Menses: A Medical History In Fatuity

The reasons women have menstrual periods have fascinated and baffled medics and philosophers in equal measure for millennia. This is unsurprising, given the curious nature of a monthly episode of blood loss that happens to healthy women. The connection between per­iods and fertility was well known, but it was not until the twentieth century, when scientists understood the role of the monthly process of ovulation, that the process was fully explained. That did not stop (normally male) medical thinkers from offering theories about why women naturally bled each month. In formulating and promoting these theories, they paid little att­ention to the effects menstruation had on women’s bodies and mood and sidelined the experiences of many women who have to cope with painful or heavy periods routinely.

We have recorded theories of menstruation going back over two millennia. In anc­ient Greece, men like Pythagoras, now best known for his mathematical theories, Aristotle and Hippocrates formulated their own conclusions on the nature of women’s bleeding. Aristotle, for example, concluded that menstrual blood was the matter on which an embryo was nourished in the womb. For him, the male contribution to conception was what animated the matter, but the female blood provided the ‘nutritive soul’ of the infant. Similarly, a Greek physician working in Rome called Claude Galen, building on the Hippocratic texts (which themselves perhaps had Egyptian/Mesopotamian ant­ecedents), described the processes of the body in terms of the doctrine of the four humours, or four main fluids (blood, bile, melancholy and phlegm), which needed to be kept in perfect balance for people to keep well. Galen argued that it was necessary for women to bleed each month because they led comparatively sedate lives, which meant they were predisposed to accumulating too much blood in their bodies, known as a plethora of blood. This didn’t happen to men, Galen explained, because they worked harder and more physically than women, and so sweated out their exc­ess humours.

In this humoral system, great importance was placed on bodily evacuations as the way we kept well. From the time of Galen, for nearly 2,000 years this theory dominated ideas about the body in the West and continues to underpin Unani medicine, practised across Asia today, and India’s Ayurveda. The four humours or akhlat are known in Unani as dam, safra, sauda and balgham. (Ayur­veda accepted a tripartite division that relates bodily essences to the elements: kapham, pittam, vatham.) Because balance and in particular the removal of excess was so important to health in this model, humoral practitioners often prescribed purging medicines to make their patients sick, or go to the toilet. Women already exp­erienced a natural monthly purge, which meant a great emphasis was placed on the regularity of periods to a woman’s health.

One of the most influential medical writers from the past was the 11th-century Persian, Ibn Sina (died 1037), known as Avicenna in the West. Ibn Sina left a huge body of work, including a vast encyclopaedia known as The Canon of Medicine (1025). This built on the Greek and Roman medical theories, particularly the works of Galen, and added contemporary Persian and Indian medical ideas, such as those of Abu Bakr Muham­mad ibn Zakariyya al-Razi (died 925), often known by the name Rhazes, whose approach developed humoral theory in new ways. Both men’s views inform Unani. While Ibn Sina’s views on menstruation were informed by Galen, he also added that the womb was the last formed organ in the female body, which accounted for its ‘weakness’. Ibn Sina’s works were the main medical teaching texts in Western universities for several hundred years, meaning his views on the womb and menstruation were widely disseminated and accepted.

In time, other ideas were put forward about the medical causes of menstruation. One such theory, founded in the then-new chemical ideas about the way the body worked, was only current for a time between the mid-1500s into the 18th century in Europe. It described how a ‘ferment’ brewed in women’s bodies, which built up to a crisis point each month when the body would evacuate this matter with a menstrual period. One 18th-century phy­­sician, James Drake, proposed that this ferment built up in the gall bladder, thereby giving this mysterious organ a purpose. The fermented blood flowed from the womb, advocates of this theory asserted, because the womb was a fundamentally ‘weak’ part of the female ana­­­­tomy. It might seem inc­r­­e­dible that an organ which gives life and powerfully contracts to push out a baby could have been thought to be a weak point in a woman’s body.

As so often in the past, religion and medical ideas shared common ground and thus in Christian thought it was proposed that the ferment entered Eve’s body when she ate the forbidden fruit growing on the tree of knowledge in the Garden of Eden, as des­cribed in Genesis in the Bible. Eve is known as the first mother in Christian doctrine and so the person from whom all women are des­cended—her sin and this ferment were and are seen as passed down from mother to daughter. An early Belgian chemist, Jan Baptist van Helmont (d.1644), explained that the ferment (and so menstruation) was a permanent reminder of the inherent sinfulness of women’s nature. Van Helmont’s work was published in Latin at first but got paraphrased by a medical writer, John Marten, in English in the early 18th century. He described how, as soon as Eve ate this fruit, she was no longer ‘mistress of her own desires’. And whereas before she had not menstruated, she was now ‘exposed to the Pangs of Child-birth’ or labour pains and the ‘shame and confusion of seeing herself defiled once a month with her own impure blood’.

Yet another historical medical theory about the causes of menstruation connects it to the moon. This notion held that somehow the action of the moon caused women to bleed on a monthly basis. Even though this connection is still advocated by some today, including by scientists who cite research data correlating the two, hundreds of years ago medical authors were dismissing it with the obvious point that if the moon caused periods, then surely every woman of menstruating age would have her period at the same time. However, the role of the lunar cycle was not enti­rely dismissed by early modern doctors who did agree that younger women were more likely to bleed at the rising moon and older ones as the moon waned. The sun was also thought to play a role. It was suggested that women who lived in hotter climes, such as India and Africa, started having their periods at a younger age than those who lived further from the equator.

We can’t help but notice that the medical history outlined here is all by men theorising how women’s bodies might work, according to their own belief systems, which is perhaps unsurprising, given male dominance on medicine for millennia. None of the men considered how experiencing a monthly period might make a woman feel or how she might tackle pain or heavy bleeding. They were primarily concerned with keeping the body in good health and fertile. Words like ‘shame’, ‘defiled’, ‘weak’--or its variants in other languages--cannot have helped women view this normal function in a positive way though. But intriguingly, some female writers’ views on the body are preserved and offer us an insight into how women reacted to the views of male writers who lacked first-hand experience of this bodily process. One such example is the work of the German abbess Hildegard of Bingen (d.1179), who left a large body of writing which includes texts on medicine. Her ideas were based on humoral models and, like the chemical physicians, interpreted the body through a Christian lens—arg­uing that disease or imbalanced humours entered the body as a result of the ‘fall’ in the Garden of Eden.

Another woman who left medical writings was Trota of Salerno in Italy, a 12th century medic who is thought to have put together a compendium of medical texts in On Treatments for Women, which drew on existing theories, but to which she added her own ideas. While we only have a few extant writings by women explaining menstruation, none of this means women more widely didn’t have views about the causes of menstruation, or the management of menstrual disorders. Much of this practical wisdom was passed on from woman to woman, mother to daughter, aunts to nieces, sisters to sisters, by word of mouth. From the 16th century onwards in England, a significant number of notebooks left behind by women describe cures for all sorts of ailments, including ones for heavy or painful periods.

The role of ovulation in the menstrual cycle has a similarly intriguing history. The follicles in which the egg dev­elops were first seen in the later 17th century and rec­orded by Regnier de Graaf (d.1673), after whom the follicles are named. De Graaf concluded that eggs must be present but it was not until microscopes became powerful enough in the following centuries that the tiny eggs themselves could be viewed. Throughout the 19th century, work was done to test the presumption that the release of these eggs, ovulation and menstruation happened at the same time. One woman, Mary Putnam Jacobi, proposed that menstruation was caused by a nutritive wave passing through the female body, measured by temperature changes. Her work was praised at the time. But as so often the case, it was a man, American physician William Stephenson, who published on this in 1882, and it was the ‘Stephenson wave’ that bec­ame known. It was only in the early 20th century that the timing of ovulation at the mid-point of the cycle was fin­ally understood, and not until the 1920s that microscopy had reached the stage that a human egg could be seen for the first time.

Once 20th century scientists had worked out the role of hormones in controlling the menstrual cycle, it was possible to see how changing hormone levels within the month could affect women’s moods and overall health. Some women experience anxiety and low mood, as well as other disorders like diarrhoea in the days before their monthly period. In the previous century, this phenomenon was observed but put down to the nervous connection between the womb and the brain. Seen as outlandish at first and still unresolved scientifically, the idea that many women suffer from PMS or pre-menstrual syndrome is widely accepted today. Until modern times, women suffering from often severe pain were advised that having a baby would solve their problems, or if already mothers, that this was just part of being a woman. However, modern medicine has also made innovations in treating symptoms from painful periods. These range from effective painkillers, to advanced techniques like end­ometrial ablation, which burns away the womb lining and either stops or greatly red­uces menstrual bleeding and pain. No woman needs to suffer in silence nowadays.

What exactly the discharge of a period consisted of has occupied the thoughts of medics and philosophers alm­ost as much as why it happ­ens. Nowadays it is und­erstood that the hormone progesterone prepares the lining of the womb, the endometrium, to be ready for the fertilised egg to implant if conception happens. If pregnancy does not occur, both oestrogen and progesterone levels decrease, and this triggers the shedding of the womb lining and the cycle beg­INS again. So a period consists of blood and tissue from the endometrium.

One of the oldest accounts of the properties of menstrual blood was contained in Roman historian Pliny the Elder’s Natural History, in the first century BC. Pliny claimed menstrual blood was so potent that just the touch of a woman on her per­iod could cause wine to go sour, trees and crops to die, bees to abandon their hives, razors to become blunt, horses to miscarry, and dogs to go mad upon tasting it. These ideas were reproduced in medical, religious and other texts from then on, often using terms like ‘venomous’ and ‘malignant’ or ‘poisonous’ to des­cribe it. He even described how menstrual blood was thought to be able to control the weather: “Hailstorms and whirlwinds are driven away if menstrual fluid is exposed to the very flashes of lightning: that stormy weather too is thus kept away, and that at sea exposure, even without that, menstruation prevents storms”. Something that many of us might think a good thing! Pliny also noted that menstrual blood might cure gout, abscesses, and some thought it a cure for epilepsy. Obviously, none of this is true.

While women might have wanted to laugh at the myths, authoritative texts conti­nued to reproduce them, and we know that versions of these myths have influenced many and varied societies across the world. In the Abrahamic religions of Christianity, Islam and Judaism, pagan myths bec­ame mingled with doctrine and so Leviticus in the Bible repeats notions that women should be kept apart from men while having a period. Indeed, women of menstruating age are barred from entering the historic Sabari­mala temple in Kerala. Fears that a woman on her period would somehow defile a sacred space is a factor that controls entry of women into a lot of temples in India—with respect to Sabarimala, it is more a question of menstruation marking a sexually active (and desirable) age, while a monthly cycle also precludes the chance of women being able to keep a 41-day ritual purity. It wasn’t until 2006 that the Supreme Court was asked to rule on the matter. While it seems incredible that people bel­ieve these fanciful ideas of menstruation making women unclean today, they continue to have a negative impact on women. Some still believe a menstruating woman should not cook. In India today, agencies like Unicef, and even New Age figures like Anandmurti Gurumaa, are working to deb­unk the many myths and superstitions that still persist about women on their periods being unclean. While modern medicine can work wonders in terms of treating unpleasant symptoms associated with heavy and painful periods, even stopping them altogether with ablation, or destroying the womb lining, it won’t be until people stop giving credibility to superstitious notions about the nature of a period—notions that often rest on outdated medical theories—that experiencing periods will at last be acc­epted as a natural and normal part of living in a female body.

(Sara Read is the author of Menstruation and the Female Body in Early Modern England)