The two faces of Eve

One of the things that especially appeals to me about general practice is the way that people continue to present me with angles on their problems that I have not met before. Sometimes this causes me to re-evaluate my own assumptions and preconceptions in a way which can be challenging.

Not long ago a young woman came to see me. “I think,” she said, “I could be suffering from premenstrual tension.” I have learnt over the years to be suspicious of the conditional when used in this way. Women seem on the whole to be decided on this issue, only rarely do they want my opinion as to the nature of the diagnosis. So I asked her what made her think so, expecting to receive the usual catalogue of unhappy and uncomfortable symptoms loosely related to the days before her period. But such was not the case. Her boss, she explained, was a new man who took pride in his role as a caring employer. He understood about women's issues and had tactfully pointed out to my patient that her typing was perhaps not as accurate as usual and that her attitude was a little less compliant towards the end of the month than at the beginning. He thought that she should consult her doctor and seek treatment for what must surely be a case of premenstrual tension. She was unsure of the diagnostic criteria for this condition and did not want to disappoint him so she had made an appointment.

At first I was shocked at what seemed to me to be quite extraordinarily inappropriate advice. The patient, however, did not share my astonishment and was happy to report back that we had discussed the issue and agreed that her symptoms were quite mild and did not really warrant intervention. She seemed reassured, as no doubt her boss would be, that all was well and no action need be taken.

Why did I feel so outraged at the implications of this consultation? Was it really so unreasonable a presentation? This normal young woman, in common with many others, had been encouraged to entertain the possibility of disease as an explanation for her cyclical symptoms and had been exposed to the accusation of incapacity. Why has society in general and the medical profession in particular chosen to emphasise so negatively but one aspect of a physiology that is quintessentially cyclical? Continually ebbing and flowing—in marine terminology it is as if high tide is to be accepted as normal and low tide as pathological. That is obviously nonsensical. Yet is it not so with our approach to the cyclical influence of hormones on female physiology? If women are to be categorised as premenstrually tense are they not inevitably postmenstrually docile? Could it not be that this is where nature has placed the emphasis, enabling receptive behaviour to occur in a period of reproductive fertility before ovulation? When no longer capable of conception the woman can be released from the calming influence of her early cycle and restored to the norm of human behaviour, aggressive, competitive, and uncompliant. Naturally when faced with the two faces of Eve in this way society has the opportunity to prefer one to the other. That is not to say, however, that either is not entirely normal. When asked to choose between the Jekyll and Hyde in their own nature, who would not choose to prefer the meek and gentle Dr Jekyll? It is only women who have the opportunity to experience and be experienced in these two differing phases of themselves. It is up to us not to collude with the condemnation of part of a woman's nature. Is it not possible that the influence has fallen not so much on the phase of the cycle that most inconveniences the woman, but on the phase that most inconveniences everyone else? Why, for example, do we not contemplate pharmacologically relieving women from the self evident and extraordinary burden of cyclical uterine bleeding? If we treat a woman for premenstrual tension is she the patient or is it really her husband or even her boss?

External bleeding is a dire portent in any context other than menstruation, and the anthropological literature abounds with purification rites necessary to counteract the malign and dangerous influence of menstruating women. It seems that our society take such matters in its stride. We accept as commonplace the manifestations of the cycle in terms of uterine bleeding but not in terms of behavioural change. Perhaps it is because menstruation does not inconvenience anyone else.—MARILYN PLANT is a general practitioner in London