INTRODUÇÃO: O transtorno disfórico pré-menstrual (TDPM) é uma variante mais grave da síndrome pré-menstrual que apresenta a oscilação do humor como fator mais perturbador e debilitante, repercutindo na qualidade de vida das mulheres em idade reprodutiva. O objetivo deste estudo foi identificar as principais repercussões físicas e emocionais causadas pela TDPM entre universitárias de Fisioterapia. MÉTODO: Estudo do tipo corte transversal, descritivo e analítico, realizado no período de agosto a dezembro de 2008 em 259 universitárias. Os instrumentos utilizados para a realização desta pesquisa foram: um questionário contendo questões socioeconômicas, o Questionário de Sintomas Menstruais (Menstrual Symptom Questionnaire, MSQ), a escala de autoavaliação de síndrome de transtorno pré-menstrual de Steiner e o Questionário de Autoavaliação da Escala de Hamilton para Depressão. A análise estatística foi descritiva e analítica, sendo utilizado o teste qui-quadrado ou o teste exato de Fisher, sendo que todas as conclusões foram tomadas ao nível de significância de 5%. RESULTADOS: Encontramos alta prevalência de repercussões somáticas e emocionais. Através dos sinais e sintomas pesquisados pelo MSQ entre as portadoras de TDPM, observou-se uma associação do transtorno com os sintomas depressivos (p = 0,048). Os demais sintomas como ansiedade, labilidade de humor, sintomas somáticos, habilidade para realizar tarefas e dor não apresentaram correlação. CONCLUSÃO: O TDPM provocou desconforto físico e emocional e revelou uma correlação significativa com os sintomas depressivos, sugerindo tratar-se de uma expressão clínica de transtorno de humor.
Transtorno disfórico pré-menstrua; ciclo menstrual; saúde da mulher
INTRODUCTION: Maternal premenstrual dysphoric disorder (PMDD) is a severe variant of premenstrual syndrome in which mood swings is the most disturbing and debilitating symptom, affecting the quality of life of women of reproductive age. The objective of this study was to identify the main physical and emotional manifestations of PMDD among undergraduate students of Physical Therapy. METHODS: A cross-sectional, descriptive, analytical study was carried between August and December 2008, with 259 undergraduate students. The following instruments were used: a questionnaire covering social and economic data; the Menstrual Symptom Questionnaire (MSQ); Steiner's self-rated premenstrual syndrome questionnaire; and the Hamilton Self-Rating Depression Questionnaire. Descriptive and analytical statistical analysis was performed using the chi-square test or Fisher's exact test. Significance was set at 5%. RESULTS: A high prevalence of physical and emotional symptoms was found. Among the signs and symptoms assessed by MSQ, only depression showed a significant correlation with PMDD (p = 0.048). Other symptoms, such as anxiety, mood lability, physical symptoms, the ability to perform daily tasks, and pain, were not correlated with PMDD. CONCLUSION: PMDD caused physical and emotional distress among the women assessed and was significantly correlated with depression. These findings suggest that PMDD should be classified as a clinical manifestation of mood disorders.
Premenstrual dysphoric disorder; menstrual cycle; women's health
Effects of premenstrual dysphoric disorder among college students
Valéria Conceição Passos de CarvalhoI; Amaury CantilinoII; Nathália Machado Porto CarreiroIII; Luciene Fontes de SáIII; Everton Botelho SougeyIV
IPhD student, Graduate Program in Neuropsychiatry and Behavioral Sciences, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil. Assistant professor, Universidade Católica de Pernambuco (UNICAP), Recife, PE, Brazil. Assistant professor, Faculdade Integrada do Recife (FIR), Recife, PE, Brazil
IIPhD, Neuropsychiatry and Behavioral Sciences. Coordinator, Women's Mental Health Program, Affective Disorders Research Center, Hospital das Clínicas, UFPE, Recife, PE, Brazil
IIISpecialist, Physical therapist, FIR, Recife, PE, Brazil
IVPost-PhD, Free University of Brussels, Brussels, Belgium. Coordinator, Graduate Program in Neuropsychiatry and Behavioral Sciences, UFPE, Recife, PE, Brazil
This study was conducted at the Graduate Program in Neuropsychiatry and Behavioral Sciences, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil
INTRODUCTION: Maternal premenstrual dysphoric disorder (PMDD) is a severe variant of premenstrual syndrome in which mood swings are the most disturbing and debilitating symptom, affecting the quality of life of women of reproductive age. The objective of this study was to identify the main physical and emotional manifestations of PMDD among undergraduate students of Physical Therapy.
METHODS: A cross-sectional, descriptive, analytical study was carried between August and December 2008, with 259 undergraduate students. The following instruments were used: a questionnaire covering social and economic data; the Menstrual Symptom Questionnaire (MSQ); Steiner's self-rated premenstrual syndrome questionnaire; and the Hamilton Self-Rating Depression Questionnaire. Descriptive and analytical statistical analysis was performed using the chi-square test or Fisher's exact test. Significance was set at 5%.
RESULTS: A high prevalence of physical and emotional symptoms was found. Among the signs and symptoms assessed by MSQ, only depression showed a significant correlation with PMDD (p = 0.048). Other symptoms, such as anxiety, mood lability, physical symptoms, the ability to perform daily tasks, and pain, were not correlated with PMDD.
CONCLUSION: PMDD caused physical and emotional distress among the women assessed and was significantly correlated with depression. These findings suggest that PMDD should be classified as a clinical manifestation of mood disorders.
Keywords: Premenstrual dysphoric disorder, menstrual cycle, women's health.
The menstrual cycle (MC) lasts, on average, 28 days and it may be divided into three different phases: the follicular phase, ovulation, and the luteal phase. The follicular phase begins on the first day of menstruation and lasts from 8 to 23 days; ovulation can last up to 3 days; and the luteal phase lasts from the end of ovulation until the beginning of the menstrual flow. These phases are characterized by a specific serum concentration profile of sexual hormones.1
Therefore, the premenstrual period is a phase of vulnerability for the occurrence of physical and psychic symptoms that usually appear 1 week before menstruation and disappear with the beginning of the menstrual flow. According to estimates of epidemiological studies, 75% of the women at reproductive age experience some symptoms related to the premenstrual phase of the cycle. More than 100 physical and psychological symptoms have been reported, but many women are able to deal with them by changing their lifestyle and using conservative therapies.2
Premenstrual dysphoric syndrome or premenstrual dysphoric disorder (PMDD) is a more severe variant of the premenstrual syndrome, showing intense mood change as the most perturbing and debilitating factor within the set of symptoms. Its etiology has not been well defined because it is influenced by hormonal, family, environmental, and sociocultural factors; therefore, it does not necessarily have physical symptoms. Such condition, however, has a significant influence on the daily and working activities of women.2-4
Symptoms of PMDD can occur from the menarche to the menopause and are present in women's life throughout the whole reproductive period, often being interpreted as symptoms of an imaginary disorder and being caused by the increasingly stressful modern life. On the other hand, countless women have reported an increase in the severity and duration of the symptoms as they get closer to the menopausal period, which brings consequences to their quality of life.3
The lack of an established concept of PMDD explains the existence of multiple scales and diagnostic criteria for this disorder. Thus, a standard methodology of assessment has not been defined yet. The validation of scales of this poorly delimited syndrome is incomplete, and the existing scales try to establish one or more standards of change and intensity of symptoms throughout the menstrual cycle.5
The differential diagnosis between the premenstrual syndrome (PMS) and PMDD is difficult to be established because there is not any laboratory test that can serve as a biological marker of one or the other syndrome. However, most gynecologists or psychiatrists establish their diagnosis based on the assessment of the exacerbated symptoms during the menstrual period, considering both physical and depressive symptoms.6
The early identification and the appropriate treatment of PMDD reduce the probability of chronic and recurrent symptoms. There is still a controversy regarding the methods of intervention for this disorder; however, changes in the eating habits, administration of medication (psychotropic and contraceptive drugs), and physical activity have shown positive results for women with PMDD.1,4
The main characteristic of PMDD is the clinical recurrence during the luteal phase and mood and behavioral symptoms, among which depression, anxiety, affective lability, tension, irritability, and sleep disorder are the most frequent ones. In addition, it causes severe impairment of the individual's social and occupational functioning, which usually gets worse closer to the menstrual flow phase and generally ceases immediately after the menstrual flow starts.7
The objective of the present study is to identify the main psychosomatic consequences of PMDD among college students, describing its prevalence and investigating its association with socioeconomic, demographic, and behavioral factors.
MATERIALS AND METHOD
This is an analytical, descriptive, cross-sectional study. It was conducted at Faculdade Integrada do Recife (FIR), Recife, state of Pernambuco, Brazil, from August to December 2008. This research project was approved by the Research Ethics Committee of Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil, (CAEE: 0001.0.100.172-08).
Our sample comprised 259 female college students enrolled in the major of physical therapy of FIR. All participants signed a written consent form. Women with amenorrhea (who did not menstruate, including cases of pregnancy) and women who had irregular cycles (shorter than 25 days or longer than 35 days) were excluded.
Data collection was carried out at the classrooms. At first, students were approached, and the objectives of the research were explained to them. Then the assessment instruments were handed out to them. Confidentiality of the information was guaranteed so that the individuals could not be identified.
The instruments used in the present study were: a questionnaire containing socioeconomic data, clinical history, habits and specific scales related to the objective of the research including closed and structured questions arranged according to certain topics so that the logical organization of ideas was easier; the Menstrual Symptom Questionnaire (MSQ), containing 23 questions; the Steiner's self-rated premenstrual syndrome questionnaire, which defines the diagnosis of PMDD, containing 36 items; and the Hamilton Self-Rating Depression Questionnaire (HSRD-Q), which had its Brazilian version validated, containing 18 items.5,8,9
In order to define the presence or absence of PMDD using the Steiner's scale, we followed the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM IV), which requires the presence of five or more symptoms in the last two menstrual cycles and the presence of at least one of the symptoms reported in items 1, 2, 3 and 4 (Table 1).5
Mood, depressive, and physical symptoms of the MSQ were investigated separately. With the purpose of identifying the presence of symptoms, we considered the choice of options from 2 to 6 (2 - very mild; 3 - mild; 4 - moderate; 5 - severe; and 6 - extreme), so that when number 1 was chosen (not applicable, absent, no alterations), this indicated that the interviewee did not have the symptoms. Therefore, it was possible to classify the volunteers according to the presence of symptoms if the answers between options 2 and 6 accounted for 50% or higher of the answers in each category (Table 2).8
And for the classification of the presence or absence of depressive symptoms used in the HSRD-Q, we established 10 as a cutoff point, indicating the presence of depressive symptoms.9
A descriptive and analytical analysis of the results was carried out. The variables measured are shown in tables and figures. We used the chi-square test or Fisher's exact test when chi-square could not be used for the analysis of the quantitative variables. All conclusions were reached based on the significance level of 5%. The computer programs Excel 2000 and SPSS version 8.0 were used.10
The profile of the sample reveals that the mean age was 22.4±3.8, and most of the individuals, 75.7% (n = 196), were between 20 and 25 years old; 85.3% (n = 221) of the college students were single, and 64.1% (n = 166) lived in the Metropolitan area of Recife, state of Pernambuco, Brazil. A large portion of the sample, 80.3% (n = 208), reported being employed; of these, only 17.0% (n = 44) had a salary of R$ 683.05±736.41. With regard to ethnicity, there were predominantly white subjects, 58.7% (n = 152), and most of the subjects, 72.6% (n = 188), reported to be catholic (Table 3).
In terms of menarche, we found that in 62.9% (n = 163) of the cases, it had occurred by 12 years of age. Menstruation usually presented a moderate flow in 71.4% (n = 185); 58.7% (n = 152) of the college students were in the middle of the cycle. With regard to sexual activities, 70.7% (n = 183) reported to have an active sexual life, and 59.6% (n = 109) began their sexual life before turning 18 years old; 94.5% (n = 173) used contraceptive methods, among which the contraceptive pill was the most often used – 60.7% (n = 105).
We found that 74.6% (n = 106) of the college students had back pain as the most prevalent associated physical condition (Figure 1). Among the participants, 37.3% (n = 53) were moderately worried about this pain or discomfort, 47.9% (n = 68) of the college students reported they felt a mild difficulty to deal with these symptoms, 43.7% (n = 62) confirmed that the pain or discomfort almost did not prevent them from accomplishing their daily physical activities, and 34.5% (n = 49) were slightly tired due to this problem.
After analyzing the main symptoms described by the subjects, we found that the intensity of predominant pain was moderate according to the following symptoms: 25.5% (n = 66) of the college students had a sensation of abdominal weight associated with discomfort and pain; in 22.8% (n = 59) of the cases they felt intermittent pain or abdominal cramp; 26.3% (n = 68) felt a swelling sensation; and 26.6% (n = 69) have swollen breasts (Figure 2).
In the sample studied, we found the prevalence of 6.2% (n = 16) of college students with PMDD. When we correlated personal history with comorbidities, we found that the fact that the college students already had emotional problems was associated with the presence of PMDD (p = 0.03); however, the other variables investigated, such as use of medications, family history, and presence of comorbidities, did not show any significant association with PMDD (Table 4).
When we used the symptoms included in the MSQ and related them to the presence of the PMDD, we found a statistically significant association of this disorder with depression (p = 0.048). The other symptoms, such as anxiety, mood lability, somatic symptoms, abilities, and pain were not statistically significant when correlated with PMDD (Table 5).
In other studies conducted in Brazil, the authors have found a profile of socioeconomic and demographical variables similar to that of the present study, in which most of the college students were single, at reproductive age, and had a job.11-13
In the present study, the menarche was more prevalent in the age group of 12 years old, and the beginning of the sexual life was prevalent in the age group younger than 18 years old. In a study conducted with adolescents in the municipality of Santo André, state of São Paulo, Brazil, by Azevedo et al.,14 the female youths who had their menarche early also reported an early beginning of their sexual life. And according to Veras & Nardi,15 the early occurrence of the menarche favors the higher incidence of depressive symptoms among women.
It is important to keep in mind that PMDD is characterized by a mood disorder present in the late luteal phase of the reproductive cycle, a phase during which women have immunological and neuroendocrine responses to stress. This suggests that the hormonal alterations at this moment of the menstrual cycle can contribute to the development of PMDD symptoms, and in our sample most college students were at reproductive age.15,16
For birth control, we found a high use of contraceptive methods among the college students, with prevalence of the contraceptive pill. It has been established that the anovulatory cycles could result in a reduction of the prevalent signs and symptoms of PMS, but the same is not true for the patients diagnosed with PMDD. Antunes et al.17 concluded, in their study conducted at Universidade Paulista in Bauru, state of São Paulo, Brazil, that the psychiatric disorders related to the premenstrual variation do not seem to improve with the use of contraceptive pills. On the other hand, Bianco et al.18 suggested that the use of contraceptive pills can be related to higher levels of depression in women vulnerable to this symptom.
The most frequent comorbidity reported by the college students was lumbar pain, and in the study carried out by Muramatsu et al.,11 the authors found that the presence of pain was the most prevalent physical symptom in women with PMS, suggesting that the physical symptoms are presented as clinical complaints both in women with PMS and in those with a diagnosis of PMDD.
In the sample investigated, the authors found a prevalence of 6.2% of college students with PMDD, which is similar to the findings by da Silva19 in a population-based cohort study in which the same criteria suggested in the DSM IV for the classification of PMDD were used. In the present study, we found a prevalence of 5.8% for PMDD, and, after 20 months of follow up with the same population, the cumulative incidence was 7.4%.
An increasing number of women at reproductive age have reported the physical and emotional consequences of PMS, but the emotional symptoms have been reported as the most intense problems. Such fact is also mentioned in other studies that assessed the premenstrual symptoms and their consequences in the daily life of women, emphasizing that the symptoms of mood alteration can cause impairment or even result in cancelling commitments, which causes problems related to family and social relationships, as well as difficulties regarding the academic and/or professional performance.1,3,7,14
A hypothesis that can be raised is that premenstrual dysphoric conditions are a sequela of a previous depressive episode or, on the other hand, a sign of a depressive episode that will occur later.20
The alterations in the levels of estrogen and progesterone explain some symptoms of PMDD in which the lack of estrogen can be related to the occurrence of depression, with a decrease in the psychomotor activity, and its high levels can be associated with dysphoric states, such as excitement, anxiety, and irritability, which were present in all college students that had PMDD.21
Depression is a disease that affects many people currently. According to Campos,22 the estimate of depressive people in the population ranges from 10 to 15%; among women, this rate increases to 20%. In the present study, we found a positive correlation between depressive symptoms and PMDD. These data suggest that this might be a clinical subtype of depressive disorder. This confirms the findings of the study by Veras & Nardi,15 that demonstrated that depression is a clinical variable consistently related to PMDD.
In the present study, we found a high prevalence of somatic symptoms associated with PMDD, but, as mentioned above, they did not have a significant influence on the daily activity of the college students. However, among the emotional symptoms, the depressive symptoms showed a positive correlation with the diagnostic criteria of PMDD used in the present study.
PMDD revealed a significant correlation with depressive symptoms, suggesting that it is a clinical expression of mood disorder.
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Valéria Conceição Passos de CarvalhoRua Guedes Pereira, 77/401CEP 52060-150, Bairro Casa Amarela, Recife, PEE-mail:
Publication in this collection
18 Mar 2010
Date of issue