PMDD: The Sociological Impact of Forgotten Pain

Miraya Choudhury

The Science of the Forgotten: Hybrid Vigor 2022-2023 Edition

While it might be second nature to comfort a friend with “I feel your pain” during a difficult time, this platitude won’t do the trick for something like chronic pain. In fact, Harvard professor and essayist Elaine Scarry would argue it is impossible to empathize with any physical pain. To be in pain is one of the most certain and visceral experiences. But, as far as an outsider is concerned, that pain is impossible to confirm and is only understood through their external expression of discomfort (Scarry 1985). Scarry elaborates on the inexpressibility of pain, emphasizing that no matter how well-described it is, pain will never be universally understood. 

That being said, physical pain – particularly menstrual pain– is often freely discussed by young women and those who get periods as an objective experience. The objectivity which is used to talk about abdominal cramps and aches that come with periods are all in good faith. Young people want to support each other and unite around what is generally agreed to be an uncomfortable, awkward, and even dreadful biological process. A survey conducted by OnePoll and Lunette also found that Gen Z respondents were more likely to believe periods should be openly discussed by everyone, including men and women. However, there may be an unintended outcome of the efforts to destigmatize periods. When spreading the message that periods are natural processes, advocates might accidentally imply that their debilitating side effects are also normal. This then can lead to underdiagnosis of health outcomes such as Premenstrual Dysphoric Disorder, or PMDD. 

PMDD is a severe mood disorder which occurs during the luteal phase of the menstrual cycle and is often blended together under the umbrella term of “PMS” despite it being a distinct condition. Unlike PMS, PMDD is categorized by a “cyclical recurrence of distressing or impairing affective symptoms” which shows up in at least 2 consecutive cycles (Eisenlohr-Moul 2019). PMDD affects anywhere between 1.3 to 5.3% of people with periods, though this estimate is likely an underrepresentation of the true proportion (Hofmeister 2016). It was first recognized in the Diagnostic and Statistical Manual of Mental Disorders in 2013, but nearly a decade later, the disorder is still far from colloquial. A few factors likely play into this – the difficulty of diagnosis being the most prominent. 

A qualitative study of the New Zealand Services for chronic pelvic pain found 58% of participants felt that their doctor did not take their pain seriously (Grace 1995). These same results are found across healthcare systems and discourage women from taking their concerns to a clinical setting in the first place. The bias against diagnosing female-presenting patients is structural. From anti-women bias found in medical textbooks to “clinical practices designed…for and by men,” the U.S. healthcare system often works against rather than for female patients (Sadick 2019). A 1992 study even indicated that nurses believed women have a higher pain tolerance than men (McCaffrey 1997).  It is important to note that the problem is not only perpetuated by male physicians, as “there’s little evidence to show that female providers offer women more equal care” than their male counterparts (Pagan 2022). These systemic biases affect diagnosis of disorders like PMDD, which relies on the patient’s description of their psychosomatic symptoms. 

Scarry employs the term “unreliable narrator” to describe how outsiders view the person in pain. In a clinical setting, women are often viewed as unreliable narrators and this has severe ramifications when it comes to diagnosis. Given the nature of PMDD symptoms, which include irritability, hopelessness, and extreme mood swings, a diagnosis can be the most important step in seeking proper care and turning one’s life around (Hantsoo 2015). But the journey to a PMDD diagnosis can be long and arduous, a constant fight against mental hardships and sometimes against healthcare providers (Osborn 2020). Patients might start to blame themself for their irritability and potentially exacerbate depressive symptoms. But with an early diagnosis and a proper treatment plan, healthcare providers can minimize the detrimental effects of PMDD. 

The underlying issues which prevent a PMDD diagnosis are so deeply ingrained in the medical system that it’s impossible to pinpoint a definitive solution. In general, female patients must be empowered to speak their mind in a clinical setting and voice their concerns to a healthcare provider. Though the burden of reducing bias in diagnosis should not fall on the patient, women can advocate for themselves by asking follow-up questions, obtaining second opinions, and reaching out to others in similar situations (O'Donnell 2021). It may take a while before PMDD becomes a well-studied and legitimate condition according to the public, but in the meantime, we must not forget to validate women as reliable narrators of their own health. 

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Eisenlohr-Moul, T. (2019). Premenstrual Disorders: A Primer and Research Agenda for Psychologists. The Clinical psychologist, 72(1), 5–17.

Grace, V. M. (1995). Problems of communication, diagnosis, and treatment experienced by women using the New Zealand health services for chronic pelvic pain: a quantitative analysis. Health care for women international, 16(6), 521–535. https://doi.org/10.1080/07399339509516207

Hantsoo, L., & Epperson, C. N. (2015). Premenstrual Dysphoric Disorder: Epidemiology and Treatment. Current psychiatry reports, 17(11), 87. https://doi.org/10.1007/s11920-015-0628-3  

Hofmeister, S., & Bodden, S. (2016). Premenstrual Syndrome and Premenstrual Dysphoric Disorder. American family physician, 94(3), 236–240.

McCaffery, M., & Ferrell, B. R. (1997). Nurses' knowledge of pain assessment and management: how much progress have we made?. Journal of pain and symptom management, 14(3), 175–188. https://doi.org/10.1016/s0885-3924(97)00170-x

Noe Pagán, C. (2018). When Doctors Downplay Women’s Health Concerns. The New York Times. https://www.nytimes.com/2018/05/03/well/live/when-doctors-downplay-womens-health-concerns.html 

O'Donnell, M. (2021). Medical Misogyny: The Lack of Research and Attention on Women’s Health Issues Leading to Ignored Symptoms, Misdiagnoses, and Unjust Death. Gleanings: A Journal Of First Year Student Writing, 11, 86-91.  

Osborn, E., Wittkowski, A., Brooks, J., Briggs, P. E., & O'Brien, P. M. S. (2020). Women's experiences of receiving a diagnosis of premenstrual dysphoric disorder: a qualitative investigation. BMC women's health, 20(1), 242. https://doi.org/10.1186/s12905-020-01100-8

Sadick, B. (2021). Women Die from Heart Attacks More Often Than Men. Here’s Why – and What Doctors are Doing About it. Time Magazine, https://time.com/5499872/women-heart-disease/ 

Scarry E., (1989). Introduction, The Body in Pain (3-23). Oxford University Press. https://doi.org/10.1017/s0033291700012812