Prevalence of Premenstrual Syndrome In Females of Gujranwala Division And Its Associated Risk Factors

: Introduction: Premenstrual syndrome (PMS) is characterized by cyclic reoccurrence of distressing somatic and psychological manifestations, during luteal phase of menstrual cycle. Present research work aims to investigate prevalence of PMS in females of Gujranwala division Pakistan and to explore various risk factors associated with this syndrome. Methods: The study included self-administered questionnaire, for diagnosis of PMS and PMDD. Participants were analysed for socio-demographic characteristics and menstrual history, serum cholesterol and haemoglobin levels of patients and control were measured. Results: In the present study, 56% females were screened positive for PMS while Prevalence PMDD was 18%. Most common physical symptoms of PMS were abdominal bloating (63.2%), muscle pain (71.73%), lack of energy (85.85%) and appetite change (79.15%) whereas major distressing psychological were Irritability (82.32%), anger (74.55%), depression (49%) and anxiety (63.2%). Prevalence of PMS was 22.6% in underweight, 50.1% in participants having normal weight, 15.5% in overweight individuals and 11.6% in obese. Anaemia (P = 0.00), fatigue (P = 0.00), dysmenorrhea (P = 0.00), family history of PMS (P = 0.00) and residential area (P = 0.047) were major risk factors for development of different symptoms of PMS. Conclusion: Statistically significant association was not confirmed between PMS, obesity and blood cholesterol level. PMS is a common menstrual disorder among reproductive females of Gujranwala division, Pakistan. Findings of the study revealed that anemic females were at risk to develop PMS symptoms.


Introduction
Premenstrual syndrome (PMS) is a psychotic neuroendocrine disorder having biological, social and psychological parameters.It refers to a collection of distressing symptoms that arise around the end of luteal phase (7 to 14 days prior menstruation) of menstrual cycle and remit with onset of menstruation [1].Most common symptoms include anger, irritability, anxiety, mood swings, fatigue, headache, back pain, nausea, bowel movements, mastalgia, weight gain, acne, joint pain, peripheral edema and bloating [2].Premenstrual Dysphoric disorder (PMDD) is an extreme, predominantly psychological end of PMS [3].Incidence of PMS is widespread, epidemiological surveys indicated that 100% adolescents are suffering from at least one symptom of PMS [4].About 80% women report mild symptoms while 20-50% report moderate symptoms, severe symptoms of PMS has been reported by 5% females with impairment of functioning in social and occupational context [5].The aetiology of PMS is unclear and multifactorial.Emergence of PMS has been related to biological, genetic, social, psychological and environmental factors [6].Among the causative factors of PMS [7].Hormonal, metabolic and neurotransmitter actions are of great interest.Stress is considered as an important contributor to develop psychological symptoms of PMS by increasing adrenal cortisol and decreasing brain beta-endrophin [8].In medical practice PMS remains a clinical entity of great significance.It is not a life threatening disorder but it can seriously affect quality of life and productivity of women besides physical and mental health [9].Different treatments such as lifestyle modification, stress management, sports, herbal medicines, selective serotonin reuptake inhibitors (SSRIs), and anti-depressants have been utilized to cure symptoms of PMS [10].The aim of the study was to investigate prevalence of PMS in females of Gujranwala division Pakistan, to assess haemoglobin level in subjects having PMS and its possible correlation with PMS and to explore association between obesity, serum cholesterol level and PMS.Several studies have been conducted globally to find out possible association of PMS with obesity and dyslipidemia.Results of some studies identify a positive relation between PMS, obesity and family history of dyslipidemia while others identify not a statistically significant association between them.We have designed this study for better understanding of pathophysiology of PMS.In countries like Pakistan it was usually considered as a stigma even to talk about problems related to menstruation.But now, perception has been changed with time and health is considered as obvious right of women still, women in Pakistan are raised thinking that PMS is not a disease, it is a part of being women.We considered it as an under investigated area as few studies, only in Karachi and Islamabad have been conducted, reporting higher prevalence rate (80.6%) of PMS hence, the study was planned.It is very important to pay attention to problems of women such as PMS that are related to their physical and mental health.

Study design and participants:
The cross-sectional study comprised of two stages.At first stage 500 respondents (age between 14-45) for prevalence were evaluated, including housewives, working ladies from rural and urban areas, students from different schools, colleges and universities of Gujranwala division Pakistan.In second step premenstrual serum cholesterol levels and Hb of only 80 PMS-patients and 20 controls were measured, due to lack of funding resources.But majority of surveyed population represented age group of 14-25 years (70.2%) as older age females of Gujranwala region considered menstrual illness as a taboo or stigma which hinders open communication and it was rooted in the believes of the older age females that menstrual issues are source of shame and not to be discussed.Pregnant females, hospitalized Patients with psychological and medical problems that mimic with PMS, subjects taking antidepressant and psychotherapy, having family history of high blood pressure and thyroid diseases were excluded from study.The purpose of the study was explained and informed consent was obtained from participants.The participants were asked to fill a self-administered questionnaire, designed with the help of gynecologist and statistician.Questionnaire comprised of socio-demographic and premenstrual assessment form for diagnosis of PMS based on diagnostic criteria of American College of Obstetricians and Gynecologists (ACOG).Subjects were requested to rate different items that represent signs and symptoms of PMS on a 4 point scale ranging from no change to severe change of usual condition.Participants of the study having at least one effective and one somatic symptom, five days before the onset of menses, these symptoms remit within four days of onset of menses, with no reappearance till day thirteen and this situation is consistent in last three months, were considered as patients of clinically significant PMS.PMDD require presence of at least five symptoms (one of which must be effective symptom).Interference in social activities, work, school or relationship must be experienced [3].

Calculation of body mass index:
Body Mass Index (BMI) was utilized as an indicator of obesity.On the basis of BMI participants were categorized as underweight (BMI < 18.5), normal (BMI = 18.5-24.9),Overweight (BMI = 25-29.9)and obese (BMI of 30 or greater).
Collection of blood samples and lab measurements: After completion of questionnaire 5cc blood samples were collected aseptically from PMS patients (n = 80) and controls (n = 20) by venepuncture.ACOG criteria for PMS was used to categorize cases and control group.Blood samples (1.5 cc) were collected in CBC vials and stored at 4°C for analysis of blood haemoglobin level.Remaining 3.5cc blood samples were stored in clot activator tube, centrifuged at 13500 rpm to get the serum and stored at -20°C for analysis.All the samples were analysed in Biochemical Lab of University of Gujrat.The concentration of haemoglobin was determined by Sahli'shemoglobinometer.Total serum cholesterol, low density lipoprotein (LDL) levels were determined by using commercially available kits (Merck, Germany) and microplate reader (Diamate, UK).Serum Triglycerides level was determined by using commercially available kit (Merck, Germany) and spectrophotometer (Teico diagnostic, USA).

Statistical analysis:
The statistical analysis was carried out using IBM SPSS statistics v. 23.0.Pearson's chi square test and student t-test were utilized for data analysis.P-value of less than 0.05 was considered statistically significant.

Results:
Mean age of the participants was 21.9 ± 5.74 years, most of them were students (82%), unmarried (84.4%) and urban residents (58%).Mean weight and height of participants was 55.6 ± 13.09 (kg) and 5.2 ± 0.29 (feet) respectively.Largest group was represented by women having menstrual cycle duration of 21-35 days (71.4%) with duration of menstruation 4-7 days (74.1%) and age at menarche 12-14 years (67.8%).The overview of sociodemographic characteristics of surveyed population is presented in Table 1.Mean ± SD 5.2 ± 0.29 In the current study magnitude of PMS was found to be 56% and PMDD was 18% in females of Gujranwala division Pakistan and 26% participants were normal as shown in  3.More than half (64%) of the participants were having menstrual irregularities.Only 17% females were aware of PMS and 83% of the participants felt that it is normal part of menstruation.Prevalence rate of PMS was higher (68.9%) in urban area as compared to rural area (31%).PMS was found to be a major gynecological problem (78%) in younger females (14-25 years) as compared to (22.2%) in older (25-45 years).Prevalence of PMS in participants having family history of PMS was 67.84% and 32.15% in participants without PMS history.The results of our study shows possible association of PMS with dysmenorrhea.Prevalence of PMS was lower (25%) in participants having regular exercise and higher (74.9%) in participants without regular exercise but a statistically significant association was not reported (P = 0.682).Statistically significant association between PMS, dysmenorrhea (P = 0.00), family history of PMS (P = 0.00), fatigue (P = 0.00) and residential area (P = 0.047) was observed in our study.Findings of present study reported that prevalence of PMS in underweight, overweight, healthy weight and obese females was 22.6%, 15.5%, 50.1% and 11.6% respectively.A statistically significant relation between BMI and occurrence of PMS was not detected (P = 0.15) as shown in Table 2.

Data expressed as number (Percentage)
Mean haemoglobin level of PMS patients was lower 9.2 ± 1.003 g/dL as compared to participants who did not have PMS 10.3 ± 1.087 g/dL.Significant difference was reported between mean Hb levels of PMS patients and control (P = 0.00).We found that total cholesterol level of PMS patients and controls were 205.7 ± 37.72 mg/dL and 199.3 ± 31.89 mg/dL respectively, means of both the groups do not differ significantly from each other (P = 0.500) while mean TG level of PMS patients was 164.6 ± 45.8 mg/dL and control was 159 ± 13.2 mg/dL our level of significance was (P = 0.147) which is greater than (P= 0.05).According to our results mean LDL level of PMS cases was 107.5 ± 28.6 mg/dL as compared to control 95.3 ± 31.9 mg/dL (P = 0.11) as represented in Table 4.

DISCUSSION
In this study 56% females of Gujranwala division Pakistan were reported as having PMS while 18% participants were characterized as patients of PMDD.The prevalence rate of PMS seems to be varied in different populations.This figure is consistent with literature reporting rates between 40 and 60% [11][12][13].Moreover, lower prevalence rate (27%) were reported in some previous literature studies [14,15].Higher prevalence rate of PMS (80.6%) and PMDD (71.7%) has been identified among university students of Islamabad [16].It is difficult to directly compare the findings of different studies because of differences in definition of PMS, social and cultural beliefs, target population and screening tools.The study indicates that most commonly reported physical symptom is lack of energy/fatigue (85.8%).Similar findings were reported in previous studies [2,17,18].Fatigue was third most common symptom demonstrated by Nisar et al [12].Other highly reported somatic complaints among participants were abdominal bloating (63.2%), muscle pain (71.7%), appetite change (79.1%).These findings are in consistent with literature [5,17].Major distressing psychological symptoms reported in our study were Irritability (82.3%), anger (74.5%), depression (49%) and anxiety (63.2%).Our study results replicate relatively well with literature reporting that anger feeling, depression, irritability and difficulty in concentration are most common physiological symptoms of PMS [3,19].We have assessed that majority of females (93%) considered PMS symptoms as a normal part of menstruation and did not visited gynecologist for a single time to treat PMS, which identifies hesitation to report problems related to menstrual cycle, due to social and cultural beliefs.Other similar studies reported that 52.6% females of Islamabad were aware of PMS and 49.3% females were having treatment of PMS [16].The current study indicates that a family history of PMS seems to be an important characteristic for women with PMS.It seems that genetics plays an important role in occurrence of different symptoms of PMS.These findings are in agreement with data from other reserchers [12,20].Meaningful relationship between PMS and family history of PMS was also observed in literature [18,21].According to our data students with menstrual pain or dysmenorrhea were more at risk for development of different symptoms of PMS compared with those who had no dysmenorrhea.The possible explanation of this association might be that dysmenorrhea may aggravates behavioral and emotional responses to menstrual symptomology and leads to likelihood of PMS.These results are in accordance with the studies conducted in Iran, Pakistan, Egypt, India and Ethiopia [2,6,22,23].As per our analysis the number of sufferers of PMS are significantly higher in urban area (68.9%) as compared to rural area (31%).It seems that healthy environment may help to prevent occurrence of PMS.On the other hand, among college students of Gujarat India, a significant association between residential area and PMS was not reported [3].The study findings indicate that participants who were engaged in regular physical activity (exercise, yoga, sports, jogging) had lower risk to develop PMS symptoms (25%) as compared to those who had sedentary lifestyle, but a statistically significant association was not confirmed.A study conducted in India reported non-significant (P = 0.11) association between exercise and PMS [3].But, small trials have suggested aerobic exercise to be beneficial for PMS treatment.Literature reported physical activity/exercise has been associated with decreased stress complaints the association between PMS and exercise needs to be further investigated.Our results represents that there was not a statistically significant association between obesity and occurrence rate of PMS (P = 0.15), magnitude of PMS was higher in normal weight persons as compared to overweight and obese.This replicates findings of previous studies conducted in Greece and Taiwan [17,24].This is also in agreement with a research from India (MR &Suryakantha, 2017) and Karachi, Pakistan [19,25].However, our study results are contradictory to other studies reporting, adiposity as a contributing factor to develop PMS symptoms [21,26,27].Previous studies demonstrated that obese women had nearly three-fold (2.8-folds) increased risk of PMS than non-obese women [13] so further studies are needed in order to validate the relationship between obesity and PMS.The study findings admit a statistically significant association between low blood haemoglobin level and occurrence of PMS.Literature also said that presence of anemia is significantly associated with PMS [28,29].Estimation of Hb level may emerge as an important inclusion criteria for diagnosis of PMS [30].This study indicates that there is not a statistically significant difference between PMS sufferers and control group in terms of blood cholesterol level.Our results are contradictory to a study conducted in Taiwan, demonstrating positive relation between PMS and high serum cholesterol levels [17].However, another researcher reported, levels of LDL (99.21 mg/dL) cholesterol were low in females with PMS as compared to females without PMS (LDL = 102.73mg/dL) and level of TG was higher (57.89 mg/dL) in PMS patients as compared to subjects without PMS (53 mg/dL) [24].

CONCLUSION
In conclusion we report that PMS and PMDD are highly prevalent among females of Gujranwala division Pakistan.This study revealed that age, residential area, dysmenorrhea, family history of PMS and fatigue act as risk factors to develop various symptoms of PMS.The results of our study purposed that anemia could be a major contributing factor to develop various symptoms of PMS whereas blood cholesterol level and obesity were not significantly associated with PMS in our population.This study will be helpful to create awareness regarding diagnosis, assessment and treatment among general population as it was seen that menstrual issues are traditionally seen as source of shame in underdeveloped countries.

Table 1 :
Sociodemographic characteristics of participants

Table 2 :
Risk Factors Associated with PMS.

Table 3 :
Comparison of premenstrual symptoms score between PMS and Non-PMS

Table 4 :
Association of PMS with haemoglobin and blood cholesterol level.