Introduction:
Premenstrual dysphoric disorder (PMDD), a severe mood disorder, is characterized by cognitive–affective and physical symptoms in the week before menses and affects millions of women worldwide [1, 2]. Premenstrual dysphoric disorder (PMDD) comprises emotional and physical symptoms and functional impairment that lie on the severe end of the continuum of premenstrual symptoms. Women with PMDD have a differential response to normal hormonal fluctuations. This susceptibility may involve the serotonin system, altered sensitivity of the GABAA receptor to the neurosteroid allopregnanalone, and altered brain circuitry involving emotional and cognitive functions [3].
Premenstrual dysphoric disorder (PMDD) is the severe form of premenstrual syndrome (PMS). The psychological symptoms are irritability, emotional lability, anxiety, and depression. Somatic symptoms include edema, weight gain, mastalgia, headache, syncope, and paresthesia. They appear about 1 week before the onset of menses and disappear soon after onset of menses. [4] Premenstrual Dysphoric Disorder (PMDD) affects daily functioning and the disability-adjusted life years (DALY) lost because of it are comparable to those of major recognised diseases.[5]
Up to 70-90 % of women of reproductive age have one or more signs of physical discomfort or emotional symptoms in the premenstrual, i.e. luteal phase of their menstrual cycle. About 20-40 % of menstruating women has premenstrual syndrome (PMS) and experience luteal phase symptoms that are bothersome. Up to 8 %, experience more severe symptoms, which lead to substantial distress or functional impairment and are referred to as premenstrual dysphoric disorder (PMDD) [6-8].
PSST, is a fast, reliable and better tool for screening and is specially tailored for diagnosing PMS and PMDD [5, 9]. It is the screening tool developed by Steiner et al., [10] which reflects and translates categorical DSM-IV-TR criteria [11] into a rating scale with degrees of severity. Clinical and basic science researchers in wide-ranging fields of study including gynaecology, psychology, psychiatry, endocrinology, genetics, brain imaging, and neurophysiology have been interested in the exploration of this disorder for over 70 years, with an escalation of interest around the mid 1970s until today [12, 13].
Methodology:
The main purpose of the study was to find the prevalence of PMDD and its relationship with diet and lifestyle pattern among the women. A co relational study with the sample size of 200 was conducted in Mumbai city. The participants were selected on random basis from Mumbai city. Random sampling method was used for the study. Survey based research design was used, where the information was obtained individually/ from group of individuals, representative of large number of population. The participants were selected for the study purely based on their willingness to participate. The participants were informed about the study conducted, its design and the purpose of the study. The required consent was also taken. Interview cum questionnaire method was used to collect the data from the participants. Premenstrual Symptom Screening tool (PSST) was used to assess prevalence of PMDD in participants. The analysis was done using Statistical Package of Social Software for Windows (SPSS, version 20). The analysis of data included t-test and Chi-Square tests.
Results and Discussion
A total 200 participants filled the questionnaire without missing any data. The prevalence with various factors was analyzed and results were estimated.
Basic characteristics of the population: Among 200 participants, 42% of participants were of age from 10 to 20 years, 57% of participants were of age from 21 to 30 years and 1% included the participants with age of 41 to 50 years. Of the participants 66.5% were Hindu, 4% were Christian, 10% were Muslim, 19% were Jain, 0.5% were Buddhist and 2% were Assamese in terms of ethnicity. As for education, 2% of participants were in higher secondary school, 77% were in graduation and 21% were in post graduation. With regard to employment, 82% were unemployed and 18% were employed; 4% being housewives and 78.5% students. Medical history showed the presence of hypothyroidism in 0.5%, Polycystic Ovarian Syndrome in 4%, Pelvic Inflammatory Disorder in 1.5%, history of seizures in 1%, and migraine in 15% of participants.
Prevalence of PMDD: The prevalence of PMDD among 200 participants was 53.5% and 107 participants showed the presence of severe PMS/PMDD. A cross-sectional survey in Gujarat by Shruti V et al, 2019, in India among college students, also showed that 91.4% participants had at least one premenstrual symptom of any given severity (mild to severe) in at least more than or equal to half of the menstrual cycles during previous 12 months. [15]
Premenstrual Symptom Screening Tool (PSST):
The statistical analysis of signs and symptoms of 53.5% participants from PSST showed severe level of anger/irritability (89.7%), depressed mood/hopelessness (54.2%), decreased interest in social activities (62.6%), difficulty concentrating (52.4%), fatigue/lack of energy (67.3%), feeling overwhelmed or out of control (47.7%), physical symptoms including breast tenderness, headaches, joint/muscle pain, bloating and weight gain (92.5%) and moderate level of anxiety/tension (52.3%), tearful/increased sensitivity to rejection (67.3%), decreased interest in work activities (58.9%), decreased interest in home activities (57%), overeating/food cravings (50.5%), insomnia (35.5%). The above signs and symptoms interfered with their work efficiency/productivity, social life activities at severe level and their relationship with friends/classmates/ co workers, their relationship with family, their home responsibilities at moderate level; thereby establishing a highly significant relation between prevalence severity of PMDD and decreased quality of life among women. (p =.000).
Prevalence of PMDD with respect to anthropometrics:
Among participants with the presence of PMDD, maximum participants (48.6% and 40.2%) were overweight and obese and had waist to hip ratio more than 0.85 (96.5%). Table 1 gives the anthropometric parameters when classified according to presence or absence of PMDD. The mean value of height of women from the data collected with presence of PMDD was found to be in the range of 156.61± 6.196 cm. Similarly, the mean values of weight was 60.17± 8.136 kg, BMI was 24.32± 2.289 kg/m2, waist circumference was 72.83± 2.857cm, waist to hip ratio was 0.8464 ± 0.02989 and waist to height ratio was 0.4665 ± 0.2885. The mean value of height of women from the data collected with absence of PMDD was found to be in range 155.28± 6.035cm. Similarly, the mean values of weight was 52.34 ± 9.113 kg, BMI was 21.52±3.262 kg/m2, waist circumference was 70.08± 3.809 cm, waist to hip ratio was 0.8099 ± 0.04596 and waist to height ratio was 0.4525± 0.3010. (Table 1) There was a significant difference in weight, BMI, waist circumference and waist to hip ratio and waist to height ratio when classified according to presence of PMDD,(p < 0.05) whereas there was no significant difference in height when classified according to presence of PMDD. (p > 0.05). Hence, the participants with presence of PMDD had high mean values of weight, BMI, waist circumference, waist to hip ratio, waist to height ratio and were found to be highly significant with the prevalence of PMDD when t- test was performed. (p < 0.05).
| Table 1: Prevalence of PMDD with respect to Anthropometric Measurements |
| Categories |
Height (cms) |
Weight (kg) |
BMI (kg/m2) |
Waist circumference (cm) |
Waist to Hip Ratio |
Waist to Height ratio |
(Total mean) Presence of PMDD |
156.61± 6.196 |
60.17± 8.136 |
24.32± 2.289 |
72.83± 2.857 |
0.8464 ± 0.02989 |
0.4665 ± 0.2885 |
(Total mean)
Absence of PMDD |
155.28± 6.035 |
52.34 ± 9.113 |
21.52±3.262 |
70.08± 3.809 |
0.8099 ± 0.04596 |
0.4525±
0.3010 |
t-test Sig. (p value) |
0.128 |
.000* |
.000* |
.000* |
.000* |
.001* |
Prevalence of PMDD with respect to Physical activity:
Out of 107 women with PMDD, 76.6% had poor physical activity status (p=.000) whereas 23.4% indulged in exercises, majorly in the form of walking, for maximum 30 min, twice or thrice a week; Chi- Square test found the relation to be highly significant (p < 0.05) (shown in Table 2). Apart from these, among 107 participants who were suffering from PMDD, 56.1% did not indulge in household chores whereas 48% were involved in performing household work which involved washing utensils and cooking as majorly performed activity. A high significance value was found between these two variables with (p < 0.05). (Table 2)
| Table 2: Prevalence of PMDD with respect to Physical Activity |
| Categories |
Option |
Presence of PMDD (%) |
Absence of PMDD (%) |
Chi Square: Sig. |
Exercising Regularity |
Yes |
23.4% |
78.5% |
.000* |
No |
76.6% |
21.5% |
Total (%) |
100%(107) |
100% (93) |
Involvement in household chores |
Yes |
43.9% |
65.6% |
.000* |
No |
56.1% |
34.4% |
Total (%) |
100%(107) |
100% (93) |
No. of exercising times in a week |
Once |
0 |
6.5% |
.000* |
Twice |
2.8% |
10.8% |
Thrice |
10.3% |
15.1% |
Everyday |
10.3% |
46.2% |
Not at all |
76.6% |
21.5% |
Total (%) |
100%(107) |
100% (93) |
Types of exercise |
Walking |
16.8% |
33.3% |
.000* |
Yoga |
3.7% |
8.6% |
Zumba |
0% |
1.1% |
Running |
0% |
1.1% |
Gym |
2.8% |
26.9% |
Aerobics |
0% |
7.5% |
None |
76.6% |
21.5% |
Total (%) |
100%(107) |
100% (93) |
Duration of exercising |
15 min |
8.4% |
8.6% |
.000* |
30 min |
12.1% |
37.6% |
45 min |
0% |
11.8% |
1 hour |
3% |
20.4% |
Not at all |
82% |
21.5% |
Total (%) |
100%(107) |
100% (93) |
Washing Utensils |
Yes |
29.9% |
48.4% |
.009 |
No |
70.1% |
51.6% |
Total (%) |
100%(107) |
100% (93) |
Washing Clothes by hands |
Yes |
2.8% |
11.8% |
.023 |
No |
97.2% |
88.2% |
Total (%) |
100%(107) |
100% (93) |
Mopping and cleaning |
Yes |
7.5% |
24.7% |
.001* |
No |
92.5% |
75.3% |
Total (%) |
100%(107) |
100% (93) |
Cooking |
Yes |
21.5% |
38.7% |
.009 |
No |
78.5% |
61.3% |
Total (%) |
100%(107) |
100% (93) |
Prevalence of PMDD with respect to Lifestyle Pattern:
Since 100% of participants did not consume tobacco and other toxins or smoked hence no statistics were computed for smoking and tobacco and other toxins consumption because the variables in their coded form were constant. However, no significance was established (Table 3) between the alcohol consumption and presence of PMDD (p > 0.05).It was also found that the signs and symptoms involved among the participants with PMDD were affecting their day to day activities from moderate to high level; 55.1% of participants were moderately and 38.3% of participants were highly affected and this was found to be significant. (p < 0.05). This determined the low quality of life among the participants. When the stress factor was considered (Table 3), 99.1% of participants were constantly under high level of stress; a highly significant relation was determined between stress and prevalence of PMDD. (p < 0.05). When the sleeping patterns were monitored of the participants with PMDD (Table no 3), it was found that 72.9% of participants were having sleep less than 6 hours per day and 15.9% of participants were having sleep more than 7 hours. It was evident that participants were having poor sleeping patterns as well as high sleep disturbances. A significant relationship was found between the presence of PMDD and poor sleeping patterns. (p < 0.05)
| Table 3: Prevalence of PMDD with respect to Lifestyle pattern |
Questions |
Presence of PMDD |
Chi- Square Test (SIG.) |
YES |
NO |
Smoking |
- |
100% (107) |
.a |
Tobacco and other toxins consumption |
- |
100% (107) |
.a |
Alcohol |
2.8% |
97.2% |
1.000 |
Presence of constant stress |
99.1% |
0.9% |
.000* |
Sleep disturbance |
96.3% |
3.7% |
.000* |
Lifestyle pattern (Sedentary) |
100% (107) |
.a |
Stress level |
High – 40.2% |
.000* |
| Moderate – 58.9% |
| Severe – 0 |
| Mild – 0 |
No stress- 0.9% |
Sleeping hours |
6 hrs –10.3% |
.000* |
| Less than 6 hrs –72.9% |
| 7 hrs –0.9% |
More than 7 hours –15.9% |
Effect of signs and symptoms on women in their day to day activities |
High –38.3% |
.000* |
| Moderate - 55.1% |
| Less – 6.5% |
Not at all- 0% |
Prevalence of PMDD with respect to Diet:
From the data collected it was found that the maximum participants (52.3%) followed vegetarian diet and 41.1 % of participants did not consume their breakfast regularly as well as they skipped their meals frequently and a significant relationship was established with respect to these variables (p < 0.05).
The 24 Hours 3 days diet recall of the participants showed the mean values of Energy as 1439.535± 310.101 kcal, carbohydrates as 217.47±67.381 grams, protein as 39.47±12.184 grams and fats as 47.77± 14.511 grams respectively (Table 4). The t test was performed and it was computed that there was no significant difference in energy, CHO, protein and fats intake when classified according to presence of PMDD. (p > 0.05)
| Table 4: Prevalence of PMDD with respect to 24 hours 3 Days Diet Recall |
| Categories |
Energy (kcal) |
CHO (grams) |
Protein (grams) |
Fats (grams) |
Presence of PMDD |
1439.55± 310.101 |
217.46± 67.381 |
39.47± 12.184 |
47.77±14.511 |
Absence of PMDD |
1488.11± 298.008 |
211.63± 73.183 |
40.34± 11.596 |
46.65±18.922 |
t-test Sig. (p value) |
.843 |
.559 |
.604 |
.636 |
Although PMDD, like PMS includes physical symptoms, it always involves a worsening of mood that interferes significantly with the woman’s quality of life. The burden of illness of PMDD results from the severity of luteal phase symptoms, the chronic condition of the disorder and the impairment in work, relationships and activities. Recent advances and research data improved the knowledge on diagnosis, frequency, pathophysiologic mechanisms and treatment options in PMDD. The use of the term PMDD and the use of Selective Serotonin Reuptake Inhibitor in its management serve as the first line of treatment. Other treatments such as homeopathic courses, ayurvedic medicines, diet and lifestyle pattern, naturopathy, aromatherapy etc are also reported as beneficial in PMDD.[14] Risk factors for PMS/PMDD include stress, genetic factors, obesity, other health problems, a history of depression or anxiety disorder, or other psychiatric disorders [15]. Therefore, a healthy life style consisting of healthy diet and proper physical exercise is the crucial step for preventing and managing PMS which when not cured ultimately leads to PMDD.
Conclusions:
There is a significant co relationship between the presence of PMDD with poor lifestyle pattern. The presence of PMDD is more likely to be prevalent in early adulthood. Overweight and obesity along with high BMI and waist circumference might be the contributing factors in prevalence of PMDD. Lack of physical activity decreases the quality of life and contributes to gradual initiation of various disorders and diseases. Poor physical activity, sedentary lifestyle, high level of stress, poor sleeping patterns and skipping meals have positive relationship with respect to presence of PMDD, thereby decreasing the quality of life among women. Therefore, a healthy life style consisting of healthy diet and proper physical exercise is the crucial step for preventing and managing PMS which when not cured ultimately leads to PMDD. The research study was limited to Mumbai city and there are very few researches related to association of PMDD with diet and lifestyle pattern. Study can be done on a large population size in different cities on large scale to find out the prevalence and at risk groups. Precise range of age groups can be selected as well as study can be done on specific population for example, adolescent girls, working women etc., to know the various possible outcomes. Various dietary tools such as food diary, food frequency can be used to calculate the dietary intake more specifically. Nutritional educational program can be conducted to educate the participants and effect of nutrition on symptoms can be collected as well as various sessions can be conducted on physical activity and various beneficial exercises can be demonstrated that can enhance better and healthy lifestyle.
Acknowledgements:
I would gratefully thank my guide and co-author Dr. (Mrs.) Rekha Battalwar, Associate Professor of the Department of Food, Nutrition and Dietetics, S.V.T. College of Home Science. She has been a constant source of guidance, support, motivation and immense knowledge. She has helped me in every which way she could and was always ready to correct me whenever I went wrong. She made sure that my study comes out well and is perfect. I would like to thank madam for all insightful comments and constructive criticisms that have been thought provoking and helped me to be focused and give better results. I would also like to thank the participants for their participation for my research study.
Ethical Approval: The research proposal entitled “A study on relationship of prevalence of Pre Menstrual Dysphoric Disorder (PMDD) with diet and Lifestyle pattern of women in Mumbai city.” It was approved by the Institutional Ethical Committee (IEC) on 03rd August, 2019.
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