PMS: A myth or reality in women’s lives 39
Contents
Abstract 4
Abbreviations 5
List of Tables 6
List of Figures 6
Papers 7
1 Introduction 8
1.1 Context and background of the study 8
1.2 General introduction to the subject of premenstrual experiences 9
1.3 Labeling premenstrual phenomena 12
1.4 Methodology in PMS studies 13
1.4.1 Research designs in PMS studies. 13
1.4.1.1 Use of retrospective vs. prospective methods 13
1.4.1.2 Use of qualitative and quantitative research methods 14
1.4.2 Participants in PMS studies 16
1.4.3 Defining PMS 18
1.4.3.1 The symptoms experienced 19
1.4.3.2 Difference in severity between the postmenstrual and premenstrual phase 21
1.4.3.3 Stability in symptom change between cycles 21
1.4.3.4 The symptomatic baseline on which symptoms fluctuate 23
1.4.3.5 The relationship between appearance of symptoms and menstruation 23
1.5 Prevalence of premenstrual experiences 26
1.6 Demographic characteristics 26
1.7 Theoretical framework in premenstrual syndrome studies 27
1.7.1 Pathophysiology of premenstrual syndrome 27
1.7.2 Other influences on perceptions of PMS 29
1.7.2.1 Psychosomatic influences 29
1.7.2.2 Socialization towards women’s roles 29
1.7.2.3 Social expectation 30
1.7.2.4 Menstrual socialization 30
1.7.2.5 Attribution sof negative moods to the premenstruum 32
1.7.2.6 PMS as a social construction 33
1.7.2.7 Influence of media on PMS reporting 33
1.7.2.8 Theoretical debates 34
1.8 Management of premenstrual experiences 37
1.9 Rationale for the study 38
2 Aims of the thesis 40
3 Methods 41
3.1 Participants 41
3.1.1 Participants in study 1 41
3.1.2 Participants and procedure in study 2 41
3.1.3 Participants in study 3 43
3.2 Design 44
3.3 Measures 44
3.3.1 Measures in study 1 44
3.4 Measures in study 2. 45
3.4.1 Menstrual cycle experiences 45
3.4.2 Cyclicity of symptoms and symptom groups 46
3.4.3 Criteria for diagnosing PMDD 47
3.5 Cyclicity of symptoms and symptom groups 47
3.5.1 Health interview containing items related to menstrual socialization and aspects of daily living 48
3.6 Measures in study 3. 50
3.6.1 Participant selection 50
3.6.2 Interviews 51
3.7 Statistics 53
3.8 Ethical considerations 55
4 Results 56
4.1 Demographic characteristic of participants in studies 1-3 56
4.2 Premenstrual changes as described in retrospective report 56
4.3 Cyclicity in symptoms and symptom groups as described in daily prospective charting 57
4.4 Changes in symptom cyclicity and symptoms group cyclicity in multiple menstrual cycles as described in daily prospective charting 60
4.5 Severity changes between menstrual cycles 62
4.6 Healthy women’s perceptions of experiences that they label PMS 62
4.7 Perceptions of the discussion of PMS in the participants’ own social groups as well as generally in society 62
4.8 Relationship between menstrual cycle experiences with menstrual socialization and various aspects of daily living 63
4.8.1 Study 1 63
4.8.2 Studies 2 and 3 63
4.8.2.1 Menstrual characteristics and recollection of menarche 63
4.8.2.2 Health and health practices 63
4.8.2.3 Attitudes towards menstruation 64
5 Discussion 65
5.1 Retrospective vs. prospective prevalence rates of premenstrual experiences 66
5.2 Explaining differences in prevalence according to assessment methods 67
5.2.1 Social cultural explanations 67
5.2.2 Cyclical experiences 68
5.3 Type of symptoms experienced 69
5.4 Emphasis on negative experiences 70
5.5 Variability of PMS 71
5.6 Menstrual socialization and daily living 72
5.7 Conflicting perceptions 72
5.8 The importance of recognizing PMS 73
5.9 Use of oral contraceptives 74
5.10 Methodological considerations 74
5.10.1 Participation 74
5.10.2 Number of symptoms tested – grouping of symptoms 75
5.10.3 The use of interviews to collect data 76
5.10.4 Language 77
6 General conclusion 78
7 Acknowledgements 79
8 References 80
Abstract
The main aim of this thesis is to describe the premenstrual cycle experiences in a sample of healthy Icelandic women. In order to do so three studies were conducted. The first study was a retrospective study of the prevalence of premenstrual syndrome (PMS) in a randomly selected sample of healthy women (n=133). A list of 20 experiences, that the participants rated retrospectively, was used to assess PMS. The second study was a prospective study of the prevalence of symptom cyclicity and of Premenstrual Dysphoric Disorder (PMDD) (n=83) in a random sample of healthy women using and not using oral contraceptives (OCs) (II, III). The participants rated daily a list of 57 experiences for one to six menstrual cycles each, with the majority charting three cycles. In the third study an in depth interview was performed with a subgroup of the women participating in study 2, in order to gain an understanding of the perceptions they have about PMS (IV, V). The data from studies 1 and 2 were analyzed by use of descriptive and inferential statistics. Cyclicity between the follicular phase and the luteal phase was ascertained by use of the Mann-Whitney U test. Significance level was set at p.< 0.05. The data from study 3 were analyzed by use of qualitative content analysis.
The findings are that retrospectively 64% of the participants in study 1 reported PMS, with 30% experiencing severe PMS (I). In study 2, 52% of the participants were self-diagnosed with PMS. However, by use of prospective charting only 2-6% of the participants fulfilled criteria for PMDD. Over 90% of the participants experienced cyclicity in at least one symptom in at least one menstrual cycle charted. Eighty-one percent experienced a PMS-like pattern of cyclical change (higher severity during the premenstrual phase compared to the postmenstrual phase) and 72% a reverse PMS-like pattern of cyclical change in at least one symptom. A major conclusion is that cyclicity is common in healthy women and should be interpreted as normal. Thirty-three women experienced a recurrent cyclicity in two or more menstrual cycles. However, each of them experienced recurrent cyclicity in few symptoms; 12 of them experienced a recurring cyclicity in one symptom only; 11 in two symptoms only and 10 experienced symptom cyclicity in three to eight symptoms. More than half of the 33 women displaying recurrent cyclicity, displayed different kinds of cyclicity (a PMS-like or reverse PMS-like) in different menstrual cycles. It is concluded that cyclicity is highly variable and does not at all follow a typical PMS pattern. Somatic symptoms did most often display cyclicity. Only six symptoms displayed cyclicity in multiple cycles by four or more women. Those symptoms were: painful or tender breasts, demonstrated by 10 women; bloating or swelling of abdomen, demonstrated by seven women; sensation of weight gain, demonstrated by six women; and skin disorders, dizziness or light headedness and increased food intake each demonstrated by four women. Only one psychoemotional symptom, irritability, displayed cyclicity in one woman in two menstrual cycles.
The qualitative interviews reveal that when women say they have PMS they are not saying that they have a medical condition. Rather, they say that they are aware of changes in various experiences during the premenstrual phase of some menstrual cycles, changes most women can manage by themselves. This they label PMS. It is possible that women attach different meaning to the construct PMS than researchers and clinicians do. This might in part explain the discrepancy between studies that have assessed the prevalence of PMS by use of prospective vs. retrospective methods. In addition women perceive that the public talk about PMS turns their own experiences against them. The study confirms the picture drawn previously that media description of the experiences of women reflects men’s views rather than women’s experiences. The study adds to the picture that women base discussion about their own experiences on those same experiences but base their talk about other women’s experiences on negative, stereotypical, male-based, view of the premenstrual woman. In so doing women themselves take part in constructing and sustaining a negative, stereotypical view of the premenstrual woman, a view they themselves reject.
It is concluded that due to varied direction of symptom severity change over multiple cycles, prospective daily ratings are necessary to achieve a true picture of menstrual related symptom cyclicity in the general population. In order to understand the premenstrual experiences of women these experiences should also be viewed within the physiological, psychological, sociological, historical and cultural context each woman finds herself in.
Key words: Premenstrual syndrome, menstrual cycle, women’s health, content analysis, cyclicity, qualitative analysis, premenstrual dysphoric disorder.
Abbreviations
ATM Attitudes towards menstruation
CPD Cycle phase difference
DHD Daily Health Diary
DSM Diagnostic and Statistical Manual
FP Follicular phase
LLPDD Late luteal phase dysphoric disorder
LP Luteal phase
MAQ Menstrual attitude questionnaire
MC Menstrual cycle
MDQ Menstrual distress questionnaire
MPMC Minor premenstrual changes
OC Oral contraceptive
PAF Premenstrual assessment form
PCL Premenstrual change list
PMC Premenstrual changes
PMDD Premenstrual dysphoric disorder
PMM Premenstrual magnification pattern
PMS Premenstrual syndrome
PMT Premenstrual tension
SPMC Severe premenstrual changes
SSS Summarized symptom scores
List of tables Page
Table 1 Definitional aspects of PMS addressed inconsistently across studies 18
Table 2 Criteria for premenstrual dysphoric disorder (PMDD) 19
Table 3 Methods used in different studies to detect symptom change over
the menstrual cycle 22
Table 4 Days used in different studies to define the postmenstrual
and premenstrual phases of the menstrual cycle 24
Table 5 Characteristics of the participants and study design 42
Table 6 The symptom checklist as presented to the participants 46
Table 7 Menstrual cycle pattern 49
Table 8 Individual menstrual cycle patterns of women who for at least one
menstrual cycle display a high cycle phase difference 51
Table 9 Statistics used 54
Table 10 Type of change/cyclicity demonstrated by participants in
at least one symptom 57
Table 11 Number of times each symptom displays a PMS-like and a reverse PMS- like
pattern of change by menstrual cycle, total sample and use of OCs* 58
Table 12 Number of women demonstrating symptom change in recurrent cycles by
use of OCs, number of cycles charted, number of symptoms demonstrating
change and symptom patterns 61
List of figures
Figure 1 Mean Z-scores for mood and physical symptoms, and hormone variation
during the menstrual cycle in patients with PMS 11
Figure 2 Different types of PMS patterns 25
Papers
The thesis will be based on the following original articles, which will be referred to in the text by their roman numerals.
I Sveinsdóttir, H. & Marteinsdóttir, G. (1991). Retrospective assessment of premenstrual changes in Icelandic women. Health Care for Women International, 12, 303-315.
II Sveinsdóttir, H. & Bäckström, T. Prevalence of menstrual cycle symptom cyclicity and premenstrual dysphoric disorder in a random sample of women using and not using oral contraceptives. Acta Obstetricia et Gynecologica Scandinavica, in press.
III Sveinsdóttir, H. & Bäckström, T. Menstrual cycle symptom variation in a community sample of women using and not using oral contraceptives. Acta Obstetricia et Gynecologica Scandinavica, in press.
IV Sveinsdóttir, H., Lundman, B. & Norberg, A. (1999). Women’s perceptions of phenomena they label premenstrual tension: Normal experiences reflecting ordinary behavior. Journal of Advanced Nursing, 30, 916-925.
V Sveinsdóttir, H., Lundman, B. & Norberg, A. Whose voice? Whose experiences? Women’s qualitative accounts of general and private discussion of premenstrual syndrome. Manuscript submitted for publication.
The papers have been printed with the kind permission of the respective journals.
1 Introduction
1.1 Context and background of the study
This study is a population-based community study on premenstrual experiences among Icelandic women. My interest in premenstrual experiences was awakened when, in 1984, I started my graduate studies in the United States of America (USA). At that time I had not heard of this phenomenon. I had heard of menstrual pain, but not of women suffering from changes with various psychoemotional experiences premenstrually. This seemed however to be general knowledge in the USA. I found my gap in knowledge on this subject very interesting, especially since, apart from being a woman, I was educated in a woman’s profession (nursing) and worked mostly with women. During my study years in the USA and after my return to Iceland, I found it relevant to study this phenomenon in my own culture in order to get a better understanding of it for the sake of better healthcare in Iceland. Prior to the present study only one study had been done in Iceland on the prevalence of premenstrual experiences (Sigur›ardóttir et al. 1987). Nursing students under the guidance of Dr. Gu›rún Marteinsdóttir, who is the co-author of the first study in this thesis, conducted the study. Premenstrual experiences have not received much public coverage in Iceland. Icelanders have however read in Icelandic magazines that up to 40% of women are severely debilitated by their premenstrual symptoms and that the symptoms can be treated (Ármannsdóttir, 1988; Hauksson, 1989; Leósdóttir, 1993). Icelandic media and magazines have however never been Icelanders’ only access to ‘public’ information. They have access to a variety of English/American literature with 79% of the nation having access to the Internet (Office of the Prime Minister of Iceland, 1999).
Premenstrual experiences seem to be a phenomenon laden with cultural and social connotations (Johnson, 1987; Parlee, 1992). It is therefore important for the reader of the study to be somewhat familiar with the social and cultural context of the participants. A short presentation on this context therefore follows.
The small nation of Iceland has a mostly homogeneous Nordic population, a high standard of living, good education, little unemployment and national health insurance. The total population is 270,000, with 995 women per 1000 men (National Bureau of Iceland, 1997). Over half the population lives in the capital Reykjavik.
Icelandic society has been slow in responding to rapid social changes that have taken place in modern society during the last 30 years (Vilhjálmsson, 1998). In a relatively short period, the employment rate of women has risen to nearly 80%. At the same time, access to childcare, longer school hours for children and more active participation of men in housework have lagged behind
(Ólafsson, 1990; National Bureau of Iceland, 1997), resulting in increased dissatisfaction among parents (Júlíusdóttir, 1997). The nuclear family is the most common family structure, the women take responsibility of family and children (Júlíusdóttur et al. 1995). Women also take what seems to be full responsibility for family planning. Clearly reflecting this is the fact that 93% of sterilization procedures in 1981-1995 were performed on women but only seven percent on men (The National Bureau of Iceland, 1997). On average Icelandic girls start menstruating 13 years of age (Knútsdóttir & Broddadóttir, 1999), first have sexual intercourse when 15.5 years old (Bender, 1999), give birth to their first child when 25 years old and have 2.1 children (National Bureau of Iceland, 1998).