MSU LIBRARIES \ RETURNING MATERIALS: PIace in book drop to remove this checkout from your record. FINES w111 be charged if book is returned after the date stamped below. PREMENSTRUAL SYNDROME: SELF REPORTED SYMPTOMS AND SEVERITY IN YOUNG ADULTS By Mary Jo Gagan A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the Degree of MASTER OF SCIENCE College of Nursing 1987 Copyright by Mary Jo Gagan 1987. ABSTRACT PMS: SELF REPORTED SYMPTOMS AND SEVERITY IN YOUNG ADULT FEMALES By Mary Jo Gagan A descriptive study of 100 young adult females ages 18 to 25 was undertaken to answer two questions. i. What physical, affective, or behavioral symptoms are most commonly self-reported retrospectively by this sample of women during the premenstrual phase of the menstrual cycle? 2. What symptoms are reported as being most severe during the premenstrual phase of the menstrual cycle? The Moos (1985) Menstrual Distress Questionnaire was utilized to collect data about symptoms. The results indicated that the majority of the women completing the MDQ (Moos, 1985) suffered from some symptomatology preceding menses. Very few women, however, suffered from severe symptoms. It was decided that, based upon the results, that the tool was an adequate screening device. It was also decided that the MDQ (Moos, 1985) was not adequate to be used alone as a conclusive device for assessing symptoms of PMS. Implications for research and clinical practice are outlined. ABSTRACT Moos, R. (1985). Premenstrual symptoms: A mannual and overview of research with the menstrual distress questionnaire. California: Standford University. ACKNOWLEDGEMENTS I wish to thank the members of committee for their patience and expertise, without which this would never have come to pass. Clare Collins, Andrea Bostrom, Sharon King, Sandy Hayes, and Liz Price thank you all. I would like to thank my lover, Barbara for her moral support and encouragement when the task seemed a little much for me to deal with. I wish to thank Barbara Given who very early in the program helped me to see some of my potential. Finally, I wish to acknowledge and thank my parents. The lessons of persistence and and courage conveyed in my youth have led to the accomplishment of one more dream. TABLE OF CONTENTS List of Tables. ................ . ..................... ...............v List Of Figures ........... O... ....... O ...... .00... ..... O 000000000000 Vi Chapter I........... .................. ........ ................... ...1 |ntroduction....................................................1 The Problem.................... ..... ............................1 Purpuse of the Study... ..... .... ......... . ...... .. ..... . ..... ...3 Research Questions........ ........... .... ..... ..................6 Definition of Concepts PMS........................................................6 Symptoms.... ......... ............ ......... . ...... ..........8 Severity..................................................10 Phases of the Menstrual Cycle.............................10 The Young Adult...........................................12 Extraneous Variable............................................13 Assumptions of the Study.......................................13 Limitations of the Study.......................................1A Overview of Chapters........ ...... ............. .......... ......14 Chapter ll...... ..... ........... .......................... . ........ 16 Conceptual Framework...........................................16 The Young Adult................................................17 Rogers' Theory.................a...............................20 Unitary Man (Human Being).................................20 Rogers' Assumptions about Man.............................21 Man.......................................................21 Environment...............................................23 Health....................................................2h Nurs‘nQOOIOO00.00.000.000.0.......00...COOOOOOOOOOOOOOOOOCZS An Integrations of the Theories of Rogers and Chickering.......26 The NurSing ProceSSOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO0.0.0.00000032 sumal'y.............................o...........o...ooo......o.3li Chapter llI........................................................36 Review of the Literature.......................................36 PMS, Women, Families, and the Workplace...................37 PMS/Etiology..............................................Al PMS/Symptoms..............................................61 PMS/Treatment.............................................72 Summary.............. ......... . ................. .. ......... ....82 Chapter IV ......... ... ....... . ...... . ............................ ..83 Overview.......................................................83 Description of Design ....... ...................................83 Sample.........................................................8A Data Collection Procedures.....................................8A Operational Definition of Variables............................86 PMS.......................................................86 Phases of the Menstrual Cycle.............................87 Symptoms..................................................87 Severity of PMS Symptoms..................................87 The Instrument.................................................89 Reliability of the MDQ....................................92 Validity of the MDQ. ..... ....... ..... .....................93 Data Analysis and Summary......................................98 Summary..................... ......................... . ...... ..100 Chapter V............... ...................................... ....101 Data Presentation.............................................101 The Study Sample..............................................101 Reliability of the Instrument....... ......... .................106 The Questions.................................................108 Additional Findings........ ......... . ......... ................122 Summary......................................... ......... .....124 Chapter VI......................... ......... ......................125 Summary and Implications......................................125 Discussion...............................................125 lmplications........ ...... ....................................129 Research.................................................129 Education................................................13h Practice.... ................... ..........................137 Summary............................................. ....... ...1A2 Appendices........................................................... Appendix A Letter to Director of Undergraduate Department.....1h3 Appendix 8 Instruction Letters to Subjects....................1A4 Appendix C Instruments........................................146 Appendix D Consent Form and Researcher's Statement............151 Appendix E Approval Letter from URICHS........................152 References ............. .. ..... ......... ........................... 153 iv LIST OF TABLES Table 1 Moos (1968, 1985) Eight subscales of the MDQ................9 Table 2 Premenstrual Symptoms, Abraham (1981)......................A6 Table 3 The Eight Subscales of the MDQ (Moos, 1985)................88 Table A Average lntercorrelations of Eight MDQ Subscales...........91 Table 5 Average Internal Consistencies for MDQ (Moos, 1985) subscales......................................................93 Table 6 Demographic Variables.....................................103 Table 7 Self-reported Health Status of Sample.....................105 Table 8 Menstrual Variables.......................................106 Table 9 Reliability of the Subscales, represented by internal conSEStenCieSo000.000.000.00000.000.0000o.00.00000000000000000107 Table 10 Frequencies of Symptoms for Three Phases of the Menstrual cycle by SUbscaleOOOOOOOOOO....0.......O...00.0.00000000000000109 Table 11 Premenstrual Symptoms in Rank Order......................111 Table 12 Rank Order of Subscales for Most Frequently Premenstrual Symptoms......................................................112 Table 13 Frequencies of Severity of Symptoms for Three Phases.....114 Table 14 Mean Symptom Severity for Three Phases...................116 Table 15 Mean Symptom Severity in Rank Order for Premenstrual Phase only.........OOOOOOOOO...0.00.....O....O.......IOOOOOOOOOOOOOOIIS Table 16 Rank Order of Scales for Premenstrual Phased Only........121 Table 17 Comparison of Frequencies and Severity for Premenstrual Phase onIYOOOOOOO......OOOOOOOO.....OOOOOOOOOOOOO0.0.000.000.0121 Table 18 Symptoms Written in by Subjects... ......... ..............123 Figure Figure Figure Figure Figure Figure TABLE OF FIGURES Chickerings psychosocial developmental madeIOOOOOOOOOOOOOOOOOOO ....... .... 0000000000000 O ....... 0018 Rogers' (1985) the spiral of life....................... ............................... 23 Interaction of the human and the environmental energy fields...00000000000000.000000000coo. ..... ooooooooooo ccccc 28 The impact of PMS on the young adult energy field 000000000000 0.... OOOOOOOOOOOOOOOOO 00.00.00.000000000030 Intervention by the CNS with the young adult with P"Soe.cocoeooooooooooooooooeoeoooeoeoooo00000000000000.0003] Algorithm for client and clinician decision making for treatment of CHAPTER I THE PROBLEM Introduction Since its first appearance in the literature some fifty years ago, Premenstrual Syndrome (PMS) and its symptoms have been increasingly discussed and studied by both the lay and health care worlds (Frank, 1931; Greene 5 Dalton, 1953; Steiner 8 Carroll, 1977; Gonzalez, 1981; Abraham, 1983; Rock, 1984; Laurensen, 1985; Frank, 1986). Despite this attention, there is little conclusive data related to symptomatology, severity, population of sufferers, or treatment modalities for PMS (Laurensen, 1985). There is little agreement in the literature regarding the number of women PMS affects. It is estimated that between 152 and 1002 of women (Woods, Most, s Dery, 1982) will report symptoms attributable to PMS during their adult lives. Shaver and Woods (1985) note that beside the presence of symptoms of PMS, an important consideration is how bothersome or disruptive the symptoms are to the woman. Symptoms reported may vary from present but not disruptive of activities of daily living to disabling. Two to three percent of women report PMS symptoms which are disabling to them (Hopson 8 Rosenfeld, 198A). The literature to date does not contain a precise definition of premenstrual syndrome. As a result of the inability to define and agree upon one definition or etiology, varying types of treatment plans have been developed and utilized with inconsistent rates of success (Abraham, 1983; Dalton, 1977; Laurensen, 1985). Due to the broadness of the syndrome, treatment is quite diverse, including diet therapy, vitamin supplements, exercise, relaxation, counseling, and education in self-care (Frank, 1986). One approach that has proven effective for many women with PMS has been education. Programs which include information about the syndrome, dietary changes, vitamin supplements, exercise, and stress reduction techniques have had some success (Laurensen, 1985). Most authors report a reduction of symptoms and an improved well-being of the woman with a combination of the above listed interventions (Abraham, 1980; Frank, 1986; Laurensen, 1985). Regardless of the etiology of the cyclic symptoms of PMS, the fact remains that for some women symptoms of PMS are severe enough to disrupt normal activities of daily living. This disruption is stressful for these women (Levitt, Freeman, Soundheimer 8 Rickels, 1986). Stressful life events have been documented as being important factors related to both physical and mental disorders (Selye, 1956). The young adult female is at a point in her life where one or more stressful life events are occurring (leaving home, starting college, getting married, giving birth to the first child, launching a career and so on). When the stress produced by the cyclic reccurence of PMS symptomatology is added to these developmental stresses, the potential for a reduction in ability and energy for developmental task accomplishment is greatly reduced. The Clinical Nurse Specialist (CNS) has an important role through education, research, and clinical practice in significantly contributing to the elimination or reduction of the impact of PMS. The CNS with psycho-social-physio-environmental knowledge, as well as background in teaching and learning theory, is well equipped to assist women suffering from PMS. Purpose gfi this Study Research regarding premenstrual symptoms has been the focus of increased attention during the past 50 years. Premenstrual symptoms which have been most commonly reported include: abdominal bloating, breast tenderness, edema of extremities, headache, backache, dizziness, joint pain, appetite changes with cravings, acne, anxiety, depression, mood swings, irritability, confusion, fatigue, tension, and crying spells (Dalton, 1977; Laurensen, 1985; Moos, 1968; Moos, 1985; Abraham, 1982). There is disagreement in the literature concerning the number of women who are affected by PMS or symptoms premenstrually. The prevalance of PMS symptoms reported ranges from 15 to 100 percent of all women (Woods, Most, 5 Dery, 1982). There is also no consensus as to which symptoms are most commonly reported. The above mentioned core of symptoms is becoming more accepted, however the actual number of symptoms is still under scrutiny (Moos, 1968; Abraham, 1983; Wood, Most, s Dery, 1982; Laurensen, 1985). Despite disagreement about the number or types of symptoms reported, many researchers are in agreement that most symptoms will be reported during the menstrual or premenstrual phases of the cycle (Moos, 1968; Moos, 1985; Abraham, 1982; Wood, Most, 8 Dery, 1982; Shaver 8 Woods, 1985). Which symptoms or how severe they will be for each phase is an area requiring clarification. Researchers who have used the Menstrual Distress Questionnaire (MDQ) (Moos, 1968) and have analyzed symptoms across phases of the menstrual cycle have obtained differing results. Woods, Most, and Dery (1982) found a substantial and statistically significant difference in the severity of symptom ratings between the menstrual phase and the remainder of the cycle, and the premenstrual phase and the remainder of the cycle for 16 of the MDQ items. Shaver and Woods (1985) studied a group of women for two cycles using the MDQ and an open ended diary. Shaver and Woods (1985) found that, in general, symptoms reported for the menstrum and premenstrum were fairly prevalent during the remainder of the month. Hargrove and Abraham (1981) utilized the Menstrual Symptom Questionnaire (MSQ) (Abraham, 1980) and found that 702 subjects suffered from at least one category of premenstrual symptomatology during the week preceding menses. Hargrove and Abraham (1981), however, utilized only two divisions for the cycle, one week preceding and one week after menses. No symptoms were measured for the menstrual phase. In the research which has been conducted to date, there is disagreement about the number of symptoms reported for any specific menstrual phase, as well as the severity levels for symptoms reported in each phase. Most studies dealing with the identification of symptoms also attempt to measure the severity of reported symptoms. Severity is a measure of the degree of disruption of normal activities caused by symptoms. One study used 6 points of sensitivity to determine severity (Moos, 1968), another used A (Abraham, 1983) and still others have used 3 (Kingsbury, 1985; Mackay, 1985). The varying sensitivities of the severity scales has made it difficult to compare results of these studies. The research findings provide information leading to an agreement that symptom severity is highest during the premenstrual and menstrual phases of the menstrual cycle, as compared to the remainder of the month (Moos, 1968; Moos, 1985; Woods, Most, 5 Dery, 1982; Abraham, 1983). Without an understanding of severity, prevalence, or common types of symptoms as a base, it is virtually impossible to plan effective nursing interventions. This study will focus on a relatively homogenous, healthy group of young women ages 18 to 25, a sample very much like that of Moos' (1968). It is hoped that a comparable study estimating the type and severity of different menstrual cycle symptoms will provide other investigators with an increased understanding of PMS to serve as a basis for formulating timely clinical interventions. The purpose of this study specifically is to: 1. Identify symptoms reported most often by a sample of women 18 to 25 years of age during the seven days prior to menses (premenstrual phase) as compared to the week of menses, and the remainder of the month; 2. Determine to what degree symptoms reported interfere with activities of daily living (severity) during the seven days prior to menses compared to the week of mensus, and the remainder of the month. Research Questions 1. What physical, affective, or behavioral symptoms are most commonly self-reported retrospectively by this sample of women 18 to 25 years of age during the premenstrual phase of the menstrual cycle? 2. What symptoms are reported as being most 3232;: during the premenstrual phase of the menstrual cycle? Definition 9: Concepts EMS As previously stated, PMS has been discussed in the literature since Frank's initial description (Frank, 1931). Frank (1931) used the term Premenstrual Tension Syndrome to describe conditions suffered by women characterized by nervousness, weight gain, swelling of face, hands, and feet, painful engorgement of the breasts, and headaches premenstrually. In 1982, Abraham, utilizing the same term as Frank (1931), described the phenomenon as a symptom complex occurring seven to ten days before menses, becoming progressively worse, and improving with menses. Dalton (1977) states that PMS is the wide variety of symptoms which occur regularly in the same phase of each menstrual cycle, followed by a symptom free time in each cycle. Moos (1968) definied PMS as the clustering of symptoms during the week preceding menses. Halbrelch, Endicott, Schacht, and Nee (1982) stated symptom clustering must occur during the 1 to 14 days preceding onset of menses to be considered a premenstrual symptom. The complexity of this syndrome and its variety of manifestations has not allowed for an easy or simple definition. There are, however, some characteristics repeated in most definitions. Common characteristics among definitions include: the cyclic nature of occurrence of the symptoms, the presence of a symptom free time, and the grouping or clustering of symptoms. For this study, the term PMS, coined by Dalton (196A), rather than PMTS (premenstrual tension syndrome, Frank, 1931), will be used. PMS will be defined as the cluster of symptoms including physical, behavioral, or affective manifestations that occur during the week preceding menses with cessation upon onset of menses. Based on a review of the literature the following symptoms are most commonly reported as clustering during the premenstrual phase of the cycle: abdominal bloating, breast tenderness, edema of extremities, headache, backache, dizziness, joint pain, appetite changes with cravings, acne, anxiety, depression, mood swings, irritability, confusion, fatigue, tension, and crying spells (Laurensen, 1985; Moos, 1985; Abraham, 1982). Symptoms Symptoms of PMS are numerous. Proposed etiologies are equally plentiful. Dalton (1977) works from the premise of hormonal imbalances. Goie and Abraham (1983) have studied vitamin deficiencies. Laurensen (1985) in a review of the literature concerning PMS, cites prolactin as a possible cause of some of the symptoms. Efforts to divide and group symptoms to facilitate study of the etiology of PMS have been made by individual researchers (Moos, 1968; Dalton, 1964; Woods, Most, 5 Dery, 1982; Abraham, 1980). Moos (1968, 1985) utilized eight groupings of symptoms. Moos' (1968, 1985) list (Table 1) includes symptoms he found women report across the entire menstrual cycle, not just symptoms reported for the premenstrum. Note that one symptom, changes in appetite, is not included in a subscale. Women frequently report a change in appetite or cravings. The symptom, however, does not consistently factor into any of the subscales (Moos, 1968, 1977, 1985). Using Moos' (1968, 1985) scale, PMS is the cluster of symptoms present the week before menses and absent during any other phase of the menstrual cycle. For this study, a single premenstrual symptom will be any physical, behavioral, or affective symptom occurring during the week preceding menses with cessation upon onset of menses. A single symptom meeting the above criterion will be considered a premenstrual symptom worthy of intervention, but will not indicate PMS. PMS refers to the cluster of symptoms, indicating the presence of more than one symptom. TABLE I. PAIN Muscle stiffness Headaches Cramps Fatigue General aches and pains Backache CONCENTRATION Insomnia Forgetfulness Confusion Lowered judgement Difficulty concentrating Distractible Accidents Lowered motor coordination BEHAVIOR CHANGES Lowered school/work performance Take naps, stay in bed Stay at home Avoid social activities Decreased efficiency AUTONOMIC REACTIONS Dizziness/faintness Cold sweats Nausea, vomiting Hot flashes Changes in Appetite Moos (1968, 1985) Eight Subscales of the MDQ. WATER RETENTION Weight gain Skin disorders Painful breasts Swelling NEGATIVE AFFECT Crying Loneliness Anxiety Restless Irritability Mood swings Depression Tension AROUSAL Affectionate Orderliness Excitement Feeling of well-being Bursts of energy @132; Feeling of suffocation Chest pain Ringing in ears Heart pounding Numbness, tingling Blind spots, fuzzy vision lO Severity The concept of severity has been discussed by many researchers (Abraham, 1980; Woods, 1985; Moos, 1968; Woods, Most, 5 Dery, 1982; Kingsbury, 1985). Moos (1968) described a six point scale ranging from: “did not experience at all" to "present and disabling" to determine severity of symptoms. Moos (1985) later reduced the severity scale to a four point scale ranging from "did not experience” to "present disabling", the two moderate scales were combined. In 1983, severity was defined by Abraham using a numerical scale ranging from "no symptoms" to "keeps me home in bed” (severe). The four point scale used by Abrahan (1983) was a revision of the scale originated by Moos (1968). Dalton (1980) described a three point scale ranging from "aware of menses coming" (mild) to "life threatening with potential for suicide, or symptoms that interfere with employment or relationship stability” (severe). The common underpinning of all the severity scales mentioned is the attempt to determine the degree to which symptoms reported in relation to the menstrual cycle disrupt the woman's activities of daily living. Thus, severity is a subjective measure indicating how the individual perceives her life disrupted by the symptom(s) during the phases of the menstrual cycle. Phases 2f the Menstrual Cycle The menstrual cycle has two divisions: The follicular and the luteal. The follicular part is approximately the first half of the 11 menstrual cycle and is characterized by the development of the graafian follicle from a number of growing follicles. The luteal part occurs as a result of a surge in gonadotropin secretion and ovulation. The graafian follicle becomes a corpus luteum which secretes estradiol and progesterone. PMS symptoms occur late in the luteal phase (Linkie, 1982). Moos (1968) divided the two parts of the menstrual cycle into three phases in the development of the Menstrual Distress Questionnaire. Since that time, other studies (Wood, Most 5 Dery, 1982; Kingsbury, 1985) have utilized the three phases as a more accurate way of determining the presence of symptoms of PMS and the symptom free time required to diagnose PMS. The use of phases as a method of dividing the menstrual cycle into units of time allows women to differentiate between their experience of different symptoms and severity in terms of different times during the cycle. Research has attempted to establish three phases (Kingsbury, 1985; Moos, 1968, 1985; Shaver 5 Woods, 1985) based on clustering of symptoms or the absence of symptoms in relation to menses. Phases, for the purpose of this study, will be units of time developed to identify what symptoms are present, when symptoms are present, and when symptoms are most severe in relation to menstrual blood flow. The phases utilized will be: (1) seven days preceding menstrual flow, (2) time during menstrual blood loss, (3) remainder of month not covered by the other two phases (Moos, 1968). It is important to determine when symptoms occur and when they are most 12 severe by comparing the phases in order to identify symptoms that fulfill the definitions of PMS and premenstrual symptoms. Young Adult Another concept requiring definition is that of the young adult female (women aged 18 to 25 years). The young adult years are a period of transition from dependence upon parents to that of autonomy and interdependence. According to Chickering (1969), as one enters the "young adult years" life phase there is a central developmental task that must be accomplished, the "establishing of identity". Chickering (1969) postulates six vectors to understanding identity development in young adulthood. Chickering (1969) suggests vectors rather than stages, as vectors connote both magnitude and direction. The vectors are not linear in progression. The first three vectors, developing competence, managing emotions, and developing autonomy provide the foundation for the last three, freeing interpersonal relationships, clarifying purpose, and developing integrity. All six vectors are required if identity is to be established (Figure 1, Chapter II). The process of I'establishing identity“ (Chickering, 1969) is one that requires major emotional and psychological changes to occur in the young adult female. Chickering (1969) states that "the individual must develop a view of self suggesting that one is capable, in control, and independant before considering how to define self" ( p.80). In essence, Chickering (1969) suggests that the 13 individual must first be assured that he/she can contend with an environment before an identity can be created. The task of ”establishing identity" can be even more complicated for the young woman dealing with PMS. The physical discomforts combined with decreased ability to control oneself may contribute to confusion and retardation of the establishing identity process. Extraneous Variables Any factor which is not included in the study design that may influence the variables under study is classified as an extraneous variable. History of menstruation, age, state of health, nutritional status, and activity level are variables of this nature which have been measured in this study. Numerous other extraneous variables, such as cultural beliefs, current mood state, and personality type are beyond the scope of this study and were not measured. Assumptions 9f the 332g! 1. All answers were given in an honest and accurate manner. 2. The symptoms which are indicative of PMS were included in the tool. 3. If symptoms are reported as occurring during the premenstrual phase of the menstrual cycle and not during the other two phases, they may be indicative of PMS. 1A Limitations pf_£hg_§£pgy 1. This questionnaire is a retrospective symptom survey requiring self-reporting. This type of reporting can lead to error in reporting of symptoms. The trend for this type of questionnaire has been toward over reporting (Ruble, 1977). Rose and Abplanalp (1983) found high concordance between reported symptoms and severity in patients with the most severe symptoms. 2. Generalizability is limited to 18 to 25 year old women enrolled at the institution where data were collected. 3. The woman's perceptions of menstruation and her earlier experiences observing her mother's menstruation may bias reporting of symptoms. Shaver and Woods (1985) found that the woman's beliefs and attitudes toward menstruation can affect the symptoms and severity reported by women. A. Volunteers often possess characteristics not found in the general population. The volunteer phenomenon will reduce generalizability of results. 5. Only one cycle 15 assessed and no other means of validating the self-report is used. 6. To date, few reliability or validity studies have been conducted on the entire MDQ, form C. Overview 9: chapters This study is presented in six chapters. Chapter I contains an introduction, statement of purpose, research questions, definitions 15 of variables, assumptions, and limitations of the study. Chapter II contains the conceptual framework. In Chapter III, a review of the literature is provided. The research design and methodology are included in Chapter IV. Chapter V contains the findings of this study and the data analysis. Finally, Chapter V1 is a summary of the study's findings, conclusions, recommendations for future research, and implications for nursing practice and education. CHAPTER II CONCEPTUAL FRAMEWORK In this chapter, the conceptual framework used to guide this study will be described. Chickering's (1969) developmental theory and Rogers' (1985) theoretical basis for nursing will be utilized as models for this framework. Chickering (1969) views the development of humans across the life cycle as a process of accomplishing developmental tasks. Concepts from Chickering's (1969) theory that will be presented include young adulthood, as a stage in the life cycle of man, and task accomplishment. Rogers' (1985) uses the principles of resonancy, helicy, and integrality to define the nature and direction of change in man and his environment. Concepts presented from Rogers' (1985) theory will include man, the environment, health, and nursing. The term man, though awkward, will be utilized within the discussion of Rogers' (1985) theory, as this is terminology taken directly from the theory. Finally, the integrated conceptual framework will be presented. It is within the integration of the theories of Rogers (1985) and Chickering (1969) that the interconnectedness of the concepts of young adulthood, as a phase in the life cycle of man, the environment, PMS, and nursing are discussed. Rogers' (1985) theory of nursing was selected as a framework for the study for two reasons. The first reason is the emphasis of the 16 17 theory on man as a unified whole and more than the sum of his parts. Rogers (1985) clearly states that man can not be broken into elements or separated from his environment to study or predict behaviors. The second reason for the selection is related to Rogers' (1985) view of universal man's ability to choose components from an environment that is all around him and a part of him to create a harmonious life pattern. Chickering's (1969) developmental theory was selected because the framework acknowledges the impact of the internal and external environments on the human being. Within this theory the elements of emotional growth, cognitive development, physical skills acquisition, and human interaction are addressed. Chickering (1969), like Rogers (1985), views the human as more than the sum of the psycho-socio-biological parts. The Young Adult The young adult is usually considered as one between the ages of 18 to 25. This span of years is a period of transition from dependence upon parents to that of autonomy and interdependence. According to Chickering's Psychosocial Developmental Model (1969), the central developmental task of young adulthood is "establishing identity". Chickering (1969) postulates that identity development is composed of six vectors (Figure 1). As mentioned in chapter I, Chickering (1969) suggests vectors rather than stages, as vectors connote both magnitude and direction while stages usually connote l8 Dael i Hmeugjnuwprsral "(////V Rflatknafipg i Bmtkrs Endflidflpg_damfiy' Iflari DaelOLCELme m—fif \Deveicp:rllm FIGURE 1. Chickering's Psychosocial Developmental Model. time. Establishing identity is the single major task for young adults. Chickering (1969) defines identity as a solid sense of self that assumes form as the developmental tasks are undertaken with some success. The sense of identity provides a framework for interpersonal relationships, purpose, and integrity in adult life. The six vectors are as follows (Chickering, 1969): 1. Developing competence: A sense of competence is defined as the "confidence one has in his ability to cope with what comes and to achieve successfully what he sets out to do” (Chickering, 1969, p.9). Chickering (1969) suggests three areas of ability which one must achieve competence: intellectual skills, physical and manual skills, and social skills. 2. Managing Emotions: Individuals must become aware of their l9 emotions and recognize them for what they are. In addition, they must manage and control emotions as they are integrated into decisions and behavior. Sex and aggression are two major areas of concern that one learns to control or manage within relationships (Chickering, 1969). 3. Developing autonomy: Chickering (1969) defines autonomy as the "independence of maturity” and views maturely autonomous persons as secure and stable, capable of coordinating behaviors to personal and social ends. Emotional independence or autonomy involves freedom from the pressing need for reassurance, affection or approval. As people become emotionally autonomous, they discover and accept the "capstone of autonomy" which is interdependence with family, peers, and society (Delworth 5 Hanson, 1980). A. Freeing Interpersonal Relations: This task involves developing a tolerance for a wide range of ideological and individual differences. Recognizing differences, tolerating them, and finally beginning to appreciate the differences in interpersonal relationships is reflected as one develops mature and intimate relationships (Chickering, 1969). 5. Clarifying Purpose: The young adult must develop plans and priorities for life and begin to integrate vocational interests with vocational plans and lifestyle considerations. This integration provides both direction and purpose to life. 6. Developing integrity: Integrity involves three steps: 20 humanizing values or recognizing the differences between absolutist rules of life and more relativistic perceptions of life, i.e., the letter of the law vs. the spirit of the law, personalizing of values or accepting and affirming one's own value system and acting according to it, and deveIOping concurrence between one's value system and actions (Chickering, 1969). In essence, Chickering (1969) is stating that the individual must develop a view of self that suggests competence, personal control, and independance before considering how to define self. The individual must be assured that they can contend with an environment before an identity can be created. This idea of self concept or identity development and environmental influence is significant to this research and will be further developed within the final section of this chapter where the theories of Rogers (1985) and Chickering (1969) are integrated to form one conceptual framework for research. fipgggs' Theory Unitary Man (Human Beigg) Rogers (1985) views nursing from a universal perspective. The broad scope of Rogers' theory makes it readily useful to all aspects of nursing practice. Rogers' (1985) theory is based upon assumptions about human beings, beliefs about nursing, and four conceptual building blocks of the theory. The assumptions at the 21 foundation of Rogers' theory are about human beings: Rogers states, "People are at the center of nursing's purpose" (1985, viii). The assumptions are listed below. Rpger's Assumptions about Man 1. The human being is a unified whole possessing his own integrity, and manifesting characteristics that are more than and different from the sum of his parts (Rogers, 1985) 2. The human being and the environment are constantly exchanging energy with one another (Rogers, 1985). 3. The life process evolves irreversibly and unidirectionally along the space-time continuum (Rogers, 1985). h. Pattern and organization identify the person and reflect his innovative wholeness (Rogers, 1985). 5. The human being is characterized by the capacity for abstraction and imagery, sensation and emotion, and language and thought (Rogers, 1985). Rogers' (1985) assumptions about man lead into the next section of this chapter, the discussion of individual concepts of the theory. The first concept described will be the the concept of man (human being). M Rogers' (1985) framework is concerned with two energy fields: the human field and the environmental field. The human energy field, viewed as a whole, is the person. Persons are identified 22 by pattern and organization which is changed by interaction with the environment as each individual moves through life. Pattern and organization are characterized by the individual's capacity for abstraction and imagery, sensation and emotion, and language and thought (Rogers, 1985). Figure 2 depicts Rogers' (1985) spiral of life. The slinky, with the differential spacing of loops, depicts helicy. Helicy is the continuous, innovative, probabilistic increasing in diversity of human and environmental field patterns characterized by non-repeating rhythmicitles. The changing size of the slinky loops depicts resonancy, the continuous change from lower to higher frequency wave patterns in human environmental fields. The slinky over time depicts the continuous mutual human and environmental field process. Thus, the spiral is a pictorial of man's development and interactions with the environment over time. This evolution implies an increasingly complex thought pattern in man over time. The person's ability to think implies an ability to make decisions, which in turn provides for choices in selecting components of the environment. By making choices, individuals influence their pattern and re-pattern to produce a harmonious life experience (Rogers, 1985). The individual's ability to influence patterning and re-patterning is significant for this study. It implies that the woman can make changes in an effort to obtain her maximum health potential via knowledge about PMS, the kinds of symptoms found, and the factors that may influence the symptoms. 23 TIME FIGURE 2. Rogers' (1985) The Spiral of Life. Environment The environmental energy field is the second energy field addressed by Rogers (1985). According to Rogers (1985), each person's environment is all that is external to the human energy field and extends into infinity. For the young adult, this would include diet, work, relationships, stress, education, climate, health care, and any other factor outside of the human energy field. Rogers (1985) also points out that the environment and man are open systems, constantly effecting change in each other. 2A This is significant as it points out that the young adult female will not only be affected by the environment, but will influence the environment establishing patterns with animate and inanimate presences. The environment is, as is the human energy field, growing increasingly complex with time, identifiable by pattern and organization, and greater and different from the sum of its parts. The environment of the young adult woman has a global effect on the young woman's process of becoming or evolving. It is the young woman's lived experience of PMS that can be altered through environmental manipulation by the young woman guided by the Clinical Nurse Specialist (CNS). The young adult's reaction to PMS, as will be discussed in the last section of this chapter, is a result of the interaction of her life pattern with the environment's pattern. seam Rogers (1985) states, ”Maintenance and promotion of health are a nation's first line of defense in building a healthy society” (p. 122). Health is individually determined and is influenced by the person's interaction with the environment. It is the individual's choice of daily activities that determines the selection and interaction of elements in their environment. The elements the individual selects influence the patterning of the individual and allows or disallows for a harmonious pattern. PMS may represent a disruption in the harmonious life 25 patterns of the young adult female. The disharmony can, for many women, be re-patterened to a harmonious state by a more careful process of selecting environmental components with which to interact. Health, then, as represented by a harmonious life pattern, is another significant concept in this study. The CNS working with the PMS client can help to clarify the client's present pattern and the environmental factors which can effect a more harmonious re-pattern. In the case of the young adult, the re-patterning may establish health oriented patterns that will be carried with the individual throughout the life span. Nursing The last Rogerian concept requiring definition is that of nursing. Rogers' (1985) five assumptions about human beings are the foundation of the conceptual framework for nursing. The purpose of the framework is to guide the nurse in practice. Rogers (1985) describes nursing as a profession that is both an art and a science. The sclenctific aspect of nursing is the study of the nature and direction of man's development, integral with the environment. The art of nursing is the utilization of nursing's body of knowledge in serving man. By describing PMS, its symptoms, severity, and frequency in relation to the phases of the menstrual cycle this study will add to the scientific knowledge base of nursing. By analyzing and applying the data 26 collected, the study will demonstrate an expanding of the art of nursing. According to Rogers (1985) nursing is concerned with all people whether they are well or ill, rich or poor, young or old. Nursing is a process directed toward the goal of assisting individuals to achieve their "maximum health potential" (Rogers, 1985, p.86). Nursing utilizes a process of assessing, diagnosing, planning, intervening, and evaluating human responses to the constant interaction with their environment. The nursing process, as applied by the nurse, focuses on the unified whole, recalling that man is a negentropic energy field, identified by patterns and organization manifesting the characteristics and behaviors that are different from those parts and which cannot be predicted from knowledge of the parts (Rogers, 1985). An example of the nursing process will be presented in the following section to demonstrate the integrated conceptual framework as applied to practice. ‘Ag Integgation p: the Theories pj_§pgers and Chickerigg Within this section, the concepts presented in the description of Rogers (1985) and Chickering (1969) will be integrated to provide the single framework which is the basis of this research. These concepts include: 1) the young adult, as a phase in the life cycle of man, 2) PMS as a disruption in the harmonious patterning of a woman, 3) the environment as 27 influencing and being influenced by the woman, and 4) the CNS as an energy field within the environment of the young adult female, capable of interacting with the young adult to assist in the choices necessary to re-pattern. Within Rogers' (1985) framework, re-patterning can lead to a more harmonious life state. Both Chickering (1969) and Rogers (1985) recognize the impact of the environment on the human being. The influence of environment on the young person is tremendous. It is at this life phase that the young woman usually leaves home bound for college, a new job, or to begin a family. It is also at this phase that the young woman establishes an identity. The process of "establishing identity" (Chickering, 1969) is a physical, social, and emotional challenge for even the healthiest young adult. Figure 3 depicts the healthy young adult female energy field interacting with the environmental energy field to accomplish the task of establishing identity. The young woman's efforts to meet this emotional challenge may be confounded by the multiple physical, behavioral, and affective symptoms of PMS, i.e., nervousness, confusion, lrritability, depression, bloating, headaches, and mood swings. For the young woman with PMS, the symptoms become a large part of the human energy field. The symptoms may become so disruptive to the life pattern that assistance is required. Figure A represents the presence of PMS symtomatology in the young adult 28 ENVIRONMENTAL ENERGY FIELD Relationships Stress l I Diet ' School Work ' Family THE YOUNG ADULT ENERGY FIELD [ Establishing Identity I Moving I Activities 1 . Climate Health Care THE LIFE PROCESS, UNIDIRECTIONAL INCREASING IN COMPLEXITY :? TIME FIGURE 3. Interaction of the human and evironmental energy fields. 29 energy field. Note that the symptomatology is using up a very large portion of the young adult's energy field. This consumption of energy may drain the energies usually available to the young adult female for establishing identity. Therefore, the process of establishing identity may be slowed or blocked. The CNS, utilizing Rogers' (1985) theory of ever growing, ever changing unidirectional life processes, Chickering's (1969) concepts of task accomplishment across the life cycle, and information about PMS, can help the young adult to incorporate the external environmental changes and the internal growth processes into the young adult's patterning. The incorporation may lead to a reduction in the impact of PMS. Figure 5 depicts the introduction of the CNS into the environmental energy field of the young adult female. The CNS can assist the young adult female to identify and select the environmental components that eventually lead to a re-pattern of the woman's energy field and a reduction in the size of PMS as an energy consumer in the woman's energy field. The decisions made will have serious consequences, as the choices determine the extent that the woman/environment interaction will shape life patterns. These choices and the impact of these choices can lead to her maximum health potential or to some degree of disharmony that prevents achievement of the maximum health potential. If the woman's health patterns are disharmonious, it will be difficult to direct energy toward other aspects of life, i.e., identity development. 3O ENVIRONMENTAL ENERGY FIELD Relationships Stress Diet l I School I i I Work I Family THE YOUNG ADULT ENERGY FIELD | l Estaalishirg Ichtity I I Activities Moving I l— ~ Climate Health Care THE LIFE PROCESS, UNIDIRECTIONAL INCREASING IN COMPLEXITY 7 TIME FIGURE A. The Impact of PMS on the young adult energy field. 31 ENVIRONMENTAL ENERGY FILED CNS CNS I {I W M ( I l ' I THE YOUNG THE YOUNG I [ADULT ENERGY FIELD I I ADULT ENERGY FIELD Establ ishirg Identity Estzbl ishirg Identity I I 9 I fms LL __J I __________ J THE LIFE PROCESS, UNIDIRECTIONAL INCREASING IN COMPLEXITY > TIME FIGURE 5. Intervention by the CNS with the young adult with PMS. 32 The Nursipg Process The CNS, utilizing the nursing process assesses the client and the client's environment, including relationships, to provide assistance to the young woman to re-pattern, and create harmony. The nurse relies upon interpretation of the interaction with the client as well as the results of tools used during the assessment to evaluate the client's needs. Tools for an assessment of PMS include a diet history, history of exercise, and information concerning the developmental tasks and successful accomplishment of them. Abraham (1982) would recommend the use of a menstrual diary, as would Dalton (1977). The diary is helpful in acquiring knowledge about the cycle, regularity, duration, and physical and emotional changes which occur during the monthly cycle. A modified version of the Menstrual Distress Scale (Moos, 1968) may be given to assess for the most common symptoms reported by women. Based upon the data collected, a diagnosis of PMS is or is not determined. It is extremely important to differentiate between PMS and other gynecological, mental, or endocrine problems for the safety of the client and for the efficacy of the treatment. Once the data have been analyzed and the diagnosis of PMS is confidently made, the planning process begins. During the planning stage, the nurse again analyzes the data collected from the client. Areas for intervention are identified with the client. Goals are set with the client for each area identified for intervention. 33 Interventions are based upon standards and current research findings in the area of PMS. Current literature contains information that nutrition is a possible cause of some PMS symptoms (Laurensen, 1985). Other researchers (Steiner 5 Carroll, 1977; Frank, 1985), indicate stress as a possible factor in PMS. Still, in another study, Woods (1985) fOund the woman's views of menstruation and how she was socialized to deal with the monthly event affected PMS symptomatology. Other researchers cite age, education, and the use of oral contraceptives as causes of some symptoms reported for PMS (Woods, Most, 5 Dery, 1982). Once the goals are set and the plan of intervention (approach to re-patterning) decided, it is time to intervene. One goal identified may be to provide data to the client encouraging the client to make choices in regard to environmental components that can affect the client's goal of reduced PMS symptomatology and suffering. If education is the selected mode, the nurse must provide the most up-to-date information available on diet factors that can influence PMS, stress management, exercise, alternatives to oral contraceptives, or other aspects of the client's environment that may be changed by the client. Another mode that has proven helpful to PMS clients, and may be offered to the young adult client, is that of group counseling. Frank (1986) documented decreases in symptoms as a result of being able to share experiences with other women and feel supported by them. The experience provided reassurance that the woman was not alone in her suffering, 3A exposure to solutions others had found, and a place to vent frustration over the symptomatology most disruptive to them. Upon completion of interventions, it is necessary to evaluate outcomes and goal attainment, including client satisfaction. To evaluate the outcomes of intervention, similar tools used during the assessment phase could be reused. The CNS having assisted in the re-patterning of the young adult female's life pattern will always be a part of the client. The support provided, the problem-solving techniques shared with the client, and the knowledge that the CNS is available for future services have become a part of the young woman's pattern, creating an ongoing relationship with the CNS. The nursing process is a scientific methodology utilized to identify and alter the woman-environment interaction. The alteration in interaction patterns, leads to alterations in the woman's health patterns. Hopefully, the alterations decrease the disruption of the harmonious life patterns (PMS) freeing energy to focus on the successful accomplishment of the developmental task of identity development. Summary In this chapter, man has been defined through the use of Rogers' (1985) conceptual framework and assumptions about human beings. Rogers' (1985) framework was further utilized to describe the interaction of man with his environment to achieve maximum health 35 potential. Health was defined and the concept of harmonious patterns was introduced as a means of describing health. A brief description of nursing was offered followed by the goals of nursing. The young adult was discussed as a phase with tasks in the developmental life cycle of man (Chickering, 1969). PMS was presented as a disruption in the life pattern of the woman with the potential to produce severe disharmony in that patterning. Also presented was an integration of concepts contained in Rogers' (1985) with concepts contain in Chickering (1969) as the actual research framework for this study. Finally, the nursing process was used to demonstrate an approach to the client with PMS. Stressed throughout this chapter was the goal of nursing, to help individuals achieve their maximum health potential. The following chapter, Chapter III, contains the review of literature related to PMS, its etiology, treatment, and impact on women. In Chapter IV the study methodology is presented. Chapter V contains the study results. Finally, in Chapter VI conclusions drawn from this study, recommendations for future research, and nursing implications for education and practice are presented. CHAPTER III REVIEW OF THE LITERATURE It is important for the CNS as a researcher and a clinician to not only be able to describe and document the symptoms of the menstrual cycle, especially PMS, but to be able to draw on theory concerning the causes of the symptoms. From the assessment of symptoms and the theoretical background concerning symptoms, the CNS can plan and carry out clinical interventions to reduce or eliminate the symptomatology of PMS. This review of the literature is conducted to: provide an overview of the theories proposed as the cause of PMS, review the symptoms documented in the literature, and briefly review therapies that are based on presenting symptoms and supposed underlying etiology. A section is also included from the lay literature to provide insight into what is available to women in the general literature. This segment contains mostly information about the impact of PMS on the woman, her family, and the work place. The literature in this review of PMS can be divided into four categories: articles focusing on the impact of PMS on the life of the woman, her family, and the workplace, studies attempting to uncover the etiology of PMS, studies describing symptoms of PMS, and studies describing treatment. The studies and articles presented in this chapter were selected on the basis of two criteria. The first criterion for selection was that the study or article was published during the time period 36 37 between 1931 and 1986. This criterion was included to help develop a historical perspective of the identification and study of PMS. The second criterion for selection was that each author included in this review is a recognized scholar, researcher, or clinician in endocrinology, gynecology, psychology, sociology, or nursing, in as much as they have been repeatedly cited in the literature. PMS, Women, Families, and the Workplace The review of the literature will begin with reference to the overall impact of PMS on the women who suffer from it, their families, and society in general. This section will briefly examine what is available in the lay and professional literature about the Impact of PMS on individual women, families, and the workplace. Dalton (1980) described cases of two women jailed for violent crimes in England. After following the women for several months Dalton (1980) concluded that the women conducted the crimes during the premenstrual phase of their cycles and consequently were not responsible for their acts. It Is clear, that Dalton (1980) views the symptoms of PMS as having a devastating impact on the control levels of these two women. In 198A, an article by Rock appeared in McCall's Maggzine, entitled ”Premenstrual misery: The once-a-month disease”. Certainly the title bears out this authors perception of the impact of PMS. Within this article one woman described the impact of PMS on her life as follows: 38 "There were times when I had the weirdest reactions to things. I would slap my three-month-old son across the face because he wet his diapers. If the toaster went on the blink, I'd try to tear out the wires. Once my husband wore a shirt I didn't like. I ripped it off his back.” The year for PMS in the literature was definitely 1986. Several articles were published in women's magazines, business magazines, and professional journals describing the impact of PMS from several differing perspectives (McCalls, Wall Street Journal, American Journal of Nursing, 5 Nurse Practitioner). Mehren (1986) approached the topic from a human interest perspective when the article about Margie Post's battle with PMS was published. Ms. Post described herself as Dr. Jekel and Mr. Hyde. PMS almost ruined her marriage and career. Post states, "PMS really is a family disease. The people closest to you suffer too, PMS turns you into a monster." The Wall Street Journal ran an article late in 1986 discussing PMS in the work place. Three issues were discussed. The first issue was the estimated cost of PMS to U.S. industry in terms of the total wages lost. Dalton is cited in this article as stating that an estimated illness cost of 82 is charged to 0.5. industry's total wage bill as a result of PMS. The second issue addressed revolved around the discussion by the American Psychiatric Association over whether to classify PMS as a bona fide mental disorder. Mario Buhagiar, a women's rights advocate is quoted as stating, "I wonder if this isn't the same old 39 guise of women being labled incompetent for high-level positions because they are to emotional." Obviously the impact of making PMS a mental disorder would be negative for women with or without PMS. Many women would refuse to seek help for PMS while others would be accused of having PMS everytime they became upset. The third issue discussed in The Wall Street Journal article is an issue that has been debated in the literature for over 20 years. That issue is whether or not women have a decreased ability to concentrate while suffering from PMS. While Dalton (196A, 1977) states that this is the case, Sommer (1982), Golub (1980), and A550 (198A) emphatically state this is not true. As long as there is a question about women's ability to concentrate, and thus, be productive every day of the year, employers will be reluctant to hire women for top level jobs. This issue threatens women's credibility in the work place. Brown, and Zimmer (1986) conducted an exploratory study of PMS, coping, personal and family impact, and alterations in family functioning attributed to PMS. The study focused on a sample of 83 women and 32 men who attended an evening lecture on premenstrual syndrome. The ages of the women ranged from 18 to A3, and the men from 27 to 52. Subjects completed a short questionnaire before the lecture. The questionnaire included items about symptoms, why they attended the lecture, coping strategies, and personal and family distress. Brown and Zimmer (1986) found that 7A different regularly A0 recurring premenstrual symptoms were reported by the women. Both men and women agreed that symptoms were cyclical in nature (962). Correlations between life disruptions and certain symptoms was found to be significant for irritability, agitation, argumentative (p‘0.01), loss of control, violence, inability to cope, dizziness, fainting, and hot flashes (p40.05). Motivations for attendance in the women included to: learn about treatments, learn about decreasing symptoms, learn about available professionals in the community treating PMS, help partner to be more supportive, and ask questions about PMS. Motivations for the men included to: demonstrate caring about partner, learn ways to help partner, understand partner better, learn ways to handle own responses, learn about PMS. Brown and Zimmer (1986) conclude that clinical descriptions have portrayed dramatic personal and familial impact of severe PMS. Family systems theory would support the idea that patterns of mutual interaction and exchange that are altered during illness affect all family members. Therefore, the nurse must assess not only the woman, but the family if treatment for PMS is to be effective. In summarizing this section, it can be said that PMS does not only affect the woman but overflows from the woman to the family and to the work place. This section briefly put forth a number of viable reasons to study PMS. The reasons included the facts that the impact of PMS can be devastating and costly to the woman as well as those around her. PMS was cited as another way to keep women in Al their place. The next section in this chapter will address some of the etiologic explanations put forth in the last 50 years. PMS/ETIOLOGY Numerous theories have been offered as explanation for the symptoms of PMS. The theories of explanation range from hormonal fluctuations to psychological manifestations. Included below are a few examples of what has been offered as possible etiologies of PMS during the time period previously mentioned. Data supporting the hypothesis of an excessive estrogen effect or a decrease in progesterone levels are limited and often contradictory. In 1931, Frank observed that a large number of women who consulted himself and colleagues were seeking relief from irritability, edema, and unrest occuring in cyclical patterns. At the same time Frank (1931) observed clients with cyclical exacerbation of asthma and epileptic activity. Frank (1931) concluded based upon four case studies of women in his practice, that "excess accumulation of female hormones caused the symptoms complex" (p. 1057). On the basis of this conclusion Frank (1931) advocated irradiation of the ovaries, and actually recorded some success with this treatment. Today, this treatment is agreed to be too drastic a therapy! Case studies are not considered to provide hard quantitative data. In 1931 laboratory tests for hormonal levels did not exist for use on humans. Frank's (1931) conclusions were based on A2 observation of clients alone. Today, observations of this type are not an acceptable methodology upon which to base the types of conclusions arrived at by Frank (1931). In 1931, these data were enough to stimulate further study of the cyclic symptoms. Since Frank (1931), various theories have been proposed as to how alterations in ovarian hormones may lead to PMS. Morton, (1953) in a descriptive study utilizing a convenience sample, collected data on 29 healthy women ages 20 to A5. A detailed history was collected on the subjects. All 29 women complained of or exhibited, to some degree, internal tension, restlessness, crying, insomnia, and other psychological and physical problems which are summarized in the study (Morton, 1953). The study consisted of basal temperatures and body weights on all subjects. Fourteen women provided hormonal assays premenstrually via a 2A hour urine test while vaginal smears were obtained premenstrually on 28 women. Serum electrolytes were obtained pre and post menstrually on all subjects. Based upon the results of the study, Morton (1953) postulated that a decrease in, or absence of, secretion of progesterone permitted an uninhibited rise of estrogen In the premenstrual phase. That is, 23 of 2A women failed to show an abrupt rise in the basal temperatures, 22 subjects displayed a proliferative or hyperplastic endometrium upon biopsy, and 26 women had vaginal smears which indicated an estrogen-progesterone imbalance based upon cell types. The estrogen-progesterone imbalance was felt to be responsible for many of the symptoms A3 experienced by women during the premenstrum. Morton (1953) attributed the following symptoms to the increased estrogen levels in this study: painful breast engorgement, abdominal bloating, gain in body weight (edema) and a nervous tension. This study was reported with actual case numbers provided for the reader. The report also included information about a variety of measures utilized to collect data from the women in the study. Limitations of the study include the use of a non-randomly selected convenience sample, a small subject size, and failure to run similar measures on women reporting no symptoms as a control for evaluating the findings. In 1960 Parker presented a review of the literature that supported his clinical observations of clients that ovarian steroids probably created a disturbance in water metabolism and hence the symptoms of PMS. Based upon case observations, Parker (1960) believed that estrogen, and to a smaller extent, progesterone caused water retention. Parker (1960) concluded that most patients obtained satisfactory relief of the distressing symptoms of PMT (premenstrual tension syndrome) by individualized programs adjusted to the individual client. Parker (1960) did not elaborate further. The observations reported by Parker (1960) are poorly documented. There is no information pertaining to age groups, number of women observed, how subjects were selected, or exactly what observations were made. The literature review, on the other hand, is well documented and includes review of some authors cited in this chapter AA (Frank, 1931; O'Brien, Craven, Selby, 5 Saymonds, 1979) Munday, Brush, and Taylor (1977) also found low levels of progesterone in women with PMS. These researchers (1977) studied 16 women ages 22 to 32, eight with and eight without reported PMS symptoms. At five to eight days premenstrually the mean plasma levels of progesterone in the control group was significantly (pt.02) higher than in the PMS group. Munday, Brush, and Taylor (1977) also found aldosterone levels to be elevated during the midluteal phase for the PMT group, but this was not a significant difference over the control group. The study reported by Munday, Brush, and Taylor (1977) is clearly reported, contains a control group, and indicates levels of significance. This study adds to the data previously cited by Morton (1953) that low progesterone levels may lead to some of the symptoms reported as PMS. The limitations of this study include the use of a convenience sample and failure to describe how the symptoms of PMS were evaluated. O'Brien, Craven, Selby, and Saymonds (1979) found just the opposite results of Morton (1953) and Munday, Brusch, and Taylor (1977). O'Brien et al., (1979) reported conducting a double blind cross over trial during four menstrual cycles. O'Brien et al., (1979) reported progesterone levels for a control group and a group suffering from PMS at ten days premenstrually. The study consisted of 28 healthy subjects, 18 symptomatic and 10 non symptomatic controls (ages not reported). Plasma aldosterone and progesterone A5 levels were drawn on the 18 symptomatic and 10 control group members for four phases, menstrual, preovulatory, postovulatory, and premenstrual. Daily weights and mood measurements were taken. The symptomatic group demonstrated significantly higher levels of progesterone (p(0.025) than the control group and a weak, but significant correlation between the Premenstrual Mood Index and postovulatory progesterone levels (p<@.05). The conclusions drawn were that aldosterone levels had no significant correlation with premenstrual moods and that there was a weak, but significant correlation between premenstrual mood and elevated progesterone levels (r - 0.A267, p<0.05). O'Brien et al., (1979) postulate, based upon the findings of this study, that PMS most probably is the result of multiple hormonal etiology, but further study is required to confirm or refute these findings. The methodology and research design (double blind cross over), the number of cycles followed, and the reporting of levels of significance and correlational data makes this one of the better studies presented in the literature. The limitations are similar to those found in the previously reviewed studies. That is, it is a convenience sample and descriptive data are missing about the subjects. Hargrove and Abraham (1981) studied A0 women ages 23 to 39. Twenty nine subjects had tubal ligations and complained of severe PMT as measured by Abraham's (1980) four subcategories of symptoms (Table 2). Eleven subjects served as a control. The control group A6 was symptom free based upon the same criteria used to identify the PMT subjects. All subjects had three samples of blood drawn on three consecutive days beginning on day 20 of an ideal 28 day cycle. Estradiol, prolactin, progesterone, thyroid stimulating hormone, and tetraiodothyronine (TA) were performed on the three samples. The results showed that the post tubal ligation women with PMT symptoms had much lower levels of progesterone than the control group (6.3ng/ml. vs. 16.0ng/ml.) and slightly higher prolactin levels (16ng/ml. vs. lAng/ml.). TABLE 2. Premenstrual Symptoms (Abraham, 1981) PMT-A, Anxiety PMT-H, Edema Anxiety Weight gain Irritability Swelling of extremities Nervous tension Breast tenderness Mood swings Abdominal bloating PMT-C, Autonomic PMT-D, Depression Headache Depression Craving sweets Forgetful Increased appetite Crying Heart pounding Confusion Fatigue Insomnia Dizziness, faintness Hargrove and Abraham (1981) concluded that the high level of PMT symptoms in post tubal ligation women together with a similar midluteal endocrine pattern to women complaining of PMT, suggest abnormal luteal functioning as a cause of symptoms. Since A7 symptoms found in post tubal ligation women were similar to PMT, they may have the same pathophysiology--ovarian steroids. This study contained the largest subject number of any reported, though still small. The study utilized current laboratory tests to quantify changes and correlated blood levels to a PMT measuring tool. Limitations consisted of failure to report the correlations between the tool for measuring PMT and the blood levels of the hormones measured and reporting means of hormonal blood levels without levels of significance or interpretation of the data. It is difficult to draw the same conclusions as Hargrove and Abraham (1980) have drawn based upon the documentation of the study in the literature. Current research on PMS appears to have moved away from studies focused upon etiology and hormonal assays and toward studies focused upon treatment modalities and the success or failure of the chosen modality. For this reason, there are no current studies, 1982 to the present, included in the previous section. In summary, the ovarian hormone hypothesis holds that PMS symptoms are etiologically related to the ratios of estrogen and progesterone. The shifts in that ratio occur during the late luteal phase. Of course, as demonstrated above, there is much confusion about how the shift or in which direction the shift must occur to create the PMS symptoms. The above studies, though conducted by leading researchers in the fields of endocrinology A8 and gynecology, display flaws in the scientific process. Most of the conclusions and postulates presented above were based upon small subject numbers. None of the studies utilized random sampling methods for subject selection. Few of the studies reported levels of significance or examples of numerical correlates. Studies replicating previous studies are virtually non-existant. None the less, the hormonal theory remains an often referred to explanation for the symptoms of PMS. Another theory with enduring qualities is that of the endocrine hypothesis. Dalton (196A), based upon clinical experience and research conducted in Britain, suggests that the symptoms of PMS related to emotional upset may occur when there is an increase in mineralocorticoids in relation to ovarian steroids. Specifically, aldosterone is implicated. Several studies have indicated a rise in aldosterone levels in the luteal phase (Dalton, 196A; Katz 5 Romfh 1972; Schwartz 5 Abraham 1975). On the other hand, there are studies that demonstrate no increase (O'Brien, et. al, 1979; Munday, Brush, 5 Taylor, 1977). Katz and Romfh (1972) conducted a non-controlled study of A healthy females ages 2A to 36 with premenstrual complaints of water retention. Peripheral plasma levels of aldosterone were sampled during the follicular and the luteal phase of 5 successive menstrual cycles. Katz and Romfh (1972) found that 3 of the A women studied had significantly (p(0.05) higher levels of aldosterone during the luteal phase. The conclusion made was A9 that the increase in aldosterone levels might be responsible for excessive premenstrual water retention and the accompanying weight gain, tender breasts, headaches, and bloating. This study's limitations include failure to describe how premenstrual symptoms were identified, failure to use a control group for comparisons, and failure to collect data on more than one cycle (except for one subject who provided data on two cycles). On the other hand, the study does include levels of significance and a clear idea of the number of subjects reaching the significance level reported. Schwartz and Abraham (1975) conducted a similar study on 5 normally menstruating women for two consecutive cycles. Three subjects suffered from mild and occasional premenstrual water retention, 1 subject suffered from midmenstrual edema and I suffered from premenstrual edema. Schwartz and Abraham (1975) found that A of 5 subjects had significantly higher aldosterone levels during the luteal phase than during the follicular phase (p(0.01). As previously discussed, O'Brien et al., (1979) found in 28 women a significant rise in plasma aldosterone levels in the premenstrual phase of all subjects to double the preovulatory levels (p(0.005). There was no significant correlation between the Premenstrual Mood Index and the premenstrual aldosterone levels (r - 0.0830). The pituitary hormone prolactin has been proposed as a cause 50 of PMS symptomatology. In a comprehensive review of the literature, Laurenson (1985) cited increases in prolactin and its influence on progesterone as a possible etiology of PMS. Increases in prolactin levels have been reported in PMS clients as compared to the normal controls (Halbreich, Ben-David, Assael, 5 Bronstein, 1976; Vekeman, Delvoye, L'Hermite, 5 Robyn, 1977; Laurenson, 1985). On the other hand, at least one study found no significant differences between the follicular and luteal phase for plasma prolactin levels (Ettva, Siler, VandeBerg, Sinha, 5 Yen, 1973). Ettva et al., (1973) studied 12 cycles in 11 non-obese healthy female volunteers ages 22-36 with a history of regular menstrual cycles. All subjects were medication free for at least 6 months prior to the study. Blood samples were drawn daily on the subjects for an entire month. No significant difference was found between luteal and follicular phases in the mean plasma prolactin levels (18.2ng/ml. vs 17.8ng/ml. respectively). Random daily fluctuations with erratic spikes were observed in all cycles. Ettva et al., (1973) concluded that the physiologic role of prolactin remains unclear with regards to the menstrual cycle. The conclusions drawn by this research group are in keeping with the data reported. Strengths include the use of several cycles, a description of the clients including age, health status, menstrual histories, and use of medications. Limitations again relate to the absence of measures taken from women with and 51 without PMS symptoms, failure to report levels of significance, and lack of information concerning population from which subjects were selected. In a study of A9 women (28 PMS and 21 control) aged 19 to A5 with 1 to A children each, Halbreich, Ben-David, Assael, and Bronstein, (1976) found that serum prolactin levels were significantly higher (p90.01) in women with PMS than in the control group. Women were diagnosed as having PMS if they met all of the following criteria: 1) cyclical recurrence of symptoms or complaints only during the premenstrum, 2) dramatic and complete relief of symptoms when full menstruation began, 3) no permanent symptoms, similar to or different from the symptoms of the premenstrum during any other times of the cycle. Tension and headaches were the most commonly reported symptoms. Every woman was examined A times, once during the second and the third week and twice during the fourth week of their cycles. At each examination a blood sample was drawn. The serum prolactin levels were significantly (p(0.01) higher in the women with PMS than in the control group throughout the menstrual cycle and the PMS group had a significantly higher surge level of prolactin during the premenstrual phase (p(0.05). Halbreich et al., (1976) felt further research was needed to determine if the Increased serum prolactin level premenstrually was contributing to the formation of some symptoms of PMS or merely an indicator of a stress condition. 52 The information provided on the above study contained details about the population, details about how PMS was diagnosed, levels of significance, and facts about methodoloy. Limitations included use of a convenience sample and data collection on only one cycle. Vekeman, Delvoye, L'Hermite, and Robyn (1977) drew daily blood samples on 51 regularly menstruating women for one cycle (ages not indicated). The 51 women were reported as having two normal cycles before the study began. All women were reported to be medication free, but no indication was given as to the preceding duration of medication free time. Vekeman et al., (1977) found a significant (pr0.001) change in circulating prolactin levels during the menstrual cycle. A biphasic increase was also detected, with the mean value during the luteal phase being significantly higher (p(0.001) than the mean value during the follicular peak. Vekeman et al., (1977) summarized the study results by stating that no conclusions could be drawn as to whether variations in prolactin levels during the menstrual cycle are of physiologic significance. Nevertheless, based on previous research conducted by this group (Robyn et al., 1976), prolactin was associated with amenorrhea, oligomenorrhea, and luteal insufficiency, and, therefore, may play a role in some of the symptoms associated with PMS. Limitations of this study include failure to report subjects ages, lack of information about the population the subjects 53 were drawn from, and following subjects for only one cycle. Strengths of this study include the inclusion of levels of significance and the subject number. This data contributes to the conclusion that prolactin levels may account for some of the symptoms of PMS. In summary, as with the progesteron-estrogen theory, the mineralocorticoid theory is based upon a shifting or fluctuation in levels of prolactin or aldosterone. Also as in the case of the hormonal theory, conclusions are drawn from studies using convenience samples, and reported without the numerical support in the form of significance levels or correlates for the conclusions. The literature contains inconclusive results as to which direction the shifts must occur to produce the symptomatology recognized as PMS. There are data enough to link fluctuations of mineralocorticoids to PMS, but not enough to claim this theory as the only theory capable of explaining the symptoms. A final explanation for the symptomatology of PMS falls into the realm of psychosomatic. Many researchers (Fortin, Wittkower, Kalz, 1958; Coppen 5 Kessel, 1960; Paulson, 1961; Woods, 1985; Whitehead, Busch, Heller, 5 Costa, 1986) believe that the source of the very real symptoms is in the minds of the women who suffer them. Other researchers can find no link between mental illness, attitudes, or affective disorders and PMS symptomatology (Diamond, Rubinstein, Dunner, 5 Fieve, 1976). 5A Fortin, Wittkower, and Kalz (1958) concluded that the evidence gathered from EA subjects participating in psychiatric interviews strongly suggests that emotional factors play an important role in the onset and clinical course of premenstrual tension syndrome. The subjects consisted of A5 women employed at a public service utility. The experimental group consisted of 25 women ages 15 to 30 years of age with an average age of 23.6 years. These women reported physical and psychological symptoms before menses. The comparison group consisted of 20 women ages 15 to 30 with an average age of 2A years who reported no symptoms. The groups were matched for age, and marital status. Each subject underwent 7 interviews with a psychiatrist, weights every other day, and a measurement of resorption time after an intradermal Injection of hylauronidase. Hylaurindase is an enzyme capable of creating mild skin irritaions in the form of wheals. Resorption time is based upon fluid retention in the skin. Based upon the results of the interviews and physical assessments, Fortin, Wittkower and Kalz (1958) state, "A psychosomatic approach to premenstrual tension syndrome will yield satisfactory results to the physician interested In diminishing the effects of premenstrual tension syndrome and modifying its social repercussions on the family unit” (p.981). The above statemet inferrs that PMS is in the heads of the women who suffer from it. This study contained ample description of the subjects, 55 resorption test, and weights. Very little information was provided concerning the interviews from which the conclusions of the study are based. The above recommendation is somewhat controversial in view of the data reported. Paulson (1961) hypothesized six factors contributing to PMS: l) intrafamilial relationships, 2) general attitude toward menarche and menses, 3) self-experience of menarche and menses, A) acceptance of the feminine psycho-social role, 5) acceptance of the feminine psycho-sexual role, and 6) self-concept. Paulson (1961) collected data on 255 women ranging in age from 18 to 50. All subjects were drawn from parent-teacher organizations, industrial and factory workers, church groups, university students, and individual women who expressed interest in the study. The subjects were divided into A groups to allow for different administrations of the two questionnaires to control for phase effect of the menstrual cycle on the data. The questionnaires, one to explore symptomatology of PMS and one to evaluate six hypothesized psychological variables, showed correlations between PMS and the 6 hypothesized psychological concomitants that were positive and statistically significant (p<0.05). The correlations with premenstrual tension range from r - 0.16 for intrafamililial relationships to r - 0 .55 for self-experience of menarche and menses. A multiple correlation of r - 0.58 indicated that the three most effective scales for predicting PMS were self-experience with menarache and menses, 56 general attitude toward menarche and menses, and self-concept. Paulson (1961) concluded that psychological factors play an important role in PMS. Also concluded was that this study, without discounting the significance of hormonal or endocrinologlc factors, demonstrated several important psychological attitude clusters which have been found to be significantly related to hieghtened premenstrual tension (p(0.05). The study reported by Paulson contains a large subject number, a thorough description of the population from which subjects were drawn, excellant documentation of results with correlation coefficients and levels of significance clearly indicated, a clear statement of purpose, and an explanation of all statistical methodologies utilized. The only weakness is the failure to randomly select the subjects. Coppen and Kessel (1963) found some symptoms of PMS to be highly correlated with neuroticism (p‘0.001). Coppen and Kessel (1963) studied 100 women randomly selected from a population of 500 women representing different areas of England. PMS symptoms such as sensations of breast swelling, abdominal bloating, depression, irritability, and headaches were the most frequently reported symptoms of PMS in this group. Coppen and Kessel (1963) also found that tension and depression were significantly correlated (p(0.01) with headaches, swelling, and decrease in activity, and that all of these symptoms were significantly 57 (p(0.01) correlated with neuroticism. Coppen and Kessel (1963) concluded that the woman's personality greatly affected the type and perception of symptoms experienced premenstrually. The strengths of this study are found in the large randomly selected subject number. Limitations include vague reports of how PMS symptoms were measured and how information concerning neuroticism was obtained. Unlike Coppen and Kessel (1963), Diamon, Rubinstein, Dunner and Fieve (1976) found no significant difference between women with affective disorders and a control goup in the frequency, type, or severity of PMS symptoms (p110.05). Diamond et. al, (1976) studied 63 women from a lithium clinic in New York City with a history of unipolar or bipolar affective disorders and a comparison group consisting of 25 social workers or wives of social workers. The groups were similar in age, menstrual cycle length, menstrual flow length, use of birth control pills, and attitudes and beliefs about menarche. Data were collected via a questionnaire containing 22 physical symptoms and a space to contribute other symptoms experienced that were not included in the list. Information was also collected with regard to incidence of premenstrual or menstrual depressions, whether they had ever consulted a physician for physical or mental symptoms during the time of menstruation, incidence of gynecological problems, mental health hospital admissions, postpartum, and menopausal symptoms. The results of this study indicate that 58 there is no significant difference (p(0.05) between women with affective disorders and the control group when reporting somatic or affective symptoms. The percentage of subjects reporting premenstrual and menstrual affective symptoms, however, was consistently higher in the affective disorders group than in that of the controls. The authors drew no conclusions from their study. Strengths of this study include the reporting of levels of significance and the use of a control group. A weakness of the study, as usual, is the small subject number. Woods (1985) studied 179 women aged 18 to 35 living in five neighborhoods in a southeastern city of the United States. Woods (1985) utilized the MDQ (Moos, 1968), the Schedule of Recent events (Holmes 5 Rahe, 1967), the Index of Sex Role Orientation (Dreyer, Woods, 5 James, 1981) and the Menstrual Attitudes Questionnaire (Brooks-Gunn 5 Ruble, 1980) to assess symptoms and attitudes of the subjects for the perimenstrual time period. Perimenstrum was defined as the time period immediately before and during menstruation. Woods (1985) found a significant association between stressful life events and perimenstrual negative affect symptoms (p<.05). Socialization was related to women's attitudes toward menstruation as were the experience of negative affect symptoms and the disability women experienced. Negative affect had the greatest impact on disability (r - 0.36, pc~osoa.o womnn_o:u c.-<\«m.:n mw _~ m o uw .w m w we a c o no_a mzoonu wn V _ 9 mm .o w n mm w c o» zmcmom\mmonn ro:o__:omu we ~m m w No we m _ mm .c d _ >:x_on< mu wm .N w m» um m _ mm .c o _ :ooa mz_:cu Nw eN Ne w ww ew flu w mm .. ~ _ nw<.=n mw wm .o N am nm m _ mo u w _ _nn_noo_a w~ e. - m - mm .e e mw m _ . Hoau.o: ew eN .. e um wm u w am m ~ . cmoqoum_oz em w~ .m m m. wm __ w mu .c ~ . woun_amu:oum uw .m m o ww - m o w. w o c 115 Continued. TABLE 13. (our womOAo zoauou :26»... 228.38.. 0.. 92a mnn.aoanm m. N N c ww m N c .oo o o o o.unwonn_o_a Na .e w _ Nw N. m . mo w c . wo:m<_0n arose» moan oonm03amanm NN .N m . mm .m .N w mm w . . zmvu.:c mN Nm m _ ee we .N m mu __ N c mnm< 3030 m. m e o am .a .c a ma w . o >wocmm_ >mmonn.osmno mN ew e _ mm wm e N am wN N c owamw__:oum Nw NN e o» um N: o o» a. .N w as mxn.noaoan mw .w e 9 cu .N o . mo .9 o o £o__Ioo_:a um N. N . um NN N o NN Nm o c wcwmnu Om oamwn< mw .e w 9 mm .. o o Nu N. o . acanno_ moo. mammononoa m. m w c me e _ _ .co 9 o a nyoun v5.3 we m . c me e N a mu w o o wc~N_:o .3 menu mm m N o m. w o o wN m o c zomnn vocaa.:u wN N m o wN w . _ mm . o a zcawammm we m _ o» mN m _ ow mm w c o» m_.:a moanm m. N N o mw m . _ mm _ . o nrmauo .3 monon_nm ww eN .m w e. e do _ mN a d d 116 TABLE 1A. Mean severity reported for the three phases. Symmon Pmmaemnal Itnis Rmahoa'ofcwfle 11am MmrhastHTnas .39 50 .09 leaned: .65 .75 .17 Cram .75 1.60 .05 Bad