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Premenstrul symptoms in adolescents
AL OF ADQLESCERIT
HEALTH C
1989;10:369-375
firstfewdays aftermews OA how these sym the daily life and work of those Many authors state that esse female has some symptom(s) of have developed stricter criteria that decreases the incidence to 2040% (6-9). More e reported that PM
a rating scale, the Pre
ti mood and behavior, especially depressive changes, which may occur in over 50% of women. whether There is little im the literature reg premenadolescent females experience th@ strual symptoms as adults. Although some studies report that PMS increases with age, others r-disagree (2,61$,9,11,16). Based on the theories currently being
changes KEY WoRDS
Premenstrual symptoms Dysmenorrhea The premenstrual syndrome (PM), as defined in adults, consists of a cluster of behavioral, emotional, From the North Shore University Hospital and Cornell Unizwsity Medical College, New York. Presented in vart at the 1987 meetings of the American Pediatric Society and the kociety fop Pediatric Reskk Anaheim, CA, April, 1987. Address reprint requests to: Martin Fisher, M.D.. Division of Adolescent Medicine, Department of Pediatrics, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030. Manuscript accepted December IS, 1988.
0 Wety for Adolescent Medicine, 1989 A.. _ . published by ElsevierScience Publishing Co., Inc., 655 Avenue ot the Americas,,New York, NY 10010
369
m.9
70/89/$3.50
370
FlSHER ET AL.
LTH CARC VU;. 10, No. 5
Table 1. Definitions of the Ratings of Severity of
Meth0fh
Change from Usual Nonpremenstrual State for the 95 Items of the Premenstrual Assessment Form”
Subjects The PAP was administered
to female patients and friends in the waiting room of the Five Towns Adolescent Health Service, a general health facility for teenagers located in a middle to upper-middle
class suburb of New York City. This health service fs used predominantly by female adolescents 1618 years of age, presenting for sexuality-related or gynecologic concerns (18). The PAP forms were distributed to 207conaecutive consenting subjects. The questionnaire was explained in detail to each subject. The forms were completed anonymously in the waiting room during the months of September 1985 through May 1986. A cover sheet included with the PAF asked each subject to provide demographic data (including age, race, religion, school level, parental education, and reason for the visit) and a complete menstrual history (including regularity, length, and &aw of period; severity, frequency, and medications for cramps; current phase of cycle; and intercourse history, oral contraceptive use, and pregnancy). The Premenstrual
JOURNAL OF ADClLESCRhJT
Assessment Po
PAF was developed in 1982 to reflect the variability of symptoms described in the premenstrual period (12-15). Its use has been reported in over 9tKl adult women and its validity has been described in detail (12-15,17). The PAP consists of 95 items describing premenstrual changes in mood, behavior, and physical condition. Each item is rated on a six-point scale for severity of change from the usual (nonpremenstrual) state to the premenstrual state. Subjects are instructed to consider their physical, behaviorial, or mood changes to be part of the premenstrual period if they appear or change during the premenstrual period, do not exist in the same form or severity immediately prior to the premenstrual period, and disappear or return to the usual state during the full menstrual flow. Each of the 95 possible premenstrual changes are described using six severity levels from “no change” to “extreme change” (Table 1). The
Data Analysis
The 207 completed questionnaires were coded, computerized, and analyzed using a statistical program developed specifically for the PAF. Specific types of changes at specified levels of severity were deter-
1. Not applicablenot present at all, or no change from usunal
level. slightly apparentto you, others would probablynot be awareof change. 3. Mild change-detinitely apparentto you and perhaps to others who know you well. 4. Moderate change-clearly apparentto you and/or others 2. Minimal change-only
who know you well. nt to you and/or others who 5. Severe change=-very ap know you well. 6. Extreme chang+-the degree of change in severity is so different from your usual state that it is very apparent to you and even people who do not know you well might notice. “Source:References 12-15.
mined for each 5 items, and diagnostic categories of prem change were established for each patient based on her response to each item. These diagnostic categories were developed by Halbreich et all.in accord with the Research Diagnostic Criteria of Spiker (12~13,J9). Categories of sic change included general discomfort and water-retention symptoms, fatigue, and automonic physical nd behavior social funcect could be classified as having none, some or all of changes. Chi-square analysis was used to dete the demographic and menstrual variables associate with premenstrual changes in our adolescent study group and to compare our fmdings to those of previous studies in a
Results
isto a mean age of 17.6 years ( f 1.71 SD). They were predominantly white (89%) and most were Catholic (55%) or Jewish (32%). Fifty-nine percent were in high school, 28% in college, and 13% not in school. Eighty-six percent of their parents had graduated from h school and 46% had attended college. Ninety-five percent of subjects reported definitely (76%) or possibly (19%) having heard of PMS prior to participating im the study. Eighty-five percent of subjects were Adolescent Health Service patients and 15% were “friends.” Subjects did not differ significantly from the general Adolescent Health Service
Percent indicating moderate, severe, or extreme change PHYSICALCHANGES General discomfort symptoms Backache/joint sti#ness/muscle ache Abdominal discomfo:tlpain Headache or migraine
Weigghtgain
39.1 31.4 27.2 41.5 40.3 24.3
Fatigue Take naps during the day
Decreased energy/fatigue Sleep too much/difficulty getting up Autonomic physical cbaqes Urinate more frequently Cold/more sensitive to temper,. tire change Dizziness/faintness/numbness
37.5 34.3 30.7 23.8 23.4 17.5
CHANGESIN MOODANDBEHAVIOR Impaired social functioning Family/friends notice moods Want to be alone Less desire to talk or move
41.1 39.2 25.9 25.5
Depressive changes Feel “sad” or “blue” Feel depressed Tend to be fearful/weep/cry Decreased self-esteem
38.2 36.9 33.3 25.2
Tendency
to “nag” or quamel
behavior Outbursts of irritability/temper Episodes of impulsive behavior Lack of self-control Become violent (break, hit)
Impulsive
Table 2. Over on emte, severe, or
“Source:References 12-15.
specific category.
39.5 17.5 15.6 15.0
372
Iw&iER
JOURNALOF ADOLESCENTHEALTH CARE Vol. IO,No. 5
irr AL.
Table 3. Categories of Change Demonstrated Adolescents and 154 Ad-&s Completing the Premenstrual Assesswnt Form
by 207
Discussion The adolescents who participated in our study, most
Percent change Adolescents
Adults’
W&r-Me&ion symptoms Fatigue Autonomic physical changes
74.4 49.8 32.4 26.6
68.2 61.p 22.7 21.4
Changes in mood and behavior Impakd social function “MajoP depressive changes “Minor”depressive changes hnpulsive behavior
49.8 47.3 18.4 37.7
34.4b 45.5 18.8 25.Sb
No sign&ant changes
3.8
2.6
No suitable subtype
7.2
11.7
‘Sowce:References 12,13. “p < 0.05.
which were each reported by significantly more adolescents. &ate Variables ge Ch&quare analysis was performed to determine whether any demographic or menstrual variables were associated with premenstrual changes in our adolescent subjects. The variables associated with premenstrual physical changes are presented in Table 4 and those associated with premenstrual changes in mood and behavior in Table 5. who were categorized as having greater strual physical changes (Table 4) were more likely heard of PMS, have dysmenorrhea od (as evidenced by greater severency and/or medication use for menstrual cramps) and to not be currently on an oral contraceptive. Similarly, those who were categorized as having greater changes in mood and behavior (Table 5) were more likely to be white, in college, of higher socioeconomic status (as evidenced by father having graduated college), to have greater fkequency and severity of menstrual cramps, and to not be on an oral contraceptive. Each of these reported variables significant at the p C t were tested but found physical or emotional included chronologic age, gynecofogic age, mother% education, reason for visit (i.e., bent versus friend), amount of bleeding during menstruation, current phase of cycle, and history of Pregnancy.
evaluating adolescents. Althoug strual distress (dysmenorrhea) has been weU studied in teenagers (20,211, no previous studies have looked specifically at premenstrual large number of teenage fe is the first to show that experience the same perception, symptoms as adult women. One pre adolescents, which included preme toms in assessing other a tory# also suggests that important in teenagers, but the authors did not attempt to compare their finding to those reporte adults (22). The classification of premenstrual s been controversial in the medical the concept of a single Premenstru been restricted to a small minority ing specific criteria, the idea that several different syndromes, each comprising multiple may be found in a large number proposed recently (10,ll). The our study, the Premenstrual As 15) specifically evaluates the latter, 1 presence and severity of 95 different s classifying them into several distinct categories. Thus, it is possible that a strictly defined premenstrual syndrome may be rarer in adolescents than in adults, while the presence of any particular physical and emotional symptom may be equivalent in the two age groups. Among the adolescents, our study, general discomfort and water-retention symptoms were the most commonly reported physical categories of change, tion and depression were reported categories of change in mood and behavior. Impaired social function was significantly more com-
General diSCQmfQti(%)
Water
retention (%)
Autmmmic chmges (%)
Fatigue(%)
Race te (n = 184) Nonwhite (n = 23)
Heard of PMS Defhwy (n = 153) ProbabIy (PI= 39) Never [n = IQ) Frequency of cramps Always (M= 89) Sometimes (n = 102) Never (n = 15) Severity of cramys None (n = 26) Mild (n = 50) oderate [n = 78) Severe (n = 46) Medication for ceamps HQ@~?J’ period (n = 37) Someties ,(n = 90) Newer (n = 72) Oral contraceptives currently used Yes (n = 46) No (n = 157) “p < 0.05. “p c O.OP. ‘p c 0.001.
t a
differemcehn
important
effects
on
moO
sometimes
a part of mid&
7a.a 39.1
.53,ab 17.4
2.8.Rn
77.8 61.5 70.0
75.5.7” 30.8 60.0
32.7’ 7-T 110.6)
36.6 23.1 20.0
90.V 63.7 53.3
7O.P 34.3 40.0
38.2 17.6 20.0
47-r 21.6 20.0
53i3. 56. 85.9 87.@
38.F 30.0 51.3 78.3
19.T 6.0 25.4 7.8
I9.T XI.0 33.3 56.5
89.I” 76.7 65.3
70Jb 54.4 33.3
46.P 27.8 16.7
51.4a 3Q.O 26.4
6o.Q 79.0
41.3 52.2
8.7 32.5
1B.B ,369
8.7
32.4
17.4
3
JOURNAL 0F ADO
Fl!SHER FZI’AL.
Vol. as, NQ. 5
hfajor depressive Race white (?I = 184) Nonwhite (n = 23)
50.0” 26.1
67.9 47.8
51.1 39.1
39.1 26.1
Education High school (n = 123) college(fl = 57) Notinschoal(n = 27)
43.1’ 61.4 37.0
61.V 80.7 55.6
46.3 61.4 40.7
39.8 a.6 25.9
50.8 46.3
76.2b 96.3
56.0 47.8
44.1 35.s
6q.r
75.r 57.8
64.r 40.2
47.2” 29.
ii:;
66.7
33.3
3%
30.8” 40.4 51.3 63.0
57.7 60.0 6y.2 73.9
30.8 40.0 52.6 67.4
26.9 32.0 34.6 56.5
26.1b 63.5
45.8 70.7
Father graduated conYes(n = 59) No (8 = 138) FPequency of cramps Alwaye(n = 691 so-es (n = ICQ Never (n = 15) Severity of ceamps None (n = 26) Mild (n = 50) Moderpte (n = 78) severe (?I = 46) Ofal contraceptives currently Yes& = 46) No (II = 157)
.6’ .8
.r 0
‘p < 0.05. “p < 0.01. ‘p < 0.001.
ar in socioecono
symptoms pqxxtively instead of deon retrospestive recall (25,245). This , dng daily logs, will likely find a place in future studies of adolescentsas a method of decreashg the more subjective nature of the ret-mspec% reports. Other authors have develo objectively studying bloating undoubte
and researchers who evaluate s should view the physicaland filldingS.
We are aware that the subjectsof OUT r-middle class patients and healthservice, may not be repescentpopulations.In fact, our
1. Vahdtaiti JL. Premenstrual 1984~11:1371-3.
syndrome. N Engl J Med
2. 3.
17.
4. 18. 5. 6. 7.
8. 9.
19.
m. 21.
22.
IQ. 11. 23. 12‘ 24.
25.
26. 2Y.
HEALTH C
1989;10:369-375
firstfewdays aftermews OA how these sym the daily life and work of those Many authors state that esse female has some symptom(s) of have developed stricter criteria that decreases the incidence to 2040% (6-9). More e reported that PM
a rating scale, the Pre
ti mood and behavior, especially depressive changes, which may occur in over 50% of women. whether There is little im the literature reg premenadolescent females experience th@ strual symptoms as adults. Although some studies report that PMS increases with age, others r-disagree (2,61$,9,11,16). Based on the theories currently being
changes KEY WoRDS
Premenstrual symptoms Dysmenorrhea The premenstrual syndrome (PM), as defined in adults, consists of a cluster of behavioral, emotional, From the North Shore University Hospital and Cornell Unizwsity Medical College, New York. Presented in vart at the 1987 meetings of the American Pediatric Society and the kociety fop Pediatric Reskk Anaheim, CA, April, 1987. Address reprint requests to: Martin Fisher, M.D.. Division of Adolescent Medicine, Department of Pediatrics, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030. Manuscript accepted December IS, 1988.
0 Wety for Adolescent Medicine, 1989 A.. _ . published by ElsevierScience Publishing Co., Inc., 655 Avenue ot the Americas,,New York, NY 10010
369
m.9
70/89/$3.50
370
FlSHER ET AL.
LTH CARC VU;. 10, No. 5
Table 1. Definitions of the Ratings of Severity of
Meth0fh
Change from Usual Nonpremenstrual State for the 95 Items of the Premenstrual Assessment Form”
Subjects The PAP was administered
to female patients and friends in the waiting room of the Five Towns Adolescent Health Service, a general health facility for teenagers located in a middle to upper-middle
class suburb of New York City. This health service fs used predominantly by female adolescents 1618 years of age, presenting for sexuality-related or gynecologic concerns (18). The PAP forms were distributed to 207conaecutive consenting subjects. The questionnaire was explained in detail to each subject. The forms were completed anonymously in the waiting room during the months of September 1985 through May 1986. A cover sheet included with the PAF asked each subject to provide demographic data (including age, race, religion, school level, parental education, and reason for the visit) and a complete menstrual history (including regularity, length, and &aw of period; severity, frequency, and medications for cramps; current phase of cycle; and intercourse history, oral contraceptive use, and pregnancy). The Premenstrual
JOURNAL OF ADClLESCRhJT
Assessment Po
PAF was developed in 1982 to reflect the variability of symptoms described in the premenstrual period (12-15). Its use has been reported in over 9tKl adult women and its validity has been described in detail (12-15,17). The PAP consists of 95 items describing premenstrual changes in mood, behavior, and physical condition. Each item is rated on a six-point scale for severity of change from the usual (nonpremenstrual) state to the premenstrual state. Subjects are instructed to consider their physical, behaviorial, or mood changes to be part of the premenstrual period if they appear or change during the premenstrual period, do not exist in the same form or severity immediately prior to the premenstrual period, and disappear or return to the usual state during the full menstrual flow. Each of the 95 possible premenstrual changes are described using six severity levels from “no change” to “extreme change” (Table 1). The
Data Analysis
The 207 completed questionnaires were coded, computerized, and analyzed using a statistical program developed specifically for the PAF. Specific types of changes at specified levels of severity were deter-
1. Not applicablenot present at all, or no change from usunal
level. slightly apparentto you, others would probablynot be awareof change. 3. Mild change-detinitely apparentto you and perhaps to others who know you well. 4. Moderate change-clearly apparentto you and/or others 2. Minimal change-only
who know you well. nt to you and/or others who 5. Severe change=-very ap know you well. 6. Extreme chang+-the degree of change in severity is so different from your usual state that it is very apparent to you and even people who do not know you well might notice. “Source:References 12-15.
mined for each 5 items, and diagnostic categories of prem change were established for each patient based on her response to each item. These diagnostic categories were developed by Halbreich et all.in accord with the Research Diagnostic Criteria of Spiker (12~13,J9). Categories of sic change included general discomfort and water-retention symptoms, fatigue, and automonic physical nd behavior social funcect could be classified as having none, some or all of changes. Chi-square analysis was used to dete the demographic and menstrual variables associate with premenstrual changes in our adolescent study group and to compare our fmdings to those of previous studies in a
Results
isto a mean age of 17.6 years ( f 1.71 SD). They were predominantly white (89%) and most were Catholic (55%) or Jewish (32%). Fifty-nine percent were in high school, 28% in college, and 13% not in school. Eighty-six percent of their parents had graduated from h school and 46% had attended college. Ninety-five percent of subjects reported definitely (76%) or possibly (19%) having heard of PMS prior to participating im the study. Eighty-five percent of subjects were Adolescent Health Service patients and 15% were “friends.” Subjects did not differ significantly from the general Adolescent Health Service
Percent indicating moderate, severe, or extreme change PHYSICALCHANGES General discomfort symptoms Backache/joint sti#ness/muscle ache Abdominal discomfo:tlpain Headache or migraine
Weigghtgain
39.1 31.4 27.2 41.5 40.3 24.3
Fatigue Take naps during the day
Decreased energy/fatigue Sleep too much/difficulty getting up Autonomic physical cbaqes Urinate more frequently Cold/more sensitive to temper,. tire change Dizziness/faintness/numbness
37.5 34.3 30.7 23.8 23.4 17.5
CHANGESIN MOODANDBEHAVIOR Impaired social functioning Family/friends notice moods Want to be alone Less desire to talk or move
41.1 39.2 25.9 25.5
Depressive changes Feel “sad” or “blue” Feel depressed Tend to be fearful/weep/cry Decreased self-esteem
38.2 36.9 33.3 25.2
Tendency
to “nag” or quamel
behavior Outbursts of irritability/temper Episodes of impulsive behavior Lack of self-control Become violent (break, hit)
Impulsive
Table 2. Over on emte, severe, or
“Source:References 12-15.
specific category.
39.5 17.5 15.6 15.0
372
Iw&iER
JOURNALOF ADOLESCENTHEALTH CARE Vol. IO,No. 5
irr AL.
Table 3. Categories of Change Demonstrated Adolescents and 154 Ad-&s Completing the Premenstrual Assesswnt Form
by 207
Discussion The adolescents who participated in our study, most
Percent change Adolescents
Adults’
W&r-Me&ion symptoms Fatigue Autonomic physical changes
74.4 49.8 32.4 26.6
68.2 61.p 22.7 21.4
Changes in mood and behavior Impakd social function “MajoP depressive changes “Minor”depressive changes hnpulsive behavior
49.8 47.3 18.4 37.7
34.4b 45.5 18.8 25.Sb
No sign&ant changes
3.8
2.6
No suitable subtype
7.2
11.7
‘Sowce:References 12,13. “p < 0.05.
which were each reported by significantly more adolescents. &ate Variables ge Ch&quare analysis was performed to determine whether any demographic or menstrual variables were associated with premenstrual changes in our adolescent subjects. The variables associated with premenstrual physical changes are presented in Table 4 and those associated with premenstrual changes in mood and behavior in Table 5. who were categorized as having greater strual physical changes (Table 4) were more likely heard of PMS, have dysmenorrhea od (as evidenced by greater severency and/or medication use for menstrual cramps) and to not be currently on an oral contraceptive. Similarly, those who were categorized as having greater changes in mood and behavior (Table 5) were more likely to be white, in college, of higher socioeconomic status (as evidenced by father having graduated college), to have greater fkequency and severity of menstrual cramps, and to not be on an oral contraceptive. Each of these reported variables significant at the p C t were tested but found physical or emotional included chronologic age, gynecofogic age, mother% education, reason for visit (i.e., bent versus friend), amount of bleeding during menstruation, current phase of cycle, and history of Pregnancy.
evaluating adolescents. Althoug strual distress (dysmenorrhea) has been weU studied in teenagers (20,211, no previous studies have looked specifically at premenstrual large number of teenage fe is the first to show that experience the same perception, symptoms as adult women. One pre adolescents, which included preme toms in assessing other a tory# also suggests that important in teenagers, but the authors did not attempt to compare their finding to those reporte adults (22). The classification of premenstrual s been controversial in the medical the concept of a single Premenstru been restricted to a small minority ing specific criteria, the idea that several different syndromes, each comprising multiple may be found in a large number proposed recently (10,ll). The our study, the Premenstrual As 15) specifically evaluates the latter, 1 presence and severity of 95 different s classifying them into several distinct categories. Thus, it is possible that a strictly defined premenstrual syndrome may be rarer in adolescents than in adults, while the presence of any particular physical and emotional symptom may be equivalent in the two age groups. Among the adolescents, our study, general discomfort and water-retention symptoms were the most commonly reported physical categories of change, tion and depression were reported categories of change in mood and behavior. Impaired social function was significantly more com-
General diSCQmfQti(%)
Water
retention (%)
Autmmmic chmges (%)
Fatigue(%)
Race te (n = 184) Nonwhite (n = 23)
Heard of PMS Defhwy (n = 153) ProbabIy (PI= 39) Never [n = IQ) Frequency of cramps Always (M= 89) Sometimes (n = 102) Never (n = 15) Severity of cramys None (n = 26) Mild (n = 50) oderate [n = 78) Severe (n = 46) Medication for ceamps HQ@~?J’ period (n = 37) Someties ,(n = 90) Newer (n = 72) Oral contraceptives currently used Yes (n = 46) No (n = 157) “p < 0.05. “p c O.OP. ‘p c 0.001.
t a
differemcehn
important
effects
on
moO
sometimes
a part of mid&
7a.a 39.1
.53,ab 17.4
2.8.Rn
77.8 61.5 70.0
75.5.7” 30.8 60.0
32.7’ 7-T 110.6)
36.6 23.1 20.0
90.V 63.7 53.3
7O.P 34.3 40.0
38.2 17.6 20.0
47-r 21.6 20.0
53i3. 56. 85.9 87.@
38.F 30.0 51.3 78.3
19.T 6.0 25.4 7.8
I9.T XI.0 33.3 56.5
89.I” 76.7 65.3
70Jb 54.4 33.3
46.P 27.8 16.7
51.4a 3Q.O 26.4
6o.Q 79.0
41.3 52.2
8.7 32.5
1B.B ,369
8.7
32.4
17.4
3
JOURNAL 0F ADO
Fl!SHER FZI’AL.
Vol. as, NQ. 5
hfajor depressive Race white (?I = 184) Nonwhite (n = 23)
50.0” 26.1
67.9 47.8
51.1 39.1
39.1 26.1
Education High school (n = 123) college(fl = 57) Notinschoal(n = 27)
43.1’ 61.4 37.0
61.V 80.7 55.6
46.3 61.4 40.7
39.8 a.6 25.9
50.8 46.3
76.2b 96.3
56.0 47.8
44.1 35.s
6q.r
75.r 57.8
64.r 40.2
47.2” 29.
ii:;
66.7
33.3
3%
30.8” 40.4 51.3 63.0
57.7 60.0 6y.2 73.9
30.8 40.0 52.6 67.4
26.9 32.0 34.6 56.5
26.1b 63.5
45.8 70.7
Father graduated conYes(n = 59) No (8 = 138) FPequency of cramps Alwaye(n = 691 so-es (n = ICQ Never (n = 15) Severity of ceamps None (n = 26) Mild (n = 50) Moderpte (n = 78) severe (?I = 46) Ofal contraceptives currently Yes& = 46) No (II = 157)
.6’ .8
.r 0
‘p < 0.05. “p < 0.01. ‘p < 0.001.
ar in socioecono
symptoms pqxxtively instead of deon retrospestive recall (25,245). This , dng daily logs, will likely find a place in future studies of adolescentsas a method of decreashg the more subjective nature of the ret-mspec% reports. Other authors have develo objectively studying bloating undoubte
and researchers who evaluate s should view the physicaland filldingS.
We are aware that the subjectsof OUT r-middle class patients and healthservice, may not be repescentpopulations.In fact, our
1. Vahdtaiti JL. Premenstrual 1984~11:1371-3.
syndrome. N Engl J Med
2. 3.
17.
4. 18. 5. 6. 7.
8. 9.
19.
m. 21.
22.
IQ. 11. 23. 12‘ 24.
25.
26. 2Y.