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Jacobs Journal of Community Medicine
Moderate to Severe Premenstrual Syndrome and Contributing Factors among
University Students in Palestine
Zaher Nazzal1*, Nidaa Hasan2, Mulham Al-Sukhon1
1Assistant Professor at the Faculty of Medicine and Health Sciences, An-Najah National University, Palestine
2Faculty of Medicine and Health Sciences, An-Najah National University, Palestine
*Corresponding author: Dr. Zaher Nazzal, Assistant Professor of Community Medicine,An-Najah National University/ Faculty of
Medicine and Health Sciences, Nablus /Palestine, Tel : +(972) (599) 545421; Email: znazzal@najah.edu
Received: 10-13-2015
Accepted: 11-23-2015
Published: 12-10-2015
Copyright: © 2015 Zaher
Research Article
Cite this article: Nazzal Z. Moderate to Severe Premenstrual Syndrome and Contributing Factors among University Students in Palestine. J J Commun Med. 2015, 1(2): 016.
Abstract
Background
Premenstrual syndrome (PMS) is a cyclic occurring disorder that affects young and middle-aged women mainly. It characterized
by group of physical, cognitive, emotional and behavioural symptoms that interfere with daily living activities. PMS is common
worldwide, but there is no published research about it in Palestine. The aim of this study is to assess the prevalence of premen-
strual syndrome and the degree of its severity among the medical students at An-Najah National University, Palestine
Methods
A cross-sectional study using a self-administered questionnaire was conducted to collect data from 260 female students. Amer-
ican Congress of Obstetricians and Gynecologists (ACOG) criteria and Shortened Premenstrual Assessment Form (SPAF) were
used to measure PMS prevalence and severity of premenstrual symptoms.
Results
The prevalence of PMS was 71.9%. The most frequently reported complaints were: lower back pain (57.7%), followed by feeling
symptoms and academic class (rank), regular coffee intake, duration of menstrual cycle and absence from lectures and rotations.
Conclusion
Premenstrual syndrome is common among female medical students and has negative effect in their academic performance and
Keywords: Premenstrual Syndrome; Medical Science Students; An-Najah National University
Introduction
Premenstrual syndrome (PMS) is a cyclic occurring disorder
that affects young and middle-aged women mainly, and char-
acterized by group of physical, cognitive, emotional and behav-
ioral symptoms that consistently occur during the luteal phase
of the menstrual cycle. [1,2]. It is characterized by the presence
days before menses for at least three menstrual cycles in a row.
Many symptoms may be associated with PMS including emo-
increase in appetite, and sensitivity and pain in the breasts [3-
predominantly psychological, end of the PMS spectrum [1].
PMS is quite prevalent among the women of reproductive
age group, especially among the young age groups. Although
reports on the prevalence of PMS are different from study to
study, most of studies conducted in the neighboring countries
it is moderate to severe form [9- 13].
-
higher work, school or college absenteeism and impairment in
their productivity and household activities [2,9]. Students af-
fected with PMS complain of inability to sleep, prolonged rest
need, fatigue and inability to study. Missed meals, lectures and
social commitments are also common complains [9]. Further-
more, as symptoms severity increased, the healthcare utiliza-
tion increased, including emergency room visits, outpatient
visits, radiology services and laboratories [2,14]. In general,
it is concluded that PMS affects the life quality of the affected
females.
Many risk factors for PMS were discussed in the literatures,
among those factors were age, obesity, overall health, stress,
(15).Obese women with body mass in-
-
er health problems are at increased risk for PMS, and current
-
orders are common in women with PMS [15].
Searching the literature showed no published data about the
burden of this problem in Palestine, in term of its magnitude,
severity, distribution and risk factors. Therefore, we aimed to
investigate the prevalence of PMS among female students of
The School of Medicine and Health Sciences at An-Najah Na-
its effects on the stu-
dents’ performance and absenteeism.
Cite this article: Nazzal Z. Moderate to Severe Premenstrual Syndrome and Contributing Factors among University Students in Palestine. J J Commun Med. 2015, 1(2): 016.
Jacobs Publishers 2
Methodology
Study Design and Setting
A cross – sectional study was conducted at ANNU, the largest
provider of higher education in Palestine, including students
The study population included
the students of the faculty of medicine and health sciences; the
largest faculty in the university.
Sample Size and Sampling Technique
gynecological diseases within the last year, or having chronic
A systematic random sampling technique was used for distrib-
-
and, before disseminating the questionnaire, a brief descrip-
tion about the study and its objectives was given to partici-
pants; and then students were selected randomly by starting
rd
student.
Study Outcomes
The main outcome variables for this study was the PMS which
following affective and somatic symptoms, that occurs during
in a row. Affective symptoms are: anger with possible out-
withdrawal [16].Somatic symptoms are: abdominal bloating,
[16].
These symptoms must remit within four days of menses onset,
not recur until at least day 13 of the subsequent cycle, and not
due to any medications including hormones. Symptoms should
also interfere with some of woman’s normal activities [16].
Other studied variables were students’ demographic and back-
ground variables such as academic level, residency, marital
status, smoking status(cigarette or water-pipe smoking), reg-
-
logical characteristics were studied such as age of menarche,
regularity of menstrual cycle, frequency of menstrual cycle and
intensity of menstrual cycle.
Measurement Tool
study by Hamaideh et al. [10], was used to collect the data. It
was divided into 2 sections;
- Part I about demographic and gynecological characteris-
tics, like academic program, marital status, smoking sta-
tus, regular coffee intake, performing physical activities,
daily sleeping hours, absence from lectures and rotations
due to premenstrual symptoms, weight and height, age at
menarche and regularity, frequency, duration and inten-
sity of menstrual cycle.
- Part II, about PMS which was measured based on the
Diagnostic Criteria adopted by the American Congress
of Obstetricians and Gynecologists (ACOG). The partici-
of symptoms present in the ACOG criteria during the last
three previous menstrual cycles.
- The severity of premenstrual symptoms was evaluat-
ed using the Shortened Premenstrual Assessment Form
(SPAF) [17] which is composed of ten items that are 1)
Pain, tenderness, enlargement or swelling of breasts; 2)
Feeling unable to cope or overwhelmed by ordinary de-
mands; 3) Feeling under stress; 4) Outburst of irritability
-
atively steady abdominal heaviness, discomfort or pain;
Feeling bloated. The participants had been asked to rate
the severity of changes in symptoms on scale of 1-6 (1=no
-
strual period. Score >30 indicates moderate or severe
PMS symptoms. The Arabic version of SPAF by Hamaideh
To ensure its validity and reliability, the measurement tool was
-
venient sample of 20 students to highlight problems associated
with it and assess the time needed to complete. Cronbach’s alpha
-
Data Entry and Analysis
The completeness and accuracy of the collected data were
Data were coded and edited properly by the second investi-
gator prior to data entry. The data entry and statistical anal-
ysis were performed using the Statistical Package for Social
Sciences (SPSS) version 17. Descriptive statistics were used
to summarize the socio-demographic and clinical charac-
teristics of the study participants. Summary tables, graphs
and charts were used for descriptive purpose.
-
ing the Chi-squared test and t-test as appropriate with the sig-
Cite this article: Nazzal Z. Moderate to Severe Premenstrual Syndrome and Contributing Factors among University Students in Palestine. J J Commun Med. 2015, 1(2): 016.
Jacobs Publishers 3
<0.1
in the univariate analysis were subject to multivariate logistic
regression analysis model to assess the predictor variable(s).
The study was conducted after getting approval from the
from the University administration. Anonymity of the partic-
Results
questionnaire. The majority of participating students were
single (96.9%). Most of them were non-smokers (95.4%), and
27.3% were regular coffee drinkers. More than half of the par-
Table 1. Characteristics of the Study Participants.
Variable Frequency (%)
Academic program
Medicine
Pharmacy
Nursing and midwifery
40 (15.4%)
Academic year
1 – 3
4 – 6
136 (52.3%)
124 (47.7%)
Marital status
Single
Married
252 (96.9%)
Body mass index
25 - 29.9 (overweight)
30 (11.5%)
200 (76.9%)
27 (10.4%)
03 (1.2%)
Smoking status
Yes
No
12 (4.6%)
Regular coffee intake
Yes
No
71 (27.3%)
Physically activities
Yes
No
72 (27.7%)
-
duration of 20 to 31 days. About 65.4% reported that their
cycle of moderate intensity. Of the total sample, only 2 (0.2%)
had been pregnant at least one time, and only 3 participants
of the participants had a sick leave or absent from lecture or
clinical training because of premenstrual symptoms (Table 2).
Table 2. Gynecological Characteristics of the Study Partici-
pants.
Variable Frequency (%)
Age of menarche
12 – 13 years
20 (7.7%)
147 (56.5%)
Menstrual cycle
Irregular
Frequency of the menstrual cycle
Less than 20 days
20 – 31 days
More than 31 days
19 (7.3%)
Duration of the menstrual cycle
< 6 days
170 (65.4%)
90 (34.6%)
Intensity of the menstrual cycle
Light
Moderate
Heavy
24 (9.2%)
19 (7.3%)
Absence from classes
Usually or Always
Sometimes
Never
27 (10.4%)
149 (57.3%)
Prevalence of PMS
The prevalence of PMS among the studied group was 71.9%,
(Figure 1).
Cite this article: Nazzal Z. Moderate to Severe Premenstrual Syndrome and Contributing Factors among University Students in Palestine. J J Commun Med. 2015, 1(2): 016.
Jacobs Publishers 4
Figure 1. The prevalence of PMS among participants.
Severity of premenstrual symptoms was measured by SPAF,
where 51% of the students showed moderate to severe symp-
toms. The most frequently reported complaints were lower
back pain (57.7%), followed by feeling bloated (51.9%) and
feeling under stress (50%) (Figure 2).
Figure 1. Frequency of Premenstrual Symptoms among Study Participants.
57.7%
51.9%
50%
48.5%
48.5%
46.9%
36.5%
31.2%
25.8%
21.2%
0% 10% 20% 30% 40% 50% 60% 70%
Lower back pain
Feeling bloated
Feeling under stress
Irritability
Abdominal pain
Feeling sad or depressed
Feeling unable to cope
Breast pain
Weight gain
Odema and swilling
Figure 2. Frequency of Premenstrual Symptoms among Study Partic-
ipants.
-
sociated with academic class, regular coffee intake, duration of
menstrual cycle and absence from classes (Table 3).
Predictors of Severe Premenstrual Symptoms
Logistic regression analysis was applied to all variables with
p-value <0.1 in univariate analysis. Predictors of severity of
premenstrual symptoms were academic class, regular coffee
intake, duration of menstrual period, Perception of health in
general and Absence from lectures and rotations due to pre-
menstrual symptoms (Table 4).
ab
Figure 1. The prevalence of PMS in female students.
71.9%
28.1%
Yes No
Variables Mild Mod - Severe p- value
Collage program
Medicine
0.06®
Pharmacy
Nursing and midwifery 27 (67.5%) 13 (32.5%)
Academic class
1 – 3 56 (41.2%)
0.03®
4 – 6 55 (44.4%) 69 (55.6%)
Smoking status
No 130 (52.4%) 0.47®
Yes 5 (41.7%)
No 107 (56.6%) 0.01®
Yes 43 (60.6%)
Physical activity
No 97 (51.6%) 0.07®
Yes 44 (61.1%)
21.61 (21.1 – 22.12) 0.54*
7.31 (7.1 – 7.52) 0.1*
Age of menarche
11 (55%) 9 (45%)
®
12 – 13 years 69 (46.9%)
55 (59.1%)
Irregular 26 (54.2%) 0.35®
113 (53.3%) 99 (46.7%)
Frequency of menstrual cycle
Less than 22 days 4 (40%) 6 (60%)
0.27®
From 20 – 31 days 124 (53.7%) 107 (46.3%)
More than 31 days 12 (63.2%)
Duration of menstrual cycle
Less than 6 days 72 (42.4%) 0.01®
6 days and more 37 (41.1%)
Intensity of menstrual cycle
Light 15 (62.5%) 9 (37.5%)
0.40®
Moderate 112 (51.6%)
Heavy 11 (57.9%)
Perception of health in general
35 (42.2%)
®
Very good 76 (52.4%) 69 (47.6%)
Good 11 (34.4% 21 (65.6%)
Absence from classes
Never
Some times
Usually or Always
92 (61.7%)
30 (35.7%)
54 (64.3%)
14 (51.9%)
0.01®
®Chi-squared test * independent T-test
Cite this article: Nazzal Z. Moderate to Severe Premenstrual Syndrome and Contributing Factors among University Students in Palestine. J J Commun Med. 2015, 1(2): 016.
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Table 3.
Variables Odd ratio CI #p- value
Collage program
Medicine *
Pharm. D and pharmacy 1.361 0.71 - 2.6 0.36
Nursing and midwifery .511 0.2 - 1.3 0.17
Academic class
1 – 3 *
2.047 1.2 - 3.6 0.01
4 – 6
Income level
Very good 0.63 - 3.5
Good or Acceptable 0.99 0.4 - 2.5 0.90
Regular coffee intake
No *
2.11 1.14 - 3.9 0.02
Yes
Physically active
No
1.44 0.76 - 2.7 0.26
Yes*
Duration of menstrual cycle
Less than 6 days *
2.10
0.01
6 days and more
Perception of health in general
Very good
Good
1.390
4.517
0.74-2.6
1.6-12.6
.311
.004
Absence from classes
Never*
Some times
Usually or Always
2.05
1.6-5.3
0.01
0.13
#
Discussion
to assess PMS and
related factors in Palestine. The prevalence of PMS was 71.9%,
congruent with the result of most studies in the region that
[10,11,13]. The medical science students are all the time in ac-
The severity and frequency of premenstrual symptoms were
different from one study to another. The most frequently re-
Jacobs Publishers 6
Cite this article: Nazzal Z. Moderate to Severe Premenstrual Syndrome and Contributing Factors among University Students in Palestine. J J Commun Med. 2015, 1(2): 016.
of physical and psychological complaints such as: lower back
pain (57.7%), feeling bloated (51.9%), feeling under stress
-
-
49.2% for irritability and 46.9%for feeling overwhelmed
[10]. These results may be due to common socio-cultural
Severity of premenstrual symptoms in the current study in-
crease with academic class of the participants and clinical
year students have more severe symptoms than basic year
Table 4. Multivariable Analysis of Characteristics Associated with the Severity of Premenstrual symptoms.
ones. This may be due to the fact that senior students are in
more academic stress and are involved in clinical rotations
in different hospitals and clinics which require more physi-
study which found that severity of premenstrual syndrome
was positively correlated with students level of training [12].
Coffee consumption was considered a behavioral risk factor
the fact that caffeine is a stimulant and increase stress, emo-
tional liability and irritability [6]. In our study it was found
-
ly associated with more coffee consumption. Additionally,
Pinar et al. [13] showed that the frequency of PMS is higher
in those who consume more coffee.
In our study, we found that severity of premenstrual symp-
toms was higher in students with longer duration of men-
strual cycle. A similar result reported by Deuster et al [6].
-
-
-
menstrual symptoms and student’s absence from lectures and
of many studies conducted in different population; like the
and the Indian medical college students(9). This association is
the student and decreases their concentration, so they tend
to miss their classes at this period.
Some limitations of this study warrant consideration. First-
ly, -
cine and Health Sciences at ANNU which may limit its gener-
alizabilty. Secondly, using a self administered questionnaire
to study such sensitive topic makes it liable to information
bias as some students might not want to disclose their per-
sonal problems, although we tried our best to ensure the
privacy of the participants. In addition, using a prospective
study design to be able to log of symptoms by the partici-
pants could be the ideal methods; however, this was impos-
sible as a matter of budget constraint, because this study
Conclusion and Recommendations
Premenstrual syndrome is common among female medical and
health science students with prevalence of 71.9%. The most
frequently reported complaints were lower back pain, followed
by feeling bloated and feeling under stress. Sever PMS have
negative effect in students academic and social performance
Jacobs Publishers 7
Cite this article: Nazzal Z. Moderate to Severe Premenstrual Syndrome and Contributing Factors among University Students in Palestine. J J Commun Med. 2015, 1(2): 016.
and attendance which may lead to poor quality of life. Higher
academic class, regular coffee intake, longer duration of men-
strual period found to predict the occurrence of severs PMS.
-
lem and provide appropriate, physical and emotional support
as well as giving more attention to psychological methods as
highly recommend increasing the awareness of PMS symp-
toms and coping strategies among university students and
high prevalent problem among female students.
Acknowledgements
this study possible. In particular, we would like to thank the
study participants for their time and efforts.
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Cite this article: Nazzal Z. Moderate to Severe Premenstrual Syndrome and Contributing Factors among University Students in Palestine. J J Commun Med. 2015, 1(2): 016.