Chapter 3 Reproductive issues

Reproductive events are primarily viewed as the onset of menstruation, conception, abortion, pregnancy, miscarriage, childbirth and menopause. Although predominantly focused on physical changes in women, these events involve many issues that affect both men and women, such as sexual dysfunction and infertility. Reproductive issues raise unique and strong ethical dilemmas such as at what point terminating a pregnancy is still morally defensible; the rights of donor parents and children of donors; and the use of in vitro fertilization (IVF) for pregnancy in women over the age of 60.

Biopsychosocial approach

An important point is that all these events can be viewed from different perspectives: biomedical, psychological, social and cultural. These perspectives affect our understanding and treatment of disorders. For example, a biomedical perspective would see PMS as caused by fluctuations and imbalances in hormones associated with the menstrual cycle. Treatment would therefore involve pharmacological methods to counteract hormonal imbalances or influence mood. A psychological perspective of PMS might examine how women’s patterns of behaving and thinking contribute to worsening mood around menstruation, such as noticing particular triggers and maladaptive responses. Treatment might involve identifying and changing maladaptive thinking or behaviour, and finding coping strategies to help women respond in a more adaptive way. A social perspective of PMS might examine women’s sociodemographic circumstances and levels of support; or cultural expectations and narratives about PMS. This might lead to treatment providing practical or emotional support to women during critical times.

It should be apparent that none of these perspectives on its own offers adequate explanation or treatment of PMS. Therefore current medical education and practice are based on a biopsychosocial approach, which considers all the perspectives outlined above and leads to a more informed and holistic approach to treatment.

Menstruation

The effect of the menstrual cycle on a wide range of behaviours has been studied with varying results. For example, research has shown that during the fertile phase of the menstrual cycle women prefer men who are taller, have a more masculine face and a masculine body and display more sexual competitiveness (Little et al., 2007). However, this is usually only the case when women are asked to rate or choose men for short-term relationships, not long-term relationships.

The menstrual cycle is also associated with physical and psychological symptoms just before menstruation, such as irritability, depression, labile mood, abdominal bloating and weight gain, which are commonly referred to as PMS. PMS is most common in women aged between 25 and 35 and is reported by up to 30% of women. For up to 8% of women these symptoms are very severe and affect their personal relationships, work and social functioning. This is referred to as premenstrual dysphoric disorder (PMDD). Women with a history of depression are more likely to suffer from PMDD, and PMDD is associated with poor overall health (Johnson, 2004). This makes it important to examine, in each case, whether PMDD symptoms are being caused by the menstrual cycle, or whether existing psychological problems are being made worse by the menstrual cycle.

Infertility

Conceiving a child is not always straightforward and around one in eight couples will seek help for infertility – defined as failure to conceive after 1 year of regular intercourse without contraception. Infertility is rated as more stressful than divorce, and women consistently report increased negative emotions, with 25% having clinically relevant depression scores. Sexuality and relationships are also affected, with women reporting less satisfaction, interest, spontaneity and pleasure during sex.

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