Journal of Obstetrics and Gynaecology, 2014; Early Online: 1–4 © 2014 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2014.948820
Premenstrual syndrome in Turkish medical students and their quality of life A. Goker, B. Artunc-Ulkumen, F. Aktenk & N. Ikiz
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Department of Obstetrics and Gynecology, Faculty of Medicine, Celal Bayar University Manisa, Turkey
This study aims to analyse the frequency and symptoms of premenstrual syndrome (PMS) and its effect on quality of life in medical students. Sociodemographic data, a symptom calendar for the following consecutive two menstrual periods and SF-36 quality of life questionnaire were collected. A total of 228 students joined the survey. The average age of the students was 20.77 1.90. The frequency of PMS was found as 91.8%. The most frequent symptoms were abdominal bloating (89.5%), irritability (88.3%) and breast tenderness (82.6%). Quality of life scores ranged from 17.00 to 97.00 and were found lowest in the severe PMS group. Alcohol consumption, stress events and fat rich diets increased severity of PMS. Family history significantly affected the severity of PMS and quality of life scores. Premenstrual syndrome was found to be a frequent entity among medical students and seemed to affect quality of life in a moderate way. Keywords: Medical student, premenstrual syndrome, quality of life, SF-36
Introduction Premenstrual syndrome (PMS) is defined as the presence of physical, behavioural and mood symptoms that arise in the luteal phase of the menstrual cycle, resolve after menstruation and have an effect on the woman’s daily life (O’Brien et al. 2011; Braverman et al. 2007). The American College of Obstetrics and Gynecology (ACOG 2001) states three key elements of the diagnosis as symptoms consistent with PMS, occurrence of symptoms during the luteal phase of the menstrual cycle and negative impact of symptoms on lifestyle. At least one mood and one physical symptom needs to be present in the week prior to menstruation and these symptoms must interfere with daily activities (ACOG 2001). This effect on social activities and occupation may lead to a decrease in quality of life. The most common symptoms of PMS include headache, bloating, sleep disturbances, change in appetite or libido, social withdrawal, anxiety and/or depression in all studies. According to reports from Turkey, the prevalence of mild/moderate and severe PMS is around 40.3% and 6.1%, respectively (Adiguzel et al. 2007). This is a relatively high prevalence and further research is needed to evaluate women’s symptoms and needs. There is little research done about PMS and its effect on young women’s quality of life in Turkey. The aim of this study was to
determine the frequency of premenstrual symptoms and PMS in a cohort of Turkish medical students and to evaluate their quality of life.
Materials and methods This cross-sectional study has been carried out at Celal Bayar University in Manisa, Turkey, over a 6-month period. Approval from the local ethics committee was obtained prior to the study. Participants were informed about the study and informed consent was obtained. Two researchers collected data from the students during their free time and the premenstrual syndrome form was distributed among the students to be filled out in the upcoming two menstrual cycles. Participation to the study was voluntary. The method for selecting the participants was just systemic sampling for distributing the questionnaire forms to the female students. The study group comprised of both pre-clinic and intern students. The sample size was calculated with power analysis. The prevalence (P) was 50%, a-error was 0.05. The power was calculated %95 with using single proportion, 95% confidence interval (CI) with the total sample size of 184. We considered a non-response rate of 20%. We therefore aimed for approximately 220 students to enrol into the study. Students with currently diagnosed pregnancy, amenorrhoea, pelvic pain due to an organic reason and endometriosis were excluded from the study. Students with known chronic diseases, such as diabetes, hypertension, connective tissue disorders which may interfere the menstrual cycle and may cause dysmenorrhoea and pelvic pain, were excluded from the study. Students with known adnexal mass, myoma uteri and students using oral contraceptives were also excluded. A detailed anamnesis was obtained from the female students prior to the study. Data were collected using a demographic form, a symptom calendar according to the diagnostic criteria of ACOG and an SF-36 quality of life questionnaire. The demographic form comprised questions about lifestyle and reproductive variables, including questions about age, economic status, menstrual characteristics and tobacco use. The symptom calendar was constructed based on ACOG PMS criteria including behavioural (irritability, anxiety, confusion, anger outbursts depression and social withdrawal) and somatic symptoms (abdominal bloating, breast tenderness, headache and swelling of extremities). A female complaining about at least one mood and one physical symptom was considered to be diagnosed with
Correspondence: A. Goker, Department of Obstetrics and Gynecology, Faculty of Medicine, Celal Bayar University, Manisa, Turkey. E-mail: [email protected]
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2 A. Goker et al. PMS. The severity of PMS was calculated according to Balaha et al.’s (2010) study. The response to each item was scored as 0 for ‘not at all’ and 3 for ‘extreme’ and the highest indicated score was used for calculation. A total score was calculated by summing the symptom scores and dividing by the mean number of symptoms, converting it to a percentage. Mild, moderate and severe PMS corresponded to 0–33%, 33–66% and 66%, respectively. Quality of life was assessed using the SF-36, which is a frequently used scale to determine general wellness of quality of life. It was developed by Ware and Sherbourne (1992) and has been widely used in many research fields. It consists of eight subscales, which evaluate physical function, wellbeing scores and psychometrically-based physical and mental health summary measures. Every sub-scale has a score of 0–100 and a higher score indicates a better quality of life. The Turkish reliability and validity study has been done by Kocyigit et al. (1999). Data were analysed using SPSS version 15.0 (SPSS Inc., Chicago, IL). Descriptive statistics were used to describe the sample and main variables in terms of frequency, means and standard deviation. Qualitative variables were analysed by the c2-test and quantitative variables by t-test. A p value 0.05 was considered statistically significant.
Results A total of 228 students joined the survey and 172 completed the questionnaire for two consecutive menstrual periods. The sociodemographic characteristics are listed in Tables I and II. Two students had no symptoms at all and scored 0 on the PMS scale. The most frequent symptoms reported by the subjects were abdominal bloating (89.5%), breast tenderness (82.6%) and irritability (88.3%) (Table III). General health scores of SF-36 were 70.4, 67.8 and 49.0 for mild, moderate and severe PMS, respectively. The overall frequency of PMS was found as 91.8%. Severity of PMS was classified as mild, moderate and severe and their frequencies were calculated as 47.0%, 47.0% and 5.8%, respectively. Only 12 (6.9%) participants declared seeking professional treatment. The lowest mean SF-36 score was found as 36.0 for role emotional function in the severe PMS group. The highest mean SF-36 score was found as 91.5 for social functioning in the mild PMS group. Scores for SF-36 are listed in Table IV. When compared according to smoking status, body mass index (BMI), mother’s education or father’s education, there was statistically no significant difference between parameters of the SF-36 scale. Family history affected all parameters of SF-36, except for physical functioning and senior students scored significantly higher on physical functioning and role emotional scores. Overall SF-36 scores are listed in Table V. Alcohol consumption, stress events and fat rich diets increased the severity of PMS. Family history significantly affected the severity of PMS and quality of life scores. Students with menarche aged 13 were more susceptible to PMS and their PMS was significantly more severe than those of older menarche age. This group complained significantly more of dysmenorrhoea and
Table I. General characteristics.
Age BMI PMS score General health score SF-36
Min.
Max.
Mean
SD
18.00 14.88 0 17.00
27.00 36.44 28.00 97.00
20.77 21.08 10.84 67.95
1.90 2.95 5.73 15.64
Table II. Sociodemographic characteristics.
School year Pre-clinic Intern Mother’s education University High school Elementary school Father’s education University High school Elementary school Exercise Yes No Tobacco Yes No Severity of PMS Mild Moderate Severe Adding salt Yes No Stress Yes No PMS in family Yes No Dysmenorrhoea Yes No Coffee Yes No Alcohol Yes No BMI Lean Normal Overweight Obese Food rich in fat Yes No
n
(%)
97 75
56.4 43.6
78 50 42
45.9 29.1 24.4
107 46 18
62.2 26.7 10.5
24 148
14.0 86.0
17 155
9.9 90.1
81 81 10
47.1 47.1 5.8
26 146
15.1 84.9
132 40
76.7 23.3
37 135
21.5 78.5
104 68
60.5 39.5
37 135
21.5 78.5
49 122
28.5 70.9
27 130 12 3
15.7 75.6 7.0 1.7
91 81
52.9 47.1
those who complained of dysmenorrhoea had a significantly more severe form of PMS.
Discussion This study is about PMS frequency, symptoms and quality of life in female medical students. The ACOG criteria have been used to evaluate PMS symptoms and the SF-36 form has been used to determine quality of life. The results show that there is a high frequency of PMS among medical school students, however their quality of life is not severely affected. The prevalence of PMS was found as 91.8%, which is to-date the highest frequency reported from Turkey. Previous studies have reported PMS rates between 6.1% and 90% (Adiguzel et al. 2007; Derman et al. 2004; Yucel et al. 2009; Guvenc et al. 2012; Demir et al. 2006), however these are results of diverse study groups. The study by Derman et al. (2004) was investigated in adolescent girls who were aged
Quality of life in premenstrual syndrome 3 Table III. Symptom distribution according to severity of PMS. Total (n 172)
n
(%)
n
(%)
n
154 142 91 65 119 152 80 101 127 62
89.5 82.6 53 37.8 69.2 88.3 46.5 58.7 73.9 36.0
64 56 26 14 38 62 18 21 41 32
79.0 69.1 32.0 17.2 46.9 76.5 22.2 25.9 50.6 39.5
80 76 55 41 71 80 52 70 76 71
98.7 93.8 67.9 50.6 87.6 98.7 64.1 86.4 93.8 87.6
10 10 10 10 10 10 10 10 10 9
Table IV. Comparison of the SF-36 scores in students with PMS (mean SD).
NS, not significant.
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Severe (n 10)
(%)
10–17 and found PMS prevalence at 61.4%. On the other hand, Adiguzel et al. (2007) investigated women aged 15–49 with a marriage rate of 88.6% and found PMS prevalence as low as 6.1%, similar to Deuster et al. (1999) who studied women between 18 and 44 and found a PMS rate of 58.7%. The study by Guvenc et al. (2012) was investigated in nursing students and found PMS prevalence at 36.4%; Pinar et al. (2011) and Attieh et al. (2013) studied medical school students and found PMS rates at 72.1% and 72.1%, respectively. Another study in students found PMS frequency at 100% in Iran (Delara et al. 2012). These great differences are important in evaluating the results objectively. Studies from western countries such as the UK, Spain and the USA report PMS prevalence as 24%, 73.7% and 31% (Sadler et al. 2010; Duenas et al. 2011; Vichnin et al. 2006). There are different methods for diagnosing PMS and results differ between methods. A study by Choi et al. (2010) found the prevalence of PMS as 98.6, 32.1 and 2.8% according to ICD-10, ACOG, DSM-IV criteria in the same study population. When comparing results, it is important to keep in mind which method has been used. Our present study shows that the most frequent physical symptom in PMS patients was abdominal bloating, which was encountered in 89.5% of the students and the most frequent emotional symptom was irritability (88.3%). A study by Adewuya et al. (2009) showed that breast tenderness was the most frequent physical symptom, seen in 35.5% of Nigerian university students. Breast tenderness was the most frequent symptom in Lebanese medical students, with a rate of 65%, followed by abdominal bloating and headache in a study by Attieh et al. (2013). Irritability ranked in first place in emotional symptoms, similar to our results. Bakshani reported tiredness or lethargy as the most common emotional symptom, followed by depressed mood and tearfulness (Bakhshani et al. 2009). Attieh et al. (2013) similarly found depression in more than half of the students. Depression
Physical functioning Role – physical Bodily pain General health Vitality Social functioning Role – emotional
Moderate (n 81)
n
Symptom Abdominal bloating Breast tenderness Headache Swelling of extremities Confusion Irritability Social withdrawal Angry outbursts Anxiety Depression
Mild (n 81)
Mild (n 81)
Moderate (n 81)
Severe (n 10)
p value
90.6 11.7 74.0 30.9 65.4 20.6 70.4 70.4 53.5 10.0 91.5 21.7 64.1 30.8
88.4 13.0 61.4 33.3 58.7 23.5 67.8 15.4 52.9 10.6 86.1 20.1 58.7 32.7
87.0 7.5 37.5 37.7 49.5 22.0 49.0 15.1 48.0 18.5 68.0 23.4 36.0 32.3
NS 0.002 NS 0.001 NS 0.005 0.045
(%) 100 100 100 100 100 100 100 100 100 90
was reported in 36% of our study group. Bakshani et al. (2009) studied a heterogenous group at different ages and found that the severity of symptoms were significantly higher for younger women. This is a similar finding to our results, where students in the younger group had more severe symptomatology of PMS. A study from Turkey reported the most common symptoms as irritability, anxiety and abdominal discomfort (Adiguzel et al. 2007). Korean women had rather more physical compared with mental symptoms, which is as in our study results (Choi et al. 2010). Dysmenorrhoea is a frequent complaint during adolescence and early adulthood, which is the same case as in our study results. We have found the rate of dysmenorrhoea as 60.5% but menstrual disorders were seen in 85.5% of the students, which is a rather high frequency. Those students with dysmenorrhoea were in the severe PMS group, which is an expected result. Similar findings were reported in a study by Chayachinda et al. (2008), where nursing students with dysmenorrhoea had a higher likelihood of experiencing PMS. Students with polycystic ovary syndrome were excluded from the study, however there was a high rate of menstrual irregularities, especially in the PMS group, which is surprising because ovulation is one of the proposed mechanism for PMS and menstrual irregularity may be a sign for anovulation. Despite the high rate of PMS, medical treatment was demanded by only 6.9% of the participants. Health professionals should be aware of this situation and adequate counselling should be offered at medical centres. Menstrual problems may be a taboo subject for conservative females, therefore consultation and education is important for treating PMS, dysmenorrhoea or other gynaecological problems. Physical and mental symptoms have an impact on quality of life, however the effect of PMS on quality of life has not been thoroughly studied. There are no studies on life quality in women with PMS conducted in Turkey. Taghizadeh et al. (2008) stated that ‘the more the severity of PMS, the less the quality of life in mental health’, especially causing nervousness, depression and sadness. Nisar et al. (2008) evaluated medical students and concluded that quality of life scores were significantly lower in the PMS sample and the most affected parameters were role limitation due to emotional problems, role limitation due to physical problems and general health. In our study, we found the general health score to be 67.95 ( 15.64), which is a moderate score. Physical functioning, bodily pain and vitality scores were not different between severity groups of PMS and the lowest scores for these parameters were 87.0, 49.5 and 48.0, respectively. Family history affected all parameters of SF-36, except for physical functioning, which is an expected result, because family history is one of the most important risk factors for PMS. The high scores in physical
4 A. Goker et al. Table V. SF-36 scores according to various characteristics (mean SD).
Physical functioning Role – physical Bodily pain General health Vitality Social functioning Role – emotional
Pre-clinic (n 97)
Intern (n 75)
p value
With family history (n 37)
Without family history (n 135)
p value
87.2 13.0 63.5 34.3 61.9 23.2 66.3 15.4 53.0 11.4 86.8 22.5 56.1 31.2
92.2 10.4 69.0 32.5 60.6 21.4 69.9 15.8 52.7 10.4 88.6 20.4 64.8 33.2
0.006 NS NS NS NS NS 0.040
88.6 11.9 49.3 38.4 50.4 25.8 62.2 16.2 47.4 10.7 78.8 24.2 48.6 31.0
89.5 12.2 70.5 30.7 64.3 20.5 69.5 15.1 54.4 10.5 90.0 20.2 63.1 32.1
NS 0.003 0.004 0.012 0.000 0.014 0.015
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NS, not significant.
functioning and role emotional scores of senior year students may be explained by the responsibility these students have in their last year of medical education. The internship may be contributing to increased confidence. The limitations of this study was the use of a self-completion questionnaire but its strength lies in the fact that it was prospectively conducted. The sample used was a selective group of unmarried medical students. This study does not aim to generalise results to the population as a whole. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References ACOG. 2001. Practice bulletin: premenstrual syndrome. International Journal of Gynecology and Obstetrics 73:183–191. Adewuya AO, Loto OM, Adewumi TA. 2009. Pattern and correlates of premenstrual symptomatology amongst Nigerian University students. Journal of Psychosomatic Obstetrics and Gynaecology 30:127–132. Adiguzel H, Taskin EO, Danaci AE. 2007. The symptomatology and prevalence of symptoms of premenstrual syndrome in Manisa, Turkey. Turk Psikiyatri Dergisi 18:215–222. Attieh E, Maalouf S, Richa S, Kesrouani A. 2013. Premenstrual syndrome among Lebanese medical students and residents. International Journal of Gynaecology and Obstetrics 121:184–185. Bakhshani NM, Mousavi MN, Khodabandeh G. 2009. Prevalence and severity of premenstrual symptoms among Iranian female university students. Journal of the Pakistan Medical Association 59:205–208. Balaha MH, Amr MA, Saleh Al Moghannum M, Saab Al Muhaidab N. 2010. The phenomenology of premenstrual syndrome in female medical students: a cross sectional study. Pan African Medical Journal 5:4. Braverman PK. 2007. Premenstrual syndrome and premenstrual dysphoric disorder. Journal of Pediatric and Adolescent Gynecology 20:3–12. Chayachinda C, Rattanachaiyanont M, Phattharayuttawat S, Kooptiwoot S. 2008. Premenstrual syndrome in Thai nurses. Journal of Psychosomatic Obstetrics and Gynaecology 29:199–205. Choi D, Lee DY, Lehert P, Lee IS, Kim SH, Dennerstein L. 2010. The impact of premenstrual symptoms on activities of daily life in Korean women. Journal of Psychosomatic Obstetrics and Gynaecology 31:10–15. Delara M, Ghofranipour F, Azadfallah P, Tavafian SS, Kazemnejad A, Montazeri A. 2012. Health related quality of life among adolescents with
premenstrual disorders: a cross sectional study. Health and Quality of Life Outcomes 10:1. Demir B, Algul LY, Guven ES. 2006. Analysis of premenstrual syndrome incidence in medical staff and factors affecting premenstrual syndrome incidence. J Turkish Gynaecol Obstet Found 3:262–270. Derman O, Kanbur N.O, Tokur T, Kutluk T. 2004. Premenstrual syndrome and associated symptoms in adolescent girls. European Journal of Obstetrics, Gynecology and Reproductive Biology 116:201–206. Deuster PA, Adera T, South P. 1999. Biological, social and behavioral factors associated with premenstrual syndrome. Archives of Family Medicine 8:122–128. Duenas JL, Lete I, Bermejo R, Arbat A, Perez-Campos E, Martinez-Salmean J et al. 2011. Prevalence of premenstrual syndrome and premenstrual dysphoric disorder in a representative cohort of Spanish women of fertile age. European Journal of Obstetrics, Gynecology, and Reproductive Biology 156:72–77. Guvenc G, Kilic A, Akyuz A, Ustunsoz A. 2012. Premenstrual syndrome and attitudes toward menstruation in a sample of nursing students. Journal of Psychosomatic Obstetrics and Gynecology 33:106–111. Kocyigit H, Aydemir O, Fisek G et al. 1999. Validation of SF-36. Turkish version. Ilaç ve Tedavi Dergisi 12:102–106. Nisar N, Zehra N, Haider G, Munir AA, Sohoo NA. 2008. Frequency, intensity and impact of premenstrual syndrome in medical students. Journal of the College of Physicians and Surgeons Pakistan 18:481–484. O’Brien PM, Backstrom T, Brown C, Dennerstein L, Endicott J, Epperson CN, et al. 2011. Towards a consensus on diagnostic criteria, measurement and trial design of the premenstrual disorders: the ISPMD Montreal consensus. Archives of Women’s Mental Health 14:13–21. Pinar G, Colak M, Oksuz E. 2011. Premenstrual Syndrome in Turkish college students and its effects on life quality. Sexual & Reproductive HealthCare 2:21–27. Sadler C, Smith H, Hammond J, Bayly R, Borland S, Panay N et al.; Southampton Women’s Survey Study Group. 2010. Lifestyle factors, hormonal contraception, and premenstrual symptoms: the United Kingdom Southampton Women’s Survey. Journal of Women’s Health (Larchmont) 19:391–396. Taghizadeh Z, Shirmohammadi M, Arbabi M, Mehran A. 2008. The effect of premenstrual syndrome on quality of life in adolescent girls. Iranian Journal of Psychiatry 3:105–109. Vichnin M, Freeman EW, Lin H, Hillman J, Bui S. 2006. Premenstrual syndrome (PMS) in adolescents: severity and impairment. Journal of Pediatric and Adolescent Gynecology 19:397–402. Ware JE Jr, Sherbourne CD. 1992. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Medical Care 30:473–483. Yucel U, Bilge A, Oran N, Ersoy MA, Gencdoğan B, Ozveren, O. 2009. The prevalence of premenstrual syndrome and its relationship with depression risk in adolescents. Anatolian Journal of Psychiatry 10:55–61.
Premenstrual syndrome in Turkish medical students and their quality of life A. Goker, B. Artunc-Ulkumen, F. Aktenk & N. Ikiz
J Obstet Gynaecol Downloaded from informahealthcare.com by Ondokuz Mayis Univ. on 11/11/14 For personal use only.
Department of Obstetrics and Gynecology, Faculty of Medicine, Celal Bayar University Manisa, Turkey
This study aims to analyse the frequency and symptoms of premenstrual syndrome (PMS) and its effect on quality of life in medical students. Sociodemographic data, a symptom calendar for the following consecutive two menstrual periods and SF-36 quality of life questionnaire were collected. A total of 228 students joined the survey. The average age of the students was 20.77 1.90. The frequency of PMS was found as 91.8%. The most frequent symptoms were abdominal bloating (89.5%), irritability (88.3%) and breast tenderness (82.6%). Quality of life scores ranged from 17.00 to 97.00 and were found lowest in the severe PMS group. Alcohol consumption, stress events and fat rich diets increased severity of PMS. Family history significantly affected the severity of PMS and quality of life scores. Premenstrual syndrome was found to be a frequent entity among medical students and seemed to affect quality of life in a moderate way. Keywords: Medical student, premenstrual syndrome, quality of life, SF-36
Introduction Premenstrual syndrome (PMS) is defined as the presence of physical, behavioural and mood symptoms that arise in the luteal phase of the menstrual cycle, resolve after menstruation and have an effect on the woman’s daily life (O’Brien et al. 2011; Braverman et al. 2007). The American College of Obstetrics and Gynecology (ACOG 2001) states three key elements of the diagnosis as symptoms consistent with PMS, occurrence of symptoms during the luteal phase of the menstrual cycle and negative impact of symptoms on lifestyle. At least one mood and one physical symptom needs to be present in the week prior to menstruation and these symptoms must interfere with daily activities (ACOG 2001). This effect on social activities and occupation may lead to a decrease in quality of life. The most common symptoms of PMS include headache, bloating, sleep disturbances, change in appetite or libido, social withdrawal, anxiety and/or depression in all studies. According to reports from Turkey, the prevalence of mild/moderate and severe PMS is around 40.3% and 6.1%, respectively (Adiguzel et al. 2007). This is a relatively high prevalence and further research is needed to evaluate women’s symptoms and needs. There is little research done about PMS and its effect on young women’s quality of life in Turkey. The aim of this study was to
determine the frequency of premenstrual symptoms and PMS in a cohort of Turkish medical students and to evaluate their quality of life.
Materials and methods This cross-sectional study has been carried out at Celal Bayar University in Manisa, Turkey, over a 6-month period. Approval from the local ethics committee was obtained prior to the study. Participants were informed about the study and informed consent was obtained. Two researchers collected data from the students during their free time and the premenstrual syndrome form was distributed among the students to be filled out in the upcoming two menstrual cycles. Participation to the study was voluntary. The method for selecting the participants was just systemic sampling for distributing the questionnaire forms to the female students. The study group comprised of both pre-clinic and intern students. The sample size was calculated with power analysis. The prevalence (P) was 50%, a-error was 0.05. The power was calculated %95 with using single proportion, 95% confidence interval (CI) with the total sample size of 184. We considered a non-response rate of 20%. We therefore aimed for approximately 220 students to enrol into the study. Students with currently diagnosed pregnancy, amenorrhoea, pelvic pain due to an organic reason and endometriosis were excluded from the study. Students with known chronic diseases, such as diabetes, hypertension, connective tissue disorders which may interfere the menstrual cycle and may cause dysmenorrhoea and pelvic pain, were excluded from the study. Students with known adnexal mass, myoma uteri and students using oral contraceptives were also excluded. A detailed anamnesis was obtained from the female students prior to the study. Data were collected using a demographic form, a symptom calendar according to the diagnostic criteria of ACOG and an SF-36 quality of life questionnaire. The demographic form comprised questions about lifestyle and reproductive variables, including questions about age, economic status, menstrual characteristics and tobacco use. The symptom calendar was constructed based on ACOG PMS criteria including behavioural (irritability, anxiety, confusion, anger outbursts depression and social withdrawal) and somatic symptoms (abdominal bloating, breast tenderness, headache and swelling of extremities). A female complaining about at least one mood and one physical symptom was considered to be diagnosed with
Correspondence: A. Goker, Department of Obstetrics and Gynecology, Faculty of Medicine, Celal Bayar University, Manisa, Turkey. E-mail: [email protected]
J Obstet Gynaecol Downloaded from informahealthcare.com by Ondokuz Mayis Univ. on 11/11/14 For personal use only.
2 A. Goker et al. PMS. The severity of PMS was calculated according to Balaha et al.’s (2010) study. The response to each item was scored as 0 for ‘not at all’ and 3 for ‘extreme’ and the highest indicated score was used for calculation. A total score was calculated by summing the symptom scores and dividing by the mean number of symptoms, converting it to a percentage. Mild, moderate and severe PMS corresponded to 0–33%, 33–66% and 66%, respectively. Quality of life was assessed using the SF-36, which is a frequently used scale to determine general wellness of quality of life. It was developed by Ware and Sherbourne (1992) and has been widely used in many research fields. It consists of eight subscales, which evaluate physical function, wellbeing scores and psychometrically-based physical and mental health summary measures. Every sub-scale has a score of 0–100 and a higher score indicates a better quality of life. The Turkish reliability and validity study has been done by Kocyigit et al. (1999). Data were analysed using SPSS version 15.0 (SPSS Inc., Chicago, IL). Descriptive statistics were used to describe the sample and main variables in terms of frequency, means and standard deviation. Qualitative variables were analysed by the c2-test and quantitative variables by t-test. A p value 0.05 was considered statistically significant.
Results A total of 228 students joined the survey and 172 completed the questionnaire for two consecutive menstrual periods. The sociodemographic characteristics are listed in Tables I and II. Two students had no symptoms at all and scored 0 on the PMS scale. The most frequent symptoms reported by the subjects were abdominal bloating (89.5%), breast tenderness (82.6%) and irritability (88.3%) (Table III). General health scores of SF-36 were 70.4, 67.8 and 49.0 for mild, moderate and severe PMS, respectively. The overall frequency of PMS was found as 91.8%. Severity of PMS was classified as mild, moderate and severe and their frequencies were calculated as 47.0%, 47.0% and 5.8%, respectively. Only 12 (6.9%) participants declared seeking professional treatment. The lowest mean SF-36 score was found as 36.0 for role emotional function in the severe PMS group. The highest mean SF-36 score was found as 91.5 for social functioning in the mild PMS group. Scores for SF-36 are listed in Table IV. When compared according to smoking status, body mass index (BMI), mother’s education or father’s education, there was statistically no significant difference between parameters of the SF-36 scale. Family history affected all parameters of SF-36, except for physical functioning and senior students scored significantly higher on physical functioning and role emotional scores. Overall SF-36 scores are listed in Table V. Alcohol consumption, stress events and fat rich diets increased the severity of PMS. Family history significantly affected the severity of PMS and quality of life scores. Students with menarche aged 13 were more susceptible to PMS and their PMS was significantly more severe than those of older menarche age. This group complained significantly more of dysmenorrhoea and
Table I. General characteristics.
Age BMI PMS score General health score SF-36
Min.
Max.
Mean
SD
18.00 14.88 0 17.00
27.00 36.44 28.00 97.00
20.77 21.08 10.84 67.95
1.90 2.95 5.73 15.64
Table II. Sociodemographic characteristics.
School year Pre-clinic Intern Mother’s education University High school Elementary school Father’s education University High school Elementary school Exercise Yes No Tobacco Yes No Severity of PMS Mild Moderate Severe Adding salt Yes No Stress Yes No PMS in family Yes No Dysmenorrhoea Yes No Coffee Yes No Alcohol Yes No BMI Lean Normal Overweight Obese Food rich in fat Yes No
n
(%)
97 75
56.4 43.6
78 50 42
45.9 29.1 24.4
107 46 18
62.2 26.7 10.5
24 148
14.0 86.0
17 155
9.9 90.1
81 81 10
47.1 47.1 5.8
26 146
15.1 84.9
132 40
76.7 23.3
37 135
21.5 78.5
104 68
60.5 39.5
37 135
21.5 78.5
49 122
28.5 70.9
27 130 12 3
15.7 75.6 7.0 1.7
91 81
52.9 47.1
those who complained of dysmenorrhoea had a significantly more severe form of PMS.
Discussion This study is about PMS frequency, symptoms and quality of life in female medical students. The ACOG criteria have been used to evaluate PMS symptoms and the SF-36 form has been used to determine quality of life. The results show that there is a high frequency of PMS among medical school students, however their quality of life is not severely affected. The prevalence of PMS was found as 91.8%, which is to-date the highest frequency reported from Turkey. Previous studies have reported PMS rates between 6.1% and 90% (Adiguzel et al. 2007; Derman et al. 2004; Yucel et al. 2009; Guvenc et al. 2012; Demir et al. 2006), however these are results of diverse study groups. The study by Derman et al. (2004) was investigated in adolescent girls who were aged
Quality of life in premenstrual syndrome 3 Table III. Symptom distribution according to severity of PMS. Total (n 172)
n
(%)
n
(%)
n
154 142 91 65 119 152 80 101 127 62
89.5 82.6 53 37.8 69.2 88.3 46.5 58.7 73.9 36.0
64 56 26 14 38 62 18 21 41 32
79.0 69.1 32.0 17.2 46.9 76.5 22.2 25.9 50.6 39.5
80 76 55 41 71 80 52 70 76 71
98.7 93.8 67.9 50.6 87.6 98.7 64.1 86.4 93.8 87.6
10 10 10 10 10 10 10 10 10 9
Table IV. Comparison of the SF-36 scores in students with PMS (mean SD).
NS, not significant.
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Severe (n 10)
(%)
10–17 and found PMS prevalence at 61.4%. On the other hand, Adiguzel et al. (2007) investigated women aged 15–49 with a marriage rate of 88.6% and found PMS prevalence as low as 6.1%, similar to Deuster et al. (1999) who studied women between 18 and 44 and found a PMS rate of 58.7%. The study by Guvenc et al. (2012) was investigated in nursing students and found PMS prevalence at 36.4%; Pinar et al. (2011) and Attieh et al. (2013) studied medical school students and found PMS rates at 72.1% and 72.1%, respectively. Another study in students found PMS frequency at 100% in Iran (Delara et al. 2012). These great differences are important in evaluating the results objectively. Studies from western countries such as the UK, Spain and the USA report PMS prevalence as 24%, 73.7% and 31% (Sadler et al. 2010; Duenas et al. 2011; Vichnin et al. 2006). There are different methods for diagnosing PMS and results differ between methods. A study by Choi et al. (2010) found the prevalence of PMS as 98.6, 32.1 and 2.8% according to ICD-10, ACOG, DSM-IV criteria in the same study population. When comparing results, it is important to keep in mind which method has been used. Our present study shows that the most frequent physical symptom in PMS patients was abdominal bloating, which was encountered in 89.5% of the students and the most frequent emotional symptom was irritability (88.3%). A study by Adewuya et al. (2009) showed that breast tenderness was the most frequent physical symptom, seen in 35.5% of Nigerian university students. Breast tenderness was the most frequent symptom in Lebanese medical students, with a rate of 65%, followed by abdominal bloating and headache in a study by Attieh et al. (2013). Irritability ranked in first place in emotional symptoms, similar to our results. Bakshani reported tiredness or lethargy as the most common emotional symptom, followed by depressed mood and tearfulness (Bakhshani et al. 2009). Attieh et al. (2013) similarly found depression in more than half of the students. Depression
Physical functioning Role – physical Bodily pain General health Vitality Social functioning Role – emotional
Moderate (n 81)
n
Symptom Abdominal bloating Breast tenderness Headache Swelling of extremities Confusion Irritability Social withdrawal Angry outbursts Anxiety Depression
Mild (n 81)
Mild (n 81)
Moderate (n 81)
Severe (n 10)
p value
90.6 11.7 74.0 30.9 65.4 20.6 70.4 70.4 53.5 10.0 91.5 21.7 64.1 30.8
88.4 13.0 61.4 33.3 58.7 23.5 67.8 15.4 52.9 10.6 86.1 20.1 58.7 32.7
87.0 7.5 37.5 37.7 49.5 22.0 49.0 15.1 48.0 18.5 68.0 23.4 36.0 32.3
NS 0.002 NS 0.001 NS 0.005 0.045
(%) 100 100 100 100 100 100 100 100 100 90
was reported in 36% of our study group. Bakshani et al. (2009) studied a heterogenous group at different ages and found that the severity of symptoms were significantly higher for younger women. This is a similar finding to our results, where students in the younger group had more severe symptomatology of PMS. A study from Turkey reported the most common symptoms as irritability, anxiety and abdominal discomfort (Adiguzel et al. 2007). Korean women had rather more physical compared with mental symptoms, which is as in our study results (Choi et al. 2010). Dysmenorrhoea is a frequent complaint during adolescence and early adulthood, which is the same case as in our study results. We have found the rate of dysmenorrhoea as 60.5% but menstrual disorders were seen in 85.5% of the students, which is a rather high frequency. Those students with dysmenorrhoea were in the severe PMS group, which is an expected result. Similar findings were reported in a study by Chayachinda et al. (2008), where nursing students with dysmenorrhoea had a higher likelihood of experiencing PMS. Students with polycystic ovary syndrome were excluded from the study, however there was a high rate of menstrual irregularities, especially in the PMS group, which is surprising because ovulation is one of the proposed mechanism for PMS and menstrual irregularity may be a sign for anovulation. Despite the high rate of PMS, medical treatment was demanded by only 6.9% of the participants. Health professionals should be aware of this situation and adequate counselling should be offered at medical centres. Menstrual problems may be a taboo subject for conservative females, therefore consultation and education is important for treating PMS, dysmenorrhoea or other gynaecological problems. Physical and mental symptoms have an impact on quality of life, however the effect of PMS on quality of life has not been thoroughly studied. There are no studies on life quality in women with PMS conducted in Turkey. Taghizadeh et al. (2008) stated that ‘the more the severity of PMS, the less the quality of life in mental health’, especially causing nervousness, depression and sadness. Nisar et al. (2008) evaluated medical students and concluded that quality of life scores were significantly lower in the PMS sample and the most affected parameters were role limitation due to emotional problems, role limitation due to physical problems and general health. In our study, we found the general health score to be 67.95 ( 15.64), which is a moderate score. Physical functioning, bodily pain and vitality scores were not different between severity groups of PMS and the lowest scores for these parameters were 87.0, 49.5 and 48.0, respectively. Family history affected all parameters of SF-36, except for physical functioning, which is an expected result, because family history is one of the most important risk factors for PMS. The high scores in physical
4 A. Goker et al. Table V. SF-36 scores according to various characteristics (mean SD).
Physical functioning Role – physical Bodily pain General health Vitality Social functioning Role – emotional
Pre-clinic (n 97)
Intern (n 75)
p value
With family history (n 37)
Without family history (n 135)
p value
87.2 13.0 63.5 34.3 61.9 23.2 66.3 15.4 53.0 11.4 86.8 22.5 56.1 31.2
92.2 10.4 69.0 32.5 60.6 21.4 69.9 15.8 52.7 10.4 88.6 20.4 64.8 33.2
0.006 NS NS NS NS NS 0.040
88.6 11.9 49.3 38.4 50.4 25.8 62.2 16.2 47.4 10.7 78.8 24.2 48.6 31.0
89.5 12.2 70.5 30.7 64.3 20.5 69.5 15.1 54.4 10.5 90.0 20.2 63.1 32.1
NS 0.003 0.004 0.012 0.000 0.014 0.015
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NS, not significant.
functioning and role emotional scores of senior year students may be explained by the responsibility these students have in their last year of medical education. The internship may be contributing to increased confidence. The limitations of this study was the use of a self-completion questionnaire but its strength lies in the fact that it was prospectively conducted. The sample used was a selective group of unmarried medical students. This study does not aim to generalise results to the population as a whole. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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