Menstruation is one of those topics that has long been surrounded by misunderstanding and stigma and Dr. Sara C. Flowers tells us why in today’s episode. Listen in as she explains how this common biological function can affect one’s mood and mental health, while sharing personal experiences of her own.

Sara C. Flowers, DrPH, MPH

Sara C. Flowers, DrPH, MPH, became Vice President of Education at Planned Parenthood Federation of America in 2018. An advocate for evidence-informed practice and emotional intelligence in sex education, Sara’s research focuses on fidelity and adaptation of sex education curricula, dismantling sexual and reproductive health disparities, serving youth of color, and strengthening abortion access. In this role, Sara sets the vision, priorities, and strategy for sex education and training at Planned Parenthood. She’s the spokesperson for sex education, providing contextualization and grounding for the nuanced ways sex education works to support and progress our federation’s vision and mission.

Dr. Flowers holds a doctorate in public health, a BA in psychology, and a Masters of Public Health.

Gabe Howard

Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, “Mental Illness is an Asshole and other Observations,” available from Amazon; signed copies are also available directly from the author.

To learn more about Gabe, please visit his website, gabehoward.com.

Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.

Announcer: You’re listening to Inside Mental Health: A Psych Central Podcast where experts share experiences and the latest thinking on mental health and psychology. Here’s your host, Gabe Howard.

Gabe Howard: Hello, everyone, and welcome to this week’s episode of Inside Mental Health: A Psych Central Podcast, I’m your host, Gabe Howard, and I want to quickly give a shout out to our sponsor, Better Help. You can grab a week free just by visiting BetterHelp.com/PsychCentral. Calling into the show, we have Sara C. Flowers, DrPH. Dr. Flowers became Vice President of Education at Planned Parenthood Federation of America in 2018. In this role, Dr. Flowers sets the vision, priorities and strategies for sex education and training. She holds a doctorate in public health from the Graduate Center at CUNY, as well as a B.A. in psychology and a master of public health degree, both from the George Washington University. Dr. Flowers, welcome to the show.

Sara C. Flowers, DrPH, MPH: Hi, Gabe. Thanks so much for having me.

Gabe Howard: Dr. Flowers, can you explain to me exactly what the menstrual cycle is?

Sara C. Flowers, DrPH, MPH: Absolutely, I think it’s great to get grounded in this understanding. The menstrual cycle includes the period and also the time in between periods when a person is not bleeding. The menstrual cycle is controlled by hormones like estrogen and progesterone and as the estrogen and progesterone increase or decrease throughout the cycle, some people can experience shifts or changes in their moods or emotions. During the cycle, one of the eggs in their ovary matures, the egg is released and the uterine lining thickens. If a person gets pregnant, that lining remains thick. But if they don’t, it’s shed during their period and the cycle starts over again.

Gabe Howard: So where exactly is, does like PMS or PMDD fit in in that definition?

Sara C. Flowers, DrPH, MPH: PMS, or premenstrual syndrome, refers to the physical and mood related changes that can happen before a person’s period, PMDD, or premenstrual dysphoric disorder, is a more severe form of PMS. So, for example, people who experience PMS, they might feel irritable, tired, depressed or anxious. People with periods may experience physical symptoms like bloating, headache, cramps, and all of that can also affect a person’s mood and their self-image. When we say PMDD is a more severe form of PMS, what that means is that it can cause depression, anxiety, panic attacks, inability to sleep, exhaustion and many other symptoms. What’s important to understand is that a lot of people, more than nine out of 10 of folks who have periods, experience some premenstrual symptoms before their period. Some folks have strong symptoms, strong feelings about the fact that they menstruate for a variety of reasons. And there may be other folks for whom this is no big deal. It’s like they’re putting on their socks in the morning, right?

Gabe Howard: Can mental health issues like depression or anxiety impact a person’s menstrual cycle?

Sara C. Flowers, DrPH, MPH: It’s really important to remember that we all live in one body, the ways that the different systems of our body work together can impact different parts of the other parts of our body. So I’m sorry if that seems like a little cyclic, but I think that it’s really important to remember that hormones fluctuate throughout the month or the menstrual cycle and they have an impact on our mental health. And so they work together to impact one another. I think that we couldn’t tease them apart. We want to when we’re seeking support from our doctors and nurses, bring our whole selves. If managing depression or anxiety with a doctor or a nurse and you’re noticing some patterns in your period, I would bring all of that information to your health care provider so that they can help you see the full picture. I think we don’t want to try to tease apart one or the other. We want to recognize that there can be a reciprocal relationship and how they affect each other and how we experience that in this one body that we each live in. So, I wonder if it’d be OK if I told you a personal story?

Gabe Howard: That would be great.

Sara C. Flowers, DrPH, MPH: You can use this or not, it’s not a question that you ask, but I had a lot of memories in preparation for our conversation. And one of the memories I had was I got my period really young. I was 10. And one of the things that I think a lot of people, especially non-menstruating people don’t understand is that periods don’t just show up and then they’re like clockwork every 28 days at 3:00 p.m. on the fifth of the month. That’s not how it works, right. It’s clockwork in your body, but not according to the Gregorian calendar in the same way. And so I remember being in my home that I grew up in, I was a kid not old enough to drive, and my dad was the only one home. And I was in the bathroom. I got my period. I’ve had my period. I don’t know for how long. I was still, I don’t know if I was in elementary school or seventh grade, but I was young and there were no pads in the bathroom. And so I yelled to my dad if he could go to the pharmacy around the corner and get me some pads. And my dad, like, fussed at me. I remember standing in the bathroom waiting for him to go to the store. And he was annoyed, I guess, as I think parents get, to have to stop what he was doing to go to the store. But he liked fussed and was like don’t you all know when this is going to be happening? As though it was like a, I don’t know, a GoogleCal event, but like in 1989. You know what I mean? Like

Gabe Howard: Yes.

Sara C. Flowers, DrPH, MPH: This idea that, like, it would have been like you click a switch and how did you not know the switch was going to be clicked? But like for a kid, it takes years for your period to and your hormones, I mean puberty in and of itself is a hormonal, you know, start, stop, more, duh, duh, duh. It’s not just like this smooth process. And I just remember standing there being like, I felt bad that my, I didn’t want to be having my period in the first place. I felt, you know, I felt bad that my dad was fussing at me and, you know, like all these feelings.

Gabe Howard: As you were telling the story, the first thing that jumped into my chest is I couldn’t do that. And then as you continued to tell the story, I thought, oh, that’s bad. Now I don’t have any children. So maybe it would change if I had been a father, certainly a father of daughters. But the very fact that that was my first initial impulse, this is a real burden for menstruating people because now they have to wonder if they’re, I don’t know, making the people around them uncomfortable? Well, as you pointed out, you felt uncomfortable. Is this something that is very common ? That they’re sort of navigating the discomfort of people around them while they themselves are feeling uncomfortable or potentially feeling uncomfortable?

Sara C. Flowers, DrPH, MPH: Yeah, I definitely think. So how you experience this notion of discomfort, that’s not everyone. Everyone’s going can have their own experience. But I think this idea of what are the ways that the supporting people in your life, your world can help, especially when you’re younger, can help the younger folk be set up for the most smooth transition or introduction into this next phase of life, recognizing that it might be various levels of bumpy for different folks at different times. I remember being in junior high school and going to the bathroom with friends with a tampon shoved up my sleeve. Why was I hiding my tampon? Why were we embarrassed? Half the people in that school also needed to go to the bathroom with a tampon or a pad or whatever they were using. And people today are using period underwear and cups and all of these other wonderful tools. So I think this notion that one, it was the piece of the shame that we have to hide it, I hope that we move away from that and that kids today don’t feel like they have to hide it in the way that they did when I was coming up. And I think also the ways that adults are making the things they need more accessible to them, both information and the actual products being available in a bathroom and thinking also about like not requiring money for the product. Right. In a public bathroom, like really removing the barriers.

Gabe Howard: In preparing for this episode, I realized the vast deficiencies that I have in this area. I don’t know nearly enough about women’s health. My question to you is, what should all people, whether they menstruate or not, know about periods?

Sara C. Flowers, DrPH, MPH: That’s a really good question and I really appreciate the way you framed it by thinking about all people. First of all, when I’m talking about periods, I use what we call people-first language. And so what that means is, I’ll say people who menstruate or people with uteruses, rather than assuming that all people with uteruses identify as women or girls, or rather assuming that all people who identify as women or girls have uteruses. I just wanted to sort of frame up our conversation with that thinking. And in terms of thinking about periods, one of the things to remember is that periods are a regular part of life for people with uteruses. And as you mentioned, there’s still a lot of mystery. There’s still a lot of stigma around menstruation, around periods. Part of it attributable to what you describe, which is the old school way of I don’t know how old you are, but I’m 42. So I definitely remember being pulled into the small gymnasium in my elementary school where there were like three afternoons where we talked about puberty, quote-unquote, and we were separated by our sex assigned at birth. Right. So we didn’t necessarily get the full picture. And we don’t teach sex ed in a gendered way like that any longer. But certainly those imprints and maybe folks who don’t have uteruses or don’t menstruate, don’t have siblings who did or parents who did, maybe they didn’t have exposure to periods. Maybe families didn’t talk about it. So I think what you described is really true. And there’s a lot of sort of vagaries or misinformation around periods. One of the things to know is about half the people on the planet menstruate. This is super, super normal, a regular part of life.

Gabe Howard: What’s fascinating to me is what you just said there, right? It’s super normal, everybody’s heard of it. And yet even during my research for this, I had this vague notion of discomfort, like, am I supposed to be reading this? Am I supposed to do this? Is this for me? Was kind of what was going through my head. Now, that’s completely nonsense. And it speaks more for the education that I received or the education that I was lacking. How do women handle knowing that this is very, very normal, yet they’re also burdened with this idea that they have to explain it to the non-menstruating public.

Sara C. Flowers, DrPH, MPH: I think this notion of talking about it, of explaining it, of making sense of it to folks who don’t have the experience themselves is a different piece. Right. And I think that what we want to unpack there is how comfortable you or I was talking about it, how much do I understand it? Do I feel good or comfortable talking about it to someone who doesn’t menstruate? And who might that person be? And how has it been a conversation piece or a regular part of life for me? And how did that impact my comfort level? I’ve seen experiences where people who don’t have uteruses were not remotely confused or bothered because maybe they grew up in a household full of people who did get their period.

Sara C. Flowers, DrPH, MPH: That was a part of life that they were very accustomed to. Other people who didn’t maybe were totally surprised, had no idea that this was going to be a part of their development, of their growing up, of the way that their bodies were going to change. I can imagine that that’s scary. I think about that scene from My Girl. I don’t know, maybe I’m dating myself here where the young character gets her period and she thinks she’s dying. And how are we going to set young people up so that they recognize that this is a part of life, a milestone? Another time where I’ll date myself about how periods showed up in media as I grew up on The Cosby Show and Rudy got her period and Claire Huxtable celebrated it and called it Women’s Day, and it was something to really find joy in. And so what is the story that we got and how are we experiencing it ourselves? I think is a question. How is it normalized for the other people in our family and how do we normalize it with our partners? Are we hiding it? Are we talking about it openly?

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Gabe Howard: We’re back discussing menstruation and mental health with Planned Parenthood’s Dr. Sara C. Flowers. When we consider the societal narrative, you know, you mentioned My Girl, the movie, but from my perspective and we’ve established that you and I are about the same age, periods are always handled with this fear, usually on the part of the person having the period and hilarity, hilarity ensues, generally by the men in that person’s sphere. And the whole thing tends to wrap up in a way that this natural biological function is a vehicle for entertainment. Whether that turns into shame or education, you’re right, would probably depend on where you live, who you are and how open that you talk about it. But I think you and I can both agree that there can be a lot of shame that comes along with periods from the very first one to the very last one. Why do you think periods are so stigmatized and how can people manage or even fight back against that?

Sara C. Flowers, DrPH, MPH: Well, I think that many people get very vague messages or incomplete information about their periods, and I think that that sort of underlines the stigma. It’s reflected in the lack of conversation that we have about periods. If as a society we don’t talk about it or the impact that it can have on our physical and mental health, then it becomes stigmatized. It becomes hush hush. One way to fight against stigmatizing periods is ensuring that everyone has access to sex education, which includes period education for all bodies, bodies that menstruate or bodies that don’t. So all people of all ages benefit from understanding how all bodies work, whether it’s the one that they live in or someone else’s. So if everyone learns at a young age that periods are a regular part of life for lots and lots of people, we start to chip away at the stigma.

Gabe Howard: You mentioned that different people experience menstruation differently. Do you have any advice for people whose symptoms is on the more severe end of the spectrum?

Sara C. Flowers, DrPH, MPH: Absolutely, if you experience severe emotional or physical pain during your periods, you don’t have to feel like you just have to suck it up and deal with it. Sometimes there may be an underlying condition that’s causing you to have more severe menstrual symptoms, either physical or emotional. It’s really a good idea to talk with a doctor or a nurse to help manage your pain. The doctors and nurses at Planned Parenthood health centers are there to help with just this sort of thing. And combined with any information that folks might have from their period tracker and a description of what they’re experiencing, they can work with their doctors and nurses to find treatments that will help. So one of the things I just wanted to focus on is reassuring folks that they don’t just have to suck it up. There could be underlying it like, well, maybe maybe you want to connect it to the conversation about PMS or maybe not. But I think recognizing that there could be underlying conditions that cause folks to have more severe menstrual symptoms and that they should they can seek support, that they don’t have to just suck it up.

Gabe Howard: When I think about menstruation and mental health, I think about mental health issues like depression and anxiety, can that impact someone’s menstrual cycle?

Sara C. Flowers, DrPH, MPH: The hormonal fluctuations throughout the typical twenty-eight-day period can impact or drive those diagnoses, depression, anxiety, things like that. We live in our full body. We want to be mindful of the ways the parts of our bodies connect. It would be short sighted to suggest that someone who experiences depression or anxiety because there’s a hormonal fluctuation throughout the menstrual cycle, that there wouldn’t be a connection there. I don’t know that I would say that there’s a causation piece vs. a correlation, but I think that it’s important to remember that we want to think about and be considerate of all of the ways that a person’s body functions. And so considering their mental health with their physical health as it relates to their menstrual cycle is going to be important for if they were seeking care. If they were experiencing really severe period symptoms, being able to talk about your mental health and how your mental health diagnoses or experiences may be escalated at certain times during your period could be really helpful to your care provider if they’re thinking about ways to offer relief or treatment. This might be TMI as well, but now we’re friends, Gabe.

Gabe Howard: (laughing)Yeah, yeah, we’re pals!

Sara C. Flowers, DrPH, MPH: We’re going to tell each other all our stories. So, I am a parent of an eight and a half year old kid, and when I birthed this human, I was finishing up my doctorate. I was in grad school. I was a new parent. So there were lots of stressors and pressures in my life. And despite having spent my entire career as a sex educator and being incredibly familiar with the ways that hormones impact the body and the ways that people who were pregnant are vulnerable to postpartum depression, I assumed that the stress that I was experiencing, the lack of sleep, was due to parenting and not due to another sort of biological issue or diagnosis. And I’d really sort of hit a wall and called my doctor who delivered my child, who was a trusted clinician for me. And I was in tears because I was impatient with this little innocent toddler and I was not sleeping. And I was trying to write this dissertation and I was really like up to my eyeballs, like I couldn’t function. And I assumed that the reason that I couldn’t function was just that I wasn’t sleeping. And so I had called her, telling her my whole sob story and literally actually boo-hoo, crying and thinking that I needed sleeping pills. And she asked me a lot of really helpful, important questions, including whether or not I saw a pattern in my behavior or in these symptoms that I was experiencing or my lack of sleep or my short temper. And when she listened and I was able to say, yes, I did notice that around the time that I would get a period, I actually don’t bleed because I have a hormonal IUD, I do have an awareness of the way that my cycle changes each month.

Sara C. Flowers, DrPH, MPH: And I was able to point to that based on the questions that she asked me. She diagnosed me right then and there over the phone with premenstrual dysphoric disorder and wrote me a prescription for an anti-anxiety antidepressant. And she said, I’m going to prescribe because you need more serotonin to flow over your synapses at this part of your period to alleviate these symptoms. And I take [beep] for 14 out of 28 days of my cycle and I see a real difference. I sort of tell that story to talk about the ways that I’m one person. And while I have all of these different parts of my life that are complex, they are all happening in this one body where I’m considering both my physical health and how my menstrual cycle evolves from month to month, as well as all these other stressors and my mental health. And so those pieces work together. They couldn’t be teased apart.

Gabe Howard: I’m glad that you were able to communicate that to your doctor. Now, switching gears ever so slightly, how can people who menstruate communicate with their partners about what, like mood related and physical symptoms they are experiencing because of their menstrual cycles?

Sara C. Flowers, DrPH, MPH: If people have partners who menstruate, maybe there’s a shared experience there. There might be additional need for explanation when talking to partners who don’t menstruate. So being able to identify your feelings, name your feeling, thinking about how to talk about those feelings and your physical needs to your partner and also offering some quick tips. I’d love to have my back rubbed. I actually really don’t want to be touched right now. I’d prefer just a hot bath. I want to eat these things. I feel like this. I want to be touched. I don’t want to be touched. When we’re really talking about a relationship, we all have this responsibility to identify what we need and then communicate that to our partner. And I think that applies to when we’re menstruating as well. There’s also opportunity to talk about how comfortable people are being intimate or having sex during their period. Some people really love it. Orgasms can relieve menstrual cramps because of the uterine contractions, and it feels good. Periods can offer additional lubrication, which also can make sex better. Other people, maybe don’t feel sexy at all, or aren’t interested in sex at all during their period. And so I think there’s this opportunity for folks to talk about, identify how they feel, communicate that to their partner. As the menstruating person. You could be the communicator.

Gabe Howard: Dr. Flowers, I’m thinking about my own relationship now, I don’t menstruate, but my wife does. And I understand what you’re saying about here are all the things that she could do for me. What initiative can I take without her direction?

Sara C. Flowers, DrPH, MPH: Absolutely, I think that’s such a thoughtful question. As the partner of someone who menstruates, it’s also important to consider how that non-menstruating person can seek information about how to be supportive. So, for example, it might be helpful to ask questions about how the person is feeling, what kind of activities might help them feel better, or what kind of food or what kind of rest or temperature or other things might they need? Some sort of pain reliever or a hot water bottle or a warm bath or a special dessert or a walk? Not a walk? Comfy jammies? Who knows what. There’s an opportunity for you to seek ways, ways you could offer support. I think the other key piece is to remember that everyone’s body is different. So just because a previous partner likes to have soda in the fridge and a warm compress, maybe a current partner wants to go for a walk and have multiple orgasms. Who knows? I think there’s an option to just really ask the person what would make them feel better and supported.

Gabe Howard: I really, really appreciate you being here and helping us understand the connection between menstruation and mental health, is there any tools or services that you can recommend to our listeners to help them better connect with their bodies?

Sara C. Flowers, DrPH, MPH: One thing I hope your listeners will walk away with a new or maybe a renewed awareness of is our Spot On App. So, Spot On is Planned Parenthood’s free birth control and period tracker app. We have it in English and in Spanish. En Espanol. And this tool helps people track and predict their period, understand their menstrual cycle and manage their birth control. It also provides guidance, tips, fun facts from menstrual health experts. Users are able to track their mood and emotions along with their period, and it will help people notice trends and patterns over time, which, as I mentioned earlier, was super helpful to me and so many others around the planet. A really important thing to remember is that Spot On is designed in language that is non gendered and inclusive for all people with periods. And it focuses on helping people prevent pregnancy through period tracking and also birth control tracking.

Gabe Howard: Dr. Flowers, thank you so much for your candor, your honesty and your openness and for educating folks about menstruation and mental health. It’s deeply needed and it’s very appreciated. Where can folks find Planned Parenthood online?

Sara C. Flowers, DrPH, MPH: Folks can find Planned Parenthood online at PlannedParenthood.org and on Instagram @PlannedParenthood.

Gabe Howard: Dr. Flowers, again, thank you so much for being here.

Sara C. Flowers, DrPH, MPH: Thank you so much for having me. I really appreciated our conversation.

Gabe Howard: You are very, very welcome, and to all of our listeners, a big thank you. Wherever you downloaded this episode, please follow the show, subscribe. It’s absolutely free. My name is Gabe Howard and I’m the author of “Mental Illness Is an Asshole and Other Observations,” and I’m also a nationally recognized public speaker who would love to be at your next event. You can grab a signed copy of my book over at gabehoward.com and I’ll see everybody next Thursday here on Inside Mental Health.

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