r. finmfi.‘fi -

THIN

Date

0-7639

lllllllllllllllllllllllll'llllllllllllllllllllllllllll

31293 01029 6576

This is to certify that the

thesis entitled

The RelationShip Between
Exercise and Premenstrual
Symptomatology

presented by

Elizabeth Ann Gale

has been accepted towards fulfillment
of the requirements for

mSter degree in NUI'Sing

{chel Schiffman

Major professor

 

11-11-93

MS U is an Affirmative Action/Equal Opportunity Institution

 

 

 

 

 

 

 

 

LlanAnv
Michigan State
University

 

 

 

PLACE IN RETURN BOX to romovo this chockout from your rocord.

TO AVOID FINES roturn on or botoro doto duo.

DATE DUE DATE DUE DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MSU Io An Atflnnotivo Action/Equal Opportunity Institution
«W

”311

 

THE RELATIONSHIP BETWEEN EXERCISE AND PREMENSTRUAL
SYMPTOMATOLOGY

BY
Elizabeth Ann Gale

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1993

ABSTRACT

THE RELATIONSHIP BETWEEN EXERCISE AND PREMENSTRUAL
SYMPTOMOLOGY

BY

Elizabeth Ann Gale

The purpose of this study was to investigate the
physical, psychological and behavioral premenstrual symptoms
most commonly self-reported by menstruating women between
the ages of 30 to 46, who exercise, and to determine the
relationship between exercise pattern and premenstrual

symptomology. A retrospective survey design using Moos' MDQ

and Stanley's Exercise Questionnaire was used. The sample

of 37 women came from two sources: The "WOmen's Only'I 1992

race registration list and a private obstetric/gynecology
office. The results of this study showed that women who
exercise report mild to moderate premenstrual symptoms of
weight gain, painful breasts, swelling, mood swings and
irritability; and few symptoms of pain such as cramps,
headaches and backaches. They also reported little
premenstrual symptomology of negative affect, impaired
There was no difference

concentration and behavior change.

in premenstrual symptomology among the different exercise

groups.

 

DEDICATION

This thesis is dedicated to my husband, Geoff, for his
support and technical assistance, and to my children Summer

and Amber for their patience and understanding during the

months in which this thesis was written.

iii

ACKNOWLEDGMENTS

I would like to give thanks to my thesis committee:
Rachel Schiffman, Brigid Warren, Jackie Wright, and Carol

Rogers for their expertise and guidance for making this

dream become a reality. I would also like to thank the

thesis committee for their belief in me and their genuine

concern and involvement in this project.

Table of Contents

Introduction.................................. ..... ... ....1
Research Question..... ......... . ..... . ..... . ............ ...2
Definition of Concepts...... ....... ..... ........ .. ......... 3
Premenstrual Syndrome Symptomatology. ..... . ............ :3
Exercise.. ......... .... ................................ .5
Review of the Literature ...... . .......................... ..8
Evaluation of the Literature..... .............. . ......... .11
Theoretical Framework.... ................ . ........ .. ..... .12
Methods.................. ................... . ....... .... .15
.. ..15

...... ......OOOOOOOOOOOOOOOOOOO...O.

Study Design..

Sample......... ....... .........
Field Procedures............................ ....... ....18
Protection of Human Subjects. ..... . ..... . ........... . .19
Operational Definitions...... ........ ........... ..... ..19
Instrumentation...................... .......... . .. ...23
Data Analysis...... ..... ...... ..... . ............... . ..26

..... ...... .... ..27

AssumptiODSOOOOOOOOOOOOO

Limitations of Study............ ...... .................28
Results................................ ............ .......28
Descriptive Findings of the Study Sample.. ............ .28
......... ...28

Findings Related to Research Questions.....

V

Table of Contents

000......

Introduction............

Research Question........ ......

............... ".3

Definition of Concepts.

Premenstrual Syndrome Symptomatology....

Exercise..... ...... .. ..... . ...... . ............. .. ......
Review of the Literature ...... . ............................ 8
Evaluation of the Literature..... ......................... 11

........... ......................12

Theoretical Framework....

Methods.......... ...... .

Study Design.. ....... .......... ..........
........ .........1‘7

......OOOIOOOOOOOOOOOOOO

Sample......
000000000018

Field Procedures............
..... ......19

Protection of Human Subjects. ......
....19

Operational Definitions.......... .......

Instrumentation..

.0 .......

Data Analysis. ...... .. ......
...27

AssumptionSOOO...00.00.00... ........

oo0oooo00000oo000000000000000.28

Limitations of Study.....

ooooo00o0o0oooooooo0oo0oooooooooooooo00000000.28

Results.....
he Study Sample. ......... .....28

oooooo 000000.28

Descriptive Findings of t

Findings Related to Research Questions....

Research Question 1.... ...... ....... ........ . ...... ....29

Prevalence of Premenstrual Symptomatology..............30

Severity of Premenstrual Symptoms........... ....... ....30
Research Question 2 .................................... 30
Exercise Characteristics...... ..... . ....... . ........... 32
Exercise Consistency..... ..... .. ...... . ............. ...32
Hypothesis Testing ....... . ....... . .......... .. ......... 36
Interpretation.......... ......... . ..... .. ................. 39
Implications for Nursing............ .................... . 46
Implication for Nursing Practice... .............. ......46
Recommendations for Future Research ................. ...49

Appendix A - Sample letters to potential study

participants............................. ........ . ....... .51
Appendix B - University Committee On Research

Involving Human Subjects (UCRIHS) approval .............. ..54
Appendix C - Instrument............ ............. ..........56
References.......... ..... ......... ............... .........63

vi

 

Research Question 1..... ...... .. ............. . ...... ...29
Prevalence of Premenstrual Symptomatology ........ . ..... 30
Severity of Premenstrual Symptoms...... ..... .. ..... ....30
Research Question 2... ....... ...... ...... . ........ .....30
Exercise Characteristics....... ..... . .................. 32
Exercise Consistency ...... . ..... . ................ ......32
Hypothesis Testing.... ..... ........ ............. .......36
Interpretation.. ............... . .......... .. .............. 39
Implications for Nursing.......... ........................ 46
Implication for Nursing Practice............... ....... .46
Recommendations for Future Research...... ......... .....49

Appendix A - Sample letters to potential study

participants....... ....... ........... ........... ..........51

Appendix B - University Committee On Research

Involving Human Subjects (UCRIHS) approval.... ............ 54
Appendix C - Instrument.... ...... .. ...... . ..... . .......... 56
References...... ......... .. ...... ............ ........... ..63

w

List of Tables

Table 1
MDQ Scales Derived From Menstrual, Premenstrual,

Intermenstrual, and Worst Cycle Factor Analysis

Table 2
Demographic Characteristics

Table 3
Per Cent of Premenstrual Symptomatology Reported

Table 4
Per Cent of Severity of Most Prevalent Premenstrual

Symptoms

Table 5
Exercise Characteristics

Table 6
Exercise Consistency

Table 7
Means, Standard Deviations, and Range for Each

Phase of the Most Recent Cycle

Table 8
Analysis of Variance for Differences in Mean

Total Score of the MDQ Subscales and the
Different Exercise Groups

vfi

22

29

31

32

33

34

36

37

iyvy ‘i i ..
.AV.
All,

  

  

 

 

:2

  

. . = Z, .1.

was

““I‘II’II‘IIIII‘IIIIIIIIIIIIII

31293 01029 6576

                                               

This is to certify that the

thesis entitled

'Ihe Relationship Between
Exercise and Premenstrual
Symptomatology

presented by

Elizabeth Ann Gale

has been accepted towards fulfillment
of the requirements for

Master degree in Nursing

{achelw Schiffman

Major professor

 

 

Date 11-11-93

0-7639 MS U is an Affirmative Action/Equal Opportunity Institution

___—..__ . 77,. . 1 if, if

 

 

 

 

 

 

 

LIBRARY
Michigan State
University

 

 

 

PLACE IN RETURN BOX to remove this checkout from your record.
TO AVOID FINES return on or before date due.

 

DATE DUE DATE DUE DATE DUE

 

MAY172001
3'30 5 o 4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MSU ie An Affirmative Action/Equal Opportunity Inetitution
mans-9.1

 

THE RELATIONSHIP BETWEEN EXERCISE AND PREMENSTRUAL
SYMPTOMATOLOGY

BY
Elizabeth Ann Gale

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1993

 

 

ABSTRACT

THE RELATIONSHIP BETWEEN EXERCISE AND PREMENSTRUAL
SYMPTOMOLOGY

BY

Elizabeth Ann Gale

The purpose of this study was to investigate the
physical, psychological and behavioral premenstrual symptoms
most commonly self-reported by menstruating women between
the ages of 30 to 46, who exercise, and to determine the
relationship between exercise pattern and premenstrual
symptomology. A retrospective survey design using Meos' MDQ
and Stanley's Exercise Questionnaire was used. The sample
of 37 women came from two sources: The "WOmen's Only“ 1992
race registration list and a private obstetric/gynecology
office. The results of this study showed that women who
exercise report mild to moderate premenstrual symptoms of
'weight gain, painful breasts, swelling, mood swings and
irritability; and few symptoms of pain such as cramps,
headaches and backaches. They also reported little
premenstrual symptomology of negative affect, impaired
concentration and behavior change. There was no difference

in premenstrual symptomology among the different exercise

groups.

 

DEDICATION

This thesis is dedicated to my husband, Geoff, for his
support and technical assistance, and to my children Summer
and Amber for their patience and understanding during the

months in which this thesis was written.

iii

 

ACKNOWLEDGMENTS

I would like to give thanks to my thesis committee:
Rachel Schiffman, Brigid Warren, Jackie Wright, and Carol
Rogers for their expertise and guidance for making this
dream become a reality. I would also like to thank the
thesis committee for their belief in me and their genuine

concern and involvement in this project.

Research Question 1.............. ...................... 29

Prevalence of Premenstrual Symptomatology..............30

Severity of Premenstrual Symptoms....... ........... ....30
Research Question 2.... .............................. ..30
Exercise Characteristics ............................... 32
Exercise Consistency. ............ .. ................ ....32
Hypothesis Testing. ..... ........... .................... 36
Interpretation......... ................................... 39
Implications for Nursing.......... .................... ....46
Implication for Nursing Practice... .................. ..46
Recommendations for Future Research...... .............. 49

Appendix A - Sample letters to potential study
participants.................................. ...... ......51

Appendix B - University Committee On Research

Involving Human Subjects (UCRIHS) approval. ............... 54
Appendix C - Instrument..................... ..... . ...... ..56
References................................ .............. ..63

w

List of Tables

Table 1
MDQ Scales Derived From Menstrual, Premenstrual,
Intermenstrual, and Worst Cycle Factor Analysis

Table 2
Demographic Characteristics

Table 3
Per Cent of Premenstrual Symptomatology Reported

Table 4
Per Cent of Severity of Most Prevalent Premenstrual
Symptoms

Table 5
Exercise Characteristics

Table 6
Exercise Consistency

Table 7
Means, Standard Deviations, and Range for Each
Phase of the Most Recent Cycle

Table 8

Analysis of Variance for Differences in Mean
Total Score of the MDQ Subscales and the
Different Exercise Groups

vii

22

29

31

32

33

34

36

37

 

List of Figures

Figure 1

Exercise and PMS Pattern Manifestation

Appraisal Model 16
Figure 2

PMS Symptom Profile of Women Who Exercise 44

VW

 

Introduction

Premenstrual syndrome is a constellation of physical,
psychological and/or behavioral symptoms arising from an
observable pattern related to the menstrual cycle. Women
who suffer from PMS symptomatology may experience emotional
and physical discomfort during the premenstrual phase of -
their menstrual cycle. PMS is one of the most common
complaints of childbearing women with an estimated 2% to 85%
of women having at one time or another experienced at least
one of the PMS symptoms (Johnson, McChesney, & Bean, 1988;
Wilhelm-Hass, 1984; Woods, Most, & Dery, 1982).

Women may experience PMS symptomatology at any age
during their reproductive years. However, there is evidence
that PMS symptomatology increases in severity with age and
that women over age 30 seek treatment for PMS at higher
rates than women under 30 years of age (Hsia & Long, 1990;
Johnson, McChesney, & Bean, 1988; Kirkpatrick, Brewer, &
Stocks, 1990).

The four most widely accepted theories of PMS are
progesterone deficiency, excess of prostaglandins,
deficiency of prostaglandins, and excess of estrogen (Hsia &
Long, 1990). The etiology of PMS remains an enigma;
therefore, clinicians prescribe treatment based on the

woman's symptoms of PMS. The emergence of the beta-endorphin

 

2
deficiency theory as an etiology for PMS has generated
interest in the use of exercise as a treatment modality for
PMS symptomatology. Current literature suggests that
exercise plays an important role in the management of PMS by
reducing stress and increasing beta-endorphin levels in
women who suffer from PMS symptomatology (Carr et al.,
1981).

There is no literature that examines the pattern of
exercise in women and how this pattern might be associated-
with PMS symptomatology. Clinical Nurse Specialists in the
primary care setting will have clients present with PMS
symptomatology and will need a basis on which to make
therapeutic decisions. The purpose of this study was
twofold: (1) to examine PMS symptomatology in a sample of
women who exercise, and (2) to determine the relationship
between the pattern of exercise in women and the pattern of
PMS symptomatology.

Research Questions

The research questions addressed in this study were:

1.) What physical, psychological, or behavioral
premenstrual symptoms are most commonly self-reported by a
sample of menstruating women, 30 to 46 years of age, who
exercise?

2.) Is there a relationship between the pattern of
exercise in menstruating women 30 to 46 years of age and the

severity of self-reported premenstrual symptoms?

 

3
Definition of Concepts
Premenstrua 8 nd ome S to ato o

Dalton (1984) succinctly describes premenstrual
syndrome as "the recurrence of symptoms in the premenstruum
with absence of symptoms in the postmenstruum" (p.7). She
further elaborates that recurrence of symptoms means a
repetition of symptoms for a minimum of three consecutive
cycles and that the severity of the symptoms may vary from
cycle to cycle. For example, one premenstrual cycle may be
characterized by a headache relieved with analgesics. The
next cycle may be characterized by an excruciating migraine
with visual disturbances that causes loss of functioning
(Dalton, 1984). Dalton (1984) explains that the absence of
symptoms in the postmenstruum requires a phase of a minimum
of seven days free from all symptoms.

Premenstrual syndrome has been defined by Magos and
Studd (1986) as the distressing physical, psychologic, and
behavioral symptoms, not caused by organic disease, which
regularly occur during some phase of the menstrual/ovarian
cycle and which disappear or significantly regress during
the remainder of the cycle. Rubinow and Roy-Byrne (1984)
define PMS as "the cyclic occurrence of symptoms that are of
sufficient severity to interfere with some aspects of life
and appear with a consistent and predictable relationship to
menses" (p. 114).

The American Psychiatric Association labels PMS as

Periluteal Phase Dysphoric Disorder. Periluteal Phase

4
Dysphoric Disorder is described as a pattern of clinically
significant emotional and behavioral symptoms that occur
during the last week of the luteal phase and remit within a
few days after the onset of the follicular phase (DMS-III,
1987). Diagnostic criteria include the following: (a)
symptoms that correspond to the two phases of the menstrual
cycle, (b) a disturbance that seriously interferes with work
or with social activities and relationships, and (c) a
disturbance that is not merely an exacerbation of the
symptoms of another disorder, such as Major Depression,
Panic Disorder, or Personality Disorder (DMS-III, 1987).

It is very clear that the above definitions all share a
common theme of PMS symptoms occurring in a cycle with a
pattern. The above definitions of PMS stress that there is
a symptom period as well as a distinct symptom-free period
related to the menstrual cycle. Sveinsdotter and Reame
(1991) examined the symptom characteristics and patterns of
menstrual cycles in seven healthy women who suffered from
PMS. The PMS group in their study displayed a pattern type
of increasing severity across the menstrual cycle.

According to Burkhart (1991), symptoms associated with
premenstrual syndrome can be categorized into physical
symptoms and psychological/behavioral symptoms. The common
physical symptoms associated with PMS are: abdominal
bloating, headaches, breast enlargement and tenderness,
constipation, edema of extremities, acne, and craving for

sweets or salty foods. The psychological/behavioral

5

symptoms associated with PMS are: anxiety, mood swings,
depression, irritability, lethargy, crying spells,
hostility, low morale, and sleep disorders (Burkhart, 1991).
Woods, Most, and Dery (1982) found that symptoms with a
prevalence greater than 30 per cent included: weight gain,
headache, skin disorders, cramps, anxiety, backache,
fatigue, painful breast, irritability, mood swings,
depression, and tension. For the purpose of this study PMS
symptomatology was defined as a cluster of symptoms related
to the menses which is manifested by a pattern of physical,
psychological, and/or behavioral symptoms.
Exercise

Exercise is defined as physical activity that is
planned, structured, repetitive, and purposeful (McArdel,
Katch, & Hatch, 1991). Physical activity is defined as any
body movement produced by muscles that results in increased
energy expenditure (McArdel et al., 1991). The terms
"exercise“ and "physical activity" have been used
interchangeably in the literature. There is a distinct
difference between the two. According to Caspersen, Powell,
and Christenson (1985) exercise is a subcategory of physical
activity. They concede that exercise contains the following
components: (a) bodily movement via skeletal muscles, (b)
results in energy expenditure, (c) energy expenditure (kilo-
calories) varies continuously from low to high, (d) very
positively correlated with physical fitness, (e) is planned,

structured, and repetitive, and (f) an objective is to

6
improve or maintain physical fitness. Physical activity
contains only the first four components of exercise
(Casperen et al., 1985).

Fair, Rosenaur, & Thurston (1979) define physical
exercise as an action or an activity involving either
physical and/or mental exertion. Fair et a1. (1979) define
aerobic or endurance exercise as exercise which promotes
cardiac conditioning such as running, jogging, biking,
swimming and walking. Allan (1985) also describes aerobic-
exercise as exercise that promotes cardiopulmonary endurance
or fitness. She further elaborates by stating they are
rhythmic, repetitive exercises that create a demand for
increasingly larger amounts of oxygen by using large muscle
groups.

The three components to an exercise program are: (a)
frequency, (b) intensity, and (c) duration. Frequency
refers to how many days per week the exercise is performed
(Allan, 1985). Studies have shown that fitness can be
attained and maintained on a frequency of three times per
week (Pollack, 1971; Fox, Naughton, & Gorman, 1972;
Merriman, 1978).

Intensity refers to target heart rate. Target heart
rate is exercising at a level of 70 to 85 per cent of
maximal heart rate (Allan, 1985). Duration is considered

the specific length of time an individual exercises for each

exercise session (Allan, 1985).

 

7

Consistency is another component of exercise that was
addressed in this study. Consistency was defined in this
study as the regularity, constancy, and uniformity of the
exercise program one is engaged in. Consistency is the
unaltered state of an exercise program. In other words, the
exercise program is not altered or changed due to normal
life circumstances such as time constraints.

The American College of Sports Medicine (1990)
recommends the following guidelines for developing and
maintaining cardiorespiratory fitness, body composition, and
muscular strength and endurance in the healthy adult: (a)
frequency of training: 3-5 days per week, (b) intensity of
training: 60%-90% of maximum heart rate, (c) duration of
training: 20-60 minutes of continuous aerobic activity. The
benefits of aerobic training include prevention of heart
disease, weight control, higher tolerance to fatigue, and a
reduction in tension, depression, and mood changes (Canty,
1934).

The above definitions imply that exercise contains an
element of planned activity that is repetitious and ongoing.
An exercise pattern is developed from this rhythmic,
repetitive activity. For the purpose of this study exercise
pattern was defined as the frequency, duration, and
consistency of a planned, rhythmic, repetitive activity

involving large muscle groups.

8
Review of the Literature

There is a paucity of literature on studies on PMS and
exercise. Timonen and Procope' (1971) analyzed the effect
of physical exercise on PMS by sending out questionnaires to
1,000 female students. Of a thousand questionnaires
distributed 748 were returned. Timomen and Procope' (1971)
concluded that girls who exercised regularly showed fewer
PMS symptoms than their less active counterparts. This was
a poorly written, retrospective study with confusing tables
and lacking in a clear definition of PMS, with no validity
and reliability of instruments.

Israel, Sutton, and O'Brien (1985) studied the effects
of aerobic training on primary dysmenorrhea in 36 college-
aged females suffering from primary dysmenorrhea. Eighteen
subjects were randomly assigned to a training program
consisting of a 30-minute continuous walk/jog program three
days a week at an intensity of 70-85% of heart rate range
for twelve weeks. Eighteen subjects were randomly selected
as a control and were asked not to exercise during the
twelve week period. Primary dysmenorrhea symptomatology was
measured using the Moos Menstrual Distress Questionnaire
(MDQ). The results of this study showed that the training
group had lower mean MDQ scores than the control group. The
direct cause for the decline in the MDQ scores in the
training group was not established in this study. The
authors speculate that the release and rise in beta-

endorphin in the training group could explain the perception

 

9

of less discomfort in dysmenorrhea (Israel et al., 1985).
This was a prospective, controlled study investigating the
effects of a training program on subjects who suffered from
primary dysmenorrhea. It is unclear if the variable being
studied was dysmenorrhea or premenstrual syndrome.
Prior, Vigna, Sciarretta, Alojado, and Schulzer (1987) found
an association between exercise and PMS symptomatology.
Prior et a1. (1987) studied twenty-one women with a mean age
of 33.4 years. Eight sedentary women volunteered to begin a
6-month training program. Seven women runners who were
training for a marathon (26.2 mile road race) volunteered to
record training and menstrual cycle data over six months.
Six nontraining women served as the control group. All
subjects monitored body temperature, weight, and their
exercise program. There was no change in body weight, body
mass or menstrual cycle interval in the subjects. The
training and marathon groups experienced significant
decrease in several premenstrual symptoms at six months.
The control group experienced no change in premenstrual
symptoms. This was a prospective, controlled study in which
PMS was clearly the outcome variable. The major flaw in
this study is the small sample size and one must use caution
when interpreting results.

Stanley (1985) conducted a survey on the relationship
between exercise and PMS for a thesis project on 116 women,
ranging in age from 18 to 53 years. The subjects were

recruited from three different sources: (a) a PMS clinic,

10
(b) a lecture on PMS, and (c) a PMS conference. All
subjects believed that they had PMS and were seeking
treatment for PMS or information on PMS. The survey
instrument included an exercise questionnaire and a health
questionnaire, which contained a modified version of the
Moos Menstrual Distress Questionnaire. Stanley (1985) found
that there was a significant inverse relationship between
exercise and PMS. Stanley showed that women who exercise
report few PMS symptoms. Limitations of this study were:-
(a) it was unclear whether the exercise questionnaire was
tested for validity and reliability, (b) all subjects were
volunteers, (c) there was no control group, and (d) the
sample was comprised of women from one of the highest
socioeconomic areas in the United States (Stanley, 1985).

A homogeneous group of college aged women was used in
both the Timonen and Procope' study (1971) and the Israel et
al. (1985) study. Prior et al. (1987) and Stanley (1985)
used a more heterogenous group for their sample. Prior et
al. (1987) used a sample of women with a mean age of 33.4
while Stanley used a sample of women between the ages of 18
to 53 years old.

The Israel et al. (1985) and Prior et al. (1987)
studies were similar in that each was a prospective,
controlled study in which exercise was the independent
variable. A retrospective survey questionnaire was used in
both the Timonen and Procope' study (1971) and the Stanley

(1985) study. However, Stanley's study was much better

ll
documented than Timonen and Procope's with the variables
being clearly defined.

Although, the literature fails to address the
antithesis that exercise increases PMS symptomatology,
considerable attention has been given to exercise induced
menstrual disorders. Researchers have found that menstrual
dysfunction does exist in distance runners. The most common
exercise induced menstrual disorders are oligomenorrhea and
amenorrhea (Boyden, Pamenter, Stanforth, Rotkins, & Wilmore,
1983; Bullen, Skrinar, Beitins, VonMering, Turnbull, &
McArthur, 1985; Dale, Gerlach, & Wilhite, 1979). If
exercise can have such a profound effect on the menstrual
cycle one needs to wonder what effect it has on PMS
symptomatology.

t ‘ atu

Of the three studies found in the literature on
exercise and its effects on PMS only Prior et al. (1987)
clearly define PMS. Timonen and Procope' (1971) make no
attempt to define PMS in their study and Israel et al.
(1985) label PMS as dysmenorrhea. Researchers need to
critically define PMS and remain consistent with the
definition and diagnostic criteria for PMS (Logue & Moos,
1986) in future studies.

Timonen and Procope' (1971) conducted a cross-
sectional study on exercise and PMS that was poorly
documented (Prior et al., 1987). Israel at al. (1985) were

the first to attempt a controlled trial of exercise and PMS,

12

but failed to clearly discern PMS as the outcome variable.
Prior et al. (1987) successfully completed a controlled
study of the relationship of exercise and PMS showing that
women who exercise report less PMS symptoms than women who
do not exercise. Although, Prior et al. (1987) conducted a
well documented, controlled study more research is indicated
to make a definitive statement that exercise decreases PMS
symptomatology. To date there are no studies that disprove
that exercise alleviates PMS (Prior et al., 1987). -

The studies cited do not distinguish women who
experience mild symptoms of PMS to women who suffer severe,
incapacitating symptoms of PMS. Researchers need to
delineate mild symptoms of PMS from severe symptoms and show
how exercise pattern affects the various degrees of PMS
symptomatology. Researchers should also question whether
strenuous exercise exacerbates or mitigates severe PMS
symptomatology.

Theoretical Framework

The theoretical foundation used for this study is
Rogers' Science of Unitary Human Beings. Rogers (1986)
defined unitary human beings as "irreducible, four-
dimensional energy fields identified by pattern and
manifesting characteristics that are different from those of
the parts and cannot be predicted from knowledge of the
parts” (p.5). Unitary human beings are open systems.
Unitary human beings are exemplified as energy fields in

open process with environmental energy fields (Smith, 1986).

13

Energy fields have pattern (Fawcett, 1989). This
continuous, changing human and environmental fields is
depicted as a wave pattern (Smith, 1986). Pattern
distinguishes human energy fields from their environmental
energy fields. Patterns are abstractions that are
observable through nonrepeating rhythms that are constantly
changing. Manifestations of patterns are analogous to the
wave pattern of the Great Lakes. The waves of the great
body of waters are rhythmic and continuous but the wave
pattern is constantly changing. There is continuous
variation in the waves due to shift in the winds,
interruption by water craft and change in the tide. Human
energy field patterns are observable through manifestations
of pattern such as amount of exercise and perceptions of PMS
symptomatology.

The practice of nursing mainly involves assessment and
identification of the manifestations of patterns that emerge
from the mutual person and environmental energy field
process and deliberative patterning through a nurse and
person mutual process (Lutjens, 1990). The nurse and client
participate in deliberative mutual patterning; the nurse
facilitates the client's actualization of potentials for
health and well being (Cowling, 1989). Pattern
manifestation appraisal enables the nurse to assess
recurring life themes and issues through sensory
information, thoughts, feelings, perceptions, experiences,

imagination, memory, and expressions of her/his clients

 

l4
(Cowling, 1989). Pattern manifestation appraisal centers on
"identifying manifestations of human and environmental
fields that relate to current health events" (Barrett, 1988,
p. 50).

Roger's unitary pattern-based practice model was used
in this study for identifying manifesting patterns of PMS
symptoms such as pain, bloating, breast enlargement,
anxiety, and irritability in a sample of women who exercise.
A pattern profile of PMS symptoms in exercising women was'.
developed incorporating properties, features, and qualities
derived from the pattern information. These properties
include an assessment of the exercise pattern of these
women. The author also investigated how exercise pattern
affects PMS pattern symptomatology.

Three distinct exercise patterns were identified
through pattern manifestation appraisal. These patterns
demonstrated the rhythmicity and continuum of human energy
fields. Pattern group A consisted of infrequent, and/or
inconsistent exercise behavior, of short duration depicted
in Figure 1 as a very sporadic wave pattern with much
variation in the shape and size of the peaks. Pattern group
B consisted of exercise behavior that is of moderate
frequency, consistency and duration depicted in Figure 1 as
an irregular wave pattern with some variation in the shape
and size of the peaks. Pattern group C consisted of

exercise behavior that was frequent, consistent and of

extended duration depicted in Figure 1 as a very constant

 

15
wave pattern with uniformity in the shape and size of the
peaks.

The model shown in Figure 1 shows the pattern of the
three different groups and how exercise pattern is related
to perceived amount of PMS symptoms (PMS symptom profile).
The more consistent the exercise pattern the less PMS
symptomatology. The nurse fits in this model by assessing
and identifying exercise pattern manifestation and perceived
PMS symptomatology manifestation in menstruating women. -

Methods
Study Design

A retrospective, survey questionnaire was used to
address the research questions. In a retrospective study,
the sample is questioned or interviewed after the fact. A
retrospective study is a practical and efficient method of
collecting data in a relatively short period and is used
often in nursing research (Polit & Hungler, 1991).

This was a non-experimental, ex post facto,
correlational study. The researcher did not control for the
independent variable, pattern of exercise. The researcher
did not manipulate the pattern of exercise in the study
sample. The researcher did not randomly assign individuals
to different exercise pattern groups. The dependent
variable in this study was the perceived amount of PMS
symptoms.
£91121:

A nonprobability convenience sample of 37 women between

the age of 30 and 46 was used for this study. The criteria

16

 

 

EXERCISE PATTERN
LOW -

FREQUENCY
CONSISTENCY M p M S

DURATION

 

 

 

 

EXERCISE PATTERN
MODERATE -

FREQUENCY
cons I STENCY I PM E,

DURATION

 

 

 

 

EXERCISE PATTERN
HIGH -
FREQUENCY
CONSISTENCY PMS
DURATION

 

 

 

 

PMS : PMS Symptom Profl Ie

Figure 1

EXERCISE AND PMS PATTERN MANIFESTATION APPRAISAL MODEL

 

 

 

17
for inclusion in this study were women: (a) between the ages
of 30 to 46, (b) currently not on progesterone therapy, oral
contraceptives or psychotropic agents, (c) who had two
consecutive menstrual periods 20 to 40 days apart at the
time of completing the questionnaires, and (d) who currently
reported exercising.

Women on progesterone therapy, oral contraceptives or
psychotropic agents were excluded from this study because
these agents may be used for the treatment of PMS -
symptomatology. Oral contraceptives and progesterone also
alter the menstrual cycle and may confound premenstrual
symptomatology. The normal menstrual cycle is 28 days in
duration, but cycles may range from 20 to 40 days and still
be considered normal (Ensign, Rowe, & Kowalski, 1988).
Women who reported any deviation from the average normal
cycle were excluded from this study because abnormally long
or short periods may confound premenstrual symptomatology.

The sample was obtained from two different sources: (a)
the 1992 "Women's Only" Race register list, and (b) a large
obstetric/gynecology group practice in Lansing, Michigan.
"Women's Only" is a two day annual event held in Flint,
Michigan which includes a women's health fair, fashion show
and dinner, and an 8 kilometer run, 8 kilometer competitive
walk, 5 kilometer run, and 5 kilometer fitness walk. The
researcher selected 100 names from the "Women's Only" 1992
register list for the sample. This was done by selecting

every fourth label from the computerized printout until 25

18
labels were selected from each of the four race categories
totalling 100 names. Of the 100 questionnaires sent, 46
were returned for a 46% response rate. Of the 46 returned
questionnaires, 8 were excluded due to current birth control
use; 4 were excluded due to improper completion of the MDQ
questionnaire; and 2 were excluded because the subjects
reported that they did not exercise. This resulted in 32
usable questionnaires from the "Women's Only" register list.
The researcher obtained 8 completed questionnaires from
the office site. Of the 8 questionnaires obtained from this
site, 2 were excluded due to current birth control use and 1
because she reported she did not exercise. This resulted in
5 usable questionnaires from the office site.
W
The questionnaires were mailed with instructions to the
"Women's Only" participants selected for the study. A
stamped, return envelope was included to facilitate
response. The researcher mailed the questionnaires with
written instruction (Appendix A).
Subjects from the private office site were selected on
a voluntary basis. The office nurse distributed the
questionnaires during a one month period to women from 30 to
46 years of age as they came into the clinic for their
health care needs. Those wishing to fill out the
questionnaire did so while waiting for their appointment.
There was a deposit box available in the waiting area forthe

completed questionnaires. The response rate was low for

this sample.

 

l9
ontegtiog of Human Subjects

Protection of human subjects in regard to
confidentiality was insured by anonymity. No one including
the investigator was able to associate responses from the
questionnaire with individual subjects. This was done by
instructing subjects not to write their name on the
questionnaires. No attempt was made to identify returned
questionnaires with names on the "Women's Only" register
list. Subjects were instructed that by returning the
completed questionnaire they were giving consent.

The private office clients were also assured anonymity
by instructing subjects not to write their name on the
questionnaire. The deposit box was placed in a safe area
free from intrusion. Office personnel did not tamper with
the box. The box contained one envelope size slot and was
tightly secured with packaging tape. Subjects were
instructed that by completing the questionnaire and
depositing it in the box they were giving consent. This
project was approved by the University Committee on Research
Involving Human Subjects (Appendix B).

0 er a De ' itio

Exercise pattern was operationalized according to self-
reported frequency, duration, and consistency of exercise.
The subjects were divided into three groups according to
their pattern of exercise. Exercise pattern was determined
by responses to questions 1, 2, 5, 6, 7, and 8 of the

Exercise Questionnaire (refer to questionnaire in Appendix

20
C). Question 1 of the Exercise Questionnaire addressees the
frequency of exercise. Question 2 of the Exercise
Questionnaire addresses the duration of exercise. Questions
5, 6, 7, and 8 address the consistency of exercise.

Questions 1 and 2 were scored using the following
rules. In question 1 answer (a) received a score of 0,
answer (b) received a score of 1, answer (c) received a
score of 2, and answer (d) received a score of 3. Question
one of the Exercise Questionnaire measured the frequency of
exercise.

In question 2 answer (a) received a score of 1, answer
(b) received a score of 2, and answer (c) received a score
of 3. Question 2 of the Exercise Questionnaire measured the
duration of exercise.

In questions 5 through 8 answer (a), (c), and (d)
received a 0 and answer (b) received a 1. The scores from
questions 5 through 8 were totalled. The total score of
questions 5 through 8 measured consistency of exercise.

Each respondent had three scores, one representing
their exercise frequency, the second representing their
exercise duration, and a third representing their exercise
consistency. These scores were then combined for a final
score. A final score of 2-5 represented Pattern group A
consisting of low frequency, low duration, and inconsistent
exercise. A final score of 6-7 represented Pattern group 8
consisting of moderate frequency, moderate duration and

moderately consistent exercise. A final score of 8-10

21
represented Pattern group C consisting of high frequency,
long duration and very consistent exercise.

The physical, psychological, and behavioral components
of premenstrual syndrome symptomatology was operationalized
by using six of the eight subscales of the Moos' Menstrual
Distress Questionnaire as presented in Table 1. The
subscales of Pain, Water Retention, and Autonomic Reactions
reflected the physical or somatic symptoms. The subscale of
Negative Affect reflected the psychological symptoms. -
Impaired Concentration and Behavior Change reflected the
behavioral symptoms. The subscales of Arousal and Control
were eliminated from this study because neither reflects the
physical, psychological, or behavioral symptoms generally
associated with premenstrual symptoms. The Arousal subscale
taps the positive reactions that some investigators have
linked with the menstrual cycle (Moos, 1985). The Control
subscale is composed of items that are rarely reported as
being related to the menstrual cycle (Moos, 1985).

The complete MDQ contains 47 items that are
individually scored on a Lickert scale ranging from 0 to 4,
with 0 being no experience of symptoms; with 1 meaning
symptoms are present, mild; with 2 meaning symptoms are
present, moderate; with 3 meaning symptoms are present,
strong; and with 4 meaning symptoms are present, severe.

The items were then added for a total score for each
subscale. For example, the water retention scale included

the items weight gain, skin blemish or disorder, painful or

22

 

Table 1

Egg Sgales Derived from Menstrual, Premenstrual,

 

t ‘411‘1.t ,- 810 WS ..e. --. , ‘ - t0 ‘_ a, S.

1 Pain 5 Impaired Concentration
Muscle Stiffness Insomnia
Headache Forgetfulness
Cramps Confusion
Backache Poor judgement
Fatigue Difficulty
General aches and concentration

pains Distractible
Minor motor
2 Water Retention coordination

Weight gain

Skin
blemish/disorder

Painful or tender
breasts

3 Autonomic Reactions

Dizziness, faintness
Cold sweats
Nausea, vomiting

6 Behavior Change

Poor school or work
performance

Take naps, stay in
bed

Stay at home

Avoid social
activities

Deceased efficiency

Hot flashes

4 Negative Affect
Loneliness
Anxiety
Mood swings
Crying
Irritability
Tension
Feeling sad or blue
Restlessness

 

blots. From WWW

(p.3) by R. H. Moos, 1991, Los Angeles: Western
Psychological Services. Copyright 1991 by Western

Psychological Services. Reprinted by permission.

 

 

23
tender breasts, and swelling. A raw score for water
retention was tabulated by adding the scores of the 4 items
defining the scale for each cycle phase. The raw score was
then divided by the number of items to arrive at a mean
score. The same method of scoring was done on the other 5
subscales of the MDQ.

For this study prevalence was defined as symptoms
reported by over half of the women. Severity was determined
by the raw score of each of the 47 items of the MDQ reported
during the four days before the menstrual cycle. A score of
1 or 2 received a value of 1 meaning mild to moderate
severity. A score of 3 or 4 received a value of 2 meaning
severe to disabling. These values were then entered into
SPSS which then calculated the frequency for each value and

the percent for each value for all 47 items.

Instrumentation

The investigator used two instruments to measure the
concepts: one was an adaptation of Carol Stanley's Exercise
Questionnaire to determine exercise pattern and the other
was Moos' Menstrual Distress Questionnaire to determine
premenstrual symptomatology. The Exercise Questionnaire
(Appendix C) is an eight item forced answer questionnaire
adapted from Carol Stanley (1985) to measure frequency,
duration, and consistency of exercise. The original
questionnaire contained 11 items. Four items were deleted

because they were dealing with past exercise pattern and

24
intention to exercise. The remaining item responses were
altered semantically to enable a more accurate measurement
of exercise pattern and consistency. Question 8 regarding
exercise habits during menses was added to give a more
accurate measurement of exercise pattern and consistency
over the entire menstrual cycle.

The Moos' Menstrual Distress Questionnaire (MDQ) Form C
(Appendix D) was used to measure PMS symptomatology. The
MDQ was developed over 20 years ago and has been used
extensively in the area of PMS research (Facchinetti,
Martignoni, Petraglia, Sances, Nappi, & Genazzani, 1987;
Shelley, & Anderson, 1986; & Woods et al., 1982).

Moos (1985) tested the MDQ on a sample of 839 women to
arrive at the present factor structure with eight subscales.
All of the eight subscales of the MDQ are positively
correlated. Negative Affect and Impaired Concentration were
the most highly correlated at 0.68. Pain and Negative
Affect, Pain and Behavior Change, and Pain and Impaired
Concentration were the next most highly correlated pairs at
0.59, 0.58, and 0.57 respectively. Negative Affect and
Arousal were among the least correlated at .18. The factor
analysis performed by Moos suggested a moderate to high
degree of construct validity of the instrument.

Factor analysis performed on subsets of the MDQ scales
provided further support of moderate to high construct
validity of the MDQ. Woods, Most, and Dery (1982) in their

sample of 179 women found internal consistencies, as

25
estimated by Cronbach's Alpha, to be between 0.64 and
0.88for these four scales: Pain, Water Retention, Negative
Affect, and Impaired Concentration.

The questionnaire was examined for reliability of the
eight subscales for the initial sample of 839 subjects
(Moos, 1985). In the initial sample the sub-scale internal
consistencies, as measured by Kuder-Richardson Formula 20,
varied between 0.89 for the Negative Affect scale, and 0.53
for the Control scale. Piccolo (1982) obtained similar -
results for reliability in a sample of 156 college students.

Internal consistency reliabilities for the present
study's sample of 37 women between the ages of 30 and 46 as
estimated by Cronbach's Alpha were: Pain 0.65, Water
Retention 0.75, Autonomic Reactions 0.32, Negative Affect
0.87, Impaired Concentration 0.67, and Behavior Change 0.53.
The internal consistencies for the subscales Pain, Water
Retention, Negative Affect, and Impaired Concentration were
moderate suggesting that the items on the scale are
measuring the same characteristic for this sample of women.
The subscale Autonomic Reactions had a very low alpha
coefficient which indicated that the items on this scale
were not measuring the same characteristic for this sample
of women. The alpha was increased moderately to 0.58 by
deleting item 16 (hot flashes) from the questionnaire. The
subscale Behavior Change had a moderately low alpha
coefficient which was not significantly increased by

deleting any of the items suggesting moderately low

26
reliability. The alpha coefficient for Impaired
Concentration was increased from 0.67 to 0.78 by deleting
item 23 (insomnia) giving a moderate to high alpha. There
is no standard for what an acceptable reliability
coefficient should be (Polit & Hungler, 1991). However,
coefficients in the vicinity of 0.70 is considered
sufficient when making group-level comparisons (Polit &
Hungler, 1991). The alpha's derived from the sample in the
present study have an overall lower reliability coefficient
score than those obtained from previous studies.

There is evidence of moderate to high inter-cycle
stability (reliability) of women's menstrual cycle symptom
reports (Moos, 1985). That is, women tend to report similar
symptoms from one menstrual cycle to another (Moos, 1985).
Moos (1985) also found that a "woman's retrospective reports
of her symptoms are not affected by the menstrual cycle
phase she is in when completing the MDQ" (p. 9). Rapkin,
Chang, & Reading (1988) compared a retrospective PMS
questionnaire to a daily PMS diary in 17 women by having the
women complete the daily diary, as well as the retrospective
study. Their study suggest that women reliably report
cyclical variation in PMS symptomatology when assessed by
retrospective report.

W
A. Means and standard deviations were calculated for

the demographic variable of age. Frequencies and percents

 

27
were calculated for the variables of marital status and
educational level to describe the sample.

B. The first research question (What physical,
psychological, or behavioral premenstrual symptoms are most
commonly self-reported by a sample of menstruating women, 30
to 46 years of age, who exercise?) was addressed by
obtaining frequencies and percentages of 35 items
representing the physical, psychological, and/or behavioral
symptoms of premenstrual symptomatology to determine the "
prevalence of premenstrual symptoms.

C. The second research question (Is there a
relationship between exercise pattern in menstruating women
30 to 46 years of age and the severity of self-reported
premenstrual syndrome symptoms?) was addressed by using one-
way ANOVA's to test the significant differences among the
three different exercise groups with the 6 MDQ subscales.
Mean scores and standard deviations for each of the 6
subscales of the MDQ was obtained to determine the self-
reported severity of the physical, psychological, an/or
behavioral cluster of PMS symptoms.

5993132312135

A. People are basically honest and therefore, the
women answered the questionnaire honestly.

8. Women were able to accurately recall their

premenstrual symptomatology.

28
I. 'l !' E 5! I

A. The researcher was unable to control for factors
which may influence PMS symptomatology such as the
following: (a) women who exercise may also practice other
self-care behaviors such as maintaining a diet low in
caffeine, refined sugar, salt, red meat, and fat, (b) women
who exercise may maintain lower body fat composition than
their nonexercising counterparts, and (c) the psychosocial
make-up of women who exercise may be different than the -
psychosocial make-up of women who do not exercise (different
personality types).

B. All subjects were volunteers. Women who experience
frequent, moderate to severe premenstrual symptoms may have
been more likely to participate in this study because of
their personal interest in the subject. Therefore, the
prevalence rates and self-reported severity rates may be
high.

C. Since this was a convenience sample of women,
results may not be generalizable to other women.

Results
De ' ’ F S m le

The mean age of participants was 38.92 (s.d. 3.70)
years. Most participants were married, well educated, and
all 37 were white (Table 2).

u st 5

The following describes the findings for the research

questions addressed by the study.

 

29
W:
What physical, psychological, and/or behavioral
premenstrual symptoms are most commonly self-reported by a
sample of menstruating women, 30 to 46 years of age, who

exercise?

 

Table 2

Demographic Characteristics (N = 37) -

 

 

Characteristic Frequency Per cent
Karim

Single 4 10.8
Married 29 78.4
Divorced 1 2.7
Widowed O 0.0
Living with partner 2 5.4
Missing 1 2.7

ve

Some high school 0 0.0
High school graduate 7 18.9
Trade or business school 1 2.7
Some college 8 21.6
College graduate 8 21.6
Post-graduate 13 35.1

 

The first research question was addressed by obtaining
frequencies and percentages of 35 selected items from the
MDQ that measures the presence of the physical,
psychological, and behavioral symptoms associated with

premenstrual symptomatology.

30
o e t S t o

The percentage of women reporting the 35 selected
premenstrual symptoms is given in Table 3. The 35 selected
items assess for the presence of the physical,
psychological, and behavioral symptoms associated with
premenstrual symptomatology. The six most prevalent
premenstrual symptoms, reported by more than half the women
for this sample, included weight gain, swelling, mood
swings, irritability, fatigue, and painful breasts.
Severity of Premegstrual Symptoms

Of these symptoms, most women reported their symptoms
to be mild to moderate in severity (Table 4). Three of the
six most prevalent premenstrual symptoms for this sample
fell into the Water Retention subscale (weight gain,
swelling, and painful breasts). One (fatigue) was in the
Pain subscale. Two were in the Negative AffeCt subscale
(mood swings and irritability). Symptoms that fall into the
Autonomic Reactions, Impaired Concentration, and Behavioral
Change subscales had a low prevalence rate with low
severity. Overall, most women reported mild to moderate
symptoms of PMS symptomatology.
W

Is there a relationship between the pattern of exercise
in menstruating women 30 to 46 years of age and the severity

of self-reported premenstrual symptoms?

31

 

 

 

 

Table 3
2g; gen; 0: Premenstrual Symptomatology Reported (N = 371
Symptom Per cent
Weight gain 73.0
Swelling 64.9
Mood swings 62.2
Irritability 62.2
Fatigue 59.5
Painful or tender breasts 59.5
Tension 48.6
Skin blemish 45.9
Anxiety 40.5
Feeling sad or blue 37.8
Backache 29.7
Headache 27.0
General aches and pains 27.0
Cramps 24.3
Take naps, or stay in bed 24.3
Crying 18.9
Restlessness 18.9
Loneliness 18.9
Muscle stiffness 13.5
Forgetfulness 13.5
Decrease efficiency 13.5
Poor work or school performance 10.8
Insomnia 10.8
Stay at home 10.8
Distractible 10.8
Poor judgment 08.1
Dizziness 08.1
Poor motor coordination 05.4
Difficulty concentrating 05.4
Confusion 05.4
Avoid social activities 05.4
Cold sweats 05.4
Hot flashes 02.7
02.7
02.7

Nausea\vomiting
Minor accidents

 

 

 

 

 

32
Table 4
Pe C Seve 't O ost P evalent P eme strual
EXEQEQEE

Per cent Per cent

Symptom N M/M S/D
Weight gain 27 74.1 25.9
Swelling 24 83.3 16.7
Mood swings 23 65.2 34.8
Irritability 23 69.6 30.4
Fatigue 22 72.7 27.3
Painful breasts 22 68.2 31.8

 

N = Number of women who reported symptom
M/M Mild, moderate
S/D Severe, disabling

Exercise Characteristics

As can be seen in Table 5 most women from this sample

exercised at least 3 times a week for a duration of 40
minutes or longer. The two most common types of exercises
reported were running and walking. Most women reported
exercising for more than 4 years. These findings suggest
that the women from this sample exercise on a regular basis
and have established a moderate to high level exercise
pattern.
s'st

Most women from this sample reported changing their
exercise schedule if their life became cluttered with
unexpected events or if they felt poorly physically. Most

did not change their exercise schedule if they felt poorly

emotionally or during their menses.

described in Table 6.

Table 5

33

 

WIN = 371

Exercise consistency is

 

Characteristic

Frequency

Per cent

 

E c' e enc

Once a month to

twice a week

3 to 4 times a week

5 or mere times a week

'se u ' n

Less than 20 minutes
20 to 40 minutes
40 minutes or more

W
Walking

Running

Swimming
Aerobics

Cycling
Other

W

Less than 1 month
Less than 6 months
Less than 1 year

1 to 2 years

2 to 3 years

3 to 4 years

More than 4 years

15
15

13
24

12

H
OOCDOQ

idh'etnaaazo

18.9
40.5
40.5

 

The sample was divided into three groups according to

their exercise pattern as described in the operational

definition section. The low level group consisted of 6

34
women, the moderate level exercise group consisted of 15

women, and the high level exercise group consisted of 16

 

 

women.
Table 6
s te = 7
Characteristic Frequency Per cent

 

Life flecopes Cluttered with unexpected events

Change schedule 22 59.5

No schedule change 15 40.5
Fe “ca

Change schedule 28 75.7

No schedule change 9 24.3
e na

Change schedule 13 35.1

No schedule change 24 64.9

e es
Change schedule 4 10.8
No schedule change 33 89.2

 

The means, standard deviations, and ranges were
calculated for the total scores of each of the six MDQ
subscales for the three different phases of the menstrual
cycle to measure the spread or variability of self-reported
premenstrual symptoms. The means for each subscale was much
lower in the intermenstrual phase than the premenstrual and
menstrual phases. This means that women from this sample

experience few, if any, symptoms during the intermenstrual

35
phase which was consistent with the definition of
premenstrual symptomatology.

The standard deviations shown in Table 7 point to
considerable interindividual variation in reports of
menstrual cycle symptoms for this sample. For example, a
woman who was 2 standard deviations above the mean would
obtain a score of 10.95 on the Pain scale in the
premenstrual phase. This score represents an average report
of "present, moderate" on all six Pain items or, more -
likely, a report of "present, strong" or "present, severe"
on two or three items and little or no experience of the
other symptoms (Moos, 1985). The ranges also showed
considerable variation in reports of menstrual cycle
symptoms.

Histograms of the data showed that the sample was
grossly skewed. Histograms of the Pain, Autonomic
Reactions, Negative Affect, Impaired Concentration, and
Behavior Change subscales showed the data to have an
asymmetrical shape with positive skewness and outliers. A
histogram of the Water Retention subscale showed a
symmetrical shape without outliers. The histograms reveal
that this data is not tightly clustered around the means.
There is variation in the data sets with the exception of
the Water Retention subscale. Interpretation of the means,
standard deviations, and ranges of the subscales was done

with caution because of the wide distribution of the data

sets.

36

 

 

 

 

Table 7
‘11: 21!: o D- - 01‘ one 'a 0e - g 2 ’1o 9

the HOSE Becepp Cycle in = 371

Premenstrual Menstrual Intermenstrual
Sub Total Total Total
Scale Mean SD Range Mean SD Range Mean SD Range
Pain 3.51 3.72 0-14 3.95 3.73 0-16 0.89 1.37 0-06
WR 4.65 3.55 0-11 3.27 3.26 0-11 0.43 0.80 0-03
Auto 0.38 0.98 0-24 0.30 0.85 0-03 0.16 0.60 0-03
NA 4.86 5.13 0-18 4.68 5.13 0-18 1.73 3.78 0-17
IC 0.78 1.75 0-09 0.78 1.53 0-07 0.38 0.85 0-04
SC 0.86 1.25 0-05 1.05 2.58 0-15 0.24 0.55 0-02
Subscale Possible range for each subscale

Pain =
WR - 0

Pain - Pain 0
Auto 2 O - l6

WR = Water Retention

Auto 8 Autonomic Reactions

NA 8 Negative NA = 0 32

IC 8 Impaired Concentration IC = 0 32
BC 2 0 - 20

BC - Behavioral Change

 

Hypetheeie Testing
One-way analysis of variance was used to compare the
three different exercise groups and mean total scores on the

six subscales of the MDQ: Pain, Water Retention, Autonomic

Reactions, Negative Affect, Impaired Concentration, and

Behavioral Change. On the basis of this analysis (see table

8), there was a difference in the mean scores of the Pain

subscale among the different exercise groups. The Tukey

method of post hoc comparisons was used to test which groups

differed in perceived amount of pain in the premenstrual

phase of the menstrual cycle. The low exercise group showed

37

higher mean total scores than the moderate and high exercise

groups in the Pain subscale.

 

Table 8

Anaiysie Of Variance For Differences In Mean Total Score

 

 

them 9: giving them ppaise fem thei; exercise efforts. 0;
sca ' e 'se rou 8

Scale N M so F-ratio df F Proa-

Pain

Low exercise 6 8.67 4.50 10.50 2,36 0 .0003

Moderate exercise 15 2.00 1.90

High exercise 16 3.19 3.30

We '0

Low exercise 6 6.00 3.90 1.14 2,36 0.3303

Moderate exercise 15 3.67 3.60

High exercise 16 5.13 3.40

hgpohemie heactiohs

Low exercise 6 0.00 0.00 1.03 2,36 0.3668

Moderate exercise 15 0.13 0.51

High exercise 16 0.50 1.21

N ect

Low exercise 6 6.33 6.71 0.06 2,36 0.9358

Moderate exercise 15 6.33 7.20

High exercise 16 5.36 5.34

Impaipeg echeentpatioh

Low exercise 6 0.83 1.32 0.61 2,36 0.4463

Moderate exercise 15 0.20 0.41

High exercise 16 0.90 2.15

Be av n e

Low exercise 6 1.00 2.00 0.61 2,36 0.5468

Moderate exercise 15 0.53 0.83

High exercise 16 1.00 1.26

 

There were no differences in the mean total scores of
the Water Retention, Autonomic Reactions, Negative Affect,
Impaired Concentration, and Behavioral Change subscales

among the different exercise groups. The null hypothesis

 

38
that there is no relationship between exercise pattern and
PMS symptomatology cannot be rejected based on this
analysis. Exercise pattern of women between the ages of 30
and 46 had no effect on the perceived amount of premenstrual
symptomatology. Table 8 shows that women who are in the low
exercise group have higher mean scores in the Pain scale
than women who are in the moderate and high exercise groups.
Women in the moderate exercise group have lower mean scores
in the Water Retention and Behavior Change scale than the‘.
women in the low and high exercise groups, but this finding
was not statistically significant. There were no
differences in the total mean scores among the three groups
in the Autonomic Reactions, Negative Affect, or Impaired
Concentration scales. These women essentially reported very
few symptoms in the Autonomic Reactions, Negative Affect,
and Impaired Concentration subscales regardless of their
exercise pattern.

Cochran's C was used to test for homogeneity of
variance between the groups. There was no difference in
variation between groups in the Pain, Negative Affect, and
Water Retention subscales. However, Cochran's C was
significant between groups in the Autonomic Reactions,
Impaired Concentration, and Behavior Change. Even though
ANOVA is a robust test results of this study must be
interpreted with caution because the assumption that the
variances in all groups must be equal was not met and the

population did not have a normal distribution.

39
Interpretation

The sample in the present study was composed of white,
highly educated, married women. Most of the sample (32) was
from taken from the " Womens' Only" register list. Women
who participate in the "Womens' Only" road race were white,
educated, and married. This phenomenon could be a result of
many factors. Married women may have more social support
than single women such as spouse running or walking with
Married women may experience fewer barriers and have better
access to exercise. Married women may have husbands that
accept child care duties while the wife exercises. Married
women may have husbands who contribute to household duties
providing more time for exercise. Married women may enjoy a
higher socioeconomic status providing more opportunities for
exercise. Women who are educated may be more cognizant of
the benefits of exercise than women who are not educated.
Running and walking may be considered activities for
educated whites and blacks or less educated women may feel
uncomfortable participating in such activities.

The most prevalent self-reported premenstrual symptoms
of women 30 to 46 years of age who exercise were weight
gain, fatigue, swelling, tender breasts, mood swings, and
irritability. The literature shows that the symptoms most
commonly associated with premenstrual syndrome in the

general population are fatigue, swelling, breast
tenderness, skin disorders, mood swings, anxiety,

depression, irritability, lethargy, crying spells, low

40

morale, and sleep disorders (Johnson, McChesney, & Bean,
1988; Wilhelm-Mass, 1984; Woods, Most, & Dery, 1982). The
prevalence of premenstrual symptomatology in this sample of
women 30 to 46 years of age who exercise is similar but not
identical to that of other populations studied to date.

Woods et a1. (1982) found, in their sample of 179 women
between the ages of 18 and 35, a prevalence of weight gain
to be 48 per cent, headache to be 38 per cent, swelling to
be 46 per cent, and tension to be 43 per cent. Lee and -
Rittenhouse (1991) found in their sample of 594 women
between the ages of 21 to 50 symptoms to have a prevalence
rate of greater than 30 per cent were cramps, weight gain,
swelling, headache, anxiety, irritability, tension,
backache, fatigue, painful breasts, and mood swings.

This sample of women reported little premenstrual
symptomatology of pain such as cramps, headaches, and
backaches. They also reported little premenstrual
symptomatology of negative affect, impaired concentration,
and behavior change such as depression, insomnia, and
decreased efficiency, respectfully. It is of interest that
this sample of women reported a higher prevalence rate of
symptoms in the Water Retention scale than other study
samples. One could speculate that women who exercise are
concerned with their weight and are very sensitive to water
retention symptoms.

Most of the previous studies were done on younger

women. This is the first study done on a sample of

41
exclusively older women (30 to 46 years of age) who
exercise. Other studies did not exclude women who were on
birth control pills, hormone therapy, diuretics,
antidepressants, or sedatives. Women who were on birth
control pills, hormone therapy, diuretics, antidepressants,
and sedatives were excluded from this study. Taking into
consideration that older women generally report more
premenstrual symptoms than younger women and that certain
medications positively affect PMS symptoms, this sample of-
women show low to moderate PMS symptomatology.

The women of this sample clearly showed a pattern of
exercise and this pattern was rhythmic and continuous but
constantly changing. Women from this study showed a
moderate amount of consistency in their exercise habits.
Women tended to change their exercise pattern when
unexpected life events occurred and when they were feeling
poorly physically. It stands to reason that one would not
exercise when feeling poorly physically. In this sample of
women their exercise schedule changed in response to
unexpected life events. It can be extrapolated that
exercise is important to this sample of women but does not
take absolute priority in their lives. This sample of women
did not change their exercise schedule when feeling poorly
emotionally. Perhaps this sample of women use exercise as a
form of mental health therapy. Most women of this sample

reported not changing their exercise behavior during their

 

42
menses. This sample of women may experience low menstrual
discomfort or exercise may take precedence over comfort.

This study showed that women who exercise report low
severity of premenstrual symptoms. The women of this study
reported mild to moderate premenstrual symptoms of fatigue,
weight gain, swelling, tender breasts, mood swings, and
irritability. There was no difference in premenstrual
symptomatology among the different exercise pattern groups.
This finding suggests that exercise in general can have a -
positive effect on the perceived amount of premenstrual
symptomatology in women.

The low exercise group showed significantly higher mean
scores on the Pain subscale than the moderate and high
exercise groups. This could be explained by the beta-
endorphin theory. Increased blood levels of beta-endorphins
have been found after exercise (Hsia & Long, 1990).
Increased circulating beta-endorphins has been associated
with analgesia and euphoria (Hsia & Long, 1990). Women who
exercise at a moderate to high exercise level may have more
circulating beta-endorphins than their low exercise cohorts
and have natural analgesia decreasing their pain symptoms.

The human energy field pattern of this sample of women
is observable through manifestations of exercise pattern
such as frequency, duration, and consistency of exercise and
through manifestations of premenstrual symptomatology. The

original model presented earlier was not supported by the

43
results of this study. However, Rogers' unitary pattern-
based practice model was used to develop a PMS
symptomatology profile for women over 30 who exercise.
Weight gain, fatigue, painful breasts, swelling, mood
swings, irritability, and tension in the largest box depict
the most frequently self-reported premenstrual symptoms in
this sample of women. Skin disorders, anxiety, and feeling
sad in the medium-size box depict the second most frequently
self-reported premenstrual symptoms. Backache, cramps, -
taking naps, and headaches in the small box depict the third
most frequently self-reported premenstrual symptoms. The
revised model in Figure 2 depicts the premenstrual
symptomatology pattern profile of women who exercise.

The results of this study show that exercise pattern
has little effect on how women report premenstrual symptoms.
However, women in the moderate exercise group reported less
symptoms in the Behavior Change and Water Retention
subscales of the MDQ. The majority of the women (80%)
inthis study had a fairly consistent exercise pattern. The
results of this study also show that women between the age
of 30 to 46 years of age, who exercise experience low
severity of premenstrual symptoms.

Methodological problems for this study include a small
sample size, lack of a control group, data collection was
done through a mailed questionnaire, and the researcher

needed to rely on retrospective recall for reports of PMS

symptomatology. A larger sample size may have reduced the

 

44

 

 

 

WEIGHT GAIN
SWELLING
PAINFUL BREASTS
FATIGUE
IRRITABILITY
MOOD SWING
TENSION

 

 

 

 

I

I
I

M / I SKIN DISORDERS
_/\\__3/\.__5/\__/\_._/ ANXIETY

FEELING SAD

 

 

 

 

 

I

BACKACHE
I ’ \ I CRAMPS

TAKE NAPS

HEADACHE

 

Figure 2

PMS SYMPTOM PROFILE OF WOMEN WHO EXERCISE

 

 

45
effect of extreme scores in the subscales and eliminated
outliers giving the sample a more symmetrical shape. A
control group of "no exercisers" could have been used to
compare the effect exercise has on premenstrual
symptomatology.

Another disadvantage of this study is that the
researcher had to rely on mailed questionnaires for data
collection. Mailed questionnaires commonly have a poor
response rate. Although, the response rate for this study-
was high with 46% of the women returning the questionnaire.
However, some of the questionnaires could not be used due to
the respondents failure to complete the questionnaire
accurately. A major shortcoming of a mailed questionnaire
is the inability to provide clarification of questions when
needed. Having to rely on retrospective recall may have had
a limited effect on the recollection of the presence or
absence of premenstrual symptoms and may have resulted in an
overestimation of symptom severity.

A data analysis problem for this study is that the
assumptions of analysis of variance were not met. The first
assumption that the groups must be a random sample from a
normal population was violated. The data was grossly skewed
not meeting the criteria of normalcy. The assumption that
in the population, the variances in all groups must be equal

was also violated for one-way analysis.

 

46
Implications For Nursing

Nursing implications derived from the findings of this
study are in the areas of nursing practice and future
nursing research using Rogers' unitary pattern-based
practice model as the conceptual framework.

I . . . e

The Family Clinical Nurse Specialist (FCNS) provides
primary health care to individuals and families on the
continuum of the life span. It is common knowledge that
women are the most likely age and gender group to enter the
health care delivery system. Women usually enter the health
care system seeking contraception upon becoming sexually
active. It is very typical for women to stay in the health
delivery system for health maintenance visits related to
contraception and prenatal care.

One of the primary roles of the FCNS in clinical
practice is to provide a health maintenance history and
physical promoting health and wellness for individuals. The
FCNS provides these services to women in a variety of
settings including family practice offices, family planning
centers, OB/GYN offices, college campuses, and women's
clinics.

This study of a sample of women 30 to 46 years of age
who exercise showed a prevalence rate of premenstrual
symptomatology of up to 70% but with low severity. The most
commonly reported premenstrual symptoms were weight gain,

fatigue, swelling, tender breasts, mood swings, and

47
irritability. The FCNS may provide anticipatory guidance
for women who are approaching 30 by talking to them about
the common symptoms related to the premenstruum or counsel
women who are suffering from premenstrual symptoms. The
FCNS can provide PMS counseling, education, and treatment
focusing on the most prevalent premenstrual symptoms. Most
women reported symptoms from the Water Retention and Pain
subscales. The FCNS needs to be knowledgeable in the use of
diuretics and prostaglandin inhibitors in the treatment of-
premenstrual symptoms.

Many women will not seek help for their premenstrual
symptoms with the belief that it is "normal" to have these
cyclic episodes of pain and discomfort. The first step the
FCNS takes in the management of premenstrual symptomatology
is to recognize that a premenstrual related problem exists.
If the FCNS determines that a premenstrual problem exists
he/she than needs to assess for the severity of symptoms.
This could be done by administering the MDQ or another
reliable instrument that measures premenstrual
symptomatology and severity. The FCNS functions as an
assessor by systematically collecting subjective and
objective data and formulating premenstrual symptomatology
diagnoses or problems related to premenstrual syndrome.

It is very likely that FCNS's will provide health
services in a variety of settings to women who present with
premenstrual symptomatology. These settings could include

family planning and health services to low-income and

48

minority women in low cost clinics. The FCNS can be
creative in the development and prescription of an exercise
program for this population group by networking with area
churches and neighborhood clubs. The FCNS could act as a
facilitator and help organize church and neighborhood
walking or aerobic programs for this population group.

Based on the prevalence rate of women experiencing
premenstrual symptoms it is imperative that the nurse in
advanced practice assess for premenstrual symptomatology in
women. Rogers' unitary pattern-based model is a useful tool
for the assessment of premenstrual symptoms. Rogers'
pattern manifestation appraisal model provides a systematic
approach in the identification of premenstrual
symptomatology pattern. The nurse in advanced practice can
develop a pattern profile of clients who present with PMS
symptomatology.

The etiology of premenstrual symptomatology remains
unclear. The clinician managing premenstrual symptomatology
has many treatment options available such as hormone
therapy, diuretics, psychotropic therapy and stress
management techniques. Based on this study the nurse in
advanced practice may prescribe a moderate exercise program
as part of the treatment plan of clients who present with
premenstrual symptoms of pain. The results of this study
show that women who exercise experience the common symptoms
of PMS, but report low severity of symptoms. This study

also shows that exercise does not worsen or exacerbate

49
premenstrual symptoms and may even reduce symptom severity
in the Pain subscale. Exercise is a self-care behavior that
has many benefits such as cardiovascular fitness, weight
control, and stress management and should be included in the
PMS treatment plan if not otherwise contraindicated.
W

The sample in the present study consisted mainly of
women who participated in the "Women's Only" race who were
from the ages of 30 to 46 years old. These women were -
white, well-educated, and married. A study including a
variety of subjects from different racial and ethnic
backgrounds, lower educational levels, a wider age range and
cultural differences would produce conclusions applicable to
a broader population. More experimental studies that
include a control group and groups assigned to specific
exercise levels are needed to support the hypothesis that
there is an inverse relationship between PMS and exercise.
Most of the studies done on PMS and exercise used
retrospective recall questionnaires; more studies need to be
done using prospective questionnaires or asking women to
keep daily diaries of symptoms related to their menses.

This study raises more questions than answers in regard
to the relationship between exercise pattern and PMS
symptomatology. Further research is needed to explore why
women who exercise report most of their PMS symptoms in the

Water Retention subscale. Further research

50
investigatingthis relationship is necessary in order to draw
any definitive conclusions.

The data from this study suggest that women who
exercise report mild to moderate premenstrual symptoms.
These data are limited to women from southeast Michigan, who
participated in the Women's Only race who are between the
ages of 30 to 46 years. Further study is necessary to
ascertain whether these symptoms are characteristic of

childbearing women of all ages and women who participate in

other forms of exercise.

APPENDICES

 

 

Appendix A

Sample letters to potential study participants.

52

To: Lansing OB/GYN Clients
From: Elizabeth Gale RN
Date: February 16, 1993

I am a Registered Nurse pursuing a Master's Degree in
Nursing at Michigan State University. I am doing research
on exercise pattern and the menstrual cycle for my thesis
project. The results of the study will be helpful to nurses
providing care to childbearing women. Will you please take
time to complete the enclosed questionnaire while you are.-
waiting for your appointment? The questionnaire takes about
ten minutes to complete. No attempt will be made to
identify you in any way. Please do not write your name on
the questionnaire or envelope. Participation in this study
is voluntary and you are under no obligation to participate.
If you do not wish to participate in this study your care at
Lansing OB/GYN Associates will not be affected in any way.
You indicate your voluntary agreement to participate by
completing and depositing the questionnaire into the box
labelled "Study". A written summary of the results of this
study will be available in this office in the Fall of 1993.
If you have any questions concerning your health as a result

of completing this questionnaire please consult your health

care provider. Thank you very much for your assistance.

53

To: "Women's Only" Participants
From: Elizabeth Gale RN
Date: February 16, 1993

I am a Registered Nurse pursuing a Master's Degree in
Nursing at Michigan State University. I am doing research
on exercise pattern and the menstrual cycle for my thesis
project. The results of the study will be helpful to nurses
providing care to childbearing women. Will you please take
time to complete the enclosed questionnaire and return it in
the stamped, self-addressed envelope by March 1, 1993. The
questionnaire takes about ten minutes to complete. No
attempt will be made to identify you in any way. Please do
not write your name on the questionnaire or envelope.
Participation in this study is voluntary and you are under
no obligation to participate. You indicate your voluntary
agreement to participate by completing and returning this
questionnaire. A written summary of the results of the
study will be available at the 1993 "Women's Only" race at
one of the information tables. If you have any questions
concerning your health as a result of completing this

questionnaire please consult your health care provider.

Thank you very much for your assistance.

Appendix B

University Committee on Research Involving Human
Subjects (UCRIHS) approval.

55

MICHIGAN STATE UNIVERSITY

 

OFFICE OF VICE PRESIDENT FOR RESEARCH
AND DEAN OF THE GRADUATE SCHOOL

EAST LANSING 0 MICHIGAN 0 488244046

February 10. 1993

TO: Ms. Elizabeth Gale
1225 Clearview Drive
Flushing. MI 48433

RE: IRB #: 93-027
TITLE: THE RELATIONSHIP BETWEEN EXERCISE PATTERN AND
PREMENSTRUAL SYMPTOMATOLOGY
REVISION REQUESTED: N/A
CATEGORY: l-C -
APPROVAL DATE: 02/09/1993

The University Committee on Research Involving Human Subjects' (UCRIHS) review of this project is complete.
I am pleased to advnse that the rights and welfare of the human subiects appear to be adequately protected and
methods to obtain informed consent are appropnate. Therefore. the UCRIHS approved this project including any
revision listed above.

UCRIHS approval is valid for one calendar year. beginning with the approval date shown above. Investigators
planning to continue a project beyond one year must seek updated certification. Request for renewed approval must
be accompanied by all four of the following mandatory assurances.

l. The human subjects protocol is the same as in previous studies.

2. There have been no ill effects suffered by the subjects due to their participation in the study.

3. There have been no complaints by the subjects or their representatives related to their participation in the
study.

4. There has not been a change in the research environment nor new information which would indicate greater

risk to human subjects than that assumed when the protocol was initially reviewed and approved.

There is a maximum of four such expedited renewals possible. Investigators wishing to continue a project beyond
that time need to submit it again for complete rewew.

UCRIHS must review any changes in procedures involving human subjects. prior to initiation of the change.
Investigators must notify UCRIHS promptly of any problems (unexpected side effects. complaints. etc.) involvmg
human subjects during the course of the work.

If we can be of any future help, please do not hesitate to contact us at (517) 355-2180 or FAX (517) 336-1171.

avid E. Wright. Ph.D.
UCRII-IS Chair

Sincerely.

    

DEW:pjm

cc: Dr. Rachel Schiffman

MSU is an Affirmative Action/Equal Opportunity Insulation

Appendix c

Instruments

57

Exercise Questionnaire

Today's date:

Age:
Race:___White
___Black
Asian or Pacific Islander
Hispanic

___Other, specify

Marital Status: (circle one) a. single b. married c. divorced
d. widowed e. living with partner
Educational level:

a. some high school

b. high school graduate

c. trade school or business school

d. some college

e. college graduate

f. post-graduate work at a college or university

Have you taken any of the following medications within the
last 6 months? (You may indicate more than one answer).

a. sedative

b. antidepressant

c. water pill (diuretic)

d. birth control pill

e. progesterone

f. Norplant

g. estrogen

The following questionnaire is designed to determine the
amount of exercise that you do. Please answer each question
only once. Please circle your response or, where
appropriate, write your response in the space provided.

1. On the average, how often do you exercise?
a. never (if you answer never please go to the
Menstrual Distress Questionnaire)
b. once a month to twice a week
c. 3 to 4 times a week
d. 5 or more times a week

2. When you do your exercise how much time on the average do
you spend at each session?
a. less than 20 minutes
b. 20 to 40 minutes
c. 40 minutes or more

58

What type of exercise do you participate in most
frequently? ONE ANSWER ONLY.

a. walking

b. running

c. swimming

d. aerobics

e. cycling

f. other

 

How long have you been exercising?

a. less than 3 months

b. less than 6 months

c. less than 1 year

d. 1 to 2 years

e. 2 to 3 years

f. 3 to 4 years -
g. more than 4 years

If your life becomes cluttered with unexpected events, do
you...

a. exercise more than normal

b. do not change your exercise schedule

c. exercise less than you normally would

d. not exercise at all

If you are feeling poorly physically, do you...
a. exercise more than normal

b. do not change your exercise schedule

c. exercise less than you normally would

d. not exercise at all

If you are feeling poorly emotionally, do you...
a. exercise more than normal

b. do not change your exercise schedule

c. exercise less than you normally would

d. not exercise at all

When you are on your "period" do you...
a. exercise more than normal
b. do not change your exercise schedule
c. exercise less than you normally would
d. not exercise at all

45.

46.

47.

62

Most
recent
flow

(A)

Blind spots,
fuzzy vision. ...........

Poor motor
coordination...... ......

Increased appetite......

Four
days
before
(B)

Remain-
der of
cycle

(C)

61

1 2 3
Most Four Remain-
recent days der of
flow before cycle
(A) (B) (C)

 

22. RestlessneSSOOOOOOOOO...

23. Insomnia...........

24. Poor school or work
performance............

25. Affectionate.. ..........

26. Feelings of
suffocation. ...........

27. Forgetfulness...........

28. Take naps, stay in
bedOOOOOOOOOOOOOOOOO...

29. Orderliness. ......... ...
30. Chest pains .............
31. Confusion..... ..... .....

32. Poor judgment...........
33. Stay at home............

34. Excitement....... .......

35. Ringing in the ears .....

36. Difficulty
concentrating ...........

37. Avoid social
activities...... ..... ...

38. Feelings of well-

being..................
39. Heart pounding..........
4o. Distractible...... ..... .
41. Decreased efficiency....

—
_
_
*

42. Bursts of energy,
activity................

43. Numbness, tingling......
44. Minor accidents.........

6O

Descriptive Categories:

- No experience of symptom
- Present, mild

O

1

2 - Present, moderate
3 - Present, strong

4 - Present, severe

1 2 3
Most Four Remain-
recent days der of
flow before cycle
(A) (B) (C)

 

1. Muscle stiffness........

2. Weight gain...........

3. Dizziness, faintness..

4. Loneliness............

 

5. Headache....... .........

6. Skin blemish or
disorder......... .......

7. Cold sweats.............
8. Anxiety.................
9. Mood swings.... ...... ...
10. Cramps...........

11. Painful or tender
breastOOOIOOOOOOOOIOOOOO

12. Nausea, vomiting........
13 O CrYing. O O O O O O O O O ..... O O O
14 O BaCRaChe O O O O O O C O O O O O O O O O

15. Swelling (breast,
abdomen...... .......... .

16. Hot flashes.....
17. Irritability............

18. Tension...........

19. FatigueOOOOOOOOOOIOOOOO.
20. Feeling sad or blue.....
21. General aches and

painSOOOOOOOOOOOOCOOOOOO

 

59
Menstrual Distress Questionnaire
Form C
Write the approximate dates of your most recent menstrual
period (flow) in the space marked "A" below. Then write the

dates of the menstrual period which preceded the most recent
one in the space marked "D".

 

 

 

 

 

previous
menstrual flow
from other times four days most recent flow
during most before most from
to recent cycle recent flow to
D C B A

On the next two pages is a list of symptoms that women
sometimes experience. Please describe your experience of
each of these symptoms during the three time periods listed
below:

Column 1 during your m9§t_;gggnt menstrual flow (the dates
shown in area A on the diagram above).

Column 2 during the four days before your mes; recent
menstrual flow (area B on the diagram).

Column 3 during the remainder of your most recent menstrual
cycle (area C).

Note: The answers you put in columns 1, 2, and 3 should be
accurate for your experience during your most recent
menstrual cycle. Please do not report your general
experience. Also, please report any experience of these
symptoms whether or not they seem to be related to your
menstrual cycle.

 

For each answer choose the category that best describes your
experience of that symptom during that time. Write the
number of that category in the space provided. Even if none
of the categories is exactly correct, choose the one that
best describes your experience. Do not leave any blank
spaces.

Rudolf H. Moos, Stanford University Medical Center, 1984

e the
ecent

flo-i'

tes

rual

 

 

REFERENCES

64

References

Allan, J. D. (1985). Exercise program. In G. Bulechek &

J. McCloskey (Ed. ), (pp. 198—219). Nuzsing
t ns: atm ts nu s'n dia noses.

Philadelphia: W. B. Saunders Company.

American College of Sports Medicine (1990). The recommended

Quantity of exercise for developing and
maintaining cardiorespiratory and muscular fitness in

healthy adults. P s' 'o ta

American Psychiatric Association (1987). D' s 'c
Sggnistigal Mgnual gf Mental Qigongezs (3rd ed. revisedQ,
(pp. 367-369). Washington D.C.: American Psychiatric
Preff.

Barrett, E.A.M. (1988). Using Rogers' science of
unitary human beings in nursing practice. Nursing

Sciengg Quantenly, ;, 50-51.

Boyden, T. W., Pamenter, R. W., Stanforth, P., Rotkis,
T. & Wilmore, J. H. (1983). Sex Steroids and endurance

running in women. fertilitx_end_§£erilitx, 32(5). 629-

632.

Bullen, B. A., Skrinar, G. S., Beitins, I. 2., von Mering,
G., Turnbull, B. A., & McArthur, J. W. (1985).
Induction of menstrual disorders by strenuous exercise in

untrained women. Ihe_Ne1_Englend_lsurnel_2f_uedisine,

g12(21), 1349—1353.

Burkhart-Lindow, K. (1991). Premenstrual syndrome: Family
impact and nursing implications. Jou of Obste r'

Gxne22l2gisi_and_Ne2natal_Nur§ins. 22(2). 135-138-

Canty, A. P. (1984). Can aerobic exercise relieve the
symptoms of premenstrual syndrome (PMS)? Jounnal of

§gngol Health, §5(10), 410-411.

Carr, 0. 8., Bullen, B. A., Skrinar, G. 3., Arnold, M. A.,
Rosenblat, M., Beitins, I. 2., Martin, J. 8., & MCArthur,
J. W. (1981). Physical conditioning facilitates the
exercise-induced decretion of beta-endorphin and beta-

lipotropin in women. Ine_Nes_Englsnd_Jgnrnel_2f
52912133, éflifloli 550'552-
Caspersen, C., Powell, K., & Christenson, G. (1985).

Physical activity, exercise, and physical fitness:
Definitions and distinctions for health-related research.

Rublis_nealfh_3engrf§.129(2). 126- 131-

 

65
Cowling, W. R. III (1985). Relationship of mystical
experience, differentiation, and creativity. Pe e al

Emmekille. 151.. 451-456.

Dale, E., Gerlach, D., & Wilhite, A. (1979). Menstrual
dysfunction in distance runners. ongtetrics &

Q!D§§QlQQ¥: éiflla 47-53-

Dalton, K. (1984). T e e strua S d me and
(2nd ed.). Chicago: Year Book

Medical Publishers Inc.

Facchinetti, F., Martignoni, E., Petraglia, P., Sances, M.,
Nappi, G., & Genazzani, A. R. (1987). Premenstrual fall
of plasma B-endorphin in patients with premenstrual

syndrome. zerriliry ang Sterility, 11(4), 570-573. -

Fair, J., Rosenaur, J., & Thurston, E. (1979). Exercise

Management. Wilmer May-June. 13-13.

Fawcett, J. (1989). Rogers' science of unitary human
beings. In J. Fawcett, ' v t o

W
cgnge pinnl models or nursing (2nd ed.) (pp 263- 305).

Philadelphia: F. A. Davis.

Fox, S. M., Naughton, J. P., & Gorman, P. A. (1972b).
Physical activity and cardiovascular health. III. The
Frequency and type of activity.

exercise prescription:
Mogern angents gr Cardigygsgulgr Disease, Al, 25-30.

Hsia, L. S. Y., & Long, M. H. (1990). Premenstrual
syndrome: Current concepts in diagnosis and management.

WWW. 15(6) . 351-356.

Israel, R. G., Sutton, M., & O'Brien, K. F. (1985).
Effects of aerobic training on primary dysmenorrhea

symptomatology in college females. Anerigan Journal 9f
£211£Q§_fi§elinp £2: 241"244-

Johnson, S. R., McChesney, C., & Bean, J. A. (1988).
Epidemiology of premenstrual symptoms in a nonclinical
Prevalence, natural history and help-seeking

sample I.
behavior. Journal 9: Reproductive Medicine, ;;(4), 340-

346.

Kirkpatrick, M. K., Brewer, J. A., & Stocks, B. (1990).
Efficacy of self-care measures for perimenstrual syndrome

(PMsl- W. 13. 281-285-

Lee, K. A., & Rittenhouse, C. A. (1991). Prevalence of
perimenstrual symptoms in employed women. wgngn &

Heelin. 11(3): 17'32-

66

Logue, C. M., a Moos, R. H. (1986). Perimenstrual
symptoms: Prevalence and risk factors. Esygnosgnatig
Mggiging, 48(6). 388-413.

LutjeDS. L. R. (1990). Neiee_en_Nureins_Iheeriee (Vol. 1).

Martha Rogers: The science of unitary human beings.
Newbury Park: Sage Publications.

Magos, A. L. & Studd, J. W. (1986). PMS facts and fiction.
-Qeniemnererx_gnlfixn. a. 23-24.

Merriman, J. E. (1978). Exercise prescription for
apparently healthy individuals and for cardiac patients.

In K- Wenger (Ed-l. Ezereiee_end_ihe_heeri (pp- 81-92).
Philadelphia: F. A. Davis.

McArdle, w. 0., Katch, F. 1., & Katch, v. L. (1991).
' ' . e Nutr t' a d u
Perfgrnnngg (3rd. ed.). Philadelphia: Lea & Febiger.

Moos, R. H. (1985). e ' t ua s to s- A ma ua d
' w' t s a d'
. Palo Alto: Stanford University School of
Medicine and Veterans Adminstration Medical Centers.

M008. R- H- (1991). Eeneirne1.21eireee_92eeiienne1re

Mgnngl. Los Angeles: Western Pyschological Services.

Piccolo, O. (1982). Effects of biofeedback and autogenic
training on symptoms of menstrual distress. (Doctoral
disseration, United States International University, San
Diego, CA, 1981). sse ' s t te t ,
.12, 25458.

Pollack, M. L. (1971). Effects of walking on body
composition and cardiovascular function in middle aged

men. Jenrnel_ef_Anelied_£hxeielesx .2. 126- -130-

Polit, D. F. & Hungler, B. P. (1991). Nnrsing_3g§ggrgni

Brineinlee__nd_neihede (4th ed. ). Philadelphia: J- B.
Lippincott Company.

Prior, J. C., Vigna, Y., Sciarretta, 0., Alojado, N., &
Schulzer, M. (1987). Conditioning exercise decreases
premenstrual symptoms: A prospective, controlled 6-month

trial. Eeriiliix_end_§ieriliix. 11(3). 402-408-

Rapkin, A. J., Chang, L. C., & Reading, A. E. (1988).
Comparison of retrospective and prospective assessment of

premenstrual symptoms. B§¥Qfl212§i£§l.3§22£§§, .2, 55 60.

67

Rogers, M. E. (1986). Science of unitary human beings. In
v. Malinski (Ed-). Exnlereiien_en_Eerine_Beserel_eeienee
' (pp. 4-23). Norwalk, CT:
Appletion-Century-Crofts.

Rubinow, D. R., & Roy-Bryne, P. (1984). Premenstrual
syndrome: Overview from a methodologic perspective.

Amer1een_Jesrnel_ef_£exenieirx. 111. 163-172.

Shelley, S., & Anderson, C. (1986). The influence of
selected variables on the experience of menstrual
distress in alcoholic and nonalcoholic women. Jou 0

November/December, 484-491.

Smith, M. J. (1984). Human environment process: A test of

Rogers' principle of integrality. Adyange§_in_Nnr§ing
Seienee. 2(1). 21-28.

StanleY. C- T- (1985). Exere1ee_lnieneiix_end_ine_exmniem

eexer1ix_ef_nremeneirnel_e¥ndreme.
Unpublished master's thesis, California State University,
Long Beach, CA.

Sveinsdotdtir, H., & Reame, N. (1991). Symptom patterns in
women with premenstrual syndrome complaints: A
prospective assessment using a marker for ovulation and
screening criteria for adequate ovarian function.

1enrnel_ef_Adxeneed_Nureing. 1e. 689-700.

Timonen, S., & Procope', B. (1971). Premenstrual syndrome

and physical exercise. Aeie_Qbeieirlee_end_§xneeelesx
m: at 331-337.

Wilhelm-Hass, E. (1984). Premenstrual syndrome: Its
nature, evaluation, and management. Jgnrnnl_gfi
Qbeieir1e1_exneeelesiel_end_Neeneiel_Nereing..12t4). 223

Woods, N. F., Most, A., & Dery, G. K. (1982). Prevalence
of perimenstrual symptoms. e 'c J

Heelih. 12(11): 1257-1264-

HIGRN STQTE UNIV LIBR

IIIIIO

II II III II III III 5IIIIIIBII I