For three months this year, I bled nearly every day. My doctor doesn’t know why. Google doesn’t know why. The condition is simply called “postmenopausal bleeding,” and medicine’s best guess as to the cause is that the postmenopausal hormone-replacement therapy I started last November suddenly made my endometrium, the lining of the uterus, “unstable.” All scientific knowledge added up to “If it’s still happening in six months, get back in touch.” (I’m still bleeding intermittently, and I don’t know why.) This is the kind of massive medical shrug that anyone with female anatomy has probably encountered.
Despite major advances for women over the past 100 years—the invention of the contraceptive pill, greater access to safe abortions—much of female biology is still woefully underserved by science. There are reasons for this, most notably the historical exclusion of women from medical and pharmaceutical trials, partly because our awkward hormone cycles were thought to skew results. There’s also the fact that some scientists still project findings from research on men onto women, seeming not to realize that women aren’t just small men: Women are different down to the cellular level, meaning that many of our immune responses, experiences of pain, and symptoms (including, for instance, those that accompany a heart attack) may be different from men’s. Are you having a nasty, unexpected side effect from your medication? That could be because most drugs were developed with male bodies in mind. A 2020 review of 86 common medications, including antidepressants, cardiovascular drugs, and painkillers, found that women were likely routinely overmedicated and suffered adverse reactions nearly twice as often as men.
The lagging science is particularly apparent when it comes to periods and female hormones more generally—the subject of the anthropologist Kate Clancy’s new book, Period, a scientific and cultural history that purports to tell the “real story of menstruation.” Clancy’s book makes clear that a lack of data is to blame for many of the ills that women and girls face concerning their reproductive health, like doctors’ failure to diagnose painful conditions such as endometriosis.
My severe endometriosis was discovered only when I was 41, accidentally. For decades, I had been given prescription-strength painkillers, and my doctor never seemed to wonder whether the amount of pain I was in was abnormal. When I published an essay about my menopausal depression in 2018, a deluge of women wrote to tell me that when they were going through something similar, their doctors had told them they were imagining their brain fog or panic attacks, or had put them on antidepressants that didn’t work because many depression drugs are inadequate to treat the symptoms of fluctuating estrogen.
Yet do a search online, or open any women’s magazine, and you will find repeated assertions that we are living in a time of “period positivity.” In this apparent golden age, women are more open about their menstruation; they are not ashamed of buying tampons; they aren’t afraid to talk about gynecology in general. Elite athletes now admit to being off their game when they are on their period; sensible coaches track their menstrual cycles and understand the impact of hormones on performance and energy. TV commercials for sanitary products that used to suggest that women excrete blue liquid now dare to show red, bloodlike substances in prime time. Over the past 10 years, things have definitely gotten better, for some of us. There are dozens of books about periods; there have been countless magazine articles and TV segments. The period is bloody everywhere. So why do we need yet another book about it?
Because until we have bridged the gap in scientific understanding of male and female bodies, period positivity is really only window dressing. In her book, Clancy shows that faulty and lacking science regarding periods still dominates women’s daily lives. “Within science and especially medical structures,” she writes, “knowledge is power and therefore often withheld … So we know little about menstruation, and what’s worse, what we often know is wrong.” Even the fundamental question of why we menstruate is still not fully understood. We know that the endometrium is shed each month, but is that simply because the body deems it useless if no fertilized egg is implanted? Is it to “help teach the uterus how to grow a great site for the embryo,” as Clancy puts it? Is it to conserve the body’s energy?
Ignorant views of menstruation and female biology date back thousands of years. Pliny the Elder wrote that a menstruating woman could kill a swarm of bees and rust iron. In her book, Clancy quotes the American physician Edward H. Clarke, who wrote in 1873 that women who got an education would become like a “sexless class of termites” because learning and bleeding simultaneously would overpower the reproductive system. In 2020, researchers asked 2,500 pediatricians about their knowledge, understanding, and practices surrounding menstruation. Of the 518 doctors who replied to the online survey, Clancy writes, “fewer than half … knew when in puberty menarche (that is, the first menstrual period) happens, how long menses lasts, and even how long it is safe to wear a tampon.”
That is basic ignorance. Look even further, and the picture does not improve. One of the most persistent myths about periods is the idea that the menstrual cycle should be normal, neat, and tidy. As Clancy writes, cycles are seen as “static, twenty-eight-day phenomena: the reality is they are malleable, responsive, dynamic.” When I camped in Siberia for three months as a young woman, my periods stopped for the duration and restarted when I came home, as if my uterus had realized that changing a tampon would be tricky when the toilet was a hole in the ground. The idea of a “normal” cycle can cause undue stress to those who think that their body might be abnormal. And underestimating the complexity of female hormonal cycles undermines our ability to predict dangerous conditions such as preeclampsia, or high blood pressure during pregnancy.
The female reproductive system more broadly is also misunderstood. The generally accepted narrative imagines the sperm as the hunter, while the egg is the passive and lucky object of its manly chase. But Clancy rightly gives these “ideas about eggs as princesses in a tower and sperm as rescuing princes” short shrift. The ovaries don’t simply release a chosen follicle (a sac of fluid containing an egg) into the fallopian tube right before ovulation. Instead, they ruthlessly “oversee continual, overlapping waves of competition to select” the best follicle to release. The cervix has crypts where it stores sperm “to use later … to prevent overcrowding at the egg and allow for some selection of preferred sperm.” Gamete fusion is a tango, not a one-way assault.
This poor understanding of the female body has consequences. Only recently have scientists discovered that menstrual blood may speed up skin repair because it contains powerful mesenchymal stem cells. Clancy adds that menstrual effluent, which is made up of blood, endometrial tissue, cells, biomarkers, and hormones, also contains important antimicrobials and antioxidant enzymes. And had more scientists been willing, like Clancy, to take a “deep dive into menstrual effluent,” we might have understood sooner that the menstrual cycle can cause a spike in an inflammatory biomarker called C-reactive protein (CRP). Elevated CRP is also used to diagnose people as prediabetic. How many women who thought themselves prediabetic were actually just menstruating? Female hormones don’t skew data. They are data.
Clancy’s science is revelatory, if often dense (if you don’t know your trophoblast from your oocyte, you may have to wait for several dozen pages to learn what they are). But some of her choices can blur her focus. A confident assertion that sex isn’t “solely biological” might surprise scientists who understand sex to be determined by chromosomes and anatomy. This is also a peculiar position in a book devoted to the uniqueness of female biology. I found Clancy’s preference for terms such as people who menstruate over women and girls troubling, too, in a book that seems intended to argue for the importance of studying the biology of females—and correcting a history that ignored the uniqueness of their medical experiences as women and girls.
This is not the only “real story of menstruation,” but it is definitely one that needs to be told. Clancy’s book will hopefully encourage more scientists to conduct more rigorous research on periods. Until the knowledge gap is filled, women and girls will be left in the dark about how their bodies work and how to fix what goes wrong. And it won’t matter how loud the clarion call of “period positivity” is: It will still be mostly noise.
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