Introduction
Premenstrual syndrome (PMS) is a disorder characterized by emotional, physical and behavioural symptoms in women of reproductive age that increase the severity of the menstrual cycle during the luteal phase and subsides within a few days after the onset of menstruation.1, 2 The global prevalence of women of reproductive age who experience PMS is 47.8%. About 20% of these women suffer symptoms that are severe enough to interfere with their everyday activities, while the rest of the women suffer mild to moderate symptoms.3 According to recent Indian studies, 14.3%–74.4% of the general population reported having PMS.4 Symptoms of PMS can be categorized as mild, moderate and severe which can range from emotional and behavioural issues like depression, irritability, anger, crying spells, anxiety, confusion, social withdrawal, poor concentration, sleep disturbance, changes in thirst and appetite to physical issues like breast tenderness, abdominal bloating, weight gain, headache, swelling of the extremities and aches or pains.4, 5, 6 These symptoms peak one week before the menstruation and then subside once the onset of menstruation.7 Severe PMS affects women, making it difficult for them to engage in daily activities at school and in their social and familial lives.5 The pathophysiology of premenstrual syndrome is complex and remains unclear. PMS is likely to be influenced by the action of progesterone on neurotransmitters. A variety of factors may cause PMS, including genetics, abnormal hypothalamic-pituitary-adrenal (HPA) axis function, changes in glucose metabolism, insulin resistance, elevated prolactin levels or sensitivity to the effect of prolactin, psychological variables and lifestyle changes like sleep, nutrition, exercise, stress and personal preferences.3, 4 PMS may have an impact on everyday activities, interpersonal connections, productivity at work and quality of life in terms of one's health. Additionally, it can lead to a greater need for specialized medical treatment.8 Many women prefer non-medical approaches for treating PMS, primarily due to their desire to avoid the adverse effects of the medications.9 Exercise, dietary changes, stress reduction, cognitive behavioral therapy and medications are all part of managing PMS.5 The American College of Obstetricians and Gynaecologists (ACOG) guidelines recommend non-pharmacologic therapy as the first line of treatment for all women experiencing PMS.3 Physical activity is seen as a useful alternative to medication in the management of premenstrual symptoms and has been linked to enhancing well-being throughout PMS episodes.10 Exercise and nutrition management are currently advised methods of coping with PMS. These are key non-pharmacological treatments that can be modified and are frequently mentioned as a means of controlling PMS.9 Other advantages of exercise include increased general health, socialization chances and a potential reduction in depressive symptoms. These advantages may all work to lessen the severity of PMS symptoms.10 Even though women suffer from PMS, some coping strategies help in reducing symptoms. This includes exercise, rest, sleeping, body massages, listening to music, drinking hot beverages & herbal tea, taking a hot shower, applying hot packs, using analgesics, caffeine intake, diet alteration, taking herbal medicines, drinking alcohol, smoking cigarettes and make one self-busy on other activities.11
There are several studies done in other countries but there is a lack of literature in the Indian population. Therefore, this study aims to determine the relationship between PA and PMS among college students.
Materials and Methods
We conducted a cross-sectional study to determine the relationship between premenstrual syndrome (PMS) and physical activity (PA) among female college students in India. The study was conducted between May and July 2023. In this study, 500 female college students consented to participate. The participants received information regarding our research and those who agreed to participate were included in the sample. Responses from participants were anonymous and kept confidential.
Inclusion criteria
In this study, female college students aged between 18 to 30 years old, who consented to participate and students with regular menstrual cycles were included.
Exclusion criteria
In this study, students with incomplete data, psychiatric disorders, and current pregnancy or childbirth were excluded.
The questionnaire comprised three parts. Part one was used to collect demographic characteristics which include age, education, address, height, weight and BMI. Part two was used to collect data on PMS. Premenstrual Syndrome Scale (PMSS) a 40-item Likert scale with three subscales (physiological, psychological and behavioural) was used to assess the severity of premenstrual syndrome among the participants. The minimum and maximum score is 1 -5 for each symptom. The PMS Score was generated using the combined score from three subscales. The lowest score is 40 and the highest score is 200. If the score is 1 - 40 it is considered as ‘No symptoms’, a score from 41 - 80 is considered as ‘Mild symptoms', a score from 81 - 120 is ‘Moderate symptoms' and 121 – 160 is ‘Severe' and score from161 - 200 is considered as ' Very Severe’. Additionally, the participants were also questioned about their coping mechanisms related to PMS.11, 12 Part three was used to collect data on PA. Global Physical Activity Questionnaire (GPAQ) developed by WHO was used to assess the PA level among participants. The questionnaire consists of 16 questions (P1 to P16) which gather data on physical activity participation in three domains as well as sedentary behavior. The domains are (a) Activity at work (b) Travel to and from places (c) Recreational activities. According to the GPAQ cut-off values the participants were categorized into a high, moderate and low level of PA.13, 14 Participants were contacted through a proper channel and the Google form link was circulated through WhatsApp
All the study materials have been reviewed and approved by the Srinivas Institute of Physiotherapy research ethical committee.
Statistical analysis
Descriptive statistical analysis was carried out for demographic characteristics and individual parameters. The study presented the prevalence and categorical variables in terms of frequency and percentages, while the continuous variables were described using the mean ± standard deviation. The Spearman's ratio was used to find the relation between PMS and PA. The p-value < 0.05 was considered significant. Data were analyzed by using the SPSS software (SPSS Inc.; Chicago, IL) version 26.0.
Results
A total of 500 female college students were recruited. false shows the Socio-demographic characteristics of the subjects. The mean age of participants was 21.3±1.8 years. Among the total participants, more than half of the individuals had a normal BMI (59.6%). Regarding the level of PA, 58.6% comes under low followed by 23% moderate and 16.8% high.
Concerning PMS severity, 41% of students experienced moderate PMS severity, 28.8 % had mild severity, 24.4% had severe PMS and few participants (4.4%) reported a very severe level of PMS.
Table 1
Socio-demographic characteristics
In our study, the PMS scale was used to score using three subscales: physiological, psychological, and behavioral. Table 2 shows that, among the physiological symptoms, 90.8% of participants reported experiencing severe abdominal cramps, followed by skin color changes, rashes, and pimples (84.8%). Table 3 presents the psychological symptoms, with 93.6% of students severely affected by mood swings. Table 4 highlights the behavioral symptoms, where 82% of participants lack interest in their usual activities.
Table 2
Frequency of premenstrual physiological symptoms of the study participants.
Table 3
Frequency of premenstrual psychological symptoms of the study participants.
Table 4
Frequency of premenstrual behavioural symptoms of the study participants.
Table 5
Coping strategies of participants for premenstrual syndrome.
Various coping strategies were followed by the participants, as shown in Table 5 , with relaxation and meditation being the most common (41.6%), followed by listening to music (33.6%), applying hot packs (29.6%), and sleeping (16%).
Table 6
Relation between the various domains of PMS
The Pearson correlation coefficient was used to find the relation between the various domains of PMS. There was a positive correlation (p < 0.05) between physiological and psychological symptoms, physiological and behavioral symptoms, as well as psychological and behavioral symptoms. (Table 6)
Table 7 shows the relation between PA level and individual score of three subscales of PMSS. The Spearman’s ratio was used to find out the relation. The study reported a significant correlation (p < 0.05) between behavioral symptoms and PA level. However, there is no statistically significant correlation between PA and overall components of PMS.
Discussion
A cross-sectional study was conducted to determine the relationship between the PA and PMS among college students which included 500 participants with a mean age of 21.3±1.8 years. The participants selected were college students in which 59.6 % of participants had normal BMI.
In our study, the PMS scale was scored based on three subscales (physiological, psychological and behavioral). Among these, all participants had at least one PMS symptom. In physiological symptoms, 90.8% of participants reported experiencing severe abdominal cramps followed by skin color changes, rashes and pimples (84.8%), generalized aches and pains (83%), muscle and joint pain (81.6%) and food cravings (81.4%). Regarding psychological symptoms, a majority of students, 93.6% were severely affected by mood swings. In behavioral symptoms, 82% of participants show a lack of interest in usual activities.
A study done by Chen Z et.al. showed that the most common symptom was fatigue, 46.8%, followed by headache (26.4%), gastrointestinal symptoms (15.1%), breast tenderness (7.0%) and bloating (4.6%). As for the psychological symptoms, the most common symptom was cannot concentrate (22.8%), followed by depression (19.5%/), feeling out of control (20.0%), anxiety (20.0%) and irritability (17.7%).15
There are various coping strategies followed by the participants (Table 3) in which relaxation and meditation account for 41.6% followed by listening to music (33.6%), applying hot packs (29.6%) and sleeping (16%). A study by Eshetu et.al., reported various coping mechanisms like taking rest (67.6%) and sleeping 335 (60.7%) were most common followed by applying hot packs (29.5%) and taking anti-pain drugs (28.1%).11
Our study showed the relation between the various domains of PMS. There was a positive correlation (p < 0.05) between physiological and psychological symptoms, physiological and behavioral symptoms, as well as psychological and behavioral symptoms. A similar study by Erbil et.al. showed that sleep quality was positively correlated with PMS and its subscales scores. Sleep changes were the strong predictor, followed by depressive thoughts and mood and abdominal bloating for PMS.16 Also, a study by Abu Alwafa et.al. revealed a significant relationship between physical and behavioral symptoms (p = 0.001).17
Our study reported a significant correlation (p < 0.05) between behavioral symptoms and PA level. However, there is no statistically significant correlation between PA and overall components of PMS. A similar study by Kroll-Desrosiers et al. also found no association between PA and total PMS score.18 In contradictory, a study by Kawabe et.al. reported that young women with high PA have milder symptoms of PMS.9
There are certain limitations to this study where the study relied on self-reported data for both PMS symptoms and physical activity levels, which can introduce subjectivity and recall bias. Also, no information is provided on other factors that may influence PMS symptoms such as diet, medication use and menstrual history. According to the questionnaire we used GPAQ only measures recent physical activity and may not reflect long-term activity levels. Self-reported PMS symptoms can vary monthly, so a prospective study tracking symptoms over several months may be better.
Conclusion
There is no significant correlation between overall premenstrual symptoms and physical activity however behavioral symptoms of PMS and PA levels are significantly correlated.
Acknowledgement
The authors would like to thank the Institute of Physiotherapy, Srinivas University and all the students who agreed to participate in the study.
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