Prevalence of Premenstrual Syndrome and Its Related Factors among University Students

Document Type : Original Research Article

Authors

1 Medical Student, Golestan Research Center of Psychiatry, Faculty of Medicine Golestan University of Medical Sciences, Gorgan, Iran

2 Associate Professor of Psychiatry, Department of Psychiatry, Golestan Research Center of Psychiatry, Golestan University of Medical Sciences, Gorgan, Iran

3 a) MSc of Midwifery, Clinical Research Development Unit 5azar Hospital, Golestan University of Medical Sciences, Gorgan, Iran b) PhD Student of Reproductive Health, Infertility and Reproductive Health Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran

10.22038/jmrh.2024.75933.2243

Abstract

Background & aim: Premenstrual syndrome (PMS) refers to a periodic recurrence of a combination of physical, psychological and behavioral changes in the pauses of the menstrual cycle that can disrupt one's functioning and communication. The present study was performed to evaluate the prevalence of PMS and its related factors among medical university students.
Methods: This Cross-sectional study was conducted on 450 female students of different faculties of Golestan University of Medical Sciences, Gorgan, Iran in 2021. The data were collected using the demographic questionnaire and menstrual symptom assessment questionnaire (PSST) on a self-report basis. Data were analyzed by SPSS software version 16 using Chi-square, independent T and Mann- Whitney tests. 
Results: In this study, 68% of students had the criteria of PMS. PMS had a direct and significant relationship with educational field (P=0.001), ethnicity (P=0.023), academic degree (P=0.002), educational level (P=0.031) and BMI (P=0.001),. But it had an inverse significant relationship with the number of children (P=0.001). There was no statistically significant relationship between bleeding and marital status with PMS symptoms (P<0.05).
Conclusion: The results showed that premenstrual syndrome is common among female university students in Gorgan, North Iran. Educational Field, ethnicity, academic degree, educationl level and BMI had a significant direct relationship with PMS and the number of children had a significant inverse relationship with PMS. Therefore, it seems necessary to raise awareness of university students and provide them proper training about the symptoms of PMS when they entered to the university.

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Introduction

The American College of Obstetricians and Gynecologists (ACOG) defined premenstrual syndrome (PMS) as a clinical condition that appears with the occurrence of physical and emotional symptoms unrelated to any natural disease within five days before menstruation and ends four days after the onset of menstruation in three consecutive cycles with sufficient intensity  (1). Most women of reproductive age may feel more physiological or emotional discomfort in the week before menstruation (2). These symptoms are various in different people and can affect work, personal life and create stress in social relationships (3). Hippocrates suggested the association between the menstrual cycle and behavioral changes. Hippocrates considered the cause of headache and heaviness before menstruation to be anxious blood that is looking for a way out (4). This syndrome appears with periodic changes in the physical, mental and behavioral condition of women. Its beginning is 6-12 days before the monthly bleeding and its continuation for two days (maximum 4 days) after the beginning of bleeding (5). In addition, the symptoms of the syndrome should be registered at least for two consecutive months (6). In this era, aggression, anger and quick tempers are more common, which is the cause of many fights, divorces and murders (7).

Compared to women who have no history of this syndrome, women with PMS need more outpatient care and have higher treatment costs, and a higher rate of absenteeism due to medical reasons (8). Premenstrual syndrome affects not only the individual, but also her family; among these effects are incompatibility with spouse and misbehaving with children (9). Also, this syndrome leads to an increase in adverse educational outcomes such as reduced academic performance of students and social outcomes such as committing murder, crime and suicide (10). In general, PMS in many affected women leads to a decrease in social relations and a negative attitude towards being a woman and menstruation (11). In the new era, when women have achieved diverse roles and responsible positions in the labor market, premenstrual syndrome can deprive women from obtaining the best level of efficiency in performing tasks, and this issue reveals the importance of more evaluation of the causes of this condition (12). This syndrome is known as one of the most common diseases in the world (13). The overall prevalence of premenstrual syndrome is 48%; its prevalence has been reported between 52.9 and 98.2% in different studies (14-15).

In previous study in Golestan province, the prevalence of premenstrual syndrome was reported as 57.4% (16( The results of past studies show that age, smoking, alcohol and caffeine consumption, dietary patterns, use of contraceptive pills, exercise habits, menstrual and reproductive history, history of sexual abuse (17), history of premenstrual syndrome, sexual status (18), attitude towards menstruation (19), occupation, multiple pregnancies, genetics, level of education, social and cultural factors, religion and attention to performing religious duties, duration of menstrual bleeding, duration of menstrual period, painful menstruation and presence of psychological pressure are effective in the prevalence of premenstrual syndrome (20) The cause of premenstrual syndrome has not yet been properly identified (21). This syndrome is not a single disorder, but a set of symptoms of biological origin, in which psychological and social aspects are also involved (22).

The factors such as periodic changes in ovarian estrogen and progesterone levels, disturbances in magnesium and calcium levels, endocrine disorders, disruption of the renin-angiotensin-aldosterone pathway, vitamin and mineral deficiency, genetics and lifestyle have been proposed as possible factors (23). Some researchers believe that psychological and stressful pressures can be effective in premenstrual syndrome (24). Stress causes mood symptoms by reducing beta endorphins in the brain and increasing the level of adrenal cortisol, and since cortisol and progesterone compete on common cell receptors, cortisol causes disturbances in the activity of progesterone and increases the activity of estrogen. The result of these changes causes the symptoms of premenstrual syndrome to start or worsen (25). At present, no definitive treatment is known for PMS (4,15,26). Several treatment methods include drug and non-drug treatments such as counseling and education, changes in lifestyle or diet, improvement of psychological capacity, cognitive therapy (27).

Considering that medical students are the future guardians of society's health, suffering from premenstrual syndrome can affect their individual and social functioning. The present study was conducted to investigate the frequency of premenstrual syndrome and its related factors among the students of Golestan University of Medical Sciences, Golestan, North Iran.

Materials and Methods

This cross-sectional study was conducted from April to the end of September 2021 on the students of different faculties of Golestan University of Medical Sciences Golestan, North Iran (Faculty of Nursing and Midwifery, Faculty of Health, Faculty of Medicine, Faculty of Dentistry, Faculty of New Technology and Faculty of Paramedicine).

 The inclusion criteria were female students of Golestan University of Medical Sciences who had regular menstruation in the last 12 months. The exclusion criteria were a history of serious psychiatric disorders (such as psychotic, bipolar, major depression, panic, personality, etc.), drugs use, alcohol consumption, taking contraceptive pills, having any special diet (vegetarianism, raw foodism, thinness and obesity), history of internal diseases such as glandular disorders, autoimmune diseases, gynecologic diseases such as polycystic ovary syndrome, endometriosis, and unwillingness to continue cooperation.

The sample size was calculated based on the study of Zandi et al. (28) with confidence level of 0.95 and the test power of 0.80 and considering the error value of d=0.05 using the following formula for determining the sample size. Accordingly, 360 samples was estimated. Considering the 20% dropout, this number increased to 450 sample.

The Samples from each faculty (Faculty of Nursing and Midwifery (95/280), Faculty of Health (26/78), Faculty of Medicine (192/565), Faculty of Dentistry (59/174), Faculty of Modern Technology (12/34), Faculty of Paramedical Sciences (66/194)) were randomly selected using stratified sampling method with proportional allocation. The following formula was used to allocate the number of samples from each faculty.

In this research the menstrual symptom assessment questionnaire (PSST) has been used. The PSST questionnaire consisted of 19 questions, which had two parts (the first part, which included mood, physical and behavioral symptoms, and the second part, which measured the impact of these symptoms on people's lives and included 5 questions). For each question, there was four answers: absolutely, mild, moderate and severe, and is scored  from 0 to 3. The range of scores of the questionnaire was from 0 to 57, a score of 0-19 is considered mild, 19-28 is moderate, and 28-57 was considered severe PMS. Cronbach's alpha for the German version of this tool is 0.92, and its retest reliability coefficient is 0.62 (29). The validity of the PMS questionnaire was confirmed by Dadi Givashad (30). Its reliability was calculated by Mohebi Dehnavi using Cronbach's alpha internal consistency method and the reliability coefficient was 0.77 (31).

After obtaining the necessary permission from Golestan University of Medical Sciences, the necessity of the implementation and the goals of the project were explained to the participants. Written informed consent was obtained from all participants.  To collect data,   the checklist related to demographic characteristics and menstrual status, including age, ethnicity, marital status, number of children, educational status, menstrual cycle status, duration of bleeding, and intensity of bleeding, was completed by the participants. Then, a questionnaire measuring menstrual symptoms was completed by the students using a self-report method.

The data were analyzed using SPSS software (version 16). In order to describe the data, descriptive statistics indices and appropriate tables were used to compare the variables in the two groups. Chi-square, independent T and Mann-Whitney tests were used to compare the variables in two groups. P<0.05 was considered statistically significant.

Results

Out of a total of 450 participants in the study, PMS symptoms were observed in 306 students (68%). Moreover, 135 (56%) of the participants were 22 years old and younger, and 171 (81.8%) aged 22 years and older had experienced PMS. In addition, 214 (66.5%) of the participants were single and 92 (71.9%) were married with PMS. Other demographic characteristics including educational Field, educational level, Academic degree, ethnicity/Rice and marital status, are listed in Table 1. Also, 56.1% of participants had normal BMI that 55.9% of them were over 22 years old. Most of participants (67%) were Farsi and mostly single (69.9%). The highest frequency of this syndrome (42.2%) was observed in medical students and the lowest (3.2%) in modern technology students (Table 1).

Premenstrual syndrome was also investigated based on clinical symptoms. Irritability/irritability, depressed mood and hopelessness and physical symptoms such as breast pain, headache, muscle/joint pain, abdominal bloating and weight gain were the most common clinical symptoms of the affected students (Table 2).

The relationship between various demographic factors, BMI, as well as the menstrual cycle and the intensity of bleeding with premenstrual syndrome was also investigated. PMS had a direct and significant relationship with the educational field (P=0.001), ethnicity (P=0.023), Academic degree (P=0.002), education level (P=0.031) and BMI (P=0.001). However, PMS had an inverse and significant relationship with the number of children (P=0.001) (Table 1).

Discussion

The purpose of the present study was to evaluate the prevalence of PMS and its related factors among the students of Golestan University of Medical Sciences, Golestan, North Iran. The results of the study showed that 68% of the students had symptoms and signs of premenstrual syndrome. In the study by Noorjah et al. (32), the prevalence of premenstrual syndrome reported as 82.5% that was higher than the present study. In some other studies (33-36), the prevalence of the syndrome was less than the current study. In the study of Ramadani Tehrani et al. which was conducted on 1200 Iranian women aged 18 to 45 years, 34.5% of the samples were suffering from severe type of premenstrual syndrome (15). In the studies conducted in other countries, the frequency of this syndrome was lower or higher than the present study. In a study conducted in Egypt, the prevalence of premenstrual syndrome among female students was reported to be 65% (37). In the study by Costanian et al., PMS was observed in 63% of the study subjects, which is consistent with the results of our study (39). While in the Abeje et al.'s study, the frequency of premenstrual syndrome was reported as 81.3% (38). In the study of Acikgoz et al, the prevalence of PMS among university students was 58.1% that was lower than the frequency of this syndrome in the present study (13). In the study conducted by Nandakumar et al. in 2023 on 450 female students of the Indian University of Religion, they showed that the prevalence of PMS among these students is 76.35%, and the highest rate of PMS was reported in the 18-21 year old group without physical activity and with more stress (40). The study by Su Jeong et al. (41) on the students of Si City University in South Korea, reported a prevalence of PMS of 27.3%. In general, the comparison of the prevalence of premenstrual syndrome in the present study with internal and external studies shows that there are similarities with some studies and differences with some other studies, which seems that the existing differences may be due to the use of definitions and different tools for evaluating premenstrual syndrome, different sampling method, the different individual, social and cultural characteristics of the studied community and the different inclusion and exclusion criteria in these studies.

There are differences in the symptoms reported by people with PMS in various studies. In the current study, the most common symptoms reported were anger/irritability, depressed mood and hopelessness, and physical symptoms (such as breast pain, headache, etc.). In a study conducted in Turkey, the most common reported symptoms were irritability, fatigue, anxiety, feeling of fullness, abdominal pain, and discomfort (42). In the study by Ramezani et al., the most common symptoms were depression, pain and tenderness in the breasts, bruises and muscles (15). In the study by Buddhabunyakan et al., the most common physical and behavioral symptoms in people suffering from PMS were breast pain (74.4%) and anger (97/7%) (43). In the study conducted in Lebanon, the most common affective and somatic symptoms were anger and flatulence, respectively (38). Researchers believe that people who live in different age (44), cultural (45), ethnic and racial (46) groups express different signs and symptoms.

According to the results of the present study, the frequency of PMS in students in the age group above 22 years was higher than those 22 years and less. There are conflicting results regarding the relationship between age and the prevalence of PMS. Some studies report a higher prevalence of symptoms in younger women (47-48), while in other studies, such as the study by Ramezani et al., the prevalence of PMS has also increased with age (15). This is while Gehlert S and colleagues did not report a relationship between age and PMS (49). These differences indicate that many variables are involved in the occurrence of PMS. Other studies also showed a significant relationship between education and PMS, so that higher education was associated with higher prevalence of PMS (15,50-51). In the study of Talai et al., there was a statistically significant relationship between the field of study and the level of education with the prevalence of premenstrual syndrome (34). Of course, in the study of Kayani et al., despite the fact that the lowest prevalence of PMS was found in women with primary education and the highest percentage was related to high school education, diploma and then bachelor education and higher, but this relationship was not significant (52). Higher educational levels can be associated with better recognition and understanding of the symptoms, followed by more reports of this syndrome. Students of medical science also carefully review their symptoms. In addition, higher educational levels are associated with more stressful conditions, and in many studies, stress has also been mentioned as a factor for suffering from this syndrome and increasing the severity of the symptoms (53-54).

In the present study, despite the fact that the frequency of PMS was higher in married women than that of single people, this difference was not significant. This finding was consistent with the results of other studies (19,51,55). In our study, a statistically significant relationship was observed between the frequency of premenstrual syndrome and ethnicity. In their study, Takeda et al. found that race and ethnicity is effective in the occurrence of premenstrual syndrome (56). The results of the present study showed that the pattern of the menstrual cycle, including the regularity of the menstrual cycle and the intensity of bleeding, is not related to PMS. Some other studies reported that the relationship between menstrual pattern and PMS was not significant (22, 34, 36). In the current study, the relationship between PMS and body mass index was statistically significant, so that the frequency of PMS was significantly higher in students with a body mass index more than normal. In the study of Kayani et al. and Costanian et al., suffering from premenstrual syndrome had a significant relationship with higher body mass index (38, 52).

In another study, following a 10-year follow-up of 1057 women who did not have PMS at the beginning of the study, it was found that obese women had a higher risk of developing PMS during this follow-up period. It seems that obesity with its effect on estrogen and progesterone will alter neurotransmitter function such that estrogen will increase serotonin function through increased production, transport, reuptake, and receptor expression and postsynaptic response, while lower estradiol levels associated with obesity may lead to serotonin dysfunction and then PMS (57). Considering the different variables as well as the geographical, cultural and ethnic dimensions involved in PMS, there is a need to investigate the prevalence of PMS in different communities in each geographical region, so that planning can be done for the prevention and timely treatment of this syndrome. The limitations of this study were the completion of the PSST/self-report questionnaire. Therefore, it is possible that mood, physical and behavioral symptoms are not reported in a completely real way. This study was conducted on single and married students from various medical fields, and compared to other studies, a larger sample size was examined which can be consider as the strengths of this study. It is suggested that in future studies, the effect of psychotherapy on the prevalence of PMS symptoms should be considered.

Conclusion

Premenstrual syndrome has a high prevalence among students, and its most common symptoms are anger and irritability. PMS had a direct relationship with field of study, ethnicity, level of education, and BMI, but an inverse and significant relationship with the number of children. It is suggested that students be screened at all levels and also given proper training about the symptoms of the syndrome, so that timely referral to a psychiatrist, proper diagnosis and treatment can be done.

Declerations

Acknowledgments

This research study is the result of the dissertation of General Medicine inGolestan University of Medical Sciences, Golestan, North Iran. The authors would like to express their gratitude to Golestan University of Medical Sciences Research and Technology Department, Golestan Psychiatric Research Center, 5 Azar Clinical Research Development Support Unit, officials and nurses of 5 Azar Hospital in Gorgan.

Conflicts of interest

The authors declared no conflicts of interest.

Ethical considerations

After obtaining the necessary permission from Golestan University of Medical Sciences, the necessity of the implementation and the goals of the project were explained to the participants. The participants in the study were also assured that the information would remain confidential. The participants were also assured that they could withdraw from the study at any stage. Written informed consent was obtained from all participants

Code of Ethics

The study has an ethics code number IR.GOUMS.REC. 1398.272 From Golestan University of Medical Sciences.

Use of Artificial Intelligence (AI) 

No artificial intelligence was used in writing this manuscript.

Funding

This research did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors' contribution

MZK and MAM conceived the idea and designed the work. MAM collected Data. ZK analyzed and interpreted the data. MAM prepared the draft of manuscript and MZK and ZK reviewed the manuscript critically for important intellectual content. All authors read and approved the final manuscript and agreed to be accountable for all aspects of the work.

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Journal of Midwifery and Reproductive Health
Volume 13, Issue 4
October 2025
Pages 5094-5103

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