Psychosomatic Medicine 65:1065-1069 (2003)
© 2003 American Psychosomatic Society
Socioemotional Correlates of Self-Reported Menstrual Cycle Irregularity in Premenopausal Women
Tamara L. Newton, PhD and
Correna L. Philhower, BS
University of Louisville, Louisville, KY.
Address correspondence and reprint requests to Tamara L. Newton, PhD, Department of Psychological and Brain Sciences, University of Louisville, Belknap Campus, 317 Life Sciences Building, Louisville, KY 40292. E-mail: tlnewton{at}louisville.edu
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ABSTRACT
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OBJECTIVE: Characteristics of menstrual functioning are associated with social rank and corresponding behavioral expression of dominance and subordination in female cynomolgus macaques. Extrapolating from this research, the present study examined socioemotional correlates of menstrual cycle irregularity in premenopausal women by focusing on the dimensions of dominance/submission and hostility/warmth.
MATERIALS AND METHODS: Participants were 153 premenopausal women (70 African-Americans, 83 European-Americans) who reported no current use of hormonal contraceptives. All women completed measures of socioemotional traits and reported whether the onset of their menstrual cycles was generally predictable within 4 days over the course of the past year.
RESULTS: Menstrual cycle irregularity was significantly and positively associated with the socioemotional trait of submission. This association held after adjusting for age and a number of potentially confounding health behaviors.
CONCLUSIONS: Results are consistent with the notion that menstrual functioning is sensitive to socioemotional processes, particularly those pertaining to social hierarchies. Given recent findings linking menstrual cycle irregularity to cardiovascular disease, the results of the present study highlight new biobehavioral pathways to be explored with regard to women’s cardiovascular disease risk.
Key Words: dominance, • submission, • menstrual cycle, • cardiovascular.
Abbreviations: BMI = body mass index;; CI = confidence interval;; CVD = cardiovascular disease;; HC = hormonal contraceptive;; HPA = hypothalamic-pituitary-adrenal;; IAS-R = Interpersonal Adjective Scale–Revised;; OR = odds ratio.
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INTRODUCTION
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Variations in menstrual functioning, particularly those related to the regularity or predictability of the menstrual cycle, are emerging as important correlates of women’s cardiovascular status and risk for cardiac disease. Although not all findings are consistent (1), supportive evidence comes from cross-sectional studies (2) and from prospective, longitudinal investigations. Compared with women who describe a previous history of regular menstrual cycles, those who report a history of very irregular cycles have been shown to have significantly increased risk for subsequent development of coronary heart disease (3) and type 2 diabetes (4), a risk factor for cardiovascular disease. The underlying assumption of this general area of research is that self-reported menstrual cycle irregularity is a correlate or manifestation of underlying biological processes, such as cumulatively low levels of exposure to estrogen (5) or insulin resistance and glucose intolerance (3), which may also contribute to cardiovascular diseases.
Of interest in the present study is whether menstrual cycle irregularity is associated with socioemotional traits (ie, traits that pertain to the process of social interaction and that can be accompanied by expressive behavior, subjective experience, and physiological processes). Studies of social groups of female cynomolgus macaques implicate social hierarchies, indexed by behavioral indicators of dominance and social subordination, in menstrual functioning. Subordinate female macaques—those who receive high levels of aggression, are consistently defeated in social challenges, and show fearful, vigilant scanning of their surroundings—have a significantly greater number of anovulatory and progesterone-deficient cycles compared with dominant female macaques (6). The menstrual cycles of subordinate animals do not differ in length or regularity compared with those of dominant animals, but the anovulatory cycles they more often experience are longer in duration than macaques’ ovulatory cycles (6). In addition, subordinate female macaques develop more extensive coronary artery atherosclerosis than dominant female macaques, a difference that can be eliminated by estrogen treatment (7).
Among women, there is some indirect evidence regarding connections between socioemotional processes and menstrual functioning. High levels of workplace demand, combined with low levels of perceived control, have been associated with a doubled risk for short menstrual cycle length (ie, less than 24 days) (8). Characteristics consistent with submission (ie, introversion, anxiety, low perceived control, and inhibition of aggression) have been shown to be elevated among women seeking treatment for hirsutism and irregular menses compared with women without such conditions (9). However, this association could reflect the socioemotional consequences of these medical problems and their associated features. With regard to cardiovascular status, positive associations between dominance and cardiovascular diseases have been consistently documented in men (10, 11), whereas for women the research is more limited and inconsistent. Frequent submissive behaviors have been associated with elevated resting blood pressure among healthy adult women (12), whereas trait submissiveness was prospectively associated with decreased risk of nonfatal myocardial infarction (MI) in a general population sample of women (13).
The present study extended the preliminary research on socioemotional correlates of menstrual cycle irregularity by focusing on the dimensions of hostility/warmth and dominance/submission, both of which have been implicated in cardiovascular disease (10). We also assessed a number of health behaviors that have been associated with patterns of menstrual functioning and that could potentially act as confounds (14–16). Based on research reviewed, we expected menstrual cycle irregularity to be associated with socioemotional traits, particularly those related to the dimension of dominance/submission.
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MATERIALS AND METHOD
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Participant Recruitment and Screening
Five-hundred thirty-eight women responded to advertisements for a study on communication and health and completed a phone screen to assess the following eligibility criteria for the laboratory phase of the project: self-identified as either European-American or African-American; between the ages of 18 and 45; United States citizenship (or noncitizen who had resided in the United States for at least 5 years); no hysterectomy, ovariectomy or current pregnancy; at least one menstrual cycle within the last 12 months; no prescription medications with cardiovascular effects (eg, psychotropics, beta-blockers, etc.) or medical conditions including high blood pressure or other cardiovascular conditions, diabetes, or renal disease; and no history of a hospital stay for a psychiatric or emotional condition. Women ineligible for the laboratory phase were invited to participate in the questionnaire-only phase.
Of the 538 female callers, 297 completed a questionnaire either as part of the laboratory phase or the questionnaire-only phase. From the sample of 297, we excluded women who endorsed a hysterectomy or ovariectomy (N= 4), reported no menstrual cycle in the past year (N= 8), or had missing data for these two variables (N= 52; this information was not ascertained when women were excluded based on responses to questions asked earlier in the phone screen); reported current use of hormonal contraceptives (HC) (N= 65) or had missing data for this variable (N= 2; these women were excluded because the measure of menstrual cycle irregularity used in the present study was not validated on women using HC); had missing data for the socioemotional trait measure (N= 1); or were potentially peri-menopausal, operationalized as being 40 or older and having experienced hot flashes or night sweats, possibly related to menopause (N= 12) (17). The final sample consisted of 153 premenopausal women (70 African-American, 83 European-American) who completed a questionnaire either within the context of a laboratory session (N= 106) or the questionnaire-only phase (N= 47).
Measures
Socioemotional characteristics
Participants completed the Revised Interpersonal Adjective Scale (IAS-R) by using an 8-point Likert scale (1 = extremely inaccurate, 8 = extremely accurate) to indicate how accurately 64 different interpersonal adjectives describe them in general (18). The construct validity of this measure has been well-established (19). Eight subscale scores (dominant, gregarious, warm, ingenuous, submissive, aloof, hostile, arrogant) are generated by summing responses for each of the eight items that comprise them. The eight subscale scores map onto a circular space formed by the intersection of two orthogonal dimensions: status (anchored by the subscales dominance and submission) and love (anchored by the subscales hostile and warm). Cronbach’s coefficient 
for the subscales ranged from 0.77 for ingenuous to 0.88 for dominant. For the present study, the eight subscales were aggregated into four composites as follows (20): Dominance = 0.5 (arrogant) + dominant + 0.5 (gregarious); submission = 0.5 (aloof) + submission + 0.5 (ingenuous); hostility = 0.5(arrogant) + hostile + 0.5 (aloof); friendliness = 0.5(gregarious) + warm + 0.5 (ingenuous). Means and standard deviations of each of these composites are as follows: dominance (M= 75.48, SD = 16.42), submission (M= 53.57, SD = 15.94), hostility (M= 40.04, SD = 13.71), friendliness (M= 87.6, SD = 13.62). As expected, dominance and submission were significantly and negatively correlated, r (153) = -0.69, p< 0.004, as were hostility and friendliness, r (153) = -0.51, p< 0.004. The only other significant correlation was between dominance and hostility, r (153) = 0.23, p< 0.004.
Menstrual cycle irregularity
Menstrual cycle irregularity was assessed by one yes/no question that has been validated against prospective daily diary reports (21): "Generally speaking, in the past year, has the length of your cycles usually varied by less than 4 days? That is, are your menstrual periods fairly regular (within 4 days) so that you usually know when your next menstrual period will start without using any symptoms you may have to predict this?"
Menopausal status
To identify women who might be peri-menopausal, participants answered yes, no, or maybe as to whether they had ever had hot flashes or night sweats that could be related to menopause rather than to illness, medications, or pregnancy. Endorsements of yes or maybe have a positive predictive value of 61% to identify peri-menopausal women (17).
Sociodemographics and health behaviors
Demographic characteristics (marital, educational, and occupational status) and health behaviors were assessed by self-report. Women reported whether they had ever seen a doctor or other health care provider because of menstrual irregularities or symptoms, and whether they had ever been prescribed or used any medication to regulate their cycles. Smoking status was coded as nonsmoker (N= 121) versus smoker (N= 30), and caffeine consumption as less than weekly (N= 43) versus at least weekly (N= 110). Physical activity was measured using the Paffenbarger survey and participants’ reports were converted to a composite index of physical activity expressed in kilocalories per week (22,23). For women who participated in the laboratory session, height and weight were measured and used to calculate body mass index ([weight (lbs)/height (in)/height (in)] x 703).
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RESULTS
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Demographic Characteristics and Health Behaviors
Thirty-six percent of the present sample of women reported irregularity of menstrual cycles over the past year. Rates reported in previous studies range from 14% (24) to 32% (25). As shown in Table 1, as assessed by t tests or chi-squares, there were no significant associations between cycle irregularity and any of the sociodemographic variables. With regard to health behaviors, compared with women with regular cycles, those with irregular cycles were more likely to have sought medical care for menstrual problems and they tended to report more frequent caffeine consumption. Across the entire sample, 36 women reported either a current medical condition or use of prescription medications other than hormonal contraceptives, or both. Of these women, three reported either a medication (isotretinoin/accutane), a medical condition (endometriosis), or both (polycystic ovary syndrome; aldactone/spironolactone), with clear links to menstrual functioning.
Associations Between Menstrual Cycle Irregularity and Socioemotional Composites
Point bi-serial correlations between the four socioemotional composites and reports of menstrual cycle irregularity (coded 0 for regular and 1 for irregular) yielded significant associations for submission (r= 0.24, p< 0.004) but not for dominance (r= -0.07, p>.35), hostility (r= 0.10, p> 0.19), or warmth (r= 0.04, p> 0.63). Hierarchical logistic regression was used to further assess the contribution of submission to menstrual cycle irregularity. Three models were run, all modeling the probability of having irregular cycles. As shown in Table 2, model 1, submission was associated with menstrual cycle irregularity, with the odds of reporting an irregular cycle being 3% greater for every 1-point increase in submission. Based on these parameters, for every 1 standard deviation unit increase in submission the odds of reporting an irregular cycle increase 66% (OR = 1.66, 95% CI = 1.17–2.36). The results for model 2 illustrate that associations between submission and menstrual cycle irregularity held after controlling for age, physical activity, caffeine consumption, and smoker status. No other individual predictors contributed significantly to the model, but there was a trend for caffeine consumption 
2(1, N= 151) = 3.16, p= 0.07; B= 0.19); women endorsing at least weekly caffeine consumption tended to have more irregular cycles compared with women endorsing less than weekly consumption. Based on model 2 parameters, the odds of reporting an irregular cycle increase 4% for every 1-point increase in submission, and 81% for every 1 standard deviation unit increase in submission (OR = 1.81, 95% CI = 1.24–2.63). When BMI was added to this overall model (model 3), submission remained a significant individual predictor of menstrual cycle regularity, although the overall model no longer reached significance. No other individual predictors contributed significantly to the model (p values > 0.39).1
To assess how these results were affected by the three women who reported medications or medical conditions that alter menstrual regularity, we re-ran all logistic regression models after excluding these three women from the sample. In all cases, the patterns of significance for the overall models and for each individual predictor were identical to those obtained before excluding the women.
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DISCUSSION
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In the present study, the socioemotional dimension of dominance/submission was associated with self-reported menstrual cycle irregularity in a community sample of premenopausal women. More specifically, when women described themselves as submissive they were more likely to also report experiencing irregular menstrual cycles in the past year, an association that was not appreciably altered by adjusting for age and health behaviors that have been associated with menstrual irregularity. These results are conceptually consistent with the limited data available regarding psychosocial factors and menstrual functioning in women (8,9) and they also parallel observations from studies of nonhuman primates (7) despite the many methodological differences between the studies (eg, self-reported vs. behaviorally assessed submission, and self-reported menstrual irregularity vs. biologically confirmed anovulation).
Collectively, these studies raise questions about the construct of submission and the mechanisms that link it with women’s menstrual functioning. Submission is part of the interpersonal dimension of status, a major organizing domain of social life, which refers to a way of relating to the social world by striving for power and influence (18). Individuals on the submissive part of this dimension generally do not strive for power, often experience stress in authority positions (26), have difficulty being firm with others (26), and suppress outward displays of anger (27). Functionally, submission may represent a category of complex behaviors that de-escalate social conflict and maintain social connections through appeasement (28). In addition, outward expression of anger and less anger control are most prominent when the target of the anger is perceived to be of a lower rank than one’s own (27), revealing other interpersonal struggles submissive individuals may face.
These observations provide a starting point for understanding the cognitive, emotional, and social experiences that may characterize individuals who describe themselves as submissive, but they do not address the biological mechanisms that might link these features with menstrual cycle irregularity. Because the present investigation did not include biological markers we can only speculate about this question; however, research concerning the influence of social hierarchies on hypothalamic-pituitary-adrenal (HPA) axis functioning may provide an informative context. Studies of nonhuman primates and other social mammals reveal that subordinate animals show disruption in HPA functioning characterized by failure to mount expected responses to acute stressors (29,30) and elevated resting levels of cortisol (30). Because glucocorticoids have reciprocal interactions with ovarian hormones (31), future research should examine whether stressors that emerge in social hierarchies are associated with endocrine hormone fluctuations that, in turn, influence women’s menstrual cycle regulation.
Strengths of the present investigation include the study of a multi-ethnic sample and the use of a validated measure of self-reported menstrual cycle irregularity. Limitations include sole reliance on self-report measures, and the use of a retrospective, cross-sectional rather than prospective, longitudinal design. In addition, we excluded women using hormonal contraceptives. Because some of these women may have been using hormonal contraceptives to regulate their cycles, it will be important to include and assess similar groups of women in future studies. Also, a more exhaustive assessment of potential reasons for menstrual irregularity (eg, eating disorders or body fat) is recommended.
In summary, the results of the present study are consistent with the notion that menstrual irregularity is sensitive to socioemotional processes, particularly those pertaining to social hierarchies. Menstrual cycle irregularity has been associated with incidence and severity of cardiovascular diseases in women in both cross-sectional and prospective studies (2,3). Moreover, dominance/submission has emerged as a predictor of cardiovascular disease status, although there remains a paucity of research including women. Taken together, these individual lines of research suggest that linkages should be explored among the socioemotional dimension of dominance/submission, menstrual functioning, and cardiovascular status in women.
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ACKNOWLEDGMENTS
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Tamara L. Newton and Correna L. Philhower, Department of Psychological and Brain Sciences. This work was supported by NHLBI R29 HL58528, awarded to the first author. We thank Susan Doron-LeMarca, Gretchen Gudmundsen, Cinnamon Stetler, Cherie Watters, and Rebecca Weigel for assistance with the laboratory sessions.
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NOTES
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1Given evidence for differences between African-American and European-American women in certain characteristics of menstrual functioning (32), we added the ethnicity main effect and the ethnicity x submission interaction terms to each model. We observed a significant ethnicity x submission interaction in model 3 only (p= 0.03), indicating a positive association between submission and menstrual irregularity among African-American women only (p< 0.005). Although it is not possible to determine whether this interaction is caused by the specific characteristics of the model 3 subsample or to the statistical effects of adjusting for BMI, combined with other reports of ethnicity differences in menstrual functioning it does highlight the importance of including multi-ethnic samples and testing ethnicity effects. 
Received for publication November 5, 2002.
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ABSTRACT
INTRODUCTION
