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CeMCOR Newsletter - April 2022 - Making Science of Women’s Experiences

What Women Say!
Making Science of Women’s Everyday Experiences

Jerilynn C. Prior BA, MD, FRCPC

Years ago, as a new endocrinology specialist and the only woman, I was referred many women bothered by unwanted facial hair also known as hirsutism. A number of them had surprisingly regular, normal length menstrual cycles (making a diagnosis of polycystic ovary syndrome [PCOS] unlikely). I wondered if the hirsutism was because they were not ovulating. I guessed that, if they could tell when their period was coming, that would predict an egg-releasing, ovulatory cycle. The most important clue is breast tenderness up under the armpit—with or without fluid retention, increased appetite and emotional sensitivity. These normal, not problematic premenstrual experiences are called “molimina1.

Therefore, I did a little experiment with the 61 regularly cycling women referred for hirsutism but with regular periods. As I saw each in my office, I asked whether she could tell that her period was coming. If she said yes, I asked “What was it that told you?” I recorded her answers in my chart. Then I gave her a lab slip for a progesterone blood test a week before she expected her flow. Many of these women just counted weeks; they just knew their period would come in about four weeks. A few said they knew because they got moody and junk-food hungry, but nothing else. Some said they felt a bit sensitive and had breast tenderness up near their arm.

To my surprise and delight, if a woman could not tell that her period was coming, and she did not volunteer high side-of-the-breast tenderness (without nipple/front breast soreness), she was significantly likely to have a low progesterone level. She could only tell her period was coming by the date if she was not ovulating. However, if she had high side-of-the-breast tenderness before flow, she was statistically likely to have a high progesterone level.

The data suggested that women could observe changes indicating ovulation. Woman’s answers gave a more specific and sensitive test result than most sophisticated laboratory investigations.

However, when I presented the results to my colleagues, my department head snorted, “No one will believe that!”  Why not? I asked? puzzled. He shrugged. He simply did not believe what women said. I did not publish those early data for many years, and then only in a review 2.

As CeMCOR’s March newsletter discussed, there is a belief that study of women’s menstrual cycles “Is NOT Science.” Women describing their cycle experiences today must face at least three barriers: the menstrual taboo, through which Society makes menstrual cycle discussions uncomfortable, if not downright forbidden; being thought neurotic and overly focused on our bodies, or being accused of “PMSing” with our judgement and/or values clouded by premenstrual mood changes. Not believing women extends also to non-menstrual issues—a woman reporting nausea and chest pressure is first considered to be anxious, over-breathing and to have heart-burn. By contrast, a similar aged man with the same symptoms will be promptly investigated for a heart attack.            

In late March, Scientific Reports, published our investigation of women’s 1-year experiences of menstrual cramps. These data refute the common, but not scientifically supported idea that: cramps mean ovulation! I’ll shortly describe how we did that study, its results and the story of its publication.

The backstory for those cramp data goes back to the mid-1980s and is evidence of my stubborn belief that women’s experiences can become scientific. I had gotten Federal funding to do a 1-year study of women’s cycles, exercise habits and bone changes to see whether marathon training, as expected, caused loss of periods and bone. We enrolled healthy, normal-weight women, 20-40 years old with regular cycles and normal ovulation, but differing in physical activity patterns. Some were walkers who played tennis or skied on the weekends, and some were recreational runners who planned to train for and run a marathon. We made sure all women were normally ovulatory on two cycles to be eligible. That 1-year study of exercise, cycles and bone density showed, for the first time, that ovulation disturbances were related to spine bone loss3.

Sixty six women collected cycle lengths using the Menstrual Cycle Diary©4, but 53 of these also carefully recorded 18 experiences each night before sleep. These included cramps (scored 0-4 for how painful), and changes in “feeling of energy” from “U” for usual to two letters above or below. Those days we used paper forms—the collected ~750 cycle diaries made a huge and dog-eared stack! The women also took their first morning temperatures—we could assess these to see if ovulation occurred and the luteal length was normal using the validated Quantitative Basal Temperature©5,6 (QBT) method. Eventually, over many years, those piles of paper were transformed into digital data.

As scientists volunteered, especially medical students learning scientific methods, we began to analyze women’s everyday experiences. The first Diary analysis was with a Memorial University undergraduate student who wondered about menstrual cycle-related weight changes and studied “fluid retention.” His analysis showed the day of the most bloating, surprisingly, was the first day of flow7. A psychologist, visiting professor, from the USA, who was interested in PMS, studied negative moods for the week before flow, and at the midcycle; she found no clear pattern of anxiety, depression and frustration occurred before flow in these healthy, initially ovulatory women8. Then a young woman with a masters in sex education from Australia volunteered to examine women’s interest-in-sex across the menstrual cycle to see whether women become sexy when they are most fertile. When we didn’t find that expected result, her paper was repeatedly rejected. Between 2014 and 2021 she had two children and her paper was rejected eight times. It was published finally in Women’s Reproductive Health9. The data showed that interest-in-sex was closely related to feelings of self-worth and energy but not associated with mid-cycle increased estrogen levels9

Our recently published paper on menstrual cramps asked whether it was true that cramps always go with ovulation10. Women with more intense cramps and those with few did not differ in age, exercise, cycle lengths or whether they had been pregnant. But when we examined cramps in cycles with normal ovulation versus cycles with short luteal phases or anovulation, we discovered cramp pain was significantly worse in ovulation-disturbed cycles10. We also found that cramps did not differ, within the 19 women who had both cycle types, in normally ovulatory versus anovulatory cycles10. Over 19 months, that paper was submitted six times, rejected without review three times, rejected with review twice and finally accepted following minor revision.

Women’s experiences are potentially strong scientific data. Since so little is known about what to expect or is normal for women’s menstrual cycle experiences, opportunity to analyze and share these findings lead to women’s self-learning, empowerment and can further Science. The goal of the overall Menstrual Cycle Experiences protocol is that all of the items in the Menstrual Cycle Diary will eventually be described, analyzed and published. We hope to eventually collect them into a book using lay language and translate the information for women’s learning. Finally, it is my dream that we can transform our findings/knowledge into a colourful story for girls 8 to 9 years old. Women’s experiences matter.

Reference List

1. Prior JC, Konishi C, Hitchcock CL, et al. Does Molimina Indicate Ovulation? Prospective Data in a Hormonally Documented Single-Cycle in Spontaneously Menstruating Women. Int J Env Res Pub He 2018; 15(5).

2. Prior JC. Ovulatory disturbances: they do matter. The Canadian Journal of Diagnosis 1997; February: 64-80.

3. Prior JC, Vigna YM, Schechter MT, Burgess AE. Spinal bone loss and ovulatory disturbances. New Engl J Med 1990; 323: 1221-7.

4. Prior JC. Exercise-associated menstrual disturbances. In: Adashi EY, Rock JA, Rosenwaks Z, eds. Reproductive Endocrinology, Surgery and Technology. New York: Raven Press; 1996: 1077-91.

5. Prior JC, Vigna YM, Schulzer M, Hall JE, Bonen A. Determination of luteal phase length by quantitative basal temperature methods: validation against the midcycle LH peak. Clinical & Investigative Medicine 1990; 13: 123-31.

6. Bedford JL, Prior JC, Hitchcock CL, Barr SI. Detecting evidence of luteal activity by least-squares quantitative basal temperature analysis against urinary progesterone metabolites and the effect of wake-time variability. EurJ Obstet Gynecol Reprod Biol 2009; 146(1): 76-80.

7. White CP, Hitchcock CL, Vigna YM, Prior JC. Fluid Retention over the Menstrual Cycle: 1-Year Data from the Prospective Ovulation Cohort. Obstet Gynecol Int 2011; 2011: 138451.

8. Harvey A, Hitchcock CL, Prior JC. Ovulation disturbances and mood across the menstrual cycles of healthy women. J PsychosomObstet Gynaecol 2009; 30: 207-14.

9. Macbeth AB, Goshtasebi A, Mercer GW, Prior JC. Does Interest in Sex Peak at Mid-Cycle in Ovulatory Menstrual Cycles of Healthy, Community-Dwelling Women? An 11-month Prospective Observational Study. Women's Reproductive Health 2021; 8(2): 79-91.

10. Bann S, Goshtasebi A, Shirin S, Prior JC. A one-year observational cohort study of menstrual cramps and ovulation in healthy, normally ovulating women. Sci Rep 2022; 12(1): 4738.

Estrogen’s Storm Season: Stories of Perimenopause

Estrogen's Storm Season

by Dr. Jerilynn C Prior

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