Premenstrual Dysphoric Disorder Severity and Associated Factors Among Female College Students in Nekemte Town: An Institution‐Based Cross‐Sectional Study

ABSTRACT

Background

Premenstrual Dysphoric Disorder (PMDD) is a severe form of premenstrual syndrome characterized by marked affective, behavioral, and physical symptoms that occur during the late luteal phase of the menstrual cycle and substantially impair daily functioning. Despite its considerable impact on the health and well‐being of women of reproductive age, evidence on the prevalence of probable PMDD and its associated factors among female college students in Ethiopia remains limited. This study aimed to assess the prevalence of screening‐positive probable PMDD and identify factors associated with it among female college students in Nekemte tow.

Methods

An institution‐based cross‐sectional study was conducted among 375 randomly selected female college students, with 368 participating (response rate: 98.13%). Participants were selected using a stratified random sampling technique from twelve colleges categorized by field of study. Symptoms of probable PMDD were assessed using the Premenstrual Symptoms Screening Tool for Adolescents (PSST‐A), a standardized screening instrument based on DSM criteria. Multivariable logistic regression was performed to identify factors associated with screening‐positive probable PMDD. Variables with a p‐value < 0.25 in the bivariable analysis were included in the multivariable model, and statistical significance was declared at p < 0.05.

Results

Overall, 17.4% (95% CI: 13.6–21.5) of participants screened positive for probable PMDD. Students who reported cohabiting with a boyfriend had higher odds of screening positive for probable PMDD than those living with their families (AOR = 5.80, 95% CI: 1.31–25.77). Similarly, severe dysmenorrhea (AOR = 5.88, 95% CI: 2.72–9.46) and a menstrual cycle length of ≥ 28 days (AOR = 2.52, 95% CI: 1.01–6.26) were associated with higher odds of screening‐positive probable PMDD. In contrast, living with relatives (AOR = 0.12, 95% CI: 0.02–0.60) and reporting moderate menstrual bleeding (AOR = 0.31, 95% CI: 0.10–0.92) were associated with lower odds of screening‐positive probable PMDD.

Conclusion

Approximately one in six female college students screened positive for probable PMDD using the PSST‐A screening instrument Cohabiting with a boyfriend, severe dysmenorrhea, and longer menstrual cycle length were associated with higher odds of screening‐positive probable PMDD, whereas living with relatives and moderate menstrual bleeding were associated with lower odds These findings highlight the need for routine screening, increased awareness of PMDD symptoms, and accessible campus‐based reproductive and mental health support services for female college students.

Abbreviations

ACOG

American College of Obstetrics and Gynecologic Association

APA

American Psychiatric Association

CI

Confidence Interval

CNS

Central Nerves System

CSA

Central Statistics Agency

DSM

Diagnostic and Statistical Manual

FDRE

Federal Democratic Republic of Ethiopia

FP

Family Planning

HRQL

Health‐Related Quality of Life

MOH

Ministry of Health

OA

Osteoarthritis

PMDDP

Premenstrual Dysphoric Disorder

PME

Premenstrual Exacerbation

PMS

Premenstrual Symptoms

PSSTA

Premenstrual Screening Tool for Adults

RA

Rheumatoid Arthritis

SSRI

Selective Serotonin Reuptake Inhibitors

UAE

United Arab Emirates

WU

Wollega University

1. Introduction

Premenstrual Dysphoric Disorder (PMDD) is a severe form of Premenstrual Syndrome (PMS), presenting with significant emotional, behavioral, and physical symptoms during the luteal phase of the menstrual cycle, which typically resolve after menstruation begins [1]. Research indicates that females are at a higher risk for mood disorders, particularly around menarche, due to biological and psychosocial transitions [2].

PMDD and other premenstrual disorders involve notable mood and behavioral changes that fluctuate with hormonal shifts throughout the menstrual cycle [1, 3]. While PMS encompasses a range of symptoms that generally subside with the onset of menstruation, PMDD manifests with debilitating mood swings, irritability, anxiety, and physical discomfort that substantially impair daily functioning [3, 4]. The underlying causes of PMDD are not yet fully understood; however, heightened central nervous system sensitivity to normal hormonal changes and psychosocial stressors have been identified as important contributors. A variety of treatment options exist, including lifestyle modifications, pharmacotherapy, and psychological interventions aimed at relieving both emotional and somatic symptoms [5, 6, 7].

Globally, approximately 52% of females (26% of the total population) are of childbearing age, and most experience regular menstruation [8]. Among these women, mood disturbances such as PMS and PMDD are common and can significantly interfere with interpersonal relationships, academic engagement, and overall quality of life [9]. The global magnitude of PMDD ranges from 4.6% to 6.4%, while subthreshold PMDD affects an estimated 18.6%–20.7% of reproductive‐age women [10]. International evidence also reveals considerable variation across specific populations. A study among female college students in South India reported a PMDD prevalence of 13.8%, while research in a Nigerian university found a higher prevalence of 36.1% [9, 10].

According to national demographic estimates, approximately 51% of Ethiopia's population is female, and around 23% are women of reproductive age [11]. Despite the high proportion of women potentially affected, premenstrual disorders, including PMDD, remain under recognized and under‐addressed in Ethiopia, partly because cultural taboos and stigma surrounding menstruation discourage open discussion and healthcare seeking [12, 13, 14, 15]. Furthermore, reported PMDD prevalence varies considerably across studies conducted in different countries and within Ethiopia. These variations are likely attributable to differences in study populations, age groups, sampling strategies, screening instruments, diagnostic criteria, and sociocultural contexts rather than true epidemiological differences alone [9, 10, 16, 17, 18, 19, 20]. Consequently, direct comparison of prevalence estimates should be interpreted cautiously.

Although several Ethiopian studies have investigated PMDD among female students, most were conducted in university settings or single educational institutions located in northern and central Ethiopia [16, 17, 18, 19, 20]. Evidence regarding PMDD among female college students in western Ethiopia, particularly in Nekemte Town, remains scarce. Moreover, no previous study has assessed the severity of PMDD symptoms using the Premenstrual Symptoms Screening Tool for Adolescents (PSST‐A) while examining factors associated with screening‐positive probable PMDD among female college students in this setting. Differences in sociocultural norms, living conditions, educational environments, and access to reproductive health services may influence menstrual experiences and PMDD symptoms, highlighting the importance of generating context‐specific evidence. Therefore, this study aimed to assess the prevalence of screening‐positive probable PMDD and identify factors associated with it among female college students in Nekemte Town, Oromia, western Ethiopia.

2. Methods and Materials

2.1. Study Area and Period

The study was conducted among female students from several institutions in Nekemte town from February to July 2023. Nekemte is located 331 km west of Addis Ababa in the East Wollega Zone of the Oromia region and comprises six sub‐cities. According to the Central Statistics Agency branch of the town, the estimated population in 2016 was 97,289, including 37,796 young people, of whom 19,626 were males, and 18,170 were females. During the study period, a substantial number of female students were enrolled in diploma and degree programs at both private and public colleges, with nearly 5000 female students attending institutions in the town.

2.2. Study Design

An institution‐based cross‐sectional study was conducted among female college students in Nekemte town.

2.3. Target Population

The target population comprised female students attending Nekemte Health Science College, Rift Valley University College, and New Generation College in Nekemte town. This population reflects the intended group to which the study aims to generalize its findings.

2.4. Source Population

The source population consisted of all female students enrolled in regular undergraduate programs at both government and private colleges in Nekemte town during the study period.

2.5. Study Population

The study population included all selected regular undergraduate female students from the colleges included in the sample.

2.6. Inclusion and Exclusion Criteria

2.6.1. Inclusion Criteria

All regular undergraduate female students who were 18 years or older, currently enrolled in the three selected colleges, and had not undergone recent hormonal treatments that could influence menstrual symptoms were eligible. The inclusion of only regular students was deliberate to ensure a homogeneous sample with similar academic engagement, daily routines, and campus exposure, which may influence menstrual experiences and the risk of PMDD.

2.6.2. Exclusion Criteria

Female students who were critically ill or unable to provide informed consent during data collection were excluded to ensure participant safety and data reliability.

2.7. Sample Size Determination and Sampling Procedure

2.7.1. Sample Size Determination

The sample size was calculated using a single population proportion formula based on a PMDD prevalence rate of 66.9% from a prior Ethiopian study [16]. The total sample size was set at 375 female students with including 10% non‐respondent rate and ensure sufficient precision with a target margin of error of 5%, ensure sufficient precision with a target margin of error of 5%, the calculation was as follows:

$$n=\frac{({Z\mathrm{a}/2)}^2*P(1-P)}{{\left(d\right)}^2}$$

• Where,

• n = initial sample size

• Z = 1.96 (the corresponding Z‐score for the 95% CI)

• P = proportion = 66.9%

• d = margin of error = 5%

2.8. Sampling Procedure

In our study, we categorized 12 colleges into three groups: health science colleges, non‐health science colleges, and mixed‐focus colleges. Using a lottery method, we selected three colleges: Nekemte Health Science College, Rift Valley University College, and New Generation College, from the 12 colleges located in Nekemte town. A stratified random sampling method was employed to select students from each of the chosen colleges, as presented Figure 1. The entire sample was distributed proportionately based on the number of students in each college. A sampling frame was created using student identification numbers obtained from the registrars of these colleges, and simple random sampling was used to select the study units. The final sample size selection procedure for each stratum (the three colleges) is presented in Figure 1 below.

Figure 1.

Flow chart showing sampling procedure of the study, Nekemte, Ethiopia.

2.9. Study Variables

2.9.1. Response Variable

The dependent variable of this study was PMDD Severity. This variable has a binary outcome.

2.9.2. Independent Variables

Several aspects of Socio‐demographic characteristics, premenstrual symptoms and functionality, Lifestyle habit characteristics, and menstrual cycle characteristics factor were included as independent variables in this study. The independent variables of this study with their variable name and category are presented in Table 1 below.

Table 1.

Description of covariate and code in the study.

Variables	Categories
Socio‐demographic characteristics
Age	1 = < 19
	2 = ≥ 20
Religion	1 = Protestant, 2 = Orthodox, 3 = Adventist, 4 = Others
Ethnicity	1 = Oromo, 2 = Amara, 3 = Garge, 4 = Others
Marital status	1 = Single, 2 = Cohabited, 3 = Divorced, 4 = Widowed, 5 = Married
Field of study	1 = Health sciences, 2 = Non health sciences
Living arrangements	1 = With family, 2 = With relative, Alone
Year of study	1 = First year, 2 = Second year, 3 = Third year, 4 = Fourth year
Educational level of the mother	1 = No formal education
	2 = Primary school level
	3 = High school level
	4 = College/university level
Job	1 = Yes, 2 = No
Monthly income	1 = Adequate, 2 = Not adequate
Life style habit characteristics
Sleeping duration	1 = < 6 h, 2 = 6–8 h, 3 = ≥ 9 h.
Physical activity status	1 = Physically active, 2 = Physically not active
Rx seeking behavior	1 = Not at all, 2 = Seek solution
Choice of coping measures	1 = Buying self‐prescribed drugs
	2 = Consulting physician
	3 = Seeking cultural/spiritual and Others*
Starch foods feeding status	1 = Yes, 2 = No
Animal meat and fat feeding status	1 = Yes, 2 = No
Dairy product feeding status	1 = Yes, 2 = No
Caffeinated drinking's feeding status	1 = Yes, 2 = No
Leafy green vegetables' feeding status	1 = Yes, 2 = No
Fried foods feeding status	1 = Yes,2 = No
High sugar drinking feeding status	1 = Yes, 2 = No
Menstrual cycle related characteristic
Students age at menarche	1 = < 13, 2 = 13–16, 3 = > 16
Monthly pattern of Menstrual cycle	1 = Regular, 2 = Irregular
History of dysmenorrhea	1 = Yes, 2 = No
Degree of dysmenorrhea	1 = Mild, 2 = Moderate, 3 = Severe
Days of stay of menses per cycle	1 = < 3 days, 2 = 3–5 days, 3 = > 5 days
Amount of menstrual bleeding/day	Mild (< 1 pad/day)
	Moderate (2–4 pad/day)
	Heavy (> 4 pad/day)
Average length of one cycle	1 = < 28 days, 2 = ≥ 28 days
History of FP use	1 = Yes, 1 = No
History of type of FP use	1 = Oral contraceptives, 2 = Injectable, 3 = Implants, 4 = Other

2.10. Data Collection Tools and Procedures

The data were collected using a standardized, self‐administered questionnaire. Three female psychiatric BSc nurse students were designated as facilitators, with one public health officer serving as supervisor. The study participants were questioned using a self‐administered questionnaire that consisted of four sections: Socio‐demographic information, premenstrual symptoms and functioning, lifestyle habit characteristics, and menstrual cycle characteristics. The Premenstrual Screening Tool for Adults (PSST‐A) was utilized to assess the PMDD status of female pupils. This instrument categorizes items into three groups to detect PMDD and severe PMS: (I) “core PMS” symptoms, (II) “other PMS” symptoms, and (III) “functional” items. The PSST‐A criteria for diagnosing PMDD are as follows: (a) at least one of four “core PMS” symptoms rated as severe, (b) at least four additional PMS symptoms rated as either moderate or severe, and (c) at least one of five “functional” items rated as severe. It is important to note that while this tool provides valuable insights into the prevalence of PMDD symptoms, it should not be interpreted as a definitive diagnosis for our study, as the PSST‐A is primarily a screening instrument. Students who did not meet the aforementioned criteria were classified as not having PMDD [17].

2.11. Data Collection Tools and Procedures

Data were collected using a standardized, self‐administered questionnaire. Three female Bachelor of Science (BSc) psychiatric nursing students served as data collection facilitators under the supervision of one public health officer. The questionnaire consisted of four sections: (1) sociodemographic characteristics, (2) premenstrual symptoms and their impact on daily functioning, (3) lifestyle‐related characteristics, and (4) menstrual and reproductive characteristics.

Premenstrual symptoms were assessed using the PSST‐A, a standardized screening instrument developed from the Diagnostic and Statistical Manual of Mental Disorders (DSM) symptom criteria for premenstrual disorders. The PSST‐A is designed to screen for probable PMDD and severe PMS rather than establish a clinical diagnosis. The instrument comprises three domains: (i) four core affective symptoms, (ii) ten additional emotional and physical symptoms, and (iii) five items assessing functional impairment.

Participants were considered to have screened positive for probable PMDD if they met the recommended PSST‐A screening criteria: (a) at least one of the four core symptoms rated as severe; (b) at least four additional symptoms rated as moderate or severe; and (c) at least one functional impairment item rated as severe. Participants who did not meet these screening criteria were classified as not screening positive for probable PMDD [17]. As the PSST‐A is a screening instrument, the findings represent probable PMDD and should not be interpreted as a clinical diagnosis.

2.12. Operational Definition and Definition of Terms

• PMDD: Diagnosed using the PSST‐A, criteria's: (a) at least 1 of 4 “core PMS” symptoms rated severe, (b) at least 4 additional PMS symptoms rated either moderate or severe, and (c) at least 1 of 5 “functional” items rated severe [21].

• Habitual physical exercise: Defined as students who participated in habituated physical activity three times or more per week for more than 10 min to the extent of either sweating or a significant increment in heart rate [22].

• Food intake preference: Foods preference was defined as eating/drinking particular foods that have a plausible effect on PMS/PMDD three times or more per week [22].

• Adequate monthly pocket money: Contextualized as per the World Bank's international poverty line (IPL), which is $1.90 per day [23].

2.13. Data Quality Assurance

The data collection tool was developed through a thorough review and adaptation of relevant literature to ensure quality. A language specialist, assisted by the medical and psychiatry staff at Nekemte Hospital, translated the questionnaire from English to Afan Oromo and back again. Comprehensive training was provided to data collectors on the data‐gathering procedures. To ensure accuracy, the lead investigator and supervisor regularly monitored the data collection process. Additionally, we conducted a pilot test to assess the clarity and relevance of the items. Reliability checks were performed using Cronbach's alpha to evaluate internal consistency, and test‐retest reliability was established to ensure stability over time. These steps confirm the validity and reliability of our questionnaire and effectively address the concerns raised.

2.14. Statistical Analysis

Data were carefully coded, confirmed, and put into Epi data version 4.6 before being exported to Stata version 17 for analysis. Descriptive analysis was carried out for each of the independent variables. The frequency and percentage of descriptive variables were presented by using tables and figures. We performed a multivariable logistic regression to identify factors associated with PMDD, presenting adjusted odds ratios (AOR) and 95% confidence intervals. Variables with p < 0.05 were deemed significant.

3. Results

3.1. Socio‐Demographic Characteristics

A total of 368 female students at selected colleges in Nekemte town were interviewed with a response rate of 98.13%. The average age of the study participants was 22.23 years (SD ± 3.01). More than half the study participants 251 (68.2%) were greater than 19 years. 275 (74.7%) were protestant religion follower while 63 (17.4%) were Orthodox. Regarding the ethnic background of the study participants, 346 (94.0%), 16 (4.3%), and 4(1.1%) were Oromo, Amhara, and Gurage, respectively. Among the total respondents participated in this study 217 (59%) of them were single, while 31 (8.4%) of them were cohabiting. Of the total respondents 203 (55.2%) were attending health science department while the rest was non health science students. More than half of the students 205 (55.7%) lives with the family and 65 (17.7%) were living with their relative. Regarding the educational level of the mothers of the students, 122 (33.2%), 125 (34%), 65 (17.7%) and 56 (15.2%) have no formal education, attended primary school level, high school and college/university, respectively. Around three fourth 246 (66.7%) of the students do not have their own job while others do have their job as showed in Table 2.

Table 2.

Sociodemographic characteristics of female students at Colleges in Nekemte town, Ethiopia (n = 368).

Variables	Categories	Frequencies	%
Age	< 19	117	31.8
	≥ 20	251	68.2
Religion	Protestant	275	74.7
	Orthodox	64	17.4
	Adventist	12	3.3
	Others*	17	4.6
Ethnicity	Oromo	346	94.0
	Amara	16	4.3
	Garage	4	1.1
	Others**	2	0.5
Marital status	Single	217	59.0
	Cohabited	31	8.4
	Divorced	20	5.6
	Widowed	21	5.7
	Married	79	21.5
Field of study	Health sciences	203	55.2
	Non‐health sciences	165	44.8
Living arrangements	With family	205	55.7
	With relative	65	17.7
	Alone	98	26.6
Year of study	First year	53	14.4
	Second year	57	15.5
	Third year	223	60.6
	Fourth year	35	9.5
Educational level of the mother	No formal education	122	33.2
	Primary school level	125	34.0
	High school level	65	17.7
	College/university level	56	15.2
Job	Yes	122	33.2
	No	246	66.8
Monthly income	Adequate	59	16.0
	Not adequate	309	84.0

Note: Other* = Wakeffata, Muslim… Other** = Tigre, Gambella….

3.2. Life Style Related Factors

The mean sleeping duration of the participants was 8.70 (SD ± 1.851). Adequate sleep plays a crucial role in overall health and well‐being, and its relationship with the severity of PMDD symptoms is significant. The poor sleep quality and insufficient sleep can exacerbate mood disturbances and emotional dysregulation, which are core features of PMDD. Approximately 12.2% of participants reported fewer than 6 h of sleep nightly, while others reported 6–8 h or more. 224 (60.9%) of them don't have treatment seeking behavior for menstrual related problems, while the rest do have it. Among those students who seek treatment for the menstrual related issues, 65 (17.7%) buy self‐ prescribed drugs, 27 (7.3%) of them consult physician, 30 (8.2%) the rest look for others solutions. Most respondents 229 (62.2%) consumed starchy foods, while 159 (43.2%) regularly used dairy products. 231 (62.8%) use caffeinated drinking while the rest do not use it. More than half 209 (56.8%) of the respondents used the leafy green vegetables while the rest do not use it. Around 128 (34.8%) of the students used the fried foods. Besides 103 (28%) of them consume high sugar containing drinking (Table 3).

Table 3.

Frequency distribution of lifestyle related factors of female students at College at Nekemte town, Ethiopia (n = 368).

Variables	Categories	Frequencies	%
Sleeping duration	< 6 h.	45	12.2
	6–8 h.	165	44.8
	≥ 9 h.	158	42.9
Physical activity status	Physically active	71	19.3
	Physically not active	17	4.6
Rx seeking behavior	Not at all	224	60.9
	Seek solution	144	39.1
Choice of coping measures	Buying self‐prescribed drugs	65	17.7
	Consulting physician	27	7.3
	Seeking cultural/spiritual	30	8.2
	Othersa	22	6.0
Starch foods feeding status	Yes	229	62.2
	No	139	37.8
Animal meat and fat feeding status	Yes	60	16.3
	No	308	83.7
Dairy product feeding status	Yes	159	43.2
	No	209	56.8
Caffeinated drinking's feeding status	Yes	231	62.8
	No	137	37.2
Leafy green vegetables' feeding status	Yes	209	56.8
	No	159	43.2
Fried foods feeding status	Yes	128	34.8
	No	240	65.2
High sugar drinking feeding status	Yes	103	28.0
	No	265	72.0

^a Sleeping, being alone.

Among the 368 respondents, 224 (60.9%) reported not seeking treatment for their premenstrual symptoms, whereas only 65 (17.6%) sought medical consultation from a physician (Figure 2).

Figure 2.

Coping measure options of female college students at Nekemte town, Ethiopia.

3.3. Magnitude of Screening‐Positive Probable PMDD

Symptoms of probable PMDD were assessed using the PSST‐A, a standardized screening instrument developed from the Diagnostic and Statistical Manual of Mental Disorders (DSM) symptom criteria for premenstrual disorders. Participants who met the recommended PSST‐A screening criteria were classified as screening positive for probable PMDD. In this study, 64 participants screened positive for probable PMDD, yielding a prevalence of 17.4% (95% CI: 13.6–21.5). Regarding the distribution of the PSST‐A screening criteria, 103 (28.0%) participants rated at least one of the four core symptoms as severe, 179 (48.6%) rated at least four additional symptoms as moderate or severe, and 103 (28.0%) rated at least one functional impairment item as severe (Figure 3). Because the PSST‐A is a screening instrument, these findings represent probable PMDD rather than clinically confirmed diagnoses.

Figure 3.

Distribution of premenstrual symptoms screening tool for adolescents (PSST‐A) screening criteria and corresponding symptom severity ratings among female college students in Nekemte Town, Oromia, Ethiopia.

3.4. Menstrual Cycle‐Related Factors

Table 4 presents the menstrual cycle–related characteristics of 368 female college students in Nekemte town, Ethiopia. More than half of the participants (53.5%) experienced menarche between the ages of 13 and 16 years, while 37.2% reported menarche before the age of 13 and only 9.2% after 16 years. Regarding menstrual cycle regularity, a higher proportion of students (56.8%) reported having irregular menstrual cycles. Dysmenorrhea was common among the participants, with 67.4% reporting a history of menstrual pain. Among those affected, over half (51.6%) experienced moderate dysmenorrhea, and nearly one‐third (29.4%) reported severe pain, indicating a substantial burden of menstrual discomfort. Concerning the duration of menstrual bleeding, 48.4% of students reported bleeding lasting 3–5 days, while 40.5% had menses lasting fewer than 3 days, and 11.1% reported bleeding for more than 5 days.

Table 4.

Frequency distribution of Menstrual cycle related characteristic of students at Colleges in Nekemte town, Ethiopia(n = 368).

Variables	Categories	Frequencies	Percentage
Students age at menarche	< 13	137	37.2
	13–16	197	53.5
	> 16	34	9.2
Monthly pattern of Menstrual cycle	Regular	159	43.2
	Irregular	209	56.8
History of dysmenorrhea	Yes	248	67.4
	No	120	32.6
Degree of dysmenorrhea	Mild	47	19.0
	Moderate	128	51.6
	Severe	73	29.4
Days of stay of menses per cycle	< 3 days	149	40.5
	3–5 days	178	48.4
	> 5 days	41	11.1
Amount of menstrual bleeding/day	Mild (< 1 pad/day)	107	29.1
	Moderate (2–4 pad/day)	204	55.4
	Heavy (> 4 pad/day)	57	15.5
Average length of one cycle	< 28 days	194	52.7
	≥ 28 days	174	47.3
History of FP use	Yes	111	30.2
	No	257	69.8
History of type of FP use	Oral contraceptives	23	6.3
	Injectable	46	12.5
	Other	5	1.4
	Implants	37	10.1

In terms of the amount of menstrual bleeding per day, moderate bleeding (2–4 pads/day) was most common, reported by 55.4% of participants. Mild bleeding (< 1 pad/day) was reported by 29.1%, whereas 15.5% experienced heavy bleeding (> 4 pads/day). With respect to cycle length, slightly more than half of the students (52.7%) reported average cycle lengths of less than 28 days, while 47.3% had cycles lasting 28 days or longer (≥ 28 days). Regarding family planning, the majority of students (69.8%) reported no prior use of family planning methods. Among those who had used contraception, injectable methods were the most commonly reported (12.5%), followed by implants (10.1%) and oral contraceptives (6.3%), while use of other methods was relatively low (1.4%) (Table 4).

3.5. Factors Associated With PMDD

We employed both bivariable and multivariable analyses to identify the variables associated with PMDD. Initially, we conducted bivariable analysis to select potential variables for inclusion in the multivariable logistic regression model. The following variables were identified as candidate variables with a p‐value of less than 0.25: marital status, field of study, living arrangement, year of study, educational status, consumption of meat and animal fat, consumption of caffeinated beverages, degree of dysmenorrhea, duration of menstrual bleeding, amount of menstrual bleeding per day, and the average length of the menstrual cycle. These potential candidates for multivariable analysis are detailed in Table 5.

Table 5.

Bivariable table showing potential candidate variables for multivariable analysis of female students at colleges in Nekemte town, Ethiopia

Variables	Categories	PMDD diagnosis		Crude OR (95% CI)
		Yes	No
Marital status	Single	25 (11.5)	192 (88.5)	1.01 (0.45, 1.75)
	Cohabited	9 (29.0)	22 (71.0)	3.18 (1.12, 3.23)
	Divorced	11 (25.5)	10 (24.4)	4.12 (1.81, 11.43)
	Widowed	10 (25.1)	10 (24.4)	3.21 (2.6, 3.25)
	Married	9 (11.4)	70 (88.6)	1
Field of study	Health science	41 (20.2)	162 (79.8)	1
	Non health science	23 (13.9)	142 (86.1)	0.64 (0.36, 0.96)
Living arrangements	With family	40 (19.5)	165 (80.5)	1
	With relative	7 (10.8)	58 (89.2)	0.49 (0.21,1.17)
	Alone	17 (17.3)	81 (82.7)	0.86 (0.46,1.62)
Educational level of mother	No formal education	104 (85.2)	18 (14.8)	0.41 (0.23, 1.14)
	Primary school	104 (83.2)	21 (16.8)	0.69 (0.21,1.02)
	High school level	54 (83.1)	11 (16.9)	0.27 (0.25, 0.48)
	College/university	42 (75.0)	14 (25.0)	1
Animal meat and fat feeding status	Yes	50 (16.2)	258 (83.8)	1
	No	14 (23.3)	46 (76.7)	1.57 (1.20,3.07)
Caffeinated drinking's	Yes	34 (14.7)	197 (85.3)	0.31 (0.35,1.06)
	No	30 (21.9)	107 (78.1)	1
Degree of dysmenorrhea	Mild	2 (4.3)	45 (95.7)	1
	Moderate	20 (15.6)	108 (84.4)	0.09 (0.02, 19)
	Severe	24 (32.9)	49 (67.1)	0.38 (0.26, 0.75)
Days of stay of menses per cycle	< 3 days	26 (17.4)	123 (82.6)	1
	3–5 days	25 (14.0)	153 (86.0)	0.45 (0.20,0.99)
	> 5 days	13 (31.7)	28 (68.3)	0.35 (0.16,0.7)
Amount of menstrual bleeding	Mild (< 1 pad/day)	15 (14.0)	92 (86.0)	1
	Moderate (2–4 pad/day)	34 (16.7)	170 (83.3)	1.22 (0.63, 2.36)
	Heavy ( > 4 pad/day)	15 (26.3)	42 (73.7)	2.19 (0.98, 4.89)
Length of a cycle	< 28 days	29 (14.9)	165 (85.1)	1
	≥ 28 days	35 (20.1)	139 (79.9)	1.43 (0.83,2.46)
Year of study	first year	48 (90.6)	5 (9.4)	0.80 (0.20, 3.24)
	second year	54 (94.7)	3 (5.3)	0.43 (0.09,2.05)
	third year	171 (76.7)	52 (23.3)	2.35 (0.79,6.98)
	Fourth‐year	31 (88.6)	4 (11.4)	1

Abbreviations: 1, reference category; CI, confidence interval; COR, crude odds ratio.

In a multivariate logistic regression analysis, PMDD was significantly associated with marital status (Cohabited), living arrangements with a relative, degree of dysmenorrhea with severe, the amount of daily menstrual bleeding, and average length of one cycle. The analysis of marital status revealed significant variations in the odds of experiencing PMDD across different categories. For individuals who are single, the AOR was 0.69 (0.20, 2.35), suggesting they have lower odds of experiencing PMDD compared to those who are married, although this finding is not statistically significant. In contrast, individuals who are cohabiting showed a significant AOR of 5.80 (1.30, 25.77), indicating they have approximately 5.80 times higher odds of experiencing PMDD compared to the married group. For those who are divorced, the AOR was 0.90 (0.14, 1.56), suggesting no significant change in the odds of PMDD compared to the married group, while widowed individuals had an AOR of 1.80 (0.35, 9.17), indicating a higher likelihood of PMDD, but this result also lacks statistical significance. Also, individuals living with family served as the reference group with family. Those living with relatives exhibited a significantly lower AOR of 0.12 (0.02, 0.60), indicating that this group has approximately 88% lower odds of experiencing PMDD compared to those living with family. This finding is statistically significant, suggesting a protective effect of living with relatives. Conversely, individuals living alone had an AOR of 0.77 (0.29, 2.07), indicating no significant change in the odds of PMDD compared to those living with family, as this result lacks statistical significance. Additionally, the analysis revealed important findings regarding the degree of dysmenorrhea and its association with PMDD. For those with moderate dysmenorrhea, the AOR was 4.25 (0.78, 22.97), indicating that individuals in this category have approximately 4.25 times higher odds of experiencing PMDD compared to those with mild dysmenorrhea, although this finding lacks statistical significance due to the wide confidence interval. In the case of students with severe dysmenorrhea, the AOR was 5.88 (2.73, 9.46), suggesting that individuals with severe dysmenorrhea are nearly 5.88 times more likely to experience PMDD compared to those with mild dysmenorrhea, with this result being statistically significant. Regarding bleeding intensity, individuals with moderate bleeding had an AOR of 0.31 (0.10, 0.92), indicating that they have 69% lower odds of experiencing PMDD compared to those with mild bleeding, which is statistically significant. Conversely, those with heavy bleeding had an AOR of 1.31 (0.350, 4.87), suggesting no significant change in the odds of PMDD compared to mild bleeding, as the confidence interval includes 1. The analysis also revealed significant findings regarding the length of one menstrual cycle. For individuals with a cycle length of ≥ 28 days, the AOR was 2.53 (1.02, 6.27), indicating that those with longer cycles have approximately 2.53 times higher odds of experiencing PMDD compared to those with cycles of < 28 days. This finding is statistically significant, suggesting a meaningful association between longer cycle lengths and the likelihood of PMDD, as showed in Table 6.

Table 6.

Factors associated with screening‐positive probable Premenstrual Dysphoric Disorder (PMDD) among female college students in Nekemte Town, Oromia, Ethiopia (n = 368).

Variables		PMDD status		COR with 95% CI	AOR with 95% CI
	Categories	No (%)	Yes (%)
Marital status	Single	192 (88.5)	25 (11.5)	1.01 (0.45, 1.75)	0.69 (0.20,2.35)
	Cohabited	22 (71.0)	9 (29.0)	3.18 (1.12, 3.23)	5.80 (1.30, 25.77)*
	Divorced	11 (25.5)	10 (24.4)	4.12 (1.81, 11.43)	0.90 (0.14, 1.56)
	Widowed	10 (25.1)	10 (24.4)	3.21 (2.6, 3.25)	1.80 (0.35, 9.17)
	Married	70 (88.6)	9 (11.4)	1	1
Field of study	Health science	162 (79.8)	41 (20.2)	1	1
	Non health science	142 (86.1)	23 (13.9)	0.64 (0.36, 1.11)	0.43 (0.17, 1.05)
Living arrangements	With family	165 (80.5)	40 (19.5)	1	1
	With relative	58 (89.2)	7 (10.8)	0.49 (0.21, 1.17)	0.12 (0.02, 0.60)**
	Alone	81 (82.7)	17 (17.3)	0.86 (0.46, 1.62)	0.77 (0.29, 2.07)
Year of study	First year	48 (90.6)	5 (9.4)	0.80 (0.20, 3.24)	1.44 (0.18, 11.19)
	Second year	54 (94.7)	3 (5.3)	0.43 (0.09, 2.05)	0.95 (0.12, 7.54)
	Third year	171 (76.7)	52 (23.3)	2.35 (0.79, 6.98)	4.94 (0.96, 25.41)
	Fourth‐year	31 (88.6)	4 (11.4)	1	1
Mothers educational level	No formal education	104 (85.2)	18 (14.8)	0.41 (0.23, 1.14)	0.49 (0.15, 1.66)
	Primary school	104 (83.2)	21 (16.8)	0.69 (0.21, 1.02)	1.15 (0.36,3.64)
	High school	54 (83.1)	11 (16.9)	0.27 (0.25, 0.48)	0.51 (0.13, 1.99)
	College/university	42 (75.0)	14 (25.0)	1	1
Meat & fat feeding status	Yes	46 (76.7)	14 (23.3)	1.57 (1.20, 3.07)	1.57 (0.53, 4.59)
	No	258 (83.8)	50 (16.2)	1	1
Caffeinated drinking	Yes	197 (85.3)	34 (14.7)	0.31 (0.35, 1.06)	0.43 (0.18, 1.03)
	No	107 (78.1)	30 (21.9)	1	1
Degree of dysmenorrhea	Mild	45 (95.7)	2 (4.3)	1	1
	Moderate	108 (84.4)	20 (15.6)	0.09 (0.02, 0.19)	4.25 (0.78, 22.97)
	Severe	49 (67.1)	24 (32.9)	0.38 (0.26, 0.75)	5.88 (2.73, 9.46)**
Days of menstrual bleeding	< 3 days	123 (82.6)	26 (17.4)	1	1
	3–5 days	153 (86.0)	25 (14.0)	0.45 (0.20, 0.99)	0.92 (0.35, 2.39)
	> 5 days	28 (68.3)	13 (31.7)	0.35 (0.16, 0.7)	2.12 (0.54, 8.22)
bleeding per day	Mild	92 (86.0)	15 (14.0)	1	1
	Moderate	170 (83.3)	34 (16.7)	1.22 (0.63, 2.36)	0.31 (0.10, 0.92)*
	Heavy	42 (73.7)	15 (26.3)	2.19 (0.98, 4.89)	1.31 (0.350, 4.87)
Length of one cycle	< 28 days	165 (85.1)	29 (14.9)	1	1
	≥ 28 days	139 (79.9)	35 (20.1)	1.43 (0.83, 2.46)	2.53 (1.02, 6.27)*

Abbreviations: 1, reference category; AOR, adjusted odds ratio; CI, confidence interval; COR, crude odds ratio.

^*Statistically significant at p < 0.05.

^**Statistically significant at p < 0.01.

4. Discussion

This institution‐based cross‐sectional study assessed the prevalence of screening‐positive probable PMDD and factors associated with it among female college students in Nekemte Town. Using the PSST‐A, 17.4% (95% CI: 13.6–21.5) of participants screened positive for probable PMDD. This prevalence was lower than that reported among female university students in Nigeria (42.2%) but higher than that reported among college students in South India (13.8%) [10]. Differences in prevalence across studies should be interpreted cautiously, as they may reflect variations in study populations, sampling methods, screening instruments, case definitions, and sociocultural contexts rather than true differences in the occurrence of PMDD symptoms. Additionally, differences in educational settings, access to reproductive and mental health services, and cultural perceptions related to menstruation may also influence symptom reporting and recognition across populations.

The prevalence of screening‐positive probable PMDD in this study was slightly higher than that reported among students at Debre Berhan University (13.8%) and substantially lower than that reported among students at Wollo University (66.9%) [16]. Differences in reported prevalence across these studies may be related to variations in sampling approaches, study settings, participant characteristics, and assessment methods [19, 20, 21, 24, 25, 26]. The Wollo University study included only health science students, whereas the current study included students from multiple colleges and fields of study, which may influence the distribution and reporting of premenstrual symptoms. Additionally, differences in sample size and socio‐demographic characteristics of participants may have contributed to the observed variation in estimates. Since different studies may use different screening instruments and criteria for identifying probable PMDD, comparisons across studies should be interpreted cautiously.

Marital status was significantly associated with screening‐positive probable PMDD among female college students in Nekemte Town. Specifically, students who were cohabiting with a boyfriend had higher odds of screening‐positive probable PMDD compared with married students. This finding suggests that cohabitation status, rather than being single or unmarried in general, was the category associated with higher odds of probable PMDD symptoms in this study population. The finding is partially consistent with a study conducted among Jordanian women, which reported an association between unmarried status and PMDD symptoms [27]. However, differences in the definition and categorization of marital status, as well as sociocultural contexts, should be considered when comparing findings across populations. In contrast, several Ethiopian studies reported no significant association between marital status and PMDD among university students [19, 22, 25, 26]. Since psychosocial characteristics related to relationship status were not assessed in the present study, further research is needed to explore the potential mechanisms underlying the observed association.

Living arrangement was significantly associated with screening‐positive probable PMDD in this study. Students living with relatives had lower odds of screening‐positive probable PMDD compared with those living with their families. This finding differs from previous studies that reported no significant association between living arrangements and PMDD symptoms [28, 29, 30]. Differences in findings may be related to variations in study populations, residential characteristics, sociocultural contexts, and assessment methods across studies. In this study, the majority of participants were college students living independently, often in rented accommodations or with relatives. This living situation can lead to feelings of instability and emotional distress. Students living with relatives may experience less support and potentially diminished respect compared to those living with their immediate families, which can exacerbate psychological stress, particularly during the luteal phase of the menstrual cycle when PMDD symptoms typically manifest [31, 32].

Severe dysmenorrhea was significantly associated with screening‐positive probable PMDD in this study. This finding is consistent with previous studies conducted among female students [10, 16, 19, 30]. The observed association suggests that students experiencing severe menstrual pain may also report a greater burden of premenstrual symptoms. However, because dysmenorrhea and probable PMDD symptoms were assessed simultaneously, the temporal relationship between these conditions cannot be determined. Previous studies have proposed that menstrual pain may be accompanied by psychological distress and reduced quality of life, which could influence the experience and reporting of premenstrual symptoms [33, 34, 35, 36]. Nevertheless, psychological factors, pain perception, and hormonal profiles were not assessed in the present study. Therefore, the mechanisms underlying this association remain unclear and warrant further investigation using longitudinal studies with comprehensive clinical and psychosocial assessments.

In this study, moderate menstrual bleeding was associated with lower odds of screening‐positive probable PMDD compared with mild menstrual bleeding. Although evidence regarding the relationship between menstrual bleeding patterns and PMDD remains limited, previous studies have suggested that menstrual characteristics may be associated with variations in premenstrual symptom experiences [34, 37, 38]. Differences in menstrual bleeding patterns may reflect underlying reproductive or hormonal variations that have been proposed as potential contributors to premenstrual symptoms. One possible explanation is that moderate menstrual bleeding represents a more typical physiological menstrual pattern, whereas lighter bleeding may be associated with hormonal fluctuations or menstrual irregularities that could increase susceptibility to premenstrual symptoms. Additionally, students experiencing lighter or less predictable menstrual bleeding may have greater concerns about their menstrual health, potentially contributing to increased stress, anxiety, and emotional distress, which may exacerbate symptoms characteristic of PMDD [35, 38]. However, given the cross‐sectional design of this study, these findings should be interpreted cautiously, and further longitudinal and mechanistic studies are needed to clarify the biological and psychological pathways underlying this association.

This study found that longer menstrual cycle duration was significantly associated with higher odds of screening‐positive probable PMDD, consistent with findings from a study conducted among nursing students at a Nigerian teaching hospital [39]. Students with longer menstrual cycles were more likely to screen positive for probable PMDD than those with shorter cycles. Although the biological mechanisms underlying this association are not fully understood, menstrual cycle length may reflect variations in ovarian hormone regulation that have been implicated in the pathophysiology of PMDD [36, 40]. Longer menstrual cycles may be associated with greater variability in hormonal patterns, potentially increasing susceptibility to the affective and physical symptoms characteristic of PMDD. In addition, longer or irregular cycles may create uncertainty regarding the timing of menstruation, which can contribute to psychological distress, anxiety, and perceived stress. These psychological factors may, in turn, exacerbate premenstrual symptoms and increase the likelihood of screening positive for probable PMDD [41, 42, 43, 44]. However, because this study employed a cross‐sectional design, causality cannot be inferred, and further longitudinal studies are needed to clarify the biological and psychological mechanisms linking menstrual cycle duration and PMDD. Variables that were not significantly associated with screening‐positive probable PMDD in this study, including treatment‐seeking behavior, age at menarche, duration of menstruation, family planning use, employment status, and educational characteristics, were not further interpreted because the study was not powered to identify associations for all possible factors.

4.1. Strengths of the Study

This study included female students from multiple colleges and diverse academic disciplines, including both health and non‐health science programs, thereby improving the representativeness of the study population. The relatively large sample size and high response rate enhanced the precision of the prevalence estimate and the statistical power to examine factors associated with screening‐positive probable PMDD. Furthermore, the use of a standardized screening instrument (PSST‐A) allowed for a systematic assessment of probable PMDD symptoms and facilitated comparison with studies that employed similar instruments.

4.2. Limitations of the Study

This study has several limitations. Its cross‐sectional design precludes establishing temporal or causal relationships. The use of self‐reported data may have introduced recall and reporting bias. In addition, the PSST‐A is a screening instrument rather than a diagnostic tool; therefore, the findings represent screening‐positive probable PMDD rather than clinically confirmed PMDD.

5. Conclusion

This study found that 17.4% of female college students screened positive for probable PMDD. The findings indicate that probable PMDD symptoms represent an important reproductive and mental health concern among female college students in Nekemte Town. Factors significantly associated with PMDD included cohabiting with a boyfriend, living arrangement, severe dysmenorrhea, menstrual bleeding pattern, and menstrual cycle length. These findings highlight that PMDD is a significant concern for female college students and underscore the need for targeted interventions to address both the condition itself and its associated risk factors.

To address these issues, we recommend strengthening PMDD awareness through structured reproductive health education and providing accessible medical and lifestyle support for managing severe dysmenorrhea. Colleges should also establish counseling and peer support services to assist students facing emotional stress, particularly those in cohabiting relationships. Collaboration with the Ministry of Education and local health authorities is needed to develop clear guidelines and train faculty and staff to support affected students. Additionally, distributing IEC materials alongside workshops can enhance understanding of PMDD, and further research on students’ premenstrual experiences and coping behaviors is encouraged to inform future interventions.

Author Contributions

Buzuneh Tasfa Marine: conceptualization, investigation, funding acquisition, writing – original draft, methodology, validation, visualization, writing – review and editing, software, formal analysis, project administration, data curation, supervision, resources. Kitesa Biresa Duftu: conceptualization, investigation, funding acquisition, writing – original draft, methodology, visualization, validation, writing – review and editing, software, formal analysis, project administration, data curation, supervision, resources.

Funding

The authors have nothing to report.

Ethics Statement

Ethical approval for this study was obtained from the Research and Ethics Review Committee of Wollega University Institutional Review Board (IRB). Before commencement of the study, official permission to conduct the research was also obtained from the respective participating colleges. The objectives, procedures, and purpose of the study were explained to the deans or relevant authorities of each participating college, and permission was obtained before data collection commenced. Participation in the study was entirely voluntary, and participants were informed about the purpose and procedures of the study, their right to participate or decline participation, and their right to withdraw from the study at any time without any consequences. Written informed consent was obtained from all participants before data collection. The confidentiality and privacy of participants were maintained throughout the study, and the information collected was used solely for research purposes. The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.

Consent

Informed written consent was obtained from all study participants prior to data collection. Participants were clearly informed about the purpose of the study, their right to decline participation, and their freedom to withdraw from the study at any time without any consequences. The consent procedure was reviewed and approved by the Institutional Review Board of Wollega University. Confidentiality was strictly maintained, and all data were used solely for research purposes.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead author Buzuneh Tasfa Marine affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. The corresponding author can provide access to the datasets used and analyzed during the current investigation upon reasonable request.