Premenstrual Syndrome and Premenstrual Dysphoric Disorder in Japanese Collegiate Athletes

Accepted Manuscript Premenstrual syndrome and premenstrual dysphoric disorder in Japanese collegiate athletes Takashi Takeda, MD, PhD Yoko Imoto, Hiroyo Nagasawa, Miyuki Muroya, Masami Shiina, MD, PhD PII:

S1083-3188(14)00260-5

DOI:

10.1016/j.jpag.2014.07.006

Reference:

PEDADO 1742

To appear in:

Journal of Pediatric and Adolescent Gynecology

Received Date: 19 March 2014 Revised Date:

3 June 2014

Accepted Date: 9 July 2014

Please cite this article as: Takeda T, Imoto Y, Nagasawa H, Muroya M, Shiina M, Premenstrual syndrome and premenstrual dysphoric disorder in Japanese collegiate athletes, Journal of Pediatric and Adolescent Gynecology (2014), doi: 10.1016/j.jpag.2014.07.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Premenstrual syndrome and premenstrual dysphoric disorder in Japanese

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collegiate athletes

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Takashi Takeda, MD, PhDa*, Yoko Imotoa, Hiroyo Nagasawaa, Miyuki Muroyaa,

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Masami Shiina, MD, PhDa,b

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b

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Kinki University School of Medicine, 377-2, Ohno-Higashi, Osaka-Sayama, Osaka

Division of Women’s Health, Research Institute of Traditional Asian Medicine Department of Obstetrics and Gynecology

589-8511, Japan

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*Corresponding author: Division of Women’s Health, Research Institute of Traditional

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Asian Medicine, Kinki University School of Medicine, 377-2, Ohno-Higashi,

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Osaka-Sayama, Osaka 589-8511, Japan

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Tel.: 81-72-366-0221 (Ext. 3393); Fax: 81-72-366-6661

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E-mail: [email protected]

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ABSTRACT

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Study objective: To determine the prevalence and impact of premenstrual syndrome

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(PMS) and premenstrual dysphoric disorder (PMDD) in Japanese collegiate athletes,

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with a focus on their disruption of athletic performance.

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Design: Cross-sectional study.

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Setting: A university in Osaka, the largest city in western Japan.

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Participants: 232 female collegiate athletes.

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Main Outcome Measures: Premenstrual symptoms and social activities.

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Results: The prevalence of each premenstrual symptom was high. The prevalence of

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moderate to severe PMS and PMDD was 8.6% and 2.9%, respectively, the same as in

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general high school students. The athletic performance of 44.3% of athletes was found

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to suffer in a game or in practice. ‘Elite athletes’ (OR 8.63, 95% CI: 1.22-120.0),

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‘Difficulty concentrating’ (OR 3.15, 95% CI: 1.05-10.6), and ‘Fatigue or lack of energy’

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(OR 5.92, 95% CI: 1.32-34.5) increased the risk of poor athletic performance.

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Conclusions: This study showed that premenstrual symptoms affect not only the daily

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activities but also the athletic performance of collegiate athletes.

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Running title: PMS/PMDD in athletes

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Key words: PMS, PMDD, Collegiate athlete, Athletic performance 2

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Introduction Premenstrual syndrome (PMS) is a constellation of mood, behavioral, and physical

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symptoms that are limited to the late luteal phase of the menstrual cycle.1

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Epidemiologic surveys have shown that the frequency of premenstrual symptoms is

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high (80-90%)2 and that in about 5% of women, the symptoms are so severe that they

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interfere with personal or social relationships or work, and in many cases they require

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pharmacological treatment.3 Such severe PMS is classified as premenstrual dysphoric

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disorder (PMDD).4 Previously we have reported that PMS and PMDD are common

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menstrual problems not only in adults but also in adolescents and should be treated as

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carefully as dysmenorrhea.5

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The causes of PMS and PMDD have been suggested to include hormonal changes,

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neurotransmitters, diet, stress, and lifestyle.6 Many studies have suggested that exercise

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could be a treatment for PMS,7,8 but these findings are limited to the association

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between PMS and lack of exercise. No study to date has looked at this association

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scientifically, but that it has been suggested as a causal association.8

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In the past 40 years, female athletic participation has increased, particularly at high

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school and collegiate levels.9 In spite of the numerous benefits of exercise, health

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problems unique to female athletes in intensive training, known as the female athlete

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triad, have been identified.10 The triad includes a spectrum of health problems related to

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energy availability, menstrual function, and bone mineral density, as defined by the

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American College of Sports Medicine (ACSM).11 The female athlete triad was first

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identified in 1992 by ACSM, and a significant amount of research about the triad at

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high school and collegiate levels was performed.9 Regarding menstrual dysfunction,

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most of the studies were concerned with menstrual irregularity, including primary

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amenorrhea, secondary amenorrhea, and were lacking in data about PMS and PMDD.

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Many reports have documented that the premenstrual phase is associated with

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decreased performance,12,13 but there are few reports about PMS/PMDD in athletes. A

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previous report demonstrated that premenstrual symptoms caused marked negative

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mood swings in menstruating female athletes, but the data were limited to the moods

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evaluated in the profile of mood states (POMS) questionnaire.14 The aim of this study

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was to investigate the prevalence and impact of PMS and PMDD in Japanese collegiate

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athletes, with a focus on athletic performance.

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Methods The study was carried out in accordance with the principles outlined in the

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Declaration of Helsinki. Our institutional review board at Kinki University approved the

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study.

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Study population

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A school-based cross-sectional survey was conducted in November 2012 using a

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sample of 232 Japanese female collegiate athletes at Kinki University in Osaka, the

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largest city in west Japan. All subjects belonged to authorized university clubs, which

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all have a high ranking in Japanese university sport. All subjects were undergoing

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intensive training. We recruited female collegiate athletes who had regular menstrual

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cycles (22-35 days) and were able to provide informed consent. No one in these subjects

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had a prior diagnosis of psychological disorder.

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Questionnaire

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We used the Premenstrual Symptoms Questionnaire (PSQ), which was developed in

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our previous study,15 to screen for premenstrual symptoms. The PSQ translates DSM-IV

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criteria into a rating scale with degrees of severity described in Japanese and is

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essentially identical to the Premenstrual Symptoms Screening Tool.16 The PSQ asked, 5

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“Within the last three months have you experienced the following premenstrual

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symptoms starting during the week before menses and remitting a few days after the

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onset of menses?” The premenstrual symptoms listed on the PSQ are ‘Depressed mood’,

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‘Anxiety or tension’, ‘Tearful’, ‘Anger or irritability’, ‘Decreased interest in work,

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home or social activities’, ‘Difficulty concentrating’, ‘Fatigue or lack of energy’,

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‘Overeating or food cravings’, ‘Insomnia or hypersomnia’, ‘Feeling overwhelmed’ and

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‘Physical symptoms such as tender breasts, feeling of bloating, headache, joint or

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muscle pain, weight gain’. The PSQ also asked whether such premenstrual symptoms

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interfered with ‘Work efficiency or productivity, home responsibilities’, ‘Social life

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activities’ or ‘Relationships with coworkers or family’. The PSQ asked the athletes to

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rate the severity of premenstrual symptoms as ‘not at all’, ‘mild’, ‘moderate’ or ‘severe’.

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We divided athletes with premenstrual symptoms into three groups: ‘PMDD’, ‘moderate

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to severe PMS’, and ‘no/mild PMS’ according to the criteria reported previously.15,16 In

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addition to the PSQ, we asked whether such premenstrual symptoms interfered with

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‘Athletic performance in training or competition’. This additional question also asked

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the athletes to rate the severity as ‘not at all’, ‘mild’, ‘moderate’ or ‘severe’. We further

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collected additional information about their age, type of sports, participation in national

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or international competition, regular player or not, coffee-drinking habit, craving for

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salty food, craving for sweet food and severity of dysmenorrhea. Athletes were grouped

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into 6 groups: ball games, track, swimming, fighting sports, archery and other sports.

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The other sports group consisted of yacht racing, triathlon, and equestrian sports. We

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asked the athletes about their severity of pain during menses with the categories of ‘not

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at all’, ‘mild’, ‘moderate’, and ‘severe’.

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Statistical Analyses

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Statistical analysis was performed using JMP 10.0.2 (SAS, Cary, NC, USA). Data are

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expressed as the means ± S.D. Statistical significance was set at p <0.05.

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Results A total of 212 female athletes completed the questionnaire. Thirty-eight were

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excluded from the analysis because of incomplete data; therefore, we analyzed the data

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of 174 athletes aged 18 to 23 (average 20.2 ± 1.12 (SD)).

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Characteristics of the study sample are presented in Table 1. Considering that half of

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the subjects participate in national or international competitions, all of these clubs have

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a high ranking in Japanese university sport. We further divided the group of ‘elite

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athletes’ into those who participate in national or international competition and/or

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regular players.

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The prevalence of each premenstrual symptom is shown in Table 2. More than half

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reported ‘Depressed mood’ (53.4%), ‘Anxiety or tension’ (79.9%), ‘Anger or irritability’

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(73.6%), ‘Difficulty concentrating’ (60.3%), ‘Fatigue or lack of energy’ (71.8%),

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‘Overeating or food cravings’ (72.4%), ‘Insomnia or hypersomnia’ (54.6%), or

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‘Physical symptoms’ (71.3%). Premenstrual symptoms impaired ‘Work efficiency or

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productivity, home responsibilities’ (48.3%), ‘Social life activities’ (19.0%),

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‘Relationships with coworkers or family’ (28.7%) and ‘Athletic performance in a game

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or in practice’ (44.3%). A prominent feature of premenstrual symptoms in athletes is

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that the severity of ‘Anxiety or tension’, ‘Anger or irritability’, ‘Decreased interest in

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work, home, or social activities’, ‘Overeating or food cravings’, and ‘Physical

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symptoms’ is much higher than that of high school girls (P <0.0001 by Mann-Whitney’s

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U test)5 (Fig. 1).

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The ‘PMDD’ group consisted of 5 athletes (2.9%), the ‘moderate to severe PMS’ group

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of 15 athletes (8.6%); and the ‘no/mild PMS’ group of 154 athletes (88.5%). In our

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previous report on a Japanese younger adolescent population, the ‘PMDD’ group

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consisted of 16 girls (2.6%), the ‘moderate to severe PMS’ group of 73 girls (11.8%)

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and the ‘No/Mild PMS’ group of 529 girls (85.6%).5 The rates of PMDD and moderate

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to severe PMS in our collegiate athletes population were not significantly higher than

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those in the younger adolescent population (P = 0.346 by Mann-Whitney’s U test).

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The results of multivariate analysis of the factors that were significantly associated

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with reduced of athletic performance are shown in Table 3. ‘Elite athletes’, ‘Difficulty

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concentrating’, and ‘Fatigue or lack of energy’ showed an increased risk of poor athletic

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performance.

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Discussion

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To our knowledge, this is the first study on the prevalence and impact of PMS and

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PMDD in athletes. It has been reported that an intense work load and severe stress

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worsen the symptoms of PMS/PMDD.17 Stress exposure could result in persistent

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alterations in the neuroendocrine system and induce PMS/PMDD.18 Intensive training

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and competitive anxiety induce great stress in athletes. As expected, our data showed a

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high prevalence of premenstrual symptoms in athletes, but the degree of interference

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with work, usual activities, or relationships was the same as that of general high school

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students. A likely explanation for this difference is that, unlike physical symptoms,

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psychological symptoms such as premenstrual symptoms represent a stigmatic

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weakness to athletes,19 so they do not show any influence on social activity in spite of

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severe premenstrual symptoms.

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Our data showed that the prevalence of ‘Anxiety or tension’ is very high. In general,

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the prevalence of anxiety disorders in adolescents is reported to be 6-20% and the

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prevalence is much higher in girls than in boys.20 Sports-related performance anxiety is

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common in young female athletes.21 Our data also showed that the prevalence of

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‘Overeating or food cravings’ is very high. It has been reported that eating disorders

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appear to be the most common psychiatric problem in athletes.21 It is necessary to note

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whether sports-related performance anxiety and eating disorders may be exacerbated by

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the menstrual cycle. Multivariate analysis revealed that premenstrual symptoms such as ‘Difficulty

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concentrating’ and ‘Fatigue or lack of energy’ were risk factors for athletic performance.

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Among the background and lifestyle factors, ‘Elite athletes’ was a risk factor for athletic

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performance. Elite athletes are under high pressure of expectation or attention, so they

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are under more stress than non-elite athletes. It is therefore necessary to pay special

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attention to the elite athlete group. Our previous research showed a clear correlation

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between the severity of PMS/PMDD and dysmenorrhea, and the prevalence of

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PMS/PMDD increased according to the severity of dysmenorrhea.22 In this study, no

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correlations were observed between PMS/PMDD-associated poor athletic performance

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and dysmenorrhea.

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Our study has several limitations. The main limitation is that all our data were based

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on self-reporting; therefore, the study is susceptible to recall bias. Another limitation is

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the lack of data about the prevalence of PMS/PMDD in the college age group in Japan.

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Because of their diversity, it is difficult to collect standard data about college students.

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We therefore used the data for high school students for college students.

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Given that premenstrual symptoms disappear during anovulatory cycles and GnRH

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agonist-induced anovulation, it has been speculated that progesterone is the major

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symptom-inducing factor.23 Research into the female athlete triad focused on menstrual

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irregularities, so ovulation-induced premenstrual symptoms were overlooked. Judging

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from the data that almost half of the athletes felt a negative effect of premenstrual

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symptoms on athletic performance, it is important to pay appropriate attention to

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PMS/PMDD.

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References

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2. Angst J, Sellaro R, Merikangas KR, et al: The epidemiology of perimenstrual

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Women Health (Larchmt) 2009; 18: 895. DOI: 10.1089/jwh.2008.1098

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9. Javed A, Tebben PJ, Fischer PR, et al: Female athlete triad and its components:

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10. Otis CL, Drinkwater B, Johnson M, et al: American College of Sports Medicine

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American College of Sports Medicine position stand. The female athlete triad. Med Sci

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Sports Exerc. 2007; 39:1867

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12. Eston RG: The regular menstrual cycle and athletic performance. Sports Med. 1984;

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1:431

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performance. Clin Sports Med. 2005; 24:e51

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14. Kishali NF, Imamoglu O, Katkat D, et al: Int J Neurosci. Effects of menstrual cycle

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on sports performance. 2006; 116:1549

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15. Takeda T, Tasaka K, Sakata M, et al: Prevalence of premenstrual syndrome and

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premenstrual dysphoric disorder in Japanese women. Arch Womens Ment Health 2006;

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16. Steiner M, Macdougall M, Brown E: The premenstrual symptoms screening tool

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(PSST) for clinicians. Arch Women Ment Health 2003; 6: 203

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Kingdom Southampton Women's Survey. J Womens Health (Larchmt). 2010; 19:391

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stress in women after sexual and physical abuse in childhood. JAMA. 2000; 284:592

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19. Glick ID, Horsfall JL: Diagnosis and psychiatric treatment of athletes. Clin Sports

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Med. 2005; 24:771

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20. Patel DR, Omar H, Terry M: Sport-related performance anxiety in young female

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athletes. J Pediatr Adolesc Gynecol. 2010; 23:325

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21. Reardon CL, Factor RM: Sport psychiatry: a systematic review of diagnosis and

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medical treatment of mental illness in athletes. Sports Med. 2010; 40:961

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22. Kitamura M, Takeda T, Koga S, et al: Relationship between premenstrual symptoms

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and dysmenorrhea in Japanese high school students. Arch Womens Ment health 2012;

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23. Segebladh B, Borgström A, Nyberg S, et al: Evaluation of different add-back

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Figure Legend

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Fig. 1. Comparison of the premenstrual symptoms between high school girls and

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athletes.

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Table 1. Characteristics of study participants (n = 174) Characteristics

no. (%) 44 (25.3)

Track

12 (6.9)

Swimming

20 (11.5)

Fighting sports

59 (33.9)

Archery

20 (11.5)

Others

19 (10.9)

Participation in national or

93 (53.4)

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Ball games

international competition

81 (46.6)

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Regular players

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Type of sports

Elite athletes

116 (66.7)

Craving for salty food

96 (55.2)

Craving for sweet food

144 (82.8)

Coffee-drinking habit

69 (39.7)

Not at all

Mild

Moderate

Severe

22 (12.6)

62 (35.6)

64 (36.8)

26 (14.9)

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Dysmenorrhea

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Table 2. Prevalence of premenstrual symptoms and interference with work, usual activities, or relationships with degrees of severity. N = 174 Not at all

Mild

Moderate

Severe

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Symptoms Depressed mood, no. (%)

81 (46.6)

51 (29.3)

37 (21.3)

5 (2.9)

Anxiety or tension, no. (%)

35 (20.1)

64 (36.8)

60 (34.5)

15 (8.6)

Tearful, no. (%)

90 (51.7)

45 (25.9)

28 (16.1)

11 (6.3)

Anger or irritability, no. (%)

46 (26.4)

70 (40.2)

44 (25.3)

14 (8.0)

91 (52.3)

60 (34.5)

18 (10.3)

5 (2.9)

69 (39.7)

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Premenstrual symptoms

70 (40.2)

32 (18.4)

3 (1.7)

49 (28.2)

75 (43.1)

39 (22.4)

11 (6.3)

48 (27.6)

59 (33.9)

46 (26.4)

21 (12.1)

79 (45.4)

52 (29.9)

30 (17.2)

13 (7.5)

119 (68.4)

36 (20.7)

10 (5.7)

9 (5.2)

50 (28.7)

67 (38.5)

44 (25.3)

13 (7.5)

90 (51.7)

60 (34.5)

22 (12.6)

2 (1.1)

141 (81.0)

22 (12.6)

7 (4.0)

4 (2.3)

124 (71.3)

40 (23.0)

8 (4.6)

2 (1.1)

97 (55.7)

55 (31.6)

14 (8.0)

8 (4.6)

Decreased interest in work, home, or social Difficulty concentrating, no. (%) Fatigue or lack of energy, no. (%) Overeating or food cravings, no. (%) Insomnia or hypersomnia, no. (%) Feeling overwhelmed, no. (%) Physical symptoms, no. (%)

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Interference with work, usual activities, or relationships Work

efficiency

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productivity,

responsibilities, no. (%) Social activities, no. (%)

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Relationships with coworkers or family, no. (%) competition, no. (%)

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activities, no. (%)

training

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Table 3. Multivariate analysis of risk factors for interference with athletic performance due to premenstrual symptoms Risk factors

OR

(95% CI)

0.86

(0.12-5.96)

Elite athletes

8.63*

(1.22-120.0)

Prefer sweets

5.38

(0.03-4325.2)

0.96

(0.20-4.79)

1.45

(0.24-9.62)

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Background and lifestyle risk factors Age

0.98

(0.06-14.0)

1.81

(0.52-6.11)

0.80

(0.19-2.82)

0.55

(0.14-1.90)

0.69

(0.17-2.68)

1.46

(0.56-3.96)

3.15*

(1.05-10.6)

5.92*

(1.32-34.5)

Overeating or food cravings

0.60

(0.24-1.38)

Insomnia or hypersomnia

0.84

(0.31-2.20)

0.87

(0.18-3.38)

0.53

(0.18-1.37)

0.71

(0.23-2.21)

Social activities

1.72

(0.54-5.94)

Relationships with coworkers or family

2.57

(0.76-9.53)

Prefer salty food Drink coffee Dysmenorrhea Premenstrual symptoms symptoms

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Depressed mood Anxiety or tension Tearful Anger or irritability

Decreased interest in work, home, or social activities Fatigue or lack of energy

Feeling overwhelmed Interference

with

work,

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relationships relationships Work

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Physical symptoms

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Difficulty concentrating

efficiency

or

usual

activities,

productivity,

or

home

responsibilities

OR: Odds ratio, 95% CI: 95% confidence interval *P <0.05

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