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 �:	@Pre menstrual syndrome and health related quality of life among young adult females at Northern India: A cross-sectional study
    Malhotra P1, Sharma SK2, Kaur R3, Urvashi3, Vanshika3
               
Abstract: Pre-menstrual syndrome is a cyclic recurrence of distressing somatic and affective symptoms in the luteal phase of menstrual cycle.Emerging of these symptoms during young age can complicate their interpersonal relationship, social and educational performance in a negative way resulting in poor self-esteem and sense of dissatisfaction and inadequacy. The study was carried out to assess the prevalence of pre-menstrual syndrome among the young adult female students of AIIMS Rishikesh and their health related quality of life and also the correlation between the pre-menstrual syndrome and health related quality of life. In this A descriptive cross sectional study was conducted in College of Nursing, AIIMS Rishikesh on the students of B.Sc (Hons.) Nursing first year, second year ,third year and fourth year. Total 235 subjects were selected by total enumerated sampling technique and data was collected by self-administer questionnaire. Data was analysed using descriptive and inferential statistics. The result shown that mean age of subjects was 21�1.65. Out of 235 subjects ,21% subjects had very severe, 27% severe, 35% moderate and 17% had mild PMS. Similarly out of total subjects 51% had very good followed by 29% excellent, 17% had good health related quality of life and only 3% had very poor health related quality of life. Moderately negative correlation(r=-.63) was found between PMS and health related quality of life .that shows with increase in score of PMS health related quality of life decreases. 
Keywords: Premenstrual syndrome, health related quality of life, young adult females.
INTRODUCTION
Background of the study:
Menstruation is the regular shredding of mucosal tissue and blood from the uterus through the vagina. The typical length of time between two successive periods is 21-45 days in young women and 21-31 days in adults. Bleeding usually last around 2-7 days. The four phases of menstruation cycle are bleeding phase, follicular phase, ovulation phase and luteal phase. The   first phase is a follicular phase (1-14 days) in which the ovarian follicles mature and gets ready to release an egg. Ovulation (14th day) is the second phase of the ovarian cycle in which a mature egg is released from the ovarian follicle into the oviduct. The luteal phase(14-28 days) starts from the time of ovulation and ends at the onset of menses. It corresponds to the secretary phase of uterine cycle [1].
Among the gynaecological problem, menstrual problems are said to be major ones specially among adolescent and young adult females. Some women experiences the variety of disturbing symptoms during their luteal phase and beginning of the menstrual bleeding that are known as Pre-menstrual syndrome(PMS).Oestrogen and progesterone can cause transitory fluid retention ,as can excess aldosterone and ADH in the body which may be one of the contributing factor of PMS [2].
Pre-menstrual syndrome is a cyclic recurrence of distressing somatic and affective symptoms in the luteal phase of menstrual cycle PMS is group of physical, cognitive, affective and behavioural symptoms that occur cyclically during the luteal phase of few days of the onset of menstruation. About seven to four days prior to and in some cases even during menstruation some females have clearly defined manifestations of certain symptoms with somatic and psychological components. The symptoms like anger, depression, anxiety,-and rejection adversely affect the social and work related activities of women. Emerging of these symptoms during young age can complicate their interpersonal relationship, social and educational performance in a negative way resulting in poor self-esteem and sense of dissatisfaction and inadequacy.PMS in young adults might particularly affect college function and social & interpersonal relationship in a negative way [3-5]. 
PMS is associated with reduction in health related quality of life and women with PMS have greater work productivity impairment than women without PMS.PMS is commonly encountered complaint among women and may affect women�s quality of life and reduce their occupational productivity. Despite of various physical, psychological and behavioural symptoms, true prevalence of PMS is difficult to determine because of self-treatment, difference in availability and access to medical care, definition and diagnostic criteria and cultural practices. Most young adult females of reproductive age have some physical discomfort in the week before dysmenorrhea called Pre-menstrual Syndrome. About 5-8% of young adult females suffer from PMS. In young females, it affects the educational function and social interaction in a negative way. Hence, the purpose of present study is to identify the females who suffer from PMS and to assess the health related quality of life. It is hope that this preliminary study could contribute to existing knowledge on the topic and provide information for future interventions [6,7].
Objectives:
To assess pre-menstrual syndrome among young adult females.
To assess the health related quality of life among young adult females.
   3.  To assess relationship between PMS and health related quality of life
Materials and Method                                                              
A cross sectional descriptive study design was used to assess pre-menstrual syndrome and health related quality of life among young adult female students in AIIMS Rishikesh.The study was conducted in All India Institute of Medical Science (AIIMS) Rishikesh, Uttrakhand. Institute operates autonomously under Ministry of Health & Family Welfare, Government of India. It is tertiary care institute with near about 900 beds to provide multi-speciality healthcare services and research based medical and nursing care in centre. Present study was conducted in College Of Nursing, AIIMS Rishikesh. College of�Nursing, AIIMS, Rishikesh has been started in 2013 and first of 60 B.Sc. (Hons) which was conducted by AIIMS, New Delhi. Presently, College of Nursing, is running�B.Sc. (Hons)Nursing;M.Sc.Nursing;Diploma in Peri-operative Nursing�and�PhD�programs.Target population involved all the students ( as per inclusion criteria) studying in BSc.(Hons) Nursing 1st, 2nd, 3rd,4th year of College of Nursing, AIIMS, Rishikesh and present at the time of data collection. Total enumeration sampling technique was used.The students in the age group of 18-25 years and those who are unmarried were included and students with gynaecological, medical and psychiatric problem and having ammenorrhea were excluded from this study. Ethical consideration was taken from Institutional Ethical Committee (IEC) of AIIMS Rishikesh .Self structured questionnaries were prepared for data collection which includes socio demographic profile sheet, clinical profile sheet, menstrual profile sheet, pre-menstrual syndrome assessment scale, health related quality of life assessment scale. Validity was checked through expert�s opinion and reliability was checked by test-retest method by using Karl Pearson�s correlation coefficient formula. And the reliability was found 1 for pre-menstrual syndrome assessment scale and 0.9 for health related quality of life assessment scale. Data was analysed using descriptive and inferential statistics and various statistical measures were used to find the statistical significance and SPSS software version-23 was used for data analysis.                     

RESULTS
Table 1:Socio-demographic profile sheet of subjects                                                                                                                                                N=235
Variables                                                       f(%)Academic year
First year	                   96(41)
Second year	                   47(20)
Third year	                   49(21)
Fourth year	                   43(18)

Age(in years)
18-21                                                         163(69)
22-25	                   72(30)
Mean age � SD	                 20.7�1.26

Habitat
Rural	                   69(29)
Urban	                  139(59)
Semi urban	                   27(12)

Religion
Hindu	                  193(82)
Muslim	                    14(6)
Sikh	                    14(6)
Christian and others	                    14(6)

Dietary habits
Vegetarian	                  152(65)
Non vegetarian	                   83(35)

Mother�s level of education
Illiterate	                   25(11)
Low education	                   54(23)
Middle education                                                 76(32)
High education	                   80(34)

Socio economic status*
Upper middle	                   47(20)
Lower middle	                  179(76)
Upper lower	                    09(4)

* Kuppuswamy socio-economic scale,2018
Table 2: Clinical profile of the subjects.
                                                                                                                                           N=235
Variables                                                              f(%)
Height(in cm)
140-155	                          86(36)
156-165	                         116(50)
166-175	                          33(14)

Weight(in kg)
34-55	                         164(70)
56-83	                          71(30)

BMI (in kg/m2)
Underweight(<18)	                          30(13)
Normal(18.5-24.5)	                         182(77)
Over weight(25-30)	                           19(8)
Obesity(>30)	                           04(2)

Table 3:Menstrual profile of the subjects	
	       N=235
Variables	         f(%)

Age at menarche(in years)
10-12	        58(24)
13-15	       159(68)
16-18	         18(8)

Duration of menstruation(in days)
<3	         15(6)
3-5	       184(78)
>5	        36(16)

Duration of menstrual cycle(in days)
<24	         03(1)
24-28	       157(67)
>28	        75(32)

Amount of flow
Heavy	        23(10)
Medium	       204(87)
Scanty	        08(3)

Menstrual regularity
Regular	       169(72)
Irregular	        66(28)

Amount of flow
Heavy	        23(10)
Medium	       204(87)
Scanty	        08(3)

Type of sanitary product used
Self made	         03(1)
Readymade	       232(99)

Dysmenorrhea
Absent	        24(10)
Mild pain	       123(52)
Moderate pain	        54(23)
Severe pain	        34(15)

Relief measures
Pharmacological method	         08(3)
Non pharmacological method	       177(75)
Both	        44(19)
None	         06(3)
Pharmacological method
Meftal spas	        39(17)
PCM	         10(4)
None of the above	       186(79)

Non pharmacological method
Yoga 	         14(6)
Home remedies	        24(10)
Hot application	        79(35)
Taking rest	        76(32)
Any other	        06(4)
More than one                                                     	  27(13)

Table 4: Distribution of subjects as per levels of PMS:
                                                                                                                                           N=235
PMS Levels                                                                 f(%)Mild (31-60)	                                                40(17)
Moderate(61-90)	                                                83(35)
Severe(91-120)	                                                62(27)
Verysevere(121-150)                                                    50(21)
Table 5:Distribution of subjects as per domains includes in PMS assessment scale
	                 N=235
DOMAINS	        Mean �SDPhysiological	            32�8.5
Behavioural	            19�6.8
Psychological 	            24�8.1Table 6:Distribution of subjects as per the levels of health related quality of life (HQOL) score:

                                                                                    N=235
 HQOL Levels 	        f(%)Poor(1-25)	        08(3)
Good(26-50)	        39(17)
Very good(51-75)	       119(51)
Excellent(76-100)	        69(29)
Table 7: Distribution of subjects as per domains of the Health related quality of life assessment scale
	                 N=235
Domains 	     Mean�SDPhysical	      18�4.24
Psychological	      16�4.56
Social support	      20�4.09
Activities of daily living	     20.7�12.57Table 8: Relation between  PMS and Health Related Quality of Life among subjects
Relationships
Mean +SD
rpPMS
HRQOL76�20.32
75�14.14
.-63*
0.01S          *moderately negative correlation                                  S statistically significant
DISCUSSION
The study was undertaken to assess the prevelance of PMS and health related quality of life among young adult females which includes 235 students of College Of Nursing, AIIMS Rishikesh.Higher level of PMS is related to poor health related quality of life which may interfere with their  interpersonal relationship, social and educational performances in a negative way resulting in poor self esteem and sense of dissatisfaction and inadequacy. 
Majority of subjects 163(69%) were of age group of 18-21 and majority 154(68%)had menarche at 13-15 years of age. 157(67%) had time interval of menstrual cycle between 24-28 days and only 66(20%) were having irregular menstrual cycle. Majority of subjects 184(78%) had menstrual cycle of 3-5 days. Same study was conducted by Kaur N et al(2008) conducted a descriptive study to assess the PMS and coping behaviour among all the nursing student. This study involved 248 students and self- administered questionnaire was used for data collection. The results showed that most of the students had abdominal pain, irritability, fluctuation of mood, lower work performance efficacy, difficulty in concentration and avoiding social activities. Most of the students used adaptive behaviour and healthy coping strategies.13
In the present study, Majority of subjects 177(75%) used non pharmacological relief measures followed by 8(3%) pharmacological measures. In non-pharmacological relief measures majority of subjects 35% used hot application,32% taking rest/leave from college,10% used home remedies,6% used yoga &13% used more than 1 method Similar study was conducted by Nagashekhara et al(2015) in their study ,most frequently used coping strategies to alleviate PMS symptoms were sleeping (63%),resting(62.3%) followed by listening to music (38.7%) and hot pack utilisation(32%).10
In the present study mean age of subjects was 20.7+1.26 and in present study majority of subjects had moderate 83(35%) level of PMS 27% severe,21% had very severe,29% had excellent and 17% had good and poor in 3%.In more than half of the subjects psychological and physical components was the most affected, however health related quality of life score mean in social support and activities of daily living domain was normal. 
Results of PMS and their severity suggest that they adversely affect some domains of health related quality i.e physical and psychological. In the present study there was moderately negative relationship found between PMS and health related quality of life (p=-.63) which shows that with increase in PMS score , the health related quality of life was decreased. The subjects who had mild PMS had a very good quality of life. These findings were similar to the study done by Hamid R (2014).12 As per their study 56 out  of 142 (39.4%) female medical students had PMS. In PMS group majority of girls i.e 60.6% had mild, 25% had moderate &14.2% had severe PMS. Quality of Life score was low in more than half of medical students especially in psychological and social components (p<0.5) and quality of life score in mental and environmental health was decreased as PMS Score averages increases. 
Limitations
Because of time constraint the study data was collected only from one setting i.e. College of Nursing, AIIMS, Rishikesh.
Randomisation was not done as sample was taken from single setting, hence, it was not possible to include some of the subjects of College of Nursing, AIIMS, Rishikesh and exclude other one.
CONCLUSION 
The present study concluded the prevalence of PMS and health related quality of life among young adult female students in AIIMS Rishikesh . It was found that subjects having mild, moderate, severe and very severe level of PMS and excellent, very good , good and poor health related quality of life respectively. In the present study, moderately negative relationship was found between health related quality of life and PMS that shows with increase in score of PMS health related quality of life decreases.
Recommendations
Similar study could be planned on large sample & setting to generalized the findings.
Nurses can be trained to deal with the pre-menstrual syndrome among young adult students.
Present study was mainly focus on assessing the pre-menstrual syndrome so that an intervention study can be planned in future studies for the young adult females so that they can minimise the stimuli that are responsible for provoking the PMS. 
REFERENCES
1. Buddhabunyakn N, Kaewrudee S, Chongsomchai C, Soontrapa S, Sombooneorn W, et al. (2017) Prementrual syndrome among high school students. Int J Women Health 9: 501-505. 
2. Jehan S, Auguste E, Hussain M, Merumal SR, Brzezinski A, et al (2016) Sleep and premenstrual syndrome. J Sleep Med Disord 3:1061. 
3. Zegeye DT, Megabiaw B, Mulu A (2009) Age at menarche and the menstrual pattern of secondary school adolescents in northwest Ethopia. Biomed Central Women�s Health 9:29.
4. Freeman EW, Halberstadt SM, Rickels JM, Lin H, Sammel MD (2011) Core symptoms that discriminate premenstrual syndrome. J Women Health 20:29-35.
5.Rapkin AJ, Winer SA (2009) Premenstrual syndrome and premenstrual dysphoric disorder; quality of life and burden of illness. Expert Review of Pharmacoeconomics and Outcomes Research 9:157-170. 
6. Delara M, Ghofranipour F, Azadfallah P, Tavafian SS, Kazemnejad A, et al. (2012)  Health related quality of life among adolesecent with premenstrual disorder: A cross sectional study. Health & quality of life outcome 10:1.
7. Abirami P, Ambika S (2017) Assess the prevalence of premenstrual syndrome among adolescent girls at SRM College of Nursing, SRM University, Kattankulathur. Asian J Pharmaceutical Clin Res 10:202-205.
8. Tolossa FW, Bekele ML (2014) Prevalence, impacts and medical management of premenstrual syndrome among female students: cross sectional study in college of health sciences, Mekelle University, Mekelle, Northern Ethopia. Women Health 14:52.
9. Mandal R, Sarkar AP, Ghorai S (2015) A study on premenstrual syndrome among adolescent girls students in urban area of West Bangal. Int J Reprod, contraception, obstetric and gynaecology 4:1012-1015.
10.Nagashekhara M, Tumkur A, Nilugal KC (2015) Study of premenstrual syndrome among future health care professionals in Master skills global College. 
11. Siahbazi S, Montazeria A, Taghizadeh Z, Masoomie R (2018) The consequences of premenstrual syndrome on the quality of life from the prespective of affected women: a qualitative study. J Res Med Dent Sci 6:284-292.
12.Eslamlau H, Oshnovu S, Heshmatian B, Akbari E (2014) Premenstrual syndrome & quality of life in Irarian medical students. Sexual Reprod Health care.
13. Kaur N, Thakur R (2009) A descriptive study to assess the pre menstrual syndrome and coping behaviour among Nursing students,NINE PGIMER Chandigarh. Nursing and Midwifery research journal 5(1).

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