MENSTRUAL DISORDERS: A PSYCHOSOMATIC STUDY

CHAPTER I

INTRODUCTION
I INTRODUCTION

II STATEMENT OP THE PROBLEM

PSYCHOSOMATIC DISORDERS

III CLARIFICATION OF THE BASIC TERMS

i) PSYCHOSOMATIC ILLNESS

ii) MENSTRUATION

iii) PSYCHOLOGICAL CORRELATES OF MENSTRUAL DISORDERS

(MOOD CHANGES)

iv) TYPES OP MENSTRUAL DISTURBANCES

a) DYSMENORRHEA

b) AMENORRHEA

C) MENORRHAGIA

d) METRORRHAGIA
e) OLIGOMENORRHEA
f) THE PREMENSTRUAL SYNDROME

V) FACTORS AFFECTING MENSTRUATION

a) MOTHER'S ATTITUDES TO MENSTRUATION

b) SOCIAL ATTITUDES TO MENSTRUATION

C) MYTHS ABOUT MENSTRUATION

d) REACTIONS TO MENSTRUATION OF THE GIRL/WOMAN

HERSELF

e) CONCLUSION

Vi) QUESTIONNAIRE AS A RESEARCH TOOL

Vii) PROJECTIVE TECHNIQUE AS A RESEARCH TOOL

IV PURPOSE OF THE STUDY

V SIGNIFICANCE OF THE STUDY

1
I INTRODUCTION

Whatever our aspirations to equality,.there is no denying

that, biologically and physically, women are different from men.

Our Jarains may be the same but our reproductive systems are not.
The variations between the sex organs are obvious, but .there is

another difference which is less obvious though probably much

more important because it influences every aspect of a woman's

being - physical, psychological and social - and it affects to

some degree not only the woman herself, but also those who live

or work closely with her. The difference is the woman's menstrual

cycle.

For a modern woman, the. menstrual cycle has become a sign of

the Original Curse. Many women now combine physically and

intellectually demanding jobs with caring for homes and families;

this may c r eate intolerable t e n sions that are e v e n t u a l l y

reflected in their ability to be fully effective in either.

Psychologists (SHREEVE, 1983; CQEEMAN, 1956) are of the opinion

that tension and emotional difficulties create physiologically

problematic situations which sometimes even the doctor cannot

diagnose correctly. According to the holistic approach, whenever

there is anxiety or tension that disturbs the woman emotionally,

all her physiological and biological processes are affected.

Menstruation being one of them also comes in this category.

Whether it is stress of modern life combined with greater freedom

of choice amongst women, or simply that they are more yocal about

their problems, there is little doubt that gynaecologists see a

large number of women with complaints that do not have their

origin in recognized forms of pathology.

The present research worker was directed to this problem by

2
observing certain types of abnormalities' occurring in the

menstrual cycle of college going girls. Usually, the menstrual

cycle has a fixed time limit and occurs regularly once in 26 to

30 days if the woman is healthy, normal, and w i t h o u t any

gynaecological problems. However, the research worker was aware

of the link between gynaecological disease and psychology of

women, especially so of the psychological component in the

cessation of menstruation accompanying change,in the environment,

or the stress of an examination. Thus, the irregularity was not

because of physical malfunction but because of psychological

stress. This is the. beginning of the present research work.

How far is this true ? And to what extent is the association

strongly established, is the problem of the present research

work. The present research worker is interested in finding out

whether menstrual disturbances of women can be associated to

psychosomatic disorders. If. this is so, then the entire treatment

of the gynaecological problem would take a new turn and a new

approach. The degree of association between the psychological

disturbance and menstrual disorders and its outcome would throw a

strong light on the age old mind - body relationship. Basically,

human personality is a complete unit which is divided into the

above mentioned areas for the sake of an easy approach for the

understanding of the scientist.'

Modern science has thrown light on the fact that the human

body is a well integrated unit, in which if any problem is

created in one area it is likely to affect other areas as well.

Sometimes, simple mental tension can create peptic ulcers or

hyper - tension. As psychology and biology are linked together,

each and every disease has been diagnosed to have it's

3
psychological component.- This means that the origin of the

disorder has two major variables contributing to it’s development

- physical and psychological. This approach has been called the

psychosomatic approach in modern clinical psychology and now more

and more disorders are included in this category. Menstrual

disorders have also been included as a part of this unit implying

that there is some stress or emotional tension in the personality

of the patient suffering from this kind of disorder (CAMERON,

1963;BROOME AND' WALLACE, 1984). If, however, the women are well

adjusted, they do not complain about such menstrual problems

taking it in their stride thinking of it as a normal, natural

process. So the patient group must be having some personality

characteristics which differ from the normal group. Which are

they ? This is the problem of the present study.

This kind of study eventhough important, poses many problems

when undertaken for research. Firstly, all past literature does

not seem to have concentrated on the same type of population of

subjects (Ss). In some cases, a random group of volunteer Ss has

been used (BEAUMONT, RICHARDS, AND GELDER, 1975) in others, those

admitted to the hospitals were chosen as Ss (OSBORN, 1981) while

in still others it was nurses and me d i c a l s t u d e n t s doing

university courses who were chosen as Ss (LAMB, ULLETT, MASTERS,

AND ROBINSON, 1953; SHELDRAKE AND CORMACK, 1976). As a result,

the final observations cannot be generalized to the overall

population.
Secondly, every investigator has used different types of

methods for the study of symptomatology. Some have relied on

retrospective accounts of the Ss past and their past

difficulties, while others have actually collected data from

)
 women taking treatment for menstrual disorders. Still others

consider doctor's opinion sufficient to describe this group. Here

tooi results cannot be assimilated, under one heading.
Finally, some gynaecologists are of the opinion that for
this kind of study, self reports should be considered the best
method for the assessment of the situation. Allow the S to
describe her own symptoms of present or past. This method has
been criticized by other scientists because they are of the
opinion that every S does not have the same standard of
evaluation. Some would say that they have very painful episodes
which others would just describe as uncomfortable. Therefore,

/ some kind of objective measure is necessary. But, in this case

objective measures are not very appropriate for the, measurement

;,t . of the psychological variables. Under these conditions, medical

reports, patient's past history and her responses on more than

one test may give some idea about the actual situation instead of
using just one method. Use of control group is a must because
only that would prove whether the problem described by the
> , ^ , *

patients are really serious or just their own interpretation of'a

very normal situation. This approach has, been undertaken in the

present study.
II STATEMENT OF THE PROBLEM
MENSTRUAL DISORDERS:A PSYCHOSOMATIC STUDY
"Psychosomatic disorder' is a general label used for any

disorder with somatic (bodily) manifestations that are assumed to

have atleast a partial cognitive and emotional etiology i.e. they

■>'\ are to some degree psychological. For example, asthma, peptic

Ulcers, migraine headache and many others.

;T As pointed out earlier, menstrual disorders are day by day

. ’ 5 • :

!
increasingly associated to psychological etiology. How far this

is true is the problem of the present study. However, the problem

is not as simple as it appears on paper. Any kind of disorder can

create a psychological disturbance if it is chronic or incurable.

This will create psychological disturbance similar*to that

existing in the psychosomatic personality. It is very difficult

to draw a clear demarcating line between these two groups. For

the present study, however, the diagnosis of the psychosomatic

disorder has been done on the following basis:

1. The patient cont i n u e s t a king treatment under a well

experienced gynaecologist who is of the opinion that the origin

of the disease is psychological rather than organic.

2. Normal medical treatment does not prove helpful in curing

these patients.

3. The patients have a history of psychological disturbance right

from early childhood. Therefore, development of the menstrual

disorder is not simply an organic disturbance but one of the ways

of manifesting their emotional disturbance.

On the basis of these three variables, psychosomatic

components in menstrual disorders have been identified for the

present study.

A problem arises as to the conditions responsible for the

development of psychosomatic disturbances. In clinical

psychology, functional maladjustment has been classified into

neurotic, psychotic and psychosomatic categories. It would be

interesting to note the conditions that lead to the development

of psychosomatic disorders.

6
 PSYCHOSOMATIC DISORDERS

Personality disturbances hav e been recognized as

determinants of physical illness. Now it has been clear that

susceptibility to any illness may be influenced toy emotional

disturbances, either directly or through unconscious neglect and

exposure. Hence, psychosomatic disorder is an illness in which

emotional maladaptation is dominant and may lead to irreversible

organ or tissue damage.

Psychosomatic disorders can threaten the life of a patient.

They always mean some distortion or loss of function, or at the

very least discomfort or disfigurement. However, there are some

adaptive functions of psychosomatic disorders pointed out by

CAMERON (1963) which are as follows:

1. A psychosomatic disorder puts an apparent or an actual

physical illness in place of an intolerable current situation. It

is more dignified to suffer from a psychosomatic disorder instead

of psychosis or neurosis for as long as the patient believes in

the physical origin of her illness.

2. The whole process of psychosomatic illness is unconscious and

its sym p t o m s are those of p h y s i c a l illness w h i c h seem as

unavoid a b l e as any other p h y s i c a l illness. A majority of

psychosomatic disorders are of mild or moderate degree, and do

not lead to death.

3. Psychosomatic disorders give the patient the privileges of a

sick person, without interfering with her freedom or lowering her

self esteem. Secondary gain, as this is called, and the

relationship of an unconsciously needed dependency of a parent

figure, the clinician, can bring valuable gratification to a

basically immature person. These gratifications should not be

7
scorned as they sometimes protect a person from disabling

neurotic or psy c h o t i c developments; and they often give

meaningful interpersonal relationships to an otherwise empty

life. Many emotionally immature, dependent men and Women hide
their needs, from themselves as well as from others, behind an
energetic, independent facade. The need© are still there,

however, and they are still unsatisfied.

4. Finally, the patient may use her physical illness as a means

of eliciting concern, care and affection, which she has needed

all along, but has been unable to get as long as she remained

well. Life is objectively more difficult and less rewarding for

some people than for the others; and subjectively it may seem

bleak, eventhough objectively it is considered fortunate. To

treat a psychosomatic disorder, it is necessary to bring the need

to verbal expression, if this can be done skillfully and safely,

so that, as a patient improves physically, she also matures

psychodynamica1ly.

Ill CLARIFICATION OF THE BASIC TERMS

i) PSYCHOSOMATIC ILLNESS
There are several app r o a c h e s taken to p s y c h o s o m a t i c

disorders: the one taken dictates the connotations that the term

will have. From one widely held perspective, three sub categories

of psychosomatic disorders can be distinguished:

a) those related to the individual's overall personality (for

example, highly anxious people show a higher incidence of

respiratory disorders, high rate of peptic ulcers and menstrual

disturbances)
b) those intimately connected to one's life style (for example,

people in high pressure stressful occupations show a higher rate

8
of hypertension and gastric dysfunctions)

c) those manifested primarily by heightened reaction to

substances and conditions (for example, allergies, which while
stimulated by foreign substances, are differently experienced

depending on psychological factors).

In the present study, emphasis is given to the first

category and the problem selected is the area of menstrual
disturbances.
In the present day society, psychosomatic disorders have
become the main focus of attention from the medical as well as
the psychological view point because they are associated with
stressful life in which present day human being has to live.

Modern times have put the woman in direct competition with

her male counterpart. A woman herself is motivated to be his
equal. This implies that she should be able to do everything that
the man is capable of doing. This may be directly observed in the
field of sports and any other job where traveling is virtually
continuous. Such requirements put the woman at a greater loss
because many a times her menstrual cycle comes in the way. This
creates a sort of frustration and psychologically a negative
attitude towards the menstrual process itself results.
It is quite possible that this attitude was absent 50 years
ago because women were required to handle only household work.
The woman was allowed to rest during menstruation and there was
no loss of efficiency in the work that goes on in the household

owing to the joint family system. Unfortunately, as soon as women

became independent, all. their responsibilities were equated with

those of men. She starts comparing herself with khe Joneses

"others are successful, only I failed". If some consideration is

9
m ade’for her feminity, the woman thinks that it is her -weakness.

As a result, she does not like to accept any privilege offered to

her on t h a t count. In t his condition, the stress t hat is

generated becomes intblerable. The result is the development of

p s y c h o s o m a t i c problems. Whether m e n strual d i s t u r b a n c e s also

belong to the same category, and if so, to what extent, is the

problem of the present study.

GYNAECOLOGICAL PSYCHOSOMATIC DISEASE

- "Gynaecological psychosomatic disease' is by definition th<*

effect of psychological disturbance on the pelvic organs. Ir. man

ways,, .future developments in the management of coromo

gynaecological conditions such as d y s m e n o r r h o e a m e n o r r h a g i a

pelvic pain.and vaginal discharge, lie in a proper understandinc

of the relationship between female psyche and soma. The cerebra

cortex is known to influence the h y p o t h a l a m u s and hence th

endocrine and a u t o n o m i c nervous system of the body. It i,

suggested that when the pituitary-ovarian axis is disturbed,

anovulation with menstrual- dysfunction is a common consequence

The fact that the recognition of this mechanism has not lead t

the u s e of w e l l established forms of p s y c h o t h e r a p y is a

admission of the paucity of respectable research on the subject

the gap between endocrinology and psychology is narrowing bu

still needs to be bridged. Dysmenorrhoea which is the commones4

of all compl a i n t s in gynaecological outpatient clinics, i

without demonstrable, pathology in 70-80 percent of the case;

This con d i t i o n is a u s e f u l " m o d e l for the study of possib

psychosomatic disease because of the high association

emotional dysfunction in. the majority of the cases {BROOKE A’

TJALLACE, 1984} .

10
 ii) MENSTRUATION

Menstruation is a periodic shedding of blood and the

functional layer of the endometrium from the hon-pregnant uterus

during the reproductive years.

Menstruation is a p r o c e s s w h i c h is s u b j e c t to wide

fluctuations of normal as well as producing symptoms associated

with disease and so it is important to first consider what is

normal.

As wit h all other bodi l y functions, n o r m a l i t y means

different things to different people. The range is wide and it is

difficult for any individual woman or doctor to know what it is.

There is no well recognized standard against which a woman can

measure her own pattern. The symptoms that a woman brings to a

doctor will depend on her own previous experience, on information

she may have picked up from relatives, friends or magazines, and

on other problems she may have at the time.

The first menstruation, the menarche, generally occurs at

about the age of 13 years and menstruation or the monthly period

continues till the menopause. Generally, menarche may occur at

anytime between the age of ten and sixteen years, the average age

now being 14 years particularly in India. The daughter's of

better off parents tend to start menstruating a little earlier

than those whose parents are poor, but the average difference is

no more than six to nine months.(JONES, 1986).

THE NORMAL MENSTRUAL CYCLE

The menstrual cycle consists of a period of bleeding of

variable length and-amount, followed by a longer time when there

is no bleeding.
The length of the cycle is the time from the first day of

11
one period to one day before the onset of the next menstrual

period. When asked the length of the cycle, most women answer

with the time clear between the periods. The length of the normal

cycle is variable and it may be different at different times. It

is normal for some women to start a period regularly every 28

days. It is equally normal for others to have a regular 50 day

cycle. For some women, the normal cycle is never regular so that

the length may be 25 days on some occasions and 60 on others.

For many women, the pattern changes from time to time. There

may be a temporary change as happens under stress, or long-term

changes in pat t e r n may occur. These are not symptoms of

gynaecological disease although they may be evidence of emotional

problems.
It is extremely difficult to measure or describe the amount

of bleeding. The amount of menstrual discharge that can be

described as normal is 30 ml (1 fluid ounce). A loss of more than

80 ml (2 3/4 fluid ounce) is considered as abnormal. Most doctors

are guided by the number of tampons or sanitary towels used' each

month : 10-15 is common, 30 is a lot. This is not very reliable

as some women change more frequently than the others.

An apparently normal uterus may bleed heavily as a result of

hormonal influences. Whether such bleeding is unacceptably

excessive depends upon the w o m a n ’s attitude and life style as

much as on the actual volume of blood loss. Working class women

engaged in physical labour will put up with much heavier bleeding

than will the middle class women doing jobs which require more

mental capabilities.
The length of the period also varies from two to three days

to a week or more. A period that lasts for five to six days is

12
considered to be normal but a length of period beyond that is

considered to be abnormal. Most doctors will consider bleeding to

be excessive if it results in anaemia despite a normal diet, or

if clots form, or if it in t e r f e r e s wit h a w o m a n ' s normal

activities.

Most women accept as normal, a certain amount of cramp-like

lower.abdominal pain or backache during the first day or two of

menstruation. Such pain should respond to simple medicine and

should not interfere with normal activity.

The only criteria of normality common to all women is that

. •* ” *%
i

there should be no bleeding between the periods and each episode

of menstruation should be finite.

iii) PSYCHOLOGICAL CORRELATES OP MENSTRUAL DISORDERS

(MOOD CHANGES)

The POCKET OXFORD DICTIONARY OF CURRENT ENGLISH (1942)

defines mood as a change in the state,of the mind.

According to the PENGUIN DICTIONARY OF PSYCHOLOGY (1985)

mood is any relatively short-lived, low-intensity emotional

state.

-MORGAN, KING AND ROBINSON (1979) define mood in the following

way: ,

"A mood has an emotional tone or a background that is

relatively long lasting and colours a person's outlook on the

world."
A CONCISE PSYCHOLOGICAL DICTIONARY (1987) defines mood as a

relatively protracted, stable psychic state of moderate or low

intensity, a p p e a r i n g as a p o s i t i v e or n e g a t i v e e m otional

background of the individual's mental life.

A c c o r d i n g to the p r e s e n t r e s e a r c h worker, m ood is a

13
 relatively short-lived, moderate or low intensity mental state
appearing as positive or negative.

Mood states have a dramatic effect on behaviour, and they

can affect the intensity of our reactions to emotion provoking

stimuli. For example, if a woman is depressed, relatively mild

set backs can be perceived as drastic. On the other hand, if a

woman is calm, those*set backs may seem minimal.

The role of hormones in one class of mood changes that has

been studied extensively with respect to endocrine functioning is

the mood changes that occur across the menstrual cycle. The
'1
present research worker is‘interested to study how far these "mood

cycles affect the behaviour of a woman and whether this influence

is normal or abnormal. If a woman is under stress or, suffers from

chronic low grade misery, then the normal fluctuations of mood

during the menstrual cycle may produce marked depression, anxiety

or irri t a b i l i t y during the. p r e m e n s t r u a l w eek as well as

menstrually. It seems unlikely that so called premenstrual

tension will produce these symptoms in a woman who is otherwise

well and happy but it does seem to have the effect of making her

less able to cope with stress, more vulnerable and therefore

exaggerate symptoms .which she already has but can cover up at

other times. Only in some women this creates tension to such an

extent that she requires definite medical help. Many women report

feeling somewhat depressed, anxious and irritable just before

menstruation begins, during the premenstrual period. This pattern

of mood changes is so.pervasive that it has been termed the

premenstrual syndrome (MOOS, 1968 : PARLEE, 1973).

There are two types of women who cannot ,cope with these mood

changes. .The first group, consists of women whose premenstrual

14
disorders are either serious or become unbearable. Hence medical

treatment becomes a necessity. In the second group, objectively

speaking the gynaecologist is"not able to find any physiological

factors responsible for the menstrual disturbance. However, the

patient keeps on complaining.,Sometimes, even after medication

the complaints do not stop.. And sometimes, the complaints

continue throughout the month. This group of women are included

in the psychosomatic category;

In the present study, the research worker wants to find out

the personality characteristics of this kind of patients. How far

do they differ from the normal personality ? Are they severe or

i ' - :

mild ? Does medical treatment help them in the long run ?

iv) TYPES OF MENSTRUAL DISTURBANCES

Gynaecology is a science of disease.peculiar to women,

although sometimes it may seem to be a science of peculiar women

(Me.DONALD, 1979). Modern Obstetrics and Gynaecology is dogged by

the word "abnormal" - from abnormal labour to abnormal uterine

bleeding and abnormal menstruation. The number of women labeled

as abnormal, is so great.that it must bring into question just

how much of the symptomatology is abnormal or just.a variation of

normal. At any time, women might complain that their periods

are :

too short, . ■

too long, , . .
too frequent,

too infrequent,

too light,

too heavy,

too painful,

15
 too irregular, - '

too awful !
This is excluding.the not too infrequently voiced complain

that it seems unfair that they should have periods at all. The

endFess succession of menstrual cycles to which a woman today is

subjected to is abnormal. In primitive communities, menstruation

was probably a very infrequent event since a late menarche,

lactational amenorrhoea and poor nutrition, as w ell as

pregnancies, left the women little time for menstrual cycles.

Today's woman is faced with a much earlier menarche - around the

age of 13 years - probably brought about by improved nutritiop in

childhood - but now occurring several years before she will be

ready in most instances to contemplate a pregnancy. Furthermore,

the menopause may not come for 40 years beyond the menarche, and

women in this time on average have only two full term pregnancies

and perhaps breast feed with lactational amenorrhoea for two

years at the most. Thus,, a modern day woman in our. society will

probably experience on average 300-400 menstrual cycles in her

reproductive, life. The excesses of child bearing in the past have

been changed for the excesses of menstruation in the present. As

a result, problems associated to menstruation have increased.

ORGANIC MENSTRUAL DISORDERS

< Organic gynaecological disorders are due to some basic

organic malfunction of the sex organs. Or, it may also be due to

some basic physiological disturbances of the biochemistry of the

body. In both these cases, there is some disturbance in the

normal m e n s t r u a l cycle wh i c h is not cured by simple home

medication or remedies. Such disorders require medical attention,

operative procedures or -therapeutic measures as suggested by the

16
gynaecologist.

These disturbances are actually physiogenic. However, if

they become chronic or if doctors fail to diagnose and cure them,

they do give rise to personality disturbances. The patient

becomes anxious, worried, even fearful and depressed because she

does not know the outcome of her illness. Sometimes, this is

aggravated because there are healthy examples just before her

where no such disturbances exist. This creates further anxiety

regarding her own health and the woman wants to find out what is

wrong with her. As there is no answer to this question, it gives

rise to very serious depressive ideas and pessimistic views

regarding her own future.

In the above mentioned case, one can note that psychological

disturbance is associated with menstrual disorder but it cannot

be labeled as psychosomatic because it is the result of the

illness and not the cause of it. In psychosomatic disorders,

usually personality disturbances play a causal role which

sometimes become difficult for the gynaecologists to separate

from .the former type. In the present, study, a special effort has

been made to exclude the o r g a n i c .gynaecological menstrual

disorders and to include only those cases where the psychological

variables play a dominant role in the development of menstrual

disorders. This implies that basically the personality of women

suffeping■from psychosomatic disorders should be different from

those suffering from organic gynaecological problems.

jn the present study, only women suffering from psychogenic

gynaecological menstrual disorders have been included. The

present! research worker is interested in this kind of disorder

only because of its psychological origin and not because of it's

17
psychological consequences. In short, any chronic disorder is

likely to bring about the .same personality disturbances which

menstrual disorders can develop. Therefore, this should not be

considered a very important problem from the psychological point

of view. For the psychologist, it is important to know only how

far psychogenic variables are responsible f o r ,the development of

menstrual disorders. However, this implies a causal study which

is beyond the scope of the present study. Which Ss will develop

menstrual-disorders cannot be predicted unless actual menstrual

disorder has taken place and becomes resistant to normal medical

treatment. As a result, one has to study the S's childhood and

present day personality and try to find out how far they differ
from the normal personality. In the present study, this approach

has been undertaken.

Any research, on any kind of psychosomatic disorder should

keep in mind that so far as the symptoms of the disease are

concerned, they do not differ much from those of the organic

disorder. At the symptom level, one does not find much to

distinguish between the psychogenic.and the organic origin of the

disorder. It is-the development and the causal conditions that

sustain and perpetuate them. They distinguish and bring out the

real difference.between organic.and psychogenic origin.

The most common disturbances associated with menstruation

are the absence of menstruation-i.e. amenorrhea; painful periods

i.e. dysmenorrhea; profuse or heavy loss, with periods i.e.

menorrhagia;. and exaggerated general body changes which occur

prior to menstruation i.e.' the .premenstrual syndrome,

a) DYSMENORRHEA
Dysmenorrhea simply means' painful menstruation or pain

18
associated with menstruation. Gainful periods are not a sign of

sinister disease but may be any thing from a binor irritation to

. . . . ' \

an incapacitating nuisance. It is most commonly found in young

girls within three, or four years after the onset of menstruation.

It may be a constant dull ache, in the abdomen or back, starting

the day before the bleeding starts (congestive dysmenorrhea) or

may be sharp intermittent pains or colic on the first day

(spasmodic dysmenorrhea). It may be accompanied by nausea,

headache, dizziness, or backache. It may be severe which is why a

lot of young women seek medical help. Dysmenorrhea may be

regarded as a symptom of organic disease i.e. physical, or as

having emotional undertones i.e. psychological or both physical

and psychological. According to STRUBE (1980) there is often some

a n x iety with sexual connotations such as difficulty in

establishing a sexual identity, poor relationship with the

father, or fear of pregnancy. However, this is by no means always

the case. Menstruation is affected by any sort of stress and in

many ways, there is a causal relationship between emotional

stress and dysmenorrhea (STRUBE, 1980)..

Dysmenorrhea may be Primary, when it:dates from, or shortly

follows, the menarche, or Secondary when pain appears in the

latter reproductive life after earlier years have been relatively

pain free. ,
Examination of patients suffering from dysmenorrhea reveal

little or no organic fault. The emotional element in menstrual

pain can be strong and the mother may be its source. General

factors associated to dysmenorrhea include a faulty attitude to

menstruation and sexual matters, enviornmental and parental

pressures and general ill-health (CHAMBERLAIN AND DEWHURST, 19,84;

'-V- ' 19 ‘ -
FARRER, 1979) . The present study is an attempt to find out how

many of these factors are associated with menstrual disturbances

in the population of Giajarat. The present research worker is more

interested in Primary dysmenorrhea where functional factors are

more dominant as pointed out earlier,

b) AMENORRHEA

Amenorrhea means absence or abnormal stoppage of the menses

(DORLAND'S POCKET MEDICAL DICTIONARY, 1983). It also means

complete lack of periods during not only the menstrual period but

the whole age ^during which the woman is expected to

menstruate. Mostly, there can be a physiological factor

associated with this disorder; but of late, gynaecologists and

psychologists have come to regard that extreme emotional tension

is also responsible for the same, particularly where the woman

has to participate in.extremely important physical activities

like International sports or any such event (GADPAILLE, SANBORN,

AND WAGNER, 1987).

When the girl or the woman has never menstruated, she is

said to have Primary amenorrhea. Absence of menstruation after

the menarche is termed Secondary amenorrhea.

In the present study,the research worker wants to find out

how far amenorrhea is associated with emotional disturbances and

tension.

C) MENORRHAGIA
Menorrhagia means excessive menstrual loss and it is most

commonly described as "it absolutely pours". The flow usually

occurs at n o r m a l intervals but, is incr e a s e d in a m ount or

duration. POLYMENORRHEA refers to periods that are normal in

amount but\ which occur too frequently, i.e. at intervals of 21

20
days or less. It refers to periods that are both heavy and

frequent.

Chronic excessive menstrual loss eventually leads to iron

deficiency anaemia. This gradually brings on an extra set of

symptoms to cause added a n x i e t y and a fear o f .cancer. An

important aspect here is that as soon as the gynaecologist

explains that everything is all right, the normalcy of the whole

problem affects the menstrual flow tremendously. This shows its

psychological origin..

Compared to o'tftdr disorders of menstruation, menorrhagia has

been considered more serious because the patient becomes nervous

due to actual loss, of blood, which she herself observes. If the

blood loss is top much and too frequent, then added to

physiological d e f i ciency, psychological anxiety is equally

evident. The patient becomes nervous and this nervousness becomes

and added factor in the continuation of menorrhagia. This is the

reason why it is considered as a psychosomatic disorder,

d) METRORRHAGIA
Metrorrhagia refers to irregular and unusual bleeding or

bleeding at times other than those when a period is expected

(BORLAND'S POCKET MEDICAL DICTIONARY, 1983). It makes a woman

suspect.an abnormality but it'does not always make her seek

advice. The bleeding may be,slight and unaccompanied by other

symptoms. A woman may ignore it and decide to consult a doctor

only if it gets worst. It is a symptom never to be ignored; the

discovery of abnormal, v a g i n a l bleeding must always be

investigated. The present research .worker is -interested in

finding out whether it has some psychological origin.

21
 6) OLIGOMENORRHEA

Oligomenorrhea means infrequent menstruation. It presents a

problem sim i l a r t o ' s e c o n d a r y amenorrhea. Menstruation is

irregular and infrequent, with periods occurring one to three
months apart or even longer. Associated features sometimes

present,are obesity, hirsutism and infertility. The cause is

usually organic. However, it is- psychologically important

because the patient usually has a certain set concept in her mind

about the whole menstrual cycle. Any change that occurs is likely

to arouse doubt, fear and anxiety. Patients suffering from

. ' . ’ ‘ •' . . s
oligomenorrhea usually suffer from nervousness. How far ./this

influences the normal personality and the positive aspects of

life is the problem of the present study,

f) THE PREMENSTRUAL SYNDROME

The syndrome was first described by PRANK (1931) as a

premenstrual feeling of "indescribable tension, irritability, and

a desire to find relief by foolish and unconsidered actions".

Premenstrual syndrome is a group of physical and mental

changes which begin anything between two and fourteen days before
menstruation, and which are relieved almost immediately the

period starts (SHREEVE, 1983). In many women, mood change is one

of the most prominent.features, usually to a state of extreme

irritability which expresses itself as irrational anger with or

without physical violence at one end of the spectrum and as

impatience and snappiness at the other. In very rare cases, it

may lead to homicide and suicide (DALTON, 1964 and SHREEVE,

1983) . The s y m p t o m of te n s i o n w h i c h gave the old name of

p r e menst r u a l ten s i o n to the syndrome as a whole is both

inadequate and inappropriate because it represents only one

22
characteristic of a plethora of symptoms, and understates the

case for women who also suffer from depression, lethargy and

numerous physical complaints. While periods tend to get a lot

tolerable as a woman gets older, the premenstrual syndrome tends

to get more isevere.

, Some of the physical and mental symptoms associated to the

premenstrual syndrome are mentioned below. The present research

worker is interested in mental and emotional symptoms which

include tension and irritability, intense depression, lethargy,

reduced powers of concentration, loss of confidence, feelings of

worthlessness, illogical emotional reactions, etc. Physical

symptoms include swelling of.the abdomen, ankles and fingers,

feelings of being bloated and swollen, weight gain of several

pounds; heavy, engorged, painful breasts; headaches, etc. As many

as, eighty percent of the women are aware of some degree of

premenstrual changes; forty percent are substantially disturbed

by them, and between ten and twenty percent are seriously

disabled as a result of the syndrome (DALTON, 1964; REID AND YEN,

1981).

Premenstrual syndrome has been added in the category, of

psychosomatic disorders because it is-not universal for all- women

to suffer from the s a m e ,and women suffering from menstrual

disorders.do show typical personality characteristics which are

usually associated to anxiety and nervousness. How far is this

true and whether this manifestation is also the result of

emotional disturbances in personality is the problem of the

present study.
V) FACTORS AFFECTING MENSTRUATION
In the -previous section, it has been clarified that

23
menstrual disorders can be either the cause or the result of

psychological disturbance. In the present study, the research

worker is interested in the psychological variables responsible

for the development of menstrual, disorders. Hence, in the present

section, variables that clinical psychologists consider important

in the development of menstrual disorders are discussed. Research

is already going on in this field by both gynaecologists and

psychologists. So far the following factors have been pin pointed

as the major psychological factors associated with menstrual

disturbances.

a) MOTHER'S ATTITUDES TO MENSTRUATION

The first and the most psychogenic condition associated with

menstrual disturbances is the mother's attitudes to menstruation.

The right* attitude and a healthy approach to menstruation has to

be handed down from mothers or handed across by friends. These

attitudes, largely or totally unconscious, are crucial in shaping

a woman's attitudes and responses to all the events in her life,

including menstruation. ,

DEUTSCH (1944) was the first to describe the psychological

problems of menstruation. Before the menarche, girls begin the

preparation for menstruation even if they do not know anything

about menstruation at all. An 'obscure awareness’ of her mother's

monthly indisposition shows up at an early date in the girl's

fantasy life and it is not always possible to discover when and

to what extent she becomes familiar with the real nature of this

process. Her mother's menstrual discomfort, blood-stained

garments, and even casual rem a r k s can make a very strong

impression on her daughter. The younger the daughter and the more

incapable of dealing with these impressions, "the more painful,

24
 U ^L\
bloody, cruel, and threatening are these manifestations of

feminity to her fantasy life". Menstruation is often the one

subject w h i c h women c o n s i d e r as a ma j o r 'secret' between

themselves and their daughters.

According to SELYE (1960) faulty attitude and chronic

anxiety can lead to physical changes. The personality make-up of

the patient appears to be the primary causative agent. An

ambitious person with strong dependency needs may react to any

stress related to his goals with sustained anxiety and resentment

until somatic complaints result. In other instances, the stress

situation appears to play a leading role and to elicit similar

emotional reactions in most women exposed to it. In still other

cases,, the conflict pattern may merely serve to precipitate a

psychosomatic disorder (menstrual.disturbances being one of them)

in a predisposed person.

. .Thus, a mother's ambivalent attitudes to menstruation are

passed down from generation to generation. In other words, the

mother's h e a l t h y or u n h e a l t h y atti t u d e s do have a direct

correlation with the attitudes of the daughter to menstruation.

Women who.are educated and aware of the process of menstruation

take it as a normal, natural process and their daughters too

consider it to be a natural part of life's phenomena..On the

other hand, if the mother is uneducated and unaware and if she is

highly scared, of menstruation, then the completely normal

menstrual cycle may be regarded as something horrifying by the

daughter.. Therefore^ menstrual disturbances i n ,some cases do not

exist, they are created by the woman.

It may be said that the attitudes of the mother is the

primary factor in shaping the. attitudes of the daughter. In other

25
words, mother is the primary condition for the development of

normal or abnormal attitudes towards the whole process of

menstruation.

b) SOCIAL ATTITUDES TO MENSTRUATION

'Throughout the ages, many societies have held the belief

that menstruating women are "unclean and unholy', while others

consider them to be dangerous. The attitude of our own society to

women's periods is reflected in the names that have been used to

refer to that time of the month (SHREEVE, 1983). "THE CURSE" was

the first name to be coined and became firmly established. Other

names include,

The Time of the Month,

The Monthlies,

Taking My Period, ,

Menses,

The Devil's Gateway, .

Chum.
It is thus not surprising if a young girl grows to fear

menstruation.

Religion also plays an important role in forming attitude

towards menstruation. One does not know but perhaps, looking at

the different religious approaches towards menstruation, one can

draw the conclusion that a woman during menstruation is

considered unholy and is not allowed to do either, household work

or any religious activity. The reason may be actually to give her

physical rest but society being uneducated, religion had to step

in to support the medical requirement of rest. That is why in

Jnzfjy : religion?, there are specific instructions for the woman to

follow during this period where she is required to remain away

26
from holy places.

C) MYTHS ABOUT MENSTRUATION

Like so many other areas of life, menstruation too has its

confused mythology. It is likely that a woman's perception of

menstruation will be strongly influenced by such myths. These are

the subject of extensive documentation aind include socially and

culturally dependent beliefs, for instance, that menstruating

women:-will turn milk sour; are unclean; makes hives or bees die;

makes brass and iron rust; stop the bread rising, and so on.

However, as women become more- aware of their own identities,

they develop body’ consciousness and thereby an awareness of, how

their bodies work and with the advancement of Western thinking

and o b j e c t i v e .scientific knowledge, myths are losing their

support for the educated masses. This, we can observe from our

own experiences.

In primitive societies, where women lack education and are

not allowed to come in contact with modern ideology, women still

believe in the old mythology and all the principles are accepted

as principles of God. This is the observation of the present

research worker.
d) REACTIONS TO MENSTRUATION OF THE GIRL/WOMAN HERSELF
Menarche is observed as a. traumatic event by some girls who

are ashamed of menstrual bleeding and if detected feel as if they

have done something unclean. Other girls who grow up receiving

more tender care from their mothers during illness than at other

times, experience a few days in bed during their periods as the

most pleasant days of all. It entitles them to their mother's

care without the attendant feelings of guilt. They resent any

attempt to get them out of bed {PASNAU, 1969).

27
 ' A girl's reaction to her first menstruation was thought to

be a model for menstrual reactions throughout her life. As

described earlier, a mother's reactions to menstruation are also

important. Some girls almost inherit dysmenorrhea; the mother

suffered, so does the daughter. She expects it to be bad. The

discomfort of a period is not lessened when that particular

period is unwelcome, as it is when a woman wants to be pregnant.

The period hurts, she resents it, it hurts mofe. According to

FLUHMANN (1956), the affected women are usually hypersensitive to

pain and ex h i b i t personality disorders. PAULSON (1961),

hypothesized the primary areas of conflict as involving sexual

feelings, life experiences and attitudes towards feminity as

important etiological factors in dysmenorrhea.

Excessive menstrual loss!is another symptom which prompts

women to seek medical help. But how does a woman judge her

menstrual loss to be normal or heavier than normal? Here too, the

reaction of the woman is of prime importance. Most women do not

have any idea regarding what is considered,as normal. What they

do Understand is the untimely messiness and stickiness .involved

with menstruation. Some women who are particularly fastidious

regard the normal as excessive .because they cannot bear to feel

messy at all. If the period is a real annoyance to them, in their

work or their social life, it may seem to require too much

attention and to go on for too long. On the other hand, are women

who actually have excessive menstrual flow but still put up with

it without any fuss taking it in their stride. What, is the

difference in the personality characteristics of these two groups

of women, is the problem of the present study.

The psychological factors for the absence of menstruation

28
(amenorrhea) have been described as due to the shock and horror

of the first menstrual period, essentially a defensive,

functional inhibition (DEUTSCH, 1944). Amenorrhea was noted in 73

of the 732 women who had undergone attempted rape (0'NEILL,

1954)i fifteen .percent of the women in concentration camps in

Manila had amenorrhea (O'NEILL, 1954). Other cases have been

described in Hongkong and London during war time crisis (CHEZ,

PASNAU, LEIKEN AND BATISTE, 1964). Patients with anorexia nervosa

have cessation of menses before the lack of food intake brings on

malnutrition (FLUHMANN, 1956). .

• • n

CHEZ, PASNAU et al. (1964) reported on, four patients with

amenorrhea who were evaluated for endocrine disorders and

psychopathology. Each of the four were found to have overt

endocrine disorders “
and psychiatric diagnosis ranging from

neurosis to severe character disorders. Each of them had handled

stress by neurotic or psychosomatic defense mechanisms. On

initial examination, there was repeated environmental stress or

emotional symptoms. They underwent a thorough psychiatric and

psychologic evaluation. Common denominators were psychosexual

immaturity, ambivalence regarding the f e m inine role and

pregnancy, .conflicts over, heterosexual activity, and general

difficulties in inter-personal relationships. Psychologic testing

revealed, isolation and distortion of body image.

Studies of/this kind indicate t h e .clinical spectrum of

symptoms, signs and laboratory v a l u e s .in p s y c h o s o m a t i c

amenorrhea, and point out the need for the combined approach to

patients with these disorders.. To what extent any of these

factors are reflected in the' Indian Culture — specifically in the

population of Gujarat is the problem of the present study.

29
 ' Thus, the real, purpose of the study is to find, out how far

any disturbance in menstruation is used as a defense against

greater social or personality conflict. Secondly, it is equally

important to find out the percentage of population having this

kind of disturbances and if so whether we can develop some

instruments .to find out what kind of psychological tests would be

relevant for the study of this kind of disorder,

e) CONCLUSION

It is important■to keep in mind the psychological variables

discussed above because it is important to find out how many of

these are actually revealed by the Ss of the present study. It is

quite p o s s i b l e that all the v a r i a b l e s may not be equally

important or there may be other variables which play a more

dominant role than those discussed above. This study, therefore,

is an exploratory study where the research worker wants to find

out as many psychogenic variables as, possible that are associated

with menstrual disorders.

vi) QUESTIONNAIRE AS A RESEARCH TOOL

The P E N G U I N D I C T I O N A R Y OF P S Y C H O L O G Y (1985) defines

.questionnaire as "broadly any set of questions dealing with any

topic or group of related topics designed to be answered by a

respondent".
SOMMER AND SOMMER (1986) described a questionnaire as a

series of written questions on a topic, a b o u t which the

respondent's opinions are sought.

A questionnaire thus is a set of questions designed for a

particular topic to be answered by a respondent. They are

effective in giving information about a person's beliefs,

perception, feelings, motivations, anticipations or future plans.

30
There are two general types of questionnaire: self administered,

which respondents fill out themselves and interviewer

administered, in which the interviewer asks questions and records

the responses. Heavy reliance is placed on the S's verbal report

for information about the stimuli or experiences which she is

exposed and for the knowledge of her behaviour.

The advantages and limitations of the questionnaire method

has, been described in detail in standard text books of Research

Methods (SELTIZ, JAHODA, et al. 1959; FREEMAN, 1955, 1962; MOORE,

1987).
)
In the present study, questionnaires have been used by the

method of semi structured interview in order to validate the

responses of the Ss. All the questions have been read carefully

and properly to the Ss so that they can understand without any

difficulty. Difficult questions have been clarified without

giving any suggestions.

The Ss have been requested to give their opinion about the

method and were also asked if they wished to give more details

about’themselves.

inspite of this, as SHAFFER AND LAZARUS (1952) have pointed

out, the greatest limitation of a questionnaire is the

transparency of the questions and its inability to bring out the

unconscious feelings. In order to overcome this limitation, a

semi structured verbal projective technique (ISB) has been used.

vii) PROJECTIVE TECHNIQUE AS A RESEARCH TOOL

Originally, projective techniques were developed to overcome

the limitations of the inventories. ENGLISH AND ENGLISH (1958)

defined projective technique as "a procedure for discovering a

person’s characteristic modes of behaviour (attitudes, motives

■ • 31
and dynamic traits) by observing his behaviour in response to a

situation that does not elicit or compel a particular response".

. According to LINDZEY (i96l) , "a projective technique is an

instrument that is considered especially sensitive to covert or

unconscious aspects of behaviour. It permits or encourages a

variety of S responses, it is highly multidimensional, and it

evokes unusually profuse response data with a .minimum of subject

i '

awareness concerning the purpose of the test".

In the present study, the Gujarati adaptation of the Rotter

and Rafferty's Incomplete Sentence Blank (BHATT, 1972) has been

used. It contains. 40 sentence "stubs" or "stems" or incomplete

sentences.. The S is not r e s t r a i n e d by a n y t i m e limit for

completing the sentences. The only requirement is,that while

completing a sentence one complete thought must be expressed and

there should be some aspect, of ego involvement. The S has to

express her own ideas and must complete the sentence with the

first thought that comes to her mind. There is no fixed time

limit though normal Ss complete within half an hour.

ADVANTAGES OF THE ISB

1 Views that the Ss cannot talk about openly can be expressed in

this test.
2 The Ss can express any idea without.any hesitation, restraint

or control. However, some Ss try to give good responses instead

of- valid ones. Therefore, they are to be instructed from the

beginning to express their,own personal feelings. They are made

to u n d e r s t a n d that .there is nothing- like right or wrong

responses.
3 Most of the sentence stems cover personal, social and family

life situations of an individual. Therefore, a total personality

32
picture emerges once the test is completed by' the S. .

4 Numerical interpretation and classification is already given by

ROTTER AND RAFFERTY (1950). Therefore, statistical calculations

as well as clinical interpretation are both easy.

5 It does not require much- time to be trained to use this

instrument on normal.as well as atypical sample.

Inspite, of these advantages, there are certain limitations

which every research worker should bear in mind before using this

test. They are:

1 The S is to be prevented, from giving socially acceptable

responses, proverbs or statements which are the fashions of the

day. They are to be specifically instructed to express their own

views rather than those of someone else.

2 The total test.should be completed. No sentence should be left

incomplete as far as possible.

3 Just, one idea should not be repeated throughout the test. It

implies that-the S is not co-operative.

4 Interpretation of the responses requires great precaution. It

requires the presence of the S to find out the exact meaning of

any particular response. Otherwise, the possibility of double

projection is likely ?to arise.

5 This test r e q u i r e s a good IQ level, some e d u c a t i o n and

independent thinking. Otherwise i t ,has failed to give good

results in the case of.Ss who are highly immature or mentally

retarded. Indirectly, therefore, Ss who fill up the test as per

instructions as quickly as possible can be regarded as Ss with a

good IQ.
All the above mentioned points have been kept in mind while

administering the test to the sample of the present study,

33
especially the patients.

IV PURPOSE OF THE STUDY

The present study has been undertaken for the following

purposes:

1. To study the level of self perception of the patients Vs

normal female population of Gujarat on the Self Perception

Questionnaire (SPQ).

2. To study the level of gynaecological problems of the patients

Vs normal female p o p u lation. of Gujarat on the Inventory of

Gynaecological Problems (IGP). .

-H.

3. To study the level of general Incomplete Sentence Blank (ISB)

scores of the patients Vs normal female population of Gujarat.

4. To study whether education as a variable shows any significant

difference on the three variables stated above ( 1 , 2 , 3) .

5. To study whether age as a variable shows any significant

difference on the three variables stated above (1,2,3).

6. To study whether marital status as a variable shows any

significant d i f f e r e n c e -on the three variables stated above

(1.2.3) .

7. ,To,study whether social background as a variable shows any

significant difference on the three variables stated above

(1.2.3) .
V SIGNIFICANCE OF THE STUDY

This study, if proved successful will be useful to the

following areas:
1 Parents having- daughters' complaining about menstruation.

2 'Clinical psychologists who'are treating patients with menstrual

disturbances.
3 Gynaecologists treating patients with menstrual ’disturbances

34
who do not .respond to medical treatment.

4 Research workers who want to go ahead for extensive research in

this field.

35