the relationship of premenstrual syndrome …premenstrual syndrome may negatively affect women,...

Journal of Caring Sciences, 2015, 4(3), 179-187doi:10.15171/jcs.2015.018http:// journals.tbzmed.ac.ir/ JCS

* Corresponding Author: Özlem Aşcı (PhD), email: [email protected].

Copyright © 2015 by Tabriz University of Medical Sciences

The Relationship of Premenstrual Syndrome Symptoms with MenstrualAttitude and Sleep Quality in Turkish Nursing StudentÖzlem Aşcı1, Fulya Gökdemir1, Hatice Kahyaoğlu Süt2, Fatma Payam1

1Department of Nursing, Artvin Health High School, Artvin Çoruh University, Artvin, Turkey2Department of Women's Health and Nursing, Faculty of Health Sciences, Trakya University, Edirne, Turkey

ARTICLE INFO ABSTRACTArticle Type:Original Article

Introduction: Symptoms induced by premenstrual syndrome (PMS) adversely affectthe women in reproduction period and decrease their quality of life. In literature, it is acommon opinion thought that PMS could be associated with both sleep quality andmenstrual attitudes. However, there has been no sufficient number of studies to definein what ways the PMS symptoms are correlated with sleep quality and menstrualattitudes. The objective of this study was to examine the relationship of PMSsymptoms with menstrual attitude and sleep quality.Methods: The data were collected from 183 nursing students at Health School ofArtvin Çoruh University by using a cross-sectional design. Voluntary studentscompleted a questionnaire involving socio-demographic characteristics, PremenstrualSyndrome Scale (PMSS), Menstrual Attitude Questionnaire (MAQ), and PittsburghSleep Quality Index (PSQI).Results: Average age was 19.9 (1.8). The study determined a positively significantcorrelation between score of PMSS and mean scores of PSQI (r=0.306; P<0.001), anda negatively significant correlation between score of PMSS and total mean score ofMAQ (r=-0.317; P<0.01). Similarly, multiple linear regression analysis showed thatPSQI total score (β=5.412; P<0.001) and MAQ total score (β=-27.455; P=0.001)significantly affected total score of PMSS.Conclusion: The intensity of PMS symptoms is associated with poor sleep quality andnegative menstrual attitudes. Determining the methods of coping with PMS andstrengthening the young girls on this subject may enhance their quality of future life.

Article History:Received: 22 May. 2015Accepted: 2 Jul. 2015ePublished: 1 Sep. 2015

Keywords:AttitudesMenstruationPremenstrual syndromeSleep

Introduction

Starting with menarche and continuing untilmenopause, menstruation is a physiologicalcondition.1,2 It is known that three out ofevery four women may experience slightphysical and mental disorders beforemenstruation.1 However, menstrualdisorders may become more serious in somewomen and especially the problems likedysmenorrhea, menstrual irregularity andpremenstrual syndrome may negativelyaffect women, their families and the socialenvironment.2-4

Being encountered in many women ofreproductive age, the Premenstrual

Syndrome (PMS) is a set of physical,cognitive, emotional, and behavioralsymptoms that periodically emerge in theluteal phase of the menstrual cycle andrapidly recover with the start of menstruationor a few days after the menstruation.2,4-7 It isknown that PMS especially affect the youngand emerge in adolescence at the rate of 25%and around the ages of 14-15 years in averageor 2 years after the menarche.1,2,7

Approximately 80-95% of women ofreproductive age complain about PMSsymptoms to varying degrees. On the otherhand, about 5-10% of women experienceserious PMS that requires a treatment.1,2,5,7

The studies conducted with university

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180 | Journal of Caring Sciences, Sep 2015; 4 (3), 179-187 Copyright © 2015 by Tabriz University of Medical Sciences

students in Turkey have reported that theprevalence of PMS varies between 5% and79.9%.2,5,7-9

Epidemiology, etiology, andpathophysiology of PMS have not beenknown, yet. In literature, it is a commonopinion that hormonal, genetic, psychosocial,and lifestyle factors may be effective ondevelopment of PMS.1,2,8 Additionally, it isreported that factors such as menstrualattitudes, the culture, education of theindividual’s mother and her workingcondition and menstrual problems such asdysmenorrhea may also affect the prevalenceof PMS.8 Furthermore, a limited number ofstudies have examined the relationshipbetween menstrual attitudes and PMS. WhileSong et al., stated that individuals having anegative attitude towards menstruationexperienced PMS more severely, Guvenc etal., expressed that individuals, whoconsidered the menstruation as a debilitatingphenomenon and denied the menstrualsymptoms, experienced PMS much more.10,11

There are more than 200 PMS symptomsexperienced.2 Depression, anxiety, fatigue,irritability, outbursts of anger and cryingspells, disturbance in social relations,difficulty of concentration and confusion,headache, joint pain and abdominal pain,edema and weight gain, changes in libidoand appetite, gastrointestinal symptoms,tenderness on breasts, sleep problems likeinsomnia and hypersomnia are amongexamples of these symptoms.1,5,8,12

Women with PMS frequently complainabout poor sleep quality because PMS is oneof the physiological disorders that maychange the sleep quality by causing sleepproblems such as insomnia, hypersomnia,exhaustion, fatigue, difficulty ofconcentration, and nightmares. Especiallywomen with severe PMS have greater sleepproblems.1,5,13

PMS is an important problem whichdecreases women’s self-confidence, impairsphysical, mental and social health, causes thelabor loss, negatively affects the daily life,

sleep quality, social activities, familyrelations, attendance on lessons andacademic achievement and consequentlydecreases the quality of life.1,3-5,8 Thus, thedetection of women with PMS, determinationof their frequent symptoms, and thedefinition of relevant variables increasingthese symptoms may guide the interventions(such as giving information, developingpositive attitudes, and increasing the copingmechanisms regarding the menstrual cycleand PMS) to be planned in decreasing thePMS-induced problems.4,8 In literature, it is acommon opinion thought that PMS could beassociated with both sleep quality andmenstrual attitudes.5,10,11 However, there hasbeen no sufficient number of studies to definein what ways the PMS symptoms arecorrelated with sleep quality and menstrualattitudes.

The purpose of this study was to revealthe relationship between the PMS symptoms,menstrual attitude and sleep quality innursing students receiving education at ahigh school.

Materials and methodsThis cross-sectional, descriptive and

correlational study was conducted in theprovince of Artvin between 01 September2014 and 30 November 2014. Population ofthe study consisted of nursing studentsreceiving education at Health High School ofArtvin Çoruh University. In the study, it wasaimed to reach the whole population withoutusing the sample selection methods. Therewere 254 nursing students receivingeducation at the high school between thedates when the study was conducted.However, 71 students were not included inthe study due to reasons such as theeducation mobility, class nonattendance andrejection of participating in the study. Thestudy was completed with n=183 femalestudents who constituted 72% of thepopulation. While the inclusion criteria ofthis study were as follows; being single,being woman and accepting to participate in

PMS, menstrual attitude and sleep quality

Copyright © 2015 by Tabriz University of Medical Sciences Journal of Caring Sciences, Sep 2015; 4 (3), 179-187 |181

the study, failure to precisely fill out thequestionnaire and scales was accepted as theexclusion criteria.

The data of the study were collected byusing personal information form2-5,8-11, whichwas prepared by researchers in accordancewith literature and involved socio-demographic and menstrual characteristics,as well as the Premenstrual Syndrome Scale(PMSS), Menstrual Attitude Questionnaire(MAQ), and Pittsburgh Sleep Quality Index(PSQI) whose validity and reliability wereverified.

Being developed by Gençdoğan in orderto determine the severity of premenstrualsymptoms based on the Diagnostic andStatistical Manual of Mental Disorders thirdedition (DSM III) and Diagnostic andStatistical Manual of Mental DisordersRevised fourth edition (DSM-IV-R); PMSS isa valid and reliable assessment instrument.1

This five-point Likert scale is commonly usedin Turkey. The scale involves 44 items to bemarked by the individual by taking "to havethis condition the week before menstruation"into consideration. PMSS consists of ninesubscales (Depressive affect, Anxiety,Fatigue, Irritability, Depressive thoughts,Pain, Changes in appetite, Changes insleeping habits, bloating). The Cronbach'sAlpha reliability coefficient is 0.75 for theoriginal scale and 0.97 for this study. Whilethe lowest score to be obtained from the scaleis 44, the highest score is 220. It is acceptedthat as the score obtained by the individualfrom the scale increase, the intensity of PMSsymptoms increases, as well.1,5,8,9,11

Being developed by Brooks-Gunn andRuble in order to measure the menstrualattitudes, MAQ was adapted into the Turkishculture by Firat et al., in 2009.14,15 The Turkishversion of the scale is graded in five-pointLikert type and consists of totally 31 itemsand five subscales (menstruation as adebilitating event, menstruation as abothersome event, menstruation as a naturalevent, anticipation and prediction of theonset of menstruation, denial of any effects of

menstruation). Highness of the mean scoresobtained from the scale signifies that theattitude towards the menstruation ispositive.11,15 The Cronbach's Alpha reliabilitycoefficient is 0.79 for the Turkish form of thescale and 0.61 for this study.

PSQI was developed by Buysse et al., andadapted into Turkish by Ağargün et al., PSQIis a self-report scale involving totally 19 itemsand seven subscales (subjective sleep quality,sleep latency, sleep duration, habitual sleepefficiency, sleep disturbances, use of sleepingmedication, and daytime dysfunction) thatevaluates the sleep quality and disorderwithin the last one month.16,17 Eachcomponent is evaluated on the basis of 0-3points. Total score varies between 0-21points. While those with a PSQI score of ≤ 5are evaluated as having a good sleep quality,those with a PSQI score of >5 are evaluatedas having a poor sleep quality.17

Post hoc power analysis was performedbased on minimum correlation coefficient (r=-0.232) between total score of PMSS and totalscore of MAQ. The power of this study wasfound as 0.88 based on this correlationcoefficient with an alpha level of 5% andsample size of 183. Statistical analysis of thedata was performed by using the SPSS 20.0statistical package software. The data werepresented as mean (standard deviation) andfrequency n (%). Spearman correlationanalysis was used to evaluate the correlationsbetween PMSS, PSQI, and MAQ. Effect ofmenstrual attitudes and sleep quality onPMSS scores was investigated by multiplelinear regression analysis. The limit value ofthe statistical significance was accepted as P< 0.05.

Before starting the study, an ethicalapproval was received from EthicsCommittee of the Rectorship of Artvin ÇoruhUniversity. The data were collected in such away to coincide with extracurricular times ofstudents. Before collecting the data, tworesearchers informed students, who werevoluntary to participate in the study, aboutthe purpose and period of the study and

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written consents of all participants wereobtained.

Results

This study was completed with 183nursing students who were single, had anage average of 19.9 (1.8) and stated mostly amoderate-low level of income (84.2%). Themenarche age and menstruation durationmean of students were determinedrespectively as 13.3 (1.2) and 5.6 (1.4). 90.7%of students stated that they had regularmenstruation with periods of 21-35 days.

Table 1 illustrates the mean scoresobtained by students from PMSS and itssubscales, as well as standard deviations andvalue ranges. In the study, a positive,significant and linear correlation wasdetermined between total score of PMSS andmean score of PSQI of students (r=0.306,P<0.001) Considering the results of theSpearman correlation analysis between meanscores of PMSS subscales and the total meanscore of PSQI (Table 2); it was observed thatthere were positive and significantcorrelations between total mean score ofPSQI and all subscale mean scores except forthe subscale "changes in appetite", Meanscores of PSQI increased with the increase ofthe total and subscale mean scores of PMSS(except for the subscale "changes inappetite").

As a result of the study, a negative,significant and linear correlation wasdetermined between total mean score ofPMSS and total mean score of MAQ (r=-0.232, P=0.002) Negative and significantcorrelations were determined between all thesubscale mean scores of PMSS and meanscores of MAQ subscales "Menstruation as adebilitating event" and "Anticipation andprediction of the onset of menstruation".While all the subscale mean scores of PMSSincreased, the mean scores in these twosubscales of MAQ decreased. Similarly,negative significant correlations weredetermined between mean scores ofsubscales "Depressive affect, Fatigue,

Irritability, Depressive thoughts, Bloating" ofPMSS and total mean score of MAQ (Table 2).

Negative significant correlations weredetermined between mean scores of thesubscales "Irritability, Pain, Changes inappetite, and Bloating" of PMSS and meanscore of the subscale "Menstruation as anatural event" of MAQ and mean score of thesubscale "Bloating" of PMSS and mean scoreof the subscale "Denial of any effects ofmenstruation" of MAQ. Accordingly, whilemean scores of the subscales "Irritability,Pain, Changes in appetite, and Bloating" ofPMSS increased, mean score of the subscale"Menstruation as a natural event" of MAQdecreased. Similarly, while the mean score ofthe subscale "Bloating" increased, mean scoreof the subscale "Denial of any effects ofmenstruation" of MAQ decreased (Table 2).

Effect of menstrual attitudes and the sleepquality on PMSS scores was investigated bymultiple linear regression analysis. Similarlyto the correlation analysis, it was showed thatPSQI total score (P<0.001) and MAQ totalscore (P=0.001) significantly affected PMSStotal score (Table 3).

Discussion

This study, conducted in order todetermine the relationship between the PMSsymptoms and menstrual attitudes and sleepquality, was completed with 183 singlenursing students in the late adolescenceperiod.In the study, while the menstrual attitudeswere evaluated by using MAQ, the sleepquality was assessed by using PSQI. Thesetwo assessment instruments are valid andreliable assessment instruments which havebeen commonly used in both Turkey anddifferent countries.5,11,16-18 In a studyevaluating the sleep quality in women withsevere PMS through polysomnographic andquantitative electroencephalographymeasurements; anxiety was observed to havea strong effect on sleep quality and it wasreported that controlling the affective



Table 1. Distribution of total and subscale mean scores of PMSS (n=183)

Mean ( SD) Minimum-Maximum 95% ConfidenceInterval

Total score of PMSS 114.6 (37.8) 44-220 109.1 – 120.1Subscale score of PMSS

Depressive affect 19.2 (7.6) 7-35 18.1 – 20.3Anxiety 14.4 (6.5) 7-35 13.5 – 15.4Fatigue 17.4 (6.1) 6-30 16.5 – 18.3Irritability 14.3 (5.9) 5-25 13.5 – 15.2Depressive thought 16.5 (7.4) 7-35 15.4 – 17.6Pain 8.6 (3.2) 3-15 7.0 – 8.0Changes in appetite 8.6 (3.9) 3-15 8.0 – 9.2Changes in sleeping habits 7.0 (3.3) 3-15 6.5 – 7.5Bloating 9.3 (4.1) 3-15 8.7 – 9.9

Table 2. Results of the Spearman correlation analysis between PMSS andMAQ and PSQI (n=183)

Total and Subscale scores of PMSSDepressive

affectAnxiety Fatigue Irritability Depressive

thoughtPain Changes in

appetiteChanges in

sleepinghabits

Bloating Total

PSQI total r 0.267a 0.266a 0.232b 0.208b 0.233b 0.369a 0.130 0.306a 0.207b 0.306a

MAQ subscaleMenstruation as a

debilitating eventr -0.270a -0.173c -0.369a -0.270a -0.266a -0.174c -0.157c -0.219b -0.275a -0.317a

Menstruation as abothersome event

r 0.009 0.081 -0.036 0.007 0.059 0.022 -0.015 0.011 -0.048 0.012

Menstruation as anatural event

r 0.080 0.078 0.130 0.192b 0.073 0.213b 0.163c 0.108 0.239b 0.144

Anticipation andprediction of the onsetof menstruation

r -0.322a -0.161c -0.378a -0.497a -0.258a -0.321a -0.323a -0.218a -0.433b -0.404a

Denial of anyeffects of menstruation

r -0.040 0.045 -0.066 -0.070 -0.020 -0.044 -0.031 -0.073 -0.223b 0.075

MAQ total r -0.198b -0.069 -0.260a -0.211b -0.155c -0.088 -0.121 -0.140 -0.271a -0.232b

Note. ap < 0.001, bp <0.01, c p <0 .05

Table 3. Effect of menstrual attitudes and sleep quality on total scores of PMSS

Unstandardized Coefficients t pBeta Std. Error

PSQI total score 5.412 0.967 5.594 <0.001MAQ total score -27.455 7.894 -3.478 0.001Adjusted R2 %16.9

symptoms in women with PMS wouldincrease the subjective sleep quality.19 Intheir study on female university students,Cheng et al., determined a positivesignificant correlation between PMS andPSQI scores.20 In the same study, the sleepquality was reported to be poor in 60.5% ofgirls with PMS and in 40.7% of girls withoutPMS. Comparing the relationship betweenthe period when women with PMS have no

symptoms and the period when theirsymptoms exacerbate, Baker and Colraindetermined that women showed apsychomotor retardation and became moretired and sleepy in the period when thesymptoms increased. 21 In a studyconducted by Ozişik Kahraman et al., onfemale students receiving education at ahealth high school, they determined asignificantly poor sleep quality in 75.6% of

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girls with PMS and in 58.8% of girls withoutPMS.5 In the same study, a positivecorrelation was reported between totalscore of PMSS and mean score of PSQI.There was a positive significant correlationbetween total score of PMSS and scores ofPSQI, which was in accordance withliterature. In girls with PMS, the sleepquality worsened and as the PMSsymptoms exacerbated, the sleep quality(except for the appetite change) negativelychanged, as well.

In this study, there was a negativesignificant correlation between the generalattitudes towards menstruation,considering the menstruation a debilitatingevent and anticipation and prediction of theonset of menstruation, and complainingabout the severity and symptoms of PMS.There was a higher rate of complainingabout severity and symptoms of PMS inthose displaying negative attitudes towardsmenstruation, considering the menstruationa debilitating event and failing to predictthe changes concerning menstruation onthemselves. In parallel with this study, Songet al., stated that negative menstrualattitudes in nursing students were related tothe severity of PMS and Guvenc et al.,reported that PMSS scores weresignificantly higher in those considering themenstruation a debilitating event.10,11 Inliterature, it remains in the forefront thatpositive and negative attitudes towardsmenstruation are effective on women'sperceiving and complaining aboutphysiological and psychological symptomsin the menstrual period.15,22 However, it isdifficult to interpret this difference sincethere is a limited number of studiesexamining the relationship of menstrualattitudes with complaining about PMS. Inaddition, PMS symptoms may be the causeof menstrual perception changes and thechange in an individual’s menstruationperception may also cause the PMSsymptoms to be felt in an excess orexaggerated way. The future studies may

focus on to what extent the menstrualattitudes affect PMS on the basis of therelationships revealed in this study.

This study revealed that there was anegative significant correlation betweenscores of the subscales Depressive affect,Fatigue, Irritability, Depressive Thoughtsand Bloating and total scores of MAQ.Experiencing the symptoms of bloating,fatigue, irritability, depressive thoughts anddepressive affect more frequently in thepremenstrual period was related withnegative menstrual attitudes. In parallelwith this study, Lu revealed that women’sattitudes towards menstruation wererelated with physical, cognitive, behavioral,and psychological symptoms in thepremenstrual and menstrual phases.18 Inthis study, there was a negative significantcorrelation between scores of the subscales"Irritability, Pain, Changes in appetite andBloating" and the score of the subscale"Menstruation as a natural event" andbetween the score of the subscale "Bloating"and the score of the subscale "Denial of anyeffects of menstruation". This relationshipcould be interpreted as follows; individualsnot considering the menstruation a naturalevent experience the symptoms ofirritability, pain, changes in appetite andbloating more intensely and individualsexperiencing the symptoms of bloatingmore intensely, on the other hand, have ahigher tendency to deny the effects ofmenstruation. Chaturvedi and Chandrareported attitudes regarding thepremenstrual experiences and disturbingsymptoms were related with debilitatingand bothersome attitudes.23 Kısa et al.,reported that students, who thought thatthey have insufficient knowledge aboutmenstruation (70.7%) and had negativereactions against menstruation (69.6%),experienced the PMS more frequently.8Sönmezer and Yosmaoğlu determined thatwomen with dysmenorrhea did notconsider the menstruation a natural eventand they felt physiological and



psychological symptoms such as pain,cramp, nausea and weakness moreintensely than women withoutdysmenorrhea.24 As severity ofpremenstrual and menstrual symptoms inyoung girls increases, negative attitudestowards menstruation increase; whichconstitutes a never-ending vicious cycle.18,24

It is recommended that educationalinterventions for helping young girls tocope with PMS should aim to bring inpositive menstrual attitudes.

This study has some limitations. The firstone is that even though the study includedstudents coming from different cities ofTurkey to receive education, it wasconducted at a high school in only oneprovince. The second one is that the samplegroup consisted of students receivingmedical education and the data were basedon self-report instead of prospective reports(such as PMS diaries) or clinicalmeasurements (such as polysomnography)because receiving medical education mighthave either enabled students to declare thechanges on themselves more easily orcaused them to be exaggerated orprejudiced. Additionally, the fact that thedata collection tools in this study were validand reliable and the medical personnel inthe clinic suggested they were cheaper andmore efficient in diagnosis enabled theassessment and interpretation of the data.These limitations should be taken intoconsideration while interpreting the data.

Conclusion

PMS symptoms had a positive relationshipwith sleep quality and a negativerelationship with menstrual attitudes.Considering the menstruation a debilitatingevent and failing to predict the changesregarding menstruation were related withcomplaining about the severity andsymptoms of PMS. As the complaints aboutthe symptoms of fatigue, irritability,depressive thoughts and bloating increased,the menstrual attitudes became more

negative. Significant correlations presentedin this study may be guiding in planningeducational interventions aimed at copingwith PMS symptoms, decreasing thecomplaints about poor sleep quality causedby PMS and developing positive menstrualattitudes. In addition, determining andchanging the reasons behind the negativemenstrual attitudes in female students mayenable us to decrease the symptoms causedby PMS and the prevalence of PMS.Determining the methods of coping withPMS and strengthening the young girls onthis subject may enhance their quality offuture life.

Acknowledgments

This study did not receive grant from anyinstitution or organization. We would liketo thank all the participants.

Ethical issues

None to be declared.

Conflict of interest

The data of this study were presented at the14th National Nursing Student Congress asa poster in 22-26 April 2015.

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