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Premenstrual syndrome among Lebanese medical students and residents
184
BRIEF COMMUNICATIONS
Premenstrual syndrome among Lebanese medical students and residents Elie Attieh a, Samer Maalouf a, Sami Richa b, Assaad Kesrouani c,⁎ a b c
Hôtel-Dieu de France University Hospital, Beirut, Lebanon Department of Psychiatry, St Joseph University, Beirut, Lebanon Department of Obstetrics and Gynecology, St Joseph University, Beirut, Lebanon
a r t i c l e
i n f o
Article history: Received 25 August 2012 Received in revised form 11 November 2012 Accepted 12 December 2012 Keywords: ACOG criteria Lebanon Medical students Premenstrual syndrome Quality of life
Premenstrual syndrome (PMS) may encompass distressing symptoms that occur during the final days of each menstrual cycle and are defined according to different criteria. When based on the criteria of the American College of Obstetricians and Gynecologists (ACOG) [1], the prevalence of PMS was 12.7% in a Pakistani study [2] and 35.6% in a study from Saudi Arabia [3]. There has been little research describing premenstrual disorders in Lebanon, especially premenstrual syndrome, because they are not considered to be a health concern. The aim of the present study was to determine the prevalence of premenstrual symptoms and PMS in Lebanese medical students and to evaluate their impact. A cross-sectional descriptive study was conducted between October 1, 2011 and January 31, 2012 involving all female students at the Saint Joseph University medical school and all female interns and residents at Hôtel-Dieu de France University Hospital in Beirut, Lebanon. In total, 428 questionnaires were distributed. The diagnosis of PMS was based on ACOG criteria [1], as defined by patients reporting at least 1 affective and 1 somatic symptom during the 5 days before menses over 3 consecutive menstrual cycles. The symptoms must be relieved within 4 days of the onset of menses, without any recurrence until at least cycle day 13 and be present in the absence of any pharmacologic therapy or alcohol use. Affective symptoms include depression, angry outbursts, irritability, anxiety, confusion, and social withdrawal. Somatic symptoms include breast tenderness, abdominal bloating, headache, and swelling of extremities. The ACOG Practice Bulletin on premenstrual syndrome was withdrawn in August 2012 [4] after the present study had been conducted. The Ethical Committee of Saint Joseph University approved the study on condition of participant anonymity and confidentiality, which were fully respected. Participation was voluntary and withdrawal was possible at any time. No informed consent was needed. Data were analyzed using SPSS version 17.0 (IBM, Armonk, NY, USA). Descriptive statistics, the χ2 test for qualitative variables, and the t test for quantitative variables were used in the analysis. A margin of error of 5% and less was used to define significant differences. The sample size calculated for a confidence level of 95% and a margin of error of 5% was 323, and the study was terminated when this number of answers was reached.
⁎ Corresponding author at: Hôtel-Dieu de France University Hospital, AdibIshac St, Achrafie, Beirut, Lebanon. Tel.: +961 3222034; fax: +961 5464477. E-mail address: [email protected] (A. Kesrouani).
There were no significant differences between respondents who were determined to have PMS (n = 23) and those without PMS (n= 300) for the general characteristics of age, body mass index (BMI, calculated as weight in kilograms divided by height in meters squared), marital status, religion, education level of the father or mother, occupancy of father or mother, familial history of PMS, menarche, regularity of cycles, dysmenorrhea, and duration of menses (P > 0.05). Based on the ACOG definition, 23 (7.1%) participants had premenstrual syndrome and among these 18 (78.3%) were interns and residents. A significant difference was noted between the prevalence of PMS among university students compared with interns and residents (3.3% vs 10.5%; P = 0.013); however, there was no significant difference between interns and residents (P = 0.791). This could be related to the stressful daily life at the hospital and/or possibly to age difference. A total of 314 (97.2%) participants had at least 1 premenstrual symptom, 253 (78.3%) experienced at least 1 somatic symptom, and 275 (85.1%) experienced at least 1 affective symptom. The most common somatic symptoms were breast tenderness (n= 210, 65%), abdominal bloating (n= 143, 44.3%), and headache (n= 72, 22.3%). The most common affective symptoms were irritability (n= 232, 71.8%), angry outbursts (n= 189, 58.5%), and depression (n= 181, 56.0%). Regarding secondary premenstrual symptoms, the most common were appetite changes (n= 162, 50.2%), fatigue (n= 158, 49.9%), and crying spells (n= 137, 42.4%). Symptoms in the PMS group are detailed in Table 1. A total of 158 (48.9%) medical students in the present study used some kind of remedy to relieve their symptoms; in other studies, the majority of the women did not use any treatment [2]. A reason for this could be that medical students are usually more anxious because of excessive work and studies and welcome solutions to prevent additional sources of stress. It should be noted that smoking was significantly more frequent in the PMS group compared with the non-PMS group (1 [4.3%] vs 2 [0.7%]; P = 0.076). The study also showed that 40 (12.4%) women reported experiencing insomnia, which could affect mental health and work performance (6 [26.1%] in the PMS group vs 34 [11.3%] in the nonPMS group; P = 0.038). However, Baker et al. [5] showed in a study using polysomnography that there was no relationship between disturbed sleep and premenstrual symptoms. Fatigue was reported by 19 (82.6%) women with PMS compared with 139 (46.3%) in the non-PMS group (P = 0.001). Regarding impact on academic and work performance, 194 (60.1%) participants reported more aggressive behavior, including 18 (78.3%) women with PMS and 176 (58.7%) women without PMS (P = 0.08). Sixty (18.6%) participants missed at least 1 day of work or studies, including 10 (43.5%) in the PMS group and 50 (16.7%) in the non-PMS group (P =0.001). Finally, 7 (2.2% of the total population) participants had failed an exam and 5 (1.5%) had committed a work-related mistake because of premenstrual symptoms. The results of the present study suggest that premenstrual symptoms and PMS are common among young Lebanese women and can considerably affect their daily performance. Comprehensive measures should be undertaken to alleviate their impact, especially for interns and residents among whom PMS appears more prevalent. For instance, a screening test for PMS using the ACOG criteria could be performed early in medical school, and
BRIEF COMMUNICATIONS Table 1 Distribution of symptoms among participants with premenstrual syndrome (n = 23). Symptoms
No. (%)
Irritability Depression Breast tenderness Fatigue Angry outbursts Abdominal bloating Anxiety Appetite changes Headache Crying spells Poor concentration Confusion Aches and pains Social withdrawal Swelling of extremities Insomnia Gastrointestinal symptoms Changes in sexual desire Skin problems
21 (91.3) 19 (82.6) 19 (82.6) 19 (82.6) 17 (73.9) 17 (73.9) 15 (65.2) 15 (65.2) 12 (52.2) 12 (52.2) 10 (43.5) 9 (39.1) 9 (39.1) 6 (26.1) 6 (26.1) 6 (26.1) 6 (26.1) 5 (21.7) 0 (0)
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Conflict of interest The authors declare no conflicts of interest.
References [1] American College of Obstetricians and Gynecologists. Premenstrual Syndrome. ACOG Practice Bulletin, No. 15. Washington, DC: American College of Obstetricians and Gynecologists; 2000. [2] Pal SA, Dennerstein L, Lehert P. Premenstrual symptoms in Pakistani women and their effect on activities of daily life. J Pak Med Assoc 2011;61(8):763–8. [3] Balaha MH, Amr MA, Saleh Al Moghannum M, Saab Al Muhaidab N. The phenomenology of premenstrual syndrome in female medical students: a cross sectional study. Pan Afr Med J 2010;5:4. [4] [No authors] College publications. Retraction: ACOG Practice Bulletin No. 15: Premenstrual Syndrome (Obstet Gynecol Vol. 95, No. 4) and ACOG Practice Bulletin No. 35: Diagnosis and Treatment of Cervical Carcinomas (Obstet Gynecol 2002;99: 855–867). Obstet Gynecol 2012;120(2 Pt 1):405. [5] Baker FC, Kahan TL, Trinder J, Colrain IM. Sleep quality and the sleep electroencephalogram in women with severe premenstrual syndrome. Sleep 2007;30(10): 1283–91.
those diagnosed with PMS could then be offered emotional support during the occurrence of symptoms to improve performance and prevent professional mistakes.
0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2012.11.006
BRIEF COMMUNICATIONS
Premenstrual syndrome among Lebanese medical students and residents Elie Attieh a, Samer Maalouf a, Sami Richa b, Assaad Kesrouani c,⁎ a b c
Hôtel-Dieu de France University Hospital, Beirut, Lebanon Department of Psychiatry, St Joseph University, Beirut, Lebanon Department of Obstetrics and Gynecology, St Joseph University, Beirut, Lebanon
a r t i c l e
i n f o
Article history: Received 25 August 2012 Received in revised form 11 November 2012 Accepted 12 December 2012 Keywords: ACOG criteria Lebanon Medical students Premenstrual syndrome Quality of life
Premenstrual syndrome (PMS) may encompass distressing symptoms that occur during the final days of each menstrual cycle and are defined according to different criteria. When based on the criteria of the American College of Obstetricians and Gynecologists (ACOG) [1], the prevalence of PMS was 12.7% in a Pakistani study [2] and 35.6% in a study from Saudi Arabia [3]. There has been little research describing premenstrual disorders in Lebanon, especially premenstrual syndrome, because they are not considered to be a health concern. The aim of the present study was to determine the prevalence of premenstrual symptoms and PMS in Lebanese medical students and to evaluate their impact. A cross-sectional descriptive study was conducted between October 1, 2011 and January 31, 2012 involving all female students at the Saint Joseph University medical school and all female interns and residents at Hôtel-Dieu de France University Hospital in Beirut, Lebanon. In total, 428 questionnaires were distributed. The diagnosis of PMS was based on ACOG criteria [1], as defined by patients reporting at least 1 affective and 1 somatic symptom during the 5 days before menses over 3 consecutive menstrual cycles. The symptoms must be relieved within 4 days of the onset of menses, without any recurrence until at least cycle day 13 and be present in the absence of any pharmacologic therapy or alcohol use. Affective symptoms include depression, angry outbursts, irritability, anxiety, confusion, and social withdrawal. Somatic symptoms include breast tenderness, abdominal bloating, headache, and swelling of extremities. The ACOG Practice Bulletin on premenstrual syndrome was withdrawn in August 2012 [4] after the present study had been conducted. The Ethical Committee of Saint Joseph University approved the study on condition of participant anonymity and confidentiality, which were fully respected. Participation was voluntary and withdrawal was possible at any time. No informed consent was needed. Data were analyzed using SPSS version 17.0 (IBM, Armonk, NY, USA). Descriptive statistics, the χ2 test for qualitative variables, and the t test for quantitative variables were used in the analysis. A margin of error of 5% and less was used to define significant differences. The sample size calculated for a confidence level of 95% and a margin of error of 5% was 323, and the study was terminated when this number of answers was reached.
⁎ Corresponding author at: Hôtel-Dieu de France University Hospital, AdibIshac St, Achrafie, Beirut, Lebanon. Tel.: +961 3222034; fax: +961 5464477. E-mail address: [email protected] (A. Kesrouani).
There were no significant differences between respondents who were determined to have PMS (n = 23) and those without PMS (n= 300) for the general characteristics of age, body mass index (BMI, calculated as weight in kilograms divided by height in meters squared), marital status, religion, education level of the father or mother, occupancy of father or mother, familial history of PMS, menarche, regularity of cycles, dysmenorrhea, and duration of menses (P > 0.05). Based on the ACOG definition, 23 (7.1%) participants had premenstrual syndrome and among these 18 (78.3%) were interns and residents. A significant difference was noted between the prevalence of PMS among university students compared with interns and residents (3.3% vs 10.5%; P = 0.013); however, there was no significant difference between interns and residents (P = 0.791). This could be related to the stressful daily life at the hospital and/or possibly to age difference. A total of 314 (97.2%) participants had at least 1 premenstrual symptom, 253 (78.3%) experienced at least 1 somatic symptom, and 275 (85.1%) experienced at least 1 affective symptom. The most common somatic symptoms were breast tenderness (n= 210, 65%), abdominal bloating (n= 143, 44.3%), and headache (n= 72, 22.3%). The most common affective symptoms were irritability (n= 232, 71.8%), angry outbursts (n= 189, 58.5%), and depression (n= 181, 56.0%). Regarding secondary premenstrual symptoms, the most common were appetite changes (n= 162, 50.2%), fatigue (n= 158, 49.9%), and crying spells (n= 137, 42.4%). Symptoms in the PMS group are detailed in Table 1. A total of 158 (48.9%) medical students in the present study used some kind of remedy to relieve their symptoms; in other studies, the majority of the women did not use any treatment [2]. A reason for this could be that medical students are usually more anxious because of excessive work and studies and welcome solutions to prevent additional sources of stress. It should be noted that smoking was significantly more frequent in the PMS group compared with the non-PMS group (1 [4.3%] vs 2 [0.7%]; P = 0.076). The study also showed that 40 (12.4%) women reported experiencing insomnia, which could affect mental health and work performance (6 [26.1%] in the PMS group vs 34 [11.3%] in the nonPMS group; P = 0.038). However, Baker et al. [5] showed in a study using polysomnography that there was no relationship between disturbed sleep and premenstrual symptoms. Fatigue was reported by 19 (82.6%) women with PMS compared with 139 (46.3%) in the non-PMS group (P = 0.001). Regarding impact on academic and work performance, 194 (60.1%) participants reported more aggressive behavior, including 18 (78.3%) women with PMS and 176 (58.7%) women without PMS (P = 0.08). Sixty (18.6%) participants missed at least 1 day of work or studies, including 10 (43.5%) in the PMS group and 50 (16.7%) in the non-PMS group (P =0.001). Finally, 7 (2.2% of the total population) participants had failed an exam and 5 (1.5%) had committed a work-related mistake because of premenstrual symptoms. The results of the present study suggest that premenstrual symptoms and PMS are common among young Lebanese women and can considerably affect their daily performance. Comprehensive measures should be undertaken to alleviate their impact, especially for interns and residents among whom PMS appears more prevalent. For instance, a screening test for PMS using the ACOG criteria could be performed early in medical school, and
BRIEF COMMUNICATIONS Table 1 Distribution of symptoms among participants with premenstrual syndrome (n = 23). Symptoms
No. (%)
Irritability Depression Breast tenderness Fatigue Angry outbursts Abdominal bloating Anxiety Appetite changes Headache Crying spells Poor concentration Confusion Aches and pains Social withdrawal Swelling of extremities Insomnia Gastrointestinal symptoms Changes in sexual desire Skin problems
21 (91.3) 19 (82.6) 19 (82.6) 19 (82.6) 17 (73.9) 17 (73.9) 15 (65.2) 15 (65.2) 12 (52.2) 12 (52.2) 10 (43.5) 9 (39.1) 9 (39.1) 6 (26.1) 6 (26.1) 6 (26.1) 6 (26.1) 5 (21.7) 0 (0)
185
Conflict of interest The authors declare no conflicts of interest.
References [1] American College of Obstetricians and Gynecologists. Premenstrual Syndrome. ACOG Practice Bulletin, No. 15. Washington, DC: American College of Obstetricians and Gynecologists; 2000. [2] Pal SA, Dennerstein L, Lehert P. Premenstrual symptoms in Pakistani women and their effect on activities of daily life. J Pak Med Assoc 2011;61(8):763–8. [3] Balaha MH, Amr MA, Saleh Al Moghannum M, Saab Al Muhaidab N. The phenomenology of premenstrual syndrome in female medical students: a cross sectional study. Pan Afr Med J 2010;5:4. [4] [No authors] College publications. Retraction: ACOG Practice Bulletin No. 15: Premenstrual Syndrome (Obstet Gynecol Vol. 95, No. 4) and ACOG Practice Bulletin No. 35: Diagnosis and Treatment of Cervical Carcinomas (Obstet Gynecol 2002;99: 855–867). Obstet Gynecol 2012;120(2 Pt 1):405. [5] Baker FC, Kahan TL, Trinder J, Colrain IM. Sleep quality and the sleep electroencephalogram in women with severe premenstrual syndrome. Sleep 2007;30(10): 1283–91.
those diagnosed with PMS could then be offered emotional support during the occurrence of symptoms to improve performance and prevent professional mistakes.
0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2012.11.006