Premenstrual syndrome as reported by Brazilian women

Article Outline

• Abstract
• 1. Introduction
• 2. Materials and methods
• 3. Results
• 4. Discussion
• 5. Conflict of interest
• Acknowledgments
• References
• Copyright

Abstract 

Objective

To describe the perspectives and attitudes of Brazilian women toward premenstrual syndrome (PMS).

Methods

An exploratory study was conducted in 6 major cities: 1 in each geographic region of Brazil and 1 in the Federal District. Participants were women aged 18–40years who consulted at public healthcare services or who were members of staff/faculty at university.

Results

Of 1053 women, 96.1% had heard of PMS; 65.4% considered that all or almost all women experienced the condition; 87.5% stated that symptoms occurred prior to menstruation; and 60.3% thought that they had PMS at the time of the interview. The emotional and physical symptoms most frequently mentioned were nervousness/anxiety (76.4%); mood swings/crying (55.7%); pain, swelling, and tenderness of the breasts (37.3%); and cramps (45.4%).

Conclusion

Premenstrual syndrome was reported by a large number of Brazilian women; actions need to be taken to provide more effectively the specific information required by both lay people and healthcare professionals.

Keywords: Perspective, Premenstrual syndrome, Strategies

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1. Introduction 

Many women regularly experience physical and emotional disturbances in the days immediately preceding menstruation. These disturbances may be grouped together and defined as the premenstrual syndrome (PMS)—a term that refers to a variety of symptoms. The American College of Obstetricians and Gynecologists defines PMS as “a clinical condition characterized by the cyclic presence of physical and emotional symptoms unrelated to any organic disease that appear during the luteal phase of the menstrual cycle and disappear after menstruation or within 48hours of the onset of bleeding” [1]. In the World Health Organization (WHO) International Classification of Diseases, 10th Revision [2], PMS is listed as a physical disorder (N94–3, or “premenstrual tension syndrome”). Previous studies have shown that approximately 20% of women have no premenstrual symptoms, 40% experience symptoms that do not result in problems requiring medical consultation, and the remaining 40% experience symptoms that cause them to seek medical help. In this third group, 5% experience premenstrual dysphoric disorder (PMDD), which is a more severe form of PMS [3], [4], [5].

A study based on telephone interviews with 4085 European and Latin American women found the prevalence of PMS to be lower in the former (33%) than in the latter (46%), despite the Latin American women seeming to be less well-informed and to concern themselves less with this clinical manifestation [6]. The clinical symptoms of PMS result in costs both to the individuals concerned and to society; in a study of women who kept a prospective diary for 2months, 29.6% of participants were found to have PMS, which was associated with an annual cost of US $4500 according to calculations based on health insurance reimbursements and missed working days [7].

Despite the impact of PMS on different aspects of women's lives, few studies in the medical literature focus on women's perspectives and attitudes, particularly in Latin America. The objective of the present study was to describe: (1) the perspectives and attitudes of urban Brazilian women toward PMS; (2) the symptoms provoked by this syndrome; (3) the effects that these symptoms have on women's lives; and (4) the strategies that affected women adopt to cope.

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2. Materials and methods 

In 2008, a descriptive cross-sectional study was conducted on a non-probabilistic sample of women in 6 major Brazilian cities: 1 in each geographic region of the country and 1 in the Federal District (Porto Alegre in the south, Campinas in the southeast, Campo Grande in the mid-west, Salvador in the northeast, Manaus in the north, and Brasilia constituting the Federal District). Participants were women aged 18–40years consulting at public healthcare clinics for non-gynecologic and non-obstetric conditions. In addition, 1 school unrelated to the field of medicine was randomly selected at each university in each area involved in the project. Female university staff and faculty members from the selected schools were enrolled in the study after providing written informed consent.

The cities involved in the present study comprised 4 capital cities of Brazilian states, the Federal District, and 1 non-capital city (Campinas) situated in the state of São Paulo. The municipal human development indexes were 0.591, 0.612, 0.706, 0.791, 0.799, and 0.811 for Salvador,z Manaus, Campo Grande, Porto Alegre, Brasilia, and Campinas, respectively [8]. The selection strategy was adopted to obtain a sample that would include women from different socioeconomic strata. The criteria used to define the strata were those commonly used in Brazilian market research surveys [9]: “A” is the highest socioeconomic class; “B” is middle class; “C” is lower-middle class; “D” is low class; and “E” is the poorest class. All women aged 18–40years who agreed to participate in the study answered a semi-structured, previously tested questionnaire specifically designed for this purpose.

The questionnaire included the following: sociodemographic data; recognition of the existence of PMS; women's perspectives on whether they were currently affected or had previously experienced PMS; identification of the symptoms of PMS and the way in which these symptoms affected marital life, family relationships, and work/leisure activities; the strategies used by women to deal with the symptoms; women's efforts to seek information on and/or treatment for PMS symptoms; and medical consultations related to the manifestations of PMS.

The study was approved by the Institutional Review Board of the University of Campinas and by Institutional Review Boards in each of the participating cities, both at the Municipal Health Departments and at the universities selected to participate.

Prior to commencing data collection, a trained research assistant in each of the participating cities selected, trained, and supervised the interviewers. To ensure the quality and consistency of data, the first 10 questionnaires completed in each city were sent to the coordinating center for review and, whenever necessary, any inconsistencies and/or queries were discussed. After data consistency had been assured, a descriptive analysis was performed and comparisons were evaluated using the χ² test. The relationship between the independent variables and the occurrence of PMS was tested using linear logistic regression. P<0.05 was considered to be statistically significant.

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3. Results 

In total, 1053 women were interviewed: 7.8% were aged 18–19years; 52.8% were aged 20–29years; 34.3% were aged 30–39years; and 5.1% were at least 40years of age. More than half (50.2%) stated that they were white or of African origin; 55.3% were Catholics; 67.1% were currently in paid employment; 40.1% belonged to socioeconomic strata “A” and “B;” 47.8% belonged to “C;” and the other 12.1% belonged to the lowest socioeconomic strata, “D” and “E.” At the time of interview, 54.5% of women were living with a partner; 22.4% had studied only up to elementary-school level; 45.7% had completed high school; and 31.9% had graduated or were attending university.

Most (96.1%) of the women who were interviewed had heard of PMS (data not shown). The majority (78.1%) stated that the condition is related to emotional symptoms, and 24.3% said that it is related to physical symptoms. Most women (87.5%) said that symptoms occur prior to menstruation; in addition, approximately two-thirds (66.2%) responded that all or almost all women experience PMS, and approximately one-third (29.4%) said that symptoms last for up to 7days (Table 1). Half of the 19.3% of participants who stated that not all women have PMS (102 women) thought that having the condition depended on the individual or their metabolism, which differs between women (data not shown). Less than one-fifth of respondents attributed these differences between women to disposition or mood; when asked which women were more likely to have PMS, the most prevalent answer—given by 64.2% of the participants—was those who do not include physical exercise as part of their daily routine (data not shown).

Table 1. Study participants’ knowledge of the premenstrual syndrome.

Question/answer	No. (%)
What is PMS?a
Presence of emotional symptoms	730 (71.8)
Presence of physical symptoms	247 (24.3)
A hormone imbalance	147 (14.5)
A natural part of the menstrual cycle	138 (13.6)
A woman's disease	18 (1.8)
When do the symptoms of PMS occur?a
Before menstruation	889 (87.5)
During menstruation	437 (43.0)
After menstruation	149 (14.7)
Do not know	11 (1.1)
Which women have PMS?a
Almost all women	471 (46.3)
Certain women	246 (24.2)
All women	194 (19.1)
Do not know	56 (5.5)
Not many women	50 (4.9)
For how long do the symptoms of PMS last?
≤4days	470 (46.2)
5–7days	299 (29.4)
>7days	153 (15.0)
Other	36 (3.5)
Do not know	59 (5.8)

Abbreviation: PMS, premenstrual syndrome.

The emotional symptoms mentioned most frequently by the participants were nervousness/anxiety, irritability/anger/aggressiveness, and mood swings/crying, whereas the most common physical symptoms were headache; cramps; and pain, swelling, and tenderness of the breasts (Table 2).

Table 2. Symptoms of the premenstrual syndrome perceived by the women interviewed.^a

More than half of the participants (60.3%) reported having PMS at the time of interview and 18.4% had experienced PMS in the past, although 52.3% of these women reported that their symptoms were not bothersome and 73.1% stated that they did not require medical care. In total, 21.3% answered that they had never had PMS. Furthermore, 61.6% stated that they disliked menstruating, of whom 49.2% said that this was because of PMS or dysmenorrhea. Of the women who declared that they were currently experiencing PMS or that they had done so in the past and who referred to both emotional and physical symptoms, 58.9% stated that the symptoms of PMS affected their relationship with their partner; 52.8% stated that symptoms affected their family relationships; and 42.3% reported an effect on their domestic, professional, and social activities (data not shown).

The strategies used by the women to cope with their symptoms included taking medication; trying to relax, rest, sleep, talk, and take their mind off the situation; and doing nothing. More than half (52.1%) of the women who had experienced symptoms of PMS said that they had discussed the problem with a friend or colleague, and approximately one-third had talked about it with their mother (29.7%) or a physician (35.7%). However, 33.5% of the women who did not talk about PMS said that they had not discussed the matter with others because they felt no need to do so. Of the women who had experienced PMS, the majority had never consulted a physician; however, gynecologists were the physicians of choice for 34.4% of those who had consulted a physician (Table 3). In the group of women who had seen a gynecologist, 39.9% said that the doctor had diagnosed PMS; 23.8% said that they were diagnosed as having a “woman's disease;” and 13.4% were told that they had a hormone imbalance (data not shown). According to the women, the treatments most commonly prescribed for their symptoms involved hormone preparations. In 21.9% of cases, some form of physical activity was recommended, and in a similar proportion of cases the physician recommended doing nothing “because it is normal” (Table 3).

Table 3. Strategies for dealing with the premenstrual syndrome and perspectives on consulting a physician.^a

Abbreviation: PMS, premenstrual syndrome.

Consulting a physician was more common among: women over 35years of age (41.4%); those with more than 12years of schooling (42.7%); those with no partner (41.9%); those who were not religious (47.1%); those who were in paid employment at the time of interview (39.7%); and those who belonged to socioeconomic strata “A” and “B” (40.1%). However, these correlations were not statistically significant (data not shown).

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4. Discussion 

The results may be considered to reflect the perspectives of Brazilian women in medium/large cities with regard to PMS. The level of knowledge about the existence of PMS and its symptoms was high compared with the findings of other studies carried out in Latin America [6]. Results from the present study show that 96.1% of the Brazilian women interviewed had heard of PMS, which is consistent with data from previous studies reporting that most women of reproductive age experience 1 or more premenstrual symptoms in the majority of cycles [10], [11].

The incidence of PMS in the present study was higher than that reported for other Latin American and European countries, and North America [6]. The results do not necessarily mean that the present sample of Brazilian women was more perceptive of the symptoms of PMS but, compared with women from other regions of the world, they may have considered the symptoms to be more troublesome.

Nevertheless, the present findings show that PMS was perceived by the majority of the women interviewed—who reported both physical and emotional symptoms. This finding may help to implement adequate therapeutic management of the condition because physicians should be aware of this fact and strive to treat both the physical and the emotional symptoms, rather than concentrating only on the symptoms that are experienced most frequently.

The effect of PMS on the daily lives of the women interviewed was reflected in all of the activities covered in the questionnaire—confirming the effect of the condition on aspects of women's lives such as employment, and family and personal relationships. These data are compatible with previous findings that also highlighted the social and economic impact of PMS symptoms on women's lives [5]. The most common emotional and physical manifestations of the syndrome were experienced by more than 60% of the women and were similar to those reported in other studies: nervousness/anxiety; mood swings/crying; pain, swelling, and tenderness of the breasts; and cramps [5], [11]. No major differences were found between the present study findings (60.3%) and the numbers of European (Italy 71%, Spain 78%, UK 78%) and Latin American (Brazil 72%, Mexico 75%) women affected by PMS [5].

In general, the women sought ways to relieve their PMS symptoms, as reflected by the findings that one-third had used some type of medication and that a smaller proportion had tried some form of activity to help improve symptoms. The fact that they discussed the problem also showed their interest in the subject and reflected their efforts to find ways to alleviate their symptoms. The percentage of women with PMS symptoms who consulted a physician to discuss the condition was less than 40%, and in the majority of cases the doctor in question was the woman's gynecologist—indicating that the gynecologist is the physician of reference for such women. The relatively small proportion seeking medical help probably reflects the fact that more than 50% of women reported that their symptoms were not severe; however, it may also reflect the finding that, in most cases, information and treatment were not provided by a professional.

Halbreich [12] reported a delay in the diagnosis of premenstrual symptoms and stated that a woman consults, on average, 3.8 physicians over 5.3years before being diagnosed with PMS. Most of the participants (85%) in that study reported having tried at least 1 treatment for PMS, and 45% would have liked more help than they received. Of the women with severe premenstrual symptoms, less than 50% had sought medical help, and 50% stated that none of the treatments had helped; in addition, 89% of the women with PMDD had not been diagnosed as having the disorder [12]. Such findings may indicate difficulties in communication between women and their gynecologists, either because the former are unable to describe their symptoms adequately or because the latter also lack sufficient knowledge of the routine manifestations of this clinical condition.

In the present sample, the women with PMS who were more likely to seek medical attention were those from a higher socioeconomic stratum and those with more years of schooling. It is reasonable to speculate that better-educated women have greater access to information about PMS and, consequently, are more likely to seek medical help. Moreover, those who belong to a higher socioeconomic stratum have better access to medical care. These data also show that providing women with more information about PMS, its causes, and therapeutic options—in addition to including specific care for women with PMS as part of healthcare programs—may help to promote more equal access to means of dealing with these symptoms for women from different socioeconomic and cultural strata.

In Brazil, implementing medical training that includes information and scientific data on PMS is also important, because in one-fifth of the cases in which women sought medical help the professional stated that there was nothing to be done because the symptoms were “normal.” Physicians and other healthcare professionals also need to undergo training to meet the demand by patients for advice and services, highlighting a need for continued medical education programs and more detailed information on treatment options and management. Nonetheless, the results of the present study show that many women already follow some recommendations for improving the symptoms of PMS, such as performing physical exercise and controlling their diet.

The present study was limited in that the interviews were conducted at large urban centers and, consequently, reflect the knowledge and perspectives of urban Brazilian women only. However, we conclude that symptoms of PMS were common in the study sample and that actions should be taken to provide more effectively the specific information required by both lay people and healthcare professionals about this condition.

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5. Conflict of interest 

The authors have no conflicts of interest.

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Acknowledgments 

The study was partially funded by Bayer Schering Pharma, Brazil. The sponsor was not involved in the development of the study or in the preparation of the manuscript.

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References 

1. ACOG Practice Bulletin, No. 15. Premenstrual Syndrome. Obstet Gynecol. 2000;95(4):
   • View In Article
2. World Health Organization. International Classification of Diseases. Tenth edition. Geneva: WHO; 1992;
   • View In Article
3. Ramcharan S, Love EJ, Fick GH, Goldfien A. The epidemiology of premenstrual symptoms in a population-based sample of 2650 urban women: attributable risk and risk factors. J Clin Epidemiol. 1992;45(4):377–392
   • View In Article
   • MEDLINE
   • CrossRef
4. Johnson SR. The epidemiology and social impact of premenstrual symptoms. Clin Obstet Gynecol. 1987;30(2):367–376
   • View In Article
   • MEDLINE
   • CrossRef
5. Pool S. PMS/PMDD negatively affects daily life activities. Meeting report. PharmacoEcon Outcomes News. 2005;476:3–4
   • View In Article
6. Foidart JM, Shulman LP, Buchwald S. Awareness of premenstrual syndrome and premenstrual dysphoric disorder terminology in European and Latin American countries compared with the United States. Obstet Gynecol. 2005;105:21S–22S
   • View In Article
7. Borenstein JE, Dean BB, Endicott J, Wong J, Brown C, Dickerson V, et al. Health and economic impact of the premenstrual syndrome. J Reprod Med. 2003;48(7):515–524
   • View In Article
   • MEDLINE
8. Institute of Applied Research in Economy. Report on Human Development in Brazil. Brasil: IPEA; 2001;
   • View In Article
9. Brazilian Association of Research Institutions. Economic classification criteria Brasil: 2006 and 2007. http://www.abep.org/?usaritem=arquivos&iditem=23. Accessed August 26, 2009.
   • View In Article
10. Sveinsdóttir H, Bäckström T. Menstrual cycle symptom variation in a community sample of women using and not using oral contraceptives. Acta Obstet Gynecol Scand. 2000;79(9):757–764
    • View In Article
    • MEDLINE
    • CrossRef
11. Wittchen HU, Becker E, Lieb R, Krause P. Prevalence, incidence and stability of premenstrual dysphoric disorder in the community. Psychol Med. 2002;32(1):119–132
    • View In Article
    • MEDLINE
12. Halbreich U. The etiology, biology, and evolving pathology of premenstrual syndromes. Psychoneuroendocrinology. 2003;28(Suppl 3):55–99
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (145 KB)
    • CrossRef