Sex Roles (2006) 54:377391 DOI 10.

1007/s11199-006-9009-z

ORIGINAL ARTICLE

From Its All in Your Head to Taking Back the Month: Premenstrual Syndrome (PMS) Research and the Contributions of the Society for Menstrual Cycle Research
Diana Taylor

Published online: 24 October 2006 C Springer Science+Business Media, Inc. 2006

Abstract Our understanding of Premenstrual Syndrome (PMS) as a cultural entity and a medical concern has developed from different disciplines and represents a range of intellectual approaches to a complex, ill-understood phenomenon. Unfortunately, there has been little interaction among the disciplines at an integrative level of research, outside of the Society for Menstrual Cycle Research (SMCR) conferences and publications. This paper chronicles the history of PMS research, which began in mid-19th century America, and focuses on the contributions from the SMCR conferences that brought together scholars, clinicians, scientists, and womens health advocates from across disciplines and nations to advance a multidisciplinary research agenda and the knowledge of perimenstrual experiences and syndromes. Keywords Premenstrual syndrome (PMS) . Premenstrual dysphoric disorder (PMDD) . Society for menstrual cycle research . Integrative research review . Historical review

ment to advance a comprehensive approach to the study of menstrual cyclicity and its impact on womens health (http://menstruationresearch.org/). SMCR conferences and publications focus on data-based scholarship that is feminist and multidisciplinary; the conferences have provided the theoretical and methodological roadmap for some of the most signicant and scientically sound research on the menstrual cycle in general and perimenstrual symptoms, syndromes and experiences in particular. The Development of the PMS Label and Related Research According to MEDLINE, there have been approximately 2550 references to PMS since 1930, among them perimenstrual1 symptoms and experiences, premenstrual magnication, and Premenstrual Dysphoric Disorder (PMDD). PsychINFO reports a total of 648 PMS references since 1965. Among these references are the 374 papers related to PMS that were presented at 14 SMCR conferences between 1977 and 2003. These represent the only cross-disciplinary critique of labels and explanatory models of womens menstrual cycle experiences. Table 1 provides a chronological summary of the evolution of perimenstrual experiences into a medical syndrome. Table 2 presents terminology and classications applied to perimenstrual experiences. From 1930 to 1970, research of womens perimenstrual experience was little more than misogynistic labeling. Prior
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This paper chronicles the development of PMS research from its beginning in mid-19th century America, with a particular focus on the contributions from the Society for Menstrual Cycle Research (SMCR). The SMCR is a multidisciplinary organization that has been at the vanguard of the moveA portion of this paper was presented at the 15th Conference of the Society for Menstrual Cycle Research held in June 2004 in Pittsburgh, PA. D. Taylor ( ) School of Nursing, University of California, 640 Davis St., 13 Gateway Plaza, San Francisco, California 94111 e-mail: dianataylor50@yahoo.com

Perimenstrual refers to the premenstrual phase (714 days before menses onset) and early menstrual phase (12 menstrual days). Depending on the particular research study, the premenstrual phase can be considered the whole luteal phase (1416 days) after ovulation as determined by ovarian steroids or dened as early and late luteal phase (7 days each; Mitchell, Woods, Lentz, & Taylor, 1991). Springer

378 Table 1 Terminology and classications applied to perimenstrual experiences

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Premenstrual syndrome (PMS) Both a popular term and a medical diagnostic term described in the International Classication of Diseases (ICD; World Health Organization, 1992) Cyclic recurrence of distressing physical, mood, and behavioral symptoms Severity, number, duration and pattern of symptoms vary, with less severe symptoms postmenstrually and increasing intensity during the premenstrual phase (Mitchell et al., 1991) Thirty percent to fty percent of menstruating women experience moderately severe PMS; 414% experience severe PMS (Angst, Sellaro, Merikangas, & Endicott, 2001) (Woods, Most, & Dery, 1982) Cyclic Perimenstrual Pain and Discomfort (CPPD) An evidence-based diagnosis that claries the less specic diagnoses of dysmenorrhea, pelvic pain, and PMS (Association of Womens Health Obstetrical & Neonatal Nursing, 2003) Differentiates normal cyclic changes from severe, debilitating symptoms as assessed by severity, frequency, and pattern of symptom distress Denes perimenstrual symptom clusterspain, physical discomforts, and mood discomforts (Woods, Mitchell, & Lentz, 1999) Affect up to 70% of menstruating women (Woods et al., 1982) Premenstrual dysphoric disorder (PMDD) Dened in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DMS-IV) of the American Psychiatric Association 1994) A severe form of PMS with an emphasis on mood symptoms during premenstrual phase only Diagnostic criteria: at least ve symptoms with at least one mood symptom Affects no more than 8% of menstruating women (Ross & Steiner, 2003) Premenstrual magnication (PMM) Somatic or mood symptoms continue in severity after onset of menses (Harrison, 1985; Mitchell, Woods, & Lentz, 1994) Usually reects an underlying condition that worsens premenstrually

to the rst reference to Premenstrual Tension by physician Robert Frank in 1931, Dr. William DeWees of the University of Pennsylvania coined the expression melancholies of menstruation in 1843, promoting the idea that the uterus exerts a power over every other body system (DeWees, 1843). In the early 1900s with the advancements in understanding of ovarian hormone physiology, biomedical perspectives attributed premenstrual symptoms to abnormalities of menTable 2 Label Melancholies of menstruation Premenstrual tension Witch/bitch syndrome Premenstrual syndrome Menstrual distress Premenstrual changes Menstrual joy Perimenstrual experiences Molimina Pre- and perimenstrual symptoms Premenstrual magnication Premenstrual elation syndrome Menstrually related disorders Late luteal phase dysphoric disorder Premenstrual dysphoric disorder Cyclic perimenstrual pain and discomfort Evolution of a syndrome Discipline Medicine

strual cycle hormones. The rst reference to a premenstrual disorder was in Dr. Robert Franks publication (Frank, 1931) where he used the label Premenstrual Tension (PMT) to describe the experiences of 15 women, who reported unrest, irritability (like jumping out of their skin), and a desire to nd relief by foolish and ill-considered actions (p. 1032). Franks observations also demonstrate the temporal nature of these womens experiences: It is well known that normal

Date 1843 19311985 1948 1953present 1968 1973present 1976, 1994 1977present 1979, 1987 1979present 1982present 1983 1984present 1986 1994present 2003

Psychology Feminists; psychiatry, social-behavioral scholars Feminists; social-behavioral scholars Feminists in psychology, nursing, social-behavioral sciences Reproductive endocrinology Feminists in nursing, psychology Feminists in medicine, nursing Feminists; social-behavioral scholars Medicine, psychiatry Psychiatry Psychiatry, medicine Womens health nurses

Note. Indicates rst time phenomenon noted in published literature. Multiple dates indicate when the phenomenon was reported by another discipline or cited in the published literature. Springer

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women suffer varying degrees of discomfort preceding the onset of menstruation . . . and that some women suffer indescribable tension, which is relieved within an hour or two of the onset of menstrual ow (Frank, 1931). The PMT label continued to be described in very negative ways among physicians as illustrated by a 1948 article written by a Johns Hopkins University physician, Erle Henrikson. He described PMT as the Bitch Syndrome, although the publisher later changed the term to the Witch Syndrome. After carefully observing many nurses and other perfectionistic women, Henrikson declared in his article that women who were both high achievers and not satised with their work or roles had more severe symptoms (L. Speroff, personal communication, 1988). In the 1950s, PMT was relabeled as Premenstrual Syndrome (PMS) when a British General Practitioner, Katharina Dalton, MD published accounts of perils of premenstrual women in society or the workplace and claimed that about half of all women become ill with PMS (Dalton, 1964; Dalton & Green, 1953). In the 1800s, when the uterus was viewed as the root of all womens ailments; both dangerous and ridiculous remedies predominated as therapy. The early 1900s were dominated primarily by psychoanalytic therapies. But by the 1930s, psychotherapy was seen as inadequate for the relief of PMT and a truly organic (toxic) foundation was sought to relieve the anxious patient who has been deeply afraid that the whole matter will be laid to her being neurotic and all in her head (Ehrenreich & English, 1979). At this time a strong interest also arose in the potentially detrimental effects of PMS on womens capacity to be effective workers. Robert Frank was among the rst in 1931 to recommend specic medical treatments for PMT, such as employing diuretics and saline cathartics to enhance the premenstrual excretion of sex hormones, and in severe cases, using roentgen therapy to diminish estrogen production. Franks therapies specically used venisection (80100 cc blood), laxatives and enemas to decrease sex hormones, ovarian radiation to induce temporary or permanent amenorrhea, calcium lactate to act as a sedative, and diuretics to relieve bloatingall with serious side effects. In the rst studies of these PMS treatments (Greenhill & Freed, 1940; Israel, 1938), magnesium sulfate, calcium lactate-sedatives, enemas, radiation to ovaries and the pituitary gland, progesterone, ammonium chloride, amphetamines and low-salt diets were all rated as good relief of PMT. Lydia Pinkhams elixir (containing mostly alcohol) was also rated as good, while counseling only received a fair rating. Of course, only physicians were queried; none of the women who were subjected to these treatments were asked about effectiveness (or side effects). In the 1940s studies of testosterone, vitamins, antihistamines, and minerals as treatments for PMT/PMS became popular but most were not studied for their safety or effec-

tiveness using placebo-controlled research designs (Biskind, Biskind, & Biskind, 1944; Day, 1947). The rst placebo-controlled clinical trial (Morton, Addison, Addison, Hunt, & Sullivan, 1953) was conducted in the 1950s studying the effects of diuretics, antispasmodics, caffeine, and Vitamin B on PMT severity, work output, and clinic visits. The same year Dr. Katharina Dalton opened the rst PMS clinic in London, and treated women with progesterone hormone injections and suppositories for a progesterone-deciency disease. The 1960s marked the rise of the medicalization of the menstrual cycle conditions and PMS treatments included hysterectomies with oophorectomy, the use of high-dose hormones and menstrual suppression or elimination. Most papers at the time were authored by physicians and a handful of psychologists in U.K. and Scandinavia (Backstrom, 1982; Backstrom et al., 1983; Bancroft & Backstrom, 1985; Clare, 1979; OBrien, 1987; OBrien, Craven, Selby, & Symonds, 1979; Sampson, 1979; Sanders, Warner, Backstrom, & Bancroft, 1983). The emergence of empirical denitions of perimenstrual experiences begin to be seen in the 1950s and 1960s, along with the replacement of misogyny by medical diagnoses. In the mid-1960s, psychologists such as Rudolph Moos of Stanford University initiated studies of menstruation. Moos published the Moos Menstrual Distress Questionnaire developed from a sample of graduate student wives. Although Moos applied rigorous psychometric methods to this rst questionnaire of symptoms associated with menstrual cyclicity, the very title of the instrument predicted the symptoms that they expected to isolate. And indeed in the 47 items, all but ve test negative (Moos, 1969). With the advent of the 1970s, critique and counterpoint arguments to the negative classication of perimenstrual experiences were beginning to be published. Psychologist Mary Brown Parlee criticized Daltons research methods and questioned her goal of helping women to function more smoothly in their traditional stereotypical roles as subordinate to men. As a result, Parlee recommended the use of the word change over symptom, as in premenstrual changes and suggested a complementary diagnosis, PMES or Premenstrual Elation Syndrome, to the more negative PMS classication (Parlee, 1973). Papers presented at the rst two SMCR conferences in 1977 and 1978 offered a critical review of the PMT and PMS labels, with scholars recommending that SMCR take a leadership role in deconstruction of these labels (Dan, Graham, & Beecher, 1980; Voda, 1980). In 1976, feminist scholars Janice Delaney, Mary Ann Lupton, and Emily Toth wrote The Curse: A Cultural History of Menstruation and proposed the use of the Menstrual Joy Questionnaire, which was further developed by and tested by psychologist Joan Chrisler (Chrisler, Johnson, Champagne, & Preston, 1994). Emily Culpepper, a radical theologian and Boston Womens Health
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Book Collective (BWHBC) member, suggested looking on the bright side: some women experience premenstrual energy surges as earlier suggested by Parlee (Culpepper, 1992). In 1979, feminist nurse-epidemiologist Nancy Woods rst used the term premenstrual symptoms or experiences on the basis of prospective questionnaires of community-based women while reproductive endocrinologists Guy Abraham and Jerilyn Prior used the term molimina to describe premenstrual changes of clinical samples (Abraham, 1980; Prior & Vigna, 1987; Woods, Dery, & Most, 1982; Woods & Hulka, 1979). On the basis of her clinical observations, feminist psychiatrist Michelle Harrison recommended the term Premenstrual Magnication (PMM) to refer to symptoms that worsen in the premenstrual phase but never disappear, suggesting an underlying process or disorder that varies with the menstrual cycle (Harrison, 1985). In the mid-1980s, professional medical organizations in the United States and United Kingdom met to dene PMS and the published proceedings established the medical perspective for the clinical existence of PMS as a disease classication (Dawood, McGuire, & Demers, 1985) that is now listed in the International Classication of Diseases Manual (World Health Organization, 1992). From the mid-1980s to the present, we have seen a steady push toward the medicalization of premenstrual experiences. Beginning in 1984, psychiatry provided the leadership in biomedical research of PMS. David Rubinow and his colleagues in the Biological Psychiatry Branch of the National Institute of Mental Health conducted and published multiple reports on assessment, diagnosis, and conceptual models of the neuroendocrinology of Menstrually Related Disorders (MRDs) including PMS culminating in approximately 4550 papers between 1984 and 2002. The year 1985 marked the rst reference of a premenstrual mood disorder label in MEDLINE and in the following year, the Board of Trustees of the American Psychological Association (APA) voted to include a PMS label as a diagnosis in the research appendix of the Diagnostic and Statistical Manual, third edition (APA, 1986). Although the label, Late Luteal Phase Dysphoric Disorder (LLPDD), was included in the 1987 DSM-IIIR (research appendix) in the category requiring further study, 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 scientic evidence. No warnings to clinicians were included and the LLPDD category was listed in the main text under mood disorders despite claims (from APA members) that it was not a mood disorder. In 1994, the LLPDD subcommittee of the APA conducted an extensive literature review concluding that there was very little research supporting the existence of premenstrual mental illness. In spite of the recommendation of its own subcommittee, the APA changed the LLPPD label to Premenstrual Dysphoric Disorder (PMDD);
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adding it to the DSM-IV research appendix and in main text under Depressive Disorders. It has been argued that the controversy over the labeling and treatment of PMS and its symptoms was not restricted to conict between feminists and the APA, nor was it a natural result of scientic progress. Rather, PMT/PMS/PMDD gives a diagnostic (dysfunctional) label to premenstrual experiences and ignores the underlying social causes, allowing the status quo to be maintained: 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 (Laws, Hey, & Eagen, 1985). According to Paula Caplans landmark book, They Say Youre Crazy: How the Worlds Most Powerful Psychiatrists Decide Who is Normal (Caplan, 1995), the problem with PMDD is not the women who complain of premenstrual emotional problems, but the diagnosis of PMDD itself. Empirical evidence shows these women as signicantly more likely than other women to be in difcult life situations such as being battered or mistreated at work. She also argues that labeling these women as mentally disordered sends a message that the problems are individual and psychological ones, ultimately hiding the real, external sources of trouble. Others now support Caplans claims and recently, a European pharmaceutical regulatory agency required a pharmaceutical company to remove PMDD as a diagnosis for which the companys antidepressant drug was purported to treat, citing the lack of evidence for PMDD as a well-established disease entity (Moynihan, 2004).

Models Guiding PMS Research Until the early 1980s, the anatomy and physiology of the individual woman, and particularly the idea of a faulty system, predominated as the primary etiologic theory of PMS. The faulty systems were either hormonal or psychosomatic. There was little emphasis on exploring contextual factors that might inuence both the health and illness of women. Research methodologies and therapeutic trials beyond clinical observation or simple research designs lagged far behind other empirical methods until the mid-1980s. Although a strong body of knowledge supports a biologic etiology for cyclic menstrual pain or dysmenorrhea, the etiologic mechanisms for cyclic perimenstrual physical and mood discomforts present in the classication of PMS and PMDD are not as clear. While a number of biologic and neuroendocrine etiologies have been proposed, most have been simple, linear, unsubstantiated pathophysiologic models, such as hormonal imbalances, sodium retention, nutritional deciencies, or abnormal hypothalamicpituitaryadrenal

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axis function (Backstrom et al., 1983; Keye, 1989; OBrien, 1987; Reid & Yen, 1981). Through the 1970s and 1980s as reproductive endocrinology established sound research methods and hypothesis-based experiments, investigations into the biological basis of reproductive events focused on complex interactions such as the link between endogenous opioids and ovarian hormones (Reid & Yen, 1981). Other intervening mediators of ovarian hormones were postulated to be the cause of PMS included: prostaglandins, mineralocorticoids, catecholamines, circadian rhythms, and now serotonergic systems. In contrast to hormonal dysfunction, the Psychosomatic Model suggests that a womans temperament or psychology causes cyclical changes in mood and well-being through a psychosomatic mechanism. Early theories suggested that premenstrual changes and PMS were brought on by the denial of the female role or personality characteristics (Coppen & Kessel, 1963; Paige, 1973) or were caused by the unconscious denial of a womans desire for a child (Horney, 1967). The distinguishing factor among these explanations is not hormonal but psychological. Like the biomedical model, the precise mechanism whereby these psychological processes might produce symptoms in advance of menstruation is unclear. Essentially, both Hormonal and Psychosomatic Models imply the same dichotomous frameworkPMS exists or notand is due to biological, hormonal, or psychological dysfunction as the basic etiology. While investigators in both camps suggested cross-disciplinary theories about perimenstrual symptoms and PMS, few studies have substantially supported these models and problems of operationalization and classication of PMS make interpretation of hypothesis testing studies difcult. Furthermore, major voices and programs of research had been ignored such as feminist critique, anthropology, historical research, and social-political advocacy. Prior to 1980, research about perimenstrual symptoms and PMS was weak with an overabundance of descriptive, crosssectional or retrospective designs that included measurement and sampling errors. Methodologic biases and awed study designs constrained menstrual cycle research in general but particularly investigation of PMS (Koeske, 1985). Although the rst clinical study of PMS mechanisms was published in 1950 (Morton et al., 1953) followed by an early epidemiologic study in 1953 (Morton et al., 1953), few well-designed clinical trials or epidemiologic studies were conducted until the late 1970s. Up until this time, the literature included studies that (a) included patient or institutionalized samples, (b) lacked appropriate control or comparison groups, (c) failed to report measurement validity or reliability, and (d) did not test alternative hypotheses. Conclusion validity was merely tautology whereby global explanations, based on preconceived notions, were tested using weak methodologies.

Medical researchers in the United Kingdom conducted the rst double-blind, placebo-controlled progesterone trial (Sampson, 1979) which promoted the use of progesterone for treatment of PMS. In 1981, the rst American PMS clinic was established by Ronald Norris and soon after, the National Center for Premenstrual Syndrome and Menstrual Distress, was opened in New York and Boston by businessman, James Hovey, and physician, Niels Lauerson. Although this heightened interest in womens health conditions helped increase menstrual cycle-related research funding, it was not without problems. Research became focused on singular, pharmaceutical treatments tested on clinical or non-normal samples. Women seeking professional treatments were often recruited into these drug treatment studies as well as women in prisons and psychiatric institutions. Beginning in the 1980s, increased funding for multiple well-crafted laboratory studies from the Behavioral Endocrinology Branch of the National Institutes of Mental Health tested the putative roles of pituitary, ovarian, and adrenal steroids in the etiology of PMS. Notably, the results have not supported a primary endocrine abnormality as the etiology of PMS (Bloch, Schmidt, Su, Tobin, & Rubinow, 1998; 1998a; Schmidt, Nieman, Danaceau, Adams, & Rubinow, 1998). Most recently, investigators have hypothesized the neuroregulatory effects of ovarian hormones on the central serotonin systems in humans are causative as inferred from mostly animal studies. This menstrual cycle hormone serotonin hypothesis is unconrmed and based primarily on indirect tests using selective serotonin reuptake inhibitor (SSRI) antidepressants (Freeman, 1997). Geneologic studies have claried some etiologic questions. In a study of 1312 menstruating twins, the results suggested no close etiologic relationship between PMS and major depression. Whereas premenstrual symptoms and major depression were found to share genetic and environmental risk factors, 86% of the genetic variance and 88% of the environmental variance for premenstrual symptoms were not shared with major depression (Kendler, Karkowski, Corey, & Neale, 1998). And Premenstrual Dysphoric Disorder (PMDD), dened as a severe form of PMS, may have a different pattern of heritability, which was suggested by the recent report about a relationship between a polymorphism in the serotonin transporter gene and the severity of PMDD symptoms (Praschak-Rieder et al., 2002). Expansion of the Biomedical and Psychosomatic Models has now included an explicit acknowledgement of factors external to the woman experiencing and reporting distress, as well as the inuence of culture and society that has formed her negative expectations of menstruation. Psychiatric researchers now hypothesize that premenstrual changes may result from a temporary impairment of homeostasis among a multitude of intrapersonal and environmental systems
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(Halbreich, 1995; Halbreich, 1999). This impairment can be triggered by a differential pace and magnitude of changeover-time in levels of several hormones and other substances during the luteal phase. Alternately, the social environment or other contextual factors is suggested to play a more important role than hormonal excesses or deciencies (Rubinow, Schmidt, & Roca, 1998b). The possibility that any single general theory can fully explain the manifestation of premenstrual symptoms for all women is now considered highly unlikely. Although severe PMS/PMDD has been predominantly regarded as a biologically-based illness, strong evidence now exists that variables such as life stress, response to stress, history of sexual abuse, and cultural socialization are important determinants of perimenstrual symptoms. The prevailing view is that women with PMS are more sensitive to essentially normal hormonal shifts. The effects of these physiologic changes are different for each woman based on multiple psychosocial and cultural factors, creating a variety of distinct perimenstrual experiences. The application of research to inform clinicians and health practitioners has continued to maintain the PMS disease classication. The American College of Obstetricians and Gynecologists (ACOG) have developed clinical management guidelines designed to aid practitioners in making decisions about appropriate PMS diagnosis and treatment (ACOG, 2000). The focus is on diagnosing and treating PMS rather than on assessing a womans symptom experience across the menstrual cycle with the aim to assist her in ruling out medical conditions, developing symptom management strategies, or changing external sources of stress. Currently, some progress is being made within professional and clinical communities based not only on empirical research, but on womens experiences as an important aspect of the base of evidence. A few researchers in the psychiatric discipline have recommended labeling that incorporates criteria on the basis of temporal symptom occurrences and not only objective signs or symptoms (Halbreich, 1997) (Haskett, 1987). As well, a national organization of womens health nurses has proposed a non-pathologic classication system for womens perimenstrual experiences that is included within clinical practice guidelines (Association of Womens Health Obstetrical & Neonatal Nursing 2003) on the basis of a broad range of clinical, empirical and theoretical evidence (Collins-Sharp, Taylor, Kelly-Thomas, Killeen, & Dawood, 2002). In these guidelines, they recommend the term Cyclic Perimenstrual Pain and Discomfort (CPPD) to differentiate normal cyclic changes associated with the menstrual cycle 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 sound empirical studies using quantiSpringer

tative and qualitative methods of womens experiences, not just hypothetical pigeonholing. In terms of treatment, the only non-drug PMS treatment reference found before 1985 was in a non-refereed medical journal recommending that women simply hide in their roomsa nod to the modern day menstrual hut. From 1971 to 2003 there were 78 published research studies of non-pharmaceutical therapies (Medline), the majority being herb and nutritional, including B6, calcium, tryptophan, avonoids and vitex. Since the 1990s, controlled clinical trials of perimenstrual symptom management emerged such as, sleep therapies (sleep deprivation, light therapy and melatonin), cognitive-behavioral therapies (relaxation, diet change, and exercise), alternative systems (acupuncture, massage, and homeopathy) and multimodal strategies. Although it has been argued that non-drug treatments empower women to care for themselves, others contend that self-help books and treatments for PMS continue the problemitizing of the menstrual cycle and perimenstrual experiences. Sociologist Sophie Laws contends that self-help publications with the focus on treatment of PMS are essentially instruction manuals for how to survive in a mans world (Laws et al., 1985). And unfortunately, most of the research conducted on non-drug or self-care strategies for PMS or perimenstrual symptom severity contained many of the same methodological problems as the drug treatment studies.

The Impact of the Society for Menstrual Cycle Research (SMCR) on the Study of PMS Theoretical approaches that arise from different disciplines usually represent a healthy spread of intellectual approaches to a complex, ill-understood phenomenon. However, there has been little interaction among the disciplines at this level of research outside of the SMCR. Granted, institutional, academic and professional traditions make it difcult for a researcher with a particular training to fully appreciate the theories and rationales of researchers in a different discipline. However, taking on this task was exactly what the founders of the SMCR had in mind when the organization began in 1977. The SMCR conferences and publications showcased studies that expanded theoretical and conceptual complexities in the design and analysis of menstrual cycle research well beyond bioreductionism by emphasizing dynamic interaction of menstrual cycle variables. Research presented at the SMCR conferences claried the denition of PMS by focusing on a range of positive and negative experiences and behaviors in both clinical and community-based samples using hypothesis-testing paradigms. Furthermore, SMCR conferences helped to promote the design and conduct of therapeutic research beyond the context-free clinical drug

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trials while maintaining the gold-standard experimental methods. Expanding the range of theoretical models guiding PMS research At the rst SMCR Conference held in Chicago in 1977, multiple disciplines were represented and charged with applying science to womens experiences. Initially conceptualized to recognize the menstrual cycle as a denitive gender-specic process, the conference organizers proposed a broad, inclusive perspective for interdisciplinary discussion and collaboration. The menstrual cycle was seen in the context of other biorhythms of human variability, of a sociocultural network of meanings and of a new understanding of how the endocrine system interacts with other functions. Research about the menstrual cycle was also broadly dened recognizing life cycle, as well as monthly periodicity, implications. The estimated 100 attendees represented a variety of divergent interestsfrom lab scientists, theoreticians, academics, clinicians, feminist scholars, and womens health activists. Despite their differences, however, they shared a common belief that the menstrual cycle provided a model of the kind of interdisciplinary efforts needed to reach a better understanding of complex interactions among the many types of variables involved in womens health and illness phenomena. Participants such as psychologist, Randi Koeske, challenged all disciplines to move beyond their boundaries to develop complex, multivariate models of PMS causality or explanation. She also challenged the feminist claim that research on PMS only adds credence to a patriarchal construct by arguing that the denial of PMS as an entity results in denying opportunities to help women with perimenstrual distress. Mary Brown Parlee, another psychologist, asserted that unquestioned beliefs rather than objective facts dictated the scientic inquiry about PMS (Parlee, 1980; Parlee, 1981). She suggested that dichotomizing the biological and psychological inuences such as hormonal changes and conict over sex-roles deemphasized internal factors such as biological rhythms or external factors like stress, nutrition, social network, and roles, leading to singular causes of behavior. At each of the subsequent 12 biennial conferences, the SMCR programs introduced divergent perspectives for cross-disciplinary discussion that has advanced theoretical underpinnings to guide menstrual cycle research including research on PMS. Proposed new paradigms to guide general research on the menstrual cycle called for (a) the development of testable hypotheses, concepts and complex theoretical models before doing research, (b) the application of psychoneuroendocrinology and menstrual stress models, (c) the reconceptualization of mood to include changing feelings and body states over time, and (d) the use of non-

reductionist approaches to menstrual cycle research that incorporates both the psychosomatic and endocrine regulation (Abplanalp, 1980; Dan, 1980; Koeske, 1980; Koeske, 1981; McClintock, 1981; Sommer, 1980, 1981). Beginning with the 1983 SMCR Conference held in San Francisco (Oleson & Woods, 1986), mid-range theories incorporating both empirical research ndings from across disciplines and the experiences of women were proposed to guide research, establish hypotheses, and contribute to realistic explanatory models of perimenstrual experiences and diagnostic classications such as PMS. Conceptual models and data were presented that suggested that biology is neither irrelevant nor deterministic. Nancy Woods with her team developed and tested the rst multivariate model of perimenstrual symptoms and experiences that included sex role orientation, socialization, social context, stress, wellbeing, health status, health practices, and health seeking (Brown & Woods, 1986; Taylor et al., 1991; Woods, 1985; Woods, 1986). At the 1993 SMCR Conference, Karen Pugliesi proposed a sociological perspective, drawing on the sociology of emotions, as a framework for the qualitative study of women with PMS (Pugliesi, 1993). At the 1995 and 1997 Conferences, socio-political, psycho-spiritual, and historical perspectives were used to critique the medical label for PMS and suggest alternative outcomes of the labeleither a welcomed validation to womens menstrual-related experiences or as a controlling mechanism within a patriarchal system of medicine (Cayleff, 1992; Matheson, 1995a; 1995b). Other investigators looked beyond negative mood and personal variables to consider positive feelings and experiences, and generational differences of mood and physical experiences across social, monthly, and seasonal cycles (Chrisler, 1991; Costos & Gleason, 1995; Dye, 1997; Gallant, 1991; Ripper, 1991). Progress was being made by SMCR participants in our understanding of PMS, as evidenced by biopsychosocial models (Gurevich, 1993; McDonald, 2001; Taylor et al., 1991) that claried the limitations of the biomedical model and provide a basis for hypothesis testing. Others challenged us to move beyond the PMS label to focus on the conceptualization of the meaning of menstruation and PMS in womens lives (Caplan, 2004; Cosgrove & Riddle, 2001; Lee, 2001; Walker, 1995). Clearly, the SMCR conferences have reduced the epistemological chaos that has constrained empirical research of perimenstrual experiences and reframed the PMS construct to include historical, social, cultural, and political processes without repudiation of biological and psychological inuences. Going beyond a biopsychosocial model of perimenstrual experiences will advance a comprehensive and accurate understanding of womens healthachieved through a process model that weaves biological uniqueness (particularly ovulation) with womens subordinate societal standing (Prior, 1997).
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Advancing research methods At the 1977 and 1978 SMCR Conferences, methodological assumptions that restrict research on the menstrual cycle and PMS were explored (Dan et al., 1980; Komnenich, McSweeney, Noack, & Elder, 1981). Although critical of the reductionistic biomedical methods that decontextualize womens menstrual cycle experiences, they also pointed to gaps in psychological research (Parlee, 1981). Investigators were challenged to explore perceptions, experiences, and beliefs of real women (e.g., healthy, working, communitybased samples) about their own bodies as data and not confounders (Koeske, 1981) Sommer (Ehrenreich & English, 1979) pointed to the need for prospective designs to go beyond the post hoc correlation of a plethora of menstrual cycle variables and called for carefully designed in-depth studies of groups selected through purposive sampling and the use of ethically acceptable methods for collection of qualitative data. Sociologists presenting at these early conferences challenged both biomedical and psychology research traditions. Clearly, the adoption of traditional models and methods was not sufcient to fully understand the PMS phenomenon, which had become a social problem as well as a medical concern (Rittenhouse, 1993). Although most SMCR members considered themselves feminists, they criticized the radical feminist approach to the study of PMS because it omitted important questions about the meaning that the term PMS had for the women who use it (Koeske, 1981; Rome, 1986). Lorraine Rothman from the Los Angeles Feminist Womens Health Center encouraged the group to consider participatory action research methods at the 1978 SMCR Conference (Rothman, 1980). Redesigning epidemiologic research to estimate the prevalence of PMS grew out of the SMCR conferences and was rst reported by Nancy Woods and Hulla (1979), who reversed the traditional epidemiologic model by asking women about their daily experiences across multiple menstrual cycles. Factor and cluster analysis methods allowed classication of these data on the basis of womens lives across all menstrual cycle phases rather than only the premenstrual or menstrual phase (Woods et al., 1982; Woods, Mitchell, Lentz, Taylor, & Lee, 1987). Subsequently, PMS-specic prevalence studies have been conducted that have advanced our understanding of the natural history of PMS (Gise, Paddison, Abraham, & Harkins, 1991), the complex interrelationship of stress and PMS severity (Ramacharan, Love, & Fick, 1989), the prevalence of PMS across age stratication (Nichols & Costos, 1993); and the prevalence of sexual abuse history and PMS severity (Golding, Taylor, Menard, & King, 2000; Taylor, Golding, Menard, & King, 2001). At later SMCR conferences, reports of hypothesis-testing studies were precisely specied related to menstrual cycle
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phase, mood or behavior and circadian synchrony; stress response and stress hormones; brain opioid activity; cognitive and immune function; and ovulatory and reproductive function. In these studies, popular assumptions were tested of direct linear relationships between biological variables, the menstrual cycle and mood or behavior (Cahill, 1998; Golub, 1980; Hitchcock, Barr, Bishop, & Prior, 1997; Prior, 1997; Williams, 2001; Woods, Mitchell, & Lentz, 1993). The understanding of menstrual cycle rhythms (hormonal and behavioral) have been advanced by the application of biobehavioral measures, chronobiology, and time-series analysis. Explanatory models of perimenstrual symptom experience have been developed and tested using structural equation modeling applied to empirical data from a community-based, cross-ethnic sample. Technology, such as the use of on-the-spot data collection methods, has improved our understanding of the relationships between multiple biopsychosocial variables and the menstrual cycle in everyday life (Hedricks, Church, LeFevre, & McClintock, 1993; LeFevre, Hedricks, Church, & McClintock, 1992; Lentz, 1991; Reame, Marshall, & Kelch, 1992; Smolensky, 1980; Taylor, 1990; Taylor et al., 1991). The measurement of perimenstrual experiences has become increasingly sophisticated as well as reecting its complex, nonlinear nature. Karen Schilling rst raised the issue of differences in retrospective, prospective and cycle phase-specic data collection methods in 1978 (Schilling, 1981). Joan Chrisler and associates have expanded the focus of perimenstrual negative experiences to include healthenhancing and functional experiences (Chrisler & Flannery, 1991; Chrisler et al., 1994; Gorman, Chrisler, & JohnstonRobledo, 1999). Ellen Mitchell and colleagues have made important contributions to advancing the denition of PMS through their data-based models of perimenstrual experience classication (perception, evaluation, response patterns; (Mitchell et al., 1991; Mitchell, Woods, & Lentz, 1987; Mitchell, Woods, & Lentz, 1993; Mitchell, Woods, Lentz, Taylor, & Lee, 1992). Other investigators have incorporated comparison or control groups, by gender, ethnic, dyadic, income status, intergenerational, cycle aware, symptom pattern, social week, symptom or age groups (Dan, 1980; Gallant, 1991; McFarlane, Aubertin, Williams, & Moore, 1995; Ripper, 1991; Slade & Sabin, 1997; Travis & Cronin, 2001). Research methods that go beyond the traditional quantitative approaches are now better able to capture the womens 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, 1999; Beyene, Taylor, & Lee, 2001; Dan & Al-Gasseer, 1991; Datta, Tajena, & Saxena, 1993; Marvan, Diaz-Erosa,

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& Montesinos, 1998; Monagle, Dan, & Krogh, 1991a; Monagle et al., 1991b; Williams, Brussoni, Aubertin, & Clark, 1995; Williams, Moore, Dalian, & Nicholson, 1995). Social and physical environmental effects on the menstrual cycle and PMS experience have been explored and rst presented at SMCR conferences (Hunter, Hood, & Manseld, 1993; Roberts & Garling, 1980; Ryser, 1991). For example, studies have been reported on environmental inuences on menstrual cycle variability, marital or mother daughter relationships and perimenstrual experiences, and the re-denition of questions related to work and menstrual cycle dysfunction (Harlow, 1986; Manseld & Hood, 1987; Robinson, 1997; Sanders & Reinisch, 1992; Williams et al., 1995; Williams et al., 1995; Wilson, 1991). Margie Ripper (Ripper, 1991) and Jane Ussher (1996) in Australia have endeavored to do contextualized research within an experimental design by using a qualitative methodology and combining it with measurements. They have demonstrated that feminist researchers can reclaim experimental methods without abusing their power over their research participants. Feminist experimental methods have also been applied by Joan Chrisler (Chrisler & Flannery, 1991; Chrisler et al., 1994) and others (Schwartz, Weiss, & Lennon, 2000) using the vignette experiment method that has been successfully used to study the effects of the stigma resulting from a psychiatric label (Link, Cullen, & Wozniak, 1987) to study the effects of the PMDD label. Beyond pillsadvancing research of menstrual self-care and symptom management An important contribution of the SMCR conferences was to advance research on menstrual self-care and symptom management. The rst report of the effectiveness of biofeedback and autogenic training for menstrual pain was presented by Maria Heczey (Heczey, 1980) at the 1978 SMCR Conference. At the 1983 and 1985 SMCR Conferences, feminist self-help groups (Culpepper, 1992; Rome, 1986), community education strategies (Heinz, 1986), and combined selfhelp and professional support groups (Amato, 1987; Taylor & Bledsoe, 1986) were proposed to validate womens experiences, educate women about their menstrual cycle and PMS, increase self-esteem, and indirectly reduce PMS severity and improve health practices. At the 1987 and 1989 Conferences, pilot studies and nonrandomized clinical trials were reported of behavioral (transpersonal approach, relaxation training, telephone counseling, and exercise) therapies (Maddocks & Reid, 1987; Mardenfeld, 1989; Miota, Yahle, & Bartz, 1991; Pearlstein, Rivera-Tovar, & Frank, 1989; Prior, Vigna, Sciarretta, Alojada, & Schulzer, 1987). Randomized, placebo-controlled clinical trials of natural hormones, antidepressants and light therapy were rst

presented at the 1989 SMCR Conference (Cohen, 1989) and subsequent SMCR conferences (Jensvold, Reed, Jarrett, & Hamilton, 1993; Parry et al., 1997; Rubinow, 1991). Also beginning with the 1993 Conference, well-designed, controlled clinical trials of cognitive-behavioral therapies were reported (Groer, 1993; Hightower, Karisson, James, & Jammer, 1995; Lewis, 1993; Morse, 1993). The rst NIH-funded, randomized clinical trial of a pilottested, multimodal treatment for women experiencing severe PMS was reported at the 1995 and 1999 Conferences that included personal symptom management strategies as well as strategies for controlling social stress (Taylor, 1996, 1999). This clinical trial demonstrated how environmental stress management was as important as personal stress management strategies for coping with PMS. Jane Usshers most recent study (Ussher, 2002) also provides an empirical test of an integrated theoretical model of the role of appraisal and coping strategies in related to womens subjective negotiation of premenstrual changes. It includes a cognitive-behavioral therapy intervention as well as a focus on social relationships and environmental-cultural factors. These two experimental studies have the advantage of taking womens perimenstrual experiences seriously within a nonpathologizing framework and allowing the development of effective self-care strategies and preventive interventions. Both studies also provide preliminary data on effectiveness of non-pharmacologic therapies as compared to SSRIs for women with severe perimenstrual symptoms (Hunter et al., 2002; Taylor, 2000). Research applications Putting the science back into menstrual health and selfcare has been a major contribution of the interdisciplinary SMCR conferences and publications resulting in research dissemination to consumers, starting with Michelle Harrisons rst self-help book about PMS in 1982 and now co-authored with a pharmacist, Marla Ahlgrimm (Harrison & Ahlgrimm, 1998) that included research ndings from the early SMCR conferences. Then in 1990 and 2002, Joan Chrisler critiqued the popular press and self-help books related to PMS (Chrisler & Levy, 1990; Erchull, Chrisler, Gorman, & Johnston-Robledo, 2002); these critical reviews were later quoted in popular magazines. Also in 2002, this author published the rst science-based self-help book for women that described effective, non-drug remedies for relieving perimenstrual symptom severity and improving overall health behaviors (Taylor & Colino, 2002). More and more, the impact of the SMCR research conferences and publications is demonstrated in medical and psychological clinical settings as well in non-clinical areas such as health education and the popular press. Groups of
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386 Table 3 Name Boston Womens Health Collective Publications (PMS, menstrual education) Centre for Menstrual Cycle and Ovulation Research (menstrual cycle research) Menstrual Monday (menstrual awareness) Museum of Menstruation and Womens Health (menstrual cycle/PMS history) National Womens Health Network Publications (policy, education) Red Spot (menstrual education) Red Web Foundation (menstrual education) Society for Menstrual Cycle Research (PMS and menstrual cycle research) Taking Back the Month (PMS self-help) TREMIN Research Program on Womens Health (menstrual cycle research/database) Websites for evidence-based information on perimenstrual symptoms and PMS URL

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http://www.ourbodiesourselves.org/ http://www.cemcor.ubc.ca/ http://www.moltx.org/menstrualmondayindex.html http://www.mum.org/ http://www.womenshealthnetwork.org/publications/index.php http://onewoman.com/redspot/ http://www.theredweb.org/ http://menstruationresearch.org http://www.takingbackthemonth.com/ http://www.pop.psu.edu/tremin

womens health practitioners have presented feminist frameworks and clinical recommendations for women experiencing cyclic perimenstrual mood and physical discomforts (Association of Womens Health Obstetrical & Neonatal Nursing 2003; Chrisler, 2004). In one feminist psychology clinical guide (Chrisler, 2004), Paula Caplan (2004) provides suggestions for therapists on the issues related to PMDD and SSRI treatment and Peggy Stubbs and Daryl Costos (2004) review research on how attitudes toward the experience of menstruation may be inuencing development and interpersonal relating with recommendations directed to feminist psychotherapy and educational curriculum. Magazine writers now regularly seek out SMCR members as scientic consultants, thereby enhancing accuracy in the popular press. And websites have been developed by SMCR members along with links to their recommendations and to other SMCR research publications (Table 3 presents this list).

Acknowledgment The author thanks Conference Chairpersons, Susan Cohen, Phyllis Manseld, and Peggy Stubbs, for their manuscript review and Amy Glynn-Hornick and Claudia Schumann for their research and editorial assistance.

References
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Summary Historically, biomedical classication dominated the definitions of womens perimenstrual experiences with little attention paid to alternative perspectives from other disciplines and, more importantly, from womens perspectives. The establishment of the Society for Menstrual Cycle Research and their biennial research conferences and publications, beginning in 1977, created the venue and intellectual leadership for the advancement of research in this area. The contributions of the SMCR in the past 25 years new conceptual models, advanced research methods, and linking therapeutics with health promotion and advocacy have advanced the research on perimenstrual experiences and PMS beyond the medicalization of a syndrome by encouraging an interdisciplinary model of research agenda development.
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