1.
INTRODUCTION:
Premenstrual disorders consist of series of
premenstrual symptoms starting from mild premenstrual syndrome (PMS) to
premenstrual dysphoric disorder (PMDD)1. PMS occurs during the
luteal phase of the menstrual cycle and disappears in the remainder of the
phase of the menstrual cycle, additionally, it disturbs the psychological,
physical, and behavioural symptoms2. The prevalence of PMS in health
colleges in Dammam, Saudi Arabia was 46.7%3. About 24-32% of women
reported moderate to severe PMS and 3-8% have the very severe form of PMS that
is PMDD4. PMS is therefore predominant in women of all ages
affecting considerable morbidity with apparent damage to interpersonal
relationships, work performance, lifestyle, social interactions, emotional
well-being, and overall health-related quality of life (HRQoL)5.
This disorder is particularly common in the younger age groups and therefore
represents a significant public health problem6,7.
Nearly
90% of women have experienced at least one PMS as defined by ICD-10 criteria8.
Epidemiological investigations have assessed around 75% of reproductive age
females experience some symptoms related to the premenstrual phase of the
menstrual cycle9. Also, the PMS has other consequences other than
health care costs such as daily absence from work, school, college which
negatively affects academic performance and employment potentials10.
The
PMS which is listed in the International Statistical Classification of Diseases
and Related Health Problems, 10th revision (ICD-10), and the symptoms include
mild psychological discomfort, weight gain, feelings of bloating and breast
tenderness, various aches and pains, swelling of hands and feet, sleep
disturbances, poor concentration and changes in appetite restricted to the
luteal phase of the menstrual cycle and cease with the commencement of
menstrual flow8 and that significantly interfere with social
activities or relationships with others11. Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV) helps to identify and classify
the severity of emotional, physical, and behavioural symptoms during the
premenstrual phase12. In many countries, research has been done on
PMS and PMDD, but limited studies have been reported in the Saudi population.
Hence,
this study was conducted to find the frequency of PMS in Saudi female
population according to modified Moos MDQ and to assess the severity of
emotional, physical, and behavioural symptoms.
2. MATERIALS AND METHODS:
2.1
Study Design and Setting:
The
pharmacists-led cross-sectional questionnaire-based study was conducted from
January to April 2020 among the female population in Asir region, Saudi Arabia.
Informed consent was obtained from the participants before enrollment in the
study. Institutional ethical approval was obtained before the start of the
study wide number ECM≠2020-2201.
2.2
Participants:
The
online survey questionnaire was first distributed to university students and
was requested to pass it on to their family members and others. The responses
to the study were kept anonymous and confidential. A snowball sampling strategy
was used to recruit the sample from the general community living in Abha, Asir
region, Kingdom of Saudi Arabia. The data collection form was divided into
three sections; section I: consists of age, occupation, marital status, length
of the marriage, and the number of children, section II: consists of menstrual
cycle variables like length of cycle, length of menstrual flow, contraceptive
use, the regularity of the cycle, and section III: consists of experience of symptoms.
2.3
Inclusion criteria:
Female
with 18-60 years of age were included in this study. Participants who did
not give consent to participate were not included.
2.4
Exclusion criteria:
Participants
were excluded if they were pregnant or breastfeeding, had a major psychiatric
or physical disorder, who haven’t had normal ovulatory menstrual cycles, or
previous history of severe menstrual problems. Explanation about the study was
given to the subjects and written consent was obtained from participants before
the start of the study.
2.5
Modified Moos Menstrual Distress Questionnaire (Modified MMDQ):
The
questionnaire used in this study was a prospective version of the modified Moos
MDQ established by Clare and Wiggins and it has good reliability and validity13.
The questionnaire consists of 34 items representing six of Moos’ (1968)14
and eight original sub-scales such as negative effect, cognitive symptoms,
fluid retention, behavior change, somatic symptoms, autonomic reactions. The
omitted sub-scales are namely control and arousal from Moos MDQ. The response
to each of the symptoms is categorized from no experience, to mild, moderate
and severe experience of the symptom (four-point Likert scale response from 0
to 3). The modified MDQ was shorter and easier to complete the
questionnaire, henceforth considered necessary. The modified Moos MDQ is scored
by adding together the scores for each of the symptoms on a scale. Further, the
results were analyzed by comparing the means and standard deviations for the 6 symptom
scales in each phase.
2.6
Data Analysis:
Data
were analyzed using Statistical Package for Social Science (SPSS-Version 25).
The prevalence of each symptom is calculated by computing the ratio of the
women reporting the symptom to the total number of participants. Frequency distribution
as a percentage and descriptive statistics was calculated.
3. RESULTS:
There
was a total of 383 general public responded to our questionnaire survey, where
60 responses were excluded due to incomplete data. Among the respondents,
majority were between the age group of 21 to 25 years (n=167; 51.7%), students
(n=209; 64.7%), single (n=224; 69.3%), has an average length of menstrual cycle
of 29.60±3.53 days, average length of
menstrual flow of 4.52±1.48 days. Among the married women, majority have a marital life of 11 to 15 years (n=25; 7.7%) and have
no children (n=239; 74%). More than 78 percent (n=254) of the respondents have
regular menstrual cycle and not using any contraceptive pills (n=294; 91%). The
details are given in Table 1.
Table
1 Demographic characteristics of study subjects
|
Variables
|
Study Population (n=323)
|
|
Age
|
Frequency
|
Percentage
|
|
18 to 20 years
|
52
|
16.1
|
|
21 to 25 years
|
167
|
51.7
|
|
26 to 30 years
|
27
|
8.4
|
|
31 to 39 years
|
39
|
12.1
|
|
40 to 49 years
|
36
|
11.1
|
|
50 to 60 years
|
2
|
6
|
|
Employment
|
|
|
|
Students
|
209
|
64.7
|
|
Working
|
85
|
26.3
|
|
Unemployed
|
29
|
9
|
|
Length of Marriage
|
|
|
|
Single
|
224
|
69.3
|
|
Less than 5 years
|
18
|
5.6
|
|
5 to 10 years
|
21
|
6.5
|
|
11 to 15 years
|
25
|
7.7
|
|
16 to 20 years
|
7
|
2.2
|
|
21 to 25 years
|
17
|
5.3
|
|
26 to 30 years
|
6
|
1.9
|
|
More than 30 years
|
5
|
1.5
|
|
Children
|
|
|
|
Yes
|
84
|
26
|
|
No
|
239
|
74
|
|
Menstrual cycle Variables
|
|
|
|
Length of cycle
|
29.60±3.53
|
|
|
Length of menstrual flow
|
4.52±1.48
|
|
|
Regularity of the cycle
|
|
|
|
Yes
|
254
|
78.6
|
|
No
|
69
|
21.4
|
|
Contraceptive use
|
|
|
|
Yes
|
29
|
9
|
|
No
|
294
|
91
|
3.1
Experience of premenstrual symptoms according to Modified MMDQ:
A
total of 6 subscales were used namely, the negative effect, cognitive symptoms,
fluid retention, behaviour change, somatic symptoms, and autonomic reactions.
Experience of symptoms in each subscale was categorized as no experience of
symptom, mild experience, moderate experience, and severe experience of symptom
based on scores of MMDQ.
3.2
Experience of negative effect:
Among
the study participants, majority were found to have a moderate level of
depression 29.1% (n=94), severe mood swing 37.5% (n=127), moderate crying
spells 28.5% (n=92), no symptom of loneliness 28.2% (n=91), severe irritability
30% (n=97), mild symptoms of restlessness 29.1% (n=94), mild Anxiety 27.6% (n=89),
and mild tension 30% (97) (Table
2).
3.3
Experience of cognitive symptoms:
Among
the total population, majority had mild symptoms of decreased concentration
36.2% (n=117), reported no experience of accidents 71.2% (n=230), did not
experience decrease in sleep 39.3% (n=127), no confusion 61.6% (n=199), no
decrease in decisions making 40.6% (n=131), no forgetfulness 47.4% (n=153), and
no experience of decrease of motor skills 28.8% (93) (Table 2).
3.4
Experience of fluid retention:
Majority
of the respondents do not have swelling 56.3% (n=182) and did not report weight
gain 42.1% (n=136 had mild breast pain 31.3% (n=101), and No symptoms of skin
disorder 78.6% (n=254) (Table
2).
3.5
Experience of behavior change:
Among
the respondents, majority were found to have no symptoms of decreased
efficiency 36.5% (n=118), mild symptoms of decrease in social activities
29.4% (n=95), severe symptom of staying at home 31.9% (n=103), severe symptoms to
take naps daily 26.6% (n=86) and did not experience any decrease in performance
34.4% (n=111) (Table 2).
3.6
Experience of somatic symptoms is as follows: Majority reported to have severe backache 34.1%
(n=110), no headaches 33.7% (n=109), no fatigue 25.7% (n=83), severe stomach
ache 31.9% (n=103), no symptoms of stiffness 32.8% (n=106), and severe body
aches 40.9% (n=132) (Table 2).
3.7
Experience of autonomic reactions:
Among
the study population, majority were do have any form of autonomic reactions
such as feel sick, flushes, dizziness and sweats which were observed in 106 (32.8%), 111(34.4%), 121(37.5%) and 104 (32.2%)
respondents, respectively. However, 24.8%
(n=80) experienced a severe symptom of feeling sick, 22.3% (n=72) had severe
symptom of flushes; 15.5% (n=50) had severe symptoms of dizziness, and 22.9%
(n=74) had severe symptoms of sweats (Table 2).
4. DISCUSSION:
Women
with PMS are more likely to have impairment in physical and psychosocial health
which lead to substantial lower in quality of life, frequent absents from work,
reduced productivity in workplace, impaired interpersonal and professional
relationship, and more continuous visits to healthcare facilities. Several
studies shown most women experience anyone PMS with varying in severity during
their menstrual period that has close association with their QoL. For this
reason, the prevalence and symptoms of PMS was assessed among the general
public residing in Abha.
In
the present study, most of the women experienced at least one PMS, with
varying degrees of severity from mild to severe. This was similar to a study by
Pathak and colleagues15, were 91% of participants reported at least
one PMS symptoms. More than half of the study participants (51.7%) in the
present study were 21-25 years. In the present study, most of the respondents
are female college students who undergo their undergraduate degree courses and
were below the age of 25.
In
the present study, 73% women experienced mild to severe form of depression. In
contrary to our study, a previous study reported that only 17.9% of the
population had depression16. Severe mood swing and
anger/irritability were found to be the most reported symptoms in the study
group, which has been reported by several other studies17. Also
confirms our findings that the most reported symptoms were “irritability”
without any impairment and symptoms with impairment were tiredness and lack of
energy18. The prevalence of moderate to severe symptoms in negative
effect was mood swings 71.9% followed by irritability 59.7%, anxiety (60%) and
tension (54%). While Mahesh et al. revealed in his study, the most prevalent
symptoms were increased appetite (67.5%), followed by worry and anxiety (60%)
and lethargy (54%)19. Hormonal changes during PMS period play a significant
role in the negative effect of one’s mental status which was commonly seen in
many of the present study participants. Among the fluid retention, breast
retention/pain was the most commonly reported PMS and only least number of
people do not experience it. Similar findings were also observed in many
studies, where breast retention/pain were reported in addition to other PMS20.
Gold
and colleagues21 reported that premenstrual mood symptoms, abdominal
cramps/back pain, appetite cravings/weight gain/bloating, and breast
tenderness/pain appeared to be significant. Obesity increases the production of
estrogen, is associated with body weight and fat percentage22.
Previous studies have reported the effectiveness of exercise towards physical
symptoms, including breast tenderness and fluid retention symptoms23.
The
most common psycho-behavioral PMS symptom reported was decreased efficiency and
decreased performance interest in the usual activities (73.1%)20,
whereas easy fatigability (70.2%) was the most common physical symptom16.
Another study found that PMS symptoms, such as ‘insomnia or hypersomnia’ and
‘physical symptoms such as tender breasts, feeling bloating, headache, joint or
muscle pain, and weight gain’ were risk factors for school absenteeism22.
Prevalence of moderate to severe PMS was more common in the study population
than the none to mild PMS group23. Though, PMS interferes with
day-to-day life significantly. Regarding somatic symptoms, the severe symptom
experienced was generalized body ache 40.9% followed by backache 34.1%, and
stomach pain 31.9%. Different symptoms were reported by several studies that
included abdominal bloating as the most reported symptom (75.3%)24.
Most
of the participants in the present study experienced anyone type of PMS and
that had impact on their quality of life. Many other studies on PMS also
reported similar findings as that of our study where more than half the college
students and women experienced mild to severe form of PMS at least in anyone of
their menstrual period especially in psychological and social components
(p<0.5). Students with PMS have less academic performance, low education
levels, feel more stress at school and work, increase of anxiety and dyslexia,
whereas in working women, recurrent stress and anxiety lowers their work
performance, frequent absenteeism, social isolation and in extreme cases quit
job25.
Sleep
and rest are the most reported coping strategies among women with PMS, reported
in a study by Kelbessa B, et al26. Distancing such as moving away
from the stressor mentally and emotionally, staying detached and accepting
situation are the most frequently used coping strategy by women to lower PMS
severity27.
The
study findings recommend conducting similar studies in future in larger population
for obtaining accurate rate of prevalence and incidence among the general
population of Abha, Kingdom of Saudi Arabia. Routine use of daily diaries to
record the PMS symptoms will help diagnosing the severity of PMS and PMDD
accurately. In addition to that, educational intervention programme of
menstrual health and problems associated with it must be conducted prior to
start of the future study to create awareness among the women and reduce the
impact of cultural taboos related to menstruation. Due to lack of such
programme, the women find very difficult to volunteering to share information
related to menstruation and menstrual health.
The
pharmacy settings especially community pharmacies in Kingdom of Saudi Arabia
are the major employment sector for pharmacists, employing 57% of the total
workforce of 25,11928. Community pharmacists can play a vital role
in premenstrual syndrome management along with screening the disease, patient
education and counselling, health assessments, monitoring and chronic disease
management29.
5.
CONCLUSION:
A
considerable high prevalence of PMS was found among the study population.
Community pharmacist involvement is highly required to conduct health
education, awareness programs, and counselling services for females to educate
them regarding symptoms of PMS and prevention through lifestyle modification.
Diagnostic and treatment services could be provided for the individuals with
assistance from gynaecology and psychiatry clinics to inform them about the
risk of depression and anxiety and help them to overcome PMS. There is a vital
need to actively assess the premenstrual symptoms in young women for
comprehensive treatment and good outcome.
ACKNOWLEDGEMENTS:
I would like to thank the Deanship of
Scientific Research at King Khalid University for providing adequate support
through the study. I would like to thank Dr. Dalia, Dr. Palanisamy, Dr. Mona
and Dr. Rajalakshimi for their constant support throughout the study.
CONFLICT OF INTEREST:
None.
FUNDING RESOURCES:
This study was supported by the Deanship
of Scientific Research, at King Khalid University, Abha, Kingdom
of Saudi Arabia with Project
Number GRP/339/42.
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