Prevalence, Pattern, and Predictors of Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD) in Asir Region, Saudi Arabia

Background: The prevalence and consequences of premenstrual dysphoric disorder (PMDD) and premenstrual syndrome (PMS) among Saudi women are not well understood. Consequently, the purpose of this research is to ascertain the frequency, course, and contributing factors of PMDD and PMS in the Asir area of Saudi Arabia. Methods: A cross-sectional study was conducted in Asir, Saudi Arabia, using a pre-designed questionnaire distributed among adult female patients to five primary healthcare facilities (PHCs) that were chosen at random in the Asir Region. Data were analyzed using IBM Statistical Package for the Social Sciences (SPSS, version 15). Results: The study included 506 participants; 81% of them were Saudi and 19% were non-Saudi. A percentage (46.2%) of the participants were aged between 21 and 30 years old. A total of 369 (72.9%) participants have PMS. Regarding PMS symptoms, 79.1% reported mood changes, 59.3% tantrums, 56.7% change in appetite, 47% acne, 41.9% back and joint pain, and 43.1% reported sleep disorders. Almost half (42.1%) of the participants receive treatment to relieve the symptoms of PMS (72% of them receive paracetamol and 6.1% receive nonsteroidal anti-inflammatory drugs (NSAIDs)). Some (6.4%) exercise during the menstrual cycle to relieve symptoms of PMS, while 31% eat healthy foods at the time of period to relieve the symptoms of PMS. Conclusion: The prevalence of PMS/PMDD was among the reported figures worldwide. There was a significant association between age and the use of contraceptives with symptoms of PMS/PMDD among the studied sample.


Introduction
Premenstrual disorders consist of a series of premenstrual symptoms starting from mild premenstrual syndrome (PMS) to premenstrual dysphoric disorder (PMDD), which is a more severe form.PMS manifests itself during the monthly cycle's luteal stage and goes away for the rest of the cycle; in addition, it disturbs the psychological, physical, and behavioral symptoms [1].The prevalence of PMS in health colleges in Dammam, Saudi Arabia, was 46.7% [2].About 24-32% of women reported moderate to severe PMS and 3-8% have a very severe form of PMS, which is PMDD [3].PMS is therefore predominant in women of all ages affecting considerable morbidity with apparent damage to interpersonal relationships, work performance, lifestyle, social interactions, emotional well-being, and overall health-related quality of life (HRQoL) [4].This disorder is particularly common in the younger age groups and therefore represents a significant public health problem [5].
Nearly 90% of women have experienced at least one PMS as defined by the International Classification of Diseases, Tenth Revision (ICD-10) criteria.Epidemiological investigations have assessed that around 75% of reproductive-age females experience some symptoms related to the premenstrual phase of the menstrual cycle [6].
The etiology of PMS is uncertain.Since PMS symptoms occur simultaneously with the hormonal fluctuations of the menstrual cycle, hormonal disproportion like estrogen surplus and progesterone deficiency have been proposed.Symptoms are also associated with serotonin to link as a key etiological factor [7,8].Women have mood swings due to fluctuations in their luteal stage levels of estrogen.Molecular biology research indicates that the hypothalamus releases norepinephrine in response to a drop in estrogen, and it causes acetylcholine, dopamine, and serotonin levels to drop, which in turn causes despair, exhaustion, and insomnia -all classic symptoms of PMDD and PMS [9].An Egyptian research found a favorable correlation between PMS and consuming too many sweet-tasting foods.It also showed that there was a substantial correlation between PMS and other variables, such as coffee and junk food consumption, demonstrating the strong correlation that lifestyle variables have with PMS and PMDD [10].
Many other conditions, both medical and psychological, must be ruled out in order to diagnose PMS and PMDD.The presence of three criteria, namely, consistency with PMS symptoms (I), constant occurrence of symptoms only during the luteal phase of the menstrual cycle (II), and detrimental effects on the patient's function and lifestyle (III), confirms the diagnosis.Patients should be instructed to record their premenstrual signs for a continuous month in order to check for cycle-to-cycle fluctuation, especially if the doctor has serious doubts about the diagnosis [11].
Reducing the impact of PMS on everyday activities and relieving its symptoms are the primary goals of treatment.PMS was traditionally treated with pharmacotherapy; however, more recent studies have indicated that combination therapy provides greater advantages [12].
Symptoms of PMS can be effectively treated by combining medications [13], such as non-steroidal antiinflammatory drugs (NSAIDs), selective serotonin reuptake inhibitors (SSRIs), anxiolytics, gonadotropinreleasing hormone (GnRH) agonists, the medication, and oral contraceptive pills, with nonpharmacological therapies, such as cognitive and behavioral therapies, exercises, massage therapy, light therapy, and dietary and nutritional modifications.The majority of signs of PMS might return after therapy is stopped, with the exception of menopausal and oophorectomy [14].This study looks at PMS and PMDD incidence, patterns, and determinants in Saudi Arabia's Asir Region.

Materials And Methods
This is a cross-sectional study conducted in the Asir Region of Saudi Arabia, a distinctive locale that provided the backdrop for the study's observations and conclusions.The study transpired over a timeframe spanning two months, commencing on July 1, 2022, and concluding on September 31, 2022.
The study targeted a specific demographic cohort, namely, females aged between 18 and 40 years residing in the Asir Region of Saudi Arabia.This selection criterion ensured a coherent and relevant sample group for the research objectives.The inclusion criteria outlined parameters for participation, emphasizing that women within the specified age range and from diverse educational backgrounds were eligible to take part.In addition, the participants were required to express their willingness to engage in the study, thus ensuring informed and voluntary involvement.
Conversely, the exclusion criteria delineated specific conditions that would disqualify individuals from participating in the study.Factors such as age, pregnancy or lactation, and the presence of certain health conditions like gynecological issues or chronic diseases were identified as grounds for exclusion.

Sample size
The minimum sample size for this study has been decided according to Swinscow, as follows: It was increased to 420 by adding 10%, to compensate for nonresponses and incomplete forms.

Method of gathering data
The method used for random sampling was methodical.All adult female participants at five randomly chosen PHCs in the Asir Region provided data.Every second lady who attended the research was questioned after the first respondent was chosen at random in order to ensure that the necessary sample size was achieved.In-person conversations with members of the sample population were used to gather data, and they also completed a questionnaire that helped us find the information we needed to meet the goals of the study.

Tool for gathering data
To gather data, a pre-made questionnaire was employed.There are two primary portions to it.The participants' demographic data include information on their age, marital status, educational attainment, height, weight, and number of children.The second segment will evaluate the regularity of menstruation, the kind and effectiveness of any contraception used, the incidence of PMTS symptoms, and any therapeutic options.Prior to the interview, each participant provided written informed consent.

Preliminary investigation
To determine the tool's viability, applicability, and clarity and to make any necessary modifications, a pilot study involving 10 women was conducted.Women were not allowed to participate in the pilot trial.Table 5 shows a significant association between age and PMS/PMDD, with a higher percentage of individuals aged less than 20 reporting symptoms compared to other age groups.However, no significant association was found between BMI categories and PMS/PMDD.In terms of educational status, the data indicated that participants with a university education or higher were more likely to report PMS/PMDD compared to those with other educational backgrounds.Nationality, work/profession, marital status, and contraceptive use also showed some associations with PMS/PMDD, although not all of these relationships were statistically significant.

Discussion
Premenstrual symptoms can affect any woman of reproductive age, from menarche through menopause.PMS is a common complaint among reproductive-age women.Premenstrual discomfort affects around 70-90% of women of reproductive age in the United States.PMS-like symptoms are reported by roughly onethird of these women.PMDD, the most severe form of PMS, has been reported in 3-8% of these patients [15].
According to our study results, 72.9% of the studied sample have PMS.According to a study conducted in Dammam, KSA, 96.6% of the investigated sample had at least one premenstrual symptom, and 37.5% had a high symptom severity score [16].PMS afflicted 37.0% of women in Jeddah, Saudi Arabia [17].Another population-based study found that 91% of individuals reported at least one symptom, 10.3% experienced PMS, and 3.1% matched the criteria for PMDD [18].Another study conducted in India found that the combined prevalence of PMS and PMDD was 43% and 8%, respectively [19].Women in the United States experience 481 menstrual cycles during their lives, according to Halbreich et al.When two pregnancies and postpartum periods are factored in, many women have 459 cycles during their reproductive years.Furthermore, women with PMDD in the United States experience an average of 6.4 days of severe symptoms every menstrual cycle, which is nearly equivalent to eight years of debilitating symptoms throughout the menstrual cycle.Examining the evidence reveals that PMS or PMDD can have negative repercussions and functional deterioration over a woman's entire life, making it a substantial health issue [20].
PMS symptoms can be minor, moderate, or severe.Possible symptoms include changes in appetite, weight gain, headaches, nausea, constipation, anxiety, irritability, aggressiveness, tiredness, restlessness, mood swings, and weeping.Other symptoms include back pain, lower back pain, stomach discomfort, and headaches [21].Irritability, depression, crying/tearfulness, and anxiety are all psychological symptoms of PMS.PMS causes abdominal bloating, breast discomfort, and headaches.In our study, 79.1% of the participants reported mood changes, 59.3% tantrums, 56.7% change in appetite, 47% acne, and 41.9% back and joint pain and 43.1% reported sleep disorders.
The duration of affective symptoms varies, ranging from a few days to two weeks.Usually, two days prior to menstruation, symptoms peak and become more intense a week before.Drinking alcohol is associated with a marginally elevated risk of PMS.[22].Thus, recording the patient's alcohol consumption history can help with counseling and symptom relief.In the current study, 40.1% reported three days, 30.2% reported two days, and 7.3% reported one day.
In our study, age was significantly associated with PMS symptoms among participants.Previous studies have found inconsistent connections between sociodemographic variables and PMS/PMDD.PMS/PMDD was shown to be more prevalent among women who were past reproductive age, had lower levels of education, and were unemployed in a previous study [18].There was no association with advanced age in Women who were jobless or experiencing stress at work had an increased odd ratio for a high degree of common symptoms, in accordance with a cross-sectional population-based Swedish study that looked at relationships between women's overall health and their employment and working environment [25].These findings are consistent with prior research and support the idea of a negative relationship between perceived symptom severity and amount of control.According to a previous study, adolescents were expected to have a higher prevalence of PMS, accounting for 49.6% of the population [19].
The current investigation discovered a substantial correlation between contraceptive use and PMS/PMDD.It agreed with the conclusions of earlier research examining the connection between OC usage and premenstrual symptoms.Previous research has shown that there may be no advantages for mood symptoms or even that OCs may have a harmful impact on PMS, such as persistently depressed mood, although more recent research linked OCs to benefits, especially for physical premenstrual symptoms.Preparations with drospirenone and third-generation progestogens even showed improvements in psychological symptoms [26][27][28][29][30]. Globally, it was shown that OCs had no impact on the frequency or pattern of menstrual symptoms [31].As an illustration, Segebladh et al. compared women with and without unfavorable mood effects from COCs and found a substantially greater frequency of mood disorders and PMS in those with mood effects from COCs [32].The results of this study suggest that the therapeutic effect of COCs, which replicate the ovarian cycle naturally, is little and that a potential weakness may have a bigger impact.The somewhat beneficial impact may be attributed to patients feeling more in control as a result of cycle consistency brought on by COC.
PMS in the mother, one's personal experiences with mental strain, exercise, eating sweet foods, and coffee were all found to be significantly associated with the frequency of premenstrual symptoms in a previous study, but they only accounted for 14% of the variability in the multiple regression model [16].Another study found that poor physical and mental health were strongly linked to PMS and PMDD.Sociocultural variables tend to influence the occurrence, understanding, and controlling of PMS.Considering the correlation between inadequate physical well-being and notable psychological discomfort, it is reasonable to conclude that women who satisfy the PMDD criteria have a broader underlying susceptibility that should be taken into account in clinical therapy and future research [18].
This study had several limitations, which included the focus on a specific region, potentially limiting the generalizability of the findings.In addition, the study relied on self-reported data from participants, which may introduce bias and impact the accuracy of the results.Furthermore, the absence of a control group for comparison may limit the ability to draw definitive conclusions about the prevalence, pattern, and predictors of PMS and PMDD in the Asir Region.
In terms of future implications, additional research could expand the scope of the study to encompass multiple regions within Saudi Arabia to provide a more comprehensive understanding of PMS and PMDD prevalence, patterns, and predictors across the country.Longitudinal studies could be initiated to monitor changes in the prevalence, pattern, and predictors of PMS and PMDD over time specifically in the Asir Region.Furthermore, intervention studies could be designed to explore effective strategies for managing and treating PMS and PMDD in Saudi Arabia, considering cultural and societal factors that may influence women's experiences and perceptions of these conditions.Such research efforts could contribute to improving the diagnosis, treatment, and overall well-being of individuals affected by PMS and PMDD in the region.

Conclusions
The prevalence of PMS/PMDD was among the reported figures worldwide.There was a significant association between age and the use of contraceptives with symptoms of PMS/PMDD among the studied sample.Future studies with larger sample sizes are demanded to assess the burden of PMS/PMDD symptoms among Saudi women.
Committee at King Khalid University issued approval ECM#2023-3242.Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Table 4 ,
it is highlighted that 42.1% of the participants (213 individuals) sought treatment to alleviate the symptoms of premenstrual syndrome.Within this group, 72% (153 participants) opted for paracetamol, while 6.1% (13 participants) chose NSAIDs.Moreover, 55.9% (283 participants) shared that the treatment they received helped relieve their symptoms of premenstrual syndrome.In addition, 16.4% (83 participants)Receive any treatment to relieve the symptoms of premenstrual syndrome engaged in exercise during their menstrual cycle to alleviate symptoms, while 31% (157 participants) focused on consuming healthy foods during this period for symptom relief.Furthermore, 74.5% (377 participants) implemented relaxation techniques during their menstrual cycle to alleviate symptoms of premenstrual syndrome.

TABLE 5 : Association between the sociodemographic characters of the participants with PMS/PMDD (n = 506).
Takeda et al.'s survey or Potter et al.'s cohort analysis of 2,863 French women, although age dependency could not be examined in several other research since the samples' age ranges were so narrow [23,24].Potter et al. did not find the same correlation that Cohen et al. had, and their analysis found no link with the work status.