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Association of hemogobin levels with symptoms of premenstrual syndrome in adults

1 Department of Physiology, Mandya Institute of Medical Sciences, Mandya, Karnataka, India
2 Department of Physiology, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
3 Department of Community Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India

Date of Submission18-Nov-2021
Date of Decision06-Feb-2022
Date of Acceptance06-Feb-2022

Correspondence Address:
SA Priya,
Department of Physiology, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_898_21


Background: Most women of reproductive age experience physical, emotional, and psychological discomfort in the week before menstruation called premenstrual syndrome (PMS). However, the specific cause for PMS is still not clear. In this study, we aimed at assessing the association of hemoglobin (Hb) level with PMS symptoms. Materials and Methods: One hundred and forty-nine healthy female students from medical and paramedical courses of age 18–22 years who were not on any medications were included in the study. The Hb of each participant was measured. A structured PMS symptoms questionnaire was designed based on the article by Lori M. Dickerson et al. The participants were asked to fill the questionnaire and scoring was done. Data were analyzed in SPSS V24. Descriptive statistics were used to calculate proportions and inferential statistics such as the unpaired t-test and one-way analysis of variance was used to compare the Hb level among those with PMS and those without and the association of Hb level with the type of PMS symptoms, respectively. Results: 58.4% had PMS. There was a significant association of Hb level with PMS and lower Hb level was associated with physical and emotional symptoms. Conclusion: Occurrence of PMS symptoms was proportional to a fall in Hb level. Most physical symptoms of PMS are similar to anemia, hence can be confused due to PMS. Therefore, Hb level estimation helps in preventing misdiagnosis of PMS or symptoms related to decreased Hb level and also symptoms can be reduced by improving Hb levels.

Keywords: Emotional symptoms, hemoglobin levels, physical symptoms, premenstrual syndrome, psychological symptoms

How to cite this URL:
Mamatha S D, Priya S A, Smitha M C. Association of hemogobin levels with symptoms of premenstrual syndrome in adults. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2023 Mar 20]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=343061

  Introduction Top

Premenstrual syndrome (PMS) is used to describe physical, cognitive, affective, and behavioral symptoms that occur cyclically during the luteal phase of the menstrual cycle and resolve quickly within a few days of the onset of menstruation.[1] PMS was described by the American Psychiatric Association in 1987 as the luteal dysfunctional disorder and was classified in 1992 along with other symptoms, such as nervousness, called Dysfunctional Premenstrual Diagnostic and Statistical Manual of Mental Disorders.[2] Diagnostic criteria for PMS are presented in the American College of Obstetricians and Gynecologists Practice Bulletin 15 of 2000. At least one of the affective (depression, angry outbursts, irritability, anxiety, confusion, and social withdrawal) or somatic symptoms (breast tenderness, abdominal bloating, headache, and swelling of extremities) must be experienced during the 5 days before menses in three prior menstrual cycles and relieved with the menstrual flow. The symptoms should be confirmed by two cycles of prospective reports. The symptoms cause identifiable impairment in the patient's functioning and are not accounted for by other physical or emotional disorders.[3] The symptoms must adversely affect social or work-related activities.[3],[4] These conditions are not life-threatening but they can seriously decrease the quality of life of many women and affect their mental health and their productivity.[5] Symptoms in adolescents may negatively affect their academic performance and their social interactions. Studies have also shown that adolescents with PMS are in poor health.[6]

Women experiencing some or other premenstrual symptoms constitute about 80%. Incidence of true PMS has been often overestimated by including any physical or emotional symptoms experienced before menstruation. However, 20% to 30% of women are estimated to have clinically significant PMS which is moderate to severe in intensity, which affects woman's functioning. About 2% to 6% of women are believed to have a severe variant known as premenstrual dysphoric disorder.[7],[8] Most women of reproductive age experience PMS and the specific cause for PMS is still not clear. With this background, the study was conducted to assess the association between hemoglobin (Hb) levels and PMS symptoms. The objective of the study was to assess the association between Hb level and PMS symptoms.

  Materials and Methods Top


One hundred and forty-nine healthy eumenorrheic participants from medical and paramedical courses of age 18–22 years who were not on any medications were selected for the study. Participants, with a history of irregular periods, endocrinal disorder, and any other systemic disorders were excluded from the study. Institutional ethical clearance was obtained before beginning the study. All participants received an explanation of the nature and purpose of the study and written informed consent to participate in the study was taken.


Hb of each participant was estimated by Sahli's method in the luteal phase. Measurement was done in the luteal phase for all individuals to avoid variations in Hb levels that occur in different phases of menstrual cycles. Coding of the participant was done based on the Hb level, code 0 included participants whose Hb level was <12 g/dl and code 1 included participants whose Hb was more than 12 g/dl.

A structured PMS symptoms questionnaire [Annexure 1] was designed based on the article by Dickerson et al.[9] The participants were asked to fill the questionnaire, coding and scoring were done. Diagnostic criteria for PMS: ACOG Practice bulletin 15;2000.

PMS code was done considering the number of symptoms presented by the participant. Code 0 included participants who had <2 symptoms and code 1 included participants who had more than 2 symptoms.

Further coding was done depending on the type of symptoms present.

  • Code 0-included participants who had <2 symptoms
  • Code1-physical symptoms
  • Code2-emotional symptoms
  • Code3-psychological symptoms
  • Code 4-(physical symptoms and emotional symptoms)
  • Code 5-(emotional symptoms and psychological symptoms)
  • Code 6-(physical symptoms, emotional symptoms, and psychological symptoms)
  • Code 7-(physical symptoms and psychological symptoms).

  Results Top

Data were analyzed in IBM SPSS statistical software Version 24 licensed to the institution. Descriptive statistics such as proportions mean and standard deviation was calculated. Inferential statistics such as Chi-square analysis was done to know the association of Hb levels with PMS and the type of PMS symptoms.

  • 58.4% had PMS. There was a significant association of Hb <12 g/dl with PMS as shown in [Table 1] and [Table 2]. Physical and emotional symptoms are being more with individuals having Hb < 12g/dl than Hb > 12g/dl
Table 1: Distribution of premenstrual syndrome symptoms with different hemoglobin levels

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Table 2: Distribution of various premenstrual syndrome symptoms with hemoglobin level

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  Discussion Top

Hypotheses about the cause of PMS have been proposed including changes in estrogen-progesterone ratio, fluctuation in sex hormone, increased sensitivity for these hormones, increased aldosterone activity, increased renin–angiotensin activity, impaired secretion of internal opioids, hypoglycemia without causes, opioid deficiencies, vitamins B6, B1, and A or minerals such as magnesium and calcium, excessive prolactin secretion, and prostaglandin disorder.[10],[11]

Although the cause for PMS is not clear, several factors responsible for it include cyclical changes in hormones and chemical changes in the brain. The role of ovarian hormones is still not clear since the circulating sex hormone levels are typically normal in women with PMS.

It is observed that changes in hormones level may influence centrally acting neurotransmitters (serotonin).[12] There is evidence suggesting PMS relation to enhanced sensitivity to progesterone in women with underlying serotonin deficiency.[13],[14]

In the present study, the participants who had more than 2 symptoms of PMS were found to have Hb <12 g/dl. Further, the combination of physical and emotional symptoms was reported in most of these participants. A study done in anemic patients has shown anemia aggravates PMS symptoms.[15] Possible mechanism showing the association of Hb and PMS can be explained by studies suggesting decreased transporters for serotonin and norepinephrine in iron deficiency anemia in rats.[16] Thus, decreased serotonin levels may be the cause for symptoms of PMS in low Hb level individuals.

Hence, screening for Hb level and prompt treatment for the same may reduce the troublesome symptoms of PMS.

  Conclusion Top

In the present study, PMS symptoms were seen in a significant number of the participants who had <12 g/dl Hb suggesting the occurrence of PMS symptoms proportional to a fall in Hb level. Further, the association with physical and emotional symptoms was also seen, and most physical symptoms of PMS are similar to anemia, hence can be confused due to PMS. Therefore, Hb level estimation helps in preventing the misdiagnosis of PMS. Early estimation of Hb in PMS participants and prompt improvement of Hb can benefit the participants on symptoms related to decreased Hb level.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Tolossa FW, Bekele ML. Prevalence, impacts and medical managements of premenstrual syndrome among female students: Cross-sectional study in College of Health Sciences, Mekelle University, Mekelle, Northern Ethiopia. BMC Womens Health 2014;14:52.  Back to cited text no. 1
Bertone-Johnson ER, Hankinson SE, Willett WC, Johnson SR, Manson JE. Adiposity and the development of premenstrual syndrome. J Womens Health (Larchmt) 2010;19:1955-62.  Back to cited text no. 2
Freeman EW. Premenstrual syndromes. In: Gynecology & Obstetrics. Vol. 1, Ch. 23. Philadelphia: Lippincott Williams & Wilkins; 2004.  Back to cited text no. 3
Sarkar AP, Mandal R, Ghorai S. Premenstrual syndrome among adolescent girl students in a rural school of West Bengal, India. Int J Med Sci Public Health 2016;5:408-11.  Back to cited text no. 4
O'Brien PM. The premenstrual syndrome. A review. J Reprod Med 1985;30:113-26.  Back to cited text no. 5
Vichnin M, Freeman EW, Lin H, Hillman J, Bui S. Premenstrual syndrome (PMS) in adolescents: Severity and impairment. J Pediatr Adolesc Gynecol 2006;19:397-402.  Back to cited text no. 6
Halbreich U. The etiology, biology, and evolving pathology of premenstrual syndromes. Psychoneuroendocrinology 2003;28 Suppl 3:55-99.  Back to cited text no. 7
Silotry N, Nimmagadda H, Kumari R. A comparison of hemoglobin levels in women with and without premenstrual syndrome during premenstrual, menstrual, and postmenstrual stages. Int J Biol Med Res 2011;2:1017-22.  Back to cited text no. 8
Dickerson LM, Mazyck PJ, Hunter MH. Premenstrual syndrome. Am Fam Physician 2003;67:1743-52.  Back to cited text no. 9
Yonkers KA, O'Brien PM, Eriksson E. Premenstrual syndrome. Lancet 2008;371:1200-10.  Back to cited text no. 10
Mohebbi Dehnavi Z, Torkmannejad Sabzevari M, Rastagi S, Rad M. A survey on the association of premenstrual syndrome with a type of temperament in high school students. IJOGI 2017;20:15-23.  Back to cited text no. 11
Wyatt K, Dimmock PW, O'Brien PM. Premenstrual syndrome. In: Barton S, editor. Clinical Evidence. 4th Issue. London: BMJ Publishing Group; 2000. p. 1121-33.  Back to cited text no. 12
Kessel B. Premenstrual syndrome. Advances in diagnosis and treatment. Obstet Gynecol Clin North Am 2000;27:625-39.  Back to cited text no. 13
Rapkin AJ. The role of serotonin in premenstrual syndrome. Clin Obstet Gynecol 1992;35:629-36.  Back to cited text no. 14
Sinha M, Patel AH, Naik S, Jadeja JM. Effect of anemia on premenstrual syndrome in adolescent girls. IJBAP 2013;2:104-8.  Back to cited text no. 15
Beard JL, Felt B, Schallert T, Burhans M, Connor JR, Georgieff MK. Moderate iron deficiency in infancy: Biology and behavior in young rats. Behav Brain Res 2006;170:224-32.  Back to cited text no. 16


  [Table 1], [Table 2]


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