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ORIGINAL ARTICLES |
From the Departamento de Psicología, Universidad de las Américas-Puebla, Mexico.
Address reprint requests to: Dra. Ma. Luisa Marván, Departamento de Psicología, Universidad de las Américas-Puebla, Apdo. Postal 342, CP 72820, Sta. Catarina Mártir, Cholula, Puebla, Mexico. E-mail: mmarvan{at}mail.pue.udlap.mx
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ABSTRACT |
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METHOD: We studied 86 healthy Mexican women whose highest level of education was sixth grade. Participants were assigned to one of two groups. The experimental group watched a videotape describing PMS and its negative consequences in daily life. The control group watched a videotape describing the menstrual cycle. The Menstrual Distress Questionnaire was administered to all women during the first week after menstruation, after which they were shown their designated videotape, and the questionnaire was administered again after the next menstruation.
RESULTS: In the control group, there were no significant differences in premenstrual symptoms reported both before and after the women watched the videotape. However, women in the experimental group reported more severe premenstrual symptoms after watching the videotape.
CONCLUSIONS: These results suggest that after observing the videotape, women’s expectancies of negative symptoms in the premenstrual phase increased. Thus, the symptoms reported by these women were enhanced.
Key Words: premenstrual symptoms, • premenstrual syndrome, • expectancy, • knowledge.
Abbreviations: PMS = premenstrual syndrome;; MDQ = Menstrual Distress Questionnaire.
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INTRODUCTION |
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The American Psychiatric Association introduced the term premenstrual dysphoric disorder as a provisional diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (2). The diagnosis of premenstrual dysphoric disorder is both important for and limited by its narrow focus, aiming to develop systematic diagnostic criteria and emphasizing dysphoric symptoms. A diagnosis of premenstrual dysphoric disorder may exclude women whose premenstrual distress is predominantly characterized by anxiety (3) or physical symptomatology.
Depending on the methodology used by the researchers, it has been shown that between 30% and 90% of women report some physical or emotional premenstrual symptomatology. However, only 2% to 15% report severe or disabling symptoms (4–7). On the other hand, research findings have suggested differences in premenstrual symptomatology related to sociocultural aspects, such as ethnic background, urbanization, marital status, parity, education, and occupation among others (7–11).
It has been found that Mexican women with professional degrees report more severe premenstrual symptoms than those with less formal education (ie, no schooling to middle school) (12). Taylor et al. (13) also found that women with a high level of formal education report a more negative affect during premenstruum. The authors suggest that a possible explanation is that these women, being more knowledgeable about their health, may have the ability to describe their symptoms more fully than women with less formal education. Or, attending a university and being in a professional environment may make women more aware of the existence of premenstrual symptoms because of wider exposure. Another possibility is that professional women have more access to certain media, including that of other countries, as may be the case of the North American models of PMS. Therefore, self-reported symptomatology may be affected by a woman’s ideas about the symptoms she should experience (12). In this sense, it has been proposed that women’s reports of premenstrual symptoms may be, at least in some way, a function of expectancies (14–15).
The aim of this study was to determine how women without a high level of formal education are influenced by knowledge of the existence of PMS in their reports of premenstrual symptoms. Hence, participants in our experimental group watched a videotape describing PMS and its consequences in daily life.
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METHODS |
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Instruments
Symptoms were measured by the MDQ (16), which was translated into Spanish and adopted after its reliability and validity were proven (17). The MDQ is a 47-item questionnaire that considers physical and psychological symptoms. It asks the respondent to rate each symptom listed on a scale of 0 (no experience of symptom) to 5 (acute or partially disabling). In this study, we asked women to answer the MDQ, based on experiences of their most recent cycle, during two cycle phases (premenstrual and postmenstrual). The symptom items are grouped into eight factors: pain, water retention, autonomic reactions, negative affect, impaired concentration, behavior change, arousal, and control. For this study, we excluded arousal, which comprises a separate cluster of positive symptoms.
Procedure
An appointment was set up with the owners of each factory to explain the objective of the investigation and to request access to personnel. On agreement, a schedule was established, and conditions under which the interviewer could conduct the study were arranged. These conditions included work schedule, visiting days, and a designated area in which the study would take place. Subsequently, a questionnaire requesting general information was given to all female workers of the factories to select those who met the inclusion criteria of the study.
The factories were randomly assigned to one of two groups so that all participants working in one factory would be placed into the experimental or control group. The experimental group was shown a videotape that describes PMS and its negative consequences in daily life. The control group was shown a videotape that describes the menstrual cycle. Both videotapes lasted 10 minutes. (Both the transcripts and the videotapes are available from the authors.)
Both videotapes were created using predetermined images with different software as well as graphics designed by the authors. The images in the videotape shown to the experimental group were of women who experienced various premenstrual symptoms and their negative consequences. The narrative of the videotape related to this theme. In the control-group videotape, images, graphics, and tables were used to explain the menstrual cycle. The narratives of both videotapes were created with special attention given to the language used so that it would be comprehensible to women with a low level of education.
Before this investigation was conducted, a pilot study was conducted in which the MDQ was administered to women with different levels of education. This study showed that women with a low level of education had difficulty understanding certain items of the MDQ. Therefore, in this investigation, the interviewer read each item and asked the participant if she understood it. If a participant did not understand an item, the interviewer repeatedly explained it until the woman could express it in her own words. This ensured that none of the women answered a question without properly understanding it.
The MDQ was administered in two testing sessions, once before and once after watching the videotape. Both sessions were conducted during the postmenstrual phase (4–8 days after menses). Women were interviewed individually at work and were assured of anonymity.
The interviewer was blinded to subjects’ groups. We did not inform the subjects of the purpose of the study to avoid any biases in their responses related to our hypothesis. When we finished the data analyses, the interviewer explained to the participants the objective of the study and the results obtained. This procedure was designed considering the ethical principles of psychologists (18).
Data Analyses
Because the number of items in each MDQ scale varies, the mean scores for each scale were divided by the appropriate number of items. To define an adequate amount of change in severity throughout the menstrual cycle, a difference score called "premenstrual change" was calculated as follows: the difference between the premenstrual mean and the postmenstrual mean (premenstrual minus postmenstrual) was divided by the postmenstrual mean for each woman and expressed as the percentage of change.
Moreover, four mutually exclusive levels of severity were calculated according to premenstrual change using the following criteria: 1) no symptoms, when premenstrual change was 0% to 20%; 2) mild symptoms, when premenstrual change was 20.1% to 50%; 3) moderate symptoms, when premenstrual change was 50.1% to 100%; and 4) severe symptoms, when premenstrual change was 100.1% or more. In this way, it was possible to classify each woman into one of four levels of severity of premenstrual symptoms. This analysis was performed by collapsing all MDQ scales. The statistical analyses comprised the Wilcoxon matched-pairs signed-ranks test, the Mann-Whitney U test, and the chi-square test.
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RESULTS |
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In the control group, there were no significant differences in scores of premenstrual change obtained both before and after the women watched the videotape in any MDQ scale. However, the experimental group reported a higher level of premenstrual change after the videotape presentation regarding pain, water retention, negative affect, behavioral change, autonomic reactions, and control (Table 1). In terms of the severity of premenstrual change, most women in the control group reported no symptoms or mild symptoms (55.8% and 51.2%, respectively), whereas only 2.3% reported moderate symptoms. These percentages were similar after the videotape presentation.
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DISCUSSION |
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In healthy college women, the self-preoccupation regarding premenstrual symptoms has been linked to greater premenstrual symptoms being reported, that is, self-preoccupation sensitizes women to premenstrual symptoms (19). Furthermore, McFarland et al. (20) have found that the more a woman believes in the phenomenon of menstrual distress, the more she exaggerates, in recall, the negativity of her symptoms during her last period. In addition, women tend to report more negative psychological and somatic symptoms during premenstrual and menstrual phases when they know that menstrual-cycle symptomatology is the focus of the study (21). All these findings also point toward a relationship between expectancies and premenstrual symptoms. In fact, Ruble (22) led a group of women to believe that they were either premenstrual or intermenstrual when they were all intermenstrual. He found that women reported more negative symptoms when they believed they were premenstrual. One could argue that women who are asked to describe their experience with premenstrual symptoms simply fulfill a role that society prescribes for them.
It has been demonstrated that premenarche girls have certain beliefs and expectancies about how women feel premenstrually. These expectancies tend to parallel the symptom reports and attitudes of older women. Moreover, premenarcheal expectancies seem to alter in some way the menstrual cycle-related experiences reported by the same adolescents when they become postmenarcheal (23–24). Because these studies suggest that beliefs are incorporated at an early age, they are probably culturally learned or adopted (9). However, it has been demonstrated that these expectancies are subject to modification by experimental manipulations. Fradkin and Firestone (15) studied women who were provided with information that strongly endorsed a physiological etiology for universal, unavoidable fluctuations in mood and concentration with the intent of enhancing premenstrual symptoms expectancies. Other women were told that premenstrual tension was due not to biology, but to negative societal myths. The authors found that subjects exposed to the psychological explanation of premenstrual tension expected and reported fewer premenstrual symptoms during the testing month. In another study, Olasov and Jackson (14) studied one group of women who watched a videotape lecture designed to increase expectancies for a negative mood-menstrual relationship and a second group who viewed a lecture designed to decrease such expectancies. A third group watched a lecture on an unrelated topic, and a fourth group did not watch any lecture. Results indicated that expectancies were altered in the predicted directions by the experimental manipulations. In addition, reported daily moods over the course of the menstrual cycle were also affected by the manipulations. Unlike Olasov and Jackson (14), who studied only symptoms related to mood, we analyzed both psychological and somatic symptoms.
If expectancies about premenstrual symptomatology can be changed, then this may have implications for the psychological treatment of women seeking help for PMS. For example, Morse (25) described an intervention with a health promotion focus that provides social support and a positive reframing component aimed at diminishing perimenstrual impairment in women with PMS. Positive reframing may be beneficial by providing women with the opportunity to reconstruct the social frame in which menstruation is perceived as a negative event. He clearly found that perimenstrual impairment decreased after the intervention.
It is interesting to note that in contrast to women reported in the studies cited above, the women who participated in this study had a low level of formal education. We found in a previous study of Mexican women that those with a low level of schooling reported less premenstrual change than women with professional degrees (12). This finding may be understood in social terms: in Mexico, it is not common for people with a low educational level to talk about menstruation and much less to know about the existence of PMS. Therefore, we studied women with a low level of schooling and confirmed that after women knew about the existence of PMS and its negative consequences in daily life, they reported more negative premenstrual symptoms. This may be explained by the likelihood that after watching the videotape, the women acquired both a vocabulary to use and sufficient knowledge of what symptoms to expect. This agrees with the findings of another study that assessed the prevalence and severity of premenstrual symptoms in American adolescents. Women were asked if they had heard of PMS before participating in the study. Results showed that prior knowledge of PMS was associated with the presence of premenstrual changes (26).
Positive premenstrual changes have been reported (27), but they have been ignored by most researchers. However, in a study of women without PMS, researchers found that when the concept of "menstrual joy" was introduced in a questionnaire before administration of the Menstrual Attitude Questionnaire and the MDQ, women reported more positive attitudes toward menstruation and more positive ratings of cyclic changes (28). In conclusion, the fact that beliefs and expectancies about premenstrual changes are learned offers a basis for optimism to provide women with a more positive view of menstruation and premenstrual changes.
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ACKNOWLEDGMENTS |
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Received for publication May 8, 1998.
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  S. A. Hartlage, D. L. Brandenburg, and H. M. Kravitz Premenstrual Exacerbation of Depressive Disorders In a Community-Based Sample in the United States Psychosom Med, September 1, 2004; 66(5): 698 - 706. [Abstract] [Full Text] [PDF]
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