Deducing the role of the menstrual cycle in ill health.

13 Jun 2016.

This is the second of three blog posts looking at how the menstruation taboo can undermine the diagnosis of various chronic health issues.

Last week’s post highlighted the need to use more precise language during medical consultations, since the menstrual cycle is not always ‘monthly’, and hormone-related symptoms are not only ‘premenstrual’. This post focuses on the need to consider the role of the menstrual cycle (or hormonal medication) in any chronic health issue that disproportionately affects female people.

Are patients or doctors adequately aware of the possible role of the menstrual cycle in ill health?

A 2015 BMJ (British Medical Journal) study, found that people tend to under-report symptoms that are perceived to relate to the menstrual cycle. The menstruation taboo restricts public discussion of the topic and so women normalise their symptoms, think that ‘there’s nothing that can be done to help’, or feel they ought to manage the symptoms alone and ‘not waste a doctor’s time’.

For instance, it takes a woman an average of two years before she consults a doctor about extremely painful menstruation. That’s anywhere between 20 to 34 bouts of extreme pain before deciding to seek medical help. If this was any other sort of severe pain, would women really wait this long?

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We also know that women are disproportionately affected (at least 2:1) by a range of chronic health issues that share between 67%- 93%* of the same symptoms as PMS (Premenstrual Syndrome); such as anxiety, depression, Irritable Bowel Syndrome (IBS), migraine, and chronic fatigue syndrome.

[* These percentages were calculated by comparing the lists of symptoms for each chronic health issue with those listed for PMS, according to the (evidence-based) NHS website.]

Yet, there is no medical specialisation, or comprehensive clinical training, on the intersection between the menstrual cycle and ill health (with the exception of migraine, and reproductive health). And there are no National Institute for Health and Care Excellence (NICE) diagnostic guidelines on identifying/ differentiating hormone-related symptoms. UK doctors have to instead rely on guidance developed by a charitable organisation (the National Association for PMS).

UPDATE: The Royal College of Obstetrics & Gynaecology has since published (2017) guidelines on the clinical management of PMS- although they only list 7 premenstrual symptoms (with a bias towards the psychological); depression, anxiety, irritability, loss of confidence (?), mood swings, bloating, and mastalgia (breast pain).

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Additionally, since the average NHS General Practice consultation is now just 10 minutes long, patients and doctors alike may feel pressurised into prioritising symptoms based on severity/ impact, rather than taking the time to discuss all presenting symptoms.

Whilst this approach can be very helpful for ruling out serious health issues relatively quickly, for some patients it can limit the entire diagnostic process by discounting any potential relationship with their menstrual cycle/ hormonal medication, at too early a stage (see Emily’s story below).

Unfortunately, many of these symptoms are subjective in nature, i.e. they are perceptible only to the patient. For example, a doctor cannot easily observe or measure pain, nausea, a change in appetite, fatigue, visual disturbances, irritability, anxiety, or low mood. This increases the difficulty in conclusively distinguishing between symptoms caused by a chronic health issue e.g. depression, or IBS, and those caused by the menstrual cycle/ hormonal medication.

So, once any serious health issue has been ruled out, it is all too easy for female patients presenting with a ‘main’ symptom such as low mood, or anxiety, or an upset digestive system, to be diagnosed with the corresponding ‘most likely’ chronic health issue, without adequate consideration of any hormonal relationship (which might be much more easily treated). This has a potentially enormous impact on NHS costs, as well as on the health and wellbeing of millions of people.

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So how the devil does one deduce a hormonal relationship, Mr Holmes?

As mentioned in last week’s post, the use of a symptom diary becomes a critical tool in the diagnostic process. Recording the occurrence and severity of symptoms for (at least) a couple of menstrual cycles can produce data that might rule out, or confirm, a diagnosis of PMS/ hormone-related symptoms.

Although this might delay diagnosis, it can ultimately improve the long term understanding and management of a patient’s health and wellbeing, and potentially reduce repeat consultations, and costly (and ineffective) prescription medication.

It’s elementary, my dear reader.


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