It’s not all bad: Women’s construction and lived experience of positive premenstrual change

Abstract

Although premenstrual change is invariably pathologized and described as PMS or PMDD, there is evidence that many women experience premenstrual changes positively. This suggests that premenstrual change is both a lived experience and social construction, which is not inevitably positioned as debilitating or distressing. However, previous research has provided little insight into how and why women construct premenstrual change as positive. Accordingly, the present study used a critical realist epistemology and a material-discursive-intrapsychic model to explore women’s construction and lived experience of positive premenstrual change. Drawing on focus groups with 47 women, explanations for positive premenstrual experiences included: ‘positive emotional outcomes’, ‘releasing tension’, ‘increased attractiveness’, ‘legitimacy of self-care’ and ‘indication of menstruation’. Findings not only reinforce reports from previous research that many women experience positive premenstrual changes, but also challenge bio-medical conceptualizations of premenstrual change as inherently negative, with accounts of relational negotiation emphasizing the context-dependent nature of premenstrual change.

Keywords

PMDD positioning theory positive PMS premenstrual syndrome qualitative research

The social construction of illness is now a major research concern for medical sociologists and critical health psychologists, contributing to our understanding of the social dimensions of health and illness (Conrad and Barker, 2010). Premenstrual Syndrome (PMS) is often described as an archetypal example of a socially constructed illness, where medical knowledge and the cultural meanings attached to menstruation combine to position the premenstrual woman as mad, bad or dangerous (Chrisler and Caplan, 2002; Markens, 1996). This leaves women with a restricted language for describing and understanding their lived experience of premenstrual change (Rodin, 1992), and increases the likelihood of their self-diagnosis as a PMS sufferer (Cosgrove and Riddle, 2003; Ussher, 2006). In this vein, there is research evidence that women who expect to experience distress or disturbance are more likely to position premenstrual changes as negative (Marvan and Cortes-Iniestra, 2001), or to attribute negative emotions to the body premenstrually (Koeske and Koeske, 1975). Conversely, the availability of positive discourses about menstruation can facilitate the acknowledgement and reporting of positive premenstrual changes (Chrisler et al., 1994).

There is some evidence that women experience positive changes premenstrually, such as feelings of elation (Coyne et al., 1985; Schnall et al., 2002), increased energy and creativity, tendency to clean or be tidy, more attractive breasts (Stewart, 1989), increased sexual desire (Schreiner-Engel et al., 1981), and feelings of affection, well-being, excitement and relief (Chaturvedi, 1990). However, whilst this research illustrates the nature and extent of positive premenstrual change, the use of standardized questionnaires limits and prescribes the range of experiences women can report. It also negates context, and women’s subjective negotiation and experience of positive premenstrual change, providing little insight into how and why women construct premenstrual change as positive. The aim of the present study is to redress this balance, examining women’s construction and experience of positive premenstrual change.

There is a growing body of research using qualitative methods to examine the subjective construction and experience of premenstrual distress (Cosgrove and Riddle, 2003; Swann, 1997; Ussher and Perz, 2008), however, only a limited number of qualitative studies have investigated positive premenstrual change. In Nichols’ (1995) study, semi-structured interviews allowed women to state what changes they experienced and describe the context in which these changes occurred. One participant reported experiencing increased energy premenstrually, but described this as ‘a bit odd’, which suggested that her experience was contrary to her expectations, reinforcing the notion that women’s negotiation of premenstrual change is affected by negative cultural constructions of premenstrual change (Ussher, 2003b). In Lee’s (2002) study, a number of women reported that they experienced PMS, but said that they valued premenstrual changes, and refused to be labelled as sufferers. Similarly, Ussher and Perz (2012) reported that many self-identified PMS sufferers accepted premenstrual change as a normal part of experience, embracing the access to the ‘deeper energies’ and emotions they experienced at this time. Women-centred psychological interventions for premenstrual symptoms that encourage women to reattribute the factors associated with distress have also been found to be effective in reducing the impact of negative symptoms, as well as increasing women’s self-efficacy and facilitating positive coping strategies (Ussher et al., 2002; Morse, 1999). In combination, these studies suggest that premenstrual change is both a lived experience and social construction (Cosgrove, 2000), meaning that premenstrual change may be experienced by women, but not constructed as debilitating or distressing.

Accordingly, the present study used a critical realist epistemology (Bhaskar, 1989), and a MDI model (Ussher, 2005, 2011) to explore women’s construction and lived experience of positive premenstrual change. Advocated as the way forward for research examining health in a sociocultural context (Williams, 2003), critical realism affirms the existence of reality (e.g. biological or economic factors), but recognizes that our experience of it is always mediated by culture, language and politics (Bhaskar, 1989). Within this framework, a number of feminist material-discursive approaches have recently been developed (Lafrance and Stoppard, 2007; Ussher, 1997; Yardley, 1997), in parallel with the move within post-structuralism towards acknowledgment of the ‘extra-discursive’, the material aspects of experience (Burr, 1999). This integrationist material-discursive approach is to be welcomed, yet arguably does not always go far enough, as the intrapsychic – and intersubjective – is often still left out. What we need is an approach that can address ‘how what is social is also psychic and also somatic, or bodily’ (Grace, 2010: 273), but also an approach that acknowledges the gendered context of women’s lives and of psychiatric diagnosis. A MDI approach (Ussher, 2005, 2011) can do this, providing a multidimensional analysis of the irrevocable interconnections between the materiality of women’s lives, PMS and gender as discursive categories, and the distress many women experience.

The MDI model posits that an ongoing interaction of material (e.g. changes in hormones, physiological arousal, neurotransmitters, or life stresses), discursive (e.g. cultural constructions and representations of PMS, reproduction and gender), and intrapsychic factors (e.g. mode of evaluating and coping with changes, expectations of self, defence mechanisms) combine to produce emotions and behaviours that are positioned as ‘PMS’ by a woman, or by her family – or, conversely, accepted as a normal experience. Multifactorial models for PMS, within a bio-psycho-social framework, have previously been put forward (Blake, 1995; Ussher, 1992; Walker, 1995). However, the MDI model does not position either psychological or biological aetiological factors as the point of origin of premenstrual distress or positivity. It also develops the analysis of psychological processes beyond the cognitive-behavioural and is the first to explicitly engage with constructionist accounts of PMS (e.g. Chrisler and Johnston-Robledo, 2002) through acknowledging the role of discursive representations of ‘PMS’ and menstruation in contextualizing women’s experience (Ussher, 2006).

In support of this model, there is convincing evidence that many women experience embodied and psychological change, accompanied by an increased sensitivity to emotions, or to external stress, during the premenstrual phase of the cycle (Coughlin, 1990; Fontana and Palfai, 1994; Sabin-Farrell and Slade, 1999; Ussher and Wilding, 1992). Many women report that their perception is more acute premenstrually – with noises seeming louder, and their sense of smell more acute (Walker, 1997), which can result in stress being potentially experienced as more problematic at this time (Woods et al., 1998). At the same time, emotions such as anger, sadness or irritability – as well as creativity or sexual desire – can be experienced as more powerful than usual (Ussher, 2004). The multiple tasking which is a normal part of most women’s lives can also be more difficult (Slade and Jenner, 1980), leading to distress when the responsibilities of home, work and study cannot be accommodated at the same time (Coughlin, 1990). Whilst these material and psychological changes have been positioned as causes of premenstrual distress (Bancroft, 1993) or, indeed, deemed to be PMS (Moos, 1968) within a MDI framework, it is suggested that these changes are positioned as PMS because of cultural constructions of the menstruating woman as labile or dysfunctional, and the premenstrual phase of the cycle as a time of pathology (Ussher, 2006).

This suggests that women’s active negotiation of premenstrual change, and their resistance to cultural discourse that positions such changes negatively, can result in a positive premenstrual experience. The aim of this study was thus to examine women’s accounts of experiences of positive premenstrual change, and their explanations for why these changes are constructed as positive, through the following research questions: what aspects of premenstrual change are positioned as positive by women; and how and why do women position such changes positively?

Method

Data were collected using eight focus groups (five to seven women per group, totalling 47 participants), as well as two follow-up interviews with two women from the focus groups whose accounts of positive premenstrual change were considered to be worthy of further detailed exploration. The study was advertised via an online project management system in which women were requested to take part in a focus group on positive premenstrual experiences. The advertisement provided examples of changes women may experience, both positive and negative, including being more affectionate, orderliness, sleeping more and crying.

The 47 women who took part were all undergraduate psychology students aged 18 to 42 (M = 22 years). Of the 47 women, 41 (87%) were first-year psychology students who were participating for course credit and six were fourth-year psychology student volunteers. Over half of the women (53%) identified as from an Anglo-Australian background; the backgrounds of the remaining women were culturally diverse, including Italian (6%), Filipina (4%) and Egyptian (4%). Three women (6%) did not specify their backgrounds. Data on socioeconomic class was not collected. At the time of the study, 19 women (40%) were taking the oral contraceptive pill and 28 women (60%) were not. The majority of participants were partnered (79%; 10% co-habiting), and reported having no children (68%). Of the 17% of participants with children, at least one child was living with them. All but one of the participants were full-time students, and 66% were employed part time.

The focus group and one-to-one interviews were semi-structured, and conducted by the first author. At the beginning of the focus group, an open-ended question was asked: ‘Do you experience any changes during the premenstrual phase of your cycle? If so, what are they?’ Participants were given a list of premenstrual changes (both positive and negative) to provide a vocabulary by which they could describe their premenstrual experience and to aid recollection of any changes. The interviewer then focused on exploring the range of changes women experienced premenstrually. Follow-up questions investigated women’s positioning of these changes by asking questions such as, ‘Could you explain why this is a positive (negative) change for you?’ The one-to-one interview asked women to describe their premenstrual changes in more detail, and to elaborate further on their construction and experience of such changes. In accordance with established protocols in qualitative research, sampling was discontinued when information redundancy was reached, and no additional information was forthcoming (Miles and Huberman, 1994).

The data were transcribed verbatim, taking note of laughs, emphasis and pauses, and participant names were replaced with pseudonyms to ensure anonymity. The analysis was conducted using a theoretical thematic analysis (Braun and Clarke, 2006), wherein the analytic process was informed by a feminist MDI approach, outlined above (Ussher, 2005). After transcription, a subset of the interviews were independently read and re-read by both authors to identify key themes and develop an initial coding frame. Themes were then grouped, checked for emerging patterns, variability and consistency, commonality across women, and for uniqueness within cases. The whole data set was then coded by the first author, after which a meeting was held to discuss any new or unforseen themes, and to re-evaluate the inclusion of themes that appeared with low frequency. The interpretation of these themes was conducted by a process of reading and re-reading, as well as reference to relevant literature, following established protocols for thematic analysis (Braun and Clarke, 2006). The interpretation of the data was conducted from within the framework of positioning theory (Davies and Harré, 1990), where it is assumed that narratives do not simply mirror a world ‘out there’, but that they are constructed and interpretive, reflecting subject positions taken up or given to individuals, which provide the context for the negotiation of experience. Positions are fluid and sometimes overlapping (Harré and Van Lagenhove, 1999), which suggests that premenstrual changes can simultaneously be positioned as positive and negative. All aspects of data collection and analysis were conducted in accordance with the ethical guidelines approved for this study by the University Human Research Ethics Panel.

Positioning premenstrual changes as positive

The majority of women reported a variety of positive premenstrual changes; however, the explanations provided for such changes were diverse and variable. These explanations included feeling happy and energetic, release of tension, legitimating self-care, feelings of increased attractiveness and indication of impending menstruation.

Feeling happy and energetic

Using descriptors such as ‘happiness’, ‘excitement’, ‘wellbeing’ or ‘being high’, women who reported noticeable increases in positive moods premenstrually described their elevated mood in similar ways:

Before I have my period, I’m all high and like happy. I don’t know for some reason I just wanna smile all the time … but I don’t know, I just feel so– as if I’m high on ecstasy, on drugs [laughs] I don’t know before I have my periods. (Hannah)

In many instances, women positioned elevated moods as a positive change simply because the experience of such a state was enjoyable. For some women, this appeared to further improve behaviours positioned as desirable, including being more affectionate, confident, sociable or tolerant. This is exemplified by Jessica, who stated ‘it [being in a good mood] probably makes me a bit more self-confident’, and Jill ‘sometimes it makes me self-confident … more affectionate’. As well as enjoying the general sense of happiness, for some women, being in a good mood premenstrually was positioned as positive because it was deemed to improve their outlook and attitude, resulting in increased tolerance or patience:

I’m more patient of people that I would be not friends with, and people that I’m in contact with that generally get on my nerves, type of thing. I’m more able to be patient of why they annoy me, whether it’s just general personality clash or something they do specifically, I’m more tolerating of it. (Lacey)

Premenstrual positivity in this context can be viewed as having a protective function intrapsychically, as it facilitates positive reframing of potentially negative situations. This not only allowed women to experience positive emotions premenstrually, but also had a secondary effect in facilitating women’s social and relational functioning. This stands in contrast to previous accounts of premenstrual distress, where women report decreased tolerance and increased irritation premenstrually (Cosgrove and Riddle, 2003; Ussher, 2003a), which can lead to relational discord and disharmony (Ussher et al., 2007).

In the present study, some women also associated their positive premenstrual mood with an increase in energy, motivation or drive, illustrated by Penny who stated, ‘I get happy – but I have more energy to do things – just general things like get up and go to uni, go see people, do stuff that I should be doing and go to work’. Women’s close paring of energy and motivation provides an alternate conceptualization of certain premenstrual changes. Although previous studies classify premenstrual mood change and energy or motivation as occurring on separate dimensions, or report one in the absence of the other (Moos, 1968; Stewart, 1989), in the present study women perceived their increases in positive affect, energy and motivation as occurring simultaneously, suggesting that these changes may be linked in some way. Findings in research on mood support this suggestion, as it is reported that positive mood may be associated with the increased motivation to achieve accessible goals (Tsai et al., 2007) and that motivation cannot exist without a goal and the energy or effort to achieve that goal (Hyland, 1988). This may be of particular relevance to menstrual cycle research, as it suggests that some women experience and construct their premenstrual elevations in mood, energy and motivation as a combined set, rather than as individual mood or state changes.

While it is commonly accepted that moods such as euphoria and happiness are positive (e.g. Alagna and Hamilton, 1986), the construction and positioning of heightened premenstrual emotions varied between women in the present study, with a number suggesting that positive emotions were unstable. As Penny told us: ‘Other people have said I’m really happy and everything [clicks fingers] “No, just go away” … It’s great when I was happy, but then just anything, any little stupid thing completely reverses it.’ A number of participants described this changeability as something that left them feeling annoyed, and that resulted in an overall sense of ambivalence and disappointment: ‘I like it, but at the same time I don’t like it because it’s temporary so it’s just (tsk), I want to be like that all the time’ (Hannah). This suggests that premenstrual energy and happiness is not always positioned as positive, as women can focus on factors such as temporality, when constructing their experience.

Release of tension

Of the majority of women who reported experiencing tension premenstrually, almost half positioned the release of such tension as a positive experience, as outlined below.

The expression of anger

There were a small number of participants who positioned premenstrual emotionality such as anger and crying as positive, as this facilitated expression of built-up grievances and emotions: ‘sometimes I like it that I do get angry because I let it out for something that I haven’t let out before’ (Sally). Further, it was apparent that such expression existed within a relational context, as participants’ anger was often directed toward someone who was perceived to have caused the annoyance, invariably the woman’s intimate partner:

I’ll tell him exactly what I think, my boyfriend exactly what I think and it can relate to something that he did at the start of the month and I’ll just bring it up and that’s my way of venting at the end of the month which I kind of like. (Joanne)

Through the use of words like ‘venting’ and ‘letting it out’ women are employing a pressure cooker metaphor (Ussher, 2003a) to describe the cathartic relief that followed the expression of grievances or emotions kept silent during the remainder of the month. Whilst previous research has reported the advantages of premenstrual breaks in self-silencing for preventing depression (Perz and Ussher, 2006; Ussher and Perz, 2010), it has also been reported that premenstrual irritation or anger is often followed by guilt and self-criticism (Cosgrove and Riddle, 2003; Ussher, 2000), as well as high levels of anxiety (Ussher and Perz, 2010). This was not the case in the present study, however, where many of the participants positioned being premenstrual as a legitimate reason for expressing emotion:

I think it [being premenstrual] just allows us to express ourselves – just to be how we want to be at times. Because when you’re doing it – you use that as an excuse, so to speak. If there is something negative, you’re just like – ‘I’m getting my period, so just leave me alone’. You’re allowed to be a bitch. (Lillie)

In an attempt to explain the expression of premenstrual anger within relationships, it has been argued this is the only time that some women express relationship conflicts because they can attribute anger to their hormones (McDaniel, 1988), described as a redeployment of the reproductive body to meet emotional needs (Elson, 2002). In the present study, participants who positioned premenstrual self-expression positively did not report concerns about adverse responses from others, whereas women who positioned premenstrual anger as negative did report adverse responses. This confirms previous reports that the reactions of significant others, in particular partners, are a significant factor in women’s experience and construction of premenstrual emotions (Frank. et al., 1993; Ussher et al., 2007).

Sexual tension

A number of participants positioned premenstrual increases in sexual arousal positively, as it facilitated the initiation of sex. This is illustrated by Madison who stated, ‘I like it because I’m more interested and I initiate sexual relations more than what I would, which is nice.’ Other women described increased arousal as enhancing the sexual experience: ‘It’s just more excitable I thought. I found it more intense’ (Emily). However, the most frequently reported reason why women positioned sexual arousal positively was the release of sexual tension.

I would say the actual act, it is very relieving and even much more heated, because I’m more aroused than I normally would be, so it’s more intense. Probably a bit quicker as well. (Rachel)

This is in line with previous research that reported that the menstrual phase of the cycle was associated with heightened sexual arousal and pleasure for some women (Fahs, 2011), underlining the materiality of embodied change across the menstrual cycle.

However, while it is often assumed within the research literature that increased sexual arousal is intrinsically positive (e.g. Chrisler et al., 1994), the findings of the present study suggest otherwise. Women who reported experiencing increased sexual arousal premenstrually, but who were unable to act upon it, were less likely to construct it as a positive experience. In the case of Mary, it is her partner’s lack of response to her ‘hints’ that not only results in a missed opportunity to have ‘better’ sex, but leaves her feeling rejected, which increases her frustration and her emotionality:

I try to give my partner a hint that I’m a little raunchy and he says no and I cry … Unless he’s in the mood, he won’t try so it’s frustrating … because I won’t get to use it … but when I do, it’s heaps better than what it normally is. (Mary)

This suggests that women’s construction and experience of their premenstrual sexual desire is influenced by their partner’s responsiveness; if their partner is not affirming, this could negatively impact upon the woman, in terms of how she views herself, and her desire (Fahs, 2011).

A small number of women gave accounts of coping with the absence of a partner by engaging in masturbation, allowing a release of sexual tension, or simply to ‘relax’. As Jess told us, ‘yeah. I get to use it, like I don’t have a boyfriend but I … still get to use it. It’s a modern day.’ Similarly, Hannah said, ‘yeah I end up doing it myself. I don’t have any partner … you feel more relaxed just feel so much better when you do it at that stage.’ While masturbation was an effective strategy for Hannah, she acknowledges the cultural discourses that position female masturbation as abnormal or unusual: ‘do I sound deprived?’ However, at the same time, she rejects this discourse by stating: ‘It’s good. There’s nothing wrong about it [laughs].’ This draws attention to the moral discourses that condemn female masturbation through associating it with sin and shame (Hunt, 1998), which may discourage women from enjoying their increased premenstrual sexual arousal in the absence of a sexual partner.

Orderliness

Although a relatively minor theme, orderliness, encompassing women’s urge to engage in cleaning, tidying or organizing during the premenstrual phase, was also positioned positively, because it served as a release of tension. For some participants, being orderly was described as providing a sense of control, satisfaction or comfort as demonstrated by Jillian: ‘If my room’s clean, I feel I can handle things a lot better’ and Sabrina: ‘I feel generally in myself that I can’t control anything when I have my period. I clean and I feel like my world’s in perspective.’ Orderliness also had a secondary function, as the act of cleaning provided women with a tidy, organized, or clean space to reside within, and enjoy. Interestingly, one participant positioned this change negatively, as the desire to clean often made her feel overwhelmed, stressed and unable to cope, ‘it’s one other thing that I have to do’ (Madison). Thus while the existence of increased orderliness, cleaning, or tidiness during the premenstrual phase is well documented (Stewart, 1989), the present findings suggest that contextual and intrapsychic factors play a key role in women’s positioning of this change as positive, or conversely as task overload, and thus as a negative experience.

Legitimating Self-Care

Taking time out

Constructions of adult femininity emphasize women’s relationality, in particular, putting the needs of others before the self, which can result in self-care being positioned as an indulgence (Jack and Ali, 2010; O’Grady, 2005). Many participants reported that the premenstrual phase of the cycle was one of the few times they put their own needs first, through taking time out or indulging cravings they would normally control. Self-care served to combat negative premenstrual changes and facilitate coping, as well as being pleasurable, as illustrated by the following account given by Kristen:

Before I know I get my periods, I usually get a pimple … and so then I know it’s coming, but then I like to pamper myself very much at that time. So I’ll sit in my bed longer, I’ll take hot showers and I’ll sit on the couch and put a cushion on my back … I’m taking my rest and I’m relaxing, so I think it’s good to take care of your body.

Accounts of taking time out to cope have also been reported in research on women presenting with PMS; however, this is often associated with feelings of guilt, as attention to one’s own needs is positioned as selfish, or as neglect of family (Ussher and Perz, 2012). Conversely, in the present study, Kristen positioned her premenstrual experience positively because it legitimated taking care of her-self, and she enjoyed the outcome. In other accounts, participants explained that they were able to take time out because the people around them were accommodating to their needs: ‘Mum stops asking me to do things … so I take that as a positive thing, that there’s a whole week of chores that I don’t have to do’ (Dallas). These accounts are consistent with previous research that reported that recognition and positive response to a women’s premenstrual change on the part of others reduces feelings of guilt and self-castigation, allowing her to engage in coping strategies (Ussher and Perz, 2008; Ussher et al., 2002). These self-care strategies described also resemble recommended coping strategies for premenstrual distress (Blake et al., 1998; Johnson et al., 1992; Ussher et al., 2002), suggesting that they are not simply an ‘indulgence’.

Satisfying cravings

A substantial number of participants reported experiencing craving for certain foods premenstrually, with some positioning these cravings as positive. A number of women described the consumption of ‘forbidden’ foods as resulting in mood elevation or the heightened enjoyment of eating:

I crave chocolate, and I even think that it tastes better. I don’t know if that’s just because I feel like it so much, but I can eat easily – go through more than half a block of chocolate and just eat and eat and eat and eat. (Bianca)

Some participants said that satisfying food cravings also helped them to cope with negative premenstrual changes, such as cramps, or gave them extra energy when they needed it, as was the case with Liz:

So that’s how I get my energy sort of thing so around my period when I’m feeling sort of flat … I just pack on the chocolate.

Increased or unusual appetite or cravings premenstrually have been well documented; however, most studies position cravings as a ‘symptom’ of PMS (Moos, 1968; Stewart, 1989). In contrast, for the majority of participants in the present study, premenstrual cravings were positioned as positive because they legitimated the consumption of ‘forbidden foods’, with rationalizations decreasing the potential for feeling guilt: ‘I’m sure I need it’ (Jess); ‘it’s only once a month’ (Joanne); ‘it’s an excuse to eat’ (Kate). However, there were a number of participants who did not use such rationalizations and thus positioned their premenstrual cravings negatively. This again illustrates the importance of women’s psychological appraisals of premenstrual change (Ussher, 2002), as well as their negotiation of cultural discourse that espouses dietary restraint on the part of women, resulting in certain foods being positioned as bad (Bordo, 2003).

Embodied change: Increased attractiveness and indicator of menstruation

The majority of women reported embodied changes premenstrually, including change in breast shape and size, bloating and pain. For some women, these changes were positioned positively, as they were associated with increased attractiveness, or served as an indicator for the imminence of menstruation. Thus several participants described changes in their breasts positively, as ‘rounder’, ‘firmer’, ‘fuller’, or ‘bigger’, which they said made them feel happier about their appearance: ‘It’s like they get rounder, like more attractive … It’s so much better’ (Jen). These accounts not only reflect the positioning of a woman’s breasts as signifiers of feminine sexuality, but also women’s acceptance of cultural discourses of beauty that require breasts to be a particular size and shape (Millsted and Frith, 2003). However, not all women accepted this discourse, as some positioned their breasts as a source of self-consciousness premenstrually due to a perceived inappropriate increase in size, or because they were a source of pain, which negatively impacted upon their embodied premenstrual experience: ‘I find it annoying. I don’t know, I feel really self-conscious … I freak out. I don’t want to change thank you’ (Bella).

Whilst the majority of participants positioned premenstrual bloating as a negative experience, as found in previous research on women who report PMS (Ussher, 2011), one participant positioned bloating positively, because it allowed her to fit into certain items of clothing: ‘I consider the bloating as a good thing as well … Because I can actually fit into some pants better’ (Taylor). This finding stands in contrast to the social discourses that vilify weight gain and praise women’s slenderness (Bordo, 2003), as well as research that consistently positions bloating as a premenstrual ‘symptom’ (Moos, 1968).

A small number of participants positioned embodied premenstrual changes such as back pain or cramps, as well as firmer breasts, positively, because they served as an indicator that menstruation was imminent. For example, Lillie described her change in her breasts as indicating that she is premenstrual, which results in increased sense of happiness as her concern for an unwanted pregnancy dissipates:

I notice the boobs … They just get harder or something – I don’t really know, but I love it … because it kind of tells me that I’m going to get them [periods] – that’s kind of my reminder, otherwise I have no idea … I’m not on the pill, so you’re kind of always worried that you’re not going to get it [period], and then once I know I’m going to, I think it just makes me happier. (Lillie)

In the case of Jess, premenstrual pain was positioned as positive as it allows her to prepare for menstruation, which was positioned as crucial because of her dislike of underwear being damaged by menstrual blood. She comments: ‘I have wasted too many undies … I buy expensive undies too.’ Jess adds that it is the precise timing of her back pain that allows her to embrace the pain, rather than resent it, ‘so it’s like a massive positive for me because I know exactly when I will get my period about basically down to within a few hours, it’s like a tell-tale sign’. In combination with accounts of premenstrual breast change and bloating, this demonstrates the complex interaction between social construction and lived experience in women’s intrapsychic negotiation of premenstrual change (Cosgrove, 2000). Premenstrual changes that are often perceived as negative can be positioned positively if they serve a specific function, or have a positive meaning for the woman, or if they are discursively constructed as positive within a particular social context.

Discussion

The majority of the women who participated in this study reported at least one embodied, psychological or behavioural change during the premenstrual phase of the cycle that was positioned as positive. This reinforces reports from previous research that many women experience positive premenstrual changes, either alongside negative changes or as the only premenstrual changes experienced (Chaturvedi, 1990; Nichols, 1995; Stewart, 1989). This refutes the notion that premenstrual change is inevitably experienced and constructed as negative and distressing (Halbreich et al., 2003), as it can be positioned as enjoyable, a source of motivation, and a reason to engage in self-care, rather than a source of debility, distress, and self-blame. This underlines the limitations of research that endeavours to understand the nature and aetiology of premenstrual changes, but focuses solely on negative experiences and distress, and positions premenstrual change as pathology.

The adoption of a MDI standpoint in the present study extends previous research on positive premenstrual change, through suggesting that material, discursive and intrapsychic factors interact to influence women’s lived experience and construction of the premenstrual phase of the cycle. The materiality of premenstrual changes of a physical or emotional nature is acknowledged, but women’s intrapsychic negotiation of such change, in particular their resistance to cultural discourse that positions such changes as inevitably negative, can result in a positive premenstrual experience. This suggests that the meaning of premenstrual change is fluid rather than fixed, and that no change is inherently negative, or positive. This raises questions about the utility of standardized questionnaires that measure premenstrual change (e.g. Endicott and Harrison, 1990; Moos, 1968) as they simply focus on the presence or absence of premenstrual changes, as well as duration or intensity, negating women’s ongoing appraisal and negotiation of such changes, and the fact that the construction of premenstrual experiences varies across women, as well as across social and relational context.

Premenstrual change sits in the DSM-IV (American Psychiatric Association, 2000) as premenstrual dysphoric disorder (PMDD), officially categorizing premenstrual mood or behaviour change as a psychiatric disorder (see Cosgrove and Caplan, 2004; Ussher, 2006), with a ‘mood disorders work group’ ‘accumulating evidence’ as to whether PMDD should be included in the DSM-V (Fawcett, 2010). However, PMDD was included in the DSM-IV in the face of widespread feminist opposition on the basis that there is no validity to PMDD as a distinct ‘mental illness’ (Cosgrove and Caplan, 2004). Many feminist critics have argued that premenstrual change is a normal part of women’s experience, which is only positioned as PMS because of western cultural constructions of the premenstrual phase of the cycle as a time of psychological disturbance and debilitation (e.g. Chrisler and Caplan, 2002; Rittenhouse, 1991; Rodin, 1992; Ussher, 2006). In cultures such as Hong Kong (Chang et al., 1995), China (Yu et al., 1996) or India (Chaturvedi and Chandra, 1991; Hoerster et al., 2003), where menstruation is primarily positioned as a natural event, women report premenstrual water retention, pain, fatigue and increased sensitivity to cold, but rarely report negative premenstrual moods, or ‘PMS’. Equally, a recent study of ethnic minority women living in the USA reported that the likelihood of PMDD increased as duration in the USA lengthened, suggesting that exposure to American culture elevated likelihood of reporting PMDD (Pilver et al., 2011). These findings have led to the conclusion that culture shapes the physical and psychological changes that are deemed to be premenstrual symptoms, meaning that PMS and PMDD are deemed culture-bound syndromes (Chrisler and Caplan, 2002).

The findings of the present study suggest that women’s negotiation of premenstrual change can also vary within cultures, with accounts of low levels of self-castigation, and positive constructions of premenstrual change, contrasting with the negative experiences and constructions reported in previous qualitative research studies of PMS (e.g. Cosgrove and Riddle, 2003; Ussher and Perz, 2010). One explanation for this is the method of recruitment – asking women to take part in a study about positive premenstrual experiences – as well as the provision of a list of positive, as well as negative, premenstrual changes in order to prompt discussion in the focus group. Supporting the findings of Chrisler et al (1994), who found that completion of the Menstrual Joy Questionnaire (Delaney et al., 1987) promoted more positive accounts of premenstrual change than the Menstrual Distress Questionnaire (Moos, 1968), many participants in the present study stated that the list helped them to recall and name positive changes. However, a number of participants did not feel the need to use the list at all, suggesting that reports of positive premenstrual change were not simply responses to research cues. A further explanation for our findings is that the provision of university course credit in return for participation may have attracted women who would not normally volunteer for research on premenstrual change or PMS. This may, however, redress the criticism that menstrual cycle research focuses on atypical clinical populations, and as such, does not represent the experiences of a wider range of women (Walker, 1997).

It is also of relevance that the women in the present study were relatively young, with an average age of 21, in comparison to women in previous qualitative PMS research, which focuses on women in their mid-30s (Ussher, 2003b; Ussher and Perz, 2008). Many of the cultural constructions of PMS directed at younger women (and men) parody the ‘PMS bitch’, which may allow young women to embrace a hitherto stigmatizing moniker in the same way that gay men and lesbians often embrace the label ‘queer’ (Ussher, 2011). The majority of participants in the present study were also not in long term co-habiting relationships, which meant that they were less likely to be affected by their partner’s responses to their changes in premenstrual mood or behaviour, and were less likely to have to negotiate the material consequences of gendered power relations – they could literally escape to a room of their own, rather than having to do housework and look after children, a major source of distress premenstrually for other women (Coughlin, 1990; Ussher and Perz, 2012). Younger women may also have been more able to resist the constructions of femininity that emphasize self-silencing, self-sacrifice and negation of self-care (O’Grady, 2005). However, the fact that participants reported premenstrual attention to self, or expression of emotion, as a contrast to their normal behaviour for three weeks of the month, suggests that positive premenstrual changes are partly positioned and experienced as such because of gender role demands and ideologies.

The findings of this study reinforce the need for future research on premenstrual change or distress to examine positive, as well as negative, experiences. It also suggests that therapeutic or self-help interventions for premenstrual distress may benefit from a component that educates women on the existence of positive premenstrual change, as this could increase women’s access to positive constructions of their premenstrual experience. Equally, as the response of significant others was found to play a role in women’s negotiation of premenstrual change, supporting previous research findings (Cortese and Brown, 1989; Steege et al., 1988; Ussher et al., 2007), interventions should also incorporate a relational perspective to facilitate partner support and women’s engagement in coping and self-care (Jones et al., 2000).

In conclusion, whilst this study illustrates the multiple and sometimes contradictory nature of premenstrual subjectivity, challenging modernist notions of fixed and stable premenstrual pathology, further research is warranted to explore this issue in more diverse populations of women. Future studies on positive aspects of premenstrual experience should include a broader range of age groups and cultural backgrounds, as well as women with parenting and household duties, and partner co-habitation, in order to explore how women’s appraisal of premenstrual changes is affected by such circumstances. Present findings also highlight the importance of asking how and why women position premenstrual changes as positive (or negative), as the complexity of women’s lived experience, as well as their ongoing negotiations of premenstrual changes, renders the asking of what premenstrual changes occur as insufficient.

Footnotes

Author Biographies

Marlee King is a PhD candidate in the Centre for Health Research, School of Social Sciences and Psychology, at the University of Western Sydney, Australia. Her research centres on women’s sexual and reproductive health, with her doctoral thesis focusing on men’s experiences and constructions of their partner’s premenstrual changes.

Jane Ussher is Professor of Women’s Health Psychology, in the Centre for Health Research, at the University of Western Sydney, Australia. She is editor of the Routledge Women and Psychology book series, and author of a number of books, including: The Psychology of the Female Body (Routledge, 1989), Women’s Madness: Misogyny or Mental Illness? (Harvester Wheatsheaf, 1991), Fantasies of Femininity: Reframing the Boundaries of Sex (Penguin, 1997), Managing the Monstrous Feminine: Regulating the Reproductive Body (Routledge, 2006) and The Madness of Women: Myth and Experience (Routledge, 2011).

References

Alagna

Hamilton

(1986) Social stimulus perception and self evaluation: Effects of menstrual cycle phase. Psychology of Women Quarterly 20: 327–338.

American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders, Edition IV, Washington DC: American Psychiatric Association.

Bancroft

(1993) The premenstrual syndrome: A reappraisal of the concept and the evidence. Psychological Medicine suppl. 241: 1–47.

Bhaskar

(1989) Reclaiming Reality: A Critical Introduction to Contemporary Philosophy, London: Verso.

Blake

(1995) Cognitive therapy for premenstrual syndrome. Cognitive and Behavioral Practice 2(1): 167–185.

Blake

Salkovskis

Gath

Day

Garrod

(1998) Cognitive therapy for premenstrual syndrome: A controlled trial. Journal of Psychosomatic Research 45(4): 307–318.

Bordo

(2003) Unbearable Weight: Feminism, Culture and the Body, Berkeley: University of California Press.

Braun

Clarke

(2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3(2): 77–101.

Burr

(1999) The extra-discursive in social constructionism. In: Nightingale

Cromby

(eds) Social Constructionist Psychology: A Critical Analysis of Theory and Practice, Buckingham: Open University Press, pp. 113–126.

10.

Chang

Holroyd

Chau

(1995) Premenstrual syndrome in employed Chinese women in Hong Kong. Health Care for Women International 16(6): 551–561.

11.

Chaturvedi

(1990) Stress-protective functions of positive experiences during the premenstrual period. Stress Medicine 6(1): 53–55.

12.

Chaturvedi

Chandra

(1991) Socio-cultural aspects of menstrual attitudes and premenstrual experiences in India. Social Science & Medicine 32(3): 349–351.

13.

Chrisler

Caplan

(2002) The strange case of Dr. Jekyll and Ms. Hyde: How PMS became a cultural phenomenon and a psychiatric disorder. Annual Review of Sex Research 13: 274–306.

14.

Chrisler

Johnston-Robledo

(2002) Raging hormones?: Feminist perspectives on premenstrual syndrome and postpartum depression. In: Ballou

Brown

(eds) Rethinking Mental Health and Disorder: Feminist Perspectives, New York: Guilford Press, pp. 174–197.

15.

Chrisler

Johnston

Champagne

Preston

(1994) Menstrual joy: The construct and its consequences. Psychology of Women Quarterly 18: 375–387.

16.

Conrad

Barker

(2010) The social construction of illness. Journal of Health and Social Behavior 51(1 suppl): S67–S79.

17.

Cortese

Brown

(1989) Coping responses of men whose partners experience premenstrual symptomatology. Journal of Obstetric, Gynecologic, & Neonatal Nursing 18(5): 405–412.

18.

Cosgrove

(2000) Crying out loud: Understanding women’s emotional distress as both lived experience and social construction. Feminism and Psychology 10(2): 247–267.

19.

Cosgrove

Caplan

(2004) Medicalizing menstrual distress. In: Caplan

Cosgrove

(eds) Bias in Psychiatric Diagnosis, Northvale, NJ: Jason Aronson, pp. 221–232.

20.

Cosgrove

Riddle

(2003) Constructions of femininity and experiences of menstrual distress. Women & Health 38(3): 37–58.

21.

Coughlin

(1990) Premenstrual syndrome: How marital satisfaction and role choice effect symptom severity. Social Work 35(4): 351–355.

22.

Coyne

Woods

Mitchell

(1985) Premenstrual tension syndrome. Journal of Obstetric, Gynecologic, & Neonatal Nursing 14(6): 446–454.

23.

Davies

Harré

(1990) Positioning: The discursive production of selves. Journal of the Theory of Social Behaviour 20: 43–65.

24.

Delaney

Lupton

Toth

(1987) The Curse: A Cultural History of Menstruation, Urbana, IL: University of Illinois Press.

25.

Elson

(2002) Menarche, menstruation, and gender identity: Retrospective accounts from women who have undergone premenopausal hysterectomy. Sex Roles 46: 37–48.

26.

Endicott

Harrison

(1990) Daily Rating of Severity of Premenstrual Problems Form, New York: Department of Research Assessment and Training.

27.

Fahs

(2011) Sex during menstruation: Race, sexual identity, and women’s accounts of pleasure and disgust. Feminism & Psychology 21(2): 155–178.

28.

Fawcett J (2010) Report of the DSM-5 Mood Disorders Work Group. Available at: www.dsm5.org/Progressreports/pages/0904reportofthedsm-vmooddisordersworkgroup.aspx (accessed 23 March 2010).

29.

Fontana

Palfai

(1994) Psychosocial factors in premenstrual dysphoria: Stressors, appraisal and coping processes. Journal of Psychosomatic Research 38(8): 557–567.

30.

Frank

Dixon

Grosz

(1993) Conjoint monitoring of symptoms of premenstrual syndrome: Impact on marital satisfaction. Journal of Counseling Psychology 40(1): 109–114.

31.

Grace

(2010) The desiring, gendered speakingbeing: Going a bit further with Ussher on women and depression. Feminism and Psychology 20(2): 272–277.

32.

Halbreich

Borenstein

Pearlstein

Kahn

(2003) The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD). Psychoneuroendocrinology 28(3 suppl): 1–23.

33.

Harré

Van Lagenhove

(1999) The dynamics of social episodes. In: Positioning theory: Moral contexts of intentional action, Oxford: Wiley-Blackwell, pp. 1–13.

34.

Hoerster

Chrisler

Gorman Rose

(2003) Attitudes toward and experience with menstruation in the US And India. Women and Health 38(3): 77–95.

35.

Hunt

(1998) The great masturbation panic and the discourses of moral regulation in nineteenth-and early twentieth-century Britain. Journal of the History of Sexuality 8(4): 575–615.

36.

Hyland

(1988) Motivational control theory: An integrative framework. Journal of Personality and Social Psychology 55(4): 642–642.

37.

Jack

Ali

(2010) The Depression Epidemic: International Perspectives on Women’s Self-silencing and Psychological Distress, Oxford: Oxford University Press.

38.

Johnson

Relyea

Woods

Taylor

Mitchell

Lentz

(1992) Perimenstrual symptoms and health-seeking behaviour. Western Journal of Nursing Research 14(4): 418–443.

39.

Jones

Theodos

Canar

Sher

Young

(2000) Couples and premenstrual syndrome: Partners as moderators of symptoms? In: Schmaling

(eds) The Psychology of Couples and Illness: Theory, Research, & Practice, Washington, DC: American Psychological Association, pp. 217–239.

40.

Koeske

(1975) An attributional approach to moods and the menstrual cycle. Personality and Social Psychology 31: 473–481.

41.

Lafrance

Stoppard

(2007) Re-storying women’s depression: A material-discursive approach. In: Brown

Augusta-Scott

(eds) Narrative Therapy: Making Meaning, Making Lives, Thousand Oaks, CA: Sage, pp. 23–37.

42.

Lee

(2002) Health and sickness: The meaning of menstruation and premenstrual syndrome in women’s lives. Sex Roles 46(1/2): 25–35.

43.

Markens

(1996) The problematic of ‘experience’: A political and cultural critique of PMS. Gender and Society 10(1): 42–58.

44.

Marvan

Cortes-Iniestra

(2001) Women’s beliefs about the prevalence of premenstrual syndrome and biases in recall of premenstrual changes. Health Psychology 20(4): 276–280.

45.

McDaniel

(1988) The interpersonal politics of premenstrual syndrome. Family Systems Medicine 6(2): 134–149.

46.

Miles

Huberman

(1994) Qualitative Data Analysis: An Expanded Sourcebook, Thousand Oaks, CA: Sage.

47.

Millsted

Frith

(2003) Being large-breasted: Women negotiating embodiment. Women’s Studies International Forum 26(5): 455–465.

48.

Moos

(1968) The development of a menstrual distress questionnaire. Psychosomatic Medicine 30(4): 853–867.

49.

Morse

(1999) Positively reframing perceptions of the menstrual cycle among women with premenstrual syndrome. Journal of Obstetric, Gynecologic, and Neonatal Nursing 28(2): 165–174.

50.

Nichols

(1995) Positive premenstrual experiences: Do they exist? Feminism and Psychology 5(2): 162–169.

51.

O’Grady

(2005) Women’s relationship with Herself: Gender, Foucault, Therapy, London: Routledge.

52.

Perz

Ussher

(2006) Women’s experience of premenstrual change: A case of silencing the self. Journal of Reproductive and Infant Psychology 24(4): 289–303.

53.

Pilver

Kasl

Desai

Levy

(2011) Exposure to American culture is associated with premenstrual dysphoric disorder among ethnic minority women. Journal of Affective Disorders 130(1–2): 334–341.

54.

Rittenhouse

(1991) The emergence of premenstrual syndrome as a social problem. Social Problems 38(3): 412–425.

55.

Rodin

(1992) The social construction of premenstrual syndrome. Social Science and Medicine 35(1): 49–56.

56.

Sabin-Farrell

Slade

(1999) Reconceptualizing pre-menstrual emotional symptoms as phasic differential responsiveness to stressors. Journal of Reproductive and Infant Psychology 17(4): 381–390.

57.

Schnall

Abrahamson

Laird

(2002) Premenstrual syndrome and misattribution: A self-perception, individual differences perspective. Basic and Applied Social Psychology 24(3): 215–228.

58.

Schreiner-Engel

Schaivi

Smith

(1981) Sexual arousability and the menstrual cycle. Psychosomatic Medicine 43(3): 199–214.

59.

Slade

Jenner

(1980) Performance tests in different phases of the menstrual cycle. Journal of Psychosomatic Research 24: 5–8.

60.

Steege

Stout

Rupp

(1988) Clinical features. In: Keye

(eds) The Premenstrual Syndrome, Philadelphia: WB Saunders, pp. 113–127.

61.

Stewart

(1989) Positive changes in the premenstrual period. Acta Psychiatrica Scandinavica 79: 400–405.

62.

Swann

(1997) Reading the bleeding body: Discourses of premenstrual syndrome. In: Ussher

(eds) Body Talk: The Material and Discursive Regulation Of Sexuality, Madness and Reproduction, London: Routledge, pp. 176–198.

63.

Tsai

Chen

Liu

(2007) Test of a model linking employee positive moods and task performance. Journal of Applied Psychology 92(6): 1570–1583.

64.

Ussher

(1992) Research and theory related to female reproduction: Implications for clinical psychology. British Journal of Clinical Psychology 31(2): 129–151.

65.

Ussher

(1997) Body Talk: The Material and Discursive Regulation of Sexuality, Madness, and Reproduction, London: Routledge.

66.

Ussher

(2000) Women’s madness: A material-discursive-intrapsychic approach. In: Fee

(eds) Pathology and the Postmodern: Mental Illness as Discourse and Experience, London: Sage, pp. 207–230.

67.

Ussher

(2002) Processes of appraisal and coping in the development and maintenance of premenstrual dysphoric disorder. Journal of Community and Applied Social Psychology 12: 1–14.

68.

Ussher

(2003a) The ongoing silencing of women in families: An analysis and rethinking of premenstrual syndrome and therapy. Journal of Family Therapy 25: 388–405.

69.

Ussher

(2003b) The role of premenstrual dysphoric disorder in the subjectification of women. Journal of Medical Humanities 24(1/2): 131–146.

70.

Ussher

(2004) Premenstrual syndrome and self-policing: Ruptures in self-silencing leading to increased self-surveillance and blaming of the body. Social Theory & Health 2(3): 254–272.

71.

Ussher

(2005) Unravelling women’s madness: Beyond positivism and constructivism and towards a material-discursive-intrapsychic approach. In: Chan

Chunn

Menzies

(eds) Women, Madness and the Law: A Feminist Reader, London: Glasshouse Press, pp. 19–40.

72.

Ussher

(2006) Managing the Monstrous Feminine: Regulating the Reproductive Body, London: Routledge.

73.

Ussher

(2011) Women’s Madness: Myth and Experience, London: Routledge.

74.

Ussher

Perz

(2008) Empathy, egalitarianism and emotion work in the relational negotiation of pms: The experience of lesbian couples. Feminism and Psychology 18(1): 87–111.

75.

Ussher

Perz

(2010) Disruption of the silenced-self: The case of pre-menstrual syndrome. In: Jack

Ali

(ed.) The Depression Epidemic: International Perspectives on Women’s Self-silencing and Psychological Distress, Oxford: Oxford University Press, pp. 435–458.

76.

Ussher JM and Perz J (2012) PMS as a gendered illness linked to the construction and relational experience of hetero-femininity. Sex Roles. Epub ahead of print 11 April 2011. DOI: 10.1007/s11199-011-9977-5.

77.

Ussher

Wilding

(1992) Interactions between stress and performance during the menstrual cycle in relation to the premenstrual syndrome. Journal of Reproductive and Infant Psychology 10(2): 83–101.

78.

Ussher

Hunter

Cariss

(2002) A woman-centred psychological intervention for premenstrual symptoms, drawing on cognitive-behavioural and narrative therapy. Clinical Psychology and Psychotherapy 9: 319–331.

79.

Ussher

Perz

Mooney-Somers

(2007) The experience and positioning of affect in the context of intersubjectivity: The case of premenstrual syndrome. International Journal of Critical Psychology 21: 145–165.

80.

Walker

(1995) Theory and methodology in premenstrual syndrome research. Social Science and Medicine 41(6): 793–800.

81.

Walker

(1997) The Menstrual Cycle, London: Routledge.

82.

Williams

(2003) Beyond meaning, discourse and the empirical world: Critical realist reflections on health. Social Theory & Health 1: 42–47.

83.

Woods

Lentz

Mitchell

Heitkemper

Shaver

Henker

(1998) Perceived stress, physiologic stress arousal, and premenstrual symptoms: Group differences and intra-individual patterns. Research in Nursing and Health 21(6): 511–523.

84.

Yardley

(1997) Material Discourses of Health and Illness, New York/London: Taylor and Francis/Routledge.

85.

Zhu

Oakley

Reame

(1996) Perimenstrual symptoms among Chinese women in an urban area of China. Health Care for Women International 17: 161–172.