This section is devoted to the understanding of various aspects of female human body & problems related to it. It also provides brief & basic information about Premenstrual syndrome.
A) Female Reproductive System:
The human female reproductive system has considerably greater responsibility than male reproductive system as it performs many functions like Oogenesis, Reception of Sperm during copulation, providing an environment conducive to fertilization, supplying nutrition to the baby and providing a birth canal for the baby.
Female genital organs can be mainly divided into -
1) External Genital Organs and 2) Internal Genital Organs
The exact view of external genital organs is visible in
Figure – 1 while Figure - 2 reveal internal organs.
In the true pelvic cavity lie a Pair of Ovaries, Pair of Oviducts (Fallopian tubes or uterine tubes), a Uterus and a Vagina, which are the main organs of female reproductive system (Figure – 3) whereas Mammary glands (Breasts) positioned over the pectoral muscles of the chest wall are the accessory organs of female reproductive system (Figure - 4).
Each Ovary is a compact organ made up of an outer cortex and an inner medulla. The female gametes - eggs or ova, in various stages of maturation remain enclosed in the scattered ovarian follicles that are embedded in the stroma of the cortex (Figure - 5). The main function of ovary is to produce, store and release eggs into the fallopian tubes through the process of ovulation (Figure – 6).
The ovum passes into the uterus through the fallopian tubes. During this transit, if a sperm enters through vagina and cervix of uterus, ovum gets fertilized and zygote gets implanted in the walls (endometrium) of uterus (Figure – 6).
Female Monthly Sexual Cycle:
The normal reproductive years of the female are characterized by monthly rhythmical changes in the rates of secretion of female hormones and corresponding physical changes in the ovaries and other sexual organs. This rhythmical pattern is stated to be the female monthly sexual cycle.
Two significant results of this cycle are –
1) Release of single ovum each month from ovary through ovulation which is known as ovarian cycle.
2) Formation of uterine endometrium in advance for the implantation of the fertilized ovum at the required time of the month through uterine cycle (Figure – 7 & 8).
Ovulation and Ovarian Cycle:
The shedding of the ovum from the Graffian (or ovarian) Follicle of Ovary is called Ovulation (Figure – 6). This ovum is yet not mature and is indeed a secondary oocyte which is undergoing cell division. After release of ovum, the follicle gets transformed into Corpus Luteum.
The series of changes that begin with the formation of an ovarian follicle and end with the degeneration of the corpus luteum constitute the ovarian cycle.
Fate of Corpus Luteum:
If the ovum released is not fertilized by the sperm (male gamete) the corpus luteum will persist for fourteen days and is known as Corpus Luteum of Menstruation. But as and when it gets fertilized and pregnancy results, it will be known as Corpus Luteum of Pregnancy and will persist for three to four months.
While the changes concerned with ovulation and the formation of corpus luteum are going on in the ovary, the uterine endometrium shows striking cyclical changes. These cyclical changes constitute the uterine or menstrual cycle (Singh and Pal, 2001).
“Menstruation (derived from Greek word, men= month) is the monthly vaginal bleeding coming at the interval of about 28 days from the estrogen-progesterone primed uterine endometrium” (Figure – 9).
Menstruation is a periodic haemorrhage from the corporeal endometrium which usually first appears coincident with puberty and continues throughout the fertile period of life (Figure – 10).
This occurs during the reproductive (from menarche to menopause) age of a woman except during pregnancy and sometimes during lactation. Female sexual cycle occurs 14 days after the onset of menstruation. Also, a group of symptoms occur in the week or two weeks (7 to 14 days) before this monthly bleeding and usually goes off after bleeding starts. This is known as Premenstrual Syndrome. It is different for each woman. As monthly periods stop during menopause, it brings an end to PMS also. It can be considered to be a menstrual disorder, but it shouldn’t be mistaken to be Dysmenorrhoea.
The menstrual cycle can be divided into 4 phases: Menstrual phase of 4 days, Proliferative phase of 10 days, Secretory phase of 11 days and Regressive phase of 3 days (Figure – 9). Various changes occurring during these phases are listed in table - 1.
Women’s Season – Monthly Cycle (As per Ayurveda) - compiled from the book: Ayurveda Secrets of Healing written by Maya Tiwari.
Apart from regular Seasons that we experience per year, women are believed to possess an additional season which occurs once every month. The beginning period of the full moon is the natural cycle for ovulation. Receiving the essence of the moon at this time, a woman’s sexual impulses heighten & her vitality is once more replenished. Then, during the time of the new moon, she experiences the natural cycle of menstruation. Menstruation is caused by the sun absorbing energies from the earth, which in turn draws the menstrual waste from the body. When the cycle has not been tampered by the use of contraceptive pills & other birth control devices, harmful foods & activities, disruptive sexual activities etc , the natural ebb & flow of a woman’s monthly cycle remains in harmony with the cycles of the moon.
During ovulation, Pitta is most dominant, while Vata dominates the period of menstruation & Kapha the period following menstruation (Chart - 1).
Female Hormonal System:
Female sex hormones play a significant role in above mentioned sexual cycle of a woman. It consists of three hierarchies of hormones:
1) A hypothalamic releasing hormone, gonadotropin - releasing hormone (GnRH).
2) The anterior pituitary sex hormones, follicle- stimulating hormones (FSH) and luteinizing hormone (LH), both of which are secreted in response to release of GnRH.
3) The ovarian hormones, estrogen and progesterone, which are secreted by the ovaries in response to the two female sex hormones from anterior pituitary gland (Figure -11).
FSH and LH play vital role in ovarian and uterine cycle, estrogen plays an important role in developing secondary sexual characters in a girl while progesterone is necessary for menstrual and pregnancy times.
B) Historical background of PMS:
PMS appears to be a recent phenomenon, but it was described many decades ago as premenstrual tension with increased seizure activity in the late luteal phase of menses. Hippocrates mentioned it in the fourth century B.C., however, it became only a medical epidemic in the nineteenth century. Aristotle said that a monstrous woman could dull a mirror with a look and the next person to look into it would be bewitched. Due to instinctive horror the scientific study of menstruation and its related disorders has been hampered by overpowering influence of traditions and social- cultural beliefs since ages.
Traditionally it was thought that PMS affect multiparous middle class articulate women in their late 30s and 40s (O’ Brien et al., 2003; Shaw et al., 2003). As stated by d’Orban (1983) and Fritz and Speroff (2005) in the 19th and 20th century’s menstruation and its related health problems were considered to be responsible for antisocial behaviour. A hundred years ago, Victorian physicians warned that menstruation might cause temporary insanity, and that women could go berserk, attacking friends and family or killing infants. They suggested such women to be locked up during their menstrual years for their own, and society good.
As mentioned by Israel (1967) and Sloane (1980), Robert. T. Frank, an American chief of obstetrics and gynecologist at Mt. Sinai Hospital in New York City, was the first to introduce the phrase ‘Premenstrual Tension’ in 1931 when he described 15 patients with the syndrome of irritability, anxiety, depression and edema (swelling) in the days before menstruation or in the first four days of the flow and disappear abruptly with the onset of menstrual flow. Later, Greene and Dalton extended and used the definition to ‘Premenstrual Syndrome’ in 1953 in a report of 84 cases recognizing the wider range of symptoms (Cameron, 2000; Edmonds, 2000; Cronje et al., 2003; Studd, 2003; Speroff and Fritz, 2005). Katherine Dalton (1984), an Eng. Physician who has written extensively on this, “Curse of Eve” as she said, argued PMS to be responsible for increased incidences of crime, jailing for alcoholism and prostitution, school misdemeanors, sickness in industry, hospitalization for accidents, psychiatric disorders and general hospital admissions (Sloane, 1980). Also, Insanity Defense Reform Act of 1985 in US [18 U.S.C.A.20 (Supp. 1985)], provided that PMS may be argued as a mitigating factor in criminal behaviour if it is connected with psychosis (Silberstein, 1991; Decherncy and Nathan, 1991).
Parry (1997) stated that in the last two decades a degree of understanding has emerged and treatment guidelines are now available from clinical studies. This clinical syndrome rapidly disappears with the beginning of menstrual flow and thus remains unseen by many women. In present time PMS is studied more systematically in western countries especially by psychiatrically trained clinicians as compared to the handful amount of research in Asia. Today we have succeeded in proving its existence, discovering its major symptoms, are able to classify it and find its more severe forms too.
Nowadays, psychiatrically trained clinicians have identified a variant of PMS as proposed by the American Psychiatric Association in Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1994. This was known as Late Luteal Phase Dysphoric Disorder (LLPDD) in DSM – III, but is now, known as Premenstrual Dysphoric Disorder (PMDD/ PDD) as per DSM - IV (Rivera and Frank, 1990; Keye, 1998; Fraser et al., 1998; O’ Brien et al., 2003).
Dr Katharina Dorothea Dalton: The Pioneer Researcher (Compiled from www.thelancet.com, vol.364, 30/10/2004).
Katharina Dalton began her career as a chiropodist, and even wrote a textbook on the subject, but is best known for her work describing premenstrual syndrome (PMS). Robert Frank had described “premenstrual tension” in 1931, but Dalton, along with Raymond Greene—Graham Greene’s brother—published the first paper on PMS in the BMJ in 1953. Soon after that, she established the world’s first PMS clinic at University College Hospital, London, UK. The 1953 BMJ paper was the first of many published by Dalton on PMS, based on research with tens of thousands of patients. Because she didn’t do placebo-controlled studies, some have questioned her results, although hardly anyone doubts her critical role in convincing the medical establishment that PMS was a real condition.
“She was a pioneer”, said Uriel Halbreich, professor of psychiatry & gynaecology at the State University of New York at Buffalo, “and pioneers are not necessarily the ones providing the definitive answers”. She was “a really persistent and effective advocate of the recognition of PMS” in the UK, and her work was quite well accepted there, he said. It was less accepted by US physicians, he added, but she was admired by many women and garnered much publicity.
Some of the publicity was due to high-profile court cases in which Dalton served as an expert witness. She turned down several cases in which attorneys were planning a “PMS defence” because the women didn’t have a cyclical pattern of behaviour that responded to treatment. But in 1980, she took the cases of Sandie Smith, who had convictions for crimes such as arson and assault and was charged with threatening to kill a police officer, and Christine English, charged with murder. Smith got probation after Dalton showed her crimes had occurred at monthly intervals and English were allowed to plead guilty to manslaughter due to diminished responsibility. The cases were the first successful uses of the PMS defence. Dalton later took similar cases, but was strict about the ones she accepted, concerned that the plea was not abused. “The genuine cases are few and far between”, she wrote, “it is important to ensure that PMS is not made a universal defense” (Figure – 12).
C) Definitions of PMS:
It is both difficult to define PMS and quite controversial too. However, any definition of PMS must recognize that the syndrome is a recurring cyclical disorder in the luteal phase of the menstrual cycle, involving behavioural, psychological and physical changes resulting in loss of work or social impairment (Reid and Yen, 1981; Edmonds, 2000; Cameron, 2000). As stated by Cronje et al., (2003) and Studd (2003), no one has yet provided a universal definition of PMS as so many symptoms have been associated with the condition, but there is no doubt that it does not occur prior to puberty, after menopause or during pregnancy.
Yet, some of the popularly accepted and broadly considered definitions are as follows :
1) PMS is “The cyclic occurrence of symptoms that are of sufficient severity to interfere with some aspects of life and which appear with consistent and predictable relationships to menses” was stated by Endicott et al., (1981), (http://apt.rcpsych.org/cgi/contnet/full/7/6/469).
2) “In every woman, a few days before the approach of menses, mild subjective and objective changes occur, but when, during the week or ten days before the menses these changes are exaggerated, and it is termed PMT” defined by Masani (1982).
3) “PMS is the name given to a group of symptoms that generally include headache, breast swelling and tenderness, abdominal bloating, swelling of the hands and feet’s, fatigue, depression, tension, irritability and increased appetite –especially for sweet or salty foods” (Michaud et al., 1988).
4) According to Dickerson et al., (2003), (www.aafp.org/afp/20030415/1743.html) it can be defined as, “a common cyclic disorder of young and middle age women characterized by emotional and physical symptoms that consistently occur during the luteal phase of the menstrual cycle.”
5) “PMS is a combination of emotional, physical, psychological and mood disturbances that occurs after a woman’s ovulation and normally ends with the onset of her menstrual flow” (www.medicinenet.com).
Apart from its negative effects, PMS also shows positive symptoms like productivity, high energy levels, increased sexual desires, intense and vivid dreaming and creativity (www.womenshealthlondon.org.uk).
D) Cause of PMS:
PMS is a psycho-neuro-endocrine disorder of unknown, complex and multifactorial etiology. No sure cause is yet known. Studies prior to 1983 did not incorporate appropriate diagnostic methods and thus lacked accuracy and homogeneity. Later all efforts were made in the direction of isolating a specific pathophysiologic mechanism which got failed too. Several theories have been proposed by Magos (1988), (Cronje et al., 2003; Studd, 2003), (Table – 2). Sen Gupta (2001) also supports these theories and suggests hyperprolactinaemia theory along with them. But none of these are able to find the root, instead, all work upon the justification of symptoms only. We yet don’t have any biological markers of PMS.
Apart from all the above theories, Parry (1997) suggested selective serotonin reuptake inhibitors (SSRIs), anxiolytics, and noradrenaline reuptakes inhibitors to be effective factors. Previously mentioned ovarian hormones also appear to contribute since PMS responds to the GnRH (Freeman et al., 1997). Presently, due to contradictory results of researchers, the common etiologic background is considered to be related to ovarian hormones, beta endorphin and psychosocial factors. Genetic factor also seem to play a role, as the concordance rate is two times higher in monozygotic twins than in dizygotic twins. Irrespective of which hypothesis is correct, the subjective nature of the disorder makes it impossible to deny that emotional and psychogenic factors not only aggravate the symptoms but evoke additional ones.
E) Symptoms of PMS:
Around 160 – 200 symptoms have been associated with premenstrual state. The most common symptoms were categorized into eight symptom clusters derived from forty seven symptoms on the Menstrual Distress Questionnaire (MDQ) with six (pain, concentration, behavioural change, autonomic reaction, water retention, negative affect), as most important, by Moos (1968). Later on a broader classification came into existences and PMS symptoms are nowadays grouped into physical, psychological and behavioural symptoms. Few researchers also classify these symptoms into cognitive and affective symptoms.
Commonly reported symptoms in women with PMS:
1) Psychological symptoms : Anger, irritability, cry spell/tearfulness, tension, mood swing, anxiety, nervousness, lack of concentration, confusion, forgetfulness, restlessness, loneliness, worthlessness, unsociable, feeling clumsiness, sadness/blues, boredom, skeptic, poor in judgement, lack of decision power.
2) Pain symptoms : Headache, Backache, Breast pain, Mastalgia, abdominal cramps, body ache, pain in joints, leg pain.
3) Bloatedness : weight gain, abdominal bloating, edema of extremities (arms & legs), water retention, abdominal fullness
4) Appetite symptoms : increase or decrease in appetite, total loss of hunger, binge eating, food craving, nausea,
5) Behavioural symptoms : fatigue, dizziness, sleep more, or sleeplessness, decreased efficiency, increased energy, tiredness.
Apart from all these mentioned above, there are certain symptoms like acne, dullness of skin or too much shine of skin, being very creative than in normal days, bad dreams, crave for love, thoughts related to painful events in the pasts loss of interest in routine activities or even hobbies, etc.
F) Classification of PMS:
The most common symptoms of PMS are divided into four subgroups (Abraham, 1983; Abraham and Rumley, 1987; Lark, 1989; www.drkaslow.com/html/premenstrual_syndromes.html). These can occur singly or in combination with other subgroups and are characterized by typically occurring symptoms. Even though the concept of defining sub groups of PMS based on symptom patterns is appealing, at the present time there is no evidence to suggest that these subgroups represent different etiologies or different patho-physiological mechanisms. These are:
1) PMS-A (Anxiety): wherein anxiety, irritability, mood swings and nervous tension are the main responsible symptoms.
2) PMS- C (Carbohydrates or Craving): sugar craving specially chocolates or ice-cream, palpitation, fatigue, headache, dizziness are the chief symptoms.
3) PMS- H (Hyper hydration): Here, bloating and tenderness, weight gain, breast congestion and mastalgia and occasionally edema of face and extremities are considered.
4) PMS- D (Depression): When depression, confusion, memory loss, suicidal thoughts, lethargy are the major factors, patient is considered to be of this subgroup.
G) Treatments for PMS (O’ Brien, 2003; Shaw et al., 2003)
Non – pharmacological treatments
Rest, Isolation, Psychotherapy, Education, Yoga, Self –help groups, Counseling, Intravaginal electrical stimulation, Diet, Music therapy, Hypnosis, Homeopathy, Agnus castus, Acupuncture, Stress management, Nutritional manipulation, Salt restriction, Irradiation of ovaries, Bilateral oophorectomy, Endometrial ablation, Hysterectomy.
Non – hormonal treatments
Pyridoxine, Essential fatty acids, Vitamins, Diuretics, Aldosterone antagonists, Clonidine, Non- steroidal anti- inflammatories, β- blockers, Zinc, Tranquillizers, antidepressants, Phenobarbital, Lithium, Immune complexes, Antifungals, Naltrexone, Selective serotonin reuptake inhibitors (SSRIs).
Progesterones, Pregestones, Oral contraceptions, Testosterones, Danazol, Bromocriptine, Hormone implants, GnRH analogues, Mifepristones, Drospirenone.
Table – 1 : Phases of Menses (Farrer, 1987)
|FSH released||Follicles ripen||Endometrium sheds|
|FSH continues to be released, level of FSH drops 24 hours before ovulation, LH is released- the LH 'surge'||Graffian follicle formed; estrogen –progesterone produced, ovulation occurs.||Repair and rebuilding of endometrium|
|LH continues to be released for a few days then level drops rapidly.||Corpus luteum develops from ruptured follicle and produces progesterone- estrogen.||Endometrium thickens and gets prepared nourish fertilized ovum.|
|4)Regressive (Premenstrual) phase|
|Low level of oestrogen stimulates production of FSH||Corpus luteum degenerate, so level of progesterone and estrogen fall.||Endometriun grow, secretion cease and menstruation.|
Table - 2 : Proposed theories for PMS (Magos, 1988)
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