Body Image Changes over the Menstrual Cycle in Normal Women

Body Image Changes over the Menstrual Cycle in Normal Women Rebecca E. Carr-Nangle William G. Johnson Kimberly C. Bergeron Douglas W. Nangle (Accepted 10 September 1993) Changes in body image across the menstrual cycle and the relationship between these changes and menstrual distress were investigated in an effort to identify determinants of body dissatisfaction. Twenty-six normally cycling women between 18-40 years of age and 90-115% of ideal body weight, with no history of an eating disorder, completed a series of body image measures and a measure of menstrual distress during three menstrual cycle phases: perimenstrual, follicular, and luteal. These phases were identified with serum levels of ovarian hormones and basal body temperature. Results indicated that body dissatisfaction as measured by the number of body-related negative thoughts and anxiety about appearance was significantly highest during the perimenstrual phase. In contrast, measures of body size perception remained stable. Several somatosensory and psychological symptoms of menstrual distress were significantly associated with body dissatisfaction during tfie perimenstrual pfiase including, water retention, autonomic reactivity, control, negative affect, and impaired concentration. This association of body dissatisfaction and menstrual distress strongly suggests ttiat menstrual cycle ctianges play a significant role in body image. 1994 by John Wiley & Sons, Inc. Research and clinical interest in body image has become prominent recently for its association with the eating disorders of anorexia and bulimia nervosa. Body image disturbance is a core symptom of both of these eating disorders (DSM-IV; Schlundt & Johnson, 1990). In fact, many investigators consider body image disturbance as provid- Rebecca E. Carr-Nangle is Research Associate at the University of Mississippi Medical Center. William G. Johnson is Professor of Psychiatry (Psychology) and Director of the Eating Disorders Clinic at the University of Mississippi Medical Center. Kimberly C. Bergeron is a Resident in Pediatrics at Vanderbilt University. Douglas W. Nangle is Assistant Professor of Psychological Sciences at Ball State University. Address reprint requests to William C. Johnson, Ph.D. Department of Psychiatry, University of Mississippi Medical Center, 2500 State Street, Jackson, MS 39216-4505. International journal of Eating Disorders, Vol. 16, No. 3, 267-273 (1994) 1994 by John Wiley & Sons, Inc, CCC 0276-3478/94/030267-07

268 Carr-Nangle et al. ing the motivation for anorexia and bulimia nervosa (Cooper & Taylor, 1988; Slade, 1985-1988). As a construct, body image is generally conceptualized as having two relatively independent dimensions, namely body size perception and body satisfaction (e.g., Keeton, Cash, & Brown, 1992). Body size perception involves not only the estimation of one's body size but also associated perceptual distortions and discrepancy from idealized standards. Body satisfaction refers to individuals' affect, behaviors, and cognitions concerning their size and appearance (Rucker & Cash, 1992). Research indicates that these dimensions may be differentially susceptible to change. For example, previous research has linked negative mood to increases in body dissatisfaction among non-eating disordered women (Noles, Cash, & Winstead, 1985; Taylor & Cooper, 1992) and eating forbidden foods to changes in body size perception in a bulimic sample (McKenzie, WUliamson, & Cubic, 1993). The menstrual cycle is a major source of physical and psychological variation experienced by women from menarche to menopause and the onset of menses has been associated with increased body dissatisfaction. Bodily discontent among females is first noticeable as the adolescent body becomes more physically mature (Cohn et al., 1987), and the relative dissatisfaction increases from age 12 to 18 years (Davies & Furnham, 1986). The cyclical changes of the menstrual cycle that might negatively impact body satisfaction and/or body size perception have been well documented and include: (a) water retention and its complications (e.g., weight gain, bloating, breast sensitivity); (b) pain from abdominal cramping; (c) negative mood; (d) increased appetite; and (e) visual and olfactory perceptual threshold changes (e.g., Bancroft & Backstrom, 1985; Parlee, 1983; Rubinow et al., 1986; Tucker & Whalen, 1991). In spite of the robustness of both body image and the menstrual cycle and the intuitive appeal of their correlation, empirical evaluations of body image over the cycle and its association with menstrual distress have been few. An exception is the assessment of body image over the course of a menstrual cycle in non-eating disordered women (Altabe & Thompson, 1990). Using the calendar method to document cycle phase, the results of this study indicated greater body dissatisfaction during the perimenstrual phase with no change in estimates of body size. Although women with high and low levels of menstrual distress were compared, this study did not report the association between menstrual distress symptom clusters and body image measures. Most studies investigating behavioral variables over the menstrual cycle have relied on the calendar method or basal body temperature to estimate phases of the menstrual cycle. Unfortunately, neither of these methods are as accurate as ovarian hormonal assays (see Tucker & Whalen, 1991; Tepperman & Tepperman, 1987). The present study examined changes in body image across the menstrual cycle and the relationship between body image and menstrual distress. The subjects completed a menstrual symptom questionnaire and a series of body image measures. Menstrual phases were identified with serum levels of ovarian hormones and basal body temperature. METHOD Subjects Women were recruited to participate in a larger study investigating patterns of food intake, exercise, and body weight over the course of a menstrual cycle. For their par-

Menstrual Cycle 269 ticipation, subjects received a review of their dietary intake, eating and exercise patterns, and present body fat following completion of the study. The following inclusion criteria were utilized: (a) between 18-40 years of age, (b) between 90-115% of ideal body weight, (c) no history of eating disorder, and (d) regular menses during the past 6 months. Subjects were excluded if they were smokers, pregnant, or taking oral contraceptives or any other medication that could influence their eating behavior, dietary intake, or exercise. Twenty-six women between 22 and 39 years of age (M = 32.3 years, SD = 4.3), from 90 to 115% of ideal body weight (M = 132.6 lb, SD = 12.2), an average height of 66.1 in. {SD = 2.5), and an average body mass index (BMI) of 21.5 served as subjects. Skinfold measurements indicated an average percent body fat of 22.8% {SD = 5.3). Written informed consent was obtained from each subject and the study was approved by the Institutional Review Board of the University of Mississippi Medical Center. Measures Body Parts Satisfaction Scale The Body Parts Satisfaction Scale (BPSS; Berscheid, Walster, & Bohrnstedt, 1973; Bohrnstedt, 1977) assesses hedonic ratings of specific body parts (e.g., mid-torso, face) and the body as a whole. Scores are given for the specific body areas and as well as an average score. Body Image Automatic Thoughts Questionnaire The Body Image Automatic Thoughts Questionnaire (BIATQ) is a 52-item self-report questionnaire that measures body-related cognitions (e.g.. Everybody looks better than I do; I am proud of my body). The items are sorted into two subscales: positive thoughts and negative thoughts. Moos Menstrual Distress Questionnaire A disguised version of the Menstrual Distress Questionnaire (MDQ; Moos, 1977) was administered to assess severity of menstrual symptoms. The MDQ is a 47-item selfreport questionnaire designed to assess menstrual symptoms in each of eight symptom clusters, which provide their own subscale score. Those subscales and some representative items are: water retention (e.g., weight gain, swelling); concentration (e.g., forgetfulness, confusion); negative affect (e.g., mood swings, anxiety); behavior change (e.g., poor work performance, avoid social activities); pain (e.g., headache, cramps); autonomic reactions (e.g., dizziness, nausea); arousal (e.g., affectionate, excitement); and control (e.g., feelings of suffocation, chest pains). Body Image Assessments Nine cards each with a silhouette of a female body ranging from very thin (card 1) to very obese (card 9) were presented to the subjects. The subjects were asked to choose the card most similar to their current body size and the card that was closest to their ideal body size (Williamson, Kelley, Davis, Ruggiero, & Blouin, 1985). Rating of Attractiveness During the first session, a photo was taken of each subject in form-fitting clothes. The subjects were standing against a wall and turned slightly to their right. During each

270 Carr-Nangle et al. session, the subjects viewed the photo and rated their attractiveness on a 9-point scale (1 = extremely unattractive; 5 = neither attractive nor unattractive; 9 = extremely attractive). Ratings of Anxiety In a room with a full-length mirror, each subject was instructed to "Take 30 seconds to view your body in the mirror. During this time observe your entire body. Try not to focus all your attention on any one body area." After 30 seconds, they rated their degree of anxiety about their appearance on a scale from 0 to 100, with 0 being not at all anxious and 100 being extremely anxious. Procedure Within 3 days of the onset of menses, the subjects attended an initial session during which they received verbal and written instructions for recording basal body temperature. At this time they were also instructed to maintain their usual patterns of food intake and exercise throughout the study. In addition, all physical measures were taken and measures of body image and menstrual distress were administered. After the initial session, subjects monitored their basal body temperature on a daily basis and attended weekly sessions approximating menstrual cycle phases throughout data collection. During these weekly sessions, the body image and menstrual distress measures were readministered and the subjects had blood samples drawn (10 ml from the antecubital vein) for analyses of hormones. All physical measures were repeated following the onset of the subjects' next menstrual cycle. Menstrual cycle phases were determined through the analysis of individual hormone levels, temperature recordings, and menstruation. Three phases were identified according to the following criteria: perimenstrual with low levels of estrogen and progesterone; follicular/ovulatory with increasing estrogen, low progesterone, a peak in folliclestimulating hormone (FSH) and leutinizing hormone (LH), and a rise in basal temper-" ature; and luteal with a peak in progesterone and an increase in estrogen (Tepperman & Tepperman, 1987). Body image and menstrual distress measures were identified by the menstrual cycle phase for each subject. RESULTS Menstrual Cycle Phases The menstrual cycle for the sample averaged 28.0 days {SD = 4.9) with the following average number of days in each phase: perimenstrual (M = 10.3, SD = 1.8) included 2-3 days premenses for two cycles and one menses; follicular (M = 10.2, SD = 4.8); and luteal (M = 9.6, SD = 1.3). The number of weekend days was equally distributed over the three cycle phases. Body Image Changes over the Menstrual Cycle Table 1 shows the mean scores for all body image measures during each menstrual phase and the p values of the follow-up analyses of variance (ANOVAs). Significant differences across the menstrual cycle were observed for BIATQ-negative {p =.04) and

Menstrual Cycle 271 ratings of anxiety over appearance (p =.002). Follow-up paired t tests revealed that the number of body-related negative thoughts (BIATQ-negative) was significantly higher during the perimenstrual phase [f(13) = 2.74, p <.02] than during the fouicular but was not different from the luteal. Similarly, ratings of anxiety over appearance were higher during the perimenstrual phase than the follicular [f(15) = 2.91, p <.02] and luteal [t(15) = 3.55, p <.01]. Several other measures that approached statistical significance (e.g., BPSS-overall, BPSS-lower torso, silhouettes-current) indicated higher levels of body dissatisfaction during the perimenstrual phase. Body Image and Menstrual Distress Because body dissatisfaction was highest during the perimenstrual phase, the relationship between body image and menstrual distress was investigated for this phase to determine which physical and/or psychological changes were associated with higher levels of body dissatisfaction. Pearson correlations were calculated for BIATQ-negative and ratings of anxiety with the symptom clusters of the MDQ during the perimenstrual phase. As shown in Table 2, anxiety about appearance was significantly related to all of the symptom clusters (p <.05) except increased appetite and behavior change. BIATQnegative was significantly related to several symptom clusters including: water retention, negative affect, autonomic reaction, control, and impaired concentration. DISCUSSION Two measures of body satisfaction, namely the number of body-related negative thoughts and anxiety over appearance, were higher during the perimenstrual phase as compared with other menstrual cycle phases. Other measures of body satisfaction and body size perception remained constant over the cycle. The peak in body dissatisfaction Table 1. Changes in body image measures across the menstrual cycle Menstrual Cycle Phase Measure Perimenstrual Follicular Luteal F Body Image Automatic Thoughts Questionnaire Negative Positive Body Parts Satisfaction Scale Overall Face Low torso Mid torso Breast Muscle tone Silhouettes Current Ideal Attractiveness Anxiety 1.55 2.77 4.09 4.41 3.55 3.46 4.27 3.85 4.60 2.97 5.87 40.38= 1.47" 2.57 4.40 4.35 3.83 3.58 4.46 3.77 4.20 2.80 5.88 26.25" Note. Means sharing superscripts do not differ at p <.05 using paired t tests. *p <.05. "p <.005. 1.49'" 2.52 4.33 4.16 3.71 3.65 4.31 4.15 4.53 2.87 5.81 24.38" 4.42» 0.72 2.25 1.62 2.54 1.40 0.73 1.85 0.55 0.14 0.09 12.75"

272 Carr-Nangle et al. Table 2. Pearson correlations between menstrual symptoms and body image measures during the perimenstrual phase Moos Menstrual Distress Questionnaire subscale BIATQ-Negative Anxiety Ratings Pain Water retention Behavior change Arousal Negative affect Autonomic reaction Control Impaired concentration Increased appetite.23.50*.30 -.09.43**.35**.41**.49*.19 Note. BIATQ = Body Image Automatic Thoughts Questionnaire. *p <.01. **p <.05..51*.52*.25 -.36**.60*.40**.48*.40** -.21 in the perimenstrual phase and the stable body size perception are consistent with the previous literature (Altabe & Thompson, 1990). Although changes in menstrual distress have been well documented over the course of the cycle (e.g., Rubinow et al., 1986), the association of specific menstrual complaints and body image has not been previously reported. The significant correlations between menstrual distress and body image provide preliminary information about some potential sources of body dissatisfaction. Specifically, more frequent negative body-related thoughts and higher anxiety over appearance were significantly associated with higher levels of water retention, negative affect, autonomic reaction, control, and impaired concentration. Autonomic reaction, control, and water retention are all physiological symptom clusters with demonstrable somatosensory properties. Although bodily changes over the menstrual cycle with somatosensory properties such as painful or tender breast, abdominal swelling, and nausea have been found to play an important role in explaining inaccuracies in body size perception (Lautenbacher, Roscher, Strian, Pirke, & Krieg, 1993), the pattern of correlations indicates that they may be associated with body satisfaction as well. The symptom clusters of negative affect and impaired concentration are more psychological in nature and may be consequences of the physiological changes. Regardless, the pattern of association between the two body image measures and the MDQ during the perimenstruum strongly suggests that menstrual distress during this time plays a significant role in body dissatisfaction. Methodologically, investigations of the menstrual cycle are challenging due to difficulties in cycle determination, cycle regularity, and the number of women taking oral contraceptives. The current study was limited to a relatively small number of subjects and thus had relatively low power to detect changes making the present findings of an association between body dissatisfaction and menstrual distress all the more compelling. A further methodological issue is the generalizability of the present results to other populations. Subjects in the present investigation were of normal weight, not taking oral contraceptives, had no history of an eating disorder, and had no complaints of menstrual distress. Research has found many differences between normal and eating disordered populations in body satisfaction and body size perception (Bell, Kirkpatrick, & Rinn, 1986; Davis, Williamson, Goreczny, & Bennett, 1989; Lindholm & Wilson, 1988; Williamson et al., 1985; Williamson, Cubic, & Gleaves, 1993). Whether the relationship

Menstrual Cycle 273 of body satisfactior\ and menstrual distress holds for various eating disordered populations, women taking oral contraceptives, and those experiencing menstrual distress is worthy of empirical evaluation. The present study also has implications for future investigations of body image and specifically for body satisfaction. Due to the significant change in body satisfaction over the course of a menstrual cycle, cycle phase should be documented when measuring body satisfaction. REFERENCES Altabe, M., & Thompson, J. K. (1990). Menstrual cycle, body image, and eating disturbance. International Journal of Eating Disorders, 9, 395-401. Bancroft, J. & Backstrom, T. (1985). Premenstrual syndrome. Clinical Endocrinology, 22, 313-336. Bell, C, Kirkpatrick, S. W., & Rinn, R. C. (1986). Body image of anorexic, obese, and normal females, journal of Clinical Psychology, 42, 431-439. Berscheid, E., Walster, W., & Bohrnstedt, G. (1973). The happy American body: A survey report. Psychology Today, 7, 119-131. Bohrnstedt, G. W. (1977). On measuring body satisfaction. Unpublished manuscript. Cohn, L. D., Adier, N. E., Irwin, C. E., Millstein, S. G., Kegeles, S. M., & Stone, G. (1987). Body-figure preferences in male and female adolescents. Journal of Abnormal Psychology, 96, 276-279. Cooper, P. J., & Taylor, J. J. (1988). Body image disturbance in bulimia nervosa. British Journal of Psychiatry, 153 (Suppl. 2), 32-36. Davies, E., & Furnham, A. (1986). The dieting and body shape concerns of adolescent females. Journal of Child Psychology and Psychiatry, 27, 417-428. Davis, C. J., Williamson, D. A., Goreczny, A. J., & Bennett, S. M. (1989). Body image disturbances and bulimia nervosa: An empirical analysis of recent revisions of the DSM-III. Journal of Psychopathology and Behavioral Assessment, 11, 61-69. Keeton, W. P., Cash, T. F., & Brown, T. A. (1990). Body image or body images?: Comparative, multidimensional assessment among college students. Journal of Personality Assessment, 54, 213-230. Lautenbacher, S., Roscher, S., Strain, F., Pirke, K. M., & Krieg, J. C. (1993). Theoretical and empirical considerations on the relation between 'body image', body scheme and somatosensation. Journal of Psychosomatic Research, 37, 447-454. Lindholm, L., & Wilson, G. T. (1988). Body image assessment in patients with bulimia nervosa and normal controls. International Journal of Eating Disorders, 7, 527-539. McKenzie, S. J., Williamson, D. A., & Cubic, B. A. (1993). Stable and reactive body image disturbances in bulimia nervosa. Behavior Therapy, 24, 195-207. Moos, R. H. (1977). Menstrual distress questionnaire manual. Stanford, CA: Social Ecology Laboratory. Noles, S. W., Cash, T. F., & Winstead, B. A. (1985). Body image, physical attractiveness, and depression. Journal of Consulting and Clinical Psychology, 53, 88-94. Parlee, M. B. (1983). Menstrual rhythms in sensory processes: A review of fluctuations in vision, olfaction, audition, taste, and touch. Psychological Bulletin, 93, 539-548. Rubinow, D. R., Roy-Byrne, P., Hoban, M. C, Grover, G. N., Stambler, N., & Post, R. M. (1986). Premenstrual mood changes: Characteristic patterns in women with and without premenstrual syndrome. Journal of Affective Disorders, 10, 85-90. Rucker, C. E., & Cash, T. F. (1992). Body images, body-size perceptions, and eating behaviors among African- American and white college women. International Journal of Eating Disorders, 12, 291-299. Schlundt, D. G., & Johnson, W. G. (1990). Eating disorders: Assessment and treatment. Boston, MA: Allyn & Bacon. Slade, P. D. (1985). A review of body-image studies in anorexia and bulimia nervosa. Journal of Psychiatric Research, 19, 255-265. Slade, P. D. (1988). Body image in anorexia nervosa. British Journal of Psychiatry, 153 (Suppl. 2), 20-22. Taylor, M. J., & Cooper, P. J. (1992). An experimental study of the effect of mood on body size perception. Behaviour Research and Therapy, 20, 53-58. Tepperman, J., & Tepperman, H. M. (1987). Metabolic and endocrine physiology. Chicago, IL: Year Book Medical Publishers, Inc. Tucker, J. S., & Whalen, R. E. (1991). Premenstrual syndrome. International Journal of Psychiatry in Medicine, 21, 310-341. Williamson, D. A., Cubic, B. A., & Gleaves, D. H. (1993). Equivalence of body image disturbances in anorexia and bulimia nervosa. Journal of Abnormal Psychology, 102, 177-180. Williamson, D. A., Kelley, M. L., Davis, C. J., Ruggiero, L., &Blouin, D. C. (1985). Psychopathology of eating disorders: A controlled comparison of bulimic, obese, and normal subjects. Journal of Consulting and Clinical Psychology, 53, 161-166.