Introduction and background
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- Introduction and background
Premenstrual syndrome (PMS) is a complex physical and emotional symptoms that occurs repeatedly in a cyclic fashion preceding menstruation (7–14 days before the onset of menstruation) and then disappear after the menstrual period [Dickerson et al. 2003, American College of Obstetrics and Gynecology (ACOG) 2005]. Overall, 75–85% of menstruating women reported having one or more premenstrual symptoms. Premenstrual emotional symptoms are conceptualized in feminist research as intra-psychic phenomena because changes in emotions are due to the combination of environmental and psychological factors. PMS is not always considered as pathological unless the women start suffering from feelings of out of control in their behaviours, which may affect their relationships with others especially with the intimate partner (Mooney-Somers et al. 2008).
In 1983 in the USA, the National Institute of Mental Health conference dedicated for this phenomenon and planned the first diagnostic criteria requiring a prospective and daily assessment of these symptoms. Later in 1987, the American Psychiatric Association (APA), in the Diagnostic and Statistical Manual of Mental Disorders 3rd Edition-Revision (DSM III-R), introduced the diagnosis of Late Luteal Phase Dysphoric Disorder that became in 1994 in the Diagnostic and Statistical Manual of Mental Disorders 4th Edition (DSM-IV) the premenstrual dysphoric disorder (PMDD), with the same diagnostic criteria (APA 2000, Limosin & Ades 2001). Because of psychological and emotional problems such as anxiety, mood symptoms and social impairment that appeared and involved in PMS and PMDD; psychiatrists and mental health nurses are more concerned about this syndrome and become one of their major domains (Campbell et al. 1997).
PMDD, therefore, is a well-defined clinical entity characterized by severe recurrent depressive and anxiety symptoms of premenstrual onset that remit a few days after the onset of menses (APA 2000). Symptoms of PMDD were considered if they were severe enough to interfere with social activities (Baca-Garcia et al. 2004). In both PMS and PMDD, symptoms diminished rapidly within the onset of menses (Bloch et al. 1997, Johnson 1998, Daugherty 1999, Carr 2001, Grady-Weliky 2003, Halbreich et al. 2006). The exact cause of PMS and PMDD are not clearly understood but have been attributed to hormonal changes, neurotransmitters, prostaglandins, diet, drugs and women's lifestyle (Deuster et al. 1999, Neal et al. 2000, Connolly 2001).
Women around the world usually used various self-treatment strategies or behaviours to control or relief the symptoms of PMS and PMDD based on their cultural beliefs and practices that influenced by socializing factors such as country, rural vs. urban, religion, educational level and work environment (McMaster et al. 1997). In developing countries, the educated and professional women reported more about psychological and affective symptoms of PMS than less educated women as they exposed more to media and other cultures (McMaster et al. 1997). The less educated women reported least about psychological symptoms as they are not aware about these symptoms and its relation to premenstrual period; however, most of them reported only the physical symptoms (McMaster et al. 1997). Therefore, healthcare professionals and mental health nurse in Jordan must take into consideration the awareness level of women, cultural practices and the perception of Jordanian women related PMS and PMDD psychological symptoms to bridge the gap between evidence-based health programme and the health needs of Jordanian women.
The prevalence and severity of PMS and PMDD
There are many factors that affect the prevalence and severity of both PMS and PMDD. Among these factors are: levels of perceived stress, age, level of education, socioeconomic status, marital status, body mass index (BMI), menstrual history, nutritional status and physical activity (Deuster et al. 1999). There are no statistical data about the prevalence of PMS or PMDD in Jordan. However, the literature conducted in the worldwide indicated that the prevalence of PMS ranged between 75% and 85% and the prevalence of PMDD ranged between 3% and 10% of the menstruating women (Rivera-Tovar & Frank 1990, Barnhart et al. 1995, Campbell et al. 1997, Johnson 1998, Soares et al. 2001, Eliot 2002, Tabassum et al. 2005).
Research studies showed that the prevalence of PMS and PMDD were higher among younger women, women with less than high school education, women with lower income level, women with higher BMI, women whose age at menarche was 12 years or younger, women whom menses last more than 6 days, women who are physically inactive, women who are smokers, and women who reported more perceived stress level (Cohen et al. 2002, Freeman 2003, Halbreich et al. 2003). Also, literature did not show significant differences between the prevalence of PMS or PMDD and whether the women had been pregnant or not, whether the women is considered as a regular coffee drinker or not, and whether the women taking birth control pills or not (Ellen et al. 1995, Deuster et al. 1999, Richards et al. 2006, Thu et al. 2006).
The role of stress and major life events has received considerable attention in terms of association with somatic health. With respect to PMS, women who reported significant life stressors were more likely to report premenstrual symptoms. Several studies have examined the association between stress and severity of PMS. Groups who reported low, moderate and severe stress levels had prevalence rates for PMS of 1.9%, 6.7% and 13.7% respectively (Deuster et al. 1999). Jandrof et al. (1986) supported the positive relationship between daily stress and severity of premenstrual symptoms. Beck et al. (1990) studied, prospectively during three consecutive menstrual cycles, the association between occurrence of psychological stress and severity of premenstrual symptoms among 25 women who have severe PMS. Results showed that psychological stress accounted for 6% of the severity of premenstrual symptoms.
Severe premenstrual symptoms frequently interfere with a woman's ability to function across multiple settings including home, school and work. Those symptoms adversely affect women during their reproductive years. Women complaining of PMS or PMDD have high rates of work absenteeism, lower productivity (Heinemann et al. 2010) and reduced quality of life because of physical and psychological burden and adverse effect on relationships (Halbreich et al. 2003). Premenstrual impairment may also affect women and influencing their marital relationships and housekeeping (Mooney-Somers et al. 2008).
Symptoms of PMS and PMDD
Women with PMS and PMDD share the same symptoms. What differentiates PMDD is a group of symptoms that is severe enough to cause impairment in women's function (APA 2000). Research studies have reported up to 200 premenstrual symptoms (Handerason 2000). However, the premenstrual symptoms reported in the literature fall into three domains: emotional, physical and behavioural domains. The most common emotional symptoms of PMS include depression, irritability, anxiety, tension, crying, oversensitivity, feeling out of control and mood swings. Physical symptoms include abdominal cramps, fatigue, abdominal bloating, breast tenderness and pain, acne, swelling, aches and weight gain. Behavioural symptoms include food cravings, appetite changes, poor concentration, sleep disturbances, social withdrawal, forgetfulness and decreased in activity level (Deuster et al. 1999, Freeman 2003).
The occurrence of premenstrual symptoms varies in severity according to several factors. For example, Thu et al. (2006) found that almost 60% of menstruating women complained of breast pain and discomfort, around 50% complained of lower abdominal cramp and discomfort, headache, and increasing stress before period, around 40% expressed sadness, depression, confusion, weight gain, irritability and conflict with friends. Less than 30% reported high rate of anxiety, withdrawal feeling, ineffective coping and distorted body image.
There are 11 symptoms of PMDD identified by APA and described in DSM-IV-Text Revision (DSM-IV-TR). These symptoms are briefly identified as: irritability, depression, sadness, feeling overwhelmed, stress, oedema, abdominal bloating, overweight, muscle pain, insomnia or hyperinsomnia and breast tenderness (APA 2000). Women with PMDD experience marked disruption in their relationships, work or social activities at levels similar to those with major depressive disorder (Freeman 2003).
Treatment strategies used to relieve symptoms of PMS and PMDD
Women suffering from PMS and PMDD usually used a variety of self-treatment strategies or habits to decrease or alleviate the severity of these symptoms. A wide variety of strategies and habits used by women to decrease the symptoms of PMS and PMDD have been mentioned in the literature. Many medicinal and non-medicinal treatments have been used including psychological treatments, diet modification, vitamin supplements, lifestyle changes and alternative healing modalities (Thys-Jacobs et al. 1999).
For women with mild and severe symptoms, mental health nurses can use the evidence-based practices to enhance and relief PMS and PMDD symptoms. Mental health nurses must be aware that most of the women considered PMS as a source of stress and this can be managed using different treatment strategies. Performing regular exercise, decreasing smoking, eliminating alcohol consumption, using alternative healing modalities (herbal therapies, acupuncture and aromatherapy) are efficient also in treating the symptoms of PMS. Moreover, supportive counselling, education and general self-care measures such as exercises and healthful diet (limit salt, sweet foods and caffeine) are useful in alleviating the symptoms (Handerason 2000, Macdougall et al. 2006, Indusekhar et al. 2007). For women seeking treatment for moderate to severe PMS with strong preferences for non-pharmacological interventions, mental health nurses may also consider psychological interventions such as behavioural therapy, relaxation therapy and cognitive behavioural therapy that could be effective to alleviate the symptoms of PMS and PMDD (Macdougall et al. 2006, Indusekhar et al. 2007).
Medicinal treatment may be another helpful alternative for severe symptoms when previous methods are not effective, using variety of drugs such as Selective Serotonin Reuptake Inhibitors (SSRIs), oral contraceptives, non-steroidal anti-inflammatory agents, mineral and vitamin supplements, and diuretics (Daugherty 1999, Neal et al. 2000, Carr 2001, Connolly 2001, Wyatt et al. 2001, Macdougall et al. 2006, Indusekhar et al. 2007). Taking calcium supplement during premenstrual period found to relieve severity of symptoms because calcium level is usually lower in premenstrual period (Daugherty 1999). Manganese also plays a role in alleviating PMS symptoms. The lower dietary manganese intake was associated with more severe symptoms during the premenstrual phase of cycle (Penland & Johnson 1993, Bendich 2000).
Mental health nurses must be aware when they counsel women about the medicinal and non-medicinal treatments for PMS and PMDD. While counselling, mental health nurses must take into account the personal history of the women and their psychosocial factors, their social and cultural beliefs, their cultural practices and perception of using medications to treat PMS and PMDD. Also, mental health nurses must increase women's awareness that the medications not only demonstrate efficacy in reducing the physical symptoms of PMS and PMDD but also improving psychological, social and occupational functioning, and increasing the emphasis on using medications under supervision of medical team (Indusekhar et al. 2007).
Aims of the study
No one study had investigated the prevalence of PMS and PMDD among Jordanian women; therefore this study was conducted to detect the prevalence, severity, and factors associated with PMS and PMDD among Jordanian women, and to identify the most common self-treatment strategies used by women to alleviate the symptoms associated with PMS and/or PMDD. More specifically this study aimed to answer the following research questions:
- What are the prevalences of PMS and PMDD among Jordanian women?
- What is the degree of severity of premenstrual symptoms among Jordanian women?
- What are the relationships among severity of premenstrual symptoms and perceived stress level, and some demographic and maternal variables among Jordanian women?
- What are the most common self-treatment strategies or behaviours that used by Jordanian women to alleviate symptoms of PMS and/or PMDD?
- Top of page
- Introduction and background
In the current study, the prevalence of PMS among a sample of Jordanian women was found to be 80.2%. This prevalence rate was congruent with the results of most studies. For example, Campbell et al. (1997), Johnson (1998) and Barnhart et al. (1995) found that the prevalence of PMS was 75%. Clenchner-Smith et al. (1998) found that the prevalence of PMS was slightly higher (88%) while Tabassum et al. (2005) found it to be slightly lower (53%).
Literature indicated that the prevalence of PMDD ranged between 3% and 10% (Eliot 2002). In the current study, the prevalence of PMDD was found to be 10.2%. This prevalence rate was congruent with the results of Rivera-Tovar & Frank (1990) and Soares et al. (2001) who found that the prevalence of PMDD was around 10% of the menstruating women. However, the prevalence of PMDD in the current study was slightly lower than the results of Tabassum et al. (2005), Angst et al. (2001), Spitzer et al. (2000) who found it to be 18.2%, 13% and 19% respectively.
In this study, the most severe PMS symptoms were: lower back pain (61.4%), abdominal cramp/pain (52.4%), breast pain/tenderness (49.6%), irritability (49.2%), feeling overwhelmed (46.9%) and sadness and depression (45.3%). It is obvious that severe symptoms of PMS were those related to pain (breast, abdomen, back) and negative affect (depression, irritability, sadness), and the least severe symptoms were those related to water retention (bloating, oedema and swelling). These results were congruent with the Thu et al. (2006) results. However, DeRonchi et al. (2005) found that 20% of menstruating women were affected by minor depressive symptoms.
Jordanian women reported that they control or decrease symptoms of PMS and PMDD by taking analgesics, taking hot fluids, wearing warm clothes and lying down on the abdomen. These self-treatment strategies were used mostly because pain was the most severe symptom reported by women; and because of the easiness of medication use or availability of these strategies especially for women who spend long time outside homes such as employees and students. Very few women used SSRI, hormones, diuretics and minerals because these drugs used to overcome severe symptoms, as well as using these medications require medical prescriptions. This study suggested that women with severe symptoms used self-treatment strategies and over the counter analgesics, which may reflect significant unmet medical need for Jordanian women. So, improving clinical identification of these women by mental health nurses and increasing awareness of the women will have a lot of benefit and need extensive work from health professional in educating and treating women in Jordan.
Severity of premenstrual symptoms in the current study increased with age. The least severe symptoms of PMS were reported by students whose age ranged between 18 and 22 years and who were physically active. Employees reported higher severity of premenstrual symptoms than the students. This is may be due to employers' sedentary lifestyle, as lack of exercise contributes to the severity of premenstrual symptoms. Physical activity also relief swelling that occurs before menstruation by enhancing poor physiological brain performance by increasing the circulation to the brain and in effect overrides the limitations caused by symptoms. In addition, severe symptoms were found to be higher among participants who has longer duration of menstrual cycles and who are older.
The findings in the current study regarding BMI is congruent with a study conducted by Masho et al. (2005) who found that women with higher BMI have severe premenstrual symptoms as compared with those who have lower BMI. The role of stress has received considerable attention in association with somatic health. As a result of this association, participants with low level of stress reported the least severe premenstrual symptoms. This is congruent with results of Beck et al. (1990) and Deuster et al. (1999) who found that during stressful situations, cortisol is increased, which in turn worsen the premenstrual symptoms. With respect to the income level, the prevalence of PMS among women with low income level was higher than those who have higher income. This is congruent with study conducted by Deuster et al. (1999) and this is may be due to the belief that low income level is a major life stressful event, which in turn increases the severity of premenstrual symptoms (Johnson 1998, Daugherty 1999, Thys-Jacobs et al. 1999, Bendich 2000, Neal et al. 2000, Carr 2001, Eliot 2002).
Conclusions and implications
In conclusion, this study showed a high prevalence rate of PMS/PMDD among Jordanian women similar to the results reported in different countries. Pain was found to be the most severe and prevalent symptom and using analgesics was the most self-treatment strategy used by women. Increase Jordanian women awareness, increase effectiveness of treatment strategies and improve clinical identification of PMS/PMDD are needed from mental health nurses who are working with women seeking treatment for PMS and PMDD. Mental health nurses may also involve the partners in treatment plans by explaining to them how to help their female partners to deal with the physical and emotional symptoms of PMS and PMDD. However, involving Jordanian male partners in such psycho-maternal issues still considered a cultural barrier and needs work from the mental health nurses to increase the awareness of men about emotional changes caused by PMS and PMDD. Women suffering from PMS or PMDD may use self-treatment strategies such as reducing intake of salt, sugar, caffeine, dairy products and alcohol; eating frequent and smaller portions of foods high in complex carbohydrates; performing exercise regularly; and practising relaxation and stress management techniques.
First, the sample of this study was drawn from only university students and employees who may limit the generalizability of the results to all Jordanian women. In the future, further studies using larger and more representatives sample are encouraged. Second, data of this study were obtained from participants through self-reported questionnaire, which may reflect bias in self-reporting (i.e. participants may have underestimated or overestimated their level of PMS and PMDD symptoms).