Niddah 9a ~ Fear, Mood, and Menstruation

There is a great deal of scientific work investigating the effect of the menstrual cycle on a women's mood. But there has been less examination of the effect of mood (or stress) on the cycle.  In today's page of Talmud, there is a discussion of this less well studied area: the role of psychological stress on menstruation.  

נדה ט,א

רבי מאיר אומר אם היתה במחבא והגיע שעת וסתה ולא בדקה טהורה שחרדה מסלקת את הדמים

Rabbi Meir says: If a woman was in hiding from danger, and the time of her fixed menstrual cycle came and she did not examine herself, nevertheless she is ritually pure, [as it may be assumed that she did not experience bleeding] because fear dispels the flow of menstrual blood.

Queen Esther's Stress

Elsewhere though, the Talmud suggests just the opposite - that fear induces menstruation:

סוטה כ, א

למימרא דבעיתותא מרפיא אין דכתיב ותתחלחל המלכה מאד ואמר רב שפירסה נדה והא אנן תנן חרדה מסלקת דמים פחדא צמית ביעתותא מרפיא

Does fright loosen the womb [and causes a woman to menstruate]? Yes, as the verse states (Esther 4:4) "...and the Queen [Esther] became very afraid" about which Rav explained:" she began to menstruate."

But haven't we learned elsewhere in a Mishnah (Niddah 39a) that fear suspends the discharge of menstrual blood? In fact, fear that is not sudden contracts [the womb and prevents bleeding], but sudden fear loosens [the womb and causes early menstrual bleeding].

Here are some of the things that the rabbis of the Talmud believed could induce menstruation:

1. Carrying a heavy load (Tosefta Niddah 9:1)

2. Jumping (ibid)

3. Sudden fright (Niddah 71a, and Niddah 39a)

4. Yearning for intercourse (Niddah 20b)

5. Garlic, onions and peppers (Niddah 63b)

But in today's page of Talmud, Rabbi Meir opined that fear prevents menstruation. Let's take a look at the medical literature and see whether or not it supports his assertion.

“Data from both animal and human research indicate that psychological stress is associated with altered menstrual function.”

— Barsom S, et al. Association between psychological stress and menstrual cycle characteristics in perimenopausal women. Women’s Health Issues 14 (2004) 235-241

The Effect of Stress on Menstrual Function

In a review from the Department of Biological Sciences at Ohio University, researchers acknowledged that stress is difficult to define. However, one final common pathway of stressors is the low availability of dietary energy. Ovulation - which is the first part of the cascade that leads to menstruation - has been blocked in hamsters "by food restriction, pharmacological blockers of carbohydrate and fat metabolism, insulin administration (which shunts metabolic fuels into storage), and cold exposure (which consumes metabolic fuels in thermogenesis)." Women athletes frequently experience a lack of menstruation, which is found in up to 65% of competitive young runners. But what about psychogenic causes of a disturbed menstrual cycle - after all, Rabbi Meir taught fear prevents menstruation? While not adressing this directly, the Ohio University researchers had this to say about the relationship between psychological stressors and amenorrhea (the lack of menstruation. Remember that word - it will come up again):

Associations between psychological disturbances and amenorrhea or infertility have long been interpreted as a causal relationship, but prospective studies demonstrating that psychogenic factors contribute to reproductive dysfunction in women are almost completely lacking . Early psychoanalytic conclusions that psychological conditions underlie involuntary infertility in women have been criticized recently on several grounds: first, the same psychological conditions have been found in analyses of fertile women; second, other women with very serious psychic problems conceive with ease; and third, couples with an unfulfilled desire for a child do not show psychological disorders any more frequently than do couples without fertility disorders. Even the direction of causality is questionable, because there are grounds for believing that infertility and its medical treatment cause the depression and anxiety observed in some infertility patients. These findings have led to the recommendation that the term ‘psychogenic infertility’ should be withdrawn from use because it is simplistic and anachronistic.

Menstruation and Incarceration

There is some other evidence we could consider: a 2007 paper published in Women's Health Issues which addressed the influence of stress on the menstrual cycle among newly incarcerated women.  Researchers analyzed 446 non-pregnant women who answered a number of detailed questions about their menstrual cycles.  They found that 9% reported amenorrhea (I told you what that meant two paragraphs ago) and that a third reported menstrual irregularities.  

“Incarcerated women have high rates of amenorrhea and menstrual irregularity and the prevalence may be associated with certain stresses. Further research on the causes and consequences of menstrual dysfunction in this underserved population is needed.”

— Allsworth J. et al. The influence of stress on the menstrual cycle among newly incarcerated women. Women's Helath Issues 2007; (17) 202-209.

As might be expected, the stressors of the incarcerated women in this study included drug and alcohol problems and sexual abuse. And it supports the assertion by Rabbi Meir that stress - in the form of incarceration, is causally linked to amenorrhea.  

A Longitudinal Study of Psychological Stress and Menstruation

The final study we will review comes from a cohort of predominantly white, well educated married women of whom 505 were "invited to participate join a special survey focusing on midlife and menopause." Rather than ask about stress and current menstruation, the researchers performed a two-year analysis. Here's what they found:

In analyzing stress levels and cycle characteristics across 2 years...women with marked increases in their level of stress (n =30) are shown to have decreased length (0.2 days/cycle) of menstrual cycle intervals and decreased duration of bleed (0.1 day/cycle) compared with increases in these measures (2.9 days/cycle for cycle interval; 0.3 days/cycle for duration of bleed) among women with no marked change in stress level (n=103); t-tests indicate that these differences are significant (p < .05).

Some of the differences that the researchers found in this group were really small - "0.3 days/cycle for duration of bleeding" but if you are into statistics this difference can be significant (that's what those t-tests are all about). But these statistical associations were not powerful, and the researchers concluded that "the results of this investigation...suggest that, in the long term, stressful life events have little relationship to the length of menstrual cycle intervals and the duration of menstrual bleeding in perimenopausal women."

The three studies we've reviewed (even that last one with its weak findings) all suggest that there is indeed a relationship between psychological stress and menstruation.  Generally, the effect of stress is to increase the length of the menstrual cycle which may result in amenorrhea.  Rabbi Meir, the great sage of the Mishnah, was certainly onto something when he noted just the same effect almost two thousand years ago.

Niddah 2a ~ The Ethnography of Menstruation Taboos

How the uterus lining builds up and breaks down during the menstrual cycle.

Today we start to learn the very last tractate of the Babylonian Talmud, called Niddah. It addresses the laws of a woman who is menstruating: how she becomes ritually impure, what she ritually contaminates, how she is forbidden to have sexual relations with her husband, and how she may leave her status and become ritually pure. To this day many of these laws are carefully followed by religious Jewish couples who observe periods of sexual abstinence during and following the menstrual period.

It’s Not Just Judaism

It is not just the Jewish tradition that identifies menstruation with ritual impurity (and physical danger). Mary Douglas in her now classic work Purity and Danger noted that this connection was found among many disparate cultures. For example (and there are many) the Mae Enga from the Central Highland of New Guinea also have strong beliefs about sexual pollution. “They believe that contact with it or with a menstruating women will, in the absence of appropriate counter-magic, sicken a man and cause persistent vomiting, “kill” his blood so that it turns black, corrupt his vital juices so that his skin darkens and hangs in folds as his flesh wastes, permanently dull his wits, and eventually lead to a slow decline and death.” And then there are the Lele, a group that lives in the Kinshasa region of the Democratic Republic of the Congo. Here is Douglas (P&D 152):

… a menstruating [Lele] woman could not cook for her husband or poke the fire, lest he fall ill. She could prepare the food, but when it came to approaching the fire she had to call a friend in to help. These dangers were only risked by men, not by other women or children. Finally, a menstruating woman was a danger to the whole community if she entered the forest. Not only was her menstruation certain to wreck any enterprise in the forest that she might undertake, but it was thought to produce unfavourable conditions for men.

According to the South Sudan News Agency, (which claims to be “South Sudan’s Leading Independent News Source”) the Nuer (the second largest tribe in South Sudan) also have their own version of the laws of Niddah:

Many aspects of the Nuer culture are sometimes similar to the cultural aspects of the Bible’s Old Testament people which include feature of their social structure, the kinship reckoning and the extended family aspects of marriage, divorce, rite of passage and even religious concepts of God, spirits, sin and sacrifice. In the spiritual beliefs of Nuer culture, “women who are having their menstrual period cannot drink milk, visit the cattle area or eat food that had been cooked in kettle used for boiling milk because doing so would be harmful to the cattle.”

The Koran (not the Koren) also records a warning against intimacy with a menstruating woman:

And they ask you about menstruation; Say It is harm, so keep away from women during menstruation; And do not approach them until they become pure And when they have purified themselves, then come to them from where Allah has ordained for you; Indeed, Allah loves those who are constantly repentant and loves those who purify themselves. (Al-Quran 2:222-223)

And what about Hindus? In 2011, two Indian researchers published an analysis of the social and cultural practices regarding menstruation. They studied a group of Indian adolescent girls and their mothers from various communities and classes in Ranchi in eastern India, and found that both Hindu (and Moslem) women practiced varying menstrual taboos:

Hindu girls reported restricting themselves from religious practices during menstruation whereas Muslim (follower of Islam) girls reported that they do not touch religious books or read ‘‘Namaz’’ or even do not go to the ‘‘Mazaar (shrine).’’ Even the Sarna tribe girls do not go to the ‘‘Sarnasthal (Worship place of Sarna people)’’ during menstruation however, Christian girls reported that they worship and attend church during menses and can even touch and read the holy Bible.

If you want to get a sense of prevailing attitudes about menstruation at the time of the destruction of Jerusalem, try this, written by Pliny the Elder written around 79 CE in his famous work Natural History (7:15):

But it would be difficult to find anything more bizarre than a woman's menstrual flow. Proximity to it turns new wine sour; crops tainted with it are barren, grafts die, garden seedlings shrivel, fruit falls from the tree on which it is growing, mirrors are clouded by its very reflection, knife blades are blunted, the gleam of ivory dulled, hives of bees die, even bronze and iron are instantly corroded by rust and a dreadful smell contaminates the air.

Ritual impurity as disorder

One of Mary Douglas’ many contributions to the ethnographic study of purity is her analysis of the concept of “dirt”:

If we can abstract pathogenicity and hygiene from our notion of dirt, we are left with the old definition of dirt as matter out of place. This is a very suggestive approach. It implies two conditions: a set of ordered relations and a contravention of that order. Dirt then, is never a unique, isolated event. Where there is dirt there is system. Dirt is the by-product of a systematic ordering and classification of matter, in so far as ordering involves rejecting inappropriate elements…. It is a relative idea. Shoes are not dirty in themselves, but it is dirty to place them on the dining-table; food is not dirty in itself, but it is dirty to leave cooking utensils in the bedroom, or food bespattered on clothing…(P&D 36-37)

Perhaps then, rabbinic hierarchies of ritual purity and impurity were an attempt to identify "matter out of place.” Douglas wrote that “if uncleanness is matter out of place, we must approach it through order.” Which is precisely what the complicated laws found in this tractate attempt to do.

“...the binary, pure/impure structure at the base of nidah also imposed order on the chaos.”

— Shai Secunda. The Talmud's Red Fence. Oxford University Press, forthcoming.

Shai Secunda and the Iranian Talmud

Shai Secunda is Associate Professor of Judaism at Bard College and the Persian language consultant for Koren’s Steinsaltz Talmud. He is a scholar of the historic Iran in which the Babylonian Talmud was produced, and he has written a new and invaluable book when it comes to the history of the Jewish laws of Niddah: The Talmud's Red Fence: Menstruation and Difference in Babylonian Judaism and its Sasanian Contex. Alas you will need to wait until 2020 for Oxford University Press to publish it. What makes his book really interesting is that it he reads talmudic passages alongside texts composed by the neighboring religious communities in the Sasanian Empire, which was comprised of “an impressively diverse spectrum of religious communities including, among others, Christians, Manichaeans, Mandaeans, Jews, and Zoroastrians.” The empire lasted from 224-651 CE and was the last Persian kingdom before the rise of Islam. It was inside of this empire that the Babylonian Talmud was composed. He noted for example, that in Zoroastrian tradition there was a myth about the dangerous powers of the gaze of menstruating women. (You can find more examples in his 2014 paper The Fractious Eye: On the Evil Eye of Menstruants in Zoroastrian Tradition.)

And she should not look at the sun nor at the other luminaries. And she should not look at cattle and plants. And she should not engage in conversation with a righteous man, for a demon of such violence is the demon of menstruation that, [where] the other demons do not strike things with the evil eye, this one strikes [them] with the evil eye.

The Zoroastrian Parallels of Niddah

Secunda notes some important parallels between this Zoroastrian tradition and some of the laws of Niddah that were formulated in the Babylonian Talmud. Take for example the Middle Persian compilation known as Sayist ne Sayist. Here is an excerpt, translated by Secunda:

A menstruant woman who becomes clean within a three-night period, should not wash until the fifth day. And from the fifth day to the ninth day, whenever she becomes clean, she is to keep sitting in cleanness for one day for the waiting period. Afterwards, she should wash in the usual way. And after the nine-day waiting period, the waiting period is not an issue...

[Regarding] the menstruant woman, if she has sat in [a state of] menstruation for one month and she [still] is not clean on the thirtieth day, even if she at that time did become clean, and afterwards again became a menstruant, then the [requirement of] the waiting period goes back to the beginning, and it is not authorized for her to wash until the fifth day.

“As the text makes clear,” he writes, “according to Zoroastrian law a woman cannot simply purify herself as soon as her menstrual flow ceases, rather she must wait additional time before purification is allowed. The technical Middle Persian term for the additional day is tayag – “(waiting) period,” while the practice of observing it is known as “sitting in cleanness.”  This stringency reminds us of another (Niddah 66a), this one enacted by the Jews in Babylon (and still practiced today):

R. Zeira said: The daughters of Israel were stringent on themselves that even if they see a drop of [vaginal] blood like [the size of] a mustard-seed, they sit [and wait] seven clean [days] on account of it.

Secunda notes that “as it is introduced here, the origin of the described custom is not located in Biblical law, nor is it a legacy of rabbinic legislation, rather, it is attributed to Jewish women who are said to have taken up the stringency on their own.” Thus there is

evidence that two religious communities living alongside Babylonian Jewry deliberately extended ritual impurity even beyond the actual menstrual period. Mandaean authorities strenuously maintained that a couple must wait for a final, post-menstrual baptism before reuniting sexually. Sasanian Zoroastrian priests put considerable effort into establishing, delineating, and debating a one-day ritual waiting period, which was exegetically linked to a section of their scriptures. In short, all three religious communities tried, in their own way, to extend ritual impurity beyond the menstrual flow.

Then Secunda suggests this, which he acknowledges is “entirely within the realm of speculation.”

How might we envisage the role that the Sasanian religious context may potentially have played in the invention of the Jewish “clean day” stringency? In light of our above focus on the attribution of the stringency to the “Daughters of Israel,” perhaps it was specifically Jewish women who acted as a conduit for outside religious influence. It could be argued that female piety draws more easily on neighboring female practices – even ones initiated by male religious authorities, like Zoroastrian priests. Unlike rigorously policed rabbinic discourse, Jewish women could have conceivably “traded notes” with their gentile neighbors with far greater ease than their male compatriots, allowing for a more seamless adoption of new customs and approaches…

In some of his early work on the relationship between Babylonian Jewry and Sasanian Zoroastrianism, Yaakov Elman posited a kind of one- upmanship – in his formulation, a “holier than thou syndrome” – between Jewish and Zoroastrian women. One dynamic of this competition would be that Jewish women could argue that their approach of waiting a full seven days following their period was more stringent, purer, and thus more efficacious, than both the Mandaean and Zoroastrian systems.

There is a great deal more of interest in Secunda’s book, which finishes with these wise words:

Not only do observant Jews still practice the strictures of nidah, difference and differentiation remain an important part of the calculus. To this day, one of the measures by which religious Jews identify themselves as religious is based on the observance of “family purity” – as the laws of nidah are commonly known…. 

Whether we like it or not, difference continues to form the bedrock of meaning and with it, human culture and society. …systems of purity and impurity, with their differences and distinctions, are here to stay. We might as well try to make sense of them.

From the Talmudology Archives: Queen Esther's Fight or Flight Reaction

In honor of the festival of Purim, which being celebrated either now (in Australia) tomorrow, or on Friday (if you live in a very old walled city), we are reposting this from the Talmudology archives. Enjoy.

אסתר 4:4

וַ֠תָּבוֹאינָה נַעֲר֨וֹת אֶסְתֵּ֤ר וְסָרִיסֶ֙יהָ֙ וַיַּגִּ֣ידוּ לָ֔הּ וַתִּתְחַלְחַ֥ל הַמַּלְכָּ֖ה מְאֹ֑ד וַתִּשְׁלַ֨ח בְּגָדִ֜ים לְהַלְבִּ֣ישׁ אֶֽת־מָרְדֳּכַ֗י וּלְהָסִ֥יר שַׂקּ֛וֹ מֵעָלָ֖יו וְלֹ֥א קִבֵּֽל׃

When Esther’s maidens and eunuchs came and informed her, the queen was greatly agitated. She sent clothing for Mordecai to wear, so that he might take off his sackcloth; but he refused.

The meaning of the verse seems straightforward enough. Esther learned that throughout the empire, Jews were fasting, weeping and wailing, (although she did not yet know why). This greatly upset or"agitated" her.  But in the Talmud, Rav (d. ~247) and his student Rabbi Yirmiyah are not content with this straightforward reading. 

מגילה טו, א

ותתחלחל המלכה מאי ותתחלחל אמר רב שפירסה נדה ור' ירמיה אמר שהוצרכה לנקביה 

What is the meaning of the word ותתחלחל? Rav said: It means that she started to menstruate. R. Yirmiyah said: that her bowels were loosened.

Esther before Ahasuerus by Jacopo Tintoretto (1519-94). From The Royal Academy of Arts, London.

FIGHT OR FLIGHT

Any of us who have have experienced moments of intense fear or anxiety can understand R. Yermiah's explanation. In moments of sudden severe stress, the body's sympathetic nervous system ("fight or flight") goes into overdrive and releases epinephrine (AKA adrenaline). This prepares us for battle: our heart rate increases, blood is diverted away from the digestive system and towards the muscles, and our pupils dilate, to allow for better vision. At the same time the  parasympathetic nervous system ("rest and digest") is partially activated, which results in urination and defecation (or at least the urge to do so). 

Brain circuits involved in fear and anxiety. A schematic view of major brain circuits involved in fear and anxiety. External auditory, visual, olfactory, or somatosensory stimuli are relayed by the thalamus to the amygdala and cortex. The basolateral complex (BLA) of the amygdala is the input side of the system, which also receives contextual information from the hippocampal formation (entorhinal cortex, hippocampus, and ventral subiculum). After intra-amygdala processing of the emotional stimuli, the central nucleus of the amygdala (CeA), on the output side, activates the locus ceruleus (LC) and central and peripheral noradrenaline systems (via corticotropin-releasing factor [CRF] neurons), and the hypothalamus (paraventricular nucleus [PVN] and lateral hypothalamus [LH]). The bed nucleus of the stria terminalis (BNST, part of the “extended amygdala”) is also a control center for the neuroendocrine system by integrating information originating from both the hippocampus and the amygdala. In addition, the CeA directly activates various midbrain regions or nuclei responsible for different aspects of the fear/anxiety response: freezing or escape (periaqueductal gray [PAG]), increased respiratory rate (parabrachial nucleus [PBN]), startle (caudal reticulopontine nucleus of the reticular formation [RPC]), and the dorsal motor nucleus of the vagus (DMN) in the medulla, which (together with the lateral hypothalamus) is responsible for the increase in heart rate and blood pressure associated with emotional events. The prefrontal cortex (PFC) processes more elaborate (“cognitive”) information; it modulates the physiological, neuroendocrine, and behavioral responses (via the amygdala), and it is also involved in the extinction of fear- and anxiety-related conditional responses. ACTH, adrenocorticotropic hormone; ANS, autonomous nervous system; BP, blood pressure; GABA, γ-aminobutyric acid; Glu, glutamate; NA, noradrenaline (neurotransmitter) or nucleus ambiguus (structure); NTS, nucleus tractus solitarius. From Steimer, T. The biology of fear- and anxiety-related behaviors. Dialogues in Clinical Neuroscience - Vol 4 . No. 3 . 2002, 231-249.

Queen Esther's Stress

As we saw in Megillah, Rav opined that fear can induce menstrual bleeding. In Sotah, the Talmud further delineates the effect of stress on menstruation.

סוטה כ, ב

למימרא דבעיתותא מרפיא אין דכתיב ותתחלחל המלכה מאד ואמר רב שפירסה נדה והא אנן תנן חרדה מסלקת דמים פחדא צמית ביעתותא מרפיא

Does fright loosen the womb [and causes a woman to menstruate]? Yes, as the verse states (Esther 4:4) "...and the Queen [Esther] became very afraid" about which Rav explained:" she began to menstruate."

But haven't we learned elsewhere in a Mishnah (Niddah 39a) that fear suspends the discharge of menstrual blood? In fact, fear that is not sudden contracts [the womb and prevents bleeding], but sudden fear loosens [the womb and causes early menstrual bleeding].

Here are some of the things that the rabbis of the Talmud believed could induce menstruation:

1. Carrying a heavy load (Tosefta Niddah 9:1)

2. Jumping (ibid)

3. Sudden fright (Niddah 71a, and Niddah 39a)

4. Yearning for intercourse (Niddah 20b)

5. Garlic, onions and peppers (Niddah 63b)

Let's take a look at the medical literature and see whether or not it supports Rav's assertion.

“Data from both animal and human research indicate that psychological stress is associated with altered menstrual function.”

— Barsom S, et al. Association between psychological stress and menstrual cycle characteristics in perimenopausal women. Women’s Health Issues 14 (2004) 235-241

The Effect of Stress on Menstrual Function

In a review from the Department of Biological Sciences at Ohio University, researchers acknowledged that stress is difficult to define. However, one final common pathway of stressors is the low availability of dietary energy. Ovulation - which is the first part of the cascade that leads to menstruation - has been blocked in hamsters "by food restriction, pharmacological blockers of carbohydrate and fat metabolism, insulin administration (which shunts metabolic fuels into storage), and cold exposure (which consumes metabolic fuels in thermogenesis)." Women athletes frequently experience a lack of menstruation, which is found in up to 65% of competitive young runners. But what about psychogenic causes of a disturbed menstrual cycle - after all, Rav taught that it was fear that caused Esther's presumably early onset of menstruation? While not adressing this directly, the Ohio University researchers had this to say about the relationship between psychological stressors and amenorrhea (the lack of menstruation. Remember that word - it will come up again):

Associations between psychological disturbances and amenorrhea or infertility have long been interpreted as a causal relationship, but prospective studies demonstrating that psychogenic factors contribute to reproductive dysfunction in women are almost completely lacking . Early psychoanalytic conclusions that psychological conditions underlie involuntary infertility in women have been criticized recently on several grounds: first, the same psychological conditions have been found in analyses of fertile women; second, other women with very serious psychic problems conceive with ease; and third, couples with an unfulfilled desire for a child do not show psychological disorders any more frequently than do couples without fertility disorders. Even the direction of causality is questionable, because there are grounds for believing that infertility and its medical treatment cause the depression and anxiety observed in some infertility patients. These findings have led to the recommendation that the term ‘psychogenic infertility’ should be withdrawn from use because it is simplistic and anachronistic.

Menstruation and Incarceration

Some of the rabbis viewed Esther's association with King Achashverosh as being coerced: she was brought to his palace against her will, and remained there in a similar state. So with only a bit of a stretch, we might turn to a 2007 paper published in Women's Health Issues which addressed the influence of stress on the menstrual cycle among newly incarcerated women.  Researchers analyzed 446 non-pregnant women who answered a number of detailed questions about their menstrual cycles.  They found that 9% reported amenorrhea (I told you what that meant two paragraphs ago) and that a third reported menstrual irregularities.  

“Incarcerated women have high rates of amenorrhea and menstrual irregularity and the prevalence may be associated with certain stresses. Further research on the causes and consequences of menstrual dysfunction in this underserved population is needed.”

— Allsworth J. et al. The influence of stress on the menstrual cycle among newly incarcerated women. Women's Helath Issues 2007; (17) 202-209.

As might be expected, the stressors of the incarcerated women in this study included drug and alcohol problems and sexual abuse. These are not the same stressors that faced Queen Esther - who was held in such esteem by her kingly husband that he promised her (Esther 5:6) "up to half of the kingdom."  But this work does show how stress may impact the menstrual cycle.  

A Longitudinal Study of Psychological Stress and Menstruation

The final study we will review comes from a cohort of predominantly white, well educated married women of whom 505 were "invited to participate join a special survey focusing on midlife and menopause." Rather than ask about stress and current menstruation, the researchers performed a two-year analysis. Here's what they found:

In analyzing stress levels and cycle characteristics across 2 years...women with marked increases in their level of stress (n =30) are shown to have decreased length (0.2 days/cycle) of menstrual cycle intervals and decreased duration of bleed (0.1 day/cycle) compared with increases in these measures (2.9 days/cycle for cycle interval; 0.3 days/cycle for duration of bleed) among women with no marked change in stress level (n =103); t-tests indicate that these differences are significant (p < .05).

Some of the differences that the researchers found in this group were really small - "0.3 days/cycle for duration of bleeding" but if you are into statistics this difference can be significant (that's what those t-tests are all about). But these statistical associations were not powerful, and the researchers concluded that "the results of this investigation...suggest that, in the long term, stressful life events have little relationship to the length of menstrual cycle intervals and the duration of menstrual bleeding in perimenopausal women."

The three studies we've reviewed (even that last one with its weak findings) all suggest that there is indeed some relationship between psychological stress and menstruation.  Generally, the effect of stress is to increase the length of the menstrual cycle which may result in amenorrhea.  This finding  is also mentioned in Sotah 20b:   "פחדא צמית - chronic fear contracts [the uterus and prevents menstruation]."  But according to Rav, stress caused Esther to menstruate sooner - the opposite of most modern research findings.  Single events should be used with caution when trying to build a general explanatory model, but Rav, and the other rabbis of the Talmud were onto something when they noted that both acute and chronic fear (which is of course just one type of stress) -  can effect a women's menstrual cycle.  

Queen Esther's Fight or Flight Reaction

אסתר 4:4

וַ֠תָּבוֹאינָה נַעֲר֨וֹת אֶסְתֵּ֤ר וְסָרִיסֶ֙יהָ֙ וַיַּגִּ֣ידוּ לָ֔הּ וַתִּתְחַלְחַ֥ל הַמַּלְכָּ֖ה מְאֹ֑ד וַתִּשְׁלַ֨ח בְּגָדִ֜ים לְהַלְבִּ֣ישׁ אֶֽת־מָרְדֳּכַ֗י וּלְהָסִ֥יר שַׂקּ֛וֹ מֵעָלָ֖יו וְלֹ֥א קִבֵּֽל׃

When Esther’s maidens and eunuchs came and informed her, the queen was greatly agitated. She sent clothing for Mordecai to wear, so that he might take off his sackcloth; but he refused.

The meaning of the verse seems straightforward enough. Esther learned that throughout the empire, Jews were fasting, weeping and wailing, (although she did not yet know why). This greatly upset or"agitated" her.  But in the Talmud, Rav (d. ~247) and his student Rabbi Yirmiyah are not content with this straightforward reading. 

מגילה טו, א

ותתחלחל המלכה מאי ותתחלחל אמר רב שפירסה נדה ור' ירמיה אמר שהוצרכה לנקביה 

What is the meaning of the word ותתחלחל? Rav said: It means that she started to menstruate. R. Yirmiyah said: that her bowels were loosened.

Esther before Ahasuerus by Jacopo Tintoretto (1519-94). From The Royal Academy of Arts, London.

FIGHT OR FLIGHT

Any of us who have have experienced moments of intense fear or anxiety can understand R. Yermiah's explanation. In moments of sudden severe stress, the body's sympathetic nervous system ("fight or flight") goes into overdrive and releases epinephrine (AKA adrenaline). This prepares us for battle: our heart rate increases, blood is diverted away from the digestive system and towards the muscles, and our pupils dilate, to allow for better vision. At the same time the  parasympathetic nervous system ("rest and digest") is partially activated, which results in urination and defecation (or at least the urge to do so). 

Brain circuits involved in fear and anxiety. A schematic view of major brain circuits involved in fear and anxiety. External auditory, visual, olfactory, or somatosensory stimuli are relayed by the thalamus to the amygdala and cortex. The basolateral complex (BLA) of the amygdala is the input side of the system, which also receives contextual information from the hippocampal formation (entorhinal cortex, hippocampus, and ventral subiculum). After intra-amygdala processing of the emotional stimuli, the central nucleus of the amygdala (CeA), on the output side, activates the locus ceruleus (LC) and central and peripheral noradrenaline systems (via corticotropin-releasing factor [CRF] neurons), and the hypothalamus (paraventricular nucleus [PVN] and lateral hypothalamus [LH]). The bed nucleus of the stria terminalis (BNST, part of the “extended amygdala”) is also a control center for the neuroendocrine system by integrating information originating from both the hippocampus and the amygdala. In addition, the CeA directly activates various midbrain regions or nuclei responsible for different aspects of the fear/anxiety response: freezing or escape (periaqueductal gray [PAG]), increased respiratory rate (parabrachial nucleus [PBN]), startle (caudal reticulopontine nucleus of the reticular formation [RPC]), and the dorsal motor nucleus of the vagus (DMN) in the medulla, which (together with the lateral hypothalamus) is responsible for the increase in heart rate and blood pressure associated with emotional events. The prefrontal cortex (PFC) processes more elaborate (“cognitive”) information; it modulates the physiological, neuroendocrine, and behavioral responses (via the amygdala), and it is also involved in the extinction of fear- and anxiety-related conditional responses. ACTH, adrenocorticotropic hormone; ANS, autonomous nervous system; BP, blood pressure; GABA, γ-aminobutyric acid; Glu, glutamate; NA, noradrenaline (neurotransmitter) or nucleus ambiguus (structure); NTS, nucleus tractus solitarius. From Steimer, T. The biology of fear- and anxiety-related behaviors. Dialogues in Clinical Neuroscience - Vol 4 . No. 3 . 2002, 231-249.

Queen Esther's Stress

As we saw in Megillah, Rav opined that fear can induce menstrual bleeding. In Sotah, the Talmud further delineates the effect of stress on menstruation.

סוטה כ, ב

למימרא דבעיתותא מרפיא אין דכתיב ותתחלחל המלכה מאד ואמר רב שפירסה נדה והא אנן תנן חרדה מסלקת דמים פחדא צמית ביעתותא מרפיא

Does fright loosen the womb [and causes a woman to menstruate]? Yes, as the verse states (Esther 4:4) "...and the Queen [Esther] became very afraid" about which Rav explained:" she began to menstruate."

But haven't we learned elsewhere in a Mishnah (Niddah 39a) that fear suspends the discharge of menstrual blood? In fact, fear that is not sudden contracts [the womb and prevents bleeding], but sudden fear loosens [the womb and causes early menstrual bleeding].

Here are some of the things that the rabbis of the Talmud believed could induce menstruation:

1. Carrying a heavy load (Tosefta Niddah 9:1)
2. Jumping (ibid)
3. Sudden fright (Niddah 71a, and Niddah 39a)
4. Yearning for intercourse (Niddah 20b)
5. Garlic, onions and peppers (Niddah 63b)

Let's take a look at the medical literature and see whether or not it supports Rav's assertion.

“Data from both animal and human research indicate that psychological stress is associated with altered menstrual function.”

— Barsom S, et al. Association between psychological stress and menstrual cycle characteristics in perimenopausal women. Women’s Health Issues 14 (2004) 235-241

The Effect of Stress on Menstrual Function

In a review from the Department of Biological Sciences at Ohio University, researchers acknowledged that stress is difficult to define. However, one final common pathway of stressors is the low availability of dietary energy. Ovulation - which is the first part of the cascade that leads to menstruation - has been blocked in hamsters "by food restriction, pharmacological blockers of carbohydrate and fat metabolism, insulin administration (which shunts metabolic fuels into storage), and cold exposure (which consumes metabolic fuels in thermogenesis)." Women athletes frequently experience a lack of menstruation, which is found in up to 65% of competitive young runners. But what about psychogenic causes of a disturbed menstrual cycle - after all, Rav taught that it was fear that caused Esther's presumably early onset of menstruation? While not adressing this directly, the Ohio University researchers had this to say about the relationship between psychological stressors and amenorrhea (the lack of menstruation. Remember that word - it will come up again):

Associations between psychological disturbances and amenorrhea or infertility have long been interpreted as a causal relationship, but prospective studies demonstrating that psychogenic factors contribute to reproductive dysfunction in women are almost completely lacking . Early psychoanalytic conclusions that psychological conditions underlie involuntary infertility in women have been criticized recently on several grounds: first, the same psychological conditions have been found in analyses of fertile women; second, other women with very serious psychic problems conceive with ease; and third, couples with an unfulfilled desire for a child do not show psychological disorders any more frequently than do couples without fertility disorders. Even the direction of causality is questionable, because there are grounds for believing that infertility and its medical treatment cause the depression and anxiety observed in some infertility patients. These findings have led to the recommendation that the term ‘psychogenic infertility’ should be withdrawn from use because it is simplistic and anachronistic. 

Menstruation and Incarceration

Some of the rabbis viewed Esther's association with King Achashverosh as being coerced: she was brought to his palace against her will, and remained there in a similar state. So with only a bit of a stretch, we might turn to a 2007 paper published in Women's Health Issues which addressed the influence of stress on the menstrual cycle among newly incarcerated women.  Researchers analyzed 446 non-pregnant women who answered a number of detailed questions about their menstrual cycles.  They found that 9% reported amenorrhea (I told you what that meant two paragraphs ago) and that a third reported menstrual irregularities.  

“Incarcerated women have high rates of amenorrhea and menstrual irregularity and the prevalence may be associated with certain stresses. Further research on the causes and consequences of menstrual dysfunction in this underserved population is needed.”

— Allsworth J. et al. The influence of stress on the menstrual cycle among newly incarcerated women. Women's Helath Issues 2007; (17) 202-209.

As might be expected, the stressors of the incarcerated women in this study included drug and alcohol problems and sexual abuse. These are not the same stressors that faced Queen Esther - who was held in such esteem by her kingly husband that he promised her (Esther 5:6) "up to half of the kingdom."  But this work does show how stress may impact the menstrual cycle.  

A Longitudinal Study of Psychological Stress and Menstruation

The final study we will review comes from a cohort of predominantly white, well educated married women of whom 505 were "invited to participate join a special survey focusing on midlife and menopause." Rather than ask about stress and current menstruation, the researchers performed a two-year analysis. Here's what they found:

In analyzing stress levels and cycle characteristics across 2 years...women with marked increases in their level of stress (n =30) are shown to have decreased length (0.2 days/cycle) of menstrual cycle intervals and decreased duration of bleed (0.1 day/cycle) compared with increases in these measures (2.9 days/cycle for cycle interval; 0.3 days/cycle for duration of bleed) among women with no marked change in stress level (n =103); t-tests indicate that these differences are significant (p < .05). 

Some of the differences that the researchers found in this group were really small - "0.3 days/cycle for duration of bleeding" but if you are into statistics this difference can be significant (that's what those t-tests are all about). But these statistical associations were not powerful, and the researchers concluded that "the results of this investigation...suggest that, in the long term, stressful life events have little relationship to the length of menstrual cycle intervals and the duration of menstrual bleeding in perimenopausal women."

The three studies we've reviewed (even that last one with its weak findings) all suggest that there is indeed some relationship between psychological stress and menstruation.  Generally, the effect of stress is to increase the length of the menstrual cycle which may result in amenorrhea.  This finding  is also mentioned in Sotah 20b:   "פחדא צמית - chronic fear contracts [the uterus and prevents menstruation]."  But according to Rav, stress caused Esther to menstruate sooner - the opposite of most modern research findings.  Single events should be used with caution when trying to build a general explanatory model, but Rav, and the other rabbis of the Talmud were onto something when they noted that both acute and chronic fear (which is of course just one type of stress) -  can effect a women's menstrual cycle.  

[Partial repost from Sotah 20.]