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International Journal of Research in Medical Sciences | December 2019 | Vol 7 | Issue 12 Page 4703
International Journal of Research in Medical Sciences
Rathi AK et al. Int J Res Med Sci. 2019 Dec;7(12):4703-4708
www.msjonline.org
pISSN 2320-6071 | eISSN 2320-6012
Original Research Article
A study of impact of stress: examinations on menstrual cycle among
medical students
Anant Kumar Rathi1*, Megha Agrawal2, Girish Chandra Baniya3
INTRODUCTION Premenstrual syndrome (PMS) was defined by an NIMH
Consensus workshop group as “A constellation of mood,
1Department of Psychiatry, S. P. Medical College, Bikaner, Rajasthan, India
2Department of Psychiatry, Lady Harding Medical College, New Delhi, India
3Department of Psychiatry, Government Medical College, Barmer, Rajasthan, India
Received: 25 September 2019
Revised: 07 October 2019
Accepted: 31 October 2019
*Correspondence:
Dr. Anant Kumar Rathi,
E-mail: anantkumarrathi@gmail.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20195542
ABSTRACT
Background: Premenstrual Syndrome (PMS), a common problem among adolescent girls, is associated with various
physical, mental and behavioral symptoms that lead to social and occupational impairment. Stress has also been
hypothesized to be an important etiologic factor. Examination stress may also be responsible for affecting the
premenstrual symptoms. The objectives of this study was to study the impact of exam stress on the menstrual cycle
and the relationship of perceived stress with the severity of premenstrual symptoms.
Methods: This was a cross-sectional observational study conducted among female medical students of final MBBS,
who were candidate of upcoming exams. They were assessed on semi structured socio-demographic and menstrual
history proforma, ACOG guidelines, DSM-5 criteria, Perceived Stress Scale (PSS) and Premenstrual Symptom
Screening Tool (PSST).
Results: As per ACOG guidelines, 66% participants had PMS and 6% participants had PMDD according to DSM-5
criteria. On PSST total 88% participants had premenstrual symptoms and out of them 58% had mild/no PMS while
30% had moderate to severe PMS. 5% participants also fulfilled criteria for PMDD on PSST. Stress was found to be
mild in 26% and moderate in 74% participants on PSS. PMS was found in 93.75% participants who had painful
menstruation (dysmenorrhea) and this association was statistically significant. Data wise 73.1% participants having
mild stress had PMS, while 93.2% participants having moderate stress, had PMS and this association was found to be
statistically significant. Surprisingly not a single participant consulted to any health care provider for their
menstruation related problems.
Conclusions: Premenstrual Syndrome is common in adolescent girls and exam stress is an important etiological
factor. PMS/PMDD was found significantly higher in participants who had dysmenorrhea and moderate stress. A
positive and highly significant correlation was also found between the severity of stress and severity of premenstrual
symptoms.
Keywords: Premenstrual Syndrome, Premenstrual Dysphoric Disorder, Diagnostic and statistical Manual-5,
Premenstrual Symptom Screening Tool, Perceived Stress Scale, American College of Obstetrician and
Gynaecologists
Rathi AK et al. Int J Res Med Sci. 2019 Dec;7(12):4703-4708
International Journal of Research in Medical Sciences | December 2019 | Vol 7 | Issue 12 Page 4704
behavioral and/or physical symptoms that have a regular
relationship to the luteal phase of menstrual cycle, are
present in most if not all cycles and remit by the end of
menstrual flow with a symptom free interval of at least
one week each cycle.1 Premenstrual syndrome is a
common complication among the women of childbearing
age.2 Epidemiologic surveys have estimated that as many
as 80% of women of reproductive age experience some
symptoms attributed to the premenstrual phase of the
menstrual cycle.3 The American College of Obstetricians
and Gynecologists (ACOG) published a revised practice
bulletin in 2000 for the management of Premenstrual
syndrome.4
A severe form of PMS, called as premenstrual dysphoric
disorder (PMDD), significantly impairs the daily life
activities in women. PMDD is distinguished from PMS
by the severity and number of symptoms as well as the
degree to which the function is impaired.5
Variety of factors such as change in hormone levels,
chemical changes in brain have been hypothesized to be
implicated in the etiology of PMS. Stress has also been
found an important etiologic factor. The level of stress
also relates to the severity of PMS.6 Perceived stress in
college settings may be due to academic stress of
studying for examinations with respect to grade
competition and large amount of content to master in a
small amount of time. Thus it can be seen that the
academic stress experienced by students appearing for
exams may be responsible for affecting their menstrual
symptoms.
Many girls, particularly college going, do suffer from
either new appearance or exacerbation of these symptoms
during examination and there are very few studies about
stress and its relationship with menstrual disorders, hence
this study was planned.
The objectives of this study are to study the impact of
examination stress on menstrual cycle and relationship of
perceived stress with the severity of premenstrual
symptoms.
METHODS
This study was conducted undergraduate female students
of a medical college who were candidate of Final MBBS
exams. This is a cross-sectional observational study.
Convenient sampling method was used. The study was
conducted from 01/06/2019 to 15/06/2019.
Inclusion criteria
• Those above 18 years of age
• Having attained menarche
• Willing to give informed consent
• Candidate in university exams and
• Able to recall last 3 menstrual cycles.
Exclusion criteria
• Pre-existing medical and gynaecological illnesses
(anaemia, diabetes, hypothyroidism, asthma,
migraine, epilepsy, pelvic inflammatory disease,
endometriosis and amenorrhea).
• Using medications affecting menses (e.g.,
antidepressants, anticonvulsants or herbal
medicines, hormones and vitamins) within the past
three months.
• Presence of any other stressful life event within the
past three months.
Total 137 participants were invited to achieve a desired
number of 100 participants. 12 were unwilling to
participate and 25 were excluded on the basis of
exclusion criteria. Objectives and method of the study
was explained and written informed consent was obtained
after assuring about confidentiality of the data. Socio-
demographic detail and menstrual history was taken from
all the participants in semi structured proforma.
All participants were screened on Premenstrual Symptom
Screening Tool (PSST) by enquiring detail about last 3
menstrual cycles after collecting. Stress was measured in
all participants using Perceived Stress Scale - 10 (PSS-
10).
Structured Clinical Interview was done in presence of a
female Psychiatrist to confirm the diagnosis as per DSM-
5. Data was analyzed using SPSS Version 18 and
expressed in form of mean±standard deviation for
continuous variables and percentage for categorical
variables. Chi square test was used to find out
significance of association and p<0.05 was considered as
statistically significant.
Instruments of the study
Semi-structured proforma - Used for evaluation of the
participants which included socio demographic profile
sheet and menstrual history profile sheet.
Premenstrual Symptom Screening Tool (PSST) - Devised
by Steiner et al, for diagnosis of PMS and PMDD and
very commonly used tool for the same. According to the
study conducted by Yen et al, Cronbach's alpha of the
first and second parts of PSST was 0.96 and 0.61,
respectively.8 The content validity of the first and second
parts of this test was 0.93 and 0.8%, respectively. It is a
19-item instrument consisting of two domains:7
• First domain includes 14 premenstrual symptoms
which must start before period and stop within a few
days of bleeding- (1) anger/irritability, (2)
anxiety/tension (3) tearful/increased sensitivity to
rejection, (4) depressed mood/hopelessness, (5)
decreased interest in work activities, (6) decreased
interest in home activities, (7) decreased interest in
social activities, (8) difficulty in concentrating, (9)
Rathi AK et al. Int J Res Med Sci. 2019 Dec;7(12):4703-4708
International Journal of Research in Medical Sciences | December 2019 | Vol 7 | Issue 12 Page 4705
fatigue/lack of energy, (10) overeating/food
cravings, (11) insomnia, (12) hypersomnia, (13)
feeling overwhelmed or out of control and (14)
physical symptoms: breast tenderness, headaches,
joint/muscle pain, bloating, weight gain.
• Second domain includes 5 items which evaluates
impact of symptoms on women’s functioning as
interference with - (a) work efficiency or
productivity, (b) relationships with co-workers (c)
relationships with family, (d) social life activities
and (e) home responsibilities.
Each item is rated on a four point Likert scale as not at
all, mild, moderate and severe in last 12 months duration
during most of the cycles. For diagnosis of PMS, women
must report at least five symptoms as moderate or severe
from first domain where at least one should be from core
symptoms (numbers 1-4). Also, they must report if their
symptoms interfere moderately or severely with their
ability to function in at least one of five items in the
second domain.
While for diagnosis of PMDD, the following criteria
must be present: (a) at least one of the core symptoms (1
to 4) as severe, (b) in addition, at least four of the
symptoms (1 to 14) as moderate to severe from first
domain and (c) at least one of symptom as severe from
second domain.
Perceived Stress Scale-10 (PSS-10) - It was developed by
Cohen and his colleagues and adopted to measure a
global level of perceived stress. There are 10 questions in
this scale asking about your feelings and thoughts during
the last month.9 Each item is rated on a 5-point Likert
scale ranging from never (0) to almost always (4).
Positively worded items (4, 5, 7, and 8) are reverse
scored, and the ratings are summed across all 10 items.
Scores ranging from 0-13 is considered low stress, 14-26
is considered moderate stress while 27-40 is considered
high perceived stress. A higher total score indicates a
higher level of uncontrollable, unpredictable, and
overwhelming feelings.10
ACOG Guidelines - The Key elements of a PMS
identified by ACOG include the following:4
• Symptoms consistent with PMS- at least one of each
of the following affective and somatic symptoms
during the 5 days before menses.
Affective: Depression, anger outbursts, irritability,
anxiety, confusion, social withdrawal
Somatic: Breast tenderness, abdominal bloating,
headache, swelling of extremities
• Restriction of symptoms to the luteal phase of
menstrual cycle.
• Confirmation of symptom pattern by prospective
assessment.
• The symptoms cause functional impairment.
• Exclusion of other diagnosis that may better explain
the symptoms.
Ethical clearance: First of all, approval was taken from
the ethical committee of the medical college to conduct
the study.
RESULTS
Total 100 participants were analyzed. Mean age of
participants was 20.94 years ranging from 19-24 years,
98% of them were Hindu and 68% belonged to nuclear
family, 60% were hailing from urban locality while rest
were from rural background (Table 1).
Mean age of menarche was 13.43 years ranging from 11-
17 years. Mean duration of cycle was 28.61 days ranging
from 22 - 40 days. Mean duration of flow was 4.69 days.
86% participants had duration of flow between 3-5 days
and the rest had the blood flow for more than 5 days.
Blood flow was reported scanty by 1%, normal by 87%
and heavy by 12% of the total participants.
Dysmenorrhea (painful menstruation) was reported by
64% participants. Intermenstrual bleeding wasn't reported
by any of the participant (Table 2).
Table 1: Distribution of participants according to
socio-demographic profile.
Variable
Number of
participants
(n=100)
Range
Age
Mean = 20.9
years
(19-24
Years)
Religion
Hindu
98
Non-Hindu
2
Family
type
Nuclear
68
Extended
Nuclear
9
Joint
23
Locality
Urban
60
Rural
40
Statistically 66% participants had PMS according to the
ACOG guidelines (DSM-5) and 6% fulfilled the criteria
for PMDD as per DSM-5. According to the PSST, 88
participants had one or more premenstrual symptoms out
of which 58 had mild/no PMS and 30 had moderate to
severe PMS, 5% participants were diagnosed as PMDD
according to PSST. On Perceived Stress Scale, the stress
was mild in 26% and moderate in 74% of the participants
(Table 3).
Relationship of Premenstrual Syndrome to menstrual
characteristics and perceived stress score. 93.75% of
participants reporting dysmenorrhea were having
Premenstrual syndrome and this association was found to
be statistically significant (p value<0.05). Significant
association was not found between presence of
Rathi AK et al. Int J Res Med Sci. 2019 Dec;7(12):4703-4708
International Journal of Research in Medical Sciences | December 2019 | Vol 7 | Issue 12 Page 4706
premenstrual symptoms and duration of flow, regularity
of cycles, amount of blood flow and duration of cycle (Table 4 and 5).
Table 2: Distribution of participants according to characteristics of menstrual cycle.
Variable
Number of participants (n=100)
Range
Mean age of menarche
13.4 years
(11-17 years)
Mean duration of cycle
28.6 days
(22 - 40 days)
Duration of flow
3-5 days
86
Mean duration of flow = 4.6 days
>5 days
14
Regularity of cycle
Regular
96
Irregular
4
Blood flow
Scanty
1
Normal
87
Heavy
12
Dysmenorrhoea
Present
64
Absent
36
Inter-menstrual Bleeding
Present
0
Absent
100
Table 3: Distribution of participants according to menstrual/psychological problems.
Variable
Number of participant (n=100)
Percent
PMS according to DSM-5 [ACOG criteria]
Yes
66
66 %
No
34
34 %
PMDD according to DSM-5
Yes
6
6 %
No
94
94 %
PMS according to PSST
No symptom of PMS
12
12 %
Mild/No PMS
58
58 %
Moderate/Severe PMS
30
30 %
PMDD according to PSST
Yes
5
5 %
No
95
95 %
Perceived stress on PSS
Mild (≤13)
26
26 %
Moderate (14-26)
74
74 %
PMS - Premenstrual Syndrome PMDD - Premenstrual Dysphoric Disorder, DSM 5 - Diagnostic and statistical Manual 5, PSST -
Premenstrual Symptom Screening Tool PSS - Perceived Stress Scale ACOG - American College of Obstetrician and Gynecologists
Table 4: Distribution of PMS/PMDD patients according to menstrual characteristics.
Menstrual characteristics
PMS/PMDD
[According to PSST]
p value
Present
(n=88)
Absent
(n=12)
Dysmenorrhoea
Present (64)
60 (93.75%)
4 (6.25%)
0.01 Significant
Absent (36)
28 (77.78%)
8 (22.22%)
Duration of flow
3 –5 days (86)
75 (87.2%)
11 (12.8)
0.54
> 5 days (14)
13 (92.85%)
1 (7.15%)
Regularity of cycle
Regular (96)
84 (87.5%)
12 (12.5%)
0.45
Irregular (04)
4 (100%)
0 (0%)
Blood flow
≤Normal (88)
78 (88.63%)
10 (11.37%)
0.59
Heavy (12)
10 (83.33%)
2 (16.66%)
Duration of cycle
≤30 days (87)
75 (86.2%)
12 (13.8)
0.15
>30 days (13)
13 (100%)
0 (0%)
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International Journal of Research in Medical Sciences | December 2019 | Vol 7 | Issue 12 Page 4707
Table 5: Distribution of PMS/PMDD patients
according to Perceived Stress Score.
Perceived
Stress Score
PMS/PMDD
p value
Present
(n=88)
Absent
(n=12)
Mild stress
(≤13)
19(73.1%)
7(26.9%)
0.006
Highly
Significant
Moderate
stress (14-26)
69(93.2%)
5(6.8%)
Among the participants who had mild stress, 73.1% were
having Premenstrual Syndrome, while in participants
with moderate stress, 93.2% were having Premenstrual
Syndrome and this association between stress and
presence of premenstrual symptoms was found to be
statistically significant (p value< 0.05).
A highly significant correlation was found between PSS
score and PSST score (p value=0.006, r=0.235)
explaining that as the stress increases, severity of
premenstrual syndrome also increases (Figure 1).
Figure 1: Distribution of PSST score and PSS score in
participants.
DISCUSSION
The current study has a special aim at assessing the
impact of examination stress on menstrual cycle in young
medical students, when they are more prone to emotional
and psychological burnout. Relationship in severity of
perceived stress with the severity of premenstrual
symptoms was also analyzed.
The mean age of participants was 20.94 years ranging
from 19- 24 years. Premenstrual syndrome (PMS) is quite
prevalent among women of reproductive age. Nisar M et
al. found mean age of participants 21.2 ranging from 18 -
25.11 Most of the participants (52.66%) were from age
group 21 to 24 in a study done by Bakhshani NM et al. 12
Similarly Issa BA et al, in their study found that mean
age of the participant was 21.3 years ranging from 16 - 38
years.13 Nourjah P in a study in university students found
that age of participants ranged from 18 - 24 years.14 Singh
P et al. found mean age of the participants 18.9 years
ranging from 17 to 30 years.15
The mean age of menarche was 13.43 years and mean
duration of cycle was 28.61 days. Mean duration of blood
flow was 4.69 days. Dysmenorrhea (painful
menstruation) was reported by 64% of the total
participants. Statistically significant association was
found between dysmenorrhea and PMS/PMDD (p value<
0.05). Mahin Delara et al, in 2013 also found in their
study in Iranian adolescent girls that those with
dysmenorrhea were more likely to be classified as having
PMS and PMDD.16
Statistically 66% participants had PMS and only 6% had
PMDD according to the DSM-5 criteria. Mishell DR et
al, also estimated that 75-85% of menstruating women
experience some uncomfortable symptoms during the
premenstrual phase of their cycles.17 Banerjee et al,
reported 6.4% prevalence of PMDD in Indian women.18
On PSST, 88% participants reported having premenstrual
symptoms out of which 58% had mild/no PMS and 30%
had moderate to severe PMS. Author are in agreement
with the study by Steiner et al, who reported severe PMS
in 21.3% of adolescent girls, 5% of total participants
were diagnosed as PMDD according to PSST. This study
is in agreement with the study by Steiner et al, who
reported its prevalence to be 8.3%.19 Higher number of
cases of PMS/PMDD by PSST can be due the fact that
even a single positive response of participant categorizes
her into No/mild PMS.
This study reports that mild stress was found in 26% and
moderate stress in 74% of the participants. Among
participants showing mild stress, 73.1% were having
PMS/PMDD while in subjects having moderate stress,
93.2% were having PMS/PMDD and this association
between stress and premenstrual symptoms was found to
be statistically significant (p value<0.05). Czaikowska M
et al, in 2015 also found that stress of competitive sports
and intensity of training are conducive to PMS.20
The study finds highly significant correlation between
PSS score and PSST score (p value= 0.006, r= 0.235)
explaining as the perceived stress increases, severity of
premenstrual symptoms also rises. Lustyk et al, found
significantly more perceived stress in the high symptom
group compared to the low symptom group.21
The study has certain limitations, it included a highly
selective sample of undergraduate medical college
students. Premenstrual symptoms were reported based on
retrospective recall of the participants adding a recall
bias. As there was no prospective diary charting of PMS
symptoms, the prevalence rates are of “provisional
diagnosis” according to DSM-5 criteria. Findings of this
study needs to be replicated by community based large
cross sectional survey to obtain more precision.
0
10
20
30
40
50
010 20 30
PSST Score
Perceived Stress Score p = 0.006
r= 0.235
Rathi AK et al. Int J Res Med Sci. 2019 Dec;7(12):4703-4708
International Journal of Research in Medical Sciences | December 2019 | Vol 7 | Issue 12 Page 4708
CONCLUSION
Premenstrual syndrome is common in adolescent girls.
Highly significant correlation between the severity of
stress of exams and PSST score suggests that stress is
responsible for either increase in the severity or new
appearance of premenstrual symptoms. Statistically
significant correlation between Premenstrual syndrome
and dysmenorrhea suggests that every women reporting
painful menstruation should be thoroughly screened for
presence of Pre-menstrual syndrome or Pre-menstrual
dysphoric disorder.
Final year MBBS students having menstruation related
problems, despite affecting their work efficiency, did not
consult to healthcare provider probably considering it
either as a normal phenomenon or due to their hesitation.
Simultaneously there is a need of orientation of women’s
health care providers about role of stress in Premenstrual
Syndrome or Pre-menstrual dysphoric disorder.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
Institutional Ethics Committee
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Cite this article as: Rathi AK, Agrawal M, Baniya
GC. A study of impact of stress: examinations on
menstrual cycle among medical students. Int J Res
Med Sci 2019;7:4703-8.
