A cross-sectional study on risk factors of premenstrual syndrome among college-going students in Pune

Introduction

Premenstrual syndrome (PMS) is one of the most common disorders experienced by women throughout their reproductive age. The American College of Obstetrics and Gynecology (ACOG) defines PMS as a combination of physical and psychological symptoms that are clinically significant during the luteal phase of the menstrual cycle. These symptoms typically improve or disappear within a few days after the start of menstruation. In three consecutive cycles, symptoms emerge five days before menses and vanish four days after the beginning of the menstrual cycle, ranging from mild to severe [1]. Several studies have reported the severity of PMS by using Rudolf Moose’s menstrual questionnaire. It is a precise tool comprises of 46 symptoms that are used to diagnose and assess the severity of PMS symptoms [2].

PMS is characterized by recurrent physical, cognitive, emotional, and behavioral symptoms that occur at the beginning of menstruation and usually disappear shortly before it begins [3]. Breast tenderness, cravings for certain foods, an increase in appetite, pain, fatigue, water retention in some parts of the body, and acne are among the most common physical symptoms of PMS [4]. In an Egyptian study, the most common PMS symptoms reported among university students were fatigue (34.8 %), mood swings (28.9 %), anxiety (24.1 %), irritability (21.7 %), and heavy aching legs (19 %) [5]. Most participants in an Indian study cited physical discomfort (52 %) and irritation (50 %) as their primary symptoms [6]. According to a study conducted among university students in Pakistan, 81.7 % commonly experience irritability as a symptom of PMS. Furthermore, the study highlighted that a majority (81.5 %) of female participants identified stress as an exacerbating factor in their daily routines [7]. They often experience symptoms such as depression, irritability, change in sleep pattern, abdominal bloating, and backache, which can affect their work capacity and academic performance among college-going students [8], 9]. Among university students, academic stress has been linked to risky behaviors such as excessive drinking and drug use, poor eating habits, and poor sleeping habits, all of which have been reported to increase risk of PMS [10].

Though PMS etiology is still undetermined, studies have found several factors responsible for it, including genetic, environmental, psychological, and diet [11]. Both an Indian study [12] and corresponding research conducted in the USA13 involving women aged 18–25 years revealed consistent findings and concluded that women with a BMI of 25 kg/m² are at high risk of experiencing PMS symptoms. In addition to this, several other factors, such as the consumption of birth control pills, a sedentary lifestyle, and the presence of stress, are linked with an increased risk of PMS symptoms [13].

The diet of college students has a considerable impact on the experience of PMS. Consuming a balanced and nutrient-rich diet while avoiding excessive unprocessed foods, refined fats, salt, and stimulants can potentially mitigate PMS symptoms, promoting overall health during this phase [14].

Despite the negative impact of these risk factors on students’ health and academic quality of life, little attention has been given to them, which may indicate the need for implementing preventive measures [8], 9], 11]. Thus, the objective of the study was to examine the food intake of women with and without PMS and identify lifestyle triggers for the condition.

Materials and methods

Results

A total of 360 participants ranged from 18 to 24 years, with a mean age of 20.8 ± 1.91 years. 202 participants were postgraduate students (56.1 %), while 158 were undergraduate students (43.9 %). Anthropometric data indicated that the mean height of the participants was 157 ± 6.7 cm, weight was 53 ± 11.07 kg, waist was 30.39 ± 4.22-inch, and hip was 37.17 ± 4.63 inch. The mean BMI and Waist-to-hip ratio was 21.5 ± 4.47 kg/m2 and 0.81 ± 0.55, respectively, with 75 (20.8 %) participants being overweight and 17 (4.7 %) obese.

The majority of the study participants, 119 (33.1 %), were rarely physically active, 67 (18.6 %) were as very few engaged in light to moderate physical activity daily, 170 (47.6 %) preferred yoga and 51 (14.6 %) were doing cardio exercises. No association was observed between participants’ demographic and anthropometric characteristics with PMS.

The prevalence of PMS was 51.4 %. Thus, 185 (51.4 %) participants were identified as with PMS using the MDQ [17]. For further analysis, participants were grouped into two groups – PMS and non-PMS.

Table 1 shows a comparison of anthropometric measurements between PMS and non-PMS groups, revealing no statistically significant differences. Additionally, no significant association was observed between BMI classification and the presence of PMS (p=0.13).

Table 2 shows an association between the menstrual history of participants and PMS. A positive significant association was found between the flow of menstruation (p=0.048) and the occurrence of symptoms (p=0.001) with PMS. Notably, 47 (25.4 %) individuals who encountered heavy menstrual flow exhibited a higher prevalence of PMS symptoms compared to 25 (14.3 %) without PMS. Moreover, 79 (42.7 %) PMS-affected participants experienced symptoms within 1–7 days preceding menstruation, indicating a more frequent occurrence in contrast to symptoms emerging 7–14 days before menstruation.

Table 3 demonstrates an association between participant’s lifestyle habits and PMS. A significant association was observed between consumption of prescribed medicines (p=0.05) and weekdays sleep duration (p=0.014) with PMS. Fifteen (8.1 %) participants who consume contraceptive pills and 70 (40 %) participants who sleep for 6–7 h on weekdays are likely to experience PMS. However, no association was observed with other lifestyle habits.

Table 4 illustrates an association between the consumption of foods and PMS. The table shows that the frequent category represents food items consumed daily or weekly, while the infrequent category represents food items consumed monthly or rarely. A significant association was observed between the consumption of nuts (p=0.05), oilseeds, cakes, and pastries (p=0.05), and pizza (p=0.03) with PMS, in comparison to 50 (27.03 %) who rarely consume nuts and oilseeds, 135 (72.97 %) who consume nuts and oilseeds often experience PMS symptoms. Additionally, 79 (42.71 %) participants who frequently consumed cakes and pastries and 71 (38.8 %) who frequently consumed pizza, pasta, and burgers are more likely to experience PMS symptoms than those with infrequent consumption.

The multivariable logistic (Table 5) revealed that participants who consume contraceptive pills (OR=3.42, 95 % CI: 1.15, 10.21, p=0.02) are at higher odds of experiencing PMS symptoms. In addition to this, sleep duration for more than 7 h (OR=2.88, 95 % CI: 1.16, 7.13, p=0.02) and 5–6 h on weekdays (OR=2.77, 95 % CI: 1.09, 7.03, p=0.03) are at higher risk to experience PMS symptoms. A significantly higher risk was observed in participants whose cakes and pastries (OR=2.37, 95 % CI: 0.32, 8.37, p=0.00), pizza, pasta, and burger (OR=4.67, 95 % CI: 0.41, 0.958, p=0.031) consumption was frequent.

Discussion

This study was conducted with the aim of exploring the risk predictors of PMS. The prevalence of PMS among the participants was 51.4 %. The most commonly reported symptoms were anxiety, irritability, fatigue, tearfulness, and depressed mood. Anthropometric measurements demonstrated that mean weight, BMI, waist circumference, and WHR were within normal range, and the mean WHR of participants from both groups was at a marginal cut-off <0.85 per the recommendations of the World Health Organization [19]. However, no significant difference was observed between PMS and non-PMS group participants in weight, BMI, waist circumference, and WHR. As opposed to our findings, several studies have demonstrated that BMI and WHR have been significantly associated with the occurrence of PMS [13], 20], 21]. When physical activity was assessed, it was observed that most study participants from PMS and non-PMS groups were sedentary.

The menstrual cycle is a crucial indicator of reproductive health among young women. Number of days of menstrual flow correlated significantly with PMS (p<0.01). It was observed that the occurrence of PMS was more prevalent among participants with longer days of menstrual flow. Studies have reported similar findings that menstrual flow, duration of menstrual cycle, and irregularities of menstrual cycle were associated with PMS [22], 23].

Oral contraceptive pills (OCP) intake was a risk for the occurrence of PMS (OR=3.42, 95 % CI: 1.15, 10.21, p=0.02). Studies have shown that several mild side effects of OCP use may be responsible for the occurrence of PMS [24].

Duration of sleep (OR=2.77, 95 % CI: 1.09, 7.03, p=0.03) predicted the risk for occurrence of PMS. Sleep is essential to maintain the circadian rhythm. Sleep disturbances, including less sleep (<7 h/day) and irregular sleep duration, may lead to hormonal imbalances and hormonal shifts during the luteal phase. However, this linkage has been supported by a few studies [25], 26].

Intake of nutrients plays an essential role in a woman’s menstrual health. Among the present study group, we have observed a trend of eating junk/street foods rich in refined flour, sugar, fat, and salt. A significant association was seen between the occurrence of PMS and the consumption of sweet snack foods (cakes and pastries) and savory junk foods (pizza and burgers). Also, these sweet snacks (OR=2.37, 95 % CI: 0.32, 8.37, p=0.00) and savory foods (OR=4.67, 95 % CI: 0.41, 0.958, p=0.031) were found to be risk predictors for PMS. A high MDQ score was linked with a higher intake of foods containing sugars, fat, salt, and refined flour. Similar findings have been shown by studies from the UAE [27], Iran [28], and India [17]. These studies have observed that consuming foods containing high amounts of simple carbohydrates and fats was associated with an increased risk of PMS. An inverse association of oilseeds intake with the occurrence of PMS has been observed. A similar association has been reported in a study done on young Indian women of a similar age group [17]. Nutrient intake and dietary practices play a crucial role in PMS, supported by findings from various studies. Healthy food choices, intake of a balanced diet, and a healthy lifestyle have been associated with lower incidences of PMS [26].

Strengths and limitations

The strength of the present study is the larger sample size, which was collected in a shorter time. This study provides the estimated prevalence rate of PMS among university students in Pune. We have collected data regarding a wide range of lifestyle factors that are closely related to college life.

In the study, it was not possible to determine whether these risk factors are causes or effects of PMS, which is the limitation of this study. Since participants’ dietary information was collected using a qualitative questionnaire, we did not consider the food portion size, which might have contributed to a better understanding of the study findings. Another limitation of the study is that participants filled out the questionnaire; there might be a risk of over- and under-estimation of data that can be biased by social desirability.

Conclusion

Among college students aged 18–24, this research found that PMS is a prevalent menstrual disorder, with a frequency of 51.4 %. The severity of symptoms was predominantly observed for students with consumption of contraceptive pills, sleep duration, and frequent consumption of pizza, pasta, burgers, cakes, and pastries were associated with risk of PMS.

For a more profound understanding of PMS risk factors, future studies should focus on exploring hormonal, molecular, and genetic factors. Further research is warranted to investigate how an individual’s dietary choices influence the occurrence of PMS symptoms. A comprehensive analysis of participants’ food choices during the luteal phases of the menstrual cycle is crucial for identifying specific foods that impact PMS.