KNOWLEDGE AND PRACTICE OF STUDENT GIRLS REGARDING PREMENSTRUAL SYNDROME

Introduction and Aim of the Study

1

INTRODUCTION

Premenstrual syndrome (PMS) refers to a cluster of

physical, psychological and behavioral symptoms that

occur during the luteal phase of the menstrual cycle and

end with the onset of menstruation. PMS is viewed now as

a complex psychoneuroendocrinology disorder known to

affect emotional and physical well-being. PMS is no

longer considered a single condition but a group of

menstrually related disorders and symptoms. Adolescent

girls in many cultures worldwide, have many factors

which put them at high risk for PMS, that include age,

genetic, psychological, cultural and psychosocial factors

(Lin &Thompson, 2001).

Premenstrual dysphoric disorder (PMDD) is a severe

form of PMS that is characterized by mood symptoms

such as irritable, tense, tired, sad and hypersensitive

feelings associated with high levels of interpersonal

conflict and enough to interfere markedly with

occupational and social functions (Endicott et al., 2000).

Over 150 symptoms contributing to PMS which

categorized into behavioral and emotional symptoms such

as poor coordination, loss of concentration, insomnia,

irritability, mood swings, depression, hostility, and social


2

withdrawal, whereas physical symptoms include bloating,

breast tenderness, pelvic pain, sensation of weight

increase, headache, fatigue, urinary frequency and

constipation (Ling & Duff, 2001).

Approximately 95% of girls are affected with PMS,

about 20% to 40% of these girls have more severe

symptoms that interfere with their work or social life, a

generally stressful life and problematic relationships that

may be related to intensity of symptoms (Ried, 2003).

Some girls report moderate to severe life disruptions

secondary to PMS that negatively affect their interpersonal

relationships. PMS may also be a factor in reduced

productivity, work related accidents and absenteeism (Dell

et al., 2001).

Premenstrual syndrome is of unknown cause.

Theories originally emphasized a combination of

biological, psychological and social factors. These factors

such as hormone imbalance, abnormal prostaglandin

metabolism, vitamin deficiency, changes in endorphin

levels, and external stressors also play a part in the girls'

perception of PMS and its severity (Hudson, 2002).

Nurses play an instructive and supportive role to

help girls coping with PMS and its problems. The nursing

role in PMS involves helping girls and their families to


3

become more informed about premenstrual symptoms,

causes, and rational for any planned treatment. The most

important part of management is to reassure girls,

understand girls concerns and disruptions which

symptoms are causing to girls life. As PMS can be a long-

term problem there are life style modifications which help

girls to cope with symptoms such as practicing exercise,

relaxation techniques and diet modification (Beausang &

Razor, 2004).

Justification of the problem:

Approximately 75% of adolescent girls experience

some kind of problems associated with menstruation. PMS

affects millions of girls during their reproduction years

(Ziv et al., 2000). According to Ahmed et al. (2002), the

prevalence of PMS among 800 students in Assuit

University was 73.9%. Girls had a lack of general

knowledge related to menstruation and do not understand

much about PMS, or recognize that the problems they

have are related to their menstrual cycle, such as,

absenteeism from school, low self-esteem, stressed

relationships, and limited daily home activities and social

events. They may feel symptoms are not severe enough to

discuss, so assessing of adolescent girls knowledge and

their health practices regarding PMS are the main concern

of this study.


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Aim of the Study:

To evaluate knowledge and practice of student girls

regarding premenstrual syndrome this aim was achieved

through:

1- Assessment of student girls knowledge about

PMS.

2- Assessment of student girls practices taken to

relief PMS.

Research Questions:

Is there a knowledge deficit regarding PMS that

affects on practices taken by student girls to relief

symptoms?

Review of Literature

5

PREMENSTRUAL SYNDROME

Definition:

Premenstrual syndrome describes a range of

predictable physical and affective symptoms that occur

cyclically during the luteal phase of the menstrual cycle

and resolve at the onset of menstruation. PMS begins 7 to

10 days before menses and ceases with the onset of

bleeding. PMS can be a long term condition, in some girls,

symptoms flare up before every menstrual period. This

pattern continues until menopause, it's a characteristic for

adolescent girls to experience symptoms at the time of

menses in varying degrees of severity from mild to severe

(Dicarlo et al., 2001).

Premenstrual syndrome means a group of physical,

mood, and behavioral changes that occur in a regular

cyclic relationship to the luteal phase of the menstrual

cycle. The mildest PMS changes are known as molimina

which are referring to those symptoms (breast pain,

bloating, acne and constipation) most girls experience at

or near menstruation (Meaden et al., 2005).

Premenstrual dysphoric disorder (PMDD) is a severe

form of PMS characterized by some combination of

marked mood swings, depressed mood, irritability, and


6

anxiety, which may be combined with physical symptoms

(Hylan et al., 1999).

Pathophysiology of Premenstrual Syndrome:

1- Normal hormonal changes along the menstrual cycle

Hypothalamic gonadotropin releasing hormone

(GnRH) stimulates the anterior pituitary gland to release

follicle stimulating hormone (FSH) and Luteinising

hormone (LH). FSH stimulates the initial secretion of

estrogen by the follicles and LH further stimulates

follicular development and full secretion of estrogen,

triggers ovulation, promotes formation of the corpus

luteum and stimulates the corpus luteum to produce

estrogen and progesterone. Moderate levels of estrogen

inhibit release of GnRH and secretion of LH and FSH.

High levels of progesterone also inhibit GnRH and LH

secretion. High levels of estrogen during the last part of

the preovulatory phase can actually exert positive

feedback on both the hypothalamus and anterior pituitary

gland resulting in the LH surge that triggers ovulation.

This positive effect of estrogen does not occur if

progesterone is present at the same time (Miner et al.,

2002).


7

Fig. (1): Normal menstrual cycles-hormonal fluctuations.

Adopted from Halbreich U. (2003): The etiology, biology,

and pathology of premenstrual syndrome,

Psychoneuroendocrinology 28, 55-99.

2- Abnormalities of hormones in girls with premenstrual

syndrome:

Girls with PMS demonstrate a higher frequency and

lower amplitude pulsatile pattern of progesterone secretion

which is temporally related to LH secretion which appears

to be altered in stress and affective disorders. Other

investigators have not suggest alteration in pulsatility of

LH or progesterone, but have noted a zero time lag

between LH and progesterone, at symptoms onset among

PMS girls (Halbreich et al., 2003).

When progesterone and estrogen fluctuated in

different rates there was a significant correlation between

the difference of rate and severity of symptoms


8

contributing to premenstrual symptoms formation

(Schmidt et al., 1998).

Both estrogen and progesterone interact with the

renin-angiotensin-aldosterone system (RAAS), which

influences electrolytes and fluid imbalance, aldosterone

acts to increase sodium and water retention, estrogen may

stimulate the RAAS by inducing the syntheses of

angiotensinogen in the liver, these estrogen and

progesterone effects have been suggested to underlie

menstrual related symptoms such as bloating and also

contribute to weight gain (Parsey & Pony, 2000).

Estrogen influences some of the major

neurotransmitters involved in regulation of mood,

behavior and cognitive functions including serotonin,

noradrenalin, gamma amino butyric acid (GABA),

dopamine and acetylcholine. Various serotonergic

receptors and systems appear to play different roles in the

modulation of PMS. Whole blood serotonin levels during

luteal phase have been shown to be lower in girls with

PMS as compared with girls with no PMS but also

abnormal serotonergic activity prior to the symptomatic

period is important for symptom formation (Mitwally et

al., 2002).


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Endogenous opioids activity is closely related to

hypothalamic pituitary gonadal (HPG) axis activity, the

contributing rate of the significant late luteal phase

decreases in opioids activity, that withdrawal may

contribute to symptoms formation of irritability, decreased

self-control impulsivity, aggression and anxiety (Blumer

et al., 1998).

A gradual but steady drop in serum calcium starting

about 10 days before the menstrual flow takes place. This

calcium drop is a stress condition and the adrenals are

affected in a manner that cause retention of salts and water

in the body resulting headache and depression, when the

menstrual flow occurs, the calcium drops further causing

uterine and muscular cramps, convulsions may result if the

calcium drop is markedly low (Gorman et al., 2001).

Etiology of premenstrual syndrome:

The exact cause of PMS is unknown, theories about

causes of PMS include progesterone deficiency, estrogen

excess, increased activity of aldosterone, vitamin B6

deficiency and serotonin deficiency, current research

suggests that PMS is most likely of multifactorial origin,

with involvement of neurohormones and neurotransmitters

(Stud, 2003).


10

1- Progesterone and estrogen theory

Recurrence of psychometric symptoms in relation to

the luteal phase led to the theory that, hormonal

production in the corpus luteum causes premenstrual

symptoms that, estrogen and progesterone played a role

in PMS, mainly because of their fluctuating patterns that

occur during the menstrual period (Cohen et al., 2002).

Excess estrogen, deficient progestin, and

inappropriate ratio of the two sex steroids or inadequate

corpus luteal function are associated with PMS. Recent

clinical studies haven't consistently implicated abnormal

estrogen or progesterone levels in PMS, although certain

PMS symptoms can be reproduced through hormonal

manipulation (Pregler & Decherney, 2002).

Estrogen's ability to affect serotonergic neurological

function has led some researchers and clinicians to

postulate that PMS involves problems with serotonin

system (Nelson, 1998).

2- Serotonin theory:

Serotonin is a neurotransmitter that is known to play

an important role in our mood, appetite, and behavior

patterns. Some studies have demonstrated blood serotonin

levels to be significantly lower in the luteal phase of the


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menstrual cycle of girls with PMS, reduced serotonergic

neurotransmission has been linked with depressed mood,

irritability, anger, aggression, poor control impulses and

increased craving for carbohydrates (Lewis et al., 2000).

PMS is related to enhanced sensitivity to

progesterone in girls with underlying serotonin deficiency.

This mechanism doesn't explain all cases because some

girls don't respond to treatment with selective serotonin

reuptake inhibitors (Kessel, 2000).

3- Prostaglandin theory:

Prostaglandins are produced in the breast, brain,

gastrointestinal tract, kidney and reproductive tract. These

areas often present with physical symptoms, so

deficiencies in prostaglandins related to inability to

convert linoleic acid to prostaglandin in precursors may be

involved in PMS (Steiner & Born, 2000).

4- Endorphin theory:

There is a relative decrease in the luteal phase

endorphin levels in some girls who suffer from PMS,

because these endogenous opiates are associated with a

sense of well-being, a decline in their production is seen as

a cause of these symptoms (Beckmann et al., 1998).


12

Abnormal prostaglandin production in girls with

PMS also may interfere with beta-endorphin synthesis

causing PMS alleviation of symptomatology when

moderate exercise is undertaken, presumably because of

an exercise-associated increase in endorphin production

(Gstrzenski, 2002).

5- Hypoglycemia

Studies have suggested that PMS may be related to

abnormally low blood sugar (hypoglycemia), girls with

PMS seem to have a high intake of salt and refine

carbohydrates resulting in premenstrual hypoglycemic

episodes, sometimes associated without bursts of crying

and violent behavior (Hammond & Riddick, 2000).

6- Vitamin deficiency

Deficiencies in number of vitamins, minerals and

other nutrients may by associated with premenstrual

distress and behavior symptoms. Deficiencies of

magnesium, manganese, B vitamins, vitamin E, calcium

and linoleic acid and its metabolites have been reported in

girls with PMS (Bendich, 2000).

7-Genetic factors

There is a genetic predisposition to PMS, study of

monozygotic twins demonstrated that over 90% exhibited


13

similar PMS symptoms to their twin. In contrast, about

50% of dizygotic twins and non-twin sibling had similar

PMS symptoms (Kendler et al., 1998).

Fig.(2): The etiology and Pathophysiology of PMS.

Adopted from Halbreich u, (2003): The etiology, biology and

evolving pathology of premenstrual syndrome, Psychoneuro-

endocrinology, 28, 55-99.

Symptoms of premenstrual syndrome:

Symptoms of PMS were not recognized as occurring

specifically during the late luteal phase. They were more

broadly described as being related to the general process

of menstruation and more closely linked to the actual

bleeding of menses, symptoms can begin any time after

ovulation but there must be a symptom-free interval


14

during the follicular phase of the menstrual cycle

(Pearlstien et al., 2003).

Fig. (3): Several premenstrual symptom patterns .

Adopted from Moline ML& Zendell SM (2000): Evaluating

and managing premenstrual syndrome. Med Gen, 212.

Pattern 1, symptoms begin during the week before

menstruation and remit during menses. Pattern 2 differs in

that symptoms begin around the time of ovulation and

persist through the luteal phase. In pattern 3, a brief of

symptoms occurs around ovulation with the symptoms

returning during the second week of the luteal phase. The

fourth pattern depicts symptoms that begin at ovulation

and continue through menses leaving only a symptom-free

week to 10 days.


15

Over 150 symptoms have been attributed to PMS,

there is considerable variation in the duration of

symptoms. It varies widely from one girl to another and

from cycle to the next in the same person, great variability

is found in the degree, but few are severely affected (Dog,

2001).

Symptoms may increase during periods in which

girls experience rapid hormonal changes such as puberty,

after pregnancy, discontinuation of oral contraceptives and

after periods of menstrual irregularity (Johnson, 2004).

Some girls reported symptoms that distressing them for

several days around ovulation and then again in the

premenstrual week, other girls may have troubles for only

several days before menses (Pearlstien et al., 2000).

Classification of premenstrual symptoms

Premenstrual symptoms can be classified as

affective, cognitive, autonomic, behavioral, neuro1ogic

and dermatologic symptoms.

I. Affective symptoms include sadness, anxiety, anger,

irritability and mood swings.

II. Cognitive symptoms manifested as decreased

concentration, paranoia, rejection, and suicidal

ideation.


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III. Autonomic symptoms include nausea, diarrhea, and

palpitation.

IV. Behavioral symptoms are demonstrated by decreased

motivation, poor impulse control, decrease efficiency

and social isolation.

V. Numbness and tremors are the neuralgic symptoms.

VI. Dermatologic symptoms are dry hair and pain

experience by women with PMS can manifested as

headache, breast tenderness and muscle pain

(Littleton &Engerbretson, 2005).

Major symptoms of PMS, include headache ,fatigue,

lower back pain, painful breast and feeling of abdominal

fullness, general irritability, mood swings, fear of losing

control, and crying spells may also occur (Morse, 1999)

(Table 1).


17

Table (1): Symptoms of Premenstrual Syndrome (Morse,

1999).

Physical symptoms Headache, dizziness

Abdominal bloating or swelling; swelling of extremities Weight gain

Breast tenderness Hot flashes

Abdominal cramps Generalized muscle and joint pain Fatigue

Appetite changes: binge eating, food craving Sleep changes: excessive or insomnia

Reduced sexual interest

Behavioral symptoms Depression or sadness

Feelings of hopelessness Marked anxiety

Confusion, forgetfulness, poor concentration Accident prone Irritability and anger

Emotional liability: tearfulness or crying easily, loneliness, mood instability

Reduced interest in normal daily activities Social avoidance Lethargic or energetic

Hendrick (2002) classified PMS into both physical

and emotional symptoms and listed common symptoms as,

breast swelling, tenderness, fatigue, bloating, constipation

or diarrhea, headache, food cravings, muscle pain, tension,

irritability, mood swings, depression and trouble

concentrating or remembering.


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Researchers' studies of adolescent girls discovered

that the most common manifestation of PMS was negative

affect characterized by mood swings, stress and

nervousness, and physical symptoms as breast tenderness,

abdominal bloating, fatigue and edema (Derman et al.,

2004).

Moline and Zendell (2000), also classified

symptoms of premenstrual syndrome into physical

symptoms, behavioral symptoms and psychological

symptoms (Table 2).

Table (2): Common Symptoms of Premenstrual Syndrome

(Moline & Zendell, 2000).

Behavioral symptoms: Fatigue, insomnia, dizziness, changes

in sexual interest, food cravings or overeating.

Psychological symptoms: Irritability, anger, depressed mood,

crying and tearfulness, anxiety, tension, mood swings, lack of concentration, confusion, forgetfulness, restlessness,

loneliness, decreased self-esteem and tension.

Physical symptoms: Headaches, breast tenderness and

swelling, back pain, abdominal pain and bloating, weight gain, swelling of extremities, water retention, nausea, muscle and

joint pain.


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Risk factors of premenstrual syndrome:

1- Age:

Premenstrual syndrome is higher in adolescents, it

affects girls with ovulatory cycles, older adolescents tend

to have more severe symptoms than younger adolescents

whose age at menarche was 12 years. Symptoms of PMS

diminish after age of 35 years and resolve completely at

menopause (Lowdage, 2001).

2- Psychosocial factors:

Regarded the incidence of PMS that increased after

major life events and stressors, these events are associated

with somatic health symptoms. Girls are reporting

significant life stressors which are more likely to rate

premenstrual symptoms, stressors such as premature

parental loss, childhood sexual abuse and interpersonal

difficulties; combination of lack of parental warmth and

lack of social support system (Wood et al., 1999).

3- Psychiatric disorders:

As many as 70% of girls with PMS have a history of

mood disorders including major depression, anxiety

disorders, and personality disorders, although a past

history of mood disorders is very common with PMDD,


20

the relation between them including high life time rates for

phobia and obsessive-compulsive disorder should not be

neglected that irritability, impulsivity, anger, anxiety,

tension and nervousness are very prevalent premenstrually

(Lemelledo et al., 2000).

4- Hereditary factors:

There are high correlations between premenstrual

tension of mothers and daughters. A similarity of PMS

subtype was noted if the mother had nervous symptoms,

69.8% of daughters had similar symptoms, and 62.5% of

the daughters with symptoms-free mothers were also

symptoms free (Kendler et al., 1998).

5- Life style factors:

Physical activity and dietary patterns have long been

influencing PMS. Alcohol consumption, caffeine intake

have been found to be higher with PMS prevalence among

girls who consumed more as compared with non drinkers,

A significant greater prevalence of PMS in girls who have

not reported exercising on regular basis (Deuster et al.,

1999). Also, life style plays a significant role in PMS,

symptoms appear to be most troubling in girls who smoke,

rarely exercise and who reported environmental stress

(Sternfeld et al., 2002).


21

6- Other risk factors:

Other risk factors associated with increase risk of

PMS are: low parity because fewer pregnancies mean

more menstrual cycles and greater exposure to cyclic

changes in estrogen and progesterone. A woman who uses

oral contraceptives (OCs) may be less likely to have

premenstrual symptoms suggesting that briefer exposure

to estrogen and progesterone fluctuations protects against

PMS (Johnson, 1998).

Premenstrual symptoms is prevalent regardless of

parity, race culture or socio-economic group, there is no

single cause for PMS, it's a combination of physiological,

psychological and social factors that are involved (Pregler

& Decherney, 2002).

Prevalence of premenstrual symptoms:

Studies on the prevalence of premenstrual symptoms

and syndromes have produced mixed results depending

upon the diagnostic criteria and the method of measuring

symptoms (Spitzer et al., 2000).

Researchers, who undertook broad surveys

questioning girls about general premenstrual symptoms,

found the highest prevalence of premenstrual dysphoric

and have been already reported in adolescent girls aged 14


22

and over. Approximately 50- 80% of girls experienced at

least a few premenstrual symptoms that may be varied

from mild to severe (Wittchen et al., 2002).

Premenstrual conditions grouped into 3 broad

categories: Severe PMDD that affects about 2% to 9% of

girls, moderate to severe PMS that affects about 20% to

40% of girls, and mild PMS which affects up to 80% of

girls at the reproductive age (Bornstein et al., 2003).

In Egypt, a study conducted by Amasha 1995, to

assess prevalence of premenstrual tension syndrome

among nursing students in Port Said City, the prevalence

rate was 77.2%. Of these girls 39.3% suffered from mild

PMS, 24% from moderate and 13.9% had severe PMS.

Effects of premenstrual syndrome on adolescent girls

Adolescent girls develop an altered body image,

decrease in self esteem, lack of self-confidence and

subsequently affect their relationship with others. On

reaching adulthood, these affects may give rise to broken

engagement, marital distress, difficulty in pursing

education goals or becoming withdrawn and socially

isolated (Hylan et al., 1999).

Adolescent girls with PMS have been reported to

view their bodies in a negative light, with feeling of failure


23

and shame having been expressed. PMS puts a consistent

strain on family relationships, includes increased family

conflict, disrupted communication and decreased family

cohesion (Baram, 2000). Impaired work productivity in

adolescent girls with PMS was reported perimenstrually

and continued also during the early follicular phase

(Chawla et al., 2002).

There are close link between mood and sexuality

premenstrually. Many girls are less interested in sexual

activity premenstrually due to that they suffer from

symptoms such as tiredness, breast tenderness and mood

changes which lead to tension within relationships

(Ganger & Allanch, 2001).

Premenstrual syndrome affects adolescent girls on

limiting daily home activities, participation in social

events, class concentration, home work tasks, also extends

to sleep deprivation and causes school absenteeism among

adolescent girls (Montero et al., 1999).


24

Fig. (4): Vicious circles of negative thinking in PMS. Adopted from Ganger E,& Allanch V, (2001): Gynecological

Nursing. Harcourt: London, pp. 109-125.

PMS Symptoms

Guilt Low mood Low mood

" I'm less in control. I

won't perform as well

as I should "

Being out of control is

confirmed as dreadful

Perceives further difficulty.

"I can't do it, so I am

useless, a failure."

Irritable outburst Tries harder

Anxiety, tension

depressed mood

Guilt : " I should be in

control. I should be able to do this "

Resentment: "There are too

many demands on me.

Nobody cares about me or

helps me."


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Diagnosis of premenstrual syndrome

There is no consensus for diagnosis of clinically

significant PMS. The essential components include

confirmation of the expected relationship of the symptoms

to the menstrual cycle (First et al., 1997).

Diagnosis of PMS is made only if the following

criteria are met; symptoms occur in the luteal phase and

resolve with in a few days of menses onset, symptoms free

period occur in the follicular phase, the recurrence,

cyclicity, timing of symptoms are documented by daily

symptom reports, symptoms are not explained by another

chronic physical or mood disorder, it causes emotional and

physical distress and suffering or impaired of daily

functions (ACOG, 2000).

Premenstrual symptoms are varied and no specific

diagnostic test exists, a premenstrual disorder may be

unrecognized or misdiagnosed as another condition, a

wide range of medical problems should be ruled out, such

as anemia and endometrioses, dysmenorrhea, thyroid

disorder, diabetes mellitus, psychiatric disorders such as

major depression, dythymia, bipolar disorder, generalized

anxiety and panic disorder (Mortola, 2000).


26

Diagnostic criteria are important for distinguishing

between PMS and other disorders. For determining the

effective treatment, diagnosis is determined by results of

diaries, physical examination, laboratory tests (Strine et

al., 2005).

In women with severe dysphoric symptoms research

criteria can be used to establish the diagnosis of PMDD.

(Table 3)

Table (3): Criteria for diagnosis of premenstrual dysphoric

disorder (American Psychiatric Association,

2000)

Symptoms occur 1 week before menses and resolve in the first few days after menses begins

Five or more of the following (one must be among the first four):

Markedly depressed mood with feelings of hopelessness

Marked anxiety or tension

Marked affective liability

Irritability and anger

Decreased interest in usual activities and social withdrawal

Lack of energy

Appetite change (over eating or under eating)

Change in sleep pattern (hypersomnia or insomnia)

Feeling out of control or overwhelmed

Difficulty with concentration

Somatic symptoms such as abdominal bloating, breast tenderness,

headaches, or joint pain

Symptoms are severe enough to interfere with work, school, usual activities, or interpersonal relationships


27

The patient keeps a

premenstrual daily

symptom diary for two to three months

Are the patient's

symptoms

consistent with PMS

No

Evaluate the patient

for

other physical and

psychiatric disorders.

Yes

Are the patient's

symptoms

restricted to the luteal phase

of the menstrual cycle

No

Yes

Do the patient's

symptoms interfere with

daily functioning?

No Premenstrual

symptoms

Yes

Evaluate the severity of

the patient's symptoms and refer to the

diagnostic criteria for

PMS and PMDD

Fig. (5): Diagnosis of Premenstrual Symptoms, PMS, and PMDD. Adopted from Kessel, B. (2000): Premenstrual syndrome

advanced in diagnosis and treatment. Obstet Gynecol Clinic

North Am; 27: 625-39.


28

1-Daily Symptom Reports

Daily prospective rating of symptoms, is initially the

most strong method of confirming diagnosis of symptoms

associated with PMS which typically begin during the late

luteal phase and resolve promptly with the onset of

menstruation, and this is helpful to girls having a complete

prospectively daily report about severity of symptoms

throughout their menstrual cycles (Halbreich et al., 2000).

A number of instruments have been used for rating

PMS symptoms, daily symptom reports by girls remain

the most useful diagnostic tool, they must keep a

menstrual calendar for 3 months on which she carefully

records daily symptoms, rating them on a scale of 0 to 4

with (0) used for no symptoms and (4) used for severe and

debilitating symptoms. Common tools included the

Menstrual Distress Questionnaire (MDQ), the

Premenstrual Assessment Form (PAF), and the

Prospective Record of the Impact and Severity of

Menstruation (PRISM) (Angest et al., 2001).


29

Fig. (6): Premenstrual Daily Symptom Diary.

Adopted from Dickerson et al. (2003): Premenstrual

syndrome. American Family Physician, 76 (8): 1743-1752.

2-Physical examination

History consists of a list of girl premenstrually

related symptoms and how they interfere with her daily


30

life, the timing of each symptom in relation to menses

should be reviewed carefully, other important aspect was

medical history through review of the symptoms of

conditions that can mimic PMS, history of drugs that can

affect mood or hormone levels including birth control

pills, thyroid medications and tranquilizers, should be

taken (Praschak-Rieder et al., 2001).

Physical and pelvic examination will assist in

diagnosing PMS because it will help to rule out possible

causes of the symptoms such as thyroid disorder, cardiac

abnormality, major depression, alcohol problems, drug

abuse, endometriosis, pelvic mass and allergies. Many

women experience both psychiatric disorder and PMS

simultaneously, that chronic minor depression is the most

common condition, the diagnostic challenge is to sort out

those with PMS only, another diagnosis only, or both

diagnosis concurrently (Pearlstein, 2002).

Family history, particularly that related to the

adolescent mother and female siblings is relevant because

the nature patterns of menstruation have a genetic basis

(Deuster et al., 1999).


31

3-Laboratory tests

There is no hormone or laboratory tests that indicate

PMS diagnosis, standard hematology and blood chemistry

profiles are conducted to confirm general good heath

thyroid function test that may be obtained to screen out

thyroid (Freeman, 2003).


32

MANAGEMENT OF

PREMENSTRUAL SYNDROME

Treatment for PMS depends largely on the severity

of the symptoms, and treatment goals should include

building self-esteem and self-control, reduction of stress,

eliminate symptoms, reduce their impact on activities and

interpersonal relationships (Moline & Zendell, 2000).

Non Pharmacological Treatment

Relaxation technique and exercise

Relaxation techniques are helpful tools for coping

with stress and promoting long-term health by slowing

down the body and quieting mind. Techniques generally

entail, refocusing attention, and increasing body awareness

(Lazar, 2000).

When we become stressed our bodies engage in

something called the (fight or flight response) which refers

to changes that occur in the body it prepares to either fight

or run, these changes include increased heart rate, blood

pressure, rate of breathing and 300-400 % increase in the


33

amount of blood being pumped to the muscles, over time

these reactions raise cholesterol levels, disturb intestinal

activities, depress the immune system and leave us feeling

(stressed out) (Holroyd et al., 2001).

On the other hand, the relaxation response refers to

changes that occur in the body when it is a deep state of

relaxation, changes include decreased blood pressure,

heart rate, muscle tension and rate of breathing, as well as

feelings of being calm and in control, reduce the

perception of pain and reduce symptoms. Massage therapy

has also shown to decrease anxiety, depressed mood and

pain immediately after massage sessions, that include

reduced pain, menstrual distress and fluid retention

(Hernandez-Reif et al., 2000).

Exercises the most frequently (18%) used form of

treatment for PMS among alternative therapies, exercise

infrequently prescribed as integral part of a life-style

modification program, exercise founded to be helpful by

possible increasing endogenous production of endorphins

(Strine et al., 2005).


34

Aerobic exercise, even just taking 30 minutes walk

every day, is beneficial in lowering the intensity and

number of premenstrual symptoms, although an aerobic

exercise, yoga releases muscle tension, regulates breathing

and reduces stress, some evidence indicates that exercise

can also reduce fluid retention, negative affect, bloating

and improve problems of concentration, pain, fear and

guilt (Kaur et al., 2004).

Herbal Therapy

1- Evening primrose oil

The most publicized and popular choice treatment of

PMS, is herbal product contains gamma linoleic acid. This

essential omega-6 fatty acid is a prostaglandin precursor.

Some researchers believed that girls in the premenstrual

phase of their cycle had deficiency in gamma linoleic acid,

leading to symptoms that attribute to abnormal

prostaglandin synthesis. Evening primrose oil 3 to 6g daily

has been used to treat breast tenderness, other putative

uses are for irritability, ankle swelling and depressive

symptoms (Bosarge, 2003).


35

2- Chaste berry (Vitex angus-castes)

The fruit of chaste tree, was used for variety of

gynecologic conditions such as premenstrual syndrome,

cyclical breast discomfort, menstrual cycle abnormalities

and dysfunctional uterine bleeding. Chaste berry

therapeutic effects are attributed to its direct effects on

various hormones especially prolactin and progesterone

(Czygan & Mayer, 2005).

Chaste berry reduced some symptoms, especially

breast tenderness, edema, constipation, irritability,

depressed mood, anger and headache. Over the past 50

years, European trials of chaste berry have reported

improvement of premenstrual and menstruation related

disorders (Schellenberg, 2001).

There is no drug interaction with chaste berry, it is

usually well tolerated with only minor adverse effects

reported. Side effects generally include mild

gastrointestinal complaints, dizziness, headache, tiredness,

and dry mouth (Loch et al., 2000).The dosages of chaste

berry used is 20-40mg/day of the fruit extract, fluid extract


36

40 drops/ daily and tincture 35-45 drops 3 times daily, also

have been used (Mills & Bone, 2000).

Pharmacological Therapy

1- Diet therapy

A- Vitamin B6:

Vitamin B6 is a cofactor in neurotransmitter

synthesis, this vitamin has been suggested as a treatment

for PMS on the basis of its role in carbohydrate and

gonadal steroid metabolism, daily doses of 50-100 mg

may reduce severity of premenstrual depressive and

physical symptoms, no more than 100 mg daily because of

the risk of peripheral neuropathy (Hudson, 1999).

B- Calcium:

Calcium supplementation effect against pre-

menstrual symptoms of moderate severity, 1200 mg of

calcium administered daily result in a clinically significant

reduction in cluster of physical and emotional symptoms,

it relieve symptoms of water retention, negative affect

food cravings and pain (Thys-Jacob et al., 1998).


37

C- Vitamin E:

Vitamin E exerts its effect through prostaglandin

synthesis or regulation of central neurotransmitters, it may

relieve some mood and physical symptoms, including

anxiety and breast tenderness with dose 400 Iu daily

(Stevinson & Ernest, 2001).

D- Magnesium:

Girls with PMS have lower levels of magnesium in

erythrocytes and leukocytes despite normal plasma

magnesium levels. Magnesium helps to stabilize blood

sugar levels, acting as a mild laxative, replacing

magnesium in dose 200-400mg, once daily reduced fluid

retention, can reduce constipation that exacerbates

menstrual pain and bloating with adverse reaction mild

somatic diarrhea (Golberg, 2001).

2- Non Steroidal Anti Inflammatory Drugs (NSAIDs)

Non steroidal anti inflammatory drugs effectively

treat the pain component of PMS, administered 3 to 4 days

premenstrual reduce breast tenderness, only naproxen

sodium and mefenamic acid have been evaluated for PMS


38

therapy. The most frequent adverse reactions to NSAIDs

are gastrointestinal with dyspepsia, gastric erosion, peptic

ulcerations and gastrointestinal hemorrhage are much less

common. With dose of 500 mg three times daily, pain-

related symptoms begin in the luteal phase and persist

until menstruation. NSAIDs therapy should be initiated

just prior to the onset of pain and continued until

menstruation ceases if dysmenorrhea is also a problem

(Rickels & Freeman, 2000).

3- Hormones:

A) Progesterone:

Progesterone is the most controversial treatment

regimen of premenstrual syndrome and this is based on the

theory that women who suffer from PMS are deficient of

progesterone in the luteal phase (Freeman et al., 2001).

Recent meta analysis found that progesterone and

other progestogens were no more effective, progesterone

described to be effective, delivered either as a vaginal or

rectal suppository or oral microrized progesterone, that

dosage should be 200-400mg twice daily, given for at least


39

5 days before the expected onset of symptoms (Wyatt et

al., 2001).

B) Estrogens:

Administration of estrogens late in the luteal phase

(to minimize decline in the hormone) relieves pre-

menstrual migraine, for over all management, estrogen

must be given continuously to suppress ovarian activity.

Dose of estradiol 50mg or 75mg with 100mg of

testosterone are inserted (Kessel, 2000).

C) Oral contraceptive pills:

The primary mechanism used for PMS therapy

through its capacity to suppress ovulation, it provides

significant relief for menstrual pain and breast tenderness,

psychological symptoms don't significantly improve, in

addition oral contraceptive may lead to depression in some

girls. Dose with ethinyl estradiol 30 mg plus drospirenone

3 mg (yasmin) alleviated bloating, breast tenderness and

swelling, the drospirenone component has anti androgenic

properties and may also reduce acne (Brown et al., 2002).


40

D) Gonadotropin releasing hormone agonists (GnRH):

A synthetic analog of naturally GnRH which

suppresses ovulation by inhibiting the release of pituitary

gonadotropin, GnRH agonists have been shown to be

more effective in treating behavioral and physical

symptoms of PMS. Some improvements of premenstrual

depression and irritability have been demonstrated for

lower dosages of GnRH (Sundstrom et al., 1999).

Lower dosage 100 mg of GnRH in a form of

intramuscular, subcutaneously and intranasally, can lead to

atrophic vaginities, urinary tract symptoms, decrease of

skin collagen content and chemical menopause. Use of

GnRH more than six months increases risk of

osteoporosis, that needs to add-black therapy with

estrogen and progesterone to minimize long term adverse

effects (Rapport et al., 2002).

E) Danazol

It is an androgenic agent that inhibits gonadotropin

release, by improving mastaligia and not for other

symptoms. Continues danazol thereby also relieves other


41

PMS symptoms, 200 mg twice a day for three months

given during the luteal phase of menstrual cycle is the

recommended dose (O'Brien & Abukhalil, 1999).

4- Anxiolytics

There is evidence that alpazolam taken during luteal

phase may have efficacy in treatment of PMDD in dose of

0.25mg up to 0.5 mg. It increases food craving and caloric

intake in some girls coupled with its mild cognitive,

memory impairing and withdrawal (Landen et al., 2001).

5- Diuretics

Abdominal bloating, edema and weight gain are

most common premenstrual symptoms that initially are

treated by sodium restriction. Diuretics are to be considered,

if dietary alterations are unsuccessful in reducing fluid

retention, and not effective for the treatment of all

symptoms (psychological and somatic) but they provide

some relieve from premenstrual weight gain and bloating,

diuretics may cause intravascular depletion, electrolyte

disturbance, fatigue, headache and irregular bleeding

(Dickerson et al., 2003).


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Spironolacton is the agent of choice because of its

potassium sparing diuretics at dosage of 10 mg daily,

shown to effectively relieve Premenstrual symptoms such

as breast tenderness, fluid retention, it is administrated

only during the luteal phase (Arias, 2002).

6- Antidepressant

Anti depressants are widely used in treating the

mood disturbances related to PMS, It appears to work by

increasing brain chemical (opioids, serotonin) levels,

which are affected by ovarian hormones, its importance is

in the control of mood and emotion (Dimmock et al.,

2000).

Selective serotonin-reuptake inhibitors are the first-

line agents of treating PMS, SSRI has a significant impact

on the treatment of depression and effective disorders, it

works by increasing serotonin levels in the brain by

inhibiting reuptake of serotonin (Pearlstein et al., 2000).

Fluoxetine is the first SSRI at dose of 20 mg or 60

mg daily reducing premenstrual emotional and physical

symptoms, sertraline also at dose 50-150mg daily with


43

side effects usually transient and minor such as dizziness,

headaches, nausea and insomnia (Tana & Gradyweliky,

2003).

7- Surgery

Surgical treatment, principally hysterectomy plus

bilateral oophorectomy, this would remove all ovarian

functions by removing uterus at the same time, A

hysterectomy and bilateral oophorectomy results in the

relief of all genuine PMS cyclical symptoms.

Hysterectomy plus bilateral oophorectomy is controversial

because it's irreversible and associated with significant

risks. Surgery may be considered in severely affected

cases who fail to respond to other therapies and also have

significant gynecologic problems for which surgery would

be appropriate (Wyatt et al., 2000).


44

Fig (7): Treatment strategies for premenstrual syndrome.

Adopted from Lewis SM, Heitkemper MM, Dirksen SR,

(2000): Medical surgical nursing. Boston: Mosby, pp. 1521-

1523.

Education and counseling

Knowledge of possible

causes and treatment

Daily diary

Family understanding

Support groups

Diet

Well balanced

Avoid caffeine,

alcohol

Reduce refined

Carbohydrates

Adequate intake of

vitamin B6

Stress management

Relaxation

techniques

Abdominal

breathing

Mental imagery

Progressive muscle

relaxation

Exercise

Aerobics

Walking

Swimming

Selective serotonin

Reuptake Inhibitors (SSRI)

Antidepressants

Good relief for mood symptoms

Prostaglandin Inhibitors

Administration 2-4 times

Daily at onset of symptoms

Combination oral

Contraceptives

Used for women with no

contraindications

Diuretics

Administration 2-4 during

luteal phase

Other Agents

Tranquilizers and sedatives

Gonadotropin inhibitors

(Danazol)

Evening Primrose Oil ("natural therapy")

NO NPHARMACO LO GIC STRATEGIES

PHARMACO LO GIC STRATEGIES


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NURSING MANAGEMENT

OF PREMENSTRUAL SYNDROME

Nursing management of premenstrual syndrome

starts with understanding, and caring approach, that

acknowledges the reality of what is happening to the girl

who is suffering, and provides knowledge about the

menstrual cycle, the symptoms and their effects. It also

provides reassurance by various support groups for

seeking more information, helpful literature, building self-

esteem, self-control, stress relief, eliminating symptoms,

and facilitating the body's natural healthy process to

increase feelings of well being, and helping girls to feel in

control for PMS (Endicott, 2000).

Nurses must begin any management of PMS or

PMDD with an expression of empathy and support towards

girls so as to acknowledge not only the symptoms she is

experiencing but also the possible cultural stigma that she

may be bearing or trying to avoid (Varney et al., 2004).

Nurse as Educator

1- Health education about premenstrual syndrome:

Nurses are in a prime position to help girls who

needed guidance and support. It is important to begin with


46

the process of building therapeutic communication to

establish trust between nurse and girls. Most girls feel

uncomfortable talking about their body habits and

functions, this trust will alleviate girls anxiety, reservation

and embarrassment in discussing menstrual problems.

Nurses should be aware of culture as well as family values

and previous life experiences of girls (Alderman, 2000).

All adolescent girls need reassurance that

menstruation is a normal function. When nurses are asked

for advice regarding menstrual problems, they have

available opportunity to engage in health teaching

concerning menstrual physiology and hygiene, as well as

the importance of a well balanced diet, exercise, general

health maintenance. Health teaching can dispel any myths

in relation to menstruation and feminity (Wong et al.,

2006).

Nurses are expected to be knowledgeable about

PMS providing girls a name and reason for the feeling that

may be causing her out of control. Providing discussions

of family and friends participation in PMS support group

enables them to develop ways of coping and establish

channels of communication with close family members for

understanding and help during PMS days (Marvan &

Escobedo, 1999).


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Nursing activities are directed to provide an

atmosphere of acceptance and subsequent empowerment

by increasing personal awareness and sensitivity to

individual needs. Nurses should provide actual

information concerning PMS and the current theories on

its etiology and treatment. Explanations help girls with

PMS understand the complexity and ways they can regain

a better sense of control. Girls need to be assured that their

symptoms are real, PMS exists and they are not "crazy".

Providing support to the girls in making life style changes

reduces PMS (Young Kin & Davis, 1998).

Nurses can provide girls information regarding

sexuality and that the promotion of healthy attitudes

towards sexuality will help to empower adolescent girls to

make healthy decisions about sexual behavior. Nurses also

can initiate a dialogue with girls through inquiring them

about pubertal changes, including menstrual patterns and

then gradually guiding the interview toward sexuality.

Mothers are the major source of information on topics of

sex and menstruation for their daughters and therefore it's

helpful to involve mothers in general discussions about

sexual health (Beausang & Razer, 2004).


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2- Health education about diet

Nutritional counseling through general dietary

modification is an area where nurses can be especially

helpful in assisting girls to develop a holistic symptom

management program over time. Nurses should encourage

girls to eat fresh foods rather than processed ones,

maintain balanced nutritional intake, regular eating times,

also eating fresh fruits, and vegetables which contain

vitamins and minerals, foods rich in vitamin B6 such as

liver, egg, and milk. Magnesium has been also successful

in relieving premenstrual mood fluctuations, it presents in

whole grain, sea food, also milk, yoghurt, and cheese are

good sources of calcium, and eating frequent and small

portions of foods high in complex carbohydrates improves

mood symptoms by raising level of tryptophan, (Young,

2002).

On the other hand, nurses should advice girls to

restrict foods containing chocolate and coffee which are

associated with increase in severity of premenstrual

symptoms, particularly anxiety, tension depression and

irritability. As well, sodium restriction has been proposed

to minimize bloating, fluid retention, breast tenderness and

swelling (Wyatt et al., 2000).


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Nurses can encourage girls limit consumption of

refined sugar, salt, red meat, alcohol and caffeinated

beverages. Girls can be encouraged to include whole

grains, legumes, seeds, nuts, vegetables fruits, and

vegetable oils in their diets (Lowdermilk et al., 1999).

3- Health education about exercise & relaxation

technique

Girls complaining from PMS might play a role of

student, sister, mother and care giver, all these social roles

experienced by girls lead to considerable emotional strain.

Nurses must provide girls an opportunity to discuss

stressors in their life that could be exacerbating their

symptoms, also can be learned strategies for managing

time across the menstrual cycle and how to redefine their

roles of mothers, friends, or coworkers that can ultimately

reduce stress (Taylor, 2000).

The nurse should inform girls about stress

management such as relaxation technique and aerobic

exercise, telling her benefits of a regular exercise program

that may help decrease fluid retention, this include

reading, watching television and aerobic activity like

fitness. Walking or gagging exercise also has been found

to increase blood levels of beta-endorphin. Exercise also

reduces stress by providing a time away from home by


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providing a useful outlet for any anger and aggression,

promoting relaxation and helping to sleep at night (Steege

& Blumenthal, 2004).

The nurse has to encourage girls to using such

techniques which are recommended to treat symptoms of

PMS, such as massage, reflexology, Reiki and yoga, with

an explanation of these therapies how to be performed and

possible complications (Long et al., 2000).

Nursing role as a care giver

An empathic relationship with a health care

professional to whom the girl feels free to voice concerns

is highly beneficial. The nurse can encourage girls to keep

a journal to help them identify life events associated with

PMS. Stress reduction education, self-care groups, and

self-care literature can also help girls gain control over

their bodies (Olds et al., 2004).

Nurses first step in assessing PMS is to obtain

history regarding symptoms, history is essential for

arriving at correct diagnosis. Menstrual history includes

age of menarche, regularity and duration of periods, and

number of pads or tampons used. Other areas that may

provide important information helping nurses to assess the

PMS problem accurately, include family history of

menstrual problems particularly related to adolescent


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mothers and female siblings. These are relevant because

the nature and patterns of menstruation have a genetic

basis, past medical history, medication and substance use,

sexual behavioral and other related issues such as weight

changes, nutrition, exercise and sports (Littleton &

Engerbretson, 2005).

One of the most difficult experiences facing the

adolescent girl is the gynecologic examination. She has

often feels of apprehension, and needs continuity of

support in the form of anticipatory guidance. Routine

check up such as cervical screening, physical and pelvic

examinations provide an opportunity for the nurse to

enquire about the girl' menstrual cycle and problems she is

experiencing. The nurse should rule out other possible

causes for the symptoms that the girl is experiencing such

as thyroid disorder, cardiac abnormality and pelvic mass

that could be source of symptoms thought to be related to

PMS and could be discovered on examination (Nelson,

1998).

Nurses in schools and clinics must teach girls how to

use daily symptom diary which is a useful educational

tool, in addition to its diagnostic value. The diary provides

the girl a visual record of the symptomatic intervals with

their onset and resolution each month, which can be

helpful to the girl and her family. The pictorial validation


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of the girl' cycle may stimulate her to schedule activities

so as to minimize stress and negative influences that might

exacerbate her symptoms as well as to be helpful to gain a

sense of mastery over the disorder (Moline & Zendell,

2000).

Improving detection of PMS is a vital role to the

nurse who can encourage girls to report premenstrual

symptoms and keep a prospective symptom diary. For

girls with irregular menstrual cycle or difficulties to keep a

calendar of symptoms, the nurse can recommend daily

measurements of basal body temperature throughout the

cycle, the time of ovulation can be pin pointed using this

method, allowing girls determine their symptoms

occurring during the luteal phase (Yonkers, 1999).

Symptoms management, stress reduction, and health

promoting approaches that include behavioral and

cognitive strategies present additional intervention options

for PMS. Specific nursing activities include simple

relaxation therapy, breathing exercise, stretching exercise,

progressive muscle relaxation and autogenic training.

The nurse should encourage girls to practice exercise,

medication imagery and creative activities to reduce stress

(Smeltzer & Bare, 2004).


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The nurse helping girls to take medications as

prescribed, by providing instructions about the desired

effects of medication, and by enrolling in a PMS group

that meets to discuss problems which may help girl learn

that others recognize and understand what she is

experiencing. Nurses must help the girl to make concrete

arrangements, and to obtain relief when she feels that she

may harm herself. A neighbor friend or family member

should be identified to provide immediate relief, without

question or explanations (McKinney et al., 2005).

Nurses should advice girls who are taking herbs

about the characteristics of these herbs, she should

emphasize that the herb should be pure, safe, effective,

and labeled with the following information: name of the

herb, the part of plant used, expiration date, name and

address of manufacturer. The nurse should inform her also

about important precautions during herbal treatment, these

precautions include: cautions in taking herbs during

pregnancy and lactation, avoiding regular use of large

variety of herbs together, possible stopping of herbal

therapies at least 2 weeks before elective surgery,

reporting adverse side effects to doctor, and learning as

much as possible about used herbs (Eliason & Kruger,

2000).


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Nursing efforts towards empowerment of adolescent

girls are likely to be more effective than efforts toward

compliance, that the nurse should identify the girl

appropriate levels of self-care, whereas the latter implies

the need for girls to simply follow instructions without

acknowledging the adolescent's level of maturity and

ability to take responsibility, and take care of their own

bodies can provide a sense of independence and

fulfillment (Coupey, 2000).

Frye and Silverman (2000) mentioned that, the

nurse must tell girls that although PMS is complex but is

as well highly treatable, and improvement is virtually

certain with combination of several interventions. In

addition, by reassuring girls that PMS affects millions of

girls and helping to alleviate feelings of isolation caused

by symptoms, nurses can take active role that helps girls to

take proper medication as prescribed and provide

instructions about desired effects of medications.

Many girls with PMS have sleep difficulties either

insomnia or excessive sleepiness, the nurse should

encourage these girls to adopt consistent bed times and

wake times not only at least during the luteal phase of the

cycle, but also preferably all month long. Consistent bed

times tend to decrease sleep latency, and an important part

of good sleep hygiene includes keeping a regular schedule,


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limiting caffeine and alcohol consumption after noon and

limiting the use of sedative-hypnotics (Bendich, 2000).

The nurse should encourage sedentary woman about

daily short walk at her own place that will be far more

likely to bring results than starting her a more rigorous

regimen that requires warm-up, wind-down and

calculations of pulse rate. Even basic stretching exercises

can be useful in promoting a general feeling of well being

and reducing stress due to PMS (Blake et al., 2002).

KNOWLEDGE AND PRACTICE OF STUDENT GIRLS REGARDING PREMENSTRUAL SYNDROME

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