American Based Research Journal Vol-2-Issue-2 Feb-2013 ISSN (2304-7151)http://www.abrj.org Page 19Prevalence of Premenstru...
American Based Research Journal Vol-2-Issue-2 Feb-2013 ISSN (2304-7151)http://www.abrj.org Page 20physical, mental and beh...
American Based Research Journal Vol-2-Issue-2 Feb-2013 ISSN (2304-7151)http://www.abrj.org Page 21More severe symptoms wer...
American Based Research Journal Vol-2-Issue-2 Feb-2013 ISSN (2304-7151)http://www.abrj.org Page 22concentration and social...
American Based Research Journal Vol-2-Issue-2 Feb-2013 ISSN (2304-7151)http://www.abrj.org Page 23other physical or psycho...
American Based Research Journal Vol-2-Issue-2 Feb-2013 ISSN (2304-7151)http://www.abrj.org Page 245. American College of O...
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Prevalence of premenstrual dysphoric disorder in female students of medical sciences

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  • 1. American Based Research Journal Vol-2-Issue-2 Feb-2013 ISSN (2304-7151)http://www.abrj.org Page 19Prevalence of Premenstrual dysphoric disorder in female students of medical sciencesAuthors:1)Mitra Hakim Shooshtari. MD. Psychiatrist. Associ prof of Tehran university of medical sciences ,Tehran , Iran 2)Sarah Hosseinpoor. Medical student. Isfahan University of medical sciences, Isfahan, Iran3)Fatemeh Tirandaz. MD. Tehran university of medical sciences, Tehran, Iran 4)Seyyed mohammadmahdy mirhosseini . Medical student. Isfahan University of medical sciences, Isfahan, Iran 5)Reza Bidaki .Psychiatrist. Assis prof of Rafsanjan university of medical sciences, Rafsanjan , IranCorresponding author: Reza Bidaki-Address: Iran- Rafsanjan- Moradi hospital- Psychiatry departmentAbstract: Introduction: Pre-menstrual syndrome (PMS) is a prevalent collection of emotional and physical symptomsrelated to a woman’s menstrual cycle which represents itself by adverse behavioral and mood changes as well as physicalsymptoms including bloating or breast tenderness as the most dominant ones, appearing within the luteal anddisappearing within follicular phase of a woman’s cycle.Considering the high prevalence of the issue and its’ disturbingeffect on women’s social life as well as the absence of any definite diagnostic criteria, this study is designed to provide abetter overview of patho-physiology, etiology and management of the disorder.Material and methods: A group of students from Iran University of medical sciences were chosen through systemicrandom sampling as our sample group and three questionnaires including one for patients demographic information,GHQ-28 and PMTS were translated, approved for validity and delivered to our patients. The prevalence of the issueamong our sample group as well as PMS predisposing factors were analyzed through Qui- Square and ANOVA andregistered.Results: Alpha Cronbachs coefficient was 0.4 which is above 0.7, as the minimum standard. 24 of our samplefailed to give reliable answers, so were removed from our sample size. Our analysis results on 249 observedstudents suggests a prevalence of 62% for PMS, 40.7% (92 persons) with mild PMS, 19% (43 persons) withmoderate and 2.2% (5 persons) with sever PMS. The most common symptom was irritability which was detectedin 62% of our sample and physical disturbance was reported in fourth step. There was also a noticeableconnection between a positive past history of a psychological disorder and existence of PMS. (P-value> 0.05)Conclusion: Considering the high prevalence of the syndrome and its’ adverse impacts on women’s social life,a better insight to disease’s patho-physiology, etiology, diagnostic criteria and management seems to benecessary.Key words : Premenstrual dysphoric disorder , Students , TehranConflict of interest : NoneIntroductionPMS is a complex health concern of the femalewhereas it is a disorder which remains poorlyunderstood amongst the general lay and indeedmedical population.(1)80% of women suffer from a bunch of symptomsright before their periods (2). Even about 3% to 8%of women may suffer from a more sever type ofPMS referred to as pre-menstrual dysphoricdisorder (PMDD) (3). It involves a wide range of
  • 2. American Based Research Journal Vol-2-Issue-2 Feb-2013 ISSN (2304-7151)http://www.abrj.org Page 20physical, mental and behavioral symptoms tied to awoman’s menstrual cycle. Symptoms occur twoweeks before a woman’s period and typicallybecome more intense two to three days prior to startof menstruation and usually resolves after the firstor second day of the cycle. To confirm a woman’spresentation of PMS, five physical symptoms alongwith adverse mood changes should continuouslyexist for at least three months and other possibleclinical status with same presentations includingthyroid malfunction, migraine, chronic fatiguesyndrome (CSF), LBS, epilepsy, anemia,endometriosis, drug abuse and other psychologicaldisorders have to be ruled out (4).There are no specific physical findings or laboratorytests for diagnosis of PMS. So it is a clinicallydiagnosed disorder. There are many different reportfor definition of it such as the American College ofObstetricians and Gynecologists (ACOG), theAmerican Psychiatric Association, and the NationalInstitutes of Mental Health.(5-7) The World HealthOrganization’s International Classification ofDiseases uses (ICD) code 625.4 for PremenstrualTension Syndrome and lists PMS and PMDD underthis heading.(7)In a multinational study done in Australia, Brazil,Germany and Spain on both PMS and PMDD, amoderate to severe adverse effect on social andoccupational life of women with PMS or PMDDhas been reported (8).Hurtle et al have detected PMS symptoms in 14% to45% of 670 women who have been referred to aclinic for common menstruation-relating issues (9).A study in Nigeria on PMDD prevalence was doneon 410 under-graduated women with a BMI of 21.6,an average age of 21.3 years, an average period timeof 4.35 days and a an average cycle of 27.2 daysand a positive past history of one psychologicaldisorder. The results suggest 90% have regularmenses, 1.7% with present intake of OCP and 3.2%with a past history of OCP intake. 7% with a historyof pregnancy, 18% with alcoholism and 2% with ahistory of smoking. 63% with no dysmenorrhea,56% with on and off and 27.8% with continuousdysmenorrhea. 28% with mild PMS, 40.7% withmoderate, 12.2% with sever PMS and 6.1% withfull criteria of PMDD (10).In another study done in Japan on 1187 womenaged from 20 to 49 who had filled the questionnaireof PSQ, 68.5% were reported with anxiety andtension, 70.6% with anger and irritability and 8.2%with physical symptoms. More than half of patientsreported fatigue and energy shortage for commondaily activities. These symptoms have almost ruinedoccupational practice of 49.9% women, socialactivities of 23.6% women and family relationshipsof other 22.9% women. Sever PMS and PMDDprevalence within this study was reportednoticeably less than all western studies. This couldbe due to the fact that because social well- being ismuch more important to Japanese women than theirown feelings of health, they mostly refuse toconfess problems in order to keep up with theireveryday ongoing social activities (11).In another study done by Sibil et al, 57% of womenrepresented mild symptoms of anger, irritability,fatigue, energy loss and behavioral changes, whichcovered 2 out of 41 PMDD diagnostic criteria. 75%also complained of physical symptoms. The averageperiod of symptoms resistance was reported to bethree days and 90% of women reported this to beless than five days. 6.4% of women had at least onesever symptom and 14.6% with moderate to severesymptoms. The prevalence of PMS symptomswithin this study was reported highly tied topatients’ living place as well as their marital status.There was also a connection reported betweensymptoms severity and smoking, drug abuse andover intake of NSAIDS or Benzodiazepines (12).
  • 3. American Based Research Journal Vol-2-Issue-2 Feb-2013 ISSN (2304-7151)http://www.abrj.org Page 21More severe symptoms were more reported inwomen with more stressful social life and lessphysical activity. OCP intake was also reported as afactor to decrease PMS symptoms severity (13).Material and methods :This study was done on a group of female medicalstudents of Iran University of medical sciences. Thesample size was established through randomstratified sampling method. The students weredivided to three groups of first and second yearstudents, students of pre-internship and studentswithin their internship courses. Three questionnairesincluding patients’ demographic information,PMTS-1 and GHQ-28 were translated to Persian,examined for validity and reliability by threepsychologists, two gynecologist and five generalphysicians, confirmed and delivered to 30 studentsduring two times ( 10% of our total sample size)with a one week interval. The results were thenregistered and analyzed. Our questionnairesspecifically include:1) GHQ-28:This includes 28 questions. Each question has fouralternatives to answer including no, a little, muchand very much. Two methods of scoring is applied,including the traditional and Lykert method toevaluate the questionnaire. In the first method,alternatives of each question are scored like 0-0-1-1and the maximum score is 28. In the secondmethod, the options are scored like 0-1-2-3- and themaximum score is 84. Some questions are scored inreverse.2) PMTS-1: (premature tension syndromescale)This contains ten questions with a maximum scoreof 36. Eight questions are scored from 0 to 4 andtwo questions from 0 to 2. Fill in time for thisquestionnaire is ten minutes.3) Demographic questionnaire:This contains variables like age, sex, weight, height,initiation of puberty signs, start of menstruation,days of menstruation, marital status, educationalstatus, living place, smoking or alcoholism, anyhistory of underlying physical or psychologicaldisorders, life important events within the last yearprior to clinical PMS diagnosis and a history ofPMS in first class family, specifically mother andsisters.Results:To examine PMTS questionnaire, alpha cronbachscoefficient was calculated and reported to be 0.87which is above 0.7 as the minimum standardconsidered for the ratio. This ratio did not increaseby exclusion of no specific question.273 female students of Iran University of medicalsciences entered our study and 24 were excludeddue to their failure to provide us with accurate data,which makes our sample size consisted of 249students with an age average of 22.1 years.100 student (43.5%) were in their first and secondyears of study, 77 (33.5%) students of pre-internship courses and 53 (23%) within theirinternship years. 48.8% dormitory students,50.4%living at home with family and 4.7% withroommates. 205 students (89.9%) were single and23 (10.1%) were married.PMS prevalence according to PMTS questionnairewas 61.9%, although 94% of students had at leastone symptom.Students with confirmed diagnosis of PMS weredivided to three groups. 92 students (40.7%) in mildgroup, 43 (19%) in moderate and 5 students (2.2%)in severe group. Over 75% of our sample sizepresented psychological symptoms, irritability,anger, hopelessness, tension and restlessness in81.3%, forgetfulness, dizziness, difficulty of
  • 4. American Based Research Journal Vol-2-Issue-2 Feb-2013 ISSN (2304-7151)http://www.abrj.org Page 22concentration and social issues in 66.1% and finallyphysical problems in 66.4% of patients.89 students (41.8%) believed to be overwhelmedwith PMS and a great connection existed betweentheir own perception of disease and questions dataanalysis. (P value< 0.05)1.3% of our sample group was misdiagnosed withasthma, 7% with migraine and 0.9% physicaldisorders tied to menstruation.60.3% had a GHQ result more than 21 and therewas a clear relationship between GHQ score andprevalence of PMS. (P value< 0.05)There was also a relationship between a positivehistory of psychological disorders and prevalence ofPMS. (P value< 0.05) 9.6% had a history ofdepression, 4.8% with confirmed diagnosis ofobsessive- compulsive disorder and 9.1% withanxiety disorder.34.7% of patients with confirmed diagnosis of PMShad a history of PMS existence in their first classfamily, specifically mother or sisters.0.9% had a past or present history of smoking.5.4% had gone through a medical visit for theirsymptoms, 12% with intake of not prescribedmedicines to reduce their symptoms severity and7.2% with usage of herbal medication. Although55.5% of our patients didn’t have a regular programof exercise, still no definite relationship was foundbetween exercise and less intense symptoms orlower prevalence of PMS within our study.Discussion:The prevalence of PMS within this study wasreported to be 62% which is concurrent to most ofother foreign studies. In Kiani’s study was done inIran within year 2009-2010, the prevalence of PMSin Iranian working women was reported to be66.7%, in Alavi study on students of Bandar Abbasto be 54.9% and in Zahedan to be 16%. (14) PMSprevalence was reported to be 64.6% in Japanese,99% in women of Switzerland, 73.7% in Spanishwomen, and 21.1% in women of china.(15-18)Cultural differences, measuring method variationsand the level of patients’ orientation can explain thedifference.94% of patients were detected with at least onePMS symptom which is concurrent to results ofother foreign studies which have reported this rateto be 80% to 90%.Although physical burden is reported as the mostcommonly detected symptom of PMS, our studyresults suggest irritability and anger as the mostcommon symptoms detected in patients, which issimilar to results of many foreign studies. Physicalburden within our study is reported to place infourth step, after psychological issues includingmood and behavioral changes, tension, anxiety andconcentration difficulties. Higher morbidity ofpsychological symptoms, nearly 60%, is clearly theresult of its’ greater prevalence.Five students (2%) were detected with sever PMSsymptoms which is referred to as PMDD. This ratewas similar to Shahpoorian’s study, but almost 8%less than DSM-IV estimation for PMDDprevalence. Strict DSM-IV diagnostic criteria forPMDD may explain the gap. (19)According to scores of GHQ questionnaire, 3.6% ofstudents had a score more than 21, which makesthem susceptible for psychological issues. Not onlypsychological issues were reported to be tied toGHQ score, there was also a great connectionbetween GHQ score and PMS prevalence, detectedin our study. (P value=0.56) however thisconnection was failed to being reported in Nigerianstudies.Although 65% of women with depression may endup with diagnosis of PMS, still most of them areactually experiencing a relapse or flair up of theirformer underlying psychological disorder. Since themanagement of PMS is pretty much different from
  • 5. American Based Research Journal Vol-2-Issue-2 Feb-2013 ISSN (2304-7151)http://www.abrj.org Page 23other physical or psychological disorders with sameclinical presentation to PMS, differential diagnosisof PMS are necessary to be ruled out.There was also a great connection between apositive family history of PMS and its’ existence inan individual which could be due to both geneticresemblance and similar life style. (P value=0.37)Persons’ self-diagnosis for PMS was also highlyattached with true medically diagnosis of PMS inmost patients, so self-perception of patients, markedin their questionnaires, could be applied as a PMSscreening method.5.4% of students had visited a physician or gonethrough treatment for their symptoms and 12% withusage of a non-prescribed medicine, so femaleorientation to subject seems necessary.No specific relationship was found between BMI orregular exercise schedule and PMS prevalence,which were opposite to Kiani’s study in year 2009-2010, who has reported PMS prevalence highlyassociated with both BMI and regular exercise (14).No specific relationship was found between maritalstatus and prevalence or symptoms severity of PMSwithin our study, still all patients with severe PMSor PMDD were single. This might be amisinterpretation of results due to scant number ofmarrieds in our sample size. (Only 21 out of 249patients were married)Although no relationship was found betweenpatients’ important life events within the year priorto PMS clinical diagnosis, still because the questionis both challenging to ask and blurred to interpretand due to the fact that only 129 out of 249 patientshad given answer to the question within theirquestionnaires, a better designed question in otherstudies seems necessary to clear up the issue.Only 9% of our patients were smokers, so therelationship between smoking and PMS prevalenceor symptoms severity could not be evaluated.Cronbachs alpha coefficient was reported to be0.83% that is above 0.7 as the minimum normal.Conclusion:This was a cross sectional study, so incapable ofPMS etiology negotiation. It was done on a samplesize of one faculty, so there are limitations fordistribution of its results to general population.There is also no evaluation of PMDD within thisstudy. Rates and ratios are calculated due to patientsfilled out questionnaires, so might be along withresult faults. Due all these limitations and barriersmentioned for this recent study, more accuratestudies on general population of Iranian women isnecessary to better determine PMS prevalence,diagnostic criteria and management of sufferingpatients.References1.Baker LJ, OBrien PM.Premenstrual syndrome (PMS): a perimenopausal perspective. Maturitas. 2012Jun;72(2):121-5.2.Paula K. Braverman, Premenstrual Syndrome andPremenstrual Dysphoric Disorder. J Pediatr AdolescGynecol (2007) 20:3e123. Dennerstein L, Lehert P, Bäckström TC,Heinemann K. Premenstrual symptoms—severity,duration and typology: an internationalcrosssectional study. MenopauseInt. 2009;15(3):120–126.4. Zukov I, Ptácek R, Raboch J, DomluvilováD, Kuzelová H, Fischer S, Kozelek P.Premensturaldysphoric disorder, Review of actual findings aboutMental cycle and possibilities of their thrapy.Prague Med Rep. 2010;111(1):12-24.
  • 6. American Based Research Journal Vol-2-Issue-2 Feb-2013 ISSN (2304-7151)http://www.abrj.org Page 245. American College of Obstetrics and Gynecology:ACOG practice bulletin: premenstrual syndrome.Washington, DC: ACOG, April 2000: 15.6. American Psychiatric Association: Diagnosticand Statistical Manual of Mental Disorders, 4th ed,DSM-IV-Text Revision. DSM-IV-TR, Washington,DC: American Psychiatric Association, 20007. Biggs WS, Demuth RH. Premenstrual syndromeand premenstrual dysphoric disorder. Am FamPhysician. 2011 Oct 15;84(8):918-24.8.Diana Taylor .Form its All in your head to takingback the month: Premenstrual syndrome researchand the contribution of the society for menstrualcycle research sex roles. 2006;54:377-3919. S gehlert, I H, change.S.A.Hartlage. Theprevalence of premenstrual dysphoric disorder in arandomly selected group of urban and rural women.Psychol Med.2009 january;39(1):129_136.10.Premenstural dysphoric disorder amongstNigerian university students:prevalence comorbidcondition and correlates .Arch women Menthealth(2008)11:13_1811.T.Takeda,K,Tasaka,M.sakata,andY,murata.prevallence of premenstrual syndrome and premenstrualdysphoric disorder in Japanease woman Archwoman Mental Halth. 2009;9:209_21212.prevalence and predictors of premenstrualsyndrome and premenstrual dysphoric disorder in apopulation based sample.2010,Arch women MentHealth,13:485_49413.Chapter 1 54. Mousavi NM ,bakhshani MN ,khodabande GJ Pak Med Assoc.2009.Apr;59(4):205-8 Prevalence and severity ofpremenstrual symptoms among Iranian femaleuniversity students.14.kiani.A, Heydari. M, Mohammadi Tabar.S.determining the prevalence, signs and symptomsand predisposing factor of pre-menstruationsyndrome15. Takeda T, Koga S, Yaegashi N. Prevalenceof premenstrual syndrome and premenstrual dysphoric disorder in Japanese high school students. ArchWomens Ment Health. 2010 Dec;13(6):535-716. Tschudin S, Bertea PC, Zemp E. Prevalence andpredictorsof premenstrual syndrome and premenstrual dysphoric disorder in a population-based sample. ArchWomens Ment Health. 2010 Dec;13(6):485-94.17. Dueñas JL, Lete I, Bermejo R, Arbat A, Pérez-Campos E, Martínez-Salmeán J, Serrano I, DovalJL, Coll C. Prevalenceof premenstrual syndrome and premenstrual dysphoric disorder in a representative cohort of Spanishwomen of fertile age. Eur J Obstet Gynecol ReprodBiol. 2011 May;156(1):72-718. Qiao M, Zhang H, Liu H, Luo S, WangT, Zhang J, Ji L. Prevalenceof premenstrual syndrome and premenstrual dysphoric disorder in a population-based sample in China.Eur J Obstet Gynecol Reprod Biol. 2012May;162(1):83-6.19.shahpoorian.F, mahmoodi.Z, bastani.F, Parsaei,Hosseini.F. Pre mensturation syndrome and its’most common symptoms in nursery students, winter2007

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