Abstract
Background: Premenstrual syndrome is one of the common problems affecting female in different age groups and could affects the academic performance of students.
Aims of this study were to estimate the prevalence of premenstrual syndrome and determine its effect on school performance among university medical students.
Material and Methods: It was a cross-sectional study done in Al-Madinah city, Saudi Arabia including all female medical students from level 2 to 5, enrolled at Taibah University. Data were collected through self-administrated questionnaire. It contains 4 main parts: socio demographic characters of the students, menstrual and premenstrual characteristics, and premenstrual syndrome scale.
Results: The study included 257 students, with a response rate of 70.8%. Their age ranged between 18 and 29 years with an arithmetic mean of 21.8 years and a Standard Deviation (SD) of 1.8 years. According to the premenstrual syndrome scale score with a cut-off level of 111, the prevalence of PMS among female medical students was 65.4%. PMS was not significantly associated with students` academic performance. However, it is associated with premenstrual or menstrual pain (p<0.001), family history of premenstrual syndrome (p=0.016), dysmenorrhea (p=0.002) and severe back pain or cramps (p<0.001 and p=0.007, respectively).
Conclusion: Premenstrual tension syndrome is a prevalent alarming health problem affecting a great sector of female medical University students, Taibah University, Al-Madinah, Saudi Arabia. It affected the daily work of a considerable proportion of students. However, it did not impact their academic performance.
Keywords: Premenstrual tension syndrome; Prevalence; Academic performance; Medical students
Introduction
Menstruation is a natural phenomenon involving the discharge of blood from the uterus through the vagina, occurring at more or less regular monthly intervals during the reproductive life of female [1]. Normal menstruation first occurs in adolescents between 11 and 14 years of age, with a period length of 7 days or less, and a normal cycle length of 21 to 45 days with average blood loss of 20-80ml [2].There are various types of menstrual disorders one of them is Premenstrual Syndrome (PMS).
Premenstrual Syndrome (PMS) is describing cognitive, physical, affective, psychological, and behavioral symptoms that occur during the luteal phase of the menstrual cycle and resolve quickly within a few days of the onset of menstruation. Premenstrual syndrome has different criteria by different organizations. The intensity of the symptoms varies among individuals and also between cycles in the same individual. Approximately 20-30% of premenopausal women exhibit PMS symptoms and 5-8% suffer from extreme psychological disturbances that are classified as Premenstrual Dysphoric Disorder (PMDD) under Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) [3].
While PMS is associated with 200 different symptoms, the underlying cause(s) remain unclear. It is believed that the trigger behind PMS is multifactorial in nature, with perturbations in reproductive hormone levels being one of the major causes. Hormonal fluctuations differ among women, which explain the differences in the severity of the symptoms.
Different hypotheses have been suggested for explanation how the PMS occurs such as thyroid dysfunction, genetic factors, hypoglycemia, hormonal imbalance, fluid retention, stress and psychological factors but mainly it occurs secondary to hormonal imbalance [4]. In addition, lifestyle habits like nutritional history and regular exercise could be linked with premenstrual syndrome [5]. Many studies showed that there is a strong association between the PMS and impaired quality of life among young age group women. However, the quality of life is also affected by both social and working life. PMS also has an effect on the quality of sleeping [6]. The PMS among young adolescents’ age groups girls could also affect their school performance and social interactions in a negative way. Approximately 80% of reproductive age women experience these symptoms pre-menstrual at some point in their lifetime [7].
PMS is associated with a lower positive academic affect and lower frontal rest asymmetry scores [8]. Which are themselves related to reward processing dysfunction, lower productivity, and an interference with studies, however, this has been less studied specially in Saudi Arabia. Thus this study was designed to estimate the prevalence of premenstrual syndrome and its effect on academic performance among Taibah university students in Madinah Saudi Arabia.
Methodology
This was a cross-sectional study conducted from July 2021 to December 2021, in the Taibah university, Madinah Al-Munawarah, which is located in northern Saudi Arabia. Female medical students were included from all academic years. According to the WHO sample size calculator, the sample size was 360. Data was collected through self-administrated questionnaire.
It contains 3 main parts:
1. Socio demographic characters of the students.
2. Menstrual and premenstrual characteristics.
3. Premenstrual syndrome scale to define premenstrual tension syndrome.
It includes nine subscales; “depressive feelings, anxiety, fatigue, irritability, depressive thinking pain, changed appetite, changed sleep, and swelling subscales. The total PMS score was computed PMS (44-220). Students scored 111 or higher were regards as having premenstrual syndrome [9].
After obtaining approval from the research committee in Madinah, consent was taken from the program director of Joint Program of Family Medicine. The researcher distributed a questionnaire to students after taking their consent and explained and clarified it to them and the questionnaire was taken at the same time by the researcher from the respondents.
Data were analyzed using the Statistical Package for the Social Sciences version 26 (SPSS Incl., Chicago, IL). Qualitative variables were presented as frequency and percent. Quantitative variables were tested for normality distribution and were presented as mean and standard deviation. The Chi-square test was used for group comparison. This study considered variables statistically significant at p < 0.05.Results
The study included 257 students; out of a total targeted of 363 with a response rate of 70.8%. Table 1 summarized the Sociodemographic characteristics of the participants. Their age ranged between 18 and 29 years with an arithmetic mean of 21.8±1.8 years. Majority of them 248(96.5%) were Saudis and singles 243(95.6%). Only 7(2.7%) of the students had children. More than one-quarter 70(27.2%) were enrolled in the 6th academic year whereas only 9.7% were enrolled in the 4th academic year (Table 1 and Figure 1,2 and 3).
Figure 1: Body mass index of the female medical students, Taibah University, Al Madinah.
Figure 2: History of regular practice of physical exercise among the female
medical students, Taibah University, Al Madinah.
Figure 3: History of chronic diseases among the female medical students,
Taibah University, Al Madinah.
Frequency
Percentage
Nationality
Saudi
248
96.5
Non-Saudi
9
3.5
Age in years
Range
18-29
Mean±SD
21.8±1.8
Marital status
Single
243
95.6
Married
14
5.4
Having children
No
250
97.3
Yes
7
2.7
Academic level (year)
2nd
53
20.6
3rd
53
20.6
4th
25
9.7
5th
56
21.8
6th
70
27.2
Grade point average (n=229)
Range
3.45-5
Mean±SD
4.53±0.34
SD: Standard deviation
Table 1: Sociodemographic characteristics of the participants (n=257).
Table 2 summarizes the menstrual and premenstrual characteristics of the participants. The age of menarche ranged between 9 and 19 years with an arithmetic mean of 12.5 years and standard deviation of 1.4 years. Premenstrual or menstrual pain was mentioned by majority of the students (81.3%). Family history of premenstrual syndrome was reported by 40.5% of the respondents while using drugs for menstrual regulation was seen among 13.2% of them. Almost half of them (49%) had dysmenorrheal while severe back pain and cramps were reported by 23% and 35% of the students, respectively (Table 2).
Frequency
Percentage
Age at menarche
Range
Sep-19
Mean±SD
12.5±1.4
History of premenstrual or menstrual pain
No
48
18.7
Yes
209
81.3
Family history of premenstrual syndrome
No
153
59.5
Yes
104
40.5
Using drugs for menstrual regulation
No
223
86.8
Yes
34
13.2
History of dysmenorrhoea
No
131
51
Yes
126
49
Back pain during first two days of the period
Mild
100
38.9
Moderate
98
38.1
Severe
59
23
Cramps during the first two days of the period
Mild
58
22.6
Moderate
109
42.4
Severe
90
35
Table 2: Menstrual and premenstrual characteristics of the female medical students, Taibah University, Al Madinah.
Taking pain pills (44%), hot applications (28%) and resting (21.8%) were the most frequently reported methods by students to reduce the menstrual pain (Figure 4 and 5).
Figure 4: Methods of reducing menstrual pain among the female medical
students, Taibah University, Al Madinah.
Figure 5: Affection of daily work by menstruation among the female medical
students, Taibah University, Al Madinah.
According to the premenstrual syndrome scale score with a cutoff level of 111, the prevalence of PMS among female medical students was 65.4% as clear from Figure 6.
Almost two-thirds (66.4%) of students with no children compared to 28.6%) of those with children had PMS. However, this difference was borderline insignificant, p=0.051. Other studied Sociodemographic factors (nationality, age, marital status, academic level, academic performance “GPA”, regular practice of physical exercise and smoking) were not significantly associated with PMS (Table 3).
Premenstrual tension syndrome
p-value
No
Yes
N=89
N=168
N (%)
N (%)
Nationality
Saudi (n=248)
86 (34.7)
162 (65.3)
0.619**
Non-Saudi (n=9)
3 (33.3)
6 (66.7)
Age in years
Mean±SD
21.7±1.8
21.8±1.9
0.722
Marital status
Single (n=243)
83 (34.2)
160 (65.8)
0.506*
Married (n=14)
6 (42.9)
8 (57.1)
Having children
No (n=250)
84 (33.6)
166 (66.4)
0.051**
Yes (n=7)
5 (71.4)
2 (28.6)
Academic level (year)
2nd (n=53)
14 (26.4)
39 (73.6)
0.400*
3rd (n=53)
23 (43.4)
30 (56.6)
4th (n=25)
10 (40.0)
15 (60.0)
5th (n=56)
20 (35.7)
36 (64.3)
6th (n=70)
22 (31.4)
48 (68.6)
Grade point average (n=229)
81
148
0.333
Mean±SD
4.56±0.34
4.52±0.35
Regular practice of physical exercise
No (n=192)
63 (32.8)
129 (67.2)
0.292*
Yes (n=65)
26 (40.0)
39 (60.0)
Smoking
No (n=251)
88 (35.1)
163 (64.9)
0.323**
Yes (n=6)
1 (16.7)
5 (83.3)
*Chi-square test, **Fischer Exact test, Student t-test.
Table 3: Socio-demographic factors associated with premenstrual tension syndrome among female medical students, Taibah University.
Most of students who had history of premenstrual or menstrual pain expressed PMS compared to their counterparts (70.8% vs. 41.7%), p<0.001. Students with family history of premenstrual syndrome were more likely to have PMS compared to their peers (74% vs. 59.5%), p=0.016. Similarly, students with dysmenorrhea were more likely to have PMS compared to others without such history (74.6% vs. 56.5%), p=0.002. Students with severe back pain or cramps were more likely to have PMS than those with mild degrees of both problems, p<0.001 and p=0.007, respectively (Table 4).
Premenstrual tension syndrome
p-value
No
Yes
N=89
N=168
N (%)
N (%)
Age at menarche
Mean±SD
12.4±1.4
12.6±1.5
0.166
History of premenstrual or menstrual pain
No (n=48)
28 (58.3)
20 (41.7)
<0.001*
Yes (n=209)
61 (29.2)
148 (70.8)
Family history of premenstrual syndrome
No (n=153)
62 (40.5)
91 (59.5)
0.016*
Yes (n=104)
27 (26.0)
77 (74.0)
Using drugs for menstrual regulation
No (n=222)
82 (36.9)
140 (63.1)
0.062*
Yes (n=34)
7 (20.6)
27 (79.4)
History of dysmenorrhoea
No (n=131)
57 (43.5)
74 (56.5)
0.002*
Yes (n=126)
32 (25.4)
94 (74.6)
Back pain during first two days of the period
Mild (n=100)
51 (51.0)
49 (49.0)
<0.001*
Moderate (n=98)
25 (25.5)
73 (74.5)
Severe (n=59)
13 (22.0)
46 (78.0)
Cramps during the first two days of the period
Mild (n=58)
28 (48.3)
3 (51.7)
0.007*
Moderate (n=109)
40 (36.7)
69 (63.3)
Severe (n=90)
21 (23.3)
69 (76.7)
*Chi-square test, Student t-test
Table 4: Menstrual and premenstrual factors associated with premenstrual tension syndrome among female medical students, Taibah University.
Table 5 shows the mean and standard deviation of the total and subscales of PMS score, in addition to rates of students scored over 50% in each. The highest one was observed regarding depressive thoughts and feeling (69.6%), followed by change in appetite (66.1%), fatigue (63.4%) and swelling (62.6%). The lowest percentage was observed regarding anxiety (44.4%). The mean total score was 120.01±29.39 (Table 5).
PMS score subscales
Range
Mean±SD
Girls receiving more than
50% from subscales
N (%)Depressive feeling (7 items)
7-34
20.08±6.02
179 (69.6)
Anxiety (7 items)
7-31
17.02±5.41
114 (44.4)
Fatigue (6 items)
6-30
16.82±4.53
163 (63.4)
Irritability (5 items)
5-25
12.88±4.22
143 (55.6)
Depressive thoughts (7 items)
7-35
20.73±6.30
179 (69.6)
Pain (3 items)
3-15
7.71±2.49
130 (50.6)
Changes in appetite (3 items)
3-15
8.57±2.49
170 (66.1)
Changes in sleeping habits (3 items)
3-15
7.80±2.64
134 (52.1)
Swelling (3 items)
3-15
8.40±2.85
161 (62.6)
Total score (44 items)
44-212
120.01±29.39
168 (65.4)
Table 5: Description of the total and subscales scores and frequency of students receiving over 50% from subscales and total PMS score (n=257).
Discussion
In the present study carried out among medical students at Taibah University, Al-Madinah, Saudi Arabia, the prevalence of Premenstrual syndrome (PMS) was 65.4% according to the premenstrual syndrome scale score with a cut-off level of 111. This rate although high, is lower than that reported among Palestinian university students as all of them had PMS symptoms of variable severity; 58.3% had moderate PMS whereas 17.1% had severe PMS symptoms in one study [10] while the other Palestinian study reported a rate of 71.9% [11]. Also in the United Arab of Emirates (UAE), all university students had PMS symptoms; 55% and 8% had moderate and severe PMS symptoms, respectively [12]. Very high rate also reported in Turkey among medical students (91.8%), [3] and in Dammam. Saudi Arabia among health sciences students as 91% of them suffering from some kind of menstrual problem; including irregular menstruation (27%), abnormal vaginal bleeding (9.3%), amenorrhea (9.2%), menorrhagia (3.4%), dysmenorrhea (89.7%), and premenstrual symptoms (46.7%) [7]. In Jordan, also a very high prevalence (92.3%) has been observed among University students [13]. However, our rate is higher than those reported by others. In another study carried out in Turkey, using the same tool applied in the present study with the same cutoff value (111), the prevalence among university students was 49.7% [14]. In Al-Ahsa, PMS was diagnosed in 35.6% of medical students [8]. In Ethiopia, a rate of 37% has been observed among college students [15]. In India, among medical students, also a rate of 37% has been recorded [16]. In Iran, the prevalence of PMS was 39.5% among medical students; more than half of them (60.6%) had mild, 25.1% had moderate and 14.2% had severe PMS [4].
In the current study, the highest reported domain of PMS was depressive thoughts and feeling, followed by change in appetite, fatigue and swelling and the lowest one was anxiety. In a similar Turkish study [14] using the same tool with the same cut-offs, the most frequent reported domain was changes in appetite, followed by irritability, swelling, fatigue, pain and depressive feelings in that order. Difference between the two studies could be explained by cultural difference. In another Turkish study, the commonest reported symptoms were abdominal bloating, irritability and breast tenderness. [3].
In the present study, PMS was not associated with Sociodemographic characteristics of the students. However, it was associated with premenstrual or menstrual pain, family history of premenstrual syndrome, dysmenorrhea and severe back pain or cramps. In a similar study carried out among medical students in Turkey, family history significantly affected the severity of PMS and quality of life of students [3]. In Iran, PMS was found to be significantly high in medical students who have positive history of PMS in their first degree relatives and who have used drugs to relieve PMS symptoms [4]. In Al-Hasa, older age medical students, those living in rural residence, with lower family income, family history of PMS, lower age at menarche, and irregularity of menses were more likely to be affected [8].
In the present study, PMS was not significantly associated with students` academic performance. However, more than one-third of the students (39.7%) reported affection of their daily work by menstruation. Similarly, other studies reported impact of PMS on women`s work activities [17-20]. Other studies observed negative impact of PMS on academic performance of students and explained this by the fact that university students, as a result of their stressful environment caused by their strive for higher academic achievement, may lack capabilities to manage their psychological and social demands and consequently suffer from more signs and symptoms of PMS [13,21].
Limitations of the present study including the implementation of the study in one University and among only medical students, which could influence the ability to generalize the findings over other universities and colleges in Saudi Arabia. Moreover, depending on a self-reported tool to diagnose PMS is considered a limitation, despite this tool is valid. Also, the applied tool did not classify cases according to their severity, which is important issue. Finally, the cross-sectional design, which proves only association and not causality between exposure and outcome, is considered one of the limitations. Despite those limitations, the study explored am important common health problem and investigated its impact on academic performance and other associated factors among a vulnerable sedctor of the Saudi community.
Conclusion
Premenstrual Tension Syndrome (PMS) is a prevalent alarming health problem affecting a great sector of female medical University students, Taibah University, Al-Madinah, Saudi Arabia. It affected the daily work of a considerable proportion of students. However, it did not impact their academic performance. PMS was not associated with Sociodemographic characteristics of the students. However, it was associated with premenstrual or menstrual pain, family history of premenstrual syndrome, dysmenorrhea and severe back pain or cramps. The highest reported domain of PMS was depressive thoughts and feeling, followed by change in appetite, fatigue and swelling and the lowest one was anxiety.
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