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Conceptions and Misconceptions of the Menstrual Cycle a
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Elissa Koff PhD , Jill Rierdan PhD & Margaret L. Stubbs a
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Research Associate, Psychology
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Research Associate, Department of Psychology, Wellesly Center for Research c
Research Associate, Wellesley College Published online: 26 Oct 2008.
To cite this article: Elissa Koff PhD , Jill Rierdan PhD & Margaret L. Stubbs (1990): Conceptions and Misconceptions of the Menstrual Cycle, Women & Health, 16:3-4, 119-136 To link to this article: http://dx.doi.org/10.1300/J013v16n03_07
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Conceptions and Misconceptions of the Menstrual Cycle
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Elissa Koff, PhD Jill Rierdan, PhD Margaret L. Stubbs, PhD
ABSTRACT. Eighty college women were queried about their knowledge of three aspects of the menstrual cycle (menstruation, ovulation, and menopause). Questions concerned the biology of each event and the physical, emotional, and cognitive changes believed to be associated with them. Reasoning from the biases and limitations in the scientific and popular literature, it was predicted that: (1)women would be relatively uninformed about the menstrual cycle, but more informed about menstruation than about ovulation or menopause, and (2) negatively valued changes would be described more frequently than positively valued ones. Results indicated that basic knowledge of the menstrual cycle, even among welleducated women, is at times incorrect, generally incomplete, and negatively biased. These findings confirm the need for a more comprehensive approach to menstrual education that speaks both to the biology of the menstrual cycle and to norms and variability of associated physical and behavioral changes. Elissa Koff is Research Associate, Wellesley Center for Research on Women and Professor of Psychology, ~ e l l e s l college, e~ Wellesley, MA 02181. Jill Rierdan is Research Associate, Wellesley Center for Research on Women and k c turer in Psychology, Wellesley College. Margaret L. Stubbs is Research Associate, Wellesley Center for Research on Women. This research was supported in part by Grant 16034 from the National Institute of Child Health and Human Development to authors Koff and Rierdan. A portion of this paper was presented at the meetings of the Society for Menstrual Cycle Research, Salt Lake City, Utah, June, 1989. The authors wish to thank Dr. Daryl Costos, Susannah Cohen, and Jennifer Thompson for their contributions to this project. Women & Health, Vol. 16(3/4) 1990 0 1990 by The Haworth Press, Inc. All rights reserved.
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Throughout history, the menstrual cycle-an intimate part of every woman's life for the 30 to 40 years between menarche and menopause - has been surrounded by secrecy, superstition, and stereotypes (Delaney, Lupton, & Toth, 1988). The increasingly open approach to sexual issues in contemporary society has led to greater candor about some aspects of the menstrual cycle, but in a curious way, also may have reinforced some of the more extreme attitudes that have associated menstruation with impairment, incompetence, and instability. The almost exclusive emphasis in the media on the perimenstrual period (including the four to five days preceding menstruation), when a host of negative physical, emotional, and behavioral changes are purported to occur, has created a context in which all menstrual cycle changes tend to be perceived as symptoms. The possibility of positive changes is all but precluded by this view of menstruation as a disease or a disability. Yet, as Asso (1983) has argued, alternate constructions of the 'menstrual cycle not only are feasible, but more consonant with women's subjective experiences as well as with a growing body of data. In the case of emotional changes, for example, Asso described the first half of the cycle as a time of progressive emotional relaxation and tension reduction; the follicular phase as a time of increasing alertness, self-confidence, and well-being; ovulation as a time of peak responsiveness, assertiveness, and receptivity; and the days prior to menstruation as a time of heightened arousal, tension, anxiety, and other negatively toned emotions. Asso's suggestion that feelings, moods, and behaviors vary in intensity and valence across the menstrual cycle is compatible with the regular and predictable changes in hormonal levels and in the state of the reproductive organs that essentially define the menstrual cycle (Asso, 1983; Gannon, 1985). The scientific literature on the menstrual cycle, while quite extensive, is neither comprehensive nor systematic. For a variety of reasons, including no doubt ease of identifying these cycle phases, research has focused on the premenstrual and menstrual phases of the cycle. So, for example, there is a large body of data on attitudes, beliefs, and knowledge in regard to menstruation, but relatively little in regard to other phases of the cycle (McClintock, 1981; Parlee, 1981). In addition, negative aspects of the cycle are
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assessed more frequently than positive ones in the scientific literature (Koeske, 1983), just as negative "symptoms" are emphasized in the popular literature (Budoff, 1980). Further, menopause, which marks the ending of the reproductive cycle, tends not only to be isolated from the rest of the cycle, but also to be medicalized, having been viewed until recently primarily as a deficiency disease (Goodman, 1982). The biases and limitations that characterize both the scientific and popular literature on the menstrual cycle make it likely that most women's understanding of the cycle, imperfect at best, will be particularly deficient in regard to events other than those occurring in the premenstrual and menstrual phases, as well as disproportionately negative in regard to expectations and attributions about feelings and behavior across the full cycle. The current study was undertaken to evaluate the validity of this view of women's knowledge and conceptions of the menstrual cycle. Three aspects of the cycle - menstruation, ovulation, and menopause -were examined. Questions were asked about the biology (broadly defined) of each aspect, and about the changes-physical, emotional, and cognitive-intellectual-believed to be associated with it. Two hypotheses were tested: (1) that women's knowledge of the menstrual cycle in general would be insufficient, but that women would be more informed about menstruation than about either ovulation or menopause, and (2) that negatively valued changes would be described more frequently than positively valued ones. We believed it important to test these hypotheses empirically because it seems to follow that if women lack accurate and comprehensive information about the menstrual cycle, their ability to control their reproductive and daily lives could be compromised, making it difficult, for example, for them to make informed decisions about such issues as contraception, safe and effective treatments for menstrual disorders, and strategies for adjusting to the changes associated with menopause. Also, better understanding of the scope of women's knowledge and beliefs about different aspects of the menstrual cycle could suggest useful directions for interventions by educators and health care providers. College-aged women were seen as a useful group in which to document women's personal understandings of the menstrual cycle.
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First, they have had several years of menstrual experience; second, they have been exposed for many years to menstrual socialization via their families, peers, and culture; and third, they are intelligent and educated enough to have mastered the rudimentary facts of the menstrual cycle. While data from a college sample is not fully generalizable, such a sample could serve as a reference group with whom to compare other groups who presumably would have less opportunity to become knowledgeable about the menstrual cycle. Indeed, it could be argued that use of a college sample provides a particularly stringent test of our hypotheses. To the extent that the hypotheses are validated in the current sample, this most likely means that less privileged groups would evidence even less adequate knowledge and more extensive biases. METHOD Subjects
Subjects were 80 college women with a mean age of 19.3 (SD = 1.1) years. Reported ages at menarche ranged from 9-16 years, with a mean age of 13.1 (SD = 1.4) years. Subjects were recruited from introductory and intermediate level psychology courses. Participation was voluntary, and all subjects (N = 83) who expressed interest in the study completed the questionnaire. Subjects represented a cross-section of students in the institution, and were distributed across classes (from first year students to seniors) and majors (about half were current or potential psychology majors). Data from three subjects in their late thirties to early forties were excluded from the final analyses because of the disparity between the ages of these subjects and the rest of the sample. Materials and Procedure
Subjects responded to a questionnaire about the menstrual cycle that contained a variety of questions soliciting both objective (e.g., information about the biology of the menstrual cycle) and subjective data (e.g., beliefs about menstrual experiences). The data base for this report consisted of subjects' responses to 16 open-ended questions about menstruation, ovulation, and menopause. Six ques-
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tions explored subjects' knowledge of each of these events (e.g., " What is the cause of menstruation; How can a woman determine when she is ovulating; What is menopause?"). Nine questions explored subjects' beliefs about physical, emotional, and cognitiveintellectual changes associated with each event (e.g., "What physical changes do women experience during ovulation?"). Also on the questionnaire was a question about hormonal changes across the menstrual cycle ("Describe as best you can how hormones fluctuate across the menstrual cycle"). Subjects completed the questionnaire individually or in small groups, and were asked to prpvide careful, accurate, and detailed information. Responses were anonymous.
RESULTS Responses were read by two of the investigators, who abstracted categories under which major points made by informants were subsumed. After these categories were determined, responses were reread, broken down into data points, and assigned to appropriate scoring categories when consensus between the two investigators was achieved. Although a small number of subjects responded with only a word or two, the majority were more verbose, so that the responses of most informants included multiple data points relevant to more than one scoring category. For questions that sought factual information, responses were assigned to scoring categories and also rated for accuracy. For questions that sought more subjective information, such as subjects' beliefs and expectations, responses simply were assigned to scoring categories without being rated for accuracy. The data that follow are presented in two ways, depending upon the nature of the question; in some instances, the proportion of respondents (out of 80) giving a particular response or category of response is reported, and in others, the proportion of responses assigned to particular scoring categories, relative to the total pool of responses, is reported. Since the purpose of this study was to provide normative data about women's knowledge and beliefs about menstruation, ovulation, and ,menopause, individual variation in
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subjects' knowledge and beliefs about these aspects was not analyzed.
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Menstruation Knowledge of menstruation was addressed by a question about the cause of menstruation. To be considered correct, a response had to include the information that the uterine lining was shed if fertilization had not taken place. Forty-one percent of the subjects gave responses that met this criterion (e.g., "Menstruation is the elimination of the uteral lining built up to feed a fertilized egg; if the egg is not fertilized, the lining and egg are released from the body"). Another 16% mentioned only the lining and another 9% only the unfertilized egg. Nine percent of the respondents failed to mention these elements at all, defining menstruation instead by vague references to hormones (e.g., "Menstruation is caused by hormonal changes in the body"), and 24% provided incorrect or irrelevant information. While some of these responses were classified as incorrect because they were overly general or vacuous (e.g., "Menstruation is caused by the female cycle of fertility"), most reflected confusion about the sequencing of menstrual cycle events. The most frequent of these errors was confusion with ovulation (e.g., menstruation is caused "by ovulation," or "by the passage of the egg down the fallopian tubes," or "by the discharge of ovaries"). In this sample of college women, then, over 30% were unable to provide even a rudimentary definition of menstruation. Questions about physical, emotional, and cognitive changes experienced at menstruation, specified as the actual menstrual flow, elicited a wide range of responses. Subjects' responses aboutphysical changes were extensive, with most subjects attributing multiple, and generally unpleasant, changes to menstruation. As shown in Table 1, changes could be subsumed under four broad categories: general discomfort, such as cramps, aches, and pains; water retention and/or weight gain; tender or swollen breasts; and a variety of autonomic signs, such as nausea, temperature changes, and bowel changes. Every subject responded to this question. It is noteworthy that no positive changes were thought to be associated with menstruation.
Kofl Rierdan, and Stubbs Table 1.
Physical changes attcibuted to menstruation, ovulation, and menopause.
Menstruation
Ovulation
294 294 3.7 1-9**
106
Total number of responses Total number of changes* Mean number of changes* Range*
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Types of changes and frequency (2)
,
73 1.7 1-4
Menopause 109 95 1.4 1-3
.
discomfort(36) water retention1 weight gein(3l) tenderlswollen breasts(l4) autonomic signs(l6) other(3)
discomfort(l9) cycle change(33) vaginal discharge(9) negative physiol. temperature change(9) change(51) water retention1 emotionalshift(3) weight gain(l4) don't know(l3) tenderlswollen breasts(7) other change( 12) no change(l2) don't know(l9)
%nly includes specific changes mentioned by subjects; does not include "no change" or "don't know" **excludes one outlier with 14 changes
The question about emotional changes associated with menstruation also elicited a multiplicity of responses, and again, almost all were negative. As shown in Table 2, three main categories of responses-depression, emotional lability (e.g., mood swings, emotional ups and downs), and irritability (e.g., cranky, touchy, shorttempered)-appeared with about equal frequency, and often, all three were cited by individual subjects, suggesting that subjects themselves were conceptualizing the changes as different. Other changes mentioned were tension and anxiety; low energy level, characterized by sluggishness, apathy, and fatigue; autonomic changes (e.g., nausea); and feelings of uncleanliness or "rattiness." A very small proportion of responses described positive changes (feeling "more sexy" or affectionate). The pattern of responses to the question about cognitive changes shown in Table 3 presented a sharp contrast to the data reported in Tables 1 and 2. Whereas respondents associated a large number and range of physical and emotional changes with menstruation, a much
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smaller number and more limited range of negative cognitive changes (e.g., inability to concentrate, short attention span, decreased rational thinking) was thought to be associated with menstruation. The predominant response to this question was that there were no cognitive changes associated with menstruation, or at least "none that (respondents) knew of." Confusion about what was meant by cognitive or intellectual change was evidenced by a sizable group of respondents, who described negative changes of an emotional or physical nature. In keeping with subjects' beliefs about physical and emotional changes associated with menstruation, only 2% of the responses entailed references to positive change. Ovulation
The questions about ovulation requested factual information about the event itself (i.e., "What is ovulation?") and about women's awareness of the event (i.e., "How can a woman determine when she is ovulating?"); beliefs about the various changes associTable 2.
Emotional changes attributed to menstruation, ovulation, and menopause. Uenstruation
Total number of responses Total number of changes' Mean number of changes* Range*
Ovulation
Menopause
168 161
2:s 1-7
Types of changes and frequency ( X ) depreesion(21) emotionality(22) irritability(28) other negative change(20) positlve change(2) no change(2) don't know(2)
dysphoria(33) elevated mood(l0) sexual arousal(9) no change(l5) don't know(33)
dysphoria(66) loss(2S) positive change(4) don't know(5)
*only includes specific changes mentioned by aubjectsi does not include "no change" or "don't know"
Kofi Rierdan, and Stubbs Table 3. ' Cognitive changes attributed to menstruation, ovulation, and menopause. Menstruation Total number of responses Total number of changes* Mean number of changes* Range*
82 28 1.0 1-2
Ovulation 69 8 1.0 1-2
Menopause 66 16 1.0 1-2
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Types of changes and frequency (7.) no change(50) negative change( 13) positive change(2) emotional change(l1) physical chenge(6) don't knou(l7)
no change(51) miscellaneous change(l2) don't know(38)
no change(36) positive change(9) negative emotional change( 14) don't know(39)
*only includes specific changes mentioned by subjects; does not include "no change" or "don't know"
ated with the event were solicited as well. The majority of respondents (69%), when asked to define ovulation, correctly associated it with release of the (mature) egg; within this group, most identified the ovary as the site of release, and a small number also mentioned the fallopian tubes as the target of the egg. Some respondents (9%), rather than describing the physical features of ovulation, characterized it either as the time fertilization could occur or as the point in the menstrual cycle two weeks before, or after, menstruation. Incorrect definitions of ovulation (20%) revealed confusion about both the anatomy and the physiology of ovulation; misconceptions included assumptions that the ovary discharged eggs directly into the uterus, that eggs either were somehow deposited in the ovary or traveled through the ovary, that the ovary walls were shed as the eggs were released, and that eggs were released throughout the two weeks before menstruation. As with the question concerning the biology of menstruation, about 70% of the respondents were able to provide minimally acceptable information. Responses to the question of how a female could determine when she was ovulatingwere quite detailed, and often included more than
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one sign of ovulation (total number of responses = 109). Responses fell into three major categories, which corresponded closely to those identified in the literature (Vollman, 1977) as the most accessible or obvious indicators of ovulation. The most frequently mentioned sign was an increase in body temperature (32% of responses); the next most frequent sign (22%) involved a change in the quantity or quality of vaginal discharge, or more generally, "secretions;" and the next most frequent sign (18%)was some kind of pain, primarily abdominal pain, ovary pain, or cramps. (The fourth major sign, intermenstrual bleeding (Vollman, 1977), was not mentioned at all.) Also reported (5%) was a miscellany of changes including increased energy and increased sexual interest. Fourteen percent of responses referred vaguely to cycle phase (e.g., "make a chart when period is-ovulation is two weeks prior"; "time of month in relation to last period"), and 6% of responses were incorrect, typically involving beliefs that ovulation occurred during menstruation (e.g., "when the bleeding starts, some feel cramps and experience emotional changes") or at some other (incorrect) time in the cycle. As described in the preceding section, three main types of "physical" changes were cited as signs of ovulation. In response to the specific question about physical changes associated with ovulation, some of those changes were reiterated, and several new ones were mentioned. As can be seen in Table 1, the major additional signs were bloating and/or weight gain and breast swelling andlor tenderness; other changes included increases or decreases in energy level, and "hormonal changes." It was perplexing to note that while all but 2% of subjects were able to identify specific physical changes as signs of ovulation, 19% of these same subjects responded with "don't know" and 12% declared that there were no physical changes when asked directly about physical changes accompanying ovulation. As can be seen in Table 2, the most frequent responses to the question about emotional changes associated with ovulation described dysphoric changes, the majority of which were similar to those reported for menstruation. Euphoric changes, particularly elevated mood and sexual excitement, also were described, but less frequently. The assumption reflected in the negative responses con-
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trasts with reports in the literature that typically describe heightened feelings of well-being and pleasantness around the time of ovulation (Dennerstein & Burrows, 1979). Nonetheless, it should be noted that subjects are more likely to attribute positive changes to ovulation than to menstruation. Additionally, a third of the responses to this question claimed ignorance of any changes, and a smaller number denied any changes. The pattern of responses to the question about cognitive changes, shown in Table 3, was similar to that seen in response to the parallel question about menstruation, with the predominant response being that there were no cognitive changes associated with ovulation. As with the question on menstruation, respondents described a miscellany of changes, cognitive and noncognitive, positive and negative, among which were "intellectual peak," "decreased attention span," "lowered grades,?' and "feeling more positive about oneself." One-third of respondents denied any knowledge of changes, and in a departure from the general pattern of responding to this questionnaire, a sizable number of respondents simply did not respond to this question.
Menopause Three factual questions were asked about menopause. When asked to define menopause, almost all respondents (96%) correctly associated it with the cessation of menstrual periods, with the end of ovulation, and/or with the end of the reproductive process. While the overwhelming majority of these responses conformed to the narrow definition of menopause as the last menstruation (Asso, 1983), a number of responses described a process of transition involving changes in hormonal levels and variability in the nature of rnenstrual periods, corresponding to the broader view of menopause as a gradual process associated with a progressive increase in anovulatory cycles and the eventual cessation of menstruation (Gannon, 1985). Even among misinformed respondents, there was a recognition that menopause somehow marked the end of the reproductive cycle (e.g., "When you are born, you have a certain number of oocytes, and once you have ovulated all these eggs, you go into menopause"). More subjects were able to correctly define meno-
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pause than menstruation or ovulation, but a correct response to this question may have been easier for respondents to articulate since less detail was required. The age at which respondents expected menopause to occur ranged from 34 to 70 years. Some respondents gave broad age ranges (e.g., "between 34 and 60"), but most gave accurate age estimates, with the majority of respondents (66%) placing the event somewhere between the ages of 45 and 55. Although establishing the precise facts about age at menopause has been problematic, menopause in Western societies is believed to occur on average at about 50 years of age, within a typical range of 45 to 55 years (Asso, 1983; Gannon, 1985). Responses to the question about when menopause is over indicated considerable variability in subjects' conceptions. While 36% of respondents conceived of menopause as a single physiological event, namely the cessation of menstruation, 27% believed it to be an enduring condition, that "once it starts, goes on forever," ending "only with death," and 4% believed it to be a state that was terminated when a psychological, rather than a physical, process occurred (e.g., when a woman could "emotionally deal with the fact that she was no longer in her sexual prime"). Fourteen percent erroneously associated the end of menopause with the disappearance of symptoms such as hot flashes, which in fact seem to be most frequent and most intense shortly after the cessation of menstruation (Gannon, 1985). The remaining responses (19%) were denials of any knowledge, refusals to answer, and nonspecific responses (e.g., "it varies with the woman"). Responses to questions about physical, emotional, and cognitive changes believed to be associated with menopause reflected a diversity of conceptions. Most subjects suggested multiple physical changes, which could be subsumed under two broad categories, as shown in Table 1. The first concerned physical changes in the menstrual cycle itself, notably the cessation of menstruation or ovulation, changes in the quality or quantity of menstrual bleeding, and hormonal changes or imbalances. The second, and larger category of responses, was comprised of unpleasant physiological changes, most frequently the hot flash, which is in fact the most common complaint of menopausal women. Other prominently mentioned
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changes, all of which have been associated with menopause (Gannon, 1985), were weight gain, unwanted hair growth, dry or coarsened skin, and dry vagina. Notable for its absence was any mention of osteoporosis, which, next to hot flashes, is probably the most extensively discussed and well-publicized 'menopausal change (Gannon, 1985). Answers concerning emotional changes associated with menopause also entailed a multiplicity of responses, as seen in Table 2. As already observed in the responses to the parallel questions about menstruation and ovulation,' the predominant response mentioned some type of dysphoria, most notably depression, irritability, and mood swings, or some kind of loss (specifically, loss of femininity, reproductive capacity, sex drive, or youth). A very small number of responses cited positive changes (e.g., joy, relief). While it is true that scant attention has been paid to the positive emotional changes associated with menopause, it is also the case that there is little evidence to substantiate the presence of widespread negative emotional changes such as those suggested by these responses (Asso, 1983). Subjects were much less pessimistic about cognitive changes, as seen in Table 3, and a small number (8%)of positive changes were described (e.g., a woman could now "concentrate on such things as intellect"). The bulk of responses reflected a view that there were no cognitive changes associated with menopause, or indicated ignorance of any possible changes or confusion about the meaning of cognition. As with responses to the parallel question about ovulation, a sizable proportion of subjects did not respond to this question. Hormonal Changes Across the Cycle
Respondents were poorly informed about hormonal changes across the menstrual cycle. In response to this factual question, 33% of subjects reported that they "didn't know" how hormones fluctuated across the cycle or left the question blank. To evaluate the accuracy of the remaining responses (N = 56), a simplified schema was developed, which encompassed the following information: (a) FSH (follicle-stimulating hormone) induces the develop-
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ment of follicles; (b) follicles produce estrogen, which stimulates the endometrium of the uterus to thicken; (c) a surge of LH (luteinking hormone) causes the follicle to burst and release its ovum; (d) LH then induces the follicle to become the corpus luteum, which secretes progesterone, which develops the endomentrium further, along with estrogen; (e) declines in levels of estrogen and progesterone, in the absence of fertilization, result in menstruation. When this schema was applied, only one response could be classified as even marginally correct. Thirteen percent of the responses named three or all four hormones, and 54% named one or two hormones (usually estrogen and progesterone), but these responses were all inadequate or incorrect. Another group of responses (32%) mentioned changes in hormonal levels, but did not identify the hormones. DISCUSSION
Menstruation has long suffered a poor reputation in our culture (Emster, 1975), and the results of this study suggest that intelligent, well-educated young women may still believe in the "curse" of menstruation. Negative stereotypes about the menstrual cycle apparently are so pervasive that an event such as ovulation, which is not typically identified with negative physical changes, and is in fact reported to be accompanied by positive emotional changes (Dennerstein & Burrows, 1979), is nevertheless thought to be associated primarily with negative physical, emotional, and (possibly) cognitive changes. The presence of such beliefs provides support for the hypothesis that there is a negative bias to constructions of the various aspects of menstrual life considered in this study. The hypothesis that women's knowledge of menstrual life is generally inadequate also was supported by the data, particularly in regard to menstruation and ovulation and specific hormonal changes. The women in this study had some idea of the cause of menstruation, associated ovulation with the release of the egg, and defined menopause as the cessation of menstrual periods; nonetheless, a significant proportion evidenced confusion about the specific organs and glands involved in menstruation, the process of ovula-
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tion, and the sequencing of phases and the role of hormones in the menstrual cycle. With regard to these latter aspects, it was particularly striking that the roles of estrogen and progesterone were so poorly understood, since they are widely discussed in the popular literature. It was noteworthy, too, that some respondents confounded cycle phases (e.g., they confused ovulation with the premenstrual or menstrual phase), and/or misunderstood the sequence or timing of the phases (e.g., they assumed that menstruation followed ovulation by only a few days). Not only was there a negative bias in respondents' views of menstrual life, at least in terms of physical and emotional correlates of menstrual events, but there seemed to be little distinction made among the three events. Questions about changes associated with menstruation elicited the greatest number and variety of changes, but the bulk of these actually are more identified with the premenstrual phase than with menstruation per se (Abplanalp, 1983; Parlee, 1973). The analogous view of menopause as physically and emotionally unpleasant corresponds to widely held and inaccurate beliefs about menopause,. which continue to be espoused despite recent evidence suggesting that menopausal women in fact do not view menopause as a negative life event. Rather, these women minimize the importance of menopause, do not associate it with undue stress or anxiety, and tend to report relief or neutral feelings about the cessation of menstruation (Asso, 1983; Kahana, Kiyak, & Liang, 1980; McKinlay & Jefferys, 1974). Interestingly, others (Neugarten, Wood, Kraines, & Loomis, 1963) also have found that younger women expressed more negative attitudes toward menopause than did middle-aged and elderly women, who did not anticipate menopause with trepidation or recall it as particularly stressful (Kahana et al., 1980). Like menstruation and menopause, ovulation also was associated with negative physical and emotional changes, but to a lesser degree. A greater number of respondents believed that there were no changes, or said that they did not actually know if there were changes, associated with ovulation, than with the other two events. The latter statement of uncertainty is understandable in light of the
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confusion many women expressed about the timing of ovulation within the broader menstrual cycle. While subjects believed that negative physical and emotional changes were associated with menstruation, ovulation, and menopause, they seemed less pessimistic about cognitive changes associated with these events. In large part, subjects discounted the possibility of cognitive changes, which is consistent with the bulk of published evidence that argues against a menstrual cycle effect on cognitive functioning (Sommer, 1983), or denied any knowledge about changes. Given that respondents had only to refer to their own menstrual experiences to answer the questions about changes associated with menstruation and ovulation, their denial of knowledge about these changes is puzzling. It is possible, of course, that "don't know" responses simply reflected uncertainty about what a "cognitive" change was; the detailing of physical and emotional changes when cognitive changes were requested certainly lends credence to this argument. Another possibility is that "don't know" responses were given by women who don't experience changes, but who are so influenced by negative cultural beliefs that they are unable to accept the absence of changes. The results of this study suggest the need to address the topic of menstrual education for adult women with respect to both basic knowledge of the menstrual cycle and expectations for associated physical and behavioral changes. Given the generally limited level of understanding and the generally negative tone of the responses observed in this sample of educated college women, we can only speculate about the knowledge base of women with fewer opportunities for exposure to information. It is probably not unreasonable to expect that they would demonstrate even less adequate knowledge and a more pronounced negative bias. Ignorance or misinformation about the menstrual cycle has serious implications for women's lives. Minimally, it can keep them from understanding their bodies and their reproductive lives. Additionally, it is likely to be associated with ignorance or misinformation about other intimate matters, such as sexuality. Lack of knowledge can place women at risk for unwanted pregnancy and sexually transmitted diseases, can result in misunderstanding and mistreatment of menstrual disorders, and can prevent effective communica-
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tion with other women and with health care providers. While it is certainly true that there has been a significant cultural advance in lifting the taboo against the discussion of menstruation (Delaney, Lupton, & Toth, 1988), we clearly still have far to go before such discussion is appropriately informed and unbiased.
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REFERENCES Abplanalp, J. M. (1983). Premenstrual syndrome: A selective review. In S. Golub (Ed.), Lifting the curse of menstruation. Women & Health, 8 (2/3), 107123. Asso, D. (1983). The real menstrual cycle. New York: John Wiley & Sons. Budoff, P. W. (1980). No more menstrual cramps and other good news. New York: G.P. Putnam's Sons. Delaney, J., Lupton, M. J., & Toth, E. (1988). The curse: A cultural history of menstruation (Revised edition). Urbana and Chicago, Ill: University of Illinois Press. Dennerstein, L., & Burrows, G. D. (1979). Affect and the menstrual cycle. JourM I of Aflecrive Disorders, 1 , 77-92. Ernster, V. L. (1975). American menstrual expressions. Sex Roles, 1, 3-13. Gannon, L. R. (1985). Menstrual disorders andmenopause. New York: Praeger. Goodman, M. J. (1982). A critique of menopausal research. In A. V. Voda, M. Dinnerstein, & S. R. O'Donnell (Eds.), Changingpenpectives on menopause (pp. 273-288). Austin: University of Texas Press. Kahana, E., Kiyak, A., & Liang, J. (1980). Menopause in the context of other life events. In A. J. Dan, E. A. Graham, & C. P. Beecher (Eds.), The menstrual cycle: Vol. I . A synthesis of interdisciplinary research (pp. 167-178). New York: Springer. Koeske, R.D.(1983). Lifting the curse of menstruation: Toward a feminist perspective on the menstrual cycle. In S. Golub (Ed.), Lifting the curse of mensrmation. Women & Health, 8 (213). 1-16. McClintock, M. K. (1981). Major gaps in menstrual cycle research: Behavioral and physiological controls in a biological context. In P. Komnenich, M. McSweeney, J. A. Noack, & N. Elder (Eds.), The menstrual cycle: Vol. 2. Research and implicarions for women's health (pp. 7-23). New York: Springer. McKinlay, S. M. & Jefferys, M. (1974). The menopausal syndrome. British Jountal of Preventive and Social Medicine. 28, 108-1 15. Neugarten, B. L., Wood, V., Kraines, R. J., & Loomis, B. (1963). Women's attitudes toward the menopause. Vita Humana, 6, 140-151. Parlee, M. B. (1973). The premenstrual syndrome. Psychological Bulletin, 80, 454-465.
Parlee, M. B. (1981). Gaps in behavioral research on the menstrual cycle. In P. Komnenich, M. McSweeney, J. A. Noack, & N. Elder (Eds.), The menstrual
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cycle: Vol. 2. Research and implications for women's health (pp. 45-53). New York: Springer. Sommer, B. (1983). How does menstruation affect cognitive competence and psychophysiological response? I n S. Golub (Ed.), Lifting the curse of memtmation. Women & Health, 8 (2/3), 53-90. Vollman, R. F. (1977). The menstrual cycle. I n E. A. Friedman (Ed.), Major problems in obstetrics andgynecology, Vol. 7. Philadelphia: W. B. Saunders.
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Conceptions and Misconceptions of the Menstrual Cycle a
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Elissa Koff PhD , Jill Rierdan PhD & Margaret L. Stubbs a
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Research Associate, Psychology
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Research Associate, Department of Psychology, Wellesly Center for Research c
Research Associate, Wellesley College Published online: 26 Oct 2008.
To cite this article: Elissa Koff PhD , Jill Rierdan PhD & Margaret L. Stubbs (1990): Conceptions and Misconceptions of the Menstrual Cycle, Women & Health, 16:3-4, 119-136 To link to this article: http://dx.doi.org/10.1300/J013v16n03_07
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Conceptions and Misconceptions of the Menstrual Cycle
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Elissa Koff, PhD Jill Rierdan, PhD Margaret L. Stubbs, PhD
ABSTRACT. Eighty college women were queried about their knowledge of three aspects of the menstrual cycle (menstruation, ovulation, and menopause). Questions concerned the biology of each event and the physical, emotional, and cognitive changes believed to be associated with them. Reasoning from the biases and limitations in the scientific and popular literature, it was predicted that: (1)women would be relatively uninformed about the menstrual cycle, but more informed about menstruation than about ovulation or menopause, and (2) negatively valued changes would be described more frequently than positively valued ones. Results indicated that basic knowledge of the menstrual cycle, even among welleducated women, is at times incorrect, generally incomplete, and negatively biased. These findings confirm the need for a more comprehensive approach to menstrual education that speaks both to the biology of the menstrual cycle and to norms and variability of associated physical and behavioral changes. Elissa Koff is Research Associate, Wellesley Center for Research on Women and Professor of Psychology, ~ e l l e s l college, e~ Wellesley, MA 02181. Jill Rierdan is Research Associate, Wellesley Center for Research on Women and k c turer in Psychology, Wellesley College. Margaret L. Stubbs is Research Associate, Wellesley Center for Research on Women. This research was supported in part by Grant 16034 from the National Institute of Child Health and Human Development to authors Koff and Rierdan. A portion of this paper was presented at the meetings of the Society for Menstrual Cycle Research, Salt Lake City, Utah, June, 1989. The authors wish to thank Dr. Daryl Costos, Susannah Cohen, and Jennifer Thompson for their contributions to this project. Women & Health, Vol. 16(3/4) 1990 0 1990 by The Haworth Press, Inc. All rights reserved.
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Throughout history, the menstrual cycle-an intimate part of every woman's life for the 30 to 40 years between menarche and menopause - has been surrounded by secrecy, superstition, and stereotypes (Delaney, Lupton, & Toth, 1988). The increasingly open approach to sexual issues in contemporary society has led to greater candor about some aspects of the menstrual cycle, but in a curious way, also may have reinforced some of the more extreme attitudes that have associated menstruation with impairment, incompetence, and instability. The almost exclusive emphasis in the media on the perimenstrual period (including the four to five days preceding menstruation), when a host of negative physical, emotional, and behavioral changes are purported to occur, has created a context in which all menstrual cycle changes tend to be perceived as symptoms. The possibility of positive changes is all but precluded by this view of menstruation as a disease or a disability. Yet, as Asso (1983) has argued, alternate constructions of the 'menstrual cycle not only are feasible, but more consonant with women's subjective experiences as well as with a growing body of data. In the case of emotional changes, for example, Asso described the first half of the cycle as a time of progressive emotional relaxation and tension reduction; the follicular phase as a time of increasing alertness, self-confidence, and well-being; ovulation as a time of peak responsiveness, assertiveness, and receptivity; and the days prior to menstruation as a time of heightened arousal, tension, anxiety, and other negatively toned emotions. Asso's suggestion that feelings, moods, and behaviors vary in intensity and valence across the menstrual cycle is compatible with the regular and predictable changes in hormonal levels and in the state of the reproductive organs that essentially define the menstrual cycle (Asso, 1983; Gannon, 1985). The scientific literature on the menstrual cycle, while quite extensive, is neither comprehensive nor systematic. For a variety of reasons, including no doubt ease of identifying these cycle phases, research has focused on the premenstrual and menstrual phases of the cycle. So, for example, there is a large body of data on attitudes, beliefs, and knowledge in regard to menstruation, but relatively little in regard to other phases of the cycle (McClintock, 1981; Parlee, 1981). In addition, negative aspects of the cycle are
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assessed more frequently than positive ones in the scientific literature (Koeske, 1983), just as negative "symptoms" are emphasized in the popular literature (Budoff, 1980). Further, menopause, which marks the ending of the reproductive cycle, tends not only to be isolated from the rest of the cycle, but also to be medicalized, having been viewed until recently primarily as a deficiency disease (Goodman, 1982). The biases and limitations that characterize both the scientific and popular literature on the menstrual cycle make it likely that most women's understanding of the cycle, imperfect at best, will be particularly deficient in regard to events other than those occurring in the premenstrual and menstrual phases, as well as disproportionately negative in regard to expectations and attributions about feelings and behavior across the full cycle. The current study was undertaken to evaluate the validity of this view of women's knowledge and conceptions of the menstrual cycle. Three aspects of the cycle - menstruation, ovulation, and menopause -were examined. Questions were asked about the biology (broadly defined) of each aspect, and about the changes-physical, emotional, and cognitive-intellectual-believed to be associated with it. Two hypotheses were tested: (1) that women's knowledge of the menstrual cycle in general would be insufficient, but that women would be more informed about menstruation than about either ovulation or menopause, and (2) that negatively valued changes would be described more frequently than positively valued ones. We believed it important to test these hypotheses empirically because it seems to follow that if women lack accurate and comprehensive information about the menstrual cycle, their ability to control their reproductive and daily lives could be compromised, making it difficult, for example, for them to make informed decisions about such issues as contraception, safe and effective treatments for menstrual disorders, and strategies for adjusting to the changes associated with menopause. Also, better understanding of the scope of women's knowledge and beliefs about different aspects of the menstrual cycle could suggest useful directions for interventions by educators and health care providers. College-aged women were seen as a useful group in which to document women's personal understandings of the menstrual cycle.
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First, they have had several years of menstrual experience; second, they have been exposed for many years to menstrual socialization via their families, peers, and culture; and third, they are intelligent and educated enough to have mastered the rudimentary facts of the menstrual cycle. While data from a college sample is not fully generalizable, such a sample could serve as a reference group with whom to compare other groups who presumably would have less opportunity to become knowledgeable about the menstrual cycle. Indeed, it could be argued that use of a college sample provides a particularly stringent test of our hypotheses. To the extent that the hypotheses are validated in the current sample, this most likely means that less privileged groups would evidence even less adequate knowledge and more extensive biases. METHOD Subjects
Subjects were 80 college women with a mean age of 19.3 (SD = 1.1) years. Reported ages at menarche ranged from 9-16 years, with a mean age of 13.1 (SD = 1.4) years. Subjects were recruited from introductory and intermediate level psychology courses. Participation was voluntary, and all subjects (N = 83) who expressed interest in the study completed the questionnaire. Subjects represented a cross-section of students in the institution, and were distributed across classes (from first year students to seniors) and majors (about half were current or potential psychology majors). Data from three subjects in their late thirties to early forties were excluded from the final analyses because of the disparity between the ages of these subjects and the rest of the sample. Materials and Procedure
Subjects responded to a questionnaire about the menstrual cycle that contained a variety of questions soliciting both objective (e.g., information about the biology of the menstrual cycle) and subjective data (e.g., beliefs about menstrual experiences). The data base for this report consisted of subjects' responses to 16 open-ended questions about menstruation, ovulation, and menopause. Six ques-
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tions explored subjects' knowledge of each of these events (e.g., " What is the cause of menstruation; How can a woman determine when she is ovulating; What is menopause?"). Nine questions explored subjects' beliefs about physical, emotional, and cognitiveintellectual changes associated with each event (e.g., "What physical changes do women experience during ovulation?"). Also on the questionnaire was a question about hormonal changes across the menstrual cycle ("Describe as best you can how hormones fluctuate across the menstrual cycle"). Subjects completed the questionnaire individually or in small groups, and were asked to prpvide careful, accurate, and detailed information. Responses were anonymous.
RESULTS Responses were read by two of the investigators, who abstracted categories under which major points made by informants were subsumed. After these categories were determined, responses were reread, broken down into data points, and assigned to appropriate scoring categories when consensus between the two investigators was achieved. Although a small number of subjects responded with only a word or two, the majority were more verbose, so that the responses of most informants included multiple data points relevant to more than one scoring category. For questions that sought factual information, responses were assigned to scoring categories and also rated for accuracy. For questions that sought more subjective information, such as subjects' beliefs and expectations, responses simply were assigned to scoring categories without being rated for accuracy. The data that follow are presented in two ways, depending upon the nature of the question; in some instances, the proportion of respondents (out of 80) giving a particular response or category of response is reported, and in others, the proportion of responses assigned to particular scoring categories, relative to the total pool of responses, is reported. Since the purpose of this study was to provide normative data about women's knowledge and beliefs about menstruation, ovulation, and ,menopause, individual variation in
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subjects' knowledge and beliefs about these aspects was not analyzed.
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Menstruation Knowledge of menstruation was addressed by a question about the cause of menstruation. To be considered correct, a response had to include the information that the uterine lining was shed if fertilization had not taken place. Forty-one percent of the subjects gave responses that met this criterion (e.g., "Menstruation is the elimination of the uteral lining built up to feed a fertilized egg; if the egg is not fertilized, the lining and egg are released from the body"). Another 16% mentioned only the lining and another 9% only the unfertilized egg. Nine percent of the respondents failed to mention these elements at all, defining menstruation instead by vague references to hormones (e.g., "Menstruation is caused by hormonal changes in the body"), and 24% provided incorrect or irrelevant information. While some of these responses were classified as incorrect because they were overly general or vacuous (e.g., "Menstruation is caused by the female cycle of fertility"), most reflected confusion about the sequencing of menstrual cycle events. The most frequent of these errors was confusion with ovulation (e.g., menstruation is caused "by ovulation," or "by the passage of the egg down the fallopian tubes," or "by the discharge of ovaries"). In this sample of college women, then, over 30% were unable to provide even a rudimentary definition of menstruation. Questions about physical, emotional, and cognitive changes experienced at menstruation, specified as the actual menstrual flow, elicited a wide range of responses. Subjects' responses aboutphysical changes were extensive, with most subjects attributing multiple, and generally unpleasant, changes to menstruation. As shown in Table 1, changes could be subsumed under four broad categories: general discomfort, such as cramps, aches, and pains; water retention and/or weight gain; tender or swollen breasts; and a variety of autonomic signs, such as nausea, temperature changes, and bowel changes. Every subject responded to this question. It is noteworthy that no positive changes were thought to be associated with menstruation.
Kofl Rierdan, and Stubbs Table 1.
Physical changes attcibuted to menstruation, ovulation, and menopause.
Menstruation
Ovulation
294 294 3.7 1-9**
106
Total number of responses Total number of changes* Mean number of changes* Range*
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Types of changes and frequency (2)
,
73 1.7 1-4
Menopause 109 95 1.4 1-3
.
discomfort(36) water retention1 weight gein(3l) tenderlswollen breasts(l4) autonomic signs(l6) other(3)
discomfort(l9) cycle change(33) vaginal discharge(9) negative physiol. temperature change(9) change(51) water retention1 emotionalshift(3) weight gain(l4) don't know(l3) tenderlswollen breasts(7) other change( 12) no change(l2) don't know(l9)
%nly includes specific changes mentioned by subjects; does not include "no change" or "don't know" **excludes one outlier with 14 changes
The question about emotional changes associated with menstruation also elicited a multiplicity of responses, and again, almost all were negative. As shown in Table 2, three main categories of responses-depression, emotional lability (e.g., mood swings, emotional ups and downs), and irritability (e.g., cranky, touchy, shorttempered)-appeared with about equal frequency, and often, all three were cited by individual subjects, suggesting that subjects themselves were conceptualizing the changes as different. Other changes mentioned were tension and anxiety; low energy level, characterized by sluggishness, apathy, and fatigue; autonomic changes (e.g., nausea); and feelings of uncleanliness or "rattiness." A very small proportion of responses described positive changes (feeling "more sexy" or affectionate). The pattern of responses to the question about cognitive changes shown in Table 3 presented a sharp contrast to the data reported in Tables 1 and 2. Whereas respondents associated a large number and range of physical and emotional changes with menstruation, a much
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smaller number and more limited range of negative cognitive changes (e.g., inability to concentrate, short attention span, decreased rational thinking) was thought to be associated with menstruation. The predominant response to this question was that there were no cognitive changes associated with menstruation, or at least "none that (respondents) knew of." Confusion about what was meant by cognitive or intellectual change was evidenced by a sizable group of respondents, who described negative changes of an emotional or physical nature. In keeping with subjects' beliefs about physical and emotional changes associated with menstruation, only 2% of the responses entailed references to positive change. Ovulation
The questions about ovulation requested factual information about the event itself (i.e., "What is ovulation?") and about women's awareness of the event (i.e., "How can a woman determine when she is ovulating?"); beliefs about the various changes associTable 2.
Emotional changes attributed to menstruation, ovulation, and menopause. Uenstruation
Total number of responses Total number of changes' Mean number of changes* Range*
Ovulation
Menopause
168 161
2:s 1-7
Types of changes and frequency ( X ) depreesion(21) emotionality(22) irritability(28) other negative change(20) positlve change(2) no change(2) don't know(2)
dysphoria(33) elevated mood(l0) sexual arousal(9) no change(l5) don't know(33)
dysphoria(66) loss(2S) positive change(4) don't know(5)
*only includes specific changes mentioned by aubjectsi does not include "no change" or "don't know"
Kofi Rierdan, and Stubbs Table 3. ' Cognitive changes attributed to menstruation, ovulation, and menopause. Menstruation Total number of responses Total number of changes* Mean number of changes* Range*
82 28 1.0 1-2
Ovulation 69 8 1.0 1-2
Menopause 66 16 1.0 1-2
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Types of changes and frequency (7.) no change(50) negative change( 13) positive change(2) emotional change(l1) physical chenge(6) don't knou(l7)
no change(51) miscellaneous change(l2) don't know(38)
no change(36) positive change(9) negative emotional change( 14) don't know(39)
*only includes specific changes mentioned by subjects; does not include "no change" or "don't know"
ated with the event were solicited as well. The majority of respondents (69%), when asked to define ovulation, correctly associated it with release of the (mature) egg; within this group, most identified the ovary as the site of release, and a small number also mentioned the fallopian tubes as the target of the egg. Some respondents (9%), rather than describing the physical features of ovulation, characterized it either as the time fertilization could occur or as the point in the menstrual cycle two weeks before, or after, menstruation. Incorrect definitions of ovulation (20%) revealed confusion about both the anatomy and the physiology of ovulation; misconceptions included assumptions that the ovary discharged eggs directly into the uterus, that eggs either were somehow deposited in the ovary or traveled through the ovary, that the ovary walls were shed as the eggs were released, and that eggs were released throughout the two weeks before menstruation. As with the question concerning the biology of menstruation, about 70% of the respondents were able to provide minimally acceptable information. Responses to the question of how a female could determine when she was ovulatingwere quite detailed, and often included more than
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one sign of ovulation (total number of responses = 109). Responses fell into three major categories, which corresponded closely to those identified in the literature (Vollman, 1977) as the most accessible or obvious indicators of ovulation. The most frequently mentioned sign was an increase in body temperature (32% of responses); the next most frequent sign (22%) involved a change in the quantity or quality of vaginal discharge, or more generally, "secretions;" and the next most frequent sign (18%)was some kind of pain, primarily abdominal pain, ovary pain, or cramps. (The fourth major sign, intermenstrual bleeding (Vollman, 1977), was not mentioned at all.) Also reported (5%) was a miscellany of changes including increased energy and increased sexual interest. Fourteen percent of responses referred vaguely to cycle phase (e.g., "make a chart when period is-ovulation is two weeks prior"; "time of month in relation to last period"), and 6% of responses were incorrect, typically involving beliefs that ovulation occurred during menstruation (e.g., "when the bleeding starts, some feel cramps and experience emotional changes") or at some other (incorrect) time in the cycle. As described in the preceding section, three main types of "physical" changes were cited as signs of ovulation. In response to the specific question about physical changes associated with ovulation, some of those changes were reiterated, and several new ones were mentioned. As can be seen in Table 1, the major additional signs were bloating and/or weight gain and breast swelling andlor tenderness; other changes included increases or decreases in energy level, and "hormonal changes." It was perplexing to note that while all but 2% of subjects were able to identify specific physical changes as signs of ovulation, 19% of these same subjects responded with "don't know" and 12% declared that there were no physical changes when asked directly about physical changes accompanying ovulation. As can be seen in Table 2, the most frequent responses to the question about emotional changes associated with ovulation described dysphoric changes, the majority of which were similar to those reported for menstruation. Euphoric changes, particularly elevated mood and sexual excitement, also were described, but less frequently. The assumption reflected in the negative responses con-
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trasts with reports in the literature that typically describe heightened feelings of well-being and pleasantness around the time of ovulation (Dennerstein & Burrows, 1979). Nonetheless, it should be noted that subjects are more likely to attribute positive changes to ovulation than to menstruation. Additionally, a third of the responses to this question claimed ignorance of any changes, and a smaller number denied any changes. The pattern of responses to the question about cognitive changes, shown in Table 3, was similar to that seen in response to the parallel question about menstruation, with the predominant response being that there were no cognitive changes associated with ovulation. As with the question on menstruation, respondents described a miscellany of changes, cognitive and noncognitive, positive and negative, among which were "intellectual peak," "decreased attention span," "lowered grades,?' and "feeling more positive about oneself." One-third of respondents denied any knowledge of changes, and in a departure from the general pattern of responding to this questionnaire, a sizable number of respondents simply did not respond to this question.
Menopause Three factual questions were asked about menopause. When asked to define menopause, almost all respondents (96%) correctly associated it with the cessation of menstrual periods, with the end of ovulation, and/or with the end of the reproductive process. While the overwhelming majority of these responses conformed to the narrow definition of menopause as the last menstruation (Asso, 1983), a number of responses described a process of transition involving changes in hormonal levels and variability in the nature of rnenstrual periods, corresponding to the broader view of menopause as a gradual process associated with a progressive increase in anovulatory cycles and the eventual cessation of menstruation (Gannon, 1985). Even among misinformed respondents, there was a recognition that menopause somehow marked the end of the reproductive cycle (e.g., "When you are born, you have a certain number of oocytes, and once you have ovulated all these eggs, you go into menopause"). More subjects were able to correctly define meno-
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pause than menstruation or ovulation, but a correct response to this question may have been easier for respondents to articulate since less detail was required. The age at which respondents expected menopause to occur ranged from 34 to 70 years. Some respondents gave broad age ranges (e.g., "between 34 and 60"), but most gave accurate age estimates, with the majority of respondents (66%) placing the event somewhere between the ages of 45 and 55. Although establishing the precise facts about age at menopause has been problematic, menopause in Western societies is believed to occur on average at about 50 years of age, within a typical range of 45 to 55 years (Asso, 1983; Gannon, 1985). Responses to the question about when menopause is over indicated considerable variability in subjects' conceptions. While 36% of respondents conceived of menopause as a single physiological event, namely the cessation of menstruation, 27% believed it to be an enduring condition, that "once it starts, goes on forever," ending "only with death," and 4% believed it to be a state that was terminated when a psychological, rather than a physical, process occurred (e.g., when a woman could "emotionally deal with the fact that she was no longer in her sexual prime"). Fourteen percent erroneously associated the end of menopause with the disappearance of symptoms such as hot flashes, which in fact seem to be most frequent and most intense shortly after the cessation of menstruation (Gannon, 1985). The remaining responses (19%) were denials of any knowledge, refusals to answer, and nonspecific responses (e.g., "it varies with the woman"). Responses to questions about physical, emotional, and cognitive changes believed to be associated with menopause reflected a diversity of conceptions. Most subjects suggested multiple physical changes, which could be subsumed under two broad categories, as shown in Table 1. The first concerned physical changes in the menstrual cycle itself, notably the cessation of menstruation or ovulation, changes in the quality or quantity of menstrual bleeding, and hormonal changes or imbalances. The second, and larger category of responses, was comprised of unpleasant physiological changes, most frequently the hot flash, which is in fact the most common complaint of menopausal women. Other prominently mentioned
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changes, all of which have been associated with menopause (Gannon, 1985), were weight gain, unwanted hair growth, dry or coarsened skin, and dry vagina. Notable for its absence was any mention of osteoporosis, which, next to hot flashes, is probably the most extensively discussed and well-publicized 'menopausal change (Gannon, 1985). Answers concerning emotional changes associated with menopause also entailed a multiplicity of responses, as seen in Table 2. As already observed in the responses to the parallel questions about menstruation and ovulation,' the predominant response mentioned some type of dysphoria, most notably depression, irritability, and mood swings, or some kind of loss (specifically, loss of femininity, reproductive capacity, sex drive, or youth). A very small number of responses cited positive changes (e.g., joy, relief). While it is true that scant attention has been paid to the positive emotional changes associated with menopause, it is also the case that there is little evidence to substantiate the presence of widespread negative emotional changes such as those suggested by these responses (Asso, 1983). Subjects were much less pessimistic about cognitive changes, as seen in Table 3, and a small number (8%)of positive changes were described (e.g., a woman could now "concentrate on such things as intellect"). The bulk of responses reflected a view that there were no cognitive changes associated with menopause, or indicated ignorance of any possible changes or confusion about the meaning of cognition. As with responses to the parallel question about ovulation, a sizable proportion of subjects did not respond to this question. Hormonal Changes Across the Cycle
Respondents were poorly informed about hormonal changes across the menstrual cycle. In response to this factual question, 33% of subjects reported that they "didn't know" how hormones fluctuated across the cycle or left the question blank. To evaluate the accuracy of the remaining responses (N = 56), a simplified schema was developed, which encompassed the following information: (a) FSH (follicle-stimulating hormone) induces the develop-
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ment of follicles; (b) follicles produce estrogen, which stimulates the endometrium of the uterus to thicken; (c) a surge of LH (luteinking hormone) causes the follicle to burst and release its ovum; (d) LH then induces the follicle to become the corpus luteum, which secretes progesterone, which develops the endomentrium further, along with estrogen; (e) declines in levels of estrogen and progesterone, in the absence of fertilization, result in menstruation. When this schema was applied, only one response could be classified as even marginally correct. Thirteen percent of the responses named three or all four hormones, and 54% named one or two hormones (usually estrogen and progesterone), but these responses were all inadequate or incorrect. Another group of responses (32%) mentioned changes in hormonal levels, but did not identify the hormones. DISCUSSION
Menstruation has long suffered a poor reputation in our culture (Emster, 1975), and the results of this study suggest that intelligent, well-educated young women may still believe in the "curse" of menstruation. Negative stereotypes about the menstrual cycle apparently are so pervasive that an event such as ovulation, which is not typically identified with negative physical changes, and is in fact reported to be accompanied by positive emotional changes (Dennerstein & Burrows, 1979), is nevertheless thought to be associated primarily with negative physical, emotional, and (possibly) cognitive changes. The presence of such beliefs provides support for the hypothesis that there is a negative bias to constructions of the various aspects of menstrual life considered in this study. The hypothesis that women's knowledge of menstrual life is generally inadequate also was supported by the data, particularly in regard to menstruation and ovulation and specific hormonal changes. The women in this study had some idea of the cause of menstruation, associated ovulation with the release of the egg, and defined menopause as the cessation of menstrual periods; nonetheless, a significant proportion evidenced confusion about the specific organs and glands involved in menstruation, the process of ovula-
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tion, and the sequencing of phases and the role of hormones in the menstrual cycle. With regard to these latter aspects, it was particularly striking that the roles of estrogen and progesterone were so poorly understood, since they are widely discussed in the popular literature. It was noteworthy, too, that some respondents confounded cycle phases (e.g., they confused ovulation with the premenstrual or menstrual phase), and/or misunderstood the sequence or timing of the phases (e.g., they assumed that menstruation followed ovulation by only a few days). Not only was there a negative bias in respondents' views of menstrual life, at least in terms of physical and emotional correlates of menstrual events, but there seemed to be little distinction made among the three events. Questions about changes associated with menstruation elicited the greatest number and variety of changes, but the bulk of these actually are more identified with the premenstrual phase than with menstruation per se (Abplanalp, 1983; Parlee, 1973). The analogous view of menopause as physically and emotionally unpleasant corresponds to widely held and inaccurate beliefs about menopause,. which continue to be espoused despite recent evidence suggesting that menopausal women in fact do not view menopause as a negative life event. Rather, these women minimize the importance of menopause, do not associate it with undue stress or anxiety, and tend to report relief or neutral feelings about the cessation of menstruation (Asso, 1983; Kahana, Kiyak, & Liang, 1980; McKinlay & Jefferys, 1974). Interestingly, others (Neugarten, Wood, Kraines, & Loomis, 1963) also have found that younger women expressed more negative attitudes toward menopause than did middle-aged and elderly women, who did not anticipate menopause with trepidation or recall it as particularly stressful (Kahana et al., 1980). Like menstruation and menopause, ovulation also was associated with negative physical and emotional changes, but to a lesser degree. A greater number of respondents believed that there were no changes, or said that they did not actually know if there were changes, associated with ovulation, than with the other two events. The latter statement of uncertainty is understandable in light of the
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confusion many women expressed about the timing of ovulation within the broader menstrual cycle. While subjects believed that negative physical and emotional changes were associated with menstruation, ovulation, and menopause, they seemed less pessimistic about cognitive changes associated with these events. In large part, subjects discounted the possibility of cognitive changes, which is consistent with the bulk of published evidence that argues against a menstrual cycle effect on cognitive functioning (Sommer, 1983), or denied any knowledge about changes. Given that respondents had only to refer to their own menstrual experiences to answer the questions about changes associated with menstruation and ovulation, their denial of knowledge about these changes is puzzling. It is possible, of course, that "don't know" responses simply reflected uncertainty about what a "cognitive" change was; the detailing of physical and emotional changes when cognitive changes were requested certainly lends credence to this argument. Another possibility is that "don't know" responses were given by women who don't experience changes, but who are so influenced by negative cultural beliefs that they are unable to accept the absence of changes. The results of this study suggest the need to address the topic of menstrual education for adult women with respect to both basic knowledge of the menstrual cycle and expectations for associated physical and behavioral changes. Given the generally limited level of understanding and the generally negative tone of the responses observed in this sample of educated college women, we can only speculate about the knowledge base of women with fewer opportunities for exposure to information. It is probably not unreasonable to expect that they would demonstrate even less adequate knowledge and a more pronounced negative bias. Ignorance or misinformation about the menstrual cycle has serious implications for women's lives. Minimally, it can keep them from understanding their bodies and their reproductive lives. Additionally, it is likely to be associated with ignorance or misinformation about other intimate matters, such as sexuality. Lack of knowledge can place women at risk for unwanted pregnancy and sexually transmitted diseases, can result in misunderstanding and mistreatment of menstrual disorders, and can prevent effective communica-
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tion with other women and with health care providers. While it is certainly true that there has been a significant cultural advance in lifting the taboo against the discussion of menstruation (Delaney, Lupton, & Toth, 1988), we clearly still have far to go before such discussion is appropriately informed and unbiased.
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cycle: Vol. 2. Research and implications for women's health (pp. 45-53). New York: Springer. Sommer, B. (1983). How does menstruation affect cognitive competence and psychophysiological response? I n S. Golub (Ed.), Lifting the curse of memtmation. Women & Health, 8 (2/3), 53-90. Vollman, R. F. (1977). The menstrual cycle. I n E. A. Friedman (Ed.), Major problems in obstetrics andgynecology, Vol. 7. Philadelphia: W. B. Saunders.
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