Positive perimenstrual changes: toward a new perspective on the menstrual cycle

The Prevalence of Menstrual Cycle Disorders and Menstrual Cycle-Related Symptoms in Female Athletes: A Systematic Literature Review

BACKGROUND

Menstrual cycle (MC) disorders and MC-related symptoms can have debilitating effects on the health and performance of female athletes. As the participation of women in sports continues to increase, understanding the prevalence of a range of MC disorders and MC-related symptoms may guide preventive strategies to protect the health and optimise the performance of female athletes.

OBJECTIVE

To examine the prevalence of MC disorders and MC-related symptoms among female athletes who are not using hormonal contraceptives and evaluate the assessment methods used to identify MC disorders and MC-related symptoms.

METHODS

This systematic review was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Six databases were searched until September 2022 for all original research that reported the prevalence of MC disorders and/or MC-related symptoms in athletes not using hormonal contraceptives, which included the definitions of the MC disorders examined, and the assessment methods used. MC disorders included amenorrhoea, anovulation, dysmenorrhoea, heavy menstrual bleeding (HMB), luteal phase deficiency (LPD), oligomenorrhoea, premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). MC-related symptoms included any affective and physical symptoms related to the MC that do not cause significant personal, interpersonal or functional impairment. The prevalence data across eligible studies were combined, and all studies were qualitatively synthesised to evaluate the assessment methods and tools used to identify MC disorders and MC-related symptoms. The methodological quality of studies was assessed using a modified Downs and Black checklist.

RESULTS

Sixty studies involving 6380 athletes were included. A wide range of prevalence was observed for all types of MC disorders, with a dearth of data on anovulation and LPD. Based on pooled data, dysmenorrhoea (32.3%; range 7.8-85.6%) was the most prevalent MC disorder. Studies reporting MC-related symptoms mostly examined the premenstrual and menstruation phases, where affective symptoms appeared more prevalent than physical symptoms. A larger proportion of athletes reported symptoms during the initial days of menstruation compared with the premenstrual phase. MC disorders and MC-related symptoms were retrospectively assessed using self-report methods in 90.0% of studies. Most studies (76.7%) in this review were graded as moderate quality.

DISCUSSION

MC disorders and MC-related symptoms are commonplace among female athletes, warranting further research examining their impact on performance and preventive/management strategies to optimise athlete health. To increase the quality of future studies, researchers should adopt standardised definitions of MC disorders and assessment methods such as a combination of calendar counting, urinary ovulation tests and a mid-luteal phase serum progesterone measurement when assessing menstrual function. Similarly, standardised diagnostic criteria should be used when examining MC disorders such as HMB, PMS and PMDD. Practically, implementing prospective cycle monitoring that includes ovulation testing, mid-luteal blood sampling (where feasible) and symptom logging throughout the MC could support athletes and practitioners to promptly identify and manage MC disorders and/or MC-related symptoms.

TRIAL REGISTRATION

This review has been registered in the PROSPERO database (CRD42021268757).

Menstrual distress in females of reproductive age: a literature review

Menstrual-related issues have significant public-health ramifications. Women who are having menstruation troubles should get their mental health checked by healthcare specialists. In young women, a menstrual-related condition has serious health implications. Young females who have menstrual issues miss job and school, and their behavioural and mental development suffers as a result. Depression and anxiety have an impact on women's menstrual periods in adults. Symptoms like as cramps, tiredness, backache, swelling abdomen, and painful breasts have also been described in women with menstrual misery. Menstrual distress has been shown to impair women's daily activities, as well as their reproductive and psychological health, according to research. Menstrual periods are frequently accompanied by a variety of unpleasant symptoms, such as premenstrual syndrome, which includes symptoms such as mild cramping and exhaustion. The severity of these symptoms, on the other hand, differs from woman to woman, depending on their health, food, way of life, and other factors. Women with menstrual-related issues have also reported smoking, alcohol intake, and an increase in hunger. Furthermore, young women experience emotional disturbances such as melancholy, restlessness, and despair. It is a sign of an atypical menstrual cycle if there is no cycle or if the bleeding is atypical or light. As a result, it is critical to maintain contact with a gynaecologist in order to detect any significant changes in a regular menstrual cycle.

The effect of manipulated information about premenstrual changes on the report of positive and negative premenstrual changes

Although women predominantly report negative premenstrual changes, a substantial portion of women also reports positive changes. Little is known about factors related to report of positive and negative premenstrual changes. The aim of this experimental study at the Philipps-University of Marburg from January and February 2015 was to investigate the effect of manipulated information about premenstrual changes on the retrospective report of premenstrual changes. A total of 241 healthy women were randomly assigned either to an experimental group (EG) reading: (1) text focusing on negative and positive premenstrual changes (EG1 (+/-)); (2) text focusing on negative changes (EG2 (-)); or (3) control group (CG) text. At least one positive premenstrual change was reported by the majority of the participating women. The results of the MANOVA and discriminant analysis showed that, after having read the text, EG2 (-) reported more negative and fewer positive premenstrual changes in a retrospective screening compared to EG1 (+/-) and CG. No significant difference was observed between EG1 (+/-) and CG. The results show the negative influence of information focusing on negative premenstrual changes on the retrospective report of both negative and positive premenstrual changes.

Questionnaire Studies of Paramenstrual Symptoms

A number of formal questionnaires have been devised to study paramenstrual symptomatology. It has been suggested that women's responses to these questionnaires are vulnerable to forgetting and contaminated by culturally induced expectations. Nevertheless, concurrent reports of experienced symptoms may correlate highly with retrospective judgments, even when the relevance of the menstrual cycle is disguised. They also differentiate between women with and without a self-reported history of premenstrual symptoms, although concurrent reports across several menstrual cycles are impractical to collect and may be inconsistent between successive cycles. A number of methodological criticisms have been directed toward the most commonly used device, the Menstrual Distress Questionnaire. In principle, however, retrospective questions offer a reliable and accurate indication of women's experience during the normal menstrual cycle.

Mood and Well-Being in Consecutive Menstrual Cycles

The level of consistency of cyclical change in well-being between consecutive menstrual cycles has important methodological, clinical, and theoretical implications. In this study, 109 women completed daily diaries of mood and physical well-being for two consecutive menstrual cycles. Scores in equivalent cycle phases were highly correlated, but the degree and direction of change from the pre-post menstrual phase were less consistent between cycles. Physical experiences proved more consistent across cycles than did emotional ones. Only 5.4% (nonsteroidal contraceptive users) and 7.8% (oral contraceptive users) of Cycle 2 emotional score variance could be accounted for by Cycle 1 scores compared to 15% and 22%, respectively, for physical scores. The data indicate that premenstrual experiences vary between menstrual cycles, and suggest that they cannot be adequately explained on the basis of simple biological determinism. Methodological and theoretical implications of the results are discussed.

Effects of the menstrual cycle on bipolar disorder

OBJECTIVES

Several lines of research suggest that reproductive events may affect the course of bipolar disorder (BD) in some women. With respect to the menstrual cycle, the focus has been on dysphoric symptoms [e.g., premenstrual dysphoric disorder (PMDD)], and the exacerbation of depression, in the premenstrual phase. This article reviews the literature on the potential effects of the menstrual cycle on BD.

METHODS

A systematic search for published case reports and research studies available through March, 2013 was conducted. Several combinations of search terms were entered into PubMed and PsycInfo.

RESULTS

Overall, 25 case reports, ten retrospective studies, and 11 prospective studies were identified. The majority (64%) of case reports involved hypomanic or manic episodes in the premenstrual phase. Retrospective results suggest that 25-77% and 15-27% of women with BD meet the criteria for premenstrual syndrome (PMS) and PMDD, respectively. Menstrual cycle-related mood changes were reported by 64-68% of women with BD in retrospective studies, and were displayed by 44-65% of women in prospective studies.

CONCLUSIONS

Although research has focused on the premenstrual phase to the neglect of the periovulatory phase, it appears that a subgroup of women with BD, possibly those with hormonal sensitivity, experience menstrual cycle effects on depressive, hypomanic, and manic episodes. These phase-episode effects appear to be heterogeneous and may have implications for treatment. Whether they might best be described using course specifiers, similar to postpartum onset and rapid cycling, or as diagnostic entities, like PMDD, requires further study.

Positively reframing perceptions of the menstrual cycle among women with premenstrual syndrome

OBJECTIVE

To positively reframe perceptions of menstrual cycle experiences to diminish reports of negative perimenstrual symptoms among women with premenstrual syndrome (PMS).

DESIGN/SAMPLE

A longitudinal quasi-experimental research design; data were collected on 28 women.

SETTING

Treatment sessions were conducted in a university classroom in the northeastern United States.

INTERVENTION

The intervention consisted of a health promotion program that provided social support and a psychoeducational intervention with a positive reframing psychotherapeutic maneuver.

MAIN OUTCOME MEASURES

To describe (a) perceptions of biologic, psychologic, and social outcomes related to perimenstrual changes and (b) compare biologic, psychologic, and social outcomes of women participating in a health promotion intervention with women not participating.

RESULTS

Negative perimenstrual symptom reports decreased for women in the experimental group. In addition, the participants' personal resources increased significantly.

CONCLUSIONS

Participation in a peer support group that provides women with information on positive concomitants of the menstrual cycle can benefit women with PMS.

Changes in scores on the Mental Rotations Test during the menstrual cycle

The purpose of the study was to examine changes in performance on Vandenberg's Mental Rotations Test during the menstrual cycles of college women. Participants were 12 male and 34 female students recruited from undergraduate educational psychology and nursing classes at a large southeastern university. Each woman was tested once during the menstrual phase and once during the luteal phase of her menstrual cycle. Phases in which the testings occurred were counterbalanced. Men were also tested twice. For all participants, the two testing sessions were held exactly 14 days apart. Women who were contraceptive pill users did not perform significantly differently during either phase from women who were nonusers, and there was no interaction for pill use by phase. Therefore, users and nonusers were combined for a paired-sample t test which indicated that women scored significantly higher during the menstrual phase (Days 2-7) than during the luteal phase (Days 16-22 for 31 women and Days 24-26 for three women with longer cycles). The 12 men scored significantly higher than the 34 women during the initial testing; but not significantly higher than the 17 women who were in the menstrual phase during the first testing. Therefore, that the effect of the phase of menstrual cycle influences the sex difference in performance on the Mental Rotations Test was supported.

Effect of positive reframing and social support on perception of perimenstrual changes among women with premenstrual syndrome

Traditional menstrual cycle research reflects a stereotypical negative bias that does not encompass the complexity of the phenomena. For example, even though the majority of menstrual cycle literature has focused on negative changes during the perimenstruum, some women report positive changes. This article describes a unique intervention aimed at reframing perceptions of menstrual cycle experiences for the purpose of diminishing perimenstrual impairment. The intervention was a health promotion program that provided social support and a positive reframing component for women with premenstrual syndrome (PMS) across four menstrual cycles. Through use of a preexperimental design, data were collected on 18 women. Daily measures included prospective assessment of perceptions of perimenstrual changes (impairment and activation). Retrospective assessments of moods (anxiety and depression), social resources (personal resources and marital satisfaction), and perimenstrual change perceptions were gathered at three time periods--before, during, and after the experimental condition. Data analyses included descriptive and multivariate strategies. Results indicated that, although perimenstrual activation did not increase significantly, impairment did decrease. In addition, there were significant changes from baseline to follow-up on state depression and personal resource variables. Findings from this study underscore the need for further investigation of the wide continuum of women's diverse menstrual cycle experiences.

Premenarcheal expectations and postmenarcheal experiences of positive and negative menstrual related changes

PURPOSE

Longitudinal examination of early adolescent girls' premenarcheal expectations and postmenarcheal experiences of positive and negative menstrual related changes.

METHOD

Ratings of 14 positive and negative changes were made by 80 girls on three occasions: (1) in grade 6 when girls were premenarcheal, (2) at the test occasion within six months after each girls' own menarche, and (3) in grade 9 when girls were postmenarcheal. Premenarcheal girls rated expectations of changes, and postmenarcheal girls rated experiences of changes, for both premenstrual and menstrual phases. Girls also rated preparation for, and emotional response to, menarche and mothers' helpfulness on the first two occasions.

RESULTS

Ratings for positive and negative changes were at similar levels premenarcheally and decreased at menarche; once menstruation became established, ratings of negative changes increased while those of positive changes decreased. Ratings for negative changes were higher in the menstrual phase, while ratings for positive changes were higher in the premenstrual phase. Premenarcheal expectations of changes contributed to the prediction of menarcheal experiences of changes. Premenarcheal expectations and menarcheal experiences, along with anticipated emotional response to menarche, contributed to the prediction of longer-term experience of negative changes; menarcheal experiences, along with preparation for and emotional response to menarche, contributed to the prediction of longer-term experience of positive changes.

CONCLUSIONS

Both expectations about, and initial experiences of, menstrual cycle-related changes were associated with longer-term menstrual experiences. The different outcomes for positive and negative changes have implications for menstrual socialization, and provide the basis for some optimism about facilitating a more complex and multidimensional understanding of menstruation.

Reframing women's health in nursing education: a feminist approach

To operate from a feminist paradigm is a new way of thinking for nurse educators. Feminist perspectives in nursing provide a new stage of consciousness--one that values women's voices, their way of knowing, and their life experiences, and, most important, one that challenges traditional patriarchal practices. Furthermore, nursing curricula with feminist perspectives provides a biopsychosocial approach that encourages the full recognition of variables that can influence women's health, such as socioeconomic status, racial and ethnic background, and biobehavioral factors. The debate in medicine over a specialty in women's health is not unique. The history of academia abounds with descriptions of struggles to establish new fields and disciplines. Recent specialties, such as pediatrics and gerontology, which are distinguished by age rather than specific organ or system, struggled for establishment and recognition. Historically, nursing curricula has emulated the biomedical model that is reductionistic and contradictory to nursing's holistic mission. Rather than classifying women's health into a separate entity, women's health may be introduced into present curricula by employing feminist ideals and pedagogy throughout the curriculum. This approach would provide a mechanism to explore women's health issues that were previously minimally addressed at best, or not addressed at all. More important, students would be provided with an opportunity to examine the societal effects of racism, sexism, and classism, and this education would potentially lead to a growing awareness of concerns specific to women and minorities.

Aerobic exercise, mood states and menstrual cycle symptoms

This study examined the effects of regular, moderate exercise on mood states and menstrual cycle symptoms. A group of female regular exercisers (N = 97), and a second group of female nonexercisers (N = 159), completed the Menstrual Distress Questionnaire (MDQ) and the Differential Emotions Scale (DES-IV) premenstrually, menstrually and intermenstrually. Multivariate analyses of covariance (MANCOVAs) revealed significant effects for exercise on negative mood states and physical symptoms, and significant effects on all measures across menstrual cycle phase. The regular exercisers obtained significantly lower scores on impaired concentration, negative affect, behaviour change and pain. No differences were found between groups on positive affect and other physical symptoms.

Premenstrual experiences: the four profiles and factorial patterns

Premenstrual experiences were studied in 112 non-complaining women using the Premenstrual Assessment Forms I (for positive experiences), II (for distressing experiences) and the bi-directional Visual Analog Scale. Overall, 27% of women reported no or minimal changes, 20% reported predominantly negative experiences, and 18% predominantly positive feelings. However, the commonest experience was a mixed picture with coexisting positive and negative feelings in 35% of the subjects. Severe premenstrual changes were noted in only nine (8%) of the women. None had a late luteal phase dysphoric disorder. The 26 items of the Premenstrual Assessment Forms I and II were factor analyzed by the principal components method using a varimax rotation. Four factors were derived. Factor I had 12 items indicating negative experiences. Factor II had seven items indicating positive feelings. The other two factors have vegetative features (like sleep and bowel changes) and sexual feelings. The findings also indicated that research needs to be directed towards understanding the mixed group of symptoms rather than the excessive emphasis on negative feelings.

Is premenstrual syndrome an endocrine disorder?

To both patients and physicians it seems natural to attribute adverse premenstrual phenomena to cyclic fluctuations of hormones produced by the ovary. This seems so plausible that, although the endocrine mechanism that causes premenstrual syndrome remains unknown, the condition itself is often treated with hormonal substances. Psychosocial factors are thus considered to be of only secondary importance. They may play a role as a contributing factor, to the 'real' cause of premenstrual syndrome they are not an essential ingredient. The aim of this review article is to examine how strong the evidence is for the possible existence of an endocrine factor as the causative agent in premenstrual syndrome. Using an epidemiological approach we conclude that the continuing search for the responsible mechanism that causes premenstrual syndrome may very well be an endocrine 'Holy Grail'. Human behavior cannot be understood within a single (hormonal) frame of reference. Cyclical ovarian activity is only one of the etiological factors in premenstrual syndrome. Unravelling the pathogenesis of premenstrual syndrome requires a multidisciplinary approach.

Cultural variations in attitudes toward menstruation

Attitudes towards menstruation play an important role in the perception of menstrual distress. The influence of cultural and social factors was studied in a group of 48 Indian women using the Menstrual Attitudes Questionnaire (modified version). Women over 25 years of age were significantly more likely to consider menstruation as being "natural". No other significant relationships were found between menstrual attitudes and demographic variables. The menstrual attitudes of Indian and American college women (from a previous study) were also compared.

Sociocultural aspects of menstrual attitudes and premenstrual experiences in India

Menstrual attitudes were studied in a group of 48 Indian women using the Menstrual Attitude Questionnaire, modified and adapted for Indian background. Attitudinal factors of menstruation being a natural, bothersome and debilitating event were studied, as also denial of the event and healthy/unhealthy attitudes. High rating was seen in menstruation being perceived as a natural event and least as a debilitating one. Older women considered menstruation as a natural event. Relating premenstrual experiences to attitudes, it was observed that distressful symptoms correlated significantly with debilitating and unhealthy attitudes. Similarly, premenstrual well-being correlated highly with naturalness attitudes, thereby suggesting that the personal experiences are likely to influence the menstrual attitudes.

Premenstrual syndrome

The Premenstrual Syndrome (PMS) was described as a unique entity meriting therapeutic attention in 1931. Although researchers in the area have failed to develop a widely accepted definition of PMS, substantial progress has been made in describing the variety of psychobiological profiles encompassed by this syndrome, particularly with respect to its typical symptoms, cyclical nature, symptoms recurrence and severity. Therapies ranging from diet and exercise to vitamin, hormone and drug treatment have been proposed. While none is more efficacious than placebo, several have been popularized. Our failure to develop adequate treatment may reflect our lack of understanding of either the psychosocial or biological factors involved in PMS. This, in turn, may reflect inadequate theoretical development in this research area. We provide a critical assessment of research on PMS, suggest a framework for theoretical development and advocate research strategies that might provide insights into the etiology of the premenstrual syndrome.

Men's perception of premenstrual changes on the premenstrual assessment form

Outcome research has shown that partner-spouse support can enhance the therapeutic outcome in a number of clinical problems. In the area of premenstrual tension, studies of treatment have apparently overlooked this issue of partners' support. This study was designed to address how men perceive premenstrual changes. 99 undergraduate men were asked whether they believed that women had premenstrual changes reflected on the 18 unipolar scales of the Premenstrual Assessment Form. Responses suggest that young men acknowledge that some women experience dysphoric features like hostility, mood swings, and low self-esteem as well as physical discomfort and behavioural changes. Clinical implications are outlined.

Cultural variations of premenstrual experience

Forty-eight female nursing students who were in the reproductive age group were evaluated for cognitive, affective and somatic changes in the premenstrual phase. A retrospective rating method was used with measurements on numerical and visual analogue scales. The visual analogue scale was used for bidirectionality of measurement. Ratings on 17 items were compared during the premenstrual phase and the rest of the cycle. Significant changes were seen in three of the distressing items. A Premenstrual Syndrome, the late luteal phase disorder of DSM-IIIR criteria, was identified in 6% of the women. The varying patterns of premenstrual changes and their prevalence are discussed in a sociocultural context.