The prevalence, risk factors and lifestyle patterns of Jordanian females with premenstrual syndrome: a cross-sectional study

Aim: The study aims to assess factors associated with premenstrual syndrome (PMS) and the frequency of using painkillers to relieve premenstrual pain. Methods: This is a cross-sectional study of 1580 premenopausal women. An online self-administered questionnaire consists of sociodemographics, and the diagnostic criteria using the Arabic Premenstrual Syndrome Scale (A-PMS). Results: The prevalence of PMS among Jordanian females was 94%. Moreover, a significant correlation was found between several factors, including BMI, family history of PMS, smoking, and herbal tea consumption and the psychological, physical and behavioral symptoms of PMS. Furthermore, analgesic use for pain relief and food cravings were significantly associated with psychological, physical and behavioral PMS symptoms. Conclusion: PMS is highly prevalent and affects women in different life aspects.

Premenstrual syndrome (PMS) is a group of symptoms that affect many women for a week or two before their menses, thus affecting their emotions, physical health and behavior during the luteal phase of the menstrual cycle and resolving within a few days [1].
PMS is diagnosed based on several criteria, including the International Classification of Disease (ICD-10), the American College of Obstetricians and Gynecologists (ACOG) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) [2,3].As with other syndromes, etiology is not fully understood.However, various factors contribute to the etiology, including genetic predisposition, ethnicity and hormonal fluctuations [4].
A growing body of literature has evaluated PMS and found that women with PMS have cyclic fluctuations in ovarian steroid levels, therefore causing unpredictable changes in opioid levels, the GABAergic system modulated by progestin, and eventually the serotonin levels [5,6].According to the most recent studies, it is found that there is a high prevalence of PMS symptoms in women.Epidemiological surveys have found that about 80-90% of females experience PMS symptoms and about 5% experience severe symptoms that interfere with their normal activities [7].Even though clinicians do not diagnose PMS as a medical condition, rising PMS levels would increase healthcare utilization.Thus, public clinicians should learn more about this serious condition [8].
A key problem that in case people overlook PMS diagnosis, this would result in a modest increase in direct medical costs with an average annual growth of $59 in direct costs (p < 0.026) and a significant increase in indirect costs of about $4333 per patient (p < 0.0001) compared with patients without PMS [9].Therefore, this study aimed to measure the prevalence of PMS among Jordanian women and explore lifestyle factors and dietary habits associated with PMS.

Methodology
Design & setting A cross-sectional study was conducted on Jordanian women with menses aged between 18 and 50 years from 15 November 2021 to 15 February 2022.Convenience and snowball sampling were used.An online multiple-choice questionnaire was administered via Google Forms and disseminated through social media.

Inclusion & exclusion criteria
Participants in this study included women aged between 18 and 50 years who had a menstrual period within the last 2 months.Exclusion criteria included women taking psychopharmacological medicines (e.g., antidepressants, antipsychotics), hormonal replacement therapy, lactation within 3 months before the study, pregnancy and oral contraceptive use.

Study questionnaire
A structured questionnaire was created and tested on a pilot population to improve the design and check the questionnaire's feasibility and clarity.The participants in the pilot study were eliminated from the final data analysis.
The questionnaire's final version comprised two sections and was self-administered online.The first section consisted of sociodemographic data such as age, level of education, occupation working in the health field or not and geographic area.In addition, more details were needed, such as the age at menarche, marital status, number of pregnancies and number of children.Also, anthropometric measurements were required.Based on height and body mass weight, body mass index was calculated using the Quetelet equation (body mass (kg)/height (m 2 )) and interpreted according to the criteria designated by the WHO [10].
Furthermore, in light of the data that supports PMS's relation to genetic inheritance, an additional question about PMS' family history was presented.Last, The first section ended with the Arabic Premenstrual Syndrome Scale (A-PMS) [11].Regarding similar tools, Al-Gahtani and Jahrami developed the first tool based on DSM-IV-TR criteria to screen and evaluate the severity of PMS among Arabic-speaking women.
A total of 23 items were divided into three domains: physical symptoms, psychological symptoms and impairment of functioning.Each symptom on the scale was categorized as (none [0], mild [1], moderate [2] and severe [3]).The following psychological symptoms were examined (depressed mood, feeling hopelessness, feeling guilty, anxiety, mood fluctuation, increased sensitivity toward others, anger, easily tempered, decrease or lack of interest, difficulty concentrating, lethargy, insomnia, sense of loss of control and feeling overwhelmed, etc.).Additionally, many physiological symptoms like breast tenderness, headache, muscle or joint pain and acne were also evaluated [11,12].
For lifestyle evaluation such as smoking were examined (current smoker, never a smoker, secondhand smoker or former smoker, for how long she has quit), the type of smoke (cigarettes, cigars, or shisha (hookah) or pipe (vape) which could be a contributing factor.
In addition, this study examined dietary habits among participants.We asked about the consumption of carbohydrates, healthy fats, dairy products, fruits, leafy vegetables, fast food, coffee and tea and herbal products.Supplement consumption was evaluated in the last 3 months, including (vitamin D, calcium, multivitamin, omega-3 zinc-vitamin C, other supplements or none).Furthermore, participants were asked about their dietary and lifestyle habits before or during their PMS.Finally, participants were asked about the use of pain painkillers in their menstrual cycle.

Data analysis
Descriptive analysis was illustrated as the mean and standard deviation for continuous data.In contrast, frequencies and percentages were used to summarize categorical data and present PMS symptoms' severity.The Pearson correlation coefficient was used to explain the correlation between physiological, psychological and behavioral PMS scores.In each domain, participants who provided a "none" response were deemed to have no PMS, while mild, moderate and severe responses were added and grouped as participants with PMS.
The prevalence of PMS symptoms among females scored 1485 out of 1580 responses, representing 94%.Based on the average score, we computed the score of each domain using a transformation procedure.After each domain was scored, its scores were converted into categories.The four types are: [0 to <1] refers to no PMS, [>1 to <2] refers to mild PMS, [>2 to <3] refers to moderate PMS, and [>3-to 4] refers to severe symptoms PMS.Multivariable logistic regression analysis determined independent risk factors correlated with PMS for each score category.All tests performed were two-tailed significance tests and a p-value (p = <0.05)was considered significant.Statistical analysis was performed using SPSS version 23 (IBM Corp., USA).

Results
This study included 1580 participants with a mean age of 27.3 years ±6.7.The mean BMI was 24.3 ± 4.7 kg/m 2 .More than half of the respondents' residences were from the middle region 65.8%.Furthermore, 40% were mainly employees, and 34.6% of the participants were not in the health field.The vast majority (86.4%) of participants had menarche at age ≥12 years.Below three quarters (71.1%) of the participants were single, and (28.9%) were married.In addition, participants were asked if they have a history of PMS in their families, and results showed that two-thirds (71.5%) of the participants have never had any PMS history.Other demographics of the study sample are indicated in Table 1.
Among the study participants, the prevalence of PMS was 94% and the prevalence of each premenstrual symptom (classified according to severity) is shown in Table 2. Overall, the most frequently reported premenstrual symptoms were depressed mood (45.7%), followed by muscle, joint, abdominal and back pain (43%) and anger feelings (42.3%).Nevertheless, the most frequently demonstrated severe physical symptom was muscle, joint, abdominal and back pain (43%).In comparison, anger feelings (42.3%), affective labiality (40.4%) and increased sensitivity toward others (40.1%) were the most often reported severe psychological symptoms.
As demonstrated in Table 2, commonly reported moderate symptoms were depressed mood (45.7%), noting that depression was not clinically diagnosed scale but self-reported; anxiety/worry (37.8%), and feeling overwhelmed (37.5%).While headache and acne (30.3% and 30.2%) are the most documented mild symptoms.Interestingly, most participants reported that "moderate behavioral symptoms" was found to interfere with relationships with (31.0%), work or school (44.1%) and daily routines (43.6%).Other responses are listed in Table 2.
Table 3 reveals responses to lifestyle questions.As for the smoking status, more than half of the participants were non-smokers, and slightly less than a quarter were smokers.However, when the participants were asked how often they exercise, almost half responded negatively, 'I don't do exercise' (53.7%).In addition, participants were asked about sleeping duration; more than two-thirds (69.6%) of the participants slept 6-8 h per day.
Regarding dietary habits, most participants reported consuming starchy foods and dairy products daily (44.6 and 44.0%, respectively).In addition, responses were almost similar about how many servings of fruits and leafy vegetables they consume/day; most of them answered 1-2 servings/day (46.9 and 45.5%, respectively).Interestingly, the consumption of caffeine-containing beverages (coffee and tea) was measured to be 1-2 cups a day (51.3%, 34.1%).Other responses of participants were summarized in Table 4.
According to dietary changes before or during PMS, most participants (65.7%) crave sweets.Moreover, the most common choices of herbal teas during PMS that the participants used were sage (34.4%), cinnamon (31.8%) and mint (27.0%), as shown in Table 5. Around 75% of participants reported using painkillers during PMS.Almost (45%) reported using pain killer once daily during their menstrual cycle.Concerning the type of painkiller, (46.8%) of the participants reported using paracetamol, more than two-fifths reported using a non-steroidal anti-inflammatory drug (NSAID) and (19.6%) did not use painkillers for pain management Table 5.

Discussion
The initial purpose of the current study was to identify PMS prevalence and severity among Jordanian women, identify related sociodemographic factors and examine the correlation of PMS symptoms with dietary habits.Besides, it highlights the use of analgesics to relieve PMS pain.According to the current literature, this was the first  study to examine the prevalence of PMS and its association with dietary habits among Jordanian women aged 18 to 50.
In the present study, age was significantly associated with a decreased risk of reporting psychological and behavioral symptoms of PMS.Mahin Delara et al. found similar results in an Iranian study, revealing a significant correlation between PMS and age [13].In addition, our findings showed a positive association between PMS and family history, which aligns with earlier studies, illustrating that premenstrual symptoms were associated with a mother's PMS history [14][15][16].This could be explained by shared biological and psychological factors influencing expectations and self-awareness [17,18].
The overall PMS prevalence was found to be (94%).The most frequently reported psychological and physical premenstrual symptoms were depressed mood (45.7%) and anger feelings (42.3%), muscle, joint, abdominal and back pain (43%), respectively, which is consistent with other studies, that observed how anger/irritability is the most frequently reported psychological symptom while abdominal pain was the most commonly observed physical symptom [19].Moreover, in a Jordanian study, depression and mood swings were commonly reported PMS symptoms before menstruation [20].However, another study found that the most common PMS symptoms were lethargy/fatigue, decreased energy, affective lability and depressed mood [21].Additionally, in a study on Japanese women, Takeda et al. found that most women reported anxiety, anger, fatigue or lack of energy [22]  changes, anxiety, fatigue, mood swings, abdominal bloating and tender breasts [23].Despite the difference in the prevalence of PMS symptoms between the previous studies, the selection of sample size and the diagnostic tools will likely influence the results.In this study, pregnancy history was significantly associated with PMS symptoms, decreasing the risk of reporting psychological symptoms.It has also been found that psychological and behavioral PMS symptoms are higher among single participants.In line with our findings, an earlier Jordanian study has demonstrated that PMS symptoms were more severe among married women [24].Nonetheless, the current results are contrary to those of Das's group, which reported that unmarried women have a 5.9-fold higher risk of PMS than married women [25].
Based on anthropometric measurements, the average BMI of the participants was within the normal range.BMI was significantly associated with an increased risk of physical and behavioral symptoms of PMS.Our outcomes were consistent with previous findings, demonstrating significant correlations between obesity, BMI, and PMS [15,24,26].These results have not confirmed previous research conducted by Aarushi Kharb et al., who found no correlation between PMS and BMI [27].Additionally, Isgin-Atici's study has reported insignificant differences in anthropometric measurements between PMS cases and their counterpart controls in Turkey [28].
Numerous studies have linked premenstrual symptoms with smoking [29,30].In addition, a meta-analysis of 13 studies involving 25,828 participants found that smoking increases the risk of PMS (p = 0.0001) [31].According to our results and previous research, adult female smokers have a significantly higher risk of reporting PMS than nonsmokers.This could be explained by the effect of cigarette smoking on the dysregulation of estrogen, progesterone and gonadotropin levels, which may be involved in PMS development [30].However, it is unclear whether smoking  contributes to the etiopathogenesis of PMS or whether women suffering from PMS smoke as a means of relieving their symptoms [30].Previously, it was found that carbohydrates and fiber consumption were not associated with PMS risk in a recent study by Houghton and colleagues, as well as a cross-sectional study conducted in the United Arab Emirates [4,32].On the contrary, a study by Hussein and colleagues revealed that a high intake of carbohydrates was associated with premenstrual symptoms [33].In our study, fast food consumption was positively related to psychological symptoms, future science group 10.2144/fsoa-2023-0056 similar to a study carried out in India has reported a significant association between frequent fast food consumption and PMS symptoms (p = 0.004) [34].In contrast, Houghton found no correlation between fat intake and PMS [35].This study's results reinforce Reem Abu Alwafa et al. study, which strongly recommended certain foods during menstruation [21].Another study shows the desire for foods rich in sugar, salt and fat, such as chocolate, pastries, snacks, and desserts, was higher during the premenstrual period [36,37].Moreover, according to Yukie Matsuura et al. under three-quarters (70.4%) of students had their appetites increased during menstruation cycles, but the highest number was observed before menstruation (85.8%) [38].Further, Zellner et al. stated that American women were more likely to crave chocolate during the perimenstrual period than Spanish women [39].This increase in carbohydrate consumption would also subjectively justify the increased need to consume food sources like chocolate, desserts, pastries and other foods.In theory, this may be explained by the relationship between simple carbohydrates (high glycemic index) and higher brain serotonin production [40], thus reducing negative mood effects [41].
In our study, we illustrated that PMS symptoms and analgesic use were significantly correlated, including the fact that three-quarters of participants needed analgesics to manage PMS-related pain.In agreement with our findings, participants in a cross-sectional study in Iran report that self-medication for PMS, especially using analgesics, is very common, at 70.2% [42].Taken together, self-medication of PMS-related pain indicates the need for further research on properly using painkillers to relieve PMS symptoms.
We are aware that our paper has some limitations.First, participants were asked to recall some information that could affect the accuracy of the data; this is referred to as differential recall bias.Secondly, those inherent to any self-administered questionnaire study, such as the misclassification of answers whether related to intake of foods or symptoms.Furthermore, the sample primarily represented the middle and northern regions, with limited information available from the southern regions.Additionally, cross-sectional design limits the ability to infer causal relationships.

Table 2 .
Prevalence of premenstrual syndrome symptoms by the level of severity (n = 1580).

Table 4 .
Participants' daily dietary behaviors and dietary behaviors before/during premenstrual syndrome.

Table 5 .
Dietary behaviors before/during premenstrual syndrome and pain management of premenstrual syndrome.

Table 6 .
Multiple regression analysis for dietary and lifestyle behaviors and associations with premenstrual syndrome.