weller. mens irregularity n mens symptom

7/28/2019 Weller. Mens Irregularity n Mens Symptom

1/7

Menstrual Irregularity andMenstrual Symptoms

Aron Weller, PhD; Leonard Weller, PhD

The authors examined whether women with irregular cycles showed more

symptoms of menstrual distress than women with regular cycles. One hundred

fourteen college women prospectively recorded the dates of 6 to 8 menstrual

cycles and replied to a menstrual-symptoms questionnaire. The researchers

cross-classified regularity and irregularity, by the womens self-definitions

(questionnaire data) and by objective criteria (based on the respondents

prospective recordings of their menstrual data). The results showed that

women with irregular cycles experienced twice as many menstrual symptoms

as women with regular cycles. The use of a more valid criterion for menstru-

al irregularity revealed that women with irregular cycles suffered more men-

strual distress than did women with regular cycles.

Index Terms: cycle irregularity, cycle regularity, menstrual cycles, menstrual

symptoms

We examined whether women with irregular cycles have

more menstrual symptoms than do women with regular

cycles. All previous studies relied on the womens subjec-tive definition of regular and irregular cycles. We show

the inherent difficulty in assessing such cycles. We suggest

that the relatively weak findings reported in the literature

may be the result of researchers relying solely on womens

self-definitions. Differences in menstrual symptoms may

only be found when definitions of menstrual regularity and

irregularity are based on a cross-classification of womens

self-definition of regularity and on objective criteria based

on prospective recording of menstrual cycles. We first

review the findings in the literature on the association

between menstrual irregularity and menstrual symptoms

and then discuss the inherent difficulty in assessing both

regular and irregular cycles.A number of researchers have examined whether women

with regular cycles differ from women with irregular cycles

in terms of the menstrual symptoms they experience. In one

study of 156 female college students who completed a ques-

tionnaire pertaining to menstruation, irregularity was onlyrelated to 2 of 6 items and the correlations were low but sig-

nificant (r= .20, r= .16).1

Sheldrake and Cormacks2 participants were 2,542 col-

lege women who were asked to report their responses to 9

symptoms that occurred during both the premenstrual and

the menstrual stages of the cycle. The researchers catego-

rized the women as follows: regular to the day, to within a

few days, fairly regular, or very irregular. When comparing

the extremes, that is, between regular to a day and very

irregular, the researchers found differences between these 2

groups on 6 of the 9 symptoms, with the very irregular

reporting more symptoms. However, these differences were

not large, usually no more than 7% (eg, irritability, 19% vs26%) and sometimes only 2%. Furthermore, these differ-

ences were apparent only during the menstrual phase. The

differences for these same symptoms were not so consistent

in the premenstrual phase.

Woods and associates3 reported that women who said that

they were able to predict their next menstrual period were

Dr Aron Weller is an associate professor in the Department ofPsychology at Bar-Ilan University, Ramat-Gan, Israel, whereDr

Leonard Weller is a professor in the Department of Sociology.

173


2/7

significantly more likely to experience premenstrual weight

gain and premenstrual backache than did women who said

that they were not able to predict their next menstrual peri-

od. They found no differences between these 2 groups of

women on 14 other premenstrual symptoms and none on 16

menstrual symptoms.In another study, 211 student nurses completed a ques-

tionnaire on menstruation and other items. On the basis of

their responses, the author designated which of the women

showed any interruption in their periods. They reported no

significant associations between cessation of menstruation

and the following variables: age of menarche, age of estab-

lishment of regular periods, self-definition of amount of

blood loss, usual duration of the cycle, pain, other symp-

toms, and incapacity. Furthermore, there were no associa-

tions between reported cessation of periods and 5 personal-

ity scales, although cessation of periods was significantly

related to the sixth scale, extraversion.4 Paige5 reported no

association between regularity and menstrual symptoms in

her sample of 298 unmarried university women.

In sum, the authors of these studies did not find a consis-

tent association between irregularity and menstrual symp-

toms, and any reported relationship was quite weak. All of

these studies relied on the respondents self-definitions for

designating menstrual regularity and irregularity. The use of

an improved definition of menstrual regularity and irregu-

larity would be expected to allow for a more sensitive dif-

ferentiation between the groups, which would result in an

increased number of symptoms reported by women with

irregular cycles.

Two main problems are related to the determination of acriterion for cycle irregularity. One concerns the number and

range of days that constitute a regular or an irregular cycle.

The other concerns the number of such irregular cycles that

have to occur within a designated time period for the woman

to be considered irregular. For example, if one uses a cycle

length of less than 21 days or more than 35 days as the cri-

terion for an irregular cycle, how many repeated irregular

cycles in a year would be needed for a women to be desig-

nated as exhibiting an irregular cycle pattern? And how

many 21- to 35-day cycles would she have to experience to

be considered as regular? We are unaware of any discussion

in the literature of this aspect of irregularity.

Apparently, there is no accepted objective criterion ofwhat constitutes regularity or irregularity. Three standard

gynecological texts state that the commonly observed inter-

val between menstrual periods is 26 to 30 days,6 24 to 32

days,7 and 24 to 35 days.8 One major study used less than

21 or more than 35 days as the criterion of unusual men-

strual cycle lengths.9 The authors of another major study,10

who did not use the term unusual or irregular cycle

lengths, specify in the text and make salient in their tables

that the average cycle length varies between 25 and 31 days.

Other studies concerned specifically with regularity and

irregularity used assorted criteria; many, if not most, used

35 days as the cut-off point separating regular and irregularperiods, although there is somewhat more latitude in defin-

itions of the lower cut-off point (eg, 2535 days,11,12 2035

days,13 and 2235 days14).

Several studies have attempted to determine cycle irregu-

larity by self-definition (subjective criteria) by simply ask-

ing the women whether they were regular or irregular. In a

study of college women, Sheldrake and Cormack2 reported

that 7% said that their cycles were regular to the day, 63%

said that their cycles were regular within a few days, and

21% said that their cycles were fairly or extremely irregu-

lar. In a 1992 study of Danish women,9 17% of the 20- to

24-year age group reported being irregular and 83% report-

ed being regular. An almost identical finding was reported

in Israel for university women (82% regular) and for moth-

ers (83% regular).15 In 3 additional samples, 2 of college

women16,17 and 1 of adolescents and their mothers,18 cycle

irregularity was reported by about one fourth of the women.

Overall, it seems then that about 20% of college-age women

report having irregular cycles.

Self-definitions rely on the respondents recall of their

previous patterns of cycling as well as their subjective defi-

nitions of their patterns as regular or irregular. Unfortunate-

ly, the reliability of retrospective reporting, in general19 and

of menstrual information in particular,20,21 has been serious-

ly criticized. With regard to menstrual regularity and irregu-larity, the reliability of the womens self-reporting is even

more complex, for it is not only a matter of standard relia-

bility. The lack of objective criteria for menstrual irregulari-

ty (as we have shown above) stems from the fact, attested by

all of the major studies of womens menstrual cycles, that

womens menstrual cycles are inherently variable and that

there is wide variation in cycle length both within the same

woman and among women.9,10,22,23 Consequently, womens

self-definitions of their menstrual regularity and irregularity

may be highly unreliable, not only because of the standard

problems of recall and retrospective reporting, but also

because of the inherent ambiguity of the concept itself.

We are aware of only 1 study that examined the extent towhich womens self-definitions of their menstrual regulari-

ty and irregularity were consistent with an objective criteri-

on based on self-reported prospectively collected menstrual

data.24 Eighty-two percent of the women self-defined as

regular were also deemed so by the objective criterion, but

the agreement was considerably lower for the irregular

MENSTRUAL IRREGULARITY

174 Behavioral Medicine


3/7

women: only 44% of those who defined themselves as irreg-

ular were also so defined by the objective criterion,p < .01.

Thus, there is a greater chance for a woman who considers

herself regular than for a woman who considers herself

irregular to be similarly defined by an objective criterion.

We suggest, then, that the weak relationship reported inthe literature between menstrual irregularity and menstrual

symptoms stems from the ambiguity of the definition of

menstrual irregularity because the menstrual cycle is inher-

ently variable. Therefore, a combined criterion ofboth self-

defined and objectively defined criteria is a more valid stan-

dard for determining menstrual regularity and menstrual

irregularity than self-definition alone. Using this combined

definition, we would expect to find that women with irregu-

lar cycles have more menstrual symptoms than women with

regular cycles.

METHOD

Participants

The participants were first-year university students who

lived in university residence halls. Because most Israeli

Jewish women serve in the army for 2 years, the average age

is somewhat higher than for first-year students in the Unit-

ed States. At the beginning of the study (the research lasted

8 months), the mean age was 20.3 years (SD = 1.21); 22%

were aged 19 years, 48% were 20, 18% were 21, and 11%

were 22 or older (1% rounding error).

The academic school year in Israel started on October 17

and was supposed to end on June 9, but because of a coun-

trywide university strike it was extended to June 23. During

the last week of October and the first week of November, allof the students were asked to complete a questionnaire.

They were also asked to start recording the dates of the

beginning and end of their menses during the entire school

year on menstrual calendars we supplied to them. During

the last 2 weeks of classes, we asked the students to com-

plete another questionnaire, at which time we also collected

the menstrual calendars.

At the beginning of the study, 234 women were living in

these university housing units. Seventeen of the 234 women

refused to participate in this study. During the school year,

20 of the 217 women participating in the study left the dor-

mitories and were not replaced. Of the remaining 197

women, 189 returned menstrual calendars and the secondset of questionnaires. Because of some movement in and out

of the dormitories and because of the university strike,

which lasted about 2 months (during which time not all the

women recorded their menstrual dates), we excluded 62 of

the returned menstrual calendars from the analysis because

we decided on a minimum of 6 continuous recorded men-

strual dates (5 cycles) as a requisite for the current data

analysis. Also excluded were the data from 13 women who

reported using oral contraceptives. Thus, the total number

of women for whom we report menstrual data is 114. Of

these, 11% had recorded 6 menstrual dates, 34% 7 men-

strual dates, 40% 8 menstrual dates, and 15% 9 or 10 men-strual dates. The data collected from this sample have been

used previously to examine menstrual synchrony25,26 and

the congruence between womens self-definitions of men-

strual regularity-irregularity with objective criterion of reg-

ularity and irregularity.24 The menstrual symptoms reported

from this sample have not been analyzed previously.

Instruments

The cover page of the questionnaire explained that the

major purpose of the study was to determine menstrual

symptoms, an extension of research performed previously

in the United States. It further explained that in the study,

factors were being examined that might affect ones period;

for example, how different ages, marital status, and reli-

giosity might influence a womans reaction to her menstru-

ation. Participants were assured that their responses were

confidential.

The questionnaire contained questions on demographics

and on menstruation and related issues, 3 personality scales,

and a 24-item menstrual symptom inventory27 that asked

about symptoms before, during the first day of, and during

the menstrual period. The respondents were also asked to

respond on a 5-point scale from never have this symptom to

always have this symptom (eg, headaches, back pains,

stomachaches, and tiredness).

Definitions of Irregularity

Objective Criterion

A womens menstrual pattern was considered regular if

less than a third of her cycles over the period of the study

were either less than 21 or more than 35 days long. The cri-

terion for irregularity was based on reports9,23 suggesting

that the occurrence of 1 such extreme cycle in an 8-month

period would be expected in about 35% to 40% of the sam-

ple. Thus, the occurrence of 3 such cycles would clearly

indicate an irregular pattern.

Subjective CriterionIn the context of a number of menstrual questions, we

asked the women, Do you have regular periods? Yes,No.

In a previous article24 we reported that 68% of the women

said their cycles were regular and 32% said that they were

irregular. For the objective criterion, the percentages were

similar: 74% were classified as being regular and 26% as

WELLER & WELLER

Vol 27, Winter 2002 175


4/7

irregular. We also created a truly regular and truly irreg-

ular group by cross-classifying regularity and irregularity

according to these 2 procedures: women who are either reg-

ular or irregular both by their own admission (self-defini-

tion) and by the objective criteria.

RESULTS

We used 1-tailed ttests to determine whether the regular

women differed from the irregular women on each of the 24

menstrual symptoms during 3 time periodspremenstrual,

first-day, and during the entire menses (see Table 1). We ana-lyzed these separately according to each of the 3 criteria of

regularity-irregularity: self-definition, objective, and cross-

classification of the 2. Only significant items are presented

in the table; the critical significance level was p = .05.

For the self-definition criterion of regularity, we found

significant differences in 4 of the 24 menstrual-distress

items, 1 in the premenstrual stage and the other 3 during the

menstrual period. In all instances, the irregular women

reported more menstrual distress than did the regular

women.

For the objective criterion of regularity, we also found 4

significant items, 2 of them in the premenstrual stage, 1 dur-

ing the first day, and another during the entire menstrualperiod. On these items, the women who reported irregular

cycles indicated distress more frequently than the women

who reported regular cycles.

The final comparison consisted of the cross-classification

of those women who were regular or irregular according to

both their self-definitions and the objective criteria. For 8

symptoms, the irregular women reported significantly more

menstrual distress. Four items were significant for the men-

struation stage, 1 item during the first day, and 3 items dur-

ing the menstruation period.

COMMENT

The weak relationship reported in the literature between

menstrual irregularity and menstrual symptoms may reflect

the empirical reality. Alternatively, it may stem from the

particularly difficult conceptual problem of defining men-

strual regularity and irregularity (symptom reporting couldalso be biased, but this seems less likely). Our research

the only study that did not rely solely on womens self-def-

initionsfound that women with irregular cycles experi-

enced more menstrual symptoms than women with regular

cycles. That is, in employing what we regard as a more valid

measure of menstrual irregularity, we showed twice as

many menstrual symptoms reported by women with irregu-

lar menstrual periods as women with regular periods. The

relatively few differences reported in the literature would

seem to be the result of relying solely on self-definition of

irregularity.

The number of significant menstrual symptoms was iden-

tical for the subjective (self-definition) and the objectivecriteria of irregularity. The reason the differences were not

greater for the objective criterion may lie in our definition

of regularity and irregularity. Our criterion of regularity as

cycle lengths falling between 21 and 35 days may be too

broad (even though this is a frequently used criterion in the

literature). First, a woman whose cycle length shifted from



TABLE 1Menstrual Regularity-Irregularity and Menstrual Symptoms in 114 Israeli College Women

Self-definition

Self-definition Objective criterion & objective criteriaSymptom Regular Irregular p Regular Irregular p Regular Irregular p

PremenstrualIrritability 2.29 2.80 .04Abdominal pain 2.79 3.66 .0005 2.77 3.17 .003Backache 2.31 2.89 .035 2.21 2.93 .04Tender breast 1.97 2.50 .05 1.91 2.17 .02

First dayNausea 1.65 2.18 .03 1.52 2.20 .04

During mensesWeakness, dizziness 2.21 2.71 .003 2.19 3.07 .01Lower back pain 2.81 3.43 .015 2.66 3.15 .05Continuous aching pain 2.22 2.65 .05Used aspirin 1.76 2.68 .001 1.83 3.00 .001


5/7

21 to 34 days then back to 28 days may very well consider

herself as irregular, although she would be classified as reg-

ular according to the objective criterion. Second, we defined

regularity when less than one third of the cycles were extra

long or extra short. A woman with this pattern might never-

theless consider herself irregular because, in fact, she expe-rienced some extra-long or extra-short cycles.

In an article on menstrual variability, we24 described dif-

ferent patterns of cycles. A womans cycle length can grad-

ually increase (or decrease). She may, for example, report

the following cycle lengths: 26 days, 27 days, 29 days, 32

days, 34 days (or the reverse, beginning with 34 days and

gradually decreasing to 26 days). Of course, at some point

these increasing or decreasing trends would have to alter

direction. This can be achieved in at least 2 different ways.

She could reverse her direction gradually (eg, 26, 27, 29, 32,

34, 32, 30, 28, 25, 26), or the trend may shift drastically

(jump) by including an extra-long or extra-short cycle.

This could be the result of amenorrhea, oligomenorrhea, or

polymenorrhea.6 Thus, a woman who gradually arrived at a

34-day cycle could jump back to a 24- or a 26-day cycle and

then again gradually increase her cycle length. Such a

woman could consider herself either regular or irregular.

It is possible that each pattern of irregularity reflects a

different physiological/hormonal state, so that physiologi-

cally some patterns of irregularity may be more indicative

than others of an underlying hormonal irregularity. This

may be the reason why the findings on the association

between irregularity and menstrual symptoms are not very

robust; there is no one irregular menstrual pattern, but rather

a number of patterns. Only some of these may be regardedas aberrant, causing more difficult menses.

Irregular menstrual cycles, in contrast with regular men-

strual cycles, may reflect a disregulated central LH-RH bio-

logical clock and a different peripheral physiological hor-

monal state, presenting an altered mix of estrogens,

progesterones, or prostaglandins, which coterminously may

also affect the severity of menstrual symptoms. Brooks-

Gunn1 suggests several explanations of why women with

irregular cycles would experience more severe symptoms.

They may perceive and react differently to their menses and

menstrual symptoms and thus may be more apprehensive

about their menses. Cycle characteristics therefore might be

more salient for them than for women with regular flows.During the premenstrual stage, women with irregular cycles

may not be more aware of their symptoms than women with

regular cycles, for at this time an overall heightened focus on

premenstrual symptoms is common for all women. The addi-

tional apprehension of women who regard their cycles as

irregular may then affect their reactions during their menses,

in contrast to women with regular cycles who might be less

likely to perceive this stage of the menses as stressful.

Anticipated but not predictable life events are regarded as

affecting individuals more severely than events that occur

on time. Those women who perceive their cyclicity as irreg-

ular may then view menstruation as a more serious eventand experience greater difficulty in preparing psychologi-

cally or hygienically for the onset of their menses. Further-

more, menstruation being more salient for irregular women

may lead them to search for and produce associations

between specific cues, such as premenstrual cramps and

onset of the menses.1

The particular profile of symptoms that are perceived as

more severe in women with irregular cycles is not unique to

one of the time phases we examined. Premenstrual symp-

toms and symptoms during the menses are equally repre-

sented. Future researchers should attempt to identify a spe-

cific mechanism that can account for the selective

association of these symptoms with menstrual irregularity.

NOTE

For further information, please address correspondence to DrAron Weller, Department of Psychology, Bar-Ilan University,Ramat-Gan 52900, Israel (e-mail: [email protected]).

REFERENCES

1. Brooks-Gunn J. The salience and timing of the menstrualflow. Psychosom Med. 1985;47(4):363371.

2. Sheldrake P, Cormack M. Variations in menstrual cycle symp-tom reporting.J Psychosom Res. 1976;20:169177.

3. Woods NF, Most A, Dery GK. Prevalence of menstrual symp-toms. American Journal of Public Health. 1982;72:12571264.

4. McCormick WO. Amenorrhoea and other menstrual symp-toms in student nurses. J Psychosom Res. 1974;19:131137.

5. Paige KE. Women learn to sing the menstrual blues. Psychol-ogy Today. 1973:446.

6. Couchman GM, Hammond CB. Physiology of reproduction.In: Scott JR, DiSaia PJ, Hammond CB, Spellacy WN, eds.

Danforths Obstetrics and Gynecology. 7th ed. Philadelphia:Lippincott; 1994.

7. Wentz AC.Abnormal Uterine Bleeding. In: Jones WH,WentzAC, Burnett LS, eds.Novaks Textbook of Gynecology. 11thed. Baltimore: Williams & Wilkins; 1988.

8. Speroff L, Glass RH, Kase G. Clinical Gynecologic

Endocrinology and Infertility. 5th ed. Baltimore: Williams &Wilkins; 1994.

9. Munster K, Schmidt L, Helm P. Length and variation in themenstrual cycleA cross-sectional study from a Danishcounty.Br J Obstet Gynaecol. 1992;99:422429.

10. Chiazze L Jr, Brayer FT, Macisco JJ Jr, Parker MP, Duffy BJ.The length and variability of the menstrual cycle. JAMA.1968;203:8992.

WELLER & WELLER

Vol 27, Winter 2002 177


6/7

11. Jay N, Mansfield MJ, Blizzard RM, et al. Ovulation and men-strual function of adolescent girls with central precociouspuberty after therapy with gonadotropin-releasing hormoneagonists.J Clin Endocrinol Metab. 1992;75:890894.

12. Dockery P, Li TC, Rogers AW, Cooke ID, Lenton EA, WarrenMA. An examination of the variation in timed endometrialbiopsies.Hum Reprod. 1988;3:715720.

13. Metcalf MG, Livesey JH. Pregnanediol excretion in fertilewomen: age-related changes. J Endocrinol. 1988;119:153157.

14. Kharat I, Nair NS, Dhall K, et al. Analysis of menstrualrecords of women immunized with anti-hCG vaccines induc-ing antibodies partially cross-reactive with hLH. Contracep-tion. 1990;41:293299.

15. Weller A, Weller L. Menstrual synchrony between mothersand daughters and between roommates. Physiology & Behav-ior. 1993b;53:173179.

16. Miller NM. Additional light on the dysmenorrhea problem.JAMA. 1930;35:17961803.

17. Sutherland H, Stewart I. A critical analysis of the premen-strual syndrome.Lancet. 1965;1:11801183.

18. Widholm O, Kantero RL. A statistical analysis of the men-strual patterns of 8000 Finnish girls and their mothers. ActaObstet Gynecol Scand. 1971;50:136.

19. Nisbett RE, Wilson TD. Telling more than we can know:Ver-

bal reports on mental processes. Psychol Rev. 1977;84:231259.

20. Bean JA, Leeper JD, Wallace RB, Sherman BM, Jagger H.Variations in the reporting of menstrual histories. Am J Epi-demiol. 1979;109(2):181185.

21. McFarland C, Ross M, DeCourville N. Womens theories ofmenstruation and biases in recall of menstrual symptoms. JPerson Soc Psychol. 1989;57:522531.

22. Treloar AE, Boynton RE, Borghild GB, Brown BW. Variationin the human menstrual cycle through reproductive life. Int JFertil. 1970;12:77126.

23. Vollman RF. The menstrual cycle. In: Friedman E. eds.MajorProblems in Obstetrics and Gynecology. Philadelphia: Saun-ders; 1977.

24. Weller A, Weller L. Assessment of menstrual regularity andirregularity using selfreports and objective criteria. J Psy-chosom Obstet Gynecol. 1998;19:111116.

25. Weller L, Weller A, Avinir O. Menstrual synchrony: Only inroommates who are close friends? Physiology & Behavior.

1995;58:883889.26. Weller L, Weller A. Menstrual variability and the measure-

ment of menstrual synchrony. Psychoneuroendocrinology .1997;22: 115128.

27. Chesney MA, Tasto DL. The development of a menstrualsymptom questionnaire.Behav Res Ther. 1975;13:237244.




7/7

weller. mens irregularity n mens symptom

Documents