'Just periods': How link between PMDD, an extreme form of PMS, and depression is trivialised, lacks awareness in India

One is all too familiar with chemists wrapping sanitary napkins in black plastic bags and passing them on to customers rather shiftily. Even today, the subject of menstruation is wrapped in a similar black plastic bag of stigma in our society. But with the advent of the internet and media, some of these dusty windows are opening up, and discussions on such subjects are coming to the fore. Shehla Rashid, a PhD student at Delhi’s Jawaharlal Nehru University, had recently tweeted about PMDD, or Premenstrual Dysphoric Disorder, which is an extreme form of Pre-Menstrual Syndrome (PMS). The stigma surrounding menstruation remains deeply rooted in the general populace, and Rashid’s tweet is perhaps a step forward for the cause of awareness on the matter. A 2017 study has revealed that of 20 percent of women suffering from PMS in India, 8 percent have signs of PMDD, indicating that a large chunk of the country’s female population suffers from the physical and mental trauma of the disorder.

What is PMDD? This disorder is characterised by a variety of somatic, emotional and behavioural symptoms that manifest during the final week of the menstrual cycle. It is an extreme version of PMS, with a rather distressing list of symptoms — extreme irritability, lethargy, sleep deprivation, heightened anxiety causing feelings of being overpowered, persistent rage issues and depression. In the United States, the National Institute of Health has done extensive research on PMDD, where they have found that it is a disorder caused by cellular response to estrogen and progesterone in the body. Ignorance is bliss. And this is exactly why where there is lack of understanding of the differences between PMDD and PMS. When a woman mentions such symptoms, the presumption is that it is “just periods” and that “it will pass”. As a result, lack of awareness and right perspective become the underlying problems of the issue. With her tweet, Rashid hits the nail on the head, describing the usual responses towards PMDD as a “mood swing” or a “figment of the woman’s imagination”, critiquing societal mindsets towards menstruation in general. [caption id=“attachment_5276551” align=“alignleft” width=“380”] A poster used to educate girls about menstruation. AFP[/caption] Clinical studies and research In 2013, a group of researchers conducted a survey in Ahmedabad, for which it approached five schools to study PMDD among 221 girls between the ages of 13 and 18. The study found that of the 221 girls, 27 (12.22 percent) suffered from PMDD. They showed signs of persistent irritability and work impairment. Five of the 27 girls with PMDD had comorbid depression, which means they were fighting two or more psychiatric disorders. Researchers at Khyber Medical College in Peshawar, Pakistan, conducted a study of 384 girls, of whom they diagnosed 62 with PMDD. The most frequently reported symptoms among them were stress, anxiety, general body discomfort and anger. Another study conducted by four independent experts in India stated that patients who suffer from five or more symptoms, including one mood disorder, are classified as having PMDD. PMDD and suicide: Rashid’s tweet also discusses her personal battle with one of the more serious symptoms associated with PMDD — suicidal thoughts. The research conducted on the link between suicidal thoughts and PMDD is a murky domain in India. So far, research indicates that the possible relationship between the two depends on the serum levels of serotonin. Some studies also show that women with PMDD have lower serum serotonin levels in the premenstrual phase and lower serotonin platelets as compared to women without PMDD. Moreover, the frequency of PMDD has been found to be significantly higher among those who have attempted suicide. This is quite worrying and requires a scientific, open and unconstrained discussion. The legal community is also beginning to analyse and understand symptoms associated with menstruation. Very recently, the Rajasthan High Court, in a judgment, held that a woman accused of murder had committed the crime because of insanity triggered by PMS . PMS treatments have been centred around pharmacological treatments using medicines and non-pharmacological treatments such as hormonal therapy and lifestyle modification. However, stress management and social awareness is critical to improve the patient’s overall health — both physical and mental. Studies have also suggested that in worst-case scenarios where women experience extreme pain due to PMDD, they require surgical intervention to remove their ovaries and uterus. Researchers and doctors have tried a number of other common forms of interventions and treatment, such as salt and caffeine restrictions, diuretic agents and anti-inflammatory drugs. Whatever be the treatment applied, the severity of the experience of women who suffer these symptoms suggests that the matter cannot be brushed under the carpet. Indian conditions The question still remains — how does one approach this subject in India? Women like Rashid who bring such matters to the public domain and initiate discussion must be appreciated. Her tweet has focussed the spotlight on an issue that lacks clinical studies and social awareness in India. The situation remains grim in the country as studies on PMDD have not been conducted across a larger population of adolescent girls, as a result of which, many grow up ignoring, or worse, trivialising, their experiences with menstruation and symptoms of premenstrual distress. As with most social problems, education and awareness campaigns and sensitisation drives will help provide adequate information to young girls and help them step into adulthood with greater ease and confidence. Apart from the physical distress of PMDD and PMS, the often hushed up psychological distress sometimes leads to suicidal thoughts and acute anxiety attacks, developing at a tender age that ultimately has a domino effect on the lives of young women down the years. The problem is not properly understood, and the road ahead to address the subject is foggy and uncertain. India needs to acknowledge the severity of the problem and understand that narrow-minded considerations rooted in misogyny and dogma, if left unchecked, will bring us down and oppress women for generations.