A number of population-based epidemiological investigations on the prevalence of premenstrual complications have been conducted worldwide. Although research designs and methods differ among the studies, and most of them are based on retrospective rather than prospective recording, the findings have been reasonably congruent. They indicate that nearly 90% of women of reproductive age experience at least one cyclical premenstrual symptom [2, 4, 19, 26, 27]. The present study demonstrated that, with one exception, 199 students (99.5%) experienced at least one symptom listed on the MDQ premenstrually. Regardless of severity, the ten symptoms most often occurring among the participants include: skin disorders, irritability, fatigue, mood swings, general aches and pains, lowered school or work performance, backache, painful breasts, weight gain, and swelling. The results of our study agree with those reported in earlier studies, which indicate that regardless of ethnicity, women in their late teens and early twenties frequently experience such premenstrual complications [4, 19, 21, 24, 26, 28]. As to the severity, epidemiological surveys found a certain percentage (7.7–26.6%) of college students suffering from PMDD—a particularly severe form of PMS defined as a distinct premenstrual affective disorder [29, 30]. In this study, 122 students (61%) experienced at least one severe or extremely severe symptom in the premenstrual phase. Since none of them mentioned that their premenstrual symptoms disturbed academic performance, normal social activities, or relationships, we assume that their severity did not reach the level of severe PMS or PMDD. Although we need further investigation with prospective recordings to precisely evaluate premenstrual conditions, the study in hand reconfirms that a majority of college students are commonly aware of mind and body disharmony with a wide range of severity, in the late luteal phase as previous studies have presented [4, 21, 28,29,30].
The etiopathogenesis of the complex web of biopsychosocial factors of premenstrual symptomatology remains enigmatic. The present study demonstrates that negative subjective perception of health is significantly related to premenstrual symptomatic features, including its prevalence, type, and severity, in college students. As substantial evidence from earlier PMS research has shown [2, 15,16,17,18,19], this study also clarified that self-rating stress strongly relates to premenstrual symptomatology as assessed by MDQ scores. We further revealed that the 19 women who evaluated themselves as “unhealthy and stressed” had greater prevalence of severe or extremely severe premenstrual complaints consisting of general aches and pains, confusion, lowered school or work performance, decreased efficiency, loneliness, anxiety, restlessness, mood swings, and depression. The results, in other words, indicate that the students who felt unhealthy and stressed had more psychosocial and behavioral symptoms than physical ones in the premenstrual phase.
Subjective health and global self-ratings of health have been identified as a critical indicators of the multi-dimensional construct, health [8, 9]. Poorly perceived health links various adverse psychosocial states such as social isolation, negative life events, depression, and job stress [9]. In addition, self-evaluations of health were related to personal health practices, such as dietary behaviors, physical activity, sleeping, and smoking habits [10, 11, 31]. Such tools have been rarely used to explore premenstrual features; however, we found a 2016 Korean study that revealed women premenstrually experiencing moderate to severe levels of negative affect or intense symptoms of behavioral change had significantly lower scores of perceived health status and quality of life, compared to women with mild premenstrual symptoms [20]. In contrast to subjective health, an association between self-rating stress and premenstrual symptoms has been apparent. For instance, a cross-sectional study with 448 students recruited from three universities in Pakistan demonstrated that 81.5% of the students reported stress exacerbated their premenstrual symptoms [19]. While supporting the findings obtained from cross-sectional studies [15, 16, 18, 19], a longitudinal study in the US [17] elucidated that women with high stress in the previous month were significantly more likely to report an increased number and severity of symptoms in subsequent perimenstrual (premenstrual and menstrual) phases. In addition, changing stress levels across the two cycles were associated with a changing pattern of symptom severity. Methodologies for measuring premenstrual symptoms, perceived health, and self-rating stress are not always consistent among researchers. Taking previous findings [15,16,17,18,19,20] into consideration, together with the outcomes from the present study, however, we could interpret that negative subjective perception of health along with high self-rating of stress might, at least in part, be related to worsening premenstrual health conditions among reproductive-age women.
In addition to the significant effects of perceived health and stress on premenstrual symptoms, the present study found that the percentage of breakfast eating habits was significantly lower in the “unhealthy and stressed” group than in the “healthy and non-stressed” group. The result is consistent with previous investigations with female college students: A questionnaire survey conducted in two colleges in Japan found a significantly higher population with a self-perception of poor general health among the group that skipped breakfast [23]. The survey also indicated that skipping breakfast adversely affects menstrual disorders in college students. According to a 2016 Turkish epidemiological research, college students with unhealthy behaviors, including irregular breakfast habits, had higher PMS scores [24]. The mechanism through which breakfast contributes to improving premenstrual symptoms remains unclear. Ferrer-Cascales et al. [32] suggested, however, that consuming carbohydrates at breakfast could boost beneficial nutrients for the brain after night fasting as it reduces levels of cortisol production and thereby decreases stress signals. Conversion of carbohydrates into glucose is essential for the formation of tryptophan, a precursor protein for the synthesis of serotonin, which regulates depressive symptoms, irritable mood, and cognitive functioning—all representative of the symptom-complex in the premenstrual phase.
As a first-line therapy, lifestyle modification is recommended for all women experiencing premenstrual symptoms [2]. In addition, health education programs on the effects of ovarian hormones and menstrual cycles on biopsychosocial aspects could be helpful for college students to increase the predictability of menstruation-related problems [2, 5]. A series of the authors’ investigations revealed a significant late-luteal increase in sympathetic nerve activity and decrease in parasympathetic nerve activity [12, 33]. Holistic healing treatments however, improved such autonomic imbalance [13, 34]. Taken together, the present study further implies that women in the early reproductive-age stage should learn about such menstrual-cyclic mind and body fluctuations, acquire strategies for managing stress, and conduct healthy behaviors, which could ameliorate premenstrual symptoms and, ultimately, improve quality of life.
Although the present study entails an important advance in comprehending premenstrual features in college students, we should address some limitations. First, the cross-sectional design of the study did not allow us to establish causal relationships between the variables studied. Second, the retrospective type of questionnaire could result in an overestimation of the prevalence of PMS by the participants. Prospective recording of menstrual cycle-related symptoms at least for 2 months is needed to detect frequently occurring symptoms premenstrually. Third, lifestyle factors including breakfast eating habits, regular exercise habits, and sleeping duration, were also based on self-reporting, which may be subject to error. Finally, the present study included a small, selective, and unevenly distributed sample size. This could limit the outcomes of our study to generalizability.