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Prevalence of premenstrual syndrome and premenstrual dysphoric disorder in a population-based sample in China
European Journal of Obstetrics & Gynecology and Reproductive Biology 162 (2012) 83–86
Contents lists available at SciVerse ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Prevalence of premenstrual syndrome and premenstrual dysphoric disorder in a population-based sample in China Mingqi Qiao a,*, Huiyun Zhang a, Huimin Liu a, Songping Luo b, Tianfang Wang c, Junlong Zhang d, Lijin Ji e a
Basic Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, China Guangzhou University of Traditional Chinese Medicine, First Affiliated Hospital, Guangzhou, Guangdong 510402, China c Department of Diagnostics of Traditional Chinese Medicine, Beijing University of Traditional Chinese Medicine, Beijing 100029, China d Shanxi College of Traditional Chinese Medicine, Taiyuan, Shanxi 030024, China e Department of Traditional Chinese Medicine, Fujian College of Traditional Chinese Medicine, Fuzhou, Fujian 350003, China b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 August 2011 Received in revised form 4 January 2012 Accepted 31 January 2012
Objective: To investigate the prevalence of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD), and the frequency and severity of the symptoms in a population-based sample of Chinese women of reproductive age. Study design: Women aged 18–45 years were screened for suspected PMS and PMDD based on the ACOG recommendations for a diagnosis of PMS and diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV). For those who were consistent with PMS diagnostic criteria, the daily record of severity of problems (DRSP) questionnaire was used to assess the symptoms prospectively over 2 months. Participants were then categorized as having no perceived symptoms, mild PMS, moderate PMS, and PMDD, based on a validated algorithm. Results: Among the study group, the incidence of PMDD was 2.1% and PMS was 21.1%. The most common symptoms were irritability (91.21%), breast tenderness (77.62%), depression (68.31%), abdominal bloating (63.70%) and angry outbursts (59.62%). Conclusion: The prevalence of PMS/PMDD and the frequency and severity of the symptoms have their own characteristics in Chinese women. ß 2012 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Premenstrual syndrome (PMS) is a generic term which includes a broad group of emotional, behavioral and physical symptoms that occur for several days to weeks before menses and subside following the menstrual period [1]. The American College of Obstetricians and Gynecologists defines PMS as ‘‘a clinical condition characterized by the cyclic presence of physical and emotional symptoms unrelated to any organic disease that appear during the luteal phase of the menstrual cycle and disappear after menstruation or within 48 h of the onset of bleeding’’ [2]. Premenstrual dysphoric disorder (PMDD) is a severe form of PMS. It is characterized by some combination of marked mood swings, depressed mood, irritability and anxiety, which may be accompanied by physical symptoms. These symptoms occur exclusively during the luteal phase of the menstrual cycle, with remission generally within three days after the onset of menses [3].
* Corresponding author at: Basic Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, China. Tel.: +86 13553168096; fax: +86 0531 89628077. E-mail address: [email protected] (M. Qiao). 0301-2115/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejogrb.2012.01.017
Women with confirmed PMS report significantly lower quality of life, increased absenteeism from work, decreased work productivity, impaired relationships with others and increased visits to health providers, compared with control women. PMS is common in women of reproductive age. In a study in Switzerland, ninety-one percent of the participants reported at least one symptom, 10.3% had PMS and 3.1% fulfilled the criteria for PMDD [4]. As many as 95% of Japanese women were found to suffer from premenstrual symptoms, and the rates of prevalence of moderate to severe PMS and PMDD in these women were 5.3% and 1.2%, respectively [5]. A cross-sectional nationwide survey conducted among a cohort of Spanish women found that of the 2108 participants, 73.7% complained of some of the premenstrual symptoms during the last 12 menstrual cycles: a total of 91% women presented isolated symptoms and 8.9% a moderate/severe PMS, 1.1% women fulfilled criteria for a diagnosis of PMDD [6]. In one population-based study carried out in Virginia (USA), PMS was observed in 8.3% of the women interviewed by telephone, and approximately 5% fulfilled the criteria for PMDD [7]. So far, there have been no systematic studies of the prevalence of PMS in China. The objective of the present study, therefore, was to assess the prevalence of PMS and PMDD and the frequency and severity of the premenstrual symptoms in Chinese women.
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2. Materials and methods 2.1. Study population
Table 1 Characteristics of 947 women who consistent with PMS diagnostic criteria according to stratification variables. Number (%)
Variable
A cluster sampling study was conducted by seven units (Shandong University of Traditional Chinese Medicine (TCM), Jinan Central Hospital, Guangzhou University of TCM First Affiliated Hospital, Beijing University of TCM Affiliated East Hospital, Shanxi College of TCM Second Affiliated Hospital, Qingdao Municipal Hospital and Fujian College of TCM) using a sample of Chinese women between the ages of 18 and 45 years in the communities of six cities (Jinan, Qingdao, Fuzhou, Guangzhou, Beijing and Taiyuan). We recruited Chinese women who had regular menstrual cycles (25–35 days) and were able to provide informed consent. 2.2. Measures ACOG recommendations for a diagnosis of PMS published in the 2000 ACOG practice bulletin, and the daily record of severity of problems (DRSP) form developed and described in detail by Endicott [8] were used. They had previously been translated into Chinese by us and reverse translated into English by professional translators: we then conducted an acculturated pilot study with a small sample in order to confirm their equivalence before they were used in the subsequent research. All women were screened for PMS/PMDD using tools based on the ACOG recommendations for diagnosis of PMS and the diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV). ACOG recommendations for a diagnosis of PMS specified that one or more disturbing affective or somatic symptoms must have occurred during the 5 days before menses in each of 3 previous menstrual cycles. These symptoms must be relieved within 4 days of menses onset without recurrence until at least cycle day 13. In addition, a woman who experiences these symptoms must suffer from identifiable dysfunction in social or economic performance. Furthermore, her symptoms must occur reproducibly during 2 cycles of prospective recording and in the absence of any pharmacologic therapy, hormone ingestion, or drug or alcohol abuse. Eligibility criteria included: (1) aged 18 to 45; (2) regular menstrual cycles (25–35 days); (3) no psychiatric diagnoses in the past 2 years. Women were ineligible if they: (1) were pregnant; (2) were experiencing untreated depression; (3) reported a history of gynecological inflammation, menopausal syndrome, hysterectomy or bilateral oophorectomy, mastopathy or cancer, or diabetes or any other structural diseases. Those women who were consistent with PMS diagnostic criteria and consented to participate further in the study were asked to provide further data over two consecutive observational cycles using the DRSP questionnaire to document daily symptom severity. DRSP consists of 24 items: most of the DRSP items (n = 21) assess psychological, behavioral and physical symptoms, and the last three items evaluate the degree of interference of the premenstrual symptoms with functioning and productivity, (a) at work or at school, (b) with social activities and hobbies, and (c) with relationships with others. These items are rated on a six-point scale of severity ranging from ‘no change’ to ‘extreme change’. Participants were instructed to rate their symptoms at night before going to bed.
Age, years 18–20 21–30 31–40 41–45 Education level No studies or primary education Secondary education University degree City Jinan Fuzhou Guangzhou Beijing Taiyuan Qingdao Occupation Student Worker Waiter Nurse Soldier Teachers Others
139 439 263 106
(14.7) (46.3) (27.8) (11.2)
6 (0.6) 207 (21.9) 734 (77.5) 298 138 149 110 108 144
(31.5) (14.6) (15.7) (11.6) (11.4) (15.2)
389 131 65 187 13 10 152
(41.1) (13.8) (6.9) (19.7) (1.4) (1.1) (16.0)
Percentages in parenthesis.
symptoms mentioned by the participants were, in order of frequency, irritability (91.21%), depression (68.31%), angry outbursts (59.62%), anxiety (53.77%) and confusion (19.25%), whereas the physical symptoms were breast tenderness (77.62%), abdominal bloating (63.70%), headache (36.61%) and swelling of extremities (20.08%) (Fig. 1). They were then asked to provide further data over two consecutive observational cycles using the DRSP questionnaire to document daily symptom severity. A total of 947 women who were consistent with ACOG recommendations for a diagnosis of PMS consented to complete the DRSP. Of these, 132 dropped out before study completion or did not fully complete all questionnaires. Overall, 815 women completed the study (i.e., all questionnaires including the 2-month diary were completed). These women were considered to have fully participated in the study and therefore represent the full analysis set. Table 2 shows DRSP total symptom scores of 5 days in the premenstrual phase (days 5 to 1). So from the data (Table 2) and based on the clinical practice (all these 815 Chinese women in this consecutive study met ACOG recommendations for a diagnosis of PMS), we considered that total symptom scores across 5 days in the premenstrual phase (days 5 to 1) of over 70 and less than 130 (Mean Std deviation) were mild PMS; scores over 130 and less Confusion
19.25
Swelling of extremities
20.08
Headache
36.61
Anxiety
53.77
Angry outbursts
59.62 63.7
Abdominal bloating
3. Results
Depression
We investigated a total of 4715 women, of whom 235 withdrew from the study, and 947 (21.1%) were consistent with PMS diagnostic criteria. The characteristics of these 947 women who were consistent with PMS diagnostic criteria according to stratification variables are shown in Table 1. The emotional
Breast tenderness
68.31 77.62 91.21
Irritability
0
20
40
60
80
Fig. 1. Prevalence and distribution of premenstrul symptoms (n = 947).
100
M. Qiao et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 162 (2012) 83–86 Table 2 DRSP total symptom scores of 5 days in the premenstrual phase(days
First premenstrual phase Second premenstrual phase
5 to
85
1).
n
Mean
Std deviation
Minimum
Maximum
815 815
130.25 127.31
49.720 50.770
60 67
400 411
than 180 were moderate and scores exceeding 180 (Mean + Std deviation) were considered severe symptoms. The patients with scores exceeding 180 all had mood symptoms which were sufficiently severe to interfere with work, family and social relationships, so they were thought to meet the criteria for PMDD (we used a total score to approximate a PMDD diagnosis). Those whose total symptom scores were under 70 were not thought consistent with diagnostic criteria for PMS. According to the statistical result of DRSP total symptom scores of 5 days in the premenstrual phase (days 5 to 1) and the cut-off points for PMS severity and PMDD mentioned above, the prevalence of PMDD in our study was 2.1% (102 women), and the prevalence of mild PMS and moderate PMS in our study was 11.3% (506 women) and 4.6% (206 women), respectively. One woman’s total symptom scores were under 70, so she was not thought consistent with diagnostic criteria for PMS. Each woman experienced a relatively constant degree of symptom severity, particularly for emotional symptoms over two consecutive cycles. 4. Comments This is the first large sample, multicentre Chinese study to show the prevalence of PMS from a population-based study. The findings show that the incidence of PMS in Chinese women who met ACOG recommendations for a diagnosis of PMS in the present study (21.1%) was higher than that reported for women in Switzerland, Japan and Virginia (USA) [4,5,7], but consistent with Borenstein’s studies [9] which suggested that up to 20% of all women of fertile age have premenstrual complaints that could be regarded as clinically relevant. Compared to our previous study [10], the incidence of PMS decreased dramatically from 41.9% to 21.1%. One reason is that in our previous study we used domestic diagnostic criteria for PMS of Practical obstetrics and gynecology science which provided only retrospective diagnostic conditions. The other is that eligibility criteria in the previous study included PMS patients who had combined diseases: if we calculate the prevalence of PMS excluding those who had combined diseases, the prevalence is 21.77% – approximately the same as in the present study. The prevalence rate for PMDD in the present study is higher than that of Takeda et al. [5], who observed a 1.2% prevalence of PMDD in Japan, but lower than that in other studies. Endicott [11] reported that about 3–8% of women have sufficiently severe symptoms to meet the DSM-IV criteria for PMDD. Wittchen et al. [12] observed that the prevalence of PMDD was 5.8%. Wallenstein et al. [13] administered a questionnaire to women who were 18–45 years old and observed that the prevalence of PMDD was 6.0%. We also found that in epidemiological studies and surveys, not only the rates of PMS and PMDD but also the frequency of premenstrual symptoms vary considerably. In the present study, the most frequent premenstrual symptoms were irritability (91.21%), followed by breast tenderness (77.62%) and depression (68.31%), whereas the least frequent premenstrual symptoms were swelling of extremities (20.08%) and headache (36.61%). In the study of Tschudin et al. [4], the most common complaints were physical symptoms, which were reported by 74% of women, followed by ‘‘fatigue/lack of energy’’ in 68% and ‘‘tearfulness/mood swings’’ and ‘‘anger/irritability’’ in 67% each. In the prospective
Percentiles 25th
50th
75th
95.00 94.00
117.00 115.00
150.00 146.00
longitudinal survey of Wittchen et al. [12], the five most frequently reported symptoms were physical complaints (44.9%), affect lability (41.7%), fatigability (36.6%), depressed mood (31.4%) and appetite/craving (30.3%). In Takeda et al’s study, physical symptoms were reported by 81.2%, ‘‘anger and irritability’’ by 70.6% and ‘‘anxiety and tension’’ by 68.5% [5]. The most prevalent psychological symptom in the Zurich cohort study was irritability ˜ as et al. [6], the most frequent (49.3%) [14]. In the study of Duen premenstrual symptoms were physical complaints (breast tenderness, headache, weight gain, bloating), which occurred in 81.6% of women, followed by irritability (53%), tearfulness (48.7%), and anxiety (40.5%). As to the causes of the variation in the incidence of PMS, PMDD and the frequency of premenstrual symptoms, we think this may be due to two reasons: one is sociocultural factors [15] and that the study populations selected for the studies are different, and the other is that the screening tools used by researchers are different. In our study, PMS/PMDD was less prevalent in women workers with lower education. Cohen et al. [16] also found an association with lower education, while PMS/PMDD was more prevalent in students, which is in line with Takeda et al’s study [17], and half of students felt both irritability and depression. We can suggest possible explanations about the causes of the difference in the prevalence of PMS/PMDD between different social groups: workers’ environment is simple and they do not feel so much stress, while students are under a great deal of stress due to long hours of studying and are also exposed to employment pressure. The diagnosis of PMS/PMDD by the DSM-IV criteria requires prospective daily charting which has to be completed over a period of two consecutive symptomatic cycles. In a retrospective design of PMS/PMDD which based on memory, women are likely to amplify [15] as well as reduce the recall of the severity and frequency of symptoms. Our previous study found that this may be associated with patient’s personality characteristics [18]. Usually, extroverted people tend to amplify their symptom reports, while introverted people tend to reduce their symptom reports. Prospective daily charting, however, is difficult for large samples. So the strength of our study is that we used both retrospective and prospective screening tools for PMS/PMDD and firstly put forward the diagnostic criteria for PMS with retrospective and prospective conditions in China [19]. One major limitation of our study is that it was conducted at large urban centers and, as a result, it reflected the situation of urban Chinese women only. The other limitation is that the DRSP tool has not been previously validated in a Chinese population, although a pre-test pilot study was performed. Using worldwide universally accepted diagnostic criteria for assessment of the prevalence of PMS/PMDD in China will allow for improvement in PMS/PMDD patient awareness of their conditions and selecting a therapeutic approach to relieve their symptoms. We therefore hope that this group, which is so huge in China, will benefit from the present study. Acknowledgement We thank Jingyi Wang, Yanfeng Liu and Zhiwei Xu for their help with this study, and the women who participated. This study funded by the 10th Five Years Chinese National Programs for
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Science and Technology Development (2004BA721A04) of the Ministry of Science and Technology of PRC, Grant No. 30930110 from National Natural Science Foundation of China (NSFC) and the Shandong Provincial Special Foundation on Taishan scholar Project for Mingqi Qiao. References [1] Freeman EW. Premenstrual syndrome and premenstrual dysphoric disorder: definitions and diagnosis. Psychoneuroendocrinology 2003;28(Suppl. 3): 25–37. [2] ACOG Practice Bulletin. Clinical management guidelines for obstetrician– gynecologists. Number 15. Premenstrual syndrome. Obstet Gynecol 2000; 95:4. [3] Grady-Weliky TA. Premenstrual dysphoric disorder. N Engl J Med 2003; 348(5):433–8. [4] Tschudin S, Bertea PC, Zemp E. Prevalence and predictors of premenstrual syndrome and premenstrual dysphoric disorder in a population-based sample. Arch Womens Ment Health 2010;13(6):485–94. [5] Takeda T, Tasaka K, Sakata M, Murata Y. Prevalence of premenstrual syndrome and premenstrual dysphoric disorder in Japanese women. Arch Womens Ment Health 2006;9(4):209–12. ˜ as JL, Lete I, Bermejo R, et al. Prevalence of premenstrual syndrome and [6] Duen premenstrual dysphoric disorder in a representative cohort of Spanish women of fertile age. Eur J Obstet Gynecol Reprod Biol 2011;156(1):72–7. [7] Deuster PA, Adera T, South-Paul J. Biological, social, and behavioral factors associated with premenstrual syndrome. Arch Fam Med 1999;8(2):122–8. [8] Endicott J, Nee J, Harrison W. Daily Record of Severity of Problems (DRSP): reliability and validity. Arch Womens Ment Health 2006;9(1):41–9.
[9] Borenstein J, Dean B, Endicott J, et al. Health and economic impact of the premenstrual syndrome. J Reprod Med 2003;48(7):515–24. [10] Qiao Mingqi, Xu Xujie. Epidemiological survey on syndromes distribution in PMS. Chin J Basic Med TCM 1997;3(3):31–3. [11] Endicott J. History, evolution, and diagnosis of premenstrual dysphoric disorder. J Clin Psychiatry 2000;61(Suppl. 12):5–8. [12] Wittchen HU, Becker E, Lieb R, Krause P. Prevalence, incidence and stability of premenstrual dysphoic disorder in the community. Psychol Med 2002;32: 119–32. [13] Wallenstein GV, Blaisdell-Gross B, Gajria K, et al. Development and validation of the premenstrual symptoms impact survey (PMSIS): a disease-specific quality of life assessment tool. J Womens Health 2008;17(3):439–50. [14] Merikangas KR, Foeldenyi M, Angst J. The Zurich study. XIX. Patterns of menstrual disturbances in the community: results of the Zurich cohort study. Eur Arch Psychiatry Clin Neurosci 1993;243(1):23–32. [15] Adewuya AO, Loto OM, Adewumi TA. Premenstrual dysphoric disorder amongst Nigerian university students: prevalence, comorbid conditions, and correlates. Arch Womens Ment Health 2008;11(1):13–8. [16] Cohen LS, Soares CN, Otto MW, Sweeney BH, Liberman RF, Harlow BL. Prevalence and predictors of premenstrual dysphoric disorder (PMDD) in older premenopausal women. The Harvard Study of Moods and Cycles. J Affect Disord 2002;70(2):125–32. [17] Takeda T, Koga S, Yaegashi N. Prevalence of premenstrual syndrome and premenstrual dysphoric disorder in Japanese high school students. Arch Womens Ment Health 2010;13(6):535–7. [18] Qiao Mingqi, Zhang Huiyun, Wang Wenyan, et al. A relevance study of mood and personality of invasion and stagnation of Liver-Qi. Chin J Basic Med Tradit Chin Med 2007;13(5):349–52. [19] Zhu Yuhui, Wang Haijun, Qiao Mingqi, Zhang Huiyun. Establishment of curative effect evaluation criterion of PMS Liver-Qi invasion based on DRSP. Chin J Inf Tradit Chin Med 2009;16(6):14–6.
Contents lists available at SciVerse ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Prevalence of premenstrual syndrome and premenstrual dysphoric disorder in a population-based sample in China Mingqi Qiao a,*, Huiyun Zhang a, Huimin Liu a, Songping Luo b, Tianfang Wang c, Junlong Zhang d, Lijin Ji e a
Basic Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, China Guangzhou University of Traditional Chinese Medicine, First Affiliated Hospital, Guangzhou, Guangdong 510402, China c Department of Diagnostics of Traditional Chinese Medicine, Beijing University of Traditional Chinese Medicine, Beijing 100029, China d Shanxi College of Traditional Chinese Medicine, Taiyuan, Shanxi 030024, China e Department of Traditional Chinese Medicine, Fujian College of Traditional Chinese Medicine, Fuzhou, Fujian 350003, China b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 August 2011 Received in revised form 4 January 2012 Accepted 31 January 2012
Objective: To investigate the prevalence of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD), and the frequency and severity of the symptoms in a population-based sample of Chinese women of reproductive age. Study design: Women aged 18–45 years were screened for suspected PMS and PMDD based on the ACOG recommendations for a diagnosis of PMS and diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV). For those who were consistent with PMS diagnostic criteria, the daily record of severity of problems (DRSP) questionnaire was used to assess the symptoms prospectively over 2 months. Participants were then categorized as having no perceived symptoms, mild PMS, moderate PMS, and PMDD, based on a validated algorithm. Results: Among the study group, the incidence of PMDD was 2.1% and PMS was 21.1%. The most common symptoms were irritability (91.21%), breast tenderness (77.62%), depression (68.31%), abdominal bloating (63.70%) and angry outbursts (59.62%). Conclusion: The prevalence of PMS/PMDD and the frequency and severity of the symptoms have their own characteristics in Chinese women. ß 2012 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Premenstrual syndrome (PMS) is a generic term which includes a broad group of emotional, behavioral and physical symptoms that occur for several days to weeks before menses and subside following the menstrual period [1]. The American College of Obstetricians and Gynecologists defines PMS as ‘‘a clinical condition characterized by the cyclic presence of physical and emotional symptoms unrelated to any organic disease that appear during the luteal phase of the menstrual cycle and disappear after menstruation or within 48 h of the onset of bleeding’’ [2]. Premenstrual dysphoric disorder (PMDD) is a severe form of PMS. It is characterized by some combination of marked mood swings, depressed mood, irritability and anxiety, which may be accompanied by physical symptoms. These symptoms occur exclusively during the luteal phase of the menstrual cycle, with remission generally within three days after the onset of menses [3].
* Corresponding author at: Basic Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, China. Tel.: +86 13553168096; fax: +86 0531 89628077. E-mail address: [email protected] (M. Qiao). 0301-2115/$ – see front matter ß 2012 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejogrb.2012.01.017
Women with confirmed PMS report significantly lower quality of life, increased absenteeism from work, decreased work productivity, impaired relationships with others and increased visits to health providers, compared with control women. PMS is common in women of reproductive age. In a study in Switzerland, ninety-one percent of the participants reported at least one symptom, 10.3% had PMS and 3.1% fulfilled the criteria for PMDD [4]. As many as 95% of Japanese women were found to suffer from premenstrual symptoms, and the rates of prevalence of moderate to severe PMS and PMDD in these women were 5.3% and 1.2%, respectively [5]. A cross-sectional nationwide survey conducted among a cohort of Spanish women found that of the 2108 participants, 73.7% complained of some of the premenstrual symptoms during the last 12 menstrual cycles: a total of 91% women presented isolated symptoms and 8.9% a moderate/severe PMS, 1.1% women fulfilled criteria for a diagnosis of PMDD [6]. In one population-based study carried out in Virginia (USA), PMS was observed in 8.3% of the women interviewed by telephone, and approximately 5% fulfilled the criteria for PMDD [7]. So far, there have been no systematic studies of the prevalence of PMS in China. The objective of the present study, therefore, was to assess the prevalence of PMS and PMDD and the frequency and severity of the premenstrual symptoms in Chinese women.
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M. Qiao et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 162 (2012) 83–86
2. Materials and methods 2.1. Study population
Table 1 Characteristics of 947 women who consistent with PMS diagnostic criteria according to stratification variables. Number (%)
Variable
A cluster sampling study was conducted by seven units (Shandong University of Traditional Chinese Medicine (TCM), Jinan Central Hospital, Guangzhou University of TCM First Affiliated Hospital, Beijing University of TCM Affiliated East Hospital, Shanxi College of TCM Second Affiliated Hospital, Qingdao Municipal Hospital and Fujian College of TCM) using a sample of Chinese women between the ages of 18 and 45 years in the communities of six cities (Jinan, Qingdao, Fuzhou, Guangzhou, Beijing and Taiyuan). We recruited Chinese women who had regular menstrual cycles (25–35 days) and were able to provide informed consent. 2.2. Measures ACOG recommendations for a diagnosis of PMS published in the 2000 ACOG practice bulletin, and the daily record of severity of problems (DRSP) form developed and described in detail by Endicott [8] were used. They had previously been translated into Chinese by us and reverse translated into English by professional translators: we then conducted an acculturated pilot study with a small sample in order to confirm their equivalence before they were used in the subsequent research. All women were screened for PMS/PMDD using tools based on the ACOG recommendations for diagnosis of PMS and the diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV). ACOG recommendations for a diagnosis of PMS specified that one or more disturbing affective or somatic symptoms must have occurred during the 5 days before menses in each of 3 previous menstrual cycles. These symptoms must be relieved within 4 days of menses onset without recurrence until at least cycle day 13. In addition, a woman who experiences these symptoms must suffer from identifiable dysfunction in social or economic performance. Furthermore, her symptoms must occur reproducibly during 2 cycles of prospective recording and in the absence of any pharmacologic therapy, hormone ingestion, or drug or alcohol abuse. Eligibility criteria included: (1) aged 18 to 45; (2) regular menstrual cycles (25–35 days); (3) no psychiatric diagnoses in the past 2 years. Women were ineligible if they: (1) were pregnant; (2) were experiencing untreated depression; (3) reported a history of gynecological inflammation, menopausal syndrome, hysterectomy or bilateral oophorectomy, mastopathy or cancer, or diabetes or any other structural diseases. Those women who were consistent with PMS diagnostic criteria and consented to participate further in the study were asked to provide further data over two consecutive observational cycles using the DRSP questionnaire to document daily symptom severity. DRSP consists of 24 items: most of the DRSP items (n = 21) assess psychological, behavioral and physical symptoms, and the last three items evaluate the degree of interference of the premenstrual symptoms with functioning and productivity, (a) at work or at school, (b) with social activities and hobbies, and (c) with relationships with others. These items are rated on a six-point scale of severity ranging from ‘no change’ to ‘extreme change’. Participants were instructed to rate their symptoms at night before going to bed.
Age, years 18–20 21–30 31–40 41–45 Education level No studies or primary education Secondary education University degree City Jinan Fuzhou Guangzhou Beijing Taiyuan Qingdao Occupation Student Worker Waiter Nurse Soldier Teachers Others
139 439 263 106
(14.7) (46.3) (27.8) (11.2)
6 (0.6) 207 (21.9) 734 (77.5) 298 138 149 110 108 144
(31.5) (14.6) (15.7) (11.6) (11.4) (15.2)
389 131 65 187 13 10 152
(41.1) (13.8) (6.9) (19.7) (1.4) (1.1) (16.0)
Percentages in parenthesis.
symptoms mentioned by the participants were, in order of frequency, irritability (91.21%), depression (68.31%), angry outbursts (59.62%), anxiety (53.77%) and confusion (19.25%), whereas the physical symptoms were breast tenderness (77.62%), abdominal bloating (63.70%), headache (36.61%) and swelling of extremities (20.08%) (Fig. 1). They were then asked to provide further data over two consecutive observational cycles using the DRSP questionnaire to document daily symptom severity. A total of 947 women who were consistent with ACOG recommendations for a diagnosis of PMS consented to complete the DRSP. Of these, 132 dropped out before study completion or did not fully complete all questionnaires. Overall, 815 women completed the study (i.e., all questionnaires including the 2-month diary were completed). These women were considered to have fully participated in the study and therefore represent the full analysis set. Table 2 shows DRSP total symptom scores of 5 days in the premenstrual phase (days 5 to 1). So from the data (Table 2) and based on the clinical practice (all these 815 Chinese women in this consecutive study met ACOG recommendations for a diagnosis of PMS), we considered that total symptom scores across 5 days in the premenstrual phase (days 5 to 1) of over 70 and less than 130 (Mean Std deviation) were mild PMS; scores over 130 and less Confusion
19.25
Swelling of extremities
20.08
Headache
36.61
Anxiety
53.77
Angry outbursts
59.62 63.7
Abdominal bloating
3. Results
Depression
We investigated a total of 4715 women, of whom 235 withdrew from the study, and 947 (21.1%) were consistent with PMS diagnostic criteria. The characteristics of these 947 women who were consistent with PMS diagnostic criteria according to stratification variables are shown in Table 1. The emotional
Breast tenderness
68.31 77.62 91.21
Irritability
0
20
40
60
80
Fig. 1. Prevalence and distribution of premenstrul symptoms (n = 947).
100
M. Qiao et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 162 (2012) 83–86 Table 2 DRSP total symptom scores of 5 days in the premenstrual phase(days
First premenstrual phase Second premenstrual phase
5 to
85
1).
n
Mean
Std deviation
Minimum
Maximum
815 815
130.25 127.31
49.720 50.770
60 67
400 411
than 180 were moderate and scores exceeding 180 (Mean + Std deviation) were considered severe symptoms. The patients with scores exceeding 180 all had mood symptoms which were sufficiently severe to interfere with work, family and social relationships, so they were thought to meet the criteria for PMDD (we used a total score to approximate a PMDD diagnosis). Those whose total symptom scores were under 70 were not thought consistent with diagnostic criteria for PMS. According to the statistical result of DRSP total symptom scores of 5 days in the premenstrual phase (days 5 to 1) and the cut-off points for PMS severity and PMDD mentioned above, the prevalence of PMDD in our study was 2.1% (102 women), and the prevalence of mild PMS and moderate PMS in our study was 11.3% (506 women) and 4.6% (206 women), respectively. One woman’s total symptom scores were under 70, so she was not thought consistent with diagnostic criteria for PMS. Each woman experienced a relatively constant degree of symptom severity, particularly for emotional symptoms over two consecutive cycles. 4. Comments This is the first large sample, multicentre Chinese study to show the prevalence of PMS from a population-based study. The findings show that the incidence of PMS in Chinese women who met ACOG recommendations for a diagnosis of PMS in the present study (21.1%) was higher than that reported for women in Switzerland, Japan and Virginia (USA) [4,5,7], but consistent with Borenstein’s studies [9] which suggested that up to 20% of all women of fertile age have premenstrual complaints that could be regarded as clinically relevant. Compared to our previous study [10], the incidence of PMS decreased dramatically from 41.9% to 21.1%. One reason is that in our previous study we used domestic diagnostic criteria for PMS of Practical obstetrics and gynecology science which provided only retrospective diagnostic conditions. The other is that eligibility criteria in the previous study included PMS patients who had combined diseases: if we calculate the prevalence of PMS excluding those who had combined diseases, the prevalence is 21.77% – approximately the same as in the present study. The prevalence rate for PMDD in the present study is higher than that of Takeda et al. [5], who observed a 1.2% prevalence of PMDD in Japan, but lower than that in other studies. Endicott [11] reported that about 3–8% of women have sufficiently severe symptoms to meet the DSM-IV criteria for PMDD. Wittchen et al. [12] observed that the prevalence of PMDD was 5.8%. Wallenstein et al. [13] administered a questionnaire to women who were 18–45 years old and observed that the prevalence of PMDD was 6.0%. We also found that in epidemiological studies and surveys, not only the rates of PMS and PMDD but also the frequency of premenstrual symptoms vary considerably. In the present study, the most frequent premenstrual symptoms were irritability (91.21%), followed by breast tenderness (77.62%) and depression (68.31%), whereas the least frequent premenstrual symptoms were swelling of extremities (20.08%) and headache (36.61%). In the study of Tschudin et al. [4], the most common complaints were physical symptoms, which were reported by 74% of women, followed by ‘‘fatigue/lack of energy’’ in 68% and ‘‘tearfulness/mood swings’’ and ‘‘anger/irritability’’ in 67% each. In the prospective
Percentiles 25th
50th
75th
95.00 94.00
117.00 115.00
150.00 146.00
longitudinal survey of Wittchen et al. [12], the five most frequently reported symptoms were physical complaints (44.9%), affect lability (41.7%), fatigability (36.6%), depressed mood (31.4%) and appetite/craving (30.3%). In Takeda et al’s study, physical symptoms were reported by 81.2%, ‘‘anger and irritability’’ by 70.6% and ‘‘anxiety and tension’’ by 68.5% [5]. The most prevalent psychological symptom in the Zurich cohort study was irritability ˜ as et al. [6], the most frequent (49.3%) [14]. In the study of Duen premenstrual symptoms were physical complaints (breast tenderness, headache, weight gain, bloating), which occurred in 81.6% of women, followed by irritability (53%), tearfulness (48.7%), and anxiety (40.5%). As to the causes of the variation in the incidence of PMS, PMDD and the frequency of premenstrual symptoms, we think this may be due to two reasons: one is sociocultural factors [15] and that the study populations selected for the studies are different, and the other is that the screening tools used by researchers are different. In our study, PMS/PMDD was less prevalent in women workers with lower education. Cohen et al. [16] also found an association with lower education, while PMS/PMDD was more prevalent in students, which is in line with Takeda et al’s study [17], and half of students felt both irritability and depression. We can suggest possible explanations about the causes of the difference in the prevalence of PMS/PMDD between different social groups: workers’ environment is simple and they do not feel so much stress, while students are under a great deal of stress due to long hours of studying and are also exposed to employment pressure. The diagnosis of PMS/PMDD by the DSM-IV criteria requires prospective daily charting which has to be completed over a period of two consecutive symptomatic cycles. In a retrospective design of PMS/PMDD which based on memory, women are likely to amplify [15] as well as reduce the recall of the severity and frequency of symptoms. Our previous study found that this may be associated with patient’s personality characteristics [18]. Usually, extroverted people tend to amplify their symptom reports, while introverted people tend to reduce their symptom reports. Prospective daily charting, however, is difficult for large samples. So the strength of our study is that we used both retrospective and prospective screening tools for PMS/PMDD and firstly put forward the diagnostic criteria for PMS with retrospective and prospective conditions in China [19]. One major limitation of our study is that it was conducted at large urban centers and, as a result, it reflected the situation of urban Chinese women only. The other limitation is that the DRSP tool has not been previously validated in a Chinese population, although a pre-test pilot study was performed. Using worldwide universally accepted diagnostic criteria for assessment of the prevalence of PMS/PMDD in China will allow for improvement in PMS/PMDD patient awareness of their conditions and selecting a therapeutic approach to relieve their symptoms. We therefore hope that this group, which is so huge in China, will benefit from the present study. Acknowledgement We thank Jingyi Wang, Yanfeng Liu and Zhiwei Xu for their help with this study, and the women who participated. This study funded by the 10th Five Years Chinese National Programs for
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Science and Technology Development (2004BA721A04) of the Ministry of Science and Technology of PRC, Grant No. 30930110 from National Natural Science Foundation of China (NSFC) and the Shandong Provincial Special Foundation on Taishan scholar Project for Mingqi Qiao. References [1] Freeman EW. Premenstrual syndrome and premenstrual dysphoric disorder: definitions and diagnosis. Psychoneuroendocrinology 2003;28(Suppl. 3): 25–37. [2] ACOG Practice Bulletin. Clinical management guidelines for obstetrician– gynecologists. Number 15. Premenstrual syndrome. Obstet Gynecol 2000; 95:4. [3] Grady-Weliky TA. Premenstrual dysphoric disorder. N Engl J Med 2003; 348(5):433–8. [4] Tschudin S, Bertea PC, Zemp E. Prevalence and predictors of premenstrual syndrome and premenstrual dysphoric disorder in a population-based sample. Arch Womens Ment Health 2010;13(6):485–94. [5] Takeda T, Tasaka K, Sakata M, Murata Y. Prevalence of premenstrual syndrome and premenstrual dysphoric disorder in Japanese women. Arch Womens Ment Health 2006;9(4):209–12. ˜ as JL, Lete I, Bermejo R, et al. Prevalence of premenstrual syndrome and [6] Duen premenstrual dysphoric disorder in a representative cohort of Spanish women of fertile age. Eur J Obstet Gynecol Reprod Biol 2011;156(1):72–7. [7] Deuster PA, Adera T, South-Paul J. Biological, social, and behavioral factors associated with premenstrual syndrome. Arch Fam Med 1999;8(2):122–8. [8] Endicott J, Nee J, Harrison W. Daily Record of Severity of Problems (DRSP): reliability and validity. Arch Womens Ment Health 2006;9(1):41–9.
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