The Development of a Menstrual Distress Questionnaire

RUDOLF H. MOOS, PH.D.

The development of a Menstrual Distress Questionnaire (MDQ) is described. Each of 839 women rated their experience of 47 symptoms on a six-point scale separately for the menstrual, premenstrual, and intermenstrual phases of her most recent menstrual cycle and for her worst menstrual cycle. The 47 symptoms were intercorrelated and factor analyzed separately for each phase, and eight basically replicated factors were extracted from each of these analyses. These factors, which represent separate but empirically intercorrelated clusters of symptoms, were labeled pain, concentration, behavioral change, autonomic reactions, water retention, negative affect, arousal, and control. Scores on these eight clusters of symptoms were slightly correlated with age and parity. The scores were not affected by the specific menstrual cycle phase a woman was in when filling out the questionnaire or by the length of time since the woman had experienced the symptoms. Menstrual cycle symptom-profiles graphically depicting a woman's menstrual symptomatology were constructed and illustrated. The need for and utility of standard methods with which to measure menstrual cycle symptomatology is discussed.

X HE HISTORY of concern about the menstrual cycle and menstruation is a long and varied one. For example, Pliny (quoted in Fluhmann), 1 remarked: On the approach of a woman in this state, new wine will become sour, seeds which are touched by her become sterile, grass withers
From the Department of Psychiatry, Stanford University School of Medicine, Palo Alto, Calif. The research was supported by Grant MH10976, from the National Institute of Mental Health, U. S. Public Health Service. Received for publication May 23, 1968. Particular appreciation is due Katherine Baker for her valuable assistance in all phases of this investigation, and David Hamburg, Ray Clayton, Bert Kopell, Fred Melges and Irvin Yalom for their important contributions to the development of the questionnaire and the preparation of the manuscript.

away, garden plants are parched up, and the fruit will fall from the tree beneath which she sits. It was gradually recognized that many women were handicapped by various premenstrual disturbances, and in 1847 DeWees2 wrote that menstruation ". . . rarely fails to be announced by a variety of symptoms of greater or less severity or danger." This fact was not fully appreciated until 1931 when R. T. Frank3 directed attention to these disorders and coined the term "premenstrual tension" to describe them. Fluhmann1 defined premenstrual tension as including adverse signs and symptoms of a general systemic nature which manifest themselves rhythmically during the later premenstrual or early menstrual phases. He

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also stated: "There is considerable difficulty in describing premenstrual tension as an entity because of lack of adequate information based on large groups of normal women. . . . A need exists for detailed investigations." The premenstrual syndrome has been described as the commonest endocrine disorder;4 however, estimates of its prevalence have varied considerably. Fluhmann1 estimated a prevalence of 60%; Freed,5 40%; and Sweeney,0 30% for healthy women. Stieglitz and Kimble,7 in a series of 67 women, found 68% with emotional instability and 65% with headaches; and Pennington8 found that 95% of 1000 high-school and college girls had some premenstrual symptoms. The prevalence-figures given by various authors have ranged from 25 to 100%. A comprehensive review of the literature on menstrual symptomatology9 indicated that there were also many conflicts of results with regard to specific symptomse.g., Airman et al.10 reported both "fatigue" and "bursts of energy" as premenstrual tension symptoms, and Greene and Dalton11 reported a 6% incidence of depression, whereas Paulson12 reported an 82% incidence of depression. These differences appear to be related to the lack of comparability of various authors' interests, methods of study, and selection of subjects. No standard method for collecting data about menstrual cycle symptomatology has been developed. Each investigator has utilized a data-gathering technique which is not comparable to those utilized in previous studies. Hence, many of the differences in results of different studies may be due to differences in data-collection methods. For example, three recent studies utilized three different questionnaires and obtained three different sets of results. Paulson,12 studying premenstrual tension in a sample population of 255 women, asked each woman to check the premenstrual intensity and frequency (6pomt scales) of each of 37 symptoms.

MENSTRUAL DISTRESS

He found that over 70% of the women complained of premenstrual irritability, decreased morale, depression, tension, fatigue, abdominal bloating, or backache. A relatively high proportion of women also complained of a number of other premenstrual symptoms. This questionnaire did not ask women about symptoms during the menstrual and intermenstrual phases of their cycles; unfortunately, no information was obtained on whether the reported symptoms were actually cyclical. Also, no evidence was obtained about memory effectse.g., whether women who are in the premenstrual phase at the time of the questionnaire answer differently from women who are not in the premenstrual phase at that time. Coppen and Kessel13 investigated the prevalence of dysmenorrhea and premenstrual symptoms after having concluded that there was little information on how frequently premenstrual symptoms actually occurred in the general population and how their prevalence and severity varied with age and parity. Each of 465 women rated the severity of a number of symptoms and were asked when each symptom was worst in relation to their menstrual periods. These authors reported a much lower prevalence of a number of menstrual symptomse.g., 45% of women complained of moderate or severe pain, 22% of headache, 32% of irritability, and only 23% of depression, anxiety, nervousness, or tension. Depression and irritability were generally worse premenstrually than menstrually, whereas the reverse was true for pain. Thus, this report presents some empirical evidence on the apparent cyclicity of some of these symptoms; the questionnaire, however, was arranged so that the women had to make a choice about the menstrual phase during which their symptoms were worst. Women experiencing a similar severity of symptoms both menstrually and premenstrually had no way in which
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questionnairee.g., length of menstrual cycle, duration of menstrual flow; (4) the assessment of the influence of age and parity on symptom severity; (5) the measurement of the influence of memory and of the menstrual phase a woman is in when answering the questionnaire on symptom recall. Information pertaining to the effects of memory and cycle phase on the reporting of menstrual symptoms is essential to the proper evaluation of a questionnaire method of gathering data in this area. Methods and Subjects A list of 47 symptoms for inclusion in the MDQ was obtained from several sources. (1) Women were given an open-end questionnaire and/or interview which elicited information about many possible menstrua] cycle symptoms. (2) A comprehensive detailed review of previous research on menstrual 9 cycle symptomatology was undertaken. (3) A list of control symptoms was obtained from the Blatt Menopausal Index.15 The particular symptoms selected e.g., buzzing or ringing in ears, numbness or tingling in hands or feet, feelings of suffocationwere symptoms which menopausal women endorsed with relatively high frequency but which women in the age range of our sample (20-30) endorsed with very low frequency.18 These control symptoms were included in order to obtain some measure of how likely a woman was to complain of a variety of different symptoms, regardless of whether these symptoms were usually associated with menstrual cycle changes. (4) Various authors had suggested increased prevalence of excitement and feelings of well-being occurring in conjunction with the menstrual cycle, usually before menstruation,17 and therefore a number of these reactions were included in the final questionnaire. The questionnaire asked each woman for her age, education, how long she had been married, and whether she had any children. Information about the length of cycle, length of menstrual flow, and regularity of cycle was also obtained,

they could report this. Also, this questionnaire examine only six symptoms, phrased questions in terms of usual rather than current symptoms, and did not include any check on memory effects. Sutherland and Stewart14 studied 150 women and found that only 17% were free from pain in relation to menstruation and that 15% stated they regularly lost one day's work at each menstrual period! Premenstrual irritability was shown in 60% of women, depression in 63%, and both in 45%. The authors analyzed the literature on premenstrual tension and concluded that the prevalence of premenstrual symptomsapart from dysmenorrheahad rarely been estimated. This questionnaire included only a small sample of symptoms, questioned the usual rather than the current symptoms, and included no measure of severity of symptoms, and no way of estimating the effects of memory on symptom recall. The development of standard methods for collecting cross-sectional and longitudinal information on menstrual cycle symptoms would appear to be potentially useful both for comparing estimates of the prevalence and severity of symptoms in various populations and for more careful study of the psychological and biochemical correlates of different types of menstrual and premenstrual distress. Purpose The major purposes of this investigation were: (1) the development of a Menstrual Distress Questionnaire (MDQ) which might be utilized as a standard method for assessing menstrual cycle symptomatology; (2) the gathering of normative information on symptom prevalence and severity on this questionnaire in a relatively homogeneous sample of normal married young women; (3) the identification of possible correlates of symptom severity as measured by the
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The women were asked to rate their experience of each of the 47 symptoms on the MDQ on a six-point scale ranging from no experience of the symptom to an acute or partially disabling experience of the symptom. Each woman made these ratings separately for the menstrual (during menstrual flow), premenstrual (the week before the beginning of menstrual flow), and intermenstrual (remainder of cycle) phases of her most recent menstrual cycle and for her worst menstrual cycle. Thus, women could differentiate between their experience of different symptoms in terms of the different phases during the cycle in which they occurred. The problem of memoryi.e., the problem of how much a woman remembers about her symptomswas partially handled by asking each woman to report about her most recent cycle. In addition, Paulson12 had found very high correlations between the severity and frequency of each of 37 menstrual symptoms, indicating that it was not necessary to obtain separate information about both. Each woman was also asked to write down the date on which she filled out the questionnaire and to give the dates of her most recent menstrual flow and of the menstrual flow in the cycle prior to her most recent one. This information made it possible to analyze the data in relation to which cycle phase each woman had been in on the day she had filled out the questionnaire and to discover whether this affected her symptom reports. After an initial pretest had perfected the instructions, the MDQ was filled out by a sample of 839 wives of graduate students at a large western university. This sample was geographically representativee.g., the percentage of the 839 questionnaires which came from wives of students living in university housing was very closely comparable to the percentage of all married students living in university housing. In addition, randomly selected subpopulations which differed in the percentage of women of the total group who answered the questionnaire did not differ in the prevalence of menstrual cycle symptomatology; that is, subpopulations in which 80% of the women answered the questionnaire did not differ significantly from subpopulations in which only 30% of

MENSTRUAL DISTRESS the women answered the questionnaire. These data indicate that the 839 women constituted a representative sample of the total population of graduate students' wives with respect to both geographical distribution and menstrual cycle symptomatology.

Results Table 1 summarizes background and menstrual cycle data for the total sample. This is clearly a homogeneous sample, in that the women are generally young, have attained high educational levels, over half have been married for less than 3 years, and over half do not as yet have any children. On the other hand, there is a range of characteristics even in this relatively homogeneous population. Over 5% of the women are 35 years of age or over; about 9 have a % high-school education or less; over 17% have been married 5 years or longer, and about 11% have 3 or more children. The average length of menstrual cycle and of menstrual flow* is closely comparable to results found in previous studies1e.g., Arey18 assembled some 20,000 records from 1500 women obtained from 12 different reports and found the mean length of the cycle to be 29.5 days. The majority of women report regular cycles; f however, 4535 report a variation of 3 days or more in cycle length during the past year. In this regularity of cycle scale (1-4), of the total, 54.8$ were included in the first grouping (1); 28.0% in the second (2); 8.7% in the third (3); and 8.5% in the The measure of the length of menstrual flow was the number of days from the onset to the cessation of menstrual flow. Both the first and last days were included as full days in this measure. fThe women were asked to describe the regularity of their menstrual cycle during the last year on a four point scale as follows: (1) Always within 2 days; (2) always within 36 days; (3) always within 1-2 weeks; (4) varied more than 2 weeks.
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2. Concentration 2. Insomnia 6. Forgetfulness 7. Confusion 24. Lowered judgment 29. Difficulty concentrating 33. Distractible 35. Accidents 42. Lowered motor coordination 3. Behavioral change 4. Lowered school or work performance 8. Take naps; stay in bed 15. Stay at home 20. Avoid social activities 41. Decreased efficiency 4. Autonomic reactions 17. Dizziness, faintness 23. Cold sweats 26. Nausea, vomiting 28. Hot flashes 5. Water retention 1. Weight gain 10. Skin disorders 30. Painful breasts 34. Swelling 6. Negative affect 3. Crying 11. Loneliness 21. Anxiety 27. Restlessness 36. Irritability 38. Mood swings 40. Depression 45. Tension 7. Arousal 13. Affectionate 14. Orderliness 18. Excitement 31. Feelings of well-being 47. Bursts of energy, activity 8. Control 12.'Feeling of suffocation 19.f Chest pains 32. Ringing in the ears 39. Heart pounding 43. Numbness, tingling 46. Blind spots, fuzzy vision Each woman received a score on each

TABLE 1. BACKGROUND DATA AND MENSTRUAL CYCLE VARIABLES ON TOTAL SAMPLE (N = 839)

Mean
BACKGROUND DATA*

S.D.

Age Education (yr.) Length of marriage (yr.)

25.2 15.2 2.7

3.9 1.7 2.3

MENSTRUAL CYCLE VARIABLES

Length of cycle (days) Length of menstrual flow (days)

30.3 5.5

4.7 2.0

*Of the total, 472 women have no children; 151, one child; 128, two children; 68, three children; and 30, more than three.

fourth (4) and most irregular. The 47 symptoms in the MDQ were intercorrelated and factor analyzed (principal components solution with orthogonal rotation of the factor matrix) for the total sample of 839 women separately for the menstrual, premenstrual, and intermenstrual phases of the most recent cycle and for the worst menstrual cycle. The eight resulting symptom groups listed reflect factors which were essentially replicated in all four of the factor analyses. There are only 46 symptoms listed because one symptom"change in eating habits"could not be located consistently on any one factor. Each of these eight groups reflect an empirically intercorrelated cluster of symptoms; the scale labels have been chosen to reflect the major content of the symptoms as closely as possible. The important point is that there are eight separate clusters of symptoms, each of which appear in each menstrual cycle phase: 1. Pain
5. 9. 1 16. 22. ' 25. [ 37. Muscle stiffness Headache J_ i Cramps """I ' Backache Fatigue ** General aches and pains

scale in each menstrual cycle phase by adding together her scores for each of the symptoms on that scale. The means and standard deviations for the eight scales in each phase are shown in Table 2. The pain, concentration, behavioral

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MENSTRUAL DISTRESS TABLE 2. MKANS AND STANDARD DEVIATIONS FOR EIGHT SYMPTOM SCALKS IN KACH PHASK OF THE MOST RECENT AND WORST CYCLE

Menstrual Pain X S.D. Concentration 12.59 4.99 10.84 4.24 8.08 3.78 4.98 2.08 7.67 3.22 15.79 7.18 9.53 4.40 6.74 1.68

Premenstrual 10.13 4.25 10.74 4.57 6.82 2.75 4.54 1.41 8.26 3.50 16.96 8.05 9.73 4.55 6.62 1.54

Intermenstrual Worst menstrual 7.71 2.71 9.02 2.31 5.55 1.53 4.24 0.92 4.91 1.63 10.93 4.60 9.84 4.91 6.39 1.16 17.99 6.25 13.34 6.40 14.39 7.17 7.72 4.60 9.87 4.13 21.59 9.50 8.25 3.87 7.26 2.73

X
S.D. Behavioral change X S.D. Autonomic reactions X S.D. Water retention X S.D. Negative affect X S.D. Arousal X S.I). Control X S.D.

change and autonomic reactions scales show higher mean scores in the menstrual than in the premenstrual phase, whereas the water retention, negative affect, and arousal scales show higher mean scores in the premenstrual than in the menstrual phase. All scales (except arousal and control) show large differences between menstrual and intermenstrual, and between premenstrual and intermenstrual phase scores. Worst menstrual cycle scores also reflect large changes in the expected direction for these scales. On the other hand, the arousal and control scales do not appear to be particularly reflective of cyclical changes related to the menstrual cycle, although some women do complain of the symptoms on these scales. Table 3 gives the percentage of women showing mild, moderate, strong, and se-

vere complaints on selected symptoms on each of the eight scales. This table shows the prevalence and severity of various symptoms in this sample. Each of the symptoms on the first six scales shows a statistically significant (p < 0.05, Mann-Whitney U Test) cyclical variation with the menstrual cycle, whereas the symptoms on the last two scales show no such cyclical variation. The symptoms on the pain, behavior change, water retention, and negative affect scales occur in approximately 30!? of the women. In order to compare the symptom scale scores with each other in one phase and across phases, a transformation was made that resulted in obtaining a mean of 50 and a standard deviation of 10 for each scale. Thus, each woman's score on each scale was transformed into a standPSYCHOSOMATIC MEDICINE

MOOS TABLE 3. PERCENT OF WOMKN WITH MILD, MODERATE, STRONG, AND SEVKRE COMPLAINTS ON SELECTED SYMPTOMS

859

Menstrual Scale Symptom Pain Headache Cramps Backache Concentration Difficulty concentrating Accidents Behavior Change Take naps; stay in bed Decreased efficiency Autonomic Reaction Dizziness, faintness Nausea, vomiting Water Retention Weight gain Painful breasts Swelling Negative Affect Irritability Mood swings Depression Crying Tension Arousal Well-being Energy, activity Control Suffocation Ringing in ears Mild, moderate
Strong, severe

Premenstrual Mild, moderate

Strong, severe

Intermenstrual Mild, moderate 11.8 3.6 6.3 2.6 4.0 6.3 2.1 2.3 1.7 5.2 3.9 4.2 9.2
Strong, severe

29.4 35.6
319

6.1

11.0
8.1 1.9 1.3 3.8 2.6 1.5 1.2 2.2 5.1 4.0 8.4 6.7 7.1 3.3

24.1 12.3 20.7 12.9 12.6 10.4 16.0

3.8 3.6

5.3 1.9 3.7 1.2 1.8 2.1 2.6 0.9 0.7 3.1 6.6 5.1

2.2 0.6
0.3

12.3 11.7 22.4 23.4

9.7 5.3

0.5
0.4 0.6 0.3 0.1 0.3 0.2 0.7 0.6 0.8 1.6 1.7 0.7 1.4
11.6

20.7 23.3 31.4 40.5 34.1 27.5 19.5 31.4 23.6 19.4
1.1 1.8

30.8 28.0 30.4 39.2 34.6 33.4 24.6 32.0 20.5 20.0
1.2 1.6

13.0
9.6 9.5 3.3 9.2 5.0 6.6 0.1
0.4

14.5
7.5 4.5

11.2
4.4 4.5 0.5 0.7

10.6 23.7 21.7

0.4 1.6

5.9 0.1 0.2

ard score which reflected her relative position on that scale. This transformation makes it possible to draw a menstrual symptom profile for each woman which depicts her symptoms graphically. For example, Fig. 1 shows the profile for a woman who is average or below on all symptom scales in all three phases, except for elevations on the negative affect scale in the menstrual and premenstrual phases. This woman's complaints confine themselves to a single symptom area. Figure 2 shows a woman with a quite different profile. This woman shows an elevation of several scales in the menstrual phase, particuVOL XXX, NO. 6. 1968

larly in the autonomic reactions, pain, and concentration scales; however, she is not particularly elevated on any of the symptom scales in the premenstrual or intermenstrual phases. A very different pattern is shown in Fig. 3, which gives the profile for a woman who is elevated on several scales in the premenstrual phase, particularly the concentration, behavioral change, autonomic reactions, and water retention scales, but who shows average or below average symptom severity on all scales in both the menstrual and intermenstrual phases. This woman has all of her symptoms in the premenstrual phase,

MENSTRUAL DISTRESS

I U U

A menstrual 11 9 premenstrual I 1 0 intermenstrual 80

\

70 <n i (-60 o o
\

\%

50

V \/\\ V'X \ /.
1 1 ! 1 1 1 1

\ 1 \

40

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s
FIG. 1. Menstrual cycle symptom profile; Subject No. 1551. whereas the woman shown in Fig. 2 has all her symptoms in the menstrual phase. Another pattern is shown in Fig. 4, which gives the profile for a woman who is elevated on several scales in all three phases of her cycle. She does not complain of all symptoms, since she is below average on the control scale in all three cycle phases; however, it is only on the concentration and water retention scales that her symptoms are higher in the menstrual and premenstrual than in the intermenstrual phases. These profiles are given as examples of the kind of differentiated and specific analyses of a woman's menstrual cycle symptomatology which can be made with this technique. It is possible to identify easily the symptom areas and menstrual cycle phases in which a wornans complaints are concentrated.

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JS

2^

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FIG. 2. Menstrual cycle symptom profile; Subject No. 1654 The next step in the analysis was the intercorrelation of the symptom scale scores with the background datae.g., age, number of children, length of menstrual flow, etc. Because of missing data on some of the background variables for some of the subjects, these correlations were computed on a sample size of 700 subjects. Older women have a slight tendency to complain more of symptoms in the premenstrual phasee.g., there were significant (p < 0.01) positive correlations between age and concentration (r = 0.10) and age and behavioral change (r = 0.12) scale scores. When the 99 women 21 years of age and under were compared with the 87 women 31 years of age and over, there was a statistically significant difference (t test, p < 0.05) for the behavioral change scale in the
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1 1 1 1
1 1 1

100

qo /

60
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u
tn

/v
\ i
1 I 1

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meristrual 9 pre Tienstrual O mte-menstrual " ~

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a u ffi < L > i z o < u FIG. 4. Menstrual cycle symptom profile; Subject No. 342. arousal) and positive in the premenstrual phase (significantly for pain, concentration, behavior change, and negative affect). The effects of age and parity could not be separated because it was not possible to find age-matched groups differing greatly in parity or parity-matched groups differing greatly in age. There were no significant correlations between symptom intensity and length of menstrual cycle, and the 90 women with cycle lengths of 25 days and below did not differ significantly on any scales from the 99 women with cycle lengths of 35 days and above. However, correlations between length of menstrual flow and symptom intensity were significant for the pain, concentration, behavioral change, water retention, and negative affect scales in the menstrual phase and for the pain, concentration, water reten-

a u m < >i; z o < o FIG. 3. Menstrual cycle symptom profile; Subject No. 1628. premenstrual phase. Several scales also significantly differentiated the two groups in the menstrual phase, with the younger women complaining of significantly more symptoms on the pain, autonomic reactions, water retention, and negative affect scales. The younger women had higher mean scores on all but one of the eight scales in the menstrual phase, whereas they had lower mean scores on all but one of the scales in the premenstrual phase. Thus, the younger women show relatively greater symptoms in the menstrual phase. Correlations between symptom intensity and number of children follow a pattern similar to correlations between symptom intensity and agei.e., the correlations are generally negative in the menstrual phase (significantly for autonomic reactions and water retention and
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tion, and negative affect in the premenstrual phase. The 56 women with flow lengths of 3.5 days and below were compared with the 32 women with flow lengths of 8 days and above. The women with longer flow lengths showed significantly more menstrual symptoms on the pain, concentration, behavioral change, dizziness, water retention, and negative affect scales, but did not show significant differences on any of these scales in the premenstrual phase. Correlations between symptom intensity and regularity of the menstrual cycle indicated that there was a positive relationship between degree of symptomatology and irregularity. Significant correlations were shown in both menstrual and premenstrual phases for the pain, water retention, and negative affect scales. Symptom scale scores also were correlated with a specially derived memory score. This memory score included the number of days from the beginning of the last menstrual flow to the date the questionnaire was answered. Thus, the greater the memory score, the longer was the interval between the time the woman experienced the symptoms and the time she actually filled out the questionnaire. None of the correlations between this memory score and the symptom scale scores was over 0.10, indicating that there was essentially no correlation between reports of symptom intensity and length of time since the symptoms had occurred. It has also been hypothesized that there is a relationship between the menstrual phase a woman is in when she fills out a questionnaire and her reporting of the symptoms. Thus, a woman who is in the menstrual phase when filling out a questionnaire might tend to complain more of menstrual symptoms than a comparable woman who is not actually experiencing her menstrual phase at the time she is filling out the questionnaire.

MENSTRUAL DISTRESS

The cycle phase each woman was in when she filled out the questionnaire was coded, and correlations between this phase and symptom-scale scores were calculated. None of the correlations between phase and menstrual or premenstrual symptoms were significant. This means that women in the intermenstrual phase, when answering the questionnaire, show no tendency to complain either more or less of menstrual or premenstrual phase symptoms than women who are actually in the menstrual or premenstrual phase when answering the questionnaire. Some preliminary evidence on the stability of some of these scores has also been obtained. Fifteen women were studied over two cycles in order to investigate the extent to which women were consistently high or consistently low on different scales in the menstrual (first to 156th percentile), intermenstrual (36th to 60th percentile) and premenstrual (94th to 99th percentile) phases of the two cycles. These women, who were part of a further study utilizing the MDQ, were given the questionnaire on 9 selected days on each of two menstrual cycles. Table 4 shows the correlations between Cycle 1 and Cycle 2 symptom levels for each symptom scale separately for each of these three phases. In general, the correlations are statistically significant and high, indicating that women who complain of symptoms in Cycle 1 also tend to complain of symptoms in Cycle 2. These relatively high correlations show that women tended to have generally consistent symptomatology from one menstrual cycle to another; they also provide preliminary information on the stability-reliability of the MDQ scale scores. The average cyclical change of each of the variables was plotted for each of the two cycles. Figures 5 and 6, which illustrate the findings for the variables of pain and water retention, clearly indicate both the significant changes which
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MOOS T A B L E 4. CORRELATIONS BETWEEN CYCLE 1 AND 2 SYMPTOM LEVELS FOR 15 WOMKN IN MENSTRUAL, PREMENSTRUAL AND INTERMENSTRUAL PHASES

863
pen and Kessel,13 who found that women who were actually menstruating when they filled out a questionnaire did not differ from the rest of the women in respect to the frequency or severity of menstrual symptoms. The results make it reasonable to conclude that neither the length of time since the symptoms occurred (at least for relatively short time spans of up to 30 days or so) nor the particular menstrual phase a woman is in when reporting her symptoms have much effect on reported symptom severity. These results do not bear on the extent of memory effects which might occur if the symptoms reported on occurred several months agoe.g., interviews asking women in their twenties about menstrual cycle symptoms experienced in their first year after menarche. It is likely that asking about specific recent symptom occurrence decreases distortion due to differential memory effects. This is an important finding, since it indicates that a questionnaire method of obtaining data in this area may not be subject to some of the problems which were initially thought to be critical. The specific results of the MDQ data on the particular sample utilized appear to be generally consistent with those of other studies. It is important to note that approximately 30-50% of normal young married women are bothered to some extent by cyclical symptoms of cramps, backache, headache, irritability, mood swings, tension and/or depression. This general range of symptom prevalence is similar to the range identified by Coppen and Kessel13 and by Sutherland and Stewart14 in their questionnaire studies. Average menstrual cycle and flow lengths obtained from the current sample were also quite similar to those obtained in previous studies. Reports of relationships between menstrual and premenstrual symptoms and age and parity also have been made previously. For example, Coppen and Kessel found that the prevalence of dys-

Phase Symptom scale. Pain Autonomic reactions Water retention Negative affect Control * p < O.Oo, r = .50 t p < 0.01, r = .62 M .39 PM -79f .69f .43 .63t .90| IAt .89f .95t .87f .57* .69t

.62t
.40 .61* .57*

occur for each of these variables within each of the two cycles and the stability of the pattern of changes from one cycle to the other. More detailed evidence on both the reliability and the cyclical changes of these variables is presented in another paper.19 Discussion The development and initial standardization of a Menstrual Distress Questionnaire has been presented.* The MDQ basically consists of eight scales made up of empirically distinct although correlated sets of symptoms, which were derived from the replicated results of four separate factor analyses of data from the menstrual, premenstrual, and intermenstrual phases of the current menstrual cycle and for data from the worst menstrual cycle. These analyses indicate consistent empirical groupings of symptoms regardless of whether these symptoms show relatively high (worst menstrual cycle) or relatively low (intermenstrual phase of current cycle) prevalence. The data indicated that neither memory nor phase effects had much influence on reports of symptom severity. These results are consistent with those of Cop*A copy of the Menstrual Distress Questionnaire is available upon request to the author.
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menorrhea declined with parity. Severe period pain was experienced only half as frequently following the birth of the first child, and moderate symptoms were reduced after the second child. They

MENSTRUAL DISTRESS

also found a similar negative correlation between pain and age. The reduction of dysmenorrhea with parity remained statistically significant even when the effect of age was controlled. In addition, Dal-

Day of menstrual cycle

10

12

14

16

18 20

22

24

26

28

b-

-olst cycle 2 n d cycle -

1.10 & 10 12 14 16 IS 20 22 24 26 28

Day of menstrual cycle

FIG. 5 (top). Average self-rated pain of 15 women in 2 consecutive menstrua] cycles. FIG. 6 (bottom). Average self-rated wate- retention of 15 women in 2 consecutive menstrual cycles.
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psychological and endocrine factors be understood and some of the contrasting symptoms perhaps be explained.14 It should be noted that a questionnaire method implies that a patient's own subjective assessment of the extent of her disability is one essential source of information. The MDQ takes only about 5 min. for a woman to fill out and can be given repeatedly either in longitudinal investigations of change in menstrual symptomatology or in cross-sectional investigations of large samples of women to estimate prevalence and severity of different types of menstrual cycle symptoms. The MDQ elicits concrete data about one cycle, indicates whether or not the different sets of symptoms are cyclical, has a built-in "complainer" or control scale in order to identify women who tend to complain of many different symptoms regardless of whether they are usually cyclically associated with the menstrual cycle, and shows no effects of memory on reports of symptom severity. Importantly, normative data on one large sample of women is already available. In addition, it is possible to differentiate between dysmenorrhea and premenstrual tension, as well as between other types of menstrual symptomatology. Figures 1-4 have given examples of the type of differentiated analyses which may be made through the construction of menstrual cycle symptom profiles for different women. It is possible that these types of specific analyses may identify new subtypes of groups of symptoms which may show specialized relationships either to psychological and/or endocrine factors. The important relevance of the findings to the conceptualization and differentiated analysis of menstrual cycle symptomatology, especially to the tentative development of a typology of menstrual cycle symptoms is discussed in another paper.22 There are a variety of important questions about menstrual symptomatology

ton has presented data showing an increased prevalence of the premenstrual symptoms with increasing age among childless women. She also has shown a relationship between age and increasing severity of premenstrual symptoms in women both with and without children. The endocrine and/or psychosocial correlates of these changes in menstrual symptomatology are unclear; however, the findings appear to be quite consistent, though quantitatively relatively small. The importance of menstrual and premenstrual symptomatology currently is appearing in a new light with the accumulation of evidence that a large proportion of women who commit suicide or engage in criminal acts of violence, and who as pilots have serious and fatal airplane accidents, do so during the menstrual or premenstrual phases of the cycle.4-20 Dalton has shown that during the 4 premenstrual and 4 menstrual days, 45% of industrial employees reported sick; there were 46$ of acute psychiatric admissions and 493> of acute medical and surgical admissions; 49% of prisoners committed their crimes, and 52$ of emergency accident admissions also occurred. In a more recent study, Dalton21 has related the effect of a woman's premenstrual and menstrual phase to her child's seeing a physician. She found that 54$ of all children attending clinic with minor coughs and colds did so during the 8 premenstrual and menstrual days of the mother. These findings, in conjunction with the relatively high prevalence of symptoms occurring in normal young women, suggest that these symptoms may have more important and frequent consequences than has been commonly thought. The necessity for a set of standard methods with which to obtain comparable data on menstrual symptomatology appears essential. It has been pointed out that only after more complete analyses of the syndrome can the underlying
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which need to be investigated. (1) How stable are a woman's menstrual cycle symptoms over time? Are there some subgroups of women with stable and other subgroups with unstable symptomatology? Do these subgroups differ on important psychological or endocrine variables? (2) What are the effects of medications, particularly of oral contraceptives, on different types of menstrual cycle symptoms? There is mounting evidence that a certain percentage of women react to oral contraceptive medication with an increase in symptomatology,21 and it is possible that these are women who initially have higher severity of symptoms in some symptom arease.g., water retention or negative affect. (3) Longitudinal studies of particularly interesting single cases or small groups could provide evidence on the relationship between menstrual symptoms before and after pregnancy and between menstrual symptoms and postpartum symptoms. Various hypotheses have been made about possible relationships in these areas; however, there have been no longitudinal studies which have made sufficiently detailed investigations of the same women at various stages of their life cycles. (4) A number of investigators have postulated particular relationships between menstrual cycle symptoms and personality variablese.g., that neurotic women may have a greater degree of premenstrual tension. Coppen and Kessel13 found, interestingly, that dysmenorrhea was not correlated with neuroticism, whereas symptoms such as irritability, depression, and tension were significantly correlated with neuroticism. This suggests the possibility of differential relationships between different types of symptoms and personality variables. Clearly, the possibility of comparable population studies which estimate the prevalence and severity of different types of menstrual symptoms should provide investigators with more differentiated clues about possible symptom origins.

MENSTRUAL DISTRESS

The investigation of endocrine factors e.g., corticosteroids, estrogen/progesterone ratioin longitudinal studies of specific subtypes of women chosen on the basis of initial careful behavioral studies of their symptomatology would appear also to be potentially fruitful for further understanding of etiology.
Department of Psychiatry Stanford University School of Medicine Palo Alto, Calif.

References
1. FLUHMANN, C. F. Management of

Menstrual Disorders. Saunders, Philadelphia, 1956.

2. D E W E E S , W. P. A Treatise on the Dis-

eases of Females. Lee and Blanchard, Philadelphia, 1847. 3. FRANK, R. T. The hormonal causes of premenstrual tension. Arch Neurol (Chicago) 26:1053, 1931.
4. DALTON, K. The Premenstrual Syn-

drome. Thomas, Springfield, 111., 1964. 5. FREED, S. The treatment of premenstrual distress with special consideration of the androgens. JAMA 127:377, 1945. 6. SWEENEY, J. Menstrual edema: Preliminary report. JAMA 103:234, 1934.
7. STIEGLITZ, E. J., and KIMBLE, S. T.

Premenstrual intoxication. Amer J Med Sci 218:616, 1949.

8. PENNINCTON, V. Meprobamate (Mil-

town) in premenstrual tension. JAMA 164:638, 1957. 9. Moos, R. H., and BAKER, K. Literature review and summary of the premenstrual tension syndrome. Unpublished data.
10. ALTMAN, M., KNOWLES, E., and BULL,

H. A psychometric study of the sex cycle in women. Psychosom Med 3: 199, 1941.
11. GREENE, R., and DALTON, K. The pre-

12.

menstrual syndrome. Brit Med J 1: 1007, 1953. PAULSON, M. Psychological concomitants of premenstrual tension. Doctoral dissertation, Univ. Kansas, 1956.
COPPEN, A., and KESSEL, N. MenstruaPSYCHOSOMATIC MEDICINE

13.

MOOS

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strual irregularity. Gynec 37:12, 1939.
19.

tion and personality. Brit ] Psychiat 109:711, 196&

14. SUTHERLAND, H., and STEWART, I. A

Amer

Obstet

critical analysis of the premenstrual syndrome. Lancet J . I 180, 1965.

15. BLATT, M., WIESBADER, H., and KUP-

Moos, R. H., KOPELL, B. S., MELGES, F. T., YALOM, I. D., LUNDE, D. T., CLAYTON, R. B., and HAMBURG, D. A.

PERMAN, H. Vitamin E and climacteric syndrome. Arch Intern Med (Chicago) 9J.-792, 1953.
16. NEUGARTEN, B., and KRAINES, R. Men-

Variations in symptoms and mood during the menstrual cycle. Unpublished data.
20. MANDELL, A., and MANDELL, M. Sui-

17.

18.

opausal symptoms in women of various ages. Psychosom Med 27:266, 1965. ISRAEL, S. The clinical pattern and etiology of premenstrual tension. Intern Rec Med 166:469, 1953. AHEY, L. The degree of normal men-

21.

22.

cide and the menstrual cycle. JAMA 200:792, 1967. DALTON, K. The influence of mother's menstruation on her child. Proc Roy Soc Med 59.1014, 1966. Moos, R. H. A typology of menstrual cycle symptoms. Amer J Obstet Gynec. In press.

Fellowships in Psychosomatic Medicine and Research

Beginning July 1, 1969, several full and half fellowships will be available in Psychosomatic and Liaison Psychiatry, for psychiatrists who have already completed 3 years of residency. The program, which is being offered by the Division of Psychiatry, Montefiore Hospital and Medical Center, includes experience in teaching and research, as well as in clinical work, dealing with the psychological aspects of somatic illness.
For details write to: MORTON F. REISER, M.D., Division of Psychiatry,

Montefiore Hospital and Medical Center, 111 East 210 Street, Bronx, N. Y. 10467.

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