Menopause and menstruation myths.

Why do we have myths?

Myths are an integral part of our life, both as children and adults. For children, we equate them with traditional stories, but myths are more than stories. There are many definitions as to what a myth is according to the discipline from which you are studying them. For Edward Burnett Tylor, considered by many to be the founding father of anthropology, myths belong especially to “primitive” and static cultures. Myth only exist until they are replaced by science.(1) However, as we will see later, myths are present in all our cultures and not many people like to think of their own culture as primitive. Tylor does pick up on the fact that myths often concern important and emotional life events.(2) Jung and Freud, also leaned on myths, especially the classical Greek ones, to explain human experience and psychology such as the Oedipal complex.(3) These life events are often taboo or at least not always dinner table conversation. And if you have any doubts, just ask yourself when you had the last conversation about the menopause or menstruation in an open forum?

Menstruation.

Why is it important? Because as long as we don’t discuss menstruation outside of an obs& gynae setting, we are limiting society’s access to new resources and research. Just think about how prostate or breast cancer have become mainstream. 10 years ago no-one was talking about testicular cancer or male suicide yet thanks to Movember, a movement in which facial hair is grown during November, more people are testing and treating previously taboo diseases.

Myths and superstitions about menstruation are varied and often contradictory, even within the same country. Fairly commonly, they lead to recommendations not to have a bath, from Europe to America to Africa. Some are more country specific, such as in Japan some people believe you shouldn’t eat sushsi if you have your period because you have altered taste. My own favourite, as an Agatha Christie fan, is the myth that having sex whilst menstruating can kill your partner. Although it seems to come from Poland I have been unable to verify either that fact or find any (solved) cases of this type of murder. Or would it be homicide? Other myths lead to life-altering customs such as having to live separate from their family. Chaupaudi, as it is know, is not happening just in Nepal, but there it has been outlawed in response to a number of deaths of girls being left in huts whilst menstruating. It is based on a belief that women are untouchables and as such are expected to live separate from the the rest of the community during the time that they are menstruating.

The products used for periods are also shrouded in mystery. And here is my full disclosure, until I was asked to do some writing for a buy one, gift one menstrual cup, I had not really thought about them. I certainly had no idea how medical safety questions such as to how long menstrual cups could be left in – it turns out that although the Lancet have published a review stating that menstrual cups are safe, there is a lack of well structured research on how long they can be left in.(4) The Australian Therapeutic Goods Administration recommend no longer than 8h based on research into tampons whilst other regulatory authorities have not set any time recommendations at all. Many manufacturers say they can be left in place for up to 12h.(5) At a time of period poverty, over a lifetime menstrual cups are more cost effective than traditional tampons or pads. Depending on the facilities available, including running water, and also confidence about different products, menstrual cups can be a good option in developing countries. Here in Europe, the more you know about the options available, the more you can help your patients and also yourself and the people around you find period solutions which work.

Period poverty is a concept which has come to the attention to the public only recently, and a concept which some people refuse to believe exists in more affluent countries such as Spain and the UK. Yet in 2017, 1 in 10 girls in the UK reported not being able to afford sanitary products for their menstruation, leading to 1 in 7 girls having to ask friends for sanitary products.(6) And excluded from these types of reports are often people who have periods but may not identify as women or girls. Worldwide many people with periods miss out on schooling whilst menstruating. To combat this UNESCO has a program where schools are the place to educate and provide resources for those with periods.(7) And in a glass half full world, Scotland has just become the first country to provide free menstrual products.(8) Since January 2020 English schools can order free period products for those pupils receiving free school dinners.(9)

The madness of the menopause.

At the other end of the reproductive years, is the menopause. Our knowledge about it is as old as the texts we have to record health events. The menopause was reported as early as 6th Century Byzantium, when the physician Aeitius reported that “The menses do not cease before the thirty-fifth year nor appear after the fiftieth year”. Aeitius also noted that “those who are fat cease early”.(10) In Classical times, Aristotle spoke of “the menses ceas[ing] in most women around the fortieth year.(11)

Mental health and cognitive abilities around the menopause are widely studied but you might be surprised to hear that the story of menopause and madness is not an old one. In fact in the Anglo-Saxon world it only dates back to the 18th Century when Victorian values of sexual purity led to the medicalisation of libido in women who were past their child-bearing years. Stories of hysterectomies and cliteroidectomy in a time of no or little anaesthesia are chilling. Many women did not survive the treatment of their supposedly pathological symptoms, including sexual desire, enhanced emotions and hot flushes, periods of intense heat and sweating. Isaac Baker Brown was a surgeon in Victorian England who became famous and later infamous for his clitoridectomies as treatments for hysteria, epilepsy and insanity, as according to his book published in 1866.(12) Although he was criticised by the BMJ, there is an argument that this was more to do with colleagues wishing to save their own prestige and reputation rather than disagreeing or even stopping the procedure themselves.(13)

Less extreme, the “brain fog” many women experience around the menopause is now also becoming a more accepted subject of conversation. Especially as more women become leaders and senior figures in their 40s, 50s and 60s. A longitudinal study published in Neurology concluded that a decrease in cognitive performance was transitional coinciding with the perimenopausal period with post-menopause recuperation.(14) It also concluded that 

“Hormone initiation prior to the final menstrual period had a beneficial effect whereas initiation after the final menstrual period had a detrimental effect on cognitive performance.”(14) Obviously, this is the conclusion from one study and not a recommendation. 

As with menstrual products, the more conversation, the more research but also, the more society will be able to accommodate symptoms of the menopause. Often it is not an unwillingness to help but a lack of knowledge. And this may also apply to doctors. It is not only a case of treating our patients but also looking at our employees, colleagues and maybe even ourselves. The Faculty of Occupational Medicine and Royal College of Physicians has provided guidance for employers which include ventilation, staggered or flexible work times if sleep is an issue. It promotes an open general discussion but private individual chats, potentially with occupational health if the worker prefers that option. If you are interested in finding out about how to help with the menopause in healthcare workers, Sherwood Forest Hospital have a case study as to how to go about it. At a time of increased strain on healthcare workers, this may make the difference between losing and keeping experienced senior workers. A lot of positive feedback came early on in their project when the discussion was started and the taboo about the menopause was broken. Being heard was a positive help in itself. Of note, is that it doesn’t always need to be a big organisational shift, but rather an individual champion in your department. It could be you. And it’s not just for women. Gender equality in the workplace is a legal requirement, and if you identify as a man you can be proud to join the #heforshe movement promoted by the United Nations.

If you would like more information and resources, and to record your CPD associated with this podcast, please visit the IFMiL website. You will also find links to all the projects and articles mentioned in this podcast.

1.        LARSEN T. E.B. Tylor, religion and anthropology. Br J Hist Sci [Internet]. 2013 Dec 1;46(3):467–85. Available from: http://www.jstor.org/stable/43820407

2.        Tylor EB. Primitive culture: Researches into the development of mythology, philosophy, religion, art, and custom. Primitive Culture: Researches into the Development of Mythology, Philosophy, Religion, Art, and Custom. 2010.

3.        Freud S. The Interpretation of Dreams (Second Part). The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume V (1900-1901): The Interpretation of Dreams (Second Part) and On Dreams. 1900.

4.        van Eijk AM, Zulaika G, Lenchner M, Mason L, Sivakami M, Nyothach E, et al. Menstrual cup use, leakage, acceptability, safety, and availability: a systematic  review and meta-analysis. Lancet Public Heal. 2019 Aug;4(8):e376–93.

5.        Therapeutic Goods (Standard for Menstrual Cups) Order 2018 [Internet]. [cited 2020 Dec 1]. Available from: https://www.legislation.gov.au/Details/F2018L01546

6.        Plan International UK. Plan International UK*s Preserach on Period Poverty and Stigma [Internet]. 2017 [cited 2020 Dec 1]. Available from: https://plan-uk.org/media-centre/plan-international-uks-research-on-period-poverty-and-stigma

7.        United Nations Educational  la science et la culture Organización de las Naciones Unidas para la Educación, la Ciencia y la Cultura Организация Объединенных Наций по вопросам образования, науки и культуры منظمة الأمم المتحدة للتربية والعلم والثقافة 联合国教育、 S and COO des NU pour l’éducation, UNESCO, ЮНЕСКО, اليونسكو, 联合国教科文组织, United Nations Educational S and CO, et al. Puberty education & menstrual hygiene management. UNESCO;

8.        Scotland becomes first nation to provide free period products for all | Scotland | The Guardian [Internet]. [cited 2020 Dec 1]. Available from: https://www.theguardian.com/uk-news/2020/nov/24/scotland-becomes-first-nation-to-provide-free-period-products-for-all

9.        Department for Education. Period product scheme for schools and colleges in England [Internet]. 2020 [cited 2020 Dec 1]. Available from: https://www.gov.uk/government/publications/period-products-in-schools-and-colleges/period-product-scheme-for-schools-and-colleges-in-england

10.      Amundsen DW, Diers CJ. The Age of Menopause in Medieval Europe. Hum Biol [Internet]. 1973;45(4):605–12. Available from: http://www.jstor.org/stable/41459908

11.      AMUNDSEN DW, DIERS CJ. THE AGE OF MENOPAUSE IN CLASSICAL GREECE AND ROME. Hum Biol [Internet]. 1970;42(1):79–86. Available from: http://www.jstor.org/stable/41449006

12.      Brown IB. On the curability of certain forms of insanity, epilepsy, catalepsy, and hysteria in females. Robert Hardwicke, editor. 1866.

13.      Sheehan E. Victorian clitoridectomy: Isaac Baker Brown and his harmless operative procedure. Med Anthropol Newsl [Internet]. 1981 [cited 2020 Dec 4];12(4):9–15. Available from: https://pubmed.ncbi.nlm.nih.gov/12263443/

14.      Greendale GA, Huang MH, Wight RG, Seeman T, Luetters C, Avis NE, et al. Effects of the menopause transition and hormone use on cognitive performance in midlife women. Neurology [Internet]. 2009 May 26 [cited 2020 Dec 4];72(21):1850–7. Available from: https://pubmed.ncbi.nlm.nih.gov/19470968/

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