AL OF ADQLESCERIT HEALTH C 1989;10:369-375

KEY WoRDS

Premenstrual symptoms Dysmenorrhea

The premenstrual syndrome (PM), as defined in adults, consists of a cluster of behavioral, emotional,

From the North Shore University Hospital and Cornell Unizwsity Medical College, New York.

Presented in vart at the 1987 meetings of the American Pediatric Society and the kociety fop Pediatric Reskk Anaheim, CA, April, 1987.

Address reprint requests to: Martin Fisher, M.D.. Division of Ad- olescent Medicine, Department of Pediatrics, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030.

Manuscript accepted December IS, 1988.

0 Wety for Adolescent Medicine, 1989 A.. _ . 369

published by Elsevier Science Publishing Co., Inc., 655 Avenue ot the Americas,, New York, NY 10010 m.9 70/89/$3.50

first few days after mews

OA how these sym the daily life and work of those

Many authors state that esse female has some symptom(s) of have developed stricter criteria that decreases the incidence to 2040% (6-9). More

e reported that PM

a rating scale, the Pre

changes ti mood and behavior, especially depres- sive changes, which may occur in over 50% of women.

There is little im the literature reg whether adolescent females experience th@ premen- strual symptoms as adults. Although some studies report that PMS increases with age, others r-disagree (2,61$,9,11,16). Based on the theories currently being

370 FlSHER ET AL. JOURNAL OF ADClLESCRhJT LTH CARC VU;. 10, No. 5

Meth0fh

Subjects

The PAP was administered to female patients and friends in the waiting room of the Five Towns Ad- olescent Health Service, a general health facility for teenagers located in a middle to upper-middle class suburb of New York City. This health service fs used predominantly by female adolescents 16- 18 years of age, presenting for sexuality-related or gynecologic concerns (18). The PAP forms were distributed to 207conaecutive consenting subjects. The questionnaire was explained in detail to each subject. The forms were completed anonymously in the waiting room during the months of Septem- ber 1985 through May 1986. A cover sheet included with the PAF asked each subject to provide demo- graphic data (including age, race, religion, school level, parental education, and reason for the visit) and a complete menstrual history (including reg- ularity, length, and &aw of period; severity, fre- quency, and medications for cramps; current phase of cycle; and intercourse history, oral con- traceptive use, and pregnancy).

The Premenstrual Assessment Po

The PAF was developed in 1982 to reflect the variability of symptoms described in the premenstrual period (12-15). Its use has been reported in over 9tKl adult women and its validity has been described in detail (12-15,17). The PAP consists of 95 items describing premenstrual changes in mood, behavior, and physical condition. Each item is rated on a six-point scale for severity of change from the usual (nonpremenstrual) state to the premenstrual state. Subjects are instructed to consider their physical, behaviorial, or mood changes to be part of the premenstrual period if they appear or change during the premenstrual period, do not exist in the same form or severity immediately prior to the premenstrual period, and disappear or return to the usual state during the full menstrual flow. Each of the 95 possible premenstrual changes are described using six severity levels from “no change” to “extreme change” (Table 1).

Data Analysis

The 207 completed questionnaires were coded, com- puterized, and analyzed using a statistical program developed specifically for the PAF. Specific types of changes at specified levels of severity were deter-

Table 1. Definitions of the Ratings of Severity of Change from Usual Nonpremenstrual State for the 95 Items of the Premenstrual Assessment Form”

1. Not applicablenot present at all, or no change from usunal level.

2. Minimal change-only slightly apparent to you, others would probably not be aware of change.

3. Mild change-detinitely apparent to you and perhaps to others who know you well.

4. Moderate change-clearly apparent to you and/or others who know you well.

5. Severe change=-very ap nt to you and/or others who know you well.

6. Extreme chang+-the degree of change in severity is so different from your usual state that it is very apparent to you and even people who do not know you well might notice.

“Source: References 12-15.

mined for each 5 items, and diagnostic cat- egories of prem change were established for each patient based on her response to each item. These diagnostic categories were developed by Hal- breich et all. in accord with the Research Diagnostic Criteria of Spiker (12~13,J9). Categories of sic change included general discomfort and water-re- tention symptoms, fatigue, and automonic physical

nd behavior social func- ect could be

classified as having none, some or all of changes. Chi-square analysis was used to dete the demographic and menstrual variables associate with premenstrual changes in our adolescent study group and to compare our fmdings to those of pre- vious studies in a

Results

isto a mean age of 17.6 years

( f 1.71 SD). They were predominantly white (89%) and most were Catholic (55%) or Jewish (32%). Fifty-nine percent were in high school, 28% in college, and 13% not in school. Eighty-six per- cent of their parents had graduated from h school and 46% had attended college. Ninety-five percent of subjects reported definitely (76%) or possibly (19%) having heard of PMS prior to par- ticipating im the study. Eighty-five percent of sub- jects were Adolescent Health Service patients and 15% were “friends.” Subjects did not differ signif- icantly from the general Adolescent Health Service

Table 2. Over on emte, severe, or

PHYSICAL CHANGES

General discomfort symptoms Backache/joint sti#ness/muscle ache Abdominal discomfo:tlpain Headache or migraine

Percent indicating moderate, severe, or extreme change

39.1 31.4 27.2

Weigght gain

Fatigue

Take naps during the day Decreased energy/fatigue Sleep too much/difficulty getting up

Autonomic physical cbaqes Urinate more frequently Cold/more sensitive to temper,. tire

change Dizziness/faintness/numbness

CHANGES IN MOOD AND BEHAVIOR

Impaired social functioning Tendency to “nag” or quamel Family/friends notice moods Want to be alone Less desire to talk or move

Depressive changes Feel “sad” or “blue” Feel depressed Tend to be fearful/weep/cry Decreased self-esteem

Impulsive behavior Outbursts of irritability/temper Episodes of impulsive behavior Lack of self-control Become violent (break, hit)

“Source: References 12-15.

41.5 40.3 24.3

37.5 34.3 30.7

23.8

23.4 17.5

41.1 39.2 25.9 25.5

38.2 36.9 33.3 25.2

39.5 17.5 15.6 15.0

specific category.

372 Iw&iER irr AL. JOURNAL OF ADOLESCENT HEALTH CARE Vol. IO, No. 5

Table 3. Categories of Change Demonstrated by 207 Adolescents and 154 Ad-&s Completing the Premenstrual Assesswnt Form

Percent change

Adolescents Adults’

W&r-Me&ion symptoms Fatigue Autonomic physical changes

Changes in mood and behavior Impakd social function “MajoP depressive changes “Minor” depressive changes hnpulsive behavior

No sign&ant changes

No suitable subtype

‘Sowce: References 12,13. “p < 0.05.

74.4 68.2 49.8 61.p 32.4 22.7 26.6 21.4

49.8 34.4b 47.3 45.5 18.4 18.8 37.7 25.Sb

3.8 2.6

7.2 11.7

which were each reported by significantly more adolescents.

Variables &ate ge Ch&quare analysis was performed to determine whether any demographic or menstrual variables were associated with premenstrual changes in our adolescent subjects. The variables associated with premenstrual physical changes are presented in Ta- ble 4 and those associated with premenstrual changes in mood and behavior in Table 5. who were categorized as having greater strual physical changes (Table 4) were more likely

heard of PMS, have dysmenorrhea od (as evidenced by greater sever-

ency and/or medication use for menstrual cramps) and to not be currently on an oral contra- ceptive. Similarly, those who were categorized as having greater changes in mood and behavior (Table 5) were more likely to be white, in college, of higher socioeconomic status (as evidenced by father having graduated college), to have greater fkequency and severity of menstrual cramps, and to not be on an oral contraceptive. Each of these reported variables

significant at the p C t were tested but found physical or emotional

included chronologic age, gynecofogic age, mother% education, reason for visit (i.e.,

bent versus friend), amount of bleeding during menstruation, current phase of cycle, and history of Pregnancy.

Discussion The adolescents who participated in our study, most

evaluating adolescents. Althoug strual distress (dysmenorrhea) has been weU studied in teenagers (20,211, no previous studies have looked specifically at premenstrual large number of teenage fe is the first to show that perception, experience the same symptoms as adult women. One pre adolescents, which included preme toms in assessing other a tory# also suggests that important in teenagers, but the authors did not at- tempt to compare their finding to those reporte adults (22).

The classification of premenstrual s been controversial in the medical the concept of a single Premenstru been restricted to a small minority ing specific criteria, the idea that several different syndromes, each comprising multiple may be found in a large number proposed recently (10,ll). The our study, the Premenstrual As 15) specifically evaluates the latter, 1 presence and severity of 95 different s classifying them into several distinct categories. Thus, it is possible that a strictly defined premen- strual syndrome may be rarer in adolescents than in adults, while the presence of any particular physical and emotional symptom may be equivalent in the two age groups. Among the adolescents, our study, general discomfort and water-retention symptoms were the most commonly reported phys- ical categories of change, tion and depression were reported categories of change in mood and behavior. Impaired social function was significantly more com-

Race te (n = 184)

Nonwhite (n = 23) Heard of PMS

Defhwy (n = 153) ProbabIy (PI = 39) Never [n = IQ)

Frequency of cramps Always (M = 89) Sometimes (n = 102) Never (n = 15)

Severity of cramys None (n = 26) Mild (n = 50)

oderate [n = 78) Severe (n = 46)

Medication for ceamps HQ@~?J’ period (n = 37) Someties ,(n = 90) Newer (n = 72)

Oral contraceptives currently used Yes (n = 46) No (n = 157)

General diSCQmfQti (%)

7a.a 39.1

77.8 61.5 70.0

90.V 63.7 53.3

53i3. 56. 85.9 87.@

89. I” 76.7 65.3

6o.Q 79.0

Water retention (%)

.53,ab 17.4

75.5.7” 30.8 60.0

7O.P 34.3 40.0

38.F 30.0 51.3 78.3

70Jb 54.4 33.3

41.3 52.2

Autmmmic chmges (%) Fatigue (%)

2.8.Rn 32.4 8.7 17.4

32.7’ 36.6 7-T 23.1

110.6) 20.0

38.2 47-r 17.6 21.6 20.0 20.0

19.T I9.T 6.0 XI.0

25.4 33.3 7.8 56.5

46.P 51.4a 27.8 3Q.O 16.7 26.4

8.7 1B.B 32.5 ,369

“p < 0.05. “p c O.OP. ‘p c 0.001.

t a differemce hn

important effects on moO

sometimes a part of mid&

3 Fl!SHER FZI’ AL. JOURNAL 0F ADO Vol. as, NQ. 5

hfajor depressive

Race white (?I = 184) Nonwhite (n = 23)

Education High school (n = 123) college(fl = 57) Notinschoal(n = 27)

Father graduated con- Yes(n = 59) No (8 = 138)

FPequency of cramps Alwaye(n = 691 so-es (n = ICQ Never (n = 15)

Severity of ceamps None (n = 26) Mild (n = 50) Moderpte (n = 78) severe (?I = 46)

Ofal contraceptives currently Yes& = 46) No (II = 157)

‘p < 0.05. “p < 0.01. ‘p < 0.001.

50.0” 67.9 51.1 39.1 26.1 47.8 39.1 26.1

43.1’ 61.V 46.3 39.8 61.4 80.7 61.4 a.6 37.0 55.6 40.7 25.9

50.8 76.2b 56.0 44.1 46.3 96.3 47.8 35.s

6q.r 75.r 64.r 47.2”

ii:;

57.8 40.2 29.

66.7 33.3 3%

30.8” 57.7 30.8 26.9 40.4 60.0 40.0 32.0 51.3 6y.2 52.6 34.6 63.0 73.9 67.4 56.5

26.1b 45.8 .6’ .r 63.5 70.7 .8 0

symptoms pqxxtively instead of de- on retrospestive recall (25,245). This

, dng daily logs, will likely find a place in future studies of adolescents as a method of de- creashg the more subjective nature of the ret-m- spec% reports. Other authors have develo

objectively studying bloating undoubte

We are aware that the subjects of OUT r-middle class patients and

health service, may not be rep- escent populations. In fact, our

ar in socioecono

and researchers who evaluate s should view the physical and

filldingS.

1. Vahdtaiti JL. Premenstrual syndrome. N Engl J Med 1984~11:1371-3.

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