Accepted Manuscript Premenstrual syndrome and premenstrual dysphoric disorder in Japanese collegiate athletes Takashi Takeda, MD, PhD Yoko Imoto, Hiroyo Nagasawa, Miyuki Muroya, Masami Shiina, MD, PhD PII:
S1083-3188(14)00260-5
DOI:
10.1016/j.jpag.2014.07.006
Reference:
PEDADO 1742
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 19 March 2014 Revised Date:
3 June 2014
Accepted Date: 9 July 2014
Please cite this article as: Takeda T, Imoto Y, Nagasawa H, Muroya M, Shiina M, Premenstrual syndrome and premenstrual dysphoric disorder in Japanese collegiate athletes, Journal of Pediatric and Adolescent Gynecology (2014), doi: 10.1016/j.jpag.2014.07.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
Premenstrual syndrome and premenstrual dysphoric disorder in Japanese
2
collegiate athletes
RI PT
3
Takashi Takeda, MD, PhDa*, Yoko Imotoa, Hiroyo Nagasawaa, Miyuki Muroyaa,
5
Masami Shiina, MD, PhDa,b
SC
4
6 a
8
b
9
Kinki University School of Medicine, 377-2, Ohno-Higashi, Osaka-Sayama, Osaka
Division of Women’s Health, Research Institute of Traditional Asian Medicine Department of Obstetrics and Gynecology
589-8511, Japan
TE D
10
M AN U
7
11
*Corresponding author: Division of Women’s Health, Research Institute of Traditional
13
Asian Medicine, Kinki University School of Medicine, 377-2, Ohno-Higashi,
14
Osaka-Sayama, Osaka 589-8511, Japan
15
Tel.: 81-72-366-0221 (Ext. 3393); Fax: 81-72-366-6661
16
E-mail: [email protected]
AC C
EP
12
17
1
ACCEPTED MANUSCRIPT
ABSTRACT
2
Study objective: To determine the prevalence and impact of premenstrual syndrome
3
(PMS) and premenstrual dysphoric disorder (PMDD) in Japanese collegiate athletes,
4
with a focus on their disruption of athletic performance.
5
Design: Cross-sectional study.
6
Setting: A university in Osaka, the largest city in western Japan.
7
Participants: 232 female collegiate athletes.
8
Main Outcome Measures: Premenstrual symptoms and social activities.
9
Results: The prevalence of each premenstrual symptom was high. The prevalence of
10
moderate to severe PMS and PMDD was 8.6% and 2.9%, respectively, the same as in
11
general high school students. The athletic performance of 44.3% of athletes was found
12
to suffer in a game or in practice. ‘Elite athletes’ (OR 8.63, 95% CI: 1.22-120.0),
13
‘Difficulty concentrating’ (OR 3.15, 95% CI: 1.05-10.6), and ‘Fatigue or lack of energy’
14
(OR 5.92, 95% CI: 1.32-34.5) increased the risk of poor athletic performance.
15
Conclusions: This study showed that premenstrual symptoms affect not only the daily
16
activities but also the athletic performance of collegiate athletes.
17
Running title: PMS/PMDD in athletes
AC C
EP
TE D
M AN U
SC
RI PT
1
18
19
Key words: PMS, PMDD, Collegiate athlete, Athletic performance 2
ACCEPTED MANUSCRIPT
1
Introduction Premenstrual syndrome (PMS) is a constellation of mood, behavioral, and physical
3
symptoms that are limited to the late luteal phase of the menstrual cycle.1
4
Epidemiologic surveys have shown that the frequency of premenstrual symptoms is
5
high (80-90%)2 and that in about 5% of women, the symptoms are so severe that they
6
interfere with personal or social relationships or work, and in many cases they require
7
pharmacological treatment.3 Such severe PMS is classified as premenstrual dysphoric
8
disorder (PMDD).4 Previously we have reported that PMS and PMDD are common
9
menstrual problems not only in adults but also in adolescents and should be treated as
SC
M AN U
carefully as dysmenorrhea.5
TE D
10
RI PT
2
The causes of PMS and PMDD have been suggested to include hormonal changes,
12
neurotransmitters, diet, stress, and lifestyle.6 Many studies have suggested that exercise
13
could be a treatment for PMS,7,8 but these findings are limited to the association
14
between PMS and lack of exercise. No study to date has looked at this association
15
scientifically, but that it has been suggested as a causal association.8
AC C
EP
11
16
In the past 40 years, female athletic participation has increased, particularly at high
17
school and collegiate levels.9 In spite of the numerous benefits of exercise, health
18
problems unique to female athletes in intensive training, known as the female athlete
3
ACCEPTED MANUSCRIPT
triad, have been identified.10 The triad includes a spectrum of health problems related to
2
energy availability, menstrual function, and bone mineral density, as defined by the
3
American College of Sports Medicine (ACSM).11 The female athlete triad was first
4
identified in 1992 by ACSM, and a significant amount of research about the triad at
5
high school and collegiate levels was performed.9 Regarding menstrual dysfunction,
6
most of the studies were concerned with menstrual irregularity, including primary
7
amenorrhea, secondary amenorrhea, and were lacking in data about PMS and PMDD.
M AN U
SC
RI PT
1
Many reports have documented that the premenstrual phase is associated with
9
decreased performance,12,13 but there are few reports about PMS/PMDD in athletes. A
10
previous report demonstrated that premenstrual symptoms caused marked negative
11
mood swings in menstruating female athletes, but the data were limited to the moods
12
evaluated in the profile of mood states (POMS) questionnaire.14 The aim of this study
13
was to investigate the prevalence and impact of PMS and PMDD in Japanese collegiate
14
athletes, with a focus on athletic performance.
EP
AC C
15
TE D
8
4
ACCEPTED MANUSCRIPT
1
Methods The study was carried out in accordance with the principles outlined in the
3
Declaration of Helsinki. Our institutional review board at Kinki University approved the
4
study.
RI PT
2
5
Study population
SC
6
A school-based cross-sectional survey was conducted in November 2012 using a
8
sample of 232 Japanese female collegiate athletes at Kinki University in Osaka, the
9
largest city in west Japan. All subjects belonged to authorized university clubs, which
10
all have a high ranking in Japanese university sport. All subjects were undergoing
11
intensive training. We recruited female collegiate athletes who had regular menstrual
12
cycles (22-35 days) and were able to provide informed consent. No one in these subjects
13
had a prior diagnosis of psychological disorder.
15
TE D
EP
AC C
14
M AN U
7
Questionnaire
16
We used the Premenstrual Symptoms Questionnaire (PSQ), which was developed in
17
our previous study,15 to screen for premenstrual symptoms. The PSQ translates DSM-IV
18
criteria into a rating scale with degrees of severity described in Japanese and is
19
essentially identical to the Premenstrual Symptoms Screening Tool.16 The PSQ asked, 5
ACCEPTED MANUSCRIPT
“Within the last three months have you experienced the following premenstrual
2
symptoms starting during the week before menses and remitting a few days after the
3
onset of menses?” The premenstrual symptoms listed on the PSQ are ‘Depressed mood’,
4
‘Anxiety or tension’, ‘Tearful’, ‘Anger or irritability’, ‘Decreased interest in work,
5
home or social activities’, ‘Difficulty concentrating’, ‘Fatigue or lack of energy’,
6
‘Overeating or food cravings’, ‘Insomnia or hypersomnia’, ‘Feeling overwhelmed’ and
7
‘Physical symptoms such as tender breasts, feeling of bloating, headache, joint or
8
muscle pain, weight gain’. The PSQ also asked whether such premenstrual symptoms
9
interfered with ‘Work efficiency or productivity, home responsibilities’, ‘Social life
10
activities’ or ‘Relationships with coworkers or family’. The PSQ asked the athletes to
11
rate the severity of premenstrual symptoms as ‘not at all’, ‘mild’, ‘moderate’ or ‘severe’.
12
We divided athletes with premenstrual symptoms into three groups: ‘PMDD’, ‘moderate
13
to severe PMS’, and ‘no/mild PMS’ according to the criteria reported previously.15,16 In
14
addition to the PSQ, we asked whether such premenstrual symptoms interfered with
15
‘Athletic performance in training or competition’. This additional question also asked
16
the athletes to rate the severity as ‘not at all’, ‘mild’, ‘moderate’ or ‘severe’. We further
17
collected additional information about their age, type of sports, participation in national
18
or international competition, regular player or not, coffee-drinking habit, craving for
AC C
EP
TE D
M AN U
SC
RI PT
1
6
ACCEPTED MANUSCRIPT
salty food, craving for sweet food and severity of dysmenorrhea. Athletes were grouped
2
into 6 groups: ball games, track, swimming, fighting sports, archery and other sports.
3
The other sports group consisted of yacht racing, triathlon, and equestrian sports. We
4
asked the athletes about their severity of pain during menses with the categories of ‘not
5
at all’, ‘mild’, ‘moderate’, and ‘severe’.
SC
RI PT
1
M AN U
6
7
Statistical Analyses
8
Statistical analysis was performed using JMP 10.0.2 (SAS, Cary, NC, USA). Data are
9
expressed as the means ± S.D. Statistical significance was set at p
S1083-3188(14)00260-5
DOI:
10.1016/j.jpag.2014.07.006
Reference:
PEDADO 1742
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 19 March 2014 Revised Date:
3 June 2014
Accepted Date: 9 July 2014
Please cite this article as: Takeda T, Imoto Y, Nagasawa H, Muroya M, Shiina M, Premenstrual syndrome and premenstrual dysphoric disorder in Japanese collegiate athletes, Journal of Pediatric and Adolescent Gynecology (2014), doi: 10.1016/j.jpag.2014.07.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
Premenstrual syndrome and premenstrual dysphoric disorder in Japanese
2
collegiate athletes
RI PT
3
Takashi Takeda, MD, PhDa*, Yoko Imotoa, Hiroyo Nagasawaa, Miyuki Muroyaa,
5
Masami Shiina, MD, PhDa,b
SC
4
6 a
8
b
9
Kinki University School of Medicine, 377-2, Ohno-Higashi, Osaka-Sayama, Osaka
Division of Women’s Health, Research Institute of Traditional Asian Medicine Department of Obstetrics and Gynecology
589-8511, Japan
TE D
10
M AN U
7
11
*Corresponding author: Division of Women’s Health, Research Institute of Traditional
13
Asian Medicine, Kinki University School of Medicine, 377-2, Ohno-Higashi,
14
Osaka-Sayama, Osaka 589-8511, Japan
15
Tel.: 81-72-366-0221 (Ext. 3393); Fax: 81-72-366-6661
16
E-mail: [email protected]
AC C
EP
12
17
1
ACCEPTED MANUSCRIPT
ABSTRACT
2
Study objective: To determine the prevalence and impact of premenstrual syndrome
3
(PMS) and premenstrual dysphoric disorder (PMDD) in Japanese collegiate athletes,
4
with a focus on their disruption of athletic performance.
5
Design: Cross-sectional study.
6
Setting: A university in Osaka, the largest city in western Japan.
7
Participants: 232 female collegiate athletes.
8
Main Outcome Measures: Premenstrual symptoms and social activities.
9
Results: The prevalence of each premenstrual symptom was high. The prevalence of
10
moderate to severe PMS and PMDD was 8.6% and 2.9%, respectively, the same as in
11
general high school students. The athletic performance of 44.3% of athletes was found
12
to suffer in a game or in practice. ‘Elite athletes’ (OR 8.63, 95% CI: 1.22-120.0),
13
‘Difficulty concentrating’ (OR 3.15, 95% CI: 1.05-10.6), and ‘Fatigue or lack of energy’
14
(OR 5.92, 95% CI: 1.32-34.5) increased the risk of poor athletic performance.
15
Conclusions: This study showed that premenstrual symptoms affect not only the daily
16
activities but also the athletic performance of collegiate athletes.
17
Running title: PMS/PMDD in athletes
AC C
EP
TE D
M AN U
SC
RI PT
1
18
19
Key words: PMS, PMDD, Collegiate athlete, Athletic performance 2
ACCEPTED MANUSCRIPT
1
Introduction Premenstrual syndrome (PMS) is a constellation of mood, behavioral, and physical
3
symptoms that are limited to the late luteal phase of the menstrual cycle.1
4
Epidemiologic surveys have shown that the frequency of premenstrual symptoms is
5
high (80-90%)2 and that in about 5% of women, the symptoms are so severe that they
6
interfere with personal or social relationships or work, and in many cases they require
7
pharmacological treatment.3 Such severe PMS is classified as premenstrual dysphoric
8
disorder (PMDD).4 Previously we have reported that PMS and PMDD are common
9
menstrual problems not only in adults but also in adolescents and should be treated as
SC
M AN U
carefully as dysmenorrhea.5
TE D
10
RI PT
2
The causes of PMS and PMDD have been suggested to include hormonal changes,
12
neurotransmitters, diet, stress, and lifestyle.6 Many studies have suggested that exercise
13
could be a treatment for PMS,7,8 but these findings are limited to the association
14
between PMS and lack of exercise. No study to date has looked at this association
15
scientifically, but that it has been suggested as a causal association.8
AC C
EP
11
16
In the past 40 years, female athletic participation has increased, particularly at high
17
school and collegiate levels.9 In spite of the numerous benefits of exercise, health
18
problems unique to female athletes in intensive training, known as the female athlete
3
ACCEPTED MANUSCRIPT
triad, have been identified.10 The triad includes a spectrum of health problems related to
2
energy availability, menstrual function, and bone mineral density, as defined by the
3
American College of Sports Medicine (ACSM).11 The female athlete triad was first
4
identified in 1992 by ACSM, and a significant amount of research about the triad at
5
high school and collegiate levels was performed.9 Regarding menstrual dysfunction,
6
most of the studies were concerned with menstrual irregularity, including primary
7
amenorrhea, secondary amenorrhea, and were lacking in data about PMS and PMDD.
M AN U
SC
RI PT
1
Many reports have documented that the premenstrual phase is associated with
9
decreased performance,12,13 but there are few reports about PMS/PMDD in athletes. A
10
previous report demonstrated that premenstrual symptoms caused marked negative
11
mood swings in menstruating female athletes, but the data were limited to the moods
12
evaluated in the profile of mood states (POMS) questionnaire.14 The aim of this study
13
was to investigate the prevalence and impact of PMS and PMDD in Japanese collegiate
14
athletes, with a focus on athletic performance.
EP
AC C
15
TE D
8
4
ACCEPTED MANUSCRIPT
1
Methods The study was carried out in accordance with the principles outlined in the
3
Declaration of Helsinki. Our institutional review board at Kinki University approved the
4
study.
RI PT
2
5
Study population
SC
6
A school-based cross-sectional survey was conducted in November 2012 using a
8
sample of 232 Japanese female collegiate athletes at Kinki University in Osaka, the
9
largest city in west Japan. All subjects belonged to authorized university clubs, which
10
all have a high ranking in Japanese university sport. All subjects were undergoing
11
intensive training. We recruited female collegiate athletes who had regular menstrual
12
cycles (22-35 days) and were able to provide informed consent. No one in these subjects
13
had a prior diagnosis of psychological disorder.
15
TE D
EP
AC C
14
M AN U
7
Questionnaire
16
We used the Premenstrual Symptoms Questionnaire (PSQ), which was developed in
17
our previous study,15 to screen for premenstrual symptoms. The PSQ translates DSM-IV
18
criteria into a rating scale with degrees of severity described in Japanese and is
19
essentially identical to the Premenstrual Symptoms Screening Tool.16 The PSQ asked, 5
ACCEPTED MANUSCRIPT
“Within the last three months have you experienced the following premenstrual
2
symptoms starting during the week before menses and remitting a few days after the
3
onset of menses?” The premenstrual symptoms listed on the PSQ are ‘Depressed mood’,
4
‘Anxiety or tension’, ‘Tearful’, ‘Anger or irritability’, ‘Decreased interest in work,
5
home or social activities’, ‘Difficulty concentrating’, ‘Fatigue or lack of energy’,
6
‘Overeating or food cravings’, ‘Insomnia or hypersomnia’, ‘Feeling overwhelmed’ and
7
‘Physical symptoms such as tender breasts, feeling of bloating, headache, joint or
8
muscle pain, weight gain’. The PSQ also asked whether such premenstrual symptoms
9
interfered with ‘Work efficiency or productivity, home responsibilities’, ‘Social life
10
activities’ or ‘Relationships with coworkers or family’. The PSQ asked the athletes to
11
rate the severity of premenstrual symptoms as ‘not at all’, ‘mild’, ‘moderate’ or ‘severe’.
12
We divided athletes with premenstrual symptoms into three groups: ‘PMDD’, ‘moderate
13
to severe PMS’, and ‘no/mild PMS’ according to the criteria reported previously.15,16 In
14
addition to the PSQ, we asked whether such premenstrual symptoms interfered with
15
‘Athletic performance in training or competition’. This additional question also asked
16
the athletes to rate the severity as ‘not at all’, ‘mild’, ‘moderate’ or ‘severe’. We further
17
collected additional information about their age, type of sports, participation in national
18
or international competition, regular player or not, coffee-drinking habit, craving for
AC C
EP
TE D
M AN U
SC
RI PT
1
6
ACCEPTED MANUSCRIPT
salty food, craving for sweet food and severity of dysmenorrhea. Athletes were grouped
2
into 6 groups: ball games, track, swimming, fighting sports, archery and other sports.
3
The other sports group consisted of yacht racing, triathlon, and equestrian sports. We
4
asked the athletes about their severity of pain during menses with the categories of ‘not
5
at all’, ‘mild’, ‘moderate’, and ‘severe’.
SC
RI PT
1
M AN U
6
7
Statistical Analyses
8
Statistical analysis was performed using JMP 10.0.2 (SAS, Cary, NC, USA). Data are
9
expressed as the means ± S.D. Statistical significance was set at p
