Of course PMS is "real." The real question is why we don't have a cure.

Writer Frank Bures sparked some controversy Monday with an article published at Slate called “Is PMS Real?”

For the roughly 75 percent of menstruating women who experience PMS (premenstrual syndrome), the headline’s question was both nonsensical and insulting. Of course PMS is real, say the many women who deal with symptoms like cramping, bloating, irritability, fatigue, and depression every month.

Bures’s actual argument isn’t as clumsy as the headline. He cites research that suggests PMS (and its more severe cousin PMDD, or premenstrual dysphoric disorder) may be “culturally constructed” rather than a strictly biological inevitability.

The research Bures cites is pretty interesting. There seem to be cross-cultural differences in how women report their experiences of PMS — for instance, Chinese women report sensitivity to cold as a PMS symptom and American women don’t. American women report negative emotional symptoms and Chinese women usually don’t. One study found that women who endorse traditional gender roles tend to experience more menstrual distress. Another study found that the longer women of ethnic minorities live in the United States, the more likely they are to report PMDD.

But this research doesn’t come anywhere close to concluding, as Bures does, that “if [PMS] is a syndrome, it’s almost certainly a cultural one.” As obstetrician-gynecologist Amy Tuteur explained in a blog post in response to Bures, “these studies don’t demonstrate that PMS is culturally constructed, merely that the way women experience and talk about their symptoms can be culturally mediated. The fact that the response varies among cultures is not proof that the syndrome itself exists only in the minds of its sufferers.”

The larger point, though, is that Bures ignores the most important cultural factor of all when it comes to women’s health: our tendency to discount women’s pain and their experiences, and to generally treat their needs as less urgent than men’s. And that may help explain why PMS has remained such a medical mystery.

Women’s health needs are consistently taken less seriously than men’s

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Bures discusses the history of the word “hysteria,” which for centuries was used to dismiss women’s suffering as irrational — but he draws exactly the wrong conclusions from it. PMS isn’t, as Bures suggests, some kind of revival of the old myth that women’s “wandering uteruses” make them crazy. Instead, those myths explain why women’s health concerns like PMS often get ignored or dismissed.

Research finds that doctors are less likely to take women’s reports of pain seriously than men’s, partly due to implicit sexist biases that say women are overly emotional and irrational. In one study of patients who went to the emergency room with acute abdominal pain, men waited an average of 49 minutes before being given painkillers — and women waited an average of 65 minutes.

Writer Joe Fassler penned a horrifying account for the Atlantic about what this can look like in practice. His wife Rachel had ovarian torsion, which is a serious medical emergency requiring surgery. But they didn’t know that when they went to the emergency room; all they knew was that Rachel was in excruciating pain and that the staff wasn’t treating it like the emergency it clearly was. Rachel was hastily diagnosed with kidney stones by a male doctor, and it took more than 14 hours for another (female, as it happened) doctor to discover the mistake and rush Rachel into surgery.

Women are also underrepresented in medical trials. Researchers often fail to include women, Fusion’s Taryn Hillin explained, because in a nutshell, women’s bodies are more complicated than men’s. Their hormones change over their course of their menstrual cycles, they use hormonal birth control, get pregnant, and go through menopause, and these fluctuations can affect how drugs are metabolized. But that’s precisely why it’s essential to include more women in clinical trials — otherwise, doctors will have no idea how certain medicines actually interact with the female body.

John Guillebaud, professor of reproductive health at University College London, told Quartz that for some women, period pain can be “almost as bad as having a heart attack.” In our reporting, we’ve talked to women who have experienced premenstrual moodiness, pain and depression that was so acute, it interrupted their jobs and caused them to feel suicidal every month. Yet many doctors are told that ibuprofen is enough to treat PMS, and leave it at that. “Men don’t get it and it hasn’t been given the centrality it should have,” Guillebaud said.

And then there’s the fact that women’s health issues like birth control and abortion have become politicized — often treated like thought experiments on conception and morality, instead of medical concerns that affect real women’s bodies.

Culturally, we have become indifferent to women’s suffering. Because men don’t experience PMS, they sometimes don’t have a visceral understanding of why it matters. And even many women have been raised to believe that their suffering is “natural” or “just the way it is.”

“Is PMS real?” is the wrong question to ask

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To be fair to Bures, writers often don’t choose their headlines. He tried several times in the piece to explain that he doesn’t think women are making PMS up. Just because something is a “social construction,” he writes, “does not mean we don’t experience it — it simply means that our ‘real’ physiological symptoms can have roots in our mind as well as our body.”

But then why the scare quotes around “real”? Why the patronizing opening anecdote about the time his wife got (understandably) mad at him for questioning whether her bad mood was really connected to her period? Why the bizarre suggestion that PMDD isn’t a real mental illness because we don’t know the “biomarkers” to measure it or understand precisely how hormones affect it? After all, the DSM-5 is full of mental illnesses that can only be diagnosed based on their symptoms.

Tuteur used a handy thought experiment to explain why Bures’s framing was wrong-headed:

Imagine if I asked if erectile dysfunction is real or is it socially constructed. I might write something like this:

Erectile dysfunction is widely accepted to be a real disorder and there is an entire industry devoted to treating it with everything from medications to mechanical devices. But does erectile dysfunction reflect biological causes or is it figment of our sex ambivalent culture and men’s embrace of traditional gender roles?

You’d probably think I was nuts.

As someone who actually has PMDD, I (Emily) know perfectly well that it’s real. I struggle with symptoms that range from “somewhat disruptive” to “truly debilitating” that I can literally set my calendar by, and that just as predictably vanish a few days later.

That’s how premenstrual disorders work. According to PubMed Health, women with PMS feel a range of physical discomforts: abdominal pain and cramping, backaches, headaches, bloating, weight gain, breast tenderness, and sleeping and digestive interruptions. Even worse, perhaps, is the psychological distress: sadness, anxiety, irritability, lowered self-esteem, and an all-encompassing feeling of exhaustion.

The psychological symptoms are especially acute in cases of PMDD, which about one in 20 women experience. And the incredible part is that almost as soon as a woman's period begins, the symptoms in many cases vanish: energy levels bounce back, the aches, pains, and bloating go away, and mood lifts again.

The symptoms aren't the same for every woman, but again, many of us experience some combination of them. So the question isn’t whether these symptoms are real. The question is what causes them, and how to treat them.

The causes of PMS and PMDD are still a mystery — but it's not abnormal hormone levels

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One thing Bures certainly gets right: Frustratingly, scientists don’t understand the precise causes of PMS and PMDD and why some women suffer more than others. This may not be so surprising when you consider how under-funded women’s research is generally. (According to ResearchGate, there are five times as many studies on erectile dysfunction as there are about PMS.)

For a while, researchers thought the cause might be abnormal hormone levels — though they've mostly moved away from that idea.

"When you compare hormone levels of women who [experience PMS] to those who don't have this condition, they are virtually superimposable," said Dr. Peter Schmidt, a physician-researcher who has been studying PMS and PMDD for decades at the National Institutes of Health. So there's no hormonal deficiency or excess in these women, even in the ones who have the most severe PMDD.

Still, both PMS and PMDD do seem to be linked to the menstrual cycle, and hence hormones, in some way. That's why Dr. Barbara Levy, an obstetrician-gynecologist based in Washington, DC, now describes PMS as "an abnormal response to normal hormones." In particular, the changes in hormones may send a signal to the brain that precipitates negative moods. Again, why this happens for some is a mystery.

Researchers also don’t understand why normal changes in a woman's cycle affect some women more severely than others. They’ve looked at all kinds of things — exercise levels, history of depression or trauma, vitamin deficiency, body mass index, and of course hormone levels — and nothing seems to be predictive of whether a woman will experience PMS, PMDD, or nothing at all before their periods. A few studies have found that genetics may play a role, however, so researchers are now looking at the interplay between environmental and genetic factors.

There’s no cure for PMS

As for how to treat premenstrual symptoms, there are a few things that seem to help some women — though finding the best remedy usually requires lots of trial and error, and these approaches won’t necessarily help all women.

Some women find exercising on most days can be helpful, though the research in this area isn't particularly robust. There are studies that suggest antidepressant SSRIs taken only during the luteal phase of the cycle can reduce PMS symptoms, but this can come with other side effects.

Some women find that using the birth control pill smooths out their cycles, but others don't respond to this treatment at all. There’s some evidence that that dietary supplements like pyridoxine vitamin B6, calcium, and chaste tree extracts may help relieve symptoms, according to PubMed health. Of course, over-the-counter painkillers like ibuprofen can help with period pain.

As a first line of treatment, though, doctors suggest doing all the things you'd normally do to stay healthy: eating a balanced diet, getting a good amount of sleep, avoiding too much alcohol, caffeine, and sugar, and exercising. But again, unfortunately, these practices don't minimize symptoms in all women.

So basically, there's no "cure" for PMS, which makes sense since we still don't even know exactly what causes it.

The first step to solving women’s health problems is taking them seriously

Bures isn’t a doctor or medical journalist; he’s a travel writer who has been studying bizarre maladies that only happen in some cultures but not others, like “wind attacks” in Cambodia or magical penis theft in Nigeria, and who has bizarrely concluded that PMS may be a similar phenomenon.

A lot of the backlash to Bures’s piece focused specifically on his gender, though. Here, again, was a man trying to tell women that he understands their issues better than they do. That’s why the word “mansplaining” was invented, after all; it’s an indignity that women have to deal with much too often.

There really shouldn’t be anything inherently wrong with men reporting or commenting on women’s health issues. Plenty of reputable gynecologists and women’s health researchers are men. We need more men who will take women’s issues seriously and do the hard work to help improve their lives.

But “seriously” is the key word — and too often, it’s the missing one. It’s time to stop questioning whether women’s experiences are real, and instead start making them real priorities.

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