Black box… The reduction of the menstrual cycle in medical education

What we don’t know does harm us!

Ahhhhhhh… It’s been a long time since I was able to share some of my own research on here. But, here it comes… And it’s big!

FYI- A book chapter outlining this study in detail has just been published by Oxford University Press– but here’s a helpful summary:

Black box (noun): 1. A usually complicated electronic device whose internal mechanism is hidden from or mysterious to the user. Broadly: Anything that has mysterious or unknown internal functions or mechanisms (Merriam-Webster, 2022)

1. What I did and why…

There is far more to the menstrual cycle than hormones… Image: Christina Morillo- Pexels

During my PhD research on cyclical symptoms (of all kinds), I interviewed around half of the world’s experts in PMS (Premenstrual Syndrome). This may sound super impressive, but it was only 16 people in total (we need more menstrual health researchers)!

During the interviews, I was really struck by how limited the PMS expert descriptions of healthy menstrual physiology were… I began wondering why they only talked about ‘hormones’, given that the menstrual cycle is so much more than this?

I decided to check out what GPs, gynaecologists, psychiatrists, clinical psychologists and research scientists are taught… So, I compiled a list of the most commonly used UK school biology, general biomedical, gynaecological, and reproductive physiology textbooks and reviewed their menstrual cycle content.

What I found was super shocking!

2. The criteria…

Here’s a list of the things I thought would be important for a menstruating person/ doctor to know about:

3. The results…

Brackets indicate brief mention but lack of explanation. Letters A-J correspond with the content list above.

Erm, so it turns out that even specialist reproductive physiology textbooks don’t describe much about the healthy menstrual cycle, beyond its hormonal coordination.

In fact, while all the textbooks contained a lovely diagram of the changes in hormones across the cycle – none of them mentioned spontaneous decidualisation (the mechanism we evolved to help protect us from unviable or potentially dangerous pregnancies, and the reason why we have regular periods). This meant that the highly inflammatory nature of ovulation, decidualisation, and menstruation was also almost completely absent from medical textbooks.

Perhaps most surprisingly, there was very little mention of the pain, blood loss, or typical premenstrual changes that we experience on a regular basis, or even common menstrual health issues, such as endometriosis, PCOS, or heavy menstrual bleeding. There was also no mention at all of the cyclic triggering of underlying health conditions.

4. Why?

All the textbooks effectively reduced the whole menstrual cycle to ‘changes in sex hormone levels’ only. This is simply not accurate or particularly helpful for menstrual health knowledge or clinical practice. I argue that since there is no scientific rationale, the exclusive focus on the female sex hormones in menstrual education is most likely due to the unintentional influence of the myth of the hysterical/ hormonal female.

“Yes dear, of course I believe you’re ill…” Frans Van Mieris, ‘The Doctor’s Visit’, 1657.

In ancient times, female prevalent symptoms were blamed on the womb– the essence of femininity. This led to the diagnosis of ‘hysteria’. But this inaccurate belief also exists as a gender stereotype- one we all recognise- the ‘hysterical female’ who is biologically prone (thanks to her reproductive body) to invent, exaggerate, and imagine things. This gender myth is still alive and well, although now we tend to blame the (female sex) hormones, rather than the womb itself.

The associated inaccurate belief that ‘women are hormonal’ (but men are somehow not) seems to have influenced medical education. In fact, the pretty model of cyclic hormonal changes seems to have been equated with the menstrual cycle, itself.

The actual (highly inflammatory) physical events of ovulation, decidualisation and menstruation have been obscured and largely omitted from our education, to the point that it appears we no longer ‘see’ them. For decades, we have been hoodwinked into thinking that if symptoms are cyclical then they must be ‘hormonal’- even though this has never been proven!

What is more, healthy premenstrual changes are quite literally the cardinal signs of inflammation- temperature increase/ heat, water retention/ swelling, pain, and blood flow changes- and yet, many clinicians and researchers currently do not perceive them as such. Why not? Again, there is no adequate scientific explanation, so this situation must indicate a form of bias.

5. So what?

Heat, pain, swelling, blood flow… The inflammatory nature of premenstrual changes image: Brigitte Tohm- Pexels

Despite nearly a century of research, no causal relationship between any sex hormone and female-prevalent symptoms/ conditions has ever been identified… And yet, PMS researchers are still looking for one! No doubt in part because many are unaware of menstrual physiology beyond its hormonal coordination. This is a waste of extremely limited resources for researching this topic…

If the purpose and inflammatory nature of the menstrual cycle were better understood by all, premenstrual changes would no longer seem mysterious, scary, weird, or difficult to treat. We already know that premenstrual symptoms respond really well to anti-inflammatory interventions (diet, lifestyle, medications)- and if not, symptoms are usually the sign of an underlying health condition. This information needs to be shared more widely because it could genuinely help improve the quality of life of millions!

Unfortunately, teaching the ‘hormonal’ model of the menstrual cycle, also provides pseudo-scientific ‘evidence’ for the damaging ‘hormonal female’ gender myth. This is a problem because we know that the myth contributes to disbelief in women’s accounts of painful or distressing symptoms, and even reports of abuse and discrimination.

In short, we need to teach more comprehensive menstrual health literacy to all (and especially doctors) to improve menstrual health (globally) and bust the myth of the hysterical female, once and for all.

Full study reference/ citation:

King, S. (2024) ‘Black Box: The reduction and mystification of the menstrual cycle in Western school and medical education’ in K. Standing (Ed.) Experiences of Menstruation from the Global South and North Oxford University Press


Categories: Anatomy, Gender myths and Menstrual education.