman is just another iteration of the hysterical female myth, fuelling the sexist tropes that blame the healthy reproductive body for the female prevalence of emotional distress and physical pain.
I need to find out more. So I’m very glad to welcome Sally King, a postdoctoral fellow in menstrual physiology at King’s College London, to the Transforming Society podcast. Hello, Sally.
Sally King: Hi Jessica, lovely to be here.
JM: Yes, it’s really, really good to have you on the podcast. Just because your book blew my mind a little bit. So I’m looking forward to talking to you about it more. Before we do, what’s your background and how did you come to write this book?
SK: Well, I had an earlier career, so I spent over a decade working in international development and human rights organizations, and I was a policy analyst. So really that’s sort of doing research and evaluating how well interventions and policies work. I mean, most of the organizations I worked with that had a focus on gender equality. So that was something I’ve been doing for a long time.
And then I actually had my own sort of health issue. I developed a quite sort of serious pattern of nausea and vomiting. So quite similar to morning sickness, it was really not very good. And it got progressively worse over a couple of years and I kept going to the GP. And eventually, after ruling out everything else, they said it was anxiety, which was interesting to me because I didn’t experience any anxiety, so I had a bit of worry I suppose, about being sick and not knowing what was causing it, but having had things like depression before, I knew that I wasn’t ill.
I didn’t have a mental health issue at that time. I felt good actually, and my life was going well, so I didn’t really want to take lots of medications for something that I felt was inappropriate. So being a researcher, I got a spreadsheet open, decided to track my symptoms, and I was totally sure that it would be an allergy.
I thought it was just something in the environment I’m allergic to, but by tracking it over time, I actually saw that there was a pattern. It was cyclical, and it was cyclical in a way that I hadn’t been taught to expect. So I was particularly bad around ovulation, then okay for a few days.
JM: So more nauseous around ovulation.
SK: Yeah, and then a couple of days on, a few days off, then nauseous again before the period, sort of a week to ten days before then maybe a couple of days okay. And then it was quite bad during the period. And to my mind, I’d only ever been told about sort of premenstrual sort of PMS, symptoms and nausea and vomiting had never been told to me.
I couldn’t find anything about it on the internet. But once this sort of realization of what was going on happened and I looked for information, I was able to manage my symptoms myself through sort of basic anti-inflammatory measures and also sort of wearing those nausea bands. That was really helpful.
JM: Oh yeah.
SK: Sucking ginger sweets that kind of thing. But really there was this slow realization of sort of a couple of things. One, how quickly and easily I was diagnosed with a mental health issue for something that turned out to be physiological. And also when I looked online, this was sort of 2010. So the internet was working fine. There was nothing, you know, there was no evidence based information, particularly on those symptoms, but even just sort of on reproductive health regarding physical sort of illnesses and conditions was very limited.
And because of my policy background, I thought, this is a real gap and it’s a gender gap. So I started Menstrual Matters. The website started in 2016 after doing a lot of research, and particularly I tried to work to bridge the gap of knowledge between clinical research, which does know quite a lot about physiology and clinical practice, but in particular the public’s knowledge about what’s happening in their own bodies.
And subsequently, I completed a PhD in medical sociology. So that combines biology and physiology with social theories about sort of gender myths and racial myths. And I did that about PMS, premenstrual syndrome. I compared the world’s experts and some patients descriptions of PMS with the available data that we have on cyclic symptoms, and the idea being that if people’s descriptions aren’t based on the available data and knowledge that we have, what are they based on?
Probably social constructs and sort of assumptions that we have in society. And basically this book is all about that PhD research.
JM: Yeah. We’ll go on to talk about the book and the detail of the book in a minute. But I think, I think the book’s really brilliant because it has all this real dense evidence in it, but it’s also really accessible because you do things like provide summaries at the end of the chapters, which I found really helpful when I read it.
So who have you written the book for?
SK: Well, this is definitely still an academic book. This is something I really needed to write to get kind of that academic credibility. But also if I’m talking to clinicians and trying to get medical practice to change, I need that kind of academic kudos. And as you say, all these sort of references, I’m fully supporting my arguments properly. But also I’ve worked in this space now for a long time, 12 years, menstrual activism and menopausal activism in particular have become much more mainstream and much more popular interest for people.
So I wanted to meet a need that there is to help menstrual health activists, sometimes alternative health practitioners, GP’s, teachers, pretty much anyone who’s interested in menstrual health beyond what we’re currently taught in school, which I think we can all agree is not adequate. We’re not taught enough about our bodies to know if we’re ill or not, for example.
JM: Yeah. Oh well, you’ve done a brilliant job in, doing both, doing the science bit and doing the explaining bit too. So before we talk about these myths in detail, your overall argument is that, like you’ve just said, that too much of teaching, health care and discussion around periods focuses on hormones. And we can all see that all the time. But why is this a problem?
SK: It’s a real problem because that hormonal diagram sort of image that we get when we think about the menstrual cycle maybe it’s just-
JM: That’s the diagram with the line of estrogen and the line of progestogen.
SK: Yeah, estrogen and progestogen going up and down. And it’s set over an average 28 day cycle.
JM: Yeah.
SK: All of these things, they’re very abstract. And they’re also that isn’t the menstrual cycle. That is an abstract depiction of the average hormone levels. And these hormones coordinate these very physical, physiological changes that happen in our bodies. And then by omitting what these hormonal changes are causing and really doubling down on just saying it’s hormonal is a problem because as I sort of explained that it’s sort of misleading.
It’s reducing our bodies to hormones. And then it implies that only females have hormonal bodies. So for instance, the production of sperm hormonally is actually very similar to the female production of eggs. So that ovarian hormonal cycle involving the brain, the ovaries and the way that they interact with each other is almost identical with the testes and male brains.
And if you’re not taught that, you’re being taught that this is the female body, it’s hormonal, then you’re not taught about the hormonal male body doing pretty similar things. Although although not on a monthly basis. And it feeds into this idea of otherness that the that women and girls are somehow hormonal in a way that boys aren’t, and men, and that we are, that this dictates our behaviors and our attitudes, for example.
JM: So what we’re doing is looking at that diagram and kind of stopping at the hormones, aren’t we? We aren’t going, oh, well, this change is happening in hormones and it results in this symptom.
SK: Yeah, so for instance, you probably have been taught about ovulation. And maybe a little bit about menstruation. Certainly the general gist that I remember being taught was if you’re not pregnant. So first of all it’s all about getting pregnant. And then in the-
JM: Yes, that’s our only function after all, isn’t it?
SK: Even though in out of 450 periods, even if you had loads of children, you had ten children, you’re still going to have hundreds of periods. So more often than not, you’re going to have a period. It was never explained to me really why we were having a period. But what we’re particularly not taught is this, this other function, there’s three functions in the menstrual cycle and the middle one between ovulation and menstruation is called spontaneous decidualisation. And it’s key to understanding what’s happening in our bodies.
JM: So what is, what’s spontaneous decidualisation?
SK: So spontaneous means automatic. And so this form 98% of mammals don’t have periods. So they all ovulate.
JM: Yes that was a revelation to me when I read the book.
SK: Yeah. So I think people get confused about dogs because dogs can bleed when they’re on heat. But actually that’s blood coming from their vagina not from their womb. And it’s a scent signal to male dogs to say that they’re fertile. Absolutely not what happens in us. We have no scent or any other signals when we’re fertile. So this decidualisation word is the you might have been told about the thickening of the womb, so the lining of the womb, undergoes several sort of physiological changes.
There’s lots of different cells and activity going on, these inflammatory processes where the womb thickens. So in the 98% of mammals who don’t menstruate, this only happens if there’s already an embryo ready to implant into the wall of the womb.
JM: Okay. Right. Yeah.
SK: And the hormones from the embryo are what trigger it to happen. It’s the same hormones. It’s progestins coming from the embryo.
JM: Yeah.
SK: Whereas in menstruating species which is humans, primates, few monkeys and bats, spiny mouse and the elephant shrew, very different types of mammals and different family trees. We have this decidualisation process happening automatically in response to normal changes in our hormone levels, in our case after ovulation.
So this happens whether or not you’ve ever had sex if there’s an embryo or not, if there’s an egg has been released or not, quite often, about 20% of our cycles we don’t ovulate but we still get a period. None of this matters. This is an automatic thickening of the womb lining and then menstruation happens.
So if there is no pregnancy and you don’t need this thickened womb lining, it’s already got to the point where it can’t sustain itself unless there’s a pregnancy, everything is shed, including any eggs, any sperm. Anything that’s in the womb gets shed. So this is something that just isn’t taught currently, even though it’s the reason why we have periods.
JM: The reason that this happens automatically every month for humans is because it’s not actually very safe for us to have babies. That’s what you say in the book, isn’t it?
SK: Yeah, so this isn’t my theory. This is, some evolutionary biologist theories, and it fits the data really, really well, which is that probably especially in the case of primates, but particularly humans, we have very high rates of either, unviable pregnancies where the embryo is either genetically or sort of physically abnormal in some way, but also sort of dangerous implantation, which is when the placenta joins to the lining of the womb.
It can be either too invasive to the point where it’s taking too many nutrients out of the mother’s bloodstream and can be dangerous and can cause illness in pregnancy, or it hasn’t actually attached properly. And of course, if you’re going to spend nine months feeding, providing the nutrients for an infant, that’s actually not going to survive. And because of some sort of abnormality or problem with the placental attachment, this is a waste of our resources.
And also potentially you could get pregnant again with a more successful pregnancy. So it’s thought that we evolved this abortive mechanism, the period or the early decidualisation in case there’s any pregnancy and allowing an earlier, essentially a miscarriage, a spontaneous abortion of any sort of unviable, pregnancies. And yes, this is especially relevant to humans because we have really high rates of abnormal embryos, abnormal sperms, abnormal eggs, and also really high miscarriage rates.
Unfortunately, again, this isn’t something we’re taught at school. Most of us find out through experience that in the first 12 weeks of pregnancies, a lot are miscarried and in fact, in the first week. So before you even know you’re pregnant, an even higher proportion of potentially, you know, fertilized eggs, that are lost then in the, in the in a period.
JM: Yeah.
SK: So it sort of makes sense that in species where and also something else we’re not taught that is a worldwide problem is maternal mortality. So in humans in particular, again, we’re far more likely than even our primate cousins to die in childbirth and pregnancy. So sort of illnesses, pre-eclampsia in particular, which is high blood pressure causing organ failure or just the physical difficulties of giving birth.
And again, we we don’t know for sure, but this is most likely because we walk on our hind legs, we’ve got great big heads. And, you know, we’ve sort of evolved out of an easy birthing experience. So this is sort of so it’s kind of revolutionizing the, the branding, if you like, of periods to being something that is obviously they’re painful, they’re uncomfortable, and they involve blood loss, which isn’t ideal.
It’s quite costly over time in that we become iron deficient. But it’s something that evolved to protect us from illness and death. You know, this is a sort of a new way of thinking about our periods.
JM: It’s totally new. It’s totally new and we’re educated and the way we talk to each other as well, it’s like periods of just all about pregnancy and almost if you’re trying to get pregnant to have a period is a failure. And yeah, it’s an absolutely I think it’s I’ve never thought of periods as like protective before.
SK: But I think, I think even worse for miscarriages. I think the word miscarriage in English implies that you’re to blame, that you’ve done something wrong or your body is wrong, but your body is, it’s still sad, but your body has protected you from a danger.
JM: Yeah.
SK: Or protected, you know, sort of ended something that was unviable. At the earliest stage, which again on a personal basis, that it’s still very upsetting to have lost the pregnancy. But but think of all the guilt people feel. You know, I hear this from people. I shouldn’t have gone for a run. I shouldn’t have eaten this. I shouldn’t have had the vaccine.
All of these things that actually play very little role. It’s much more likely that that was a problem with that pregnancy and your body has protected you from that.
JM: So there’s kind of there’s two things going on here and in your book, isn’t there? This like reframing or radical reframing of the way we think about periods and what they’re for and why we have them. But then also the fact that a lot of that physiology has been ignored, because it’s been ignored and because we’ve only focused on the hormones, that’s kind of feeding into these gender myths and perpetuating them.
So I just wanted to move on and talk about those and we’ll only be able to scratch the surface here in terms of these myths, because there’s so much in the book. But let’s chat as much as we can. So what what are the specific myths around menstruation that you challenge in the book? I think there are, there are four of them?
SK: Yeah. Well, there’s the overarching myth really is one that most people listening will understand which is the myth of the hysterical female.
JM: Yeah. Hormone, it’s hysterical to hormonal now more isn’t it?
SK: So I think, you know, in history it was thought that our wombs were causing us to act irrationally.
JM: As they moved around our bodies.
SK: To seek attention, to make up symptoms, to invent them, or even to psychosomatically create symptoms in ourselves because of our reproductive bodies, so it was the womb. Now, I argue that this is now hormones. People just generally they don’t name a specific hormone, which is, how you know, there’s something dodgy, but generally just sort of saying, your hormonal to imply that your reason has been affected or your emotional distress is caused by your body and not the emotionally distressing things happening around you.
And so I’ve argued that by only teaching us the hormonal coordination of the menstrual cycle, while sort of understandable maybe because you have to pick and choose what you teach people, but what it’s effectively done is, again, set up female bodies as hormonal and male bodies as not, which is not true, but also that we have these patterns of behaviors on this cycle that are generated by our reproductive bodies, rather than us being agents in the world, being able to make decisions.
JM: Or the difficult things we have to deal with all the time in the world.
SK: And then the method I use, which is to analyze what people would, how they would describing PMS to me. So these world experts and also people who self-identified as experiencing PMS from what they say, we do a particular type of discourse analysis to generate what does this mean? What are they saying here? What are the metaphors they use? How are they using humor? How are they? You know, what sort of, how are they describing pain? All of those things.
JM: Can you just say, who exactly did you speak to in your research? Which different groups of people?
SK: So I interviewed experts and patients. I ended up speaking to about half of the world’s experts in PMS, which sounds super impressive until you realise that’s 16 people, because there’s only about 30 people currently.
JM: In the whole world?
SK: Producing research and writing about it in the world. Everything about menstrual taboo affects everything, and also because it’s only affecting women, who cares if we’re the majority. This research doesn’t get funded. But also what’s in textbooks really does dictate what people know about and therefore what questions they ask in research. So I spoke to half of these experts, including six of the top ten people who published anything on PMS and PMDD, which is premenstrual dysphoric disorder, which is particularly people experiencing very severe emotional distress on a cyclic basis, even sort of suicidal ideation, that kinds of level of distress.
And then I just asked a variety, so as diverse a group as possible as possible, of people who self-identified as PMS and interestingly and compared that with the data that we have to sort of see how close those descriptions were.
JM: Yeah.
SK: So from looking at what they were telling me, these three myths, main myths came out, but all of them, just sort of sit under and reproduce the myth of the hysterical, hormonal, female. So the first one is called All in Her mind. So I think again, listeners will be all too aware of this. This is the sort of psychologization of physical symptoms, the idea that this pain that we feel might be hormonal or might be, exaggerated in some way, particularly pelvic pain or period pain, endometriosis related pain.
JM: So it’s not seen as real physical pain. It’s more of an imagined pain.
SK: Well for instance, these experts kept saying that back pain, period pain, fatigue might be coming from the psychiatric diagnosis of PMDD. So not only were they omitting and not talking about these physical things happening in our bodies, which admittedly they haven’t been taught, but ignoring all these physical things, they were implying that period pain and abdominal pain was some part of a psychiatric disorder, and they still are within the diagnostic criteria for that psychiatric disorder, with no sort of realization it seems that these are healthy, just typical menstrual changes that happen in the body, whether you have distress or not.
So this is a physical thing. So there was a real sense of psychologization, but also and particularly in the disbelief of people when they’re talking about their symptoms and ironically, disbelief whether you’re talking about emotional distress or physical pain, just the idea that who you are, so particularly racialized female patients who sort of get two myths on top of them, one, that they’re a woman and therefore they’re prone to this hysteria, exaggeration, attention seeking, making stuff up for attention, which, to be honest, I’m yet to meet a woman who’s ever sought help for menstrual symptoms, who’s been making it up not once and out of thousands of people. Usually it’s the other way around that people are really minimizing that experience. Oh, you know, I pass out every month, I vomit from the pain. I’ve fainted from the pain and then they say, is that normal? Right. No no not normal, it’s the opposite.
JM: Yeah.
SK: But also there are racial myths about that. You know, the idea that black skin is thicker, that black people have sort of can magically cope with pain in a different way, or that you shouldn’t give painkillers to black people, there were a lot of racist myths.
JM: It comes through in like childbirth, a lot doesn’t it? How black people are treated in childbirth. Yeah.
SK: And it’s really, so I also spoke to Bangladeshi British people. They also experience sort of I’d say worse examples of disbelief, a medical sort of not being examined, not being given any treatment. Or as is very common, being given a psychiatric label rather than a physical one. So you might actually have fibroids which are very easy to spot to be honest with you can even just feel them if you examine the patients. But their pain and anguish associated with severe pain or heavy bleeding gets psychologized, and they’re more likely to be sort of sent for treatment for depression or anxiety.
JM: So it means the physical symptoms don’t actually get checked out.
SK: Yes it’s not even examined. So that’s very much on racialized patients but all women. So and we know this a recent report came out from the government that women and particularly racialized patients of any sex are more subject to this disbelief, or even if it’s not conscious. A lot of this is unconscious biases. I’m not saying that the doctors mean to be biased.
But you’re far more likely to to not experience adequate medical attention and care if you’re a female patient and also for certain symptoms. So things that are feminized like IBS, migraine, fibromyalgia. So even if you’re a man experiencing a female prevalent condition, it’s still subject very much to this all in your mind myth, the idea that you’re, you’re the problem.
You know that there is no illness here. And this particularly relates to anything that that the known cause it hasn’t been found yet. You know that that there isn’t an established theory for what’s happening in the body. This tends to happen, it gets psychologized. So that’s the first sort of contributing myth. Another one is just that femininity is debility.
The idea that the female body is inferior and somehow ill, the sort of sick female body and the same again for racialized bodies that we’re somehow prone to illness. And this is due to being female. And of course, as humans-
JM: And weakness. Is it?
SK: Weakness? Yeah. Just well, these are all myths because yeah. Although, you know, there are differences in averages. So for instance I’m over six foot tall. It doesn’t make me a man. So there are a lot of people who really believe men are taller, you know, humans are not very good with stats for sure. We’re not good with maths. We’re not good at understanding what average means or these sorts of things.
But there is a real going back, you know, hundreds if not thousands of years. The idea that women don’t get the same rights as men because unfortunately, biologically speaking, and particularly intellectually, we’re not as good as men. This is an old it’s called biological essentialism, the idea that political inequalities are sadly natural and inevitable because women just aren’t as good as men.
There is no empirical evidence. And in fact girls now outperform boys at school and university. So the the data doesn’t support these things. But this is a real belief. And of course, this is a key one for hysteria. The idea that it was the womb was the problem. Now it’s our sex hormones. And this isn’t fact at all and in fact, the highest levels of estrogen, for example, are found in the male testes.
So even the way that we label things like that sex hormones is not scientific. It’s not accurate. We would be better off calling them some sort of reproductive hormone, because there’s clearly a role for estrogens in the creation of gametes, both male and what we call male and female.
JM: Yeah.
SK: We’re a victim of our own gendered language more than anything.
JM: Yeah. Yeah for sure. Yeah, definitely.
SK: And then the final sort of myth that came out was this sort of global ignorance of menstrual physiology. So we’ve discussed this a little bit already. But so the patients just said, I just don’t know I don’t know why I feel this way. I don’t know why I get pain. I don’t know why this is happening. I think it’s to do with my hormones.
So this is clearly telling me that we’re not taught enough to understand what’s going on in the body, that this is inflammation. We can manage it through anti-inflammatory methods, that it’s not mysterious. It’s not unknown. There’s nothing I call it the black box myth, the idea that the female reproductive body is just unknowable. It’s not scientific. It’s this mysterious mystique associated, which, again, is a gender myth.
This isn’t true, of course we do actually know what’s happening in the reproductive body. It’s just not taught to the right people. It’s currently just languishing there. So the people who do know all of that is people who work in infertility. There’s loads of money in infertility. There’s loads of research on infertility. But to them, a period is a failed pregnancy.
And so it’s sort of cast aside is not super interesting or relevant, but we all need to know about that end of the cycle, you know, and particularly for menstrual health issues.
JM: Thinking about this like, so you’ve got this broad hysterical female myth and then this idea that it’s all in her mind. Women are weak and prone to be ill. And then it’s all very mysterious and magical, and we just don’t know. Can you tell the story, the analogy with Dwayne The Rock Johnson that you put in the book? Because this really helped me get the whole argument.
SK: Yeah. So we do know that the reason why women and racialized women patients are dismissed by their doctors, this is a fact that it’s unconscious bias. So, okay, there might be a couple of doctors who are really racist, really sexist. But in general, doctors are really nice people. They’re very smart people. And they’re kind, you know, particularly GPs. They’ve gone into this to help people.
JM: Yeah.
SK: But we’re all victim to unconscious biases. So I just use the analogy of if you think of Dwayne The Rock Johnson, if he came to you and explained that he feeling increasingly tired, he was feeling a bit anxious when he didn’t used to is experiencing a pain that it’s not all the time, but on and off it can be quite sharp and it’s affecting his ability to sort of do stunts in his latest movie.
Just think how quickly most GP’s would say, okay, we need to look at your iron levels. We need to make sure that even if they’re not technically anemic, maybe you need some iron supplementation or an iron transfusion, for example, to make sure because a guy of your size and strength, you’re going to need your hemoglobin, you’re going to need oxygen moving around your body.
Of course. And let’s have a look at where this pain is. Where exactly is the pain. There would be an examination and even if it was caused by something that was common in men I don’t know groin strain in men that do a sort of particular sports. It would be looked into and treated appropriately. And you would hope that Dwayne The Rock Johnson would be given medication if he needed it and in strong enough dosage to, to work.
So I use that analogy because women are always going to the doctor with pain and particularly related to menstrual pain.
JM: Yeah.
SK: And quite often it will relate to something like endometriosis, which is an autoimmune disorder that really needs prompt treatment. It needs examination and it’s not impossible. These things are totally possible to to diagnose and to not, if not cure, to manage, to prevent further damage being caused and to manage some of the symptoms. But it doesn’t happen. So I just sort of say just imagine every patient you have or particularly sort of racialized women that come to see you.
Just imagine that they’re The Rock. And what would you do in that situation? Because I think it would make a difference.
JM: Yeah. I found that a really helpful way of thinking about it. I’m just going to jump a little bit ahead now to another question I had because because you were talking about doctors and the fact that this bias is for most, most, most of us, it’s very, very unconscious bias. And one thing that I thought was really interesting in the book is that it isn’t just like clinical professionals who are perpetuating these myths, but also by people who experienced periods themselves.
Right? Like in that through the language and the way they describe themselves. Can you talk a little bit about that?
SK: Yeah. What was really interesting was that these patients actually gave more evidence based responses in the descriptions of PMS than the PMS experts. So that was interesting. So they spoke a lot more about pain and physical changes whereas the experts were really talking about suicidal ideation, which is a very extreme, a symptom that you really associate with PMDD or the exacerbation of an underlying mental health disorder.
So, in some ways the patients are very accurate when you ask them to describe what they experience on a cyclic basis, they will tell you about period pain, constipation, diarrhea.
JM: So the more physical rather than emotional. Yeah.
SK: And some emotional pain. But but typically not suicidal ideation. They’ll be talking about irritability bit of low mood. And it’s very much akin to for instance feeling angry or if you haven’t slept enough. So that kind of emotional heightening that we’ve all experienced, if our body isn’t in tip top condition, or for instance, if you have too much caffeine that’s also quite similar, it will just really heighten any feelings of anxiety, irritability or low mood that you have as a menstrual cycle, particularly around just before and during the period, can certainly do that, but it’s not causing typically severe emotional distress.
But yeah, we’re not. This is a big problem if if you’re only taught that hormonal diagram and your only taught of the words PMS. So I’d say 99% of people use a medical diagnostic label to describe the typical cyclical experiences. Because we haven’t been taught that we can call these menstrual changes or healthy menstrual changes.
JM: Yeah.
SK: But even that’s a problem. We’re not supposed to say the word menstrual even though the word menstrual means monthly. It doesn’t mean anything to do with blood. The blood loss. So so we call it menstruation because it’s a monthly occurrence. They couldn’t even bring themselves to call it blood. Sanguine or something I don’t know. So we’re restricted by taboos on the female reproductive body, particularly the blood loss associated with menstruation.
And so we’ve adapted this diagnostic label, which is controversial, to put it mildly, because it’s called premenstrual syndrome. It’s not a syndrome. In 99% of the cases we’re just talking about the healthy physiological changes occurring with the menstrual cycle, which are inflammatory. Managed through anti-inflammatory measures. And we’re just not told that we can use the words healthy menstrual changes.
This has become this has only been since the 1980s. But PMS really took off as a concept and people use it themselves. And in some countries, for example, they use the English term PMS. Even though English isn’t their language. Interestingly, they only use it to refer to emotional changes. So I’d say in this country we use it to just describe anything and everything that happens on a cyclic basis.
But for instance, in Scandinavia, they say PMS to mean irritability, pretty much, or low mood.
JM: And then talk about the other changes separately?
SK: I don’t know. So it’s interesting that they’ve taken a medical because technically for the label to be applied. You have to be really debilitated by these changes.
JM: Yeah, we don’t do that with other things like hunger, do we? We don’t have like a medical term for being hungry. I mean, yeah, I mean.
SK: Again, there isn’t a scientific reason for this.
JM: No.
SK: At all. And and I would argue that if you’re debilitated by any cyclic symptoms, most likely is that you have an underlying condition. So if it’s pain, it could be fibroids, endometriosis, adenomyosis, heavy menstrual bleeding, it could be IBS if it’s digestive sort of pain, it could be a depression or irritability or PMDD if it’s mood related, this PMS idea isn’t helpful at all.
I think we we basically have healthy menstrual changes, which are inflammatory, and they’re relatively, you know, they will respond to anti-inflammatory diet, medications, activities. And if they don’t, then you’ve got something else that needs treating.
JM: Yeah. Yeah.
SK: So nobody is intentionally perpetuating sexist myths, particularly the people that, or racist myths, the people that are sort of affected by them. But if we don’t have alternative language and particularly concepts, to talk about a menstrual cycle, like a lot of people were surprised when I said, oh, yeah, constipation followed by diarrhea when your period starts, it’s very common, like 80% of the time, 80% of your cycles and the number of the participants of oh, I’m so glad they said that.
I thought it was just me. I thought it was crazy. And to me this is like, no, it’s not crazy. You’ve got an inflammation in your in your womb and around your womb, which is right next to your bowel, touching your bowel, your bladder. This makes perfect sense. But of course, if all you’ve been taught is the diagram of your hormones going up and down, it becomes really confusing and sort of mysterious because you’re sort of thinking, why would my sex hormones you know, they’re gross hormones, especially sort of regarding your sort of sex characteristics?
Why would that give me diarrhoea? Like if there is this mental weirdness that we all have because we haven’t adequately got the knowledge to sort of explain these things.
JM: So I think when I was reading the book. So I like to think I’m a feminist and I’m evidence focused, but that weird, I felt that weirdness when I was reading the book, and I felt challenged, I suppose, by what you were saying. And I think it’s probably because through my whole life, I’ve just thought of my body in a particular way and have responded to it accordingly.
And I talked to my daughter about it in similar terms, and it kind of just unsettles all of that in a good way. But it did made me feel like challenged, I suppose.
SK: Well, people you liked and trusted probably told you that this is hormonal.
JM: Yeah.
SK: People who you knew had no reason to want any harm against you. And, you know, they’re not sexist or racist people. So yeah. Yeah, I mean, still 90% of studies, if you look on reputable journals instance, they will insinuate or imply a hormonal causality for cyclical symptoms without an adequate knowledge base. So either there isn’t a reference for where they’ve come up with that theory, or if there’s a reference and you follow it through to that study, it doesn’t actually demonstrate causality, only correlation, which is when things happen at the same time as other things, but don’t actually cause those things to happen.
JM: It makes you realize how much we don’t kind of apply critical thinking to ourselves. And the things I suppose. Maybe I felt a bit silly reading your book. It’s like, oh my God, of course it’s not that. Of course, like cramps. I don’t know.
SK: Humans. We’re not good at critical thinking we’re really not good, because I don’t know if you’ve read the book Thinking Fast and Slow. It was a sort of popular book but it’s very good.
JM: I’m familiar.
SK: Because it says you actually use up more calories when you’re really deep thinking about things. It takes a lot more resources. And so that’s why we use binary thinking because friend or foe. So you’ve established this person’s like me or they’re not. It’s very easy to come to a snap decision. I like this person or I don’t.
Superficially because maybe in the past that protected you from is this a dangerous thing? Is this a safe thing? And you need that to be a quick decision because you might have to run away from it.
JM: Yeah.
SK: But actually thinking about more complex things. So anything social, anything in society, human society is largely unconscious. We don’t even know our own biases. We don’t know how we’re making decisions about things. And unfortunately, with the hormonal model, this is reinforced by what you’ve been taught and even what medics have been taught. And if you go to any physiology textbook or medical textbooks, you would just going to get this hormonal model of the menstrual cycle.
And none of the sort of physical things that are happening in our bodies it’s kind of completely omitted. But also the word hormonal is really widespread, and I think we use it very euphemistically. I think people sort of say, sorry, I’m just feeling hormonal.
JM: Yeah.
SK: Rather than I’m feeling upset. It’s still very taboo to explain that you’re feeling upset. Even if somebody said something really super rude to your face at work it’s considered unprofessional, to have any kind of emotional response to that. And this relates to sexism too, the idea that women may or may not be more likely to reveal their emotional state.
I disagree with this. I think male violence is emotional, and so you could argue it just happens in slightly different ways.
JM: Yeah.
SK: But that hormonal becomes a sort of safeword. And I think also people say hormonal when they mean cyclic. So they say, I think this is a hormonal thing. What they’re telling me is I think this is relating to my cycle in some way. It’s happening sort of every month or a couple of times a month instead of all the time.
So it’s kind of used as a metaphor, and it’s a, it’s shorthand to say to discuss menstrual health without using the word menstrual. So I cannot stress enough, even though we, we say, we’re all liberated. And it’s fine to talk about menstrual health and periods, it isn’t. You know, we have a whole euphemistic language that it’s even used within medicine.
So my doctor said to me, is this a monthly thing? I knew what they meant. They didn’t say. Do you think this correlates at all with any part of your menstrual cycle? Which would have been a different question to me because I would have thought, oh, actually it is worse during my period, but I also get it other, other times but that would have changed the whole concept of what was happening to me by saying, is it monthly?
I sort of thought no, it’s not just once a month. And I genuinely I think a lot of people think cyclic symptoms are because we get our periods once every few weeks. But the question means, is it just you just getting this, these symptoms every once, but you might be getting them around these three physical events that happen each cycle, which isn’t monthly.
JM: So then when you add to that this kind of patriarchal notion that women are hormonal, it just all feeds in together, doesn’t it?
SK: Because women, we say we’re hormonal, you know.
JM: Yeah, yeah.
SK: We’re meaning maybe cyclic, maybe meaning we’re upset, we’re maybe meaning, yeah, I think this has to do with my menstruation. Or I think this to do it just before menstruation. But we use the word hormonal. But those hormones, they’re just doing like, I feel really sorry for estrogen and progestins because they’re just doing their job and they’re doing it really well.
JM: Yeah.
SK: And whether or not you have, like, bad cyclic symptoms or not, the levels are the same, in healthy controls and people who are ill. They’re doing their job really well. They’re protecting you from dangerous pregnancies.
JM: Thank goodness for them. Yeah. Yeah.
SK: You know they’re helping you ovulate. They’re doing all sorts of great stuff.
JM: Yeah.
SK: And we’ve I think from a lack of knowledge and then a lack of language, those two things combined we’re reproducing these gender myths because we haven’t any other choice. And and we’re using this term hormonal when really, you know, it’s untrue.
JM: Yeah. And I keep thinking about and I was when I was reading your book, the conversations that I have with my daughter, and I’ve said to her, like she’ll say she’ll say, ‘Oh, I’m feeling a bit sad.” And I’ve said, “Oh, well, is it that time in the month or are you feeling a bit hormonal?” And I’m equating hormonal and sadness before a period. And and that’s how we perpetuate it, isn’t it?
SK: There is a top tip for this.
JM: I’m going to ask you about top tips actually. Yeah.
SK: Because if you just relegate something to being, oh, it’s my time of the month, that’s why I’m so lonely and so feeling lonely or feeling sort of low self esteem. Not feeling good in yourself. Then you’re not going to sort that problem out. And so it’s much better for anyone. It’s people do this in mindfulness, work out what is the emotion you’re actually feeling.
Are you feeling sad? Are you feeling lonely? Are you feeling down on yourself? Are you feeling irritable? Are you feeling angry? Are you feeling like anxiety? Work out what you’re feeling. What is it? What particularly triggers you? Like nine out of ten cases it’s a family relationship. It’s either your partner or your children or your boss, work relationships is another key thing.
JM: Yeah.
SK: They’re the ones that. And is it actually that you’re working too many hours that you just cannot sustain this job? You need somebody else to help you in your job? I don’t mean you. I mean management needs to support you in your role, is it that your partner doesn’t do their fair share of parenting work around the house?
You name it, is it that the kids just don’t get out of bed and don’t get to school on time. And at certain times in the month, your tolerance level just it just drops because this physical thing is happening in your body. If you had the start of a cold, for example, the same thing would happen. Things that you would normally let slide or wouldn’t bother you as much do bother you because you’re irritable, because you’re ill.
JM: Or if you were hungry, or if you were tired. Yeah.
SK: It’s very similar to lack of sleep and feeling hungry that you’re it’s more that your tolerance level has dipped. What it isn’t is the cause of that upset. So if you’re saying to your daughter…
JM: That’s the thing to remember, isn’t it?
SK: You’re feeling sad, can you like when did you first notice that you’re feeling sad? Oh, I woke up with it. Okay. Is there anything happening at school today? Did something happen yesterday or before?
JM: But in that moment where I go, oh, it’s probably just I say to her, it’s, oh, It’s probably just because you’re just before your period. I’m like…
SK: And you’re not being a bad parent.
JM: No, no, no, I’m not going to. I suppose I’m being very thankful for your book in the sense that it’s a revelation and that there are just better ways of talking about it I think.
SK: We all again, we’re not taught enough about periods and the experience of them, so remember that you start when you’re a child. Some of us, you know, age nine, others sort of aged 12, is the sort of average.
JM: Yeah. Yeah.
SK: So you’re 12, nobody’s telling you really all about it. And you pick up on the fact that it’s gross, it’s a negative, that you shouldn’t talk about it. You shouldn’t discuss it. You pick up that it’s supposed to be painful, really painful. It’s as bad as a heart attack. There’s loads of sort of misinformation in social media moment and you normalize it.
We all do this. So all humans normalize their experiences. You know, this helps us adapt to very traumatic experiences, but it can be unhelpful if you’ve normalized symptoms of a clearly an underlying health disorder, for example? But what you’re doing there with your language to your daughter is you’re saying, don’t worry, this will pass. This experience will pass, because that is the thing with cyclic symptoms, which is a good and a bad thing.
JM: True.
SK: That they pass. And then you kind of hurray like, I’m fine and you almost block out the fact that well it’s going to happen again.
JM: Yeah, yeah.
SK: And this is a real problem with help seeking. So people even with very severe menstrual pain, which is most likely adenomyosis for example, if it’s in the womb, right. Just get over that awful week and then they don’t want to think about it. Your body’s almost sort of…
JM: Until it comes round again.
SK: And so it takes some years often to go and see a doctor. And then if they’re slightly dismissed or totally dismissed by that doctor, they might not go again for several more years. It’s very easy for us to pick up cues from around us, particularly doctors, but just sort of general discussions and social media normalize what happens to us, because there is no open discussion of this topic.
And what you do hear is often sensationalized. So you hear the really worst stories or you hear the like four out of five women are debilitated by period pain. This isn’t actually helpful. You’re exaggerating. This is the femininity is debility myth. You’re exaggerating how many people are ill due to the period. So yeah, but that’s what you’re doing. We’re almost too kind.
JM: Yeah.
SK: To to think critically about what we’re doing. Assuming because we’re not sexist and we’re not racist. You know, you don’t think that you are.
JM: Yeah.
SK: But there’s just you can’t fix capitalism. You can’t fix the fact that we have to work really too many hours. It can feel uncontrollable. And so, so, you know, you’re sort of forced into a position of normalizing things that really you need to sort out. But there is a that is a good tip with particularly around mood. But also pain is like maybe we should start tracking your symptoms.
And if it gets worse, for example, it could be iron deficiency or it could be a problem. You can try some anti-inflammatory things. So like Ibuprofen, naproxen not paracetamol not aspirin. So if you start taking at least 400mg of ibuprofen 2 to 4 days before you really think you’re going to bleed. So for me, I get really sore boobs.
I know exactly, you know, when my period is going to be due 2 to 3 days building up to that. Start taking Ibuprofen. Not only will you not really get those severe period cramps, but you will reduce your blood loss by up to a third, which I have relatively heavy periods. This can make a big difference. I’m also a bit anemic so it stops that from becoming worse and worse.
Again, this isn’t magic. This is makes total sense once you understand what’s happening in the body. The same way that if you have inflammation in on an injury on an arm that you’d put anti-inflammatory, you might take anti-inflammatory medication, you might put a gel on, it’s all the same stuff.
JM: If it was an injury on an arm, you wouldn’t just go, oh, I feel a bit sad as well. And it’s the time of the month. So I’ll just leave it.
SK: Or, you know, I might hit my arm next month and it will be the same. Well, that’s the thing is, it’s not cyclical unless you have a maybe a job where you incur physical injuries and you know that it’s the job. Usually you just treat the, the symptoms. But with the period we’re, I think it’s interesting that the taboo placed on revealing whether we’re menstruating or not, which applies to whether we’re allowed to talk about it or not, actually has this effect on our cognition and what we feel able to think about or not. I really think that this taboo has.
So, you know, I deal with researchers, why are you not telling people this is inflammatory and why are doctors not being taught this? And again, this isn’t some dark man stroking a cat in a room saying, I hate women and we’re not going to teach this. It’s weirder than that. And more interesting than that is that all of us, including those negatively affected by these myths, our cognition, has been affected by a lack of knowledge, but also these taboos, the idea that you shouldn’t discuss, think or look into these things.
JM: Yeah. I mean, it’s just such a fascinating example of how human beings kind of make meaning generally, isn’t it? And how society works. And it’s one amazing example of all of those mechanisms. We’ve talked about things to do a little bit, but you do finish the book with calls to action, and you highlight three areas where there are implications for your work.
There’s personal and society, which we’ve talked about just there ish. I mean, there is obviously a lot, lot more in the book, but also science and funding and clinical practice. So to finish off, what suggestions would you make for improving clinical practice and teaching?
SK: So my you know, I’ve been working in this now for 12 years. My takeaway is, is that menstrual physiology physiology textbooks for medical students take a long time to change each new edition, probably about ten years in the making. And also there’s whether they admit to it or not, resistance to actually integrating female reproductive, healthy female or male reproductive physiology into medical curriculums.
So my kind of wanting things to change quicker than that is to focus on the public. We really have to start teaching kids about what’s happening in their bodies, what’s normal or not. This is very simple stuff, it is already established. We don’t need more research. We do know how to manage cyclic changes. We do know how to differentiate them from underlying health conditions.
We could always give a provisional early diagnosis of things like endometriosis instead of making people wait ten years, which is the current average diagnostic delay.
JM: For endometriosis? Wow.
SK: Yeah, this is entirely preventable right now, we do have this knowledge. So, you know, talk to anybody in fertility. They know all about this physiology, they know how inflammatory it is they just don’t think about periods because to them that’s bad news. So yeah, my my plan is to start with the public. We want children, adults, teachers to know more about, reproductive health.
I would argue male and female reproductive health, GP’s and other health care professionals will then sort of be forced almost. They’ll need to catch up and they will demand changes to the medical curriculum.
JM: Or will know the questions to ask a bit better won’t they.
SK: Yeah, yeah, I try not to be cynical, but I’ve just found but we know, for instance, that medical paradigms take at least ten years, probably longer to change practice. So even if your research finds something, unless of course you managed to find pharmaceutical drug, then it gets rolled out immediately, or even maybe before it’s been properly tested. But in general, if you’ve discovered something more physiological or sort of about diagnoses, it can take many years to change medical practice.
And I’m not really prepared to just wait for people to catch up with this. We’ve had this knowledge for centuries and we just need to get it out there.
JM: So part of the way you’re doing this is through the Menstrual Matters website, which you are the founder of, and this is the world’s first evidence based information hub on this topic. It’s menstrual-matters.com. So please can you tell us before we go about the website.
SK: So the websites got lots of actually evidence based information about how to check, track, manage and then learn about your menstrual health. There’s also loads of blogs about where these sort of menstrual gender racial myths come from. And then as for sort of what I’m working on now. I have to apply for funding all the time because menstrual health doesn’t exist as a thing yet.
And I undertake research and train people in menstrual physiology and how it can apply to, for instance, diagnosing health issues quickly. And then the idea is really if I can get any funding, I’d like to write a much more popular myth busting book, you know, for children from about age 12 upwards. So people who menstruate, covering all aspects of reproductive health and these associated societal myths to just sort of avoid them being reproduced in the future.
JM: I would love for you to write that book. I really hope you write that book. But I mean, this book is amazing and it is scientific, but it is accessible as well. Thank you so much, Sally, for, speaking to me. I could chat for a long, long, long time about this.
SK: Thanks Jess.
JM: That’s okay. So ‘Menstrual Myth Busting: The Case of the Hormonal Female’ by Sally King, is published by Policy Press and is available on our website, which is policy.bristoluniversitypress.co.uk. Don’t forget, you can get 25% of all our books by signing up to the mailing list. You can find out more as well on Sally’s Menstrual Matters website, which is menstrual-matters.com.
We’ll put the links to these in the show notes, to the podcast as well. And thank you for listening. If you’ve enjoyed this episode, please follow us wherever you get your podcasts. Thank you. Sally, it’s been absolute pleasure.
SK: Thank you.
JM: Thanks.