Endo Hope

A conversation with Chris Bobel

Dr. Bobel is Associate Professor of Women’s, Gender, and Sexuality Studies at the University of Massachusetts, and is also President of The Society for Menstrual Cycle Research. She just published a book, The Managed Body, where she explores developing girls and menstrual health in the global south.

I spoke with Dr. Bobel about how misinformation spreads about menstruation, how myths and taboos persist, as well as her thoughts on why consumer products are not the answer.

Here is an excerpt of our conversation, edited for clarity:

Ava: What misinformation about menstruation do you see spreading in the global south?

Dr. Bobel: There’s misinformation being spread by some of the NGOs and social businesses that are addressing menstrual health. There is a tendency for organizations—understandably motivated by timetables, competitive funding, competition, and a dearth of resources—that many organizations are not fact checking things like, “one out of 10 African girls misses school when she’s on her period” or that the lack of menstrual pads is making girls sick.

Those are the two claims that are often made by very well-meaning organizations to advance the cause of menstrual health, to attract attention and resources to justify their intervention. But the truth is neither of them are suitably supported by the available evidence. When it comes to the menstrual health space, we’re kind of building the house while we’re were living in it. So we’re making assumptions that we have yet to prove.

So the research just doesn’t line up yet to prove that there’s a clear relationship between access to menstrual materials and school attendance. And there’s not clear evidence that when using cloth for instance—or something else that’s not a commercial single-use menstrual pad—that people will get sick. And yet those claims are often made.

Ava: Are they myths?

Dr. Bobel: I wouldn’t call them myths per se, I would just call them assumptions or claims that are made. They hold up because they repeat what somebody else has said, or they think they heard it from UNICEF or they think they read it in a UNESCO report, or maybe they read a report on a piece of research that was done in a small population in Sierra Leone, but then they extrapolate that to a site in India.

It’s bad politics of citation, right? So people don’t get to the bottom. They don’t go to the source and actually read the study, or they don’t find out that there is no study it’s just one NGO was quoting one news article that quoted a different NGO that’s quoting a different news article and you get to the bottom and you realize there’s nothing there.

Ava: Are there other examples?

Dr. Bobel: There’s another example of this under-reliance on the evidence and over-reliance on what are called spectacles. In the absence of good science, what people often do is tell the most heart-wrenching story about the young woman who died because she wore a cloth as a menstrual absorbent and there was a rusty hook in it and she contracted tetanus and died.

These are real stories, but to position them as the norm to justify intervention, I find this problematic. It is intended to create awareness and empathy, but I think it actually serves to create distance between other people, different people. Right? So that we then sort of see the brown and black people of the global south as the savage, as ignorant, as not knowing better. I don’t think that’s actually a way to challenge inequality and improve the lives of people globally.

Ava: What role do you think consumer products do or don’t play in changing stigmas around menstruation?

Dr. Bobel: I recognize that language of menstruation, particularly in the west and increasingly in the global south, is a language of products. We equate menstruation with a mess. We equate menstruation with something that needs to be cleaned up. That’s why I titled my book “The Managed Body” because of this idea that, that the menstruating body is one in need of management. We don’t construct it as a vital sign. We don’t construct it as something neutral, normal, or healthy. We construct it as a problem that needs to be solved. And the menstrual care industry has been brilliant at delivering the “solution” and the solution comes in a box or bag.

I don’t want to eclipse menstrual discomfort, pain, or disorders. Those are a reality. But for most people, menstruation is a normal event, but it gets socially constructed. It could be constructed as a nuisance, as something you have to hate, and we just want to make it go away. And that’s the work of stigma. There are complex reasons why that has to do with gender and embodiment and in some, in some cases, race as well as class. And so, of course, people will do whatever they can to keep it quiet, keep it hidden. And this is true in consumer culture more generally—your body grows hair, but you then need to make it go away.

So the personal care products are very effective at showing up very quickly and saying, oh, we’ve got the solution for you. But they also helped to construct the problem, right? It’s shameful that you leak, the leak is a social crisis. Or, you don’t want anybody to know that that’s a tampon, so we’re going to wrap it in neon bright wrappings or make it small enough that it fits in your hand so that you can discreetly walk from the classroom to the bathroom. Or the scented products, particularly scented tampons, which are absolutely unnecessary because there is no menstrual odor if you’re wearing a product internally.

And so, of course, we want to smell like a flower. We don’t want to smell like a woman, a human woman. So that’s my worry about this emphasis on product. It’s nice to have options. I think it’s great. I’m not against options and innovation, but I think it’s a false belief that if you give people more options, that’s going to fight stigma. That doesn’t fight stigma—that accommodates stigma.

Ava: What else needs to be done to fight these taboos? Is it education to flip the script girls have internally about their menstruation?

Dr. Bobel: Yes. I think we do need to change the script, but it needs to be for more than girls. It needs to be for boys, parents, religious leaders, teachers, coaches, doctors, nurses. I did a workshop with school nurses—they were so hungry for information. They know that they have an opportunity to talk with kids about their bodies in ways that are body positive and to promote menstrual literacy. But guess what? Many of them felt constrained because they didn’t feel supported by the administration.

It wasn’t okay to talk honestly about bodies, it wasn’t okay to talk about menstruation. And we need to. We need a massive educational overhaul, where menstrual health and more generally puberty and reproductive health are wheeled not just into health class but show up in lots of places: history, political science—it can be a really productive lens to think about a lot of things.

And it will normalize it because it’s just part of the conversation. But right now we marginalize. It’s so acutely that we have some schools—even to this day—it’s one day of education about menstruation. And the boys and the girls are separated. Sometimes the boys get to play basketball and the girls see a video, right? And then no wonder kids are clueless and no wonder they weaponize menstruation because they don’t understand it and it makes them uncomfortable.

It’s weird when you think about it—blood comes out of your body, but you’re not dying. What strange thing; You need to unpack it. We really need to invest in education and I’ve talked to lots of tech innovators and startup people and I don’t think I’ve talked to anyone that’s innovating and education. They’re all innovating in product and I would really like to see some innovation in the direction of education and awareness campaign.

I would really like to see a really serious effort to teach menstrual literacy in the context of body positivity. And I don’t mean everybody has to love their period. I think that’s exchanging one tyranny—hating your period—for another one, loving your period. I don’t want to assume anybody’s relationship to their body, especially for people that are gender nonconforming or trans.

But if you don’t have good information, you can’t make informed decisions about how to care for your body. You’re operating in the dark. We have to turn the lights on and literacy training in a variety of settings—not only schools and not only for girls but for everybody—is the way to do that. I think we should do that at least as much as we do the product innovation.

Ava: What else could we be doing?

Dr. Bobel: Menstrual health is a gateway to all kinds of conversations about sexuality, about sexual violence, about healthcare decision making across the lifespan beyond the menstrual cycle. For me, this is why this issue is so fascinating—you open your mouth and start talking about menstruation and pretty soon you’re talking about 10 different issues. But how can you draw in more people into more of these conversations? How can people leverage body literacy to think critically about lots of dimensions of their life? Because it’s not only fertility that people need to learn about.

The only way forward for the mental health movement is if we build linkages with other movements. Otherwise, we’re going to languish on the margins as some kind of weird fringy cause. People say why are you talking about periods when there’s sex trafficking and there’s massive mass incarceration, and there are school shootings. But it’s the beginning of the body hatred that puts into motion an entire lifetime of disregard for staying in tune with the body—and that is powerful. And if we do it right, early, then I think we can change the script. It’s never too late. It’s not too late for somebody that’s 30 or 40 or 50 or 60 or for boys or for parents. And I think we’ve got a great opportunity there.By Lindsay Meisel | Feb 7, 2019

Lindsay Meisel

Lindsay Meisel is the Head of Content at Ava. She has over a decade of experience writing about science, technology, and health, with a focus on women’s health and the menstrual cycle. Her work has been featured on The Fertility Hour, The Birth Hour, The Breakthrough Journal, and The Rumpus.

Original article found here.

Writing for the Guardian, Nicole Davis makes a strong claim: that there’s no need for women to get their periods. Pushing back against the recent wave of feminist authors and activists calling on women to embrace their periods, Davis points out that periods are inconvenient and cause pain and discomfort in some women. And further, having a period every month may not be as “natural” as it seems, because in earlier days women experienced far fewer periods due to more pregnancies and breastfeeding. 

And then Davis drops a bombshell: she quotes a couple of medical doctors who suggest that 99% of women do not need to bleed and there is no health benefit to doing so. The doctors she quotes argue that hormonal contraception can be taken continuously to prevent any bleeding, with no negative consequences.

These are glaring claims, and what’s missing is any evidence to support them. It seems it is the opinion of the few doctors interviewed that menstrual cycles are not necessary, but opinion does not equal fact. Especially when this opinion directly contravenes the endocrine society practice guidelines around amenorrhea[1].

Bleeding itself is not a health benefit, but it is evidence that ovulation is occurring. Why does it matter that ovulation is occurring? Because a large body of research demonstrates unequivocally that there are benefits to ovulation and the hormonal changes that accompany it. As a follicle grows and the egg inside matures, estrogen increases by about 10-fold[2]. This leads to a surge in luteinizing hormone (LH), which causes ovulation. After ovulation, progesterone levels increase by more than 25-fold over baseline[3]. There are many other hormones involved in the menstrual cycle[4] as well. 

What are the benefits of the hormonal changes associated with ovulation?

The best examples come from the health effects in women who have either undergone natural or surgical menopause[5] (where ovaries and uterus are removed for medical reasons). By far the most serious change after menopause is a sharp decline in bone density[6]. We know that both estrogen and progesterone[7] are heavily involved in increasing and maintaining bone density from puberty on, as well as a number of other hormones related to the menstrual cycle such as inhibins[8], IGF-1[9], and FSH[10]. We also know that women with amenorrhea[11] tend to have lower bone density. 

Women who have gone through menopause are more likely to experience cardiovascular disease[12], and there are even studies that show that in regularly cycling women, heart attacks are more likely during the follicular phase[13,14] when estradiol is lowered. Younger women with amenorrhea show impaired vascular function[15].

There are also suggestions of increases in dementia[16] and other neurodegeneration[17] after menopause, as well as increased rate of death due to neurological causes after surgical menopause[18].

The Guardian article goes on to discuss the virtues of hormonal birth control, with mentions of a few negative side effects such as anxiety and possibly elevated cancer risks, but overall little regard for the health implications of preventing natural ovulations, on which there simply is not sufficient data.

One area where studies have found detrimental effects of hormonal contraception, even in women who were cycling normally before contraception, is lower increases in bone density than expected as compared to controls[19, 20, 21]. In addition, use of oral contraceptives may lead to deficiencies[22] in various micronutrients[23]. There are also reports of increased anxiety and depression[24] with hormonal contraceptive use in some populations.

In women who are experiencing missing periods due to underfueling—known variously as hypothalamic amenorrhea, hypogonadotropic hypogonadism, female athlete triad, or relative energy deficiency in sport—the detrimental effects of absent periods[25] can be even more stark: abnormal thyroid function, abnormal growth hormone patterns, infertility (due to lack of ovulation), digestive effects, possibly alterations to the immune system, decreased bone density leading to stress fractures, being prone to other injuries …

Hormonal birth control provides exogenous estrogens and progestins, but these are not provided at the same level as physiological estrogen and progesterone during the menstrual cycle. Indeed hormonal birth control results in much lower levels of endogenous (physiological) estrogen and progesterone[26].

Not to mention there are around 20 different hormones, enzymes, and other molecules[27] that are involved in our cycles, including GnRH, FSH, LH, inhibins A and B, prostaglandins, IFG-1 and -2, EGF, estradiol, progesterone, 17-OH-progesterone, testosterone, HETE, and more. To argue that replacing just one or two with synthetic versions that may or may not activate receptors in exactly the same way as the natural form is going to fulfill all the same functions as those 20+ hormones is not logical.

It is irresponsible to ignore years of medical literature and make the claim that there is no need to bleed (and by extension, no need to ovulate). It is irresponsible to gloss over side effects of hormonal birth control and make it sound like a panacea, particularly if it is taken to correct a period issue with a treatable medical underpinning.

Of course, every woman has the right to make her own choices around reproductive health care, and for many women, the hormonal birth control pill or other options that prevent ovulation and bleeding may be the best option. For other women, a non-hormonal method of birth control that ovulation intact is preferable. Importantly, making the optimal choice given needs, desires, and health, requires accurate and complete information. Medical professionals and journalists should be presenting women with a summary of ALL the evidence so they can make truly informed decisions.By Nicola Rinaldi, PhD | Aug 5, 2019Tags:hormones, menstruation, ovulation

VIEW SOURCES

[1]Catherine M. Gordon, Kathryn E. Ackerman, Sarah L. Berga, Jay R. Kaplan, George Mastorakos, Madhusmita Misra, M. Hassan Murad, Nanette F. Santoro, Michelle P. Warren “Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline” The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 5, 1 May 2017, Pages 1413–1439

[2]Mikael Häggström “Reference ranges for estradiol, progesterone, luteinizing hormone and follicle-stimulating hormone during the menstrual cycle” WikiJournal of Medicine

[3]ibid

[4]Beverly G Reed, MD and Bruce R Carr, MD. “The Normal Menstrual Cycle and the Control of Ovulation” 2018 Aug 5. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-.

[5]Google search, term=”surgical menopause”

[6]Karlamangla AS, Burnett-Bowie SM, Crandall CJ. “Bone Health During the Menopause Transition and Beyond.” Obstet Gynecol Clin North Am. 2018 Dec;45(4):695-708.

[7]Sundeep Khosla, L Joseph Melton III, B Lawrence Riggs “The unitary model for estrogen deficiency and the pathogenesis of osteoporosis: Is a revision needed?” J Bone Miner Res. 2011 Mar;26(3):441-51.

[8]Daniel S. Perrien, Sara J. Achenbach, Samuel E. Bledsoe, Brandon Walser, Larry J. Suva, Sundeep Khosla, Dana Gaddy “Bone Turnover across the Menopause Transition: Correlations with Inhibins and Follicle-Stimulating Hormone” The Journal of Clinical Endocrinology & Metabolism, Volume 91, Issue 5, 1 May 2006, Pages 1848–1854

[9]Southmayd EA, De Souza MJ. “A summary of the influence of exogenous estrogen administration across the lifespan on the GH/IGF-1 axis and implications for bone health.” Growth Horm IGF Res. 2017 Feb;32:2-13.

[10]Daniel S. Perrien, Sara J. Achenbach, Samuel E. Bledsoe, Brandon Walser, Larry J. Suva, Sundeep Khosla, Dana Gaddy “Bone Turnover across the Menopause Transition: Correlations with Inhibins and Follicle-Stimulating Hormone” The Journal of Clinical Endocrinology & Metabolism, Volume 91, Issue 5, 1 May 2006, Pages 1848–1854

[11]Keen AD, Drinkwater BL “Irreversible bone loss in former amenorrheic athletes.” Osteoporos Int. 1997;7(4):311-5.

[12]TAVIA GORDON; WILLIAM B. KANNEL, M.D., F.A.C.P.; MARTHANA C. HJORTLAND, Ph.D.; PATRICIA M. McNAMARA, “Menopause and Coronary Heart Disease: The Framingham Study” Ann Intern Med. 1978;89(2):157-161.

[13]Hamelin, Bettina A et al. “Influence of the menstrual cycle on the timing of acute coronary events in premenopausal women.” The American Journal of Medicine, Volume 114, Issue 7, 599 – 602.

[14]G W Lloyd, N R Patel, E McGing, A F Cooper, D Brennand-Roper, G Jackson. “Does angina vary with the menstrual cycle in women with premenopausal coronary artery disease?” Heart 2000;84:189-192.

[15]W. A. Rocca, J. H. Bower, D. M. Maraganore, J. E. Ahlskog, B. R. Grossardt, M. de Andrade, L. J. Melton. “Increased risk of cognitive impairment or dementia in women who underwent oophorectomy before menopause.” Neurology Sep 2007, 69 (11) 1074-1083.

[16]Noriko Yoshida, Hisao Ikeda, Kenzo Sugi, and Tsutomu Imaizumi. “Impaired Endothelium-Dependent and -Independent Vasodilation in Young Female Athletes With Exercise-Associated Amenorrhea” Arteriosclerosis, Thrombosis, and Vascular Biology. 2006;26:231–232.

[17]W. A. Rocca, J. H. Bower, D. M. Maraganore, J. E. Ahlskog, B. R. Grossardt, M. de Andrade, L. J. Melton. “Increased risk of parkinsonism in women who underwent oophorectomy before menopause.” Neurology Jan 2008, 70 (3) 200-209.

[18]Rivera C.M.a · Grossardt B.R.b · Rhodes D.J.a · Rocca W.A., “Increased Mortality for Neurological and Mental Diseases following Early Bilateral Oophorectomy.” Neuroepidemiology 2009;33:32–40.

[19]Talita Poli Biason, Tamara Beres Lederer Goldberg,corresponding author Cilmery Suemi Kurokawa, Maria Regina Moretto, Altamir Santos Teixeira, and Hélio Rubens de Carvalho Nunes. “Low-dose combined oral contraceptive use is associated with lower bone mineral content variation in adolescents over a 1-year period.” BMC Endocr Disord. 2015; 15: 15.

[20]Rizzo ADCB, Goldberg TBL, Biason TP, Kurokawa CS, Silva CCD, Corrente JE, Nunes HRC. “One-year adolescent bone mineral density and bone formation marker changes through the use or lack of use of combined hormonal contraceptives.” J Pediatr (Rio J). 2018 Jun 28. pii: S0021-7557(18)30069-X.

[21]Gersten J, Hsieh J, Weiss H, Ricciotti NA. “Effect of Extended 30 μg Ethinyl Estradiol with Continuous Low-Dose Ethinyl Estradiol and Cyclic 20 μg Ethinyl Estradiol Oral Contraception on Adolescent Bone Density: A Randomized Trial.” J Pediatr Adolesc Gynecol. 2016 Dec;29(6):635-642.

[22]Prabhudas R.Palan, Amy T.Magneson, MoniqueCastillo, JamesDunne, Magdy S.Mikhail. “Effects of menstrual cycle and oral contraceptive use on serum levels of lipid-soluble antioxidants.” American Journal of Obstetrics and Gynecology Volume 194, Issue 5, May 2006, Pages e35-e38.

[23]M. PALMERY, A. SARACENO, A. VAIARELLI, G. CARLOMAGNO. “Oral contraceptives and changes in nutritional requirements.” Eur Rev Med Pharmacol Sci. 2013 Jul;17(13):1804-13.

[24]Robakis T, Williams KE, Nutkiewicz L, Rasgon NL. “Hormonal Contraceptives and Mood: Review of the Literature and Implications for Future Research.” Curr Psychiatry Rep. 2019 Jun 6;21(7):57.

[25]Mountjoy M et al., “International Olympic Committee (IOC) Consensus Statement on Relative Energy Deficiency in Sport (RED-S): 2018 Update.” Int J Sport Nutr Exerc Metab. 2018 Jul 1;28(4):316-331.

[26]Elliott-Sale, K & Hicks, K 2018, Hormonal-Based Contraception and the Exercising Female. in J Forsyth & C-M Roberts (eds), The Exercising Female: Science and Its Application.Routledge Research in Sport and Exercise Science, Taylor & Francis.

[27]Beverly G Reed, MD and Bruce R Carr, MD. “The Normal Menstrual Cycle and the Control of Ovulation” 2018 Aug 5. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-.

Nicola Rinaldi, PhD

Nicola Rinaldi has a PhD in computational biology from MIT. The author of No Period Now What—a comprehensive guide for how to recover from hypothalamic amenorrhea—Rinaldi has been counseling women on how to recover their missing periods for over a decade.

Original article found here.