Prevalence of premenstrual syndrome and its effect on quality of work life in working women in South India

ABSTRACT

Background:

Premenstrual syndrome (PMS) is characterized by physical and affective symptoms that start during the luteal phase of the menstrual cycle and improve on the onset of the menstrual cycle. The estimated prevalence in India of PMS is found to be 43%, but most studies have been done on adolescent and college-going females. There is a dearth of studies in India done on PMS in working women.

Aims:

The aim of this study is to estimate the prevalence of premenstrual syndrome in working women and determine its association with the quality of their work life.

Methods:

A cross-sectional study was conducted in the city of Kochi and five different groups of professional women were included in the sample population. A total of 600 participants were analyzed for sociodemographic data, premenstrual syndrome using the premenstrual symptoms screening tool and quality of their work life using the work-related quality of life scale. Chi-square test was applied to find the association of categorical demographic parameters with premenstrual syndrome and with quality of work life in women satisfying the criteria for PMS.

Results:

A total of 48% of the participants screened positive for PMS and 35% of working women with PMS had lower quality of work life (P < 0.001). Highest educational qualification, occupation, and sexual activity were significantly associated with PMS and with quality of work life in women with PMS.

Conclusion:

There is a high prevalence of PMS in working women, which significantly affects their quality of work life. There is a need for further research in this area that can propel improvement in policies in the workplace to boost productivity and growth.

Premenstrual syndrome was first introduced by Horney in her paper as “premenstrual tension” in the 1930s.[1] However, the term “premenstrual syndrome” (PMS) emerged in the 1960s as a result of a series of observational reports by Dalton.[2] It was later in the 1980s, that the impact of hormonal changes in the menstrual cycle on mental health was accepted by psychiatrists. Designating PMS as a psychiatric condition continued to be a controversy till the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was published in 1994 wherein it was listed in the appendix.[3] In the next two decades, researchers gathered evidence that there should be a new condition introduced within the spectrum of mood disorders that acknowledged the interaction of menstrual hormones with psychiatric symptoms and morbidity. After that, the research and diagnostic criteria were made for severe and disruptive premenstrual phenomenon and labelled as Premenstrual Dysphoric Disorder (PMDD) in 2013. As per the DSM-5, it is characterized by physical symptoms such as abdominal bloating, abdominal pain, breast tenderness, joint or muscle ache, headache, swelling of extremities, weight gain, and behavioral symptoms such as anger outbursts, irritability, low mood, anxiety, confusion, and social withdrawal. These symptoms occur during the luteal phase of the menstrual cycle, which improve the onset of menstruation. It leads to significant distress and interference with work, school, usual social activities, or relationships with others, confirmed by a daily symptom severity rating for two cycles.[4]

Most Indian research around PMS has been found to focus on prevalence, etiology, risk factors, and association with other psychiatric disorders. Most of the studies have also been focused on adolescents and college students.[5] One of the criteria of PMS is how the symptoms interfere with daily life.[6] In Kerala, females occupy 50% of the workforce in the private sector and 34% in the public sector.[7] However, there is a lacuna in Indian research regarding the effects of PMS on the quality of work life. Quality of work life could be defined as a way an employee considers and evaluates their work in the context of their life. A review of existing literature reveals a few studies in foreign countries concluding that women with PMS experience a lower quality of life.[8,9] This opens up the way for further research regarding PMS in the general population in India. Hence, the aim of our study was to find the prevalence of premenstrual syndrome in working women and its association with quality of work life.

METHODS

The study was approved by the Institutional Review Board of Amrita Institute of Medical Sciences & Research Centre, Kochi, with Approval No. IRBAIMS2020263 on 11-08-2020. A cross-sectional study was done in the city of Kochi during 2020–2021. Five sets of professionals were taken, namely, advocates, healthcare workers, teachers, bankers, and engineers. These occupations were selected as they were working during the coronavirus disease 2019 (COVID-19) pandemic. Establishments, where these professionals worked, were identified within a 10 km radius from our hospital and they were approached for the study. The inclusion criteria for the study were females above 18–30 years, having regular menstrual cycles, and who have been working in the professional sector for the past 12 months. The exclusion criteria were females diagnosed with menstrual disorders, gynecological disorders, chronic medical illnesses, existing psychiatric disorders, past history of urogenital surgeries, history of pregnancy, and females taking oral contraceptive pills. The minimum sample size according to a prevalence rate of 18.4% from an earlier study, calculated for 95% confidence interval and maximum permissible estimate of 20% error of the prevalence rate, was found to be 426.[10] A total of 120 participants of each of the five occupations who fulfilled the inclusion and exclusion criteria were identified and a total of 600 participants were included in the study.

Written informed consent was obtained. Sociodemographic and clinical data were collected using a semi-structured questionnaire with no potentially identifying information. M.I.N.I. 5.0 was administered to rule out participants with preexisting psychiatric disorders.[11] Premenstrual symptoms screening tool (PSST) was administered for assessing the presence of premenstrual syndrome, which indicates the presence of moderate to severe PMS and PMDD according to the symptom severity reported for the past 12 months.[12] For the purpose of this study, those who qualified for moderate to severe PMS or PMDD on the PSST were taken to be positive for PMS, as we have not used DSM-5 in this study to diagnose PMDD, which is a clinical diagnosis requiring a daily symptoms severity rating for 2 months. Work-related quality of life scale (WRQoL) was administered for assessment of the overall quality of work life and its subscales, namely, job and career satisfaction, control at work, stress at work, home-work interface, working conditions, and general well-being. The quality of work life was then interpreted as higher, lower, or average from the scores of the subscales and the overall scale.[13] All statistical analyses were carried out using IBM Statistical Package for the Social Sciences (SPSS) version 20.0 software. Prevalence rate of premenstrual syndrome was estimated in percentage with 95% confidence. Symptom profile and severity of symptoms of premenstrual syndrome were presented in frequency (percentage). The presence of PMS (moderate to severe PMS or PMDD on PSST) was taken as the primary outcome variable and quality of work life (interpretation of WRQoL scores) was the secondary outcome variable. Pearson’s Chi-square test was applied to find the association between categorical demographic parameters with premenstrual syndrome and with quality of work-related life in women satisfying the criteria for PMS. Statistical significance was defined as P < 0.05.

RESULTS

A total of 600 participants were analyzed for this study. The mean age of the participants was 25 ± 2.4 years. Majority of our population were urban residents, having a postgraduate education, and were sexually active. As shown in Table 1, 36.2% of the population was found to have moderate to severe PMS and 12.2% was found to have PMDD, making it a total of 48% (n = 292) who screened positive for PMS (moderate to severe PMS and PMDD according to the PSST). The most common symptom of those with PMS was anger/irritability (99%), with 31% of those with PMS reporting it to be severe in intensity. The symptom most commonly experienced with severe intensity was tearfulness/increased sensitivity to rejection (48%). The highest educational qualification, occupation, and sexual activity had a statistically significant association with PMS, as shown in Table 2.

Table 1.

Distribution of frequency of PMS

PMS		Frequency	Percentage
Yes	Moderate to severe PMS	217	36.2
	PMDD	75	12.2
No	308	308	51.6
Total	600	600	100

Table 2.

Association of sociodemographic variables with PMS

Sociodemographic variables	PMS				P
	Yes		No
	n	%	n	%
Age
<25	95	48.70	100	51.30	0.528
>25	197	48.60	208	51.40
Age at menarche
≤ 13	191	49.90	192	50.10	0.434
>13 years	101	46.50	116	53.50
Highest educational qualification
Graduate	99	42.50	134	57.50	0.016*
Postgraduate	193	52.60	174	47.40
Area of residence
Rural	16	57.10	12	42.90	0.358
Urban	276	48.30	296	51.70
Sexual activity
Absent	101	43.50	131	56.50	0.046*
Present	191	51.90	177	48.10
Occupation
Advocate	64	53	56	47	<0.001*
Banker	74	61	46	39
Engineer	64	53	56	47
Healthcare worker	29	24	91	76
Teacher	60	50	60	50

*P<0.05 is significant.

The quality of work life was found to be lower in 35% of the population with PMS as compared with 19% of those without PMS, which was statistically significant (P < 0.001). As shown in Table 3, all domains of quality of work life were lower in those with PMS, with statistical significance except for home-work interface.

Table 3.

Association of quality of work life and its domains with PMS

Quality of work life	PMS				P
	Yes		No
	n	%	n	%
Quality of work life (overall)
Average	113	38.70%	128	41.60%	<0.001*
Higher	76	26.00%	119	38.60%
Lower	103	35.30%	61	19.80%
Job and career satisfaction
Average	86	29.50%	88	28.60%	<0.001*
Higher	89	30.50%	161	52.30%
Lower	117	40.10%	59	19.20%
General well being
Average	34	11.60%	52	16.90%	<0.001*
Higher	61	20.90%	133	43.20%
Lower	197	67.50%	123	39.90%
Quality of home-work interface
Average	62	21.20%	58	18.80%	0.201
Higher	79	27.10%	104	33.80%
Lower	151	51.70%	146	47.40%
Control at work
Average	88	30.10%	80	26.00%	0.022*
Higher	99	33.90%	140	45.50%
Lower	105	36.00%	88	28.60%
Working conditions
Average	45	15.40%	46	14.90%	0.014*
Higher	114	39.00%	153	49.70%
Lower	133	45.50%	109	35.40%
Stress at work
Average	40	13.70%	46	14.90%	<0.001*
Lower	224	76.70%	178	57.80%
Higher	28	9.60%	84	27.30%

*P<0.05 is significant.

DISCUSSION

In our study, the mean age was 25 ± 2.4 years, and majority of our population were urban residents, having a postgraduate degree, and were sexually active. These findings could be because of the nature of the study population included. The prevalence of PMS in our study was 48% (36.2% moderate to severe PMS and 12.2% PMDD using PSST scale) [Table 1]. This is in line with the meta-analysis done on the pooled prevalence of PMS around the world at 47.8%.[14] However, this finding is not consistent with Indian studies with prevalence ranging from 14.3% to 74.4%.[5] This suggests that PMS prevalence varies between regions. These differences may occur as some studies used the DSM-5 criteria to diagnose PMS and PMDD while other studies used different rating scales to screen for PMS. Even though menstruation is a physiological process, the secrecy, taboos, and myths associated with the menstrual cycle have been part of Indian culture. This could have been the reason for underreporting of premenstrual symptoms in many regions. Another reason for lower prevalence might be that these symptoms could have been overlooked as a part of normal menstruation due to the lack of awareness that premenstrual symptoms can be severe enough to be diagnosed as a disorder. As our study was done in the educated community, awareness regarding PMS might be present which might be the reason for higher reporting. Even though the PSST is a highly sensitive tool (sensitivity 90.9%) and the predictive value of the negative PSST is also high (97.01%), it is also possible that because it is a self-rated scale, it may contribute to a recall bias.[10]

The most common symptom of those with PMS was anger/irritability (99%), and the most common symptom experienced with severe intensity was tearfulness/increased sensitivity to rejection (48%). As per the ACOG criteria, the diagnosis of PMS requires at least one affective symptom and one somatic symptom.[6] Though PMS consists of cognitive, affective, and somatic symptoms, the reason for higher reporting of affective symptoms might be because these symptoms could have affected their interpersonal relationship or quality of life and thus would have been recalled more easily.

In our study, women with PMS had a statistically significantly lower quality of life than women with PMS. The quality of work life was found to be lower in 35% of the population with PMS as compared with 19% of those without PMS (P < 0.001). In a survey done in the United Kingdom among 125 females, it was found that higher premenstrual symptom severity was associated with high work absence.[15] The work-related quality of life scale used in our study has six domains, namely, job and career satisfaction, general well-being, control at work, home-work interface, working conditions, and stress at work. Among these, job and career satisfaction, general well-being, control at work, working conditions, and stress at work were significantly associated with PMS in our study [Table 3]. This is consistent with the study by Hatice Kahyaoglu Sut and Elcin Mestogullari[16] in nurses, which also showed when the severity of the premenstrual symptoms increased, the work-related productivity of the nurses decreased (r = −0.341; P < 0.001). PMS significantly affects how women feel about their job, how capable they feel of making decisions, and how they perceive their working conditions. This reduces their productivity and satisfaction derived from work. In other studies, severity of pain and perceived stress have also been shown to lead to absence from work.[17]

In our study, it was found that education status and occupation had a significant association with PMS [Table 2] and with the quality of work life of women with PMS [Table 4]. In our study, it was also found that among women with PMS, 47% of graduates had lower quality of work life compared with 29% of the postgraduates (P = 0.007) [Table 4]. Higher educational status may lead to better job profiles, salaries, work opportunities, and benefits.

Table 4.

Association of sociodemographic variables with quality of work life in women with PMS

Sociodemographic variables	Quality of work life						P
	Average		Higher		Lower
	n	%	n	%	n	%
Age
≤25 years	43	45.30%	19	20	33	24.7	0.17
>25 years	70	35.50%	57	28.90%	70	35.50%
Area of residence
Rural	4	25.00%	6	37.50%	6	37.50%	0.358
Urban	109	39.50%	70	25.40%	97	35.10%
Highest educational qualification
Graduate	32	32.30%	20	20.20%	47	47.50%	0.007*
Postgraduate	81	42.00%	56	29.00%	56	29.00%
Age at menarche
<=13 years	68	35.60%	54	28.30%	69	36.10%	0.279
>13 years	45	44.60%	22	21.80%	34	33.70%
Sexually active
Absent	40	39.60%	14	13.90%	47	46.50%	0.001*
Present	73	38.20%	62	32.50%	56	29.30%
Occupation
Advocate	21	32.8	22	34.4	21	32.8	0.035*
Banker	30	40.5	25	33.8	19	25.7
Engineer	23	35.9	12	18.8	29	45.3
Healthcare worker	12	41.4	2	6.9	15	51.7
Teacher	27	44.3	15	24.6	19	31.1

*P<0.05 is significant.

Bankers were found to have the highest prevalence of PMS at 61% (P < 0.001) [Table 2]. This finding is novel to our study as the literature search did not reveal studies where different professions were assessed with PMS and it is a place of scope for further research. Various studies have opined that for many years, banks have been going through changes in structure, organization resulting from digitization, and the global economic crisis, which has contributed to an increase in psychological distress among its employees.[18] It has been suggested that stress leads to a state of heightened sensitivity, which, in turn, can increase the perception of the severity of menstrual symptoms.[19]

Interestingly, even though healthcare workers had the lowest prevalence of PMS (29%), it was found in our study that healthcare workers had the highest prevalence of lower quality of work life when compared with other professions (51%, P = 0.035) [Table 4]. Recent studies have shown that the quality of life of healthcare staff is low as it has been affected by increasing shifts, wearing protective equipment during work, increased exposure to infection, and having to stay away from family in quarantine after duties.[20]

In participants who had PMS, lower quality of work life was more prevalent in those who were not sexually active (46%, P = 0.001) [Table 4]. Sexual activity has been shown to have a significant association with PMS in previous studies.[21] Our finding thus needs further evaluation as in our study, sexual activity was defined as any one-partnered sexual activity leading to intercourse and the frequency of sexual activity was not assessed. The impact of PMS on sexual satisfaction was also not assessed in our study.

CONCLUSIONS

From the study, it was found that premenstrual syndrome is highly prevalent among working women, at 48%, with the most common symptom being anger/irritability. Education status, sexual activity, and occupation have a significant association with PMS. The quality of work life is lower in 35% of the women with PMS, which is also associated significantly with their educational status, sexual activity, and occupation. Premenstrual syndrome and premenstrual dysphoric disorder are manageable and treatable. Working women also need to be targeted to identify and treat for the dysfunction caused. Timely education and identification of such symptoms will reduce the stigma, dysfunction, healthcare cost, and improve the quality of life in women.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.