Menstrual Irregularity and Menstrual 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 menstrual irregularity revealed that women with irregular cycles suffered more menstrual 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 subjective 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
Dr Aron Weller is an associate professor in the Department of Psychology at Bar-Ilan University, Ramat-Gan, Israel, where Dr Leonard Weller is a professor in the Department of Sociology.

in terms of the menstrual symptoms they experience. In one study of 156 female college students who completed a questionnaire pertaining to menstruation, irregularity was only related to 2 of 6 items and the correlations were low but significant (r = .20, r = .16).1 Sheldrake and Cormacks2 participants were 2,542 college 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 categorized 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% vs 26%) and sometimes only 2%. Furthermore, these differences 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

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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 period. 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 questionnaire 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 establishment of regular periods, self-definition of amount of blood loss, usual duration of the cycle, pain, other symptoms, and incapacity. Furthermore, there were no associations between reported cessation of periods and 5 personality 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 consistent association between irregularity and menstrual symptoms, 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 irregularity would be expected to allow for a more sensitive differentiation 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 a criterion 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 criterion for an irregular cycle, how many repeated irregular cycles in a year would be needed for a women to be designated 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 of what constitutes regularity or irregularity. Three standard gynecological texts state that the commonly observed interval 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 menstrual 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 irregular periods, although there is somewhat more latitude in definitions of the lower cut-off point (eg, 2535 days,11,12 2035 days,13 and 2235 days14). Several studies have attempted to determine cycle irregularity by self-definition (subjective criteria) by simply asking 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 irregular. In a 1992 study of Danish women,9 17% of the 20- to 24-year age group reported being irregular and 83% reported being regular. An almost identical finding was reported in Israel for university women (82% regular) and for mothers (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 definitions of their patterns as regular or irregular. Unfortunately, the reliability of retrospective reporting, in general19 and of menstrual information in particular,20,21 has been seriously criticized. With regard to menstrual regularity and irregularity, the reliability of the womens self-reporting is even more complex, for it is not only a matter of standard reliability. The lack of objective criteria for menstrual irregularity (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 to which womens self-definitions of their menstrual regularity and irregularity were consistent with an objective criterion 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

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women: only 44% of those who defined themselves as irregular 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 in the literature between menstrual irregularity and menstrual symptoms stems from the ambiguity of the definition of menstrual irregularity because the menstrual cycle is inherently variable. Therefore, a combined criterion of both selfdefined and objectively defined criteria is a more valid standard for determining menstrual regularity and menstrual irregularity than self-definition alone. Using this combined definition, we would expect to find that women with irregular 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 United 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 countrywide university strike it was extended to June 23. During the last week of October and the first week of November, all of 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 complete 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 dormitories and were not replaced. Of the remaining 197 women, 189 returned menstrual calendars and the second set 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 menstrual dates, 40% 8 menstrual dates, and 15% 9 or 10 menstrual dates. The data collected from this sample have been used previously to examine menstrual synchrony25,26 and the congruence between womens self-definitions of menstrual regularity-irregularity with objective criterion of regularity 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 religiosity might influence a womans reaction to her menstruation. 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 criterion 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 sample. Thus, the occurrence of 3 such cycles would clearly indicate an irregular pattern. Subjective Criterion In 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

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TABLE 1 Menstrual Regularity-Irregularity and Menstrual Symptoms in 114 Israeli College Women Self-definition & objective criteria Regular Irregular p

Symptom Premenstrual Irritability Abdominal pain Backache Tender breast First day Nausea During menses Weakness, dizziness Lower back pain Continuous aching pain Used aspirin

Self-definition Regular Irregular

Objective criterion Regular Irregular p

2.79

3.66

.0005 2.31 1.97 1.65 2.89 2.50 2.18 .035 .05 .03

2.29 2.77 2.21 1.91 1.52 2.19 2.66

2.80 3.17 2.93 2.17 2.20 3.07 3.15 3.00

.04 .003 .04 .02 .04 .01 .05 .001

2.21 2.81 1.76

2.71 3.43 2.68

.003 .015 2.22 .001 2.65 .05

1.83

irregular. We also created a truly regular and truly irregular group by cross-classifying regularity and irregularity according to these 2 procedures: women who are either regular or irregular both by their own admission (self-definition) and by the objective criteria. RESULTS We used 1-tailed t tests 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 analyzed these separately according to each of the 3 criteria of regularity-irregularity: self-definition, objective, and crossclassification 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 during the first day, and another during the entire menstrual period. 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 menstruation stage, 1 item during the first day, and 3 items during 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 menstrual regularity and irregularity (symptom reporting could also be biased, but this seems less likely). Our research the only study that did not rely solely on womens self-definitionsfound that women with irregular cycles experienced 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 irregular 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 identical for the subjective (self-definition) and the objective criteria 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

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21 to 34 days then back to 28 days may very well consider herself as irregular, although she would be classified as regular 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 nevertheless consider herself irregular because, in fact, she experienced some extra-long or extra-short cycles. In an article on menstrual variability, we24 described different patterns of cycles. A womans cycle length can gradually 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 physiologically 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 regarded as aberrant, causing more difficult menses. Irregular menstrual cycles, in contrast with regular menstrual cycles, may reflect a disregulated central LH-RH biological clock and a different peripheral physiological hormonal state, presenting an altered mix of estrogens, progesterones, or prostaglandins, which coterminously may also affect the severity of menstrual symptoms. BrooksGunn1 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 additional 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 irregular may then view menstruation as a more serious event and experience greater difficulty in preparing psychologically or hygienically for the onset of their menses. Furthermore, 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 symptoms and symptoms during the menses are equally represented. Future researchers should attempt to identify a specific mechanism that can account for the selective association of these symptoms with menstrual irregularity.
NOTE For further information, please address correspondence to Dr Aron Weller, Department of Psychology, Bar-Ilan University, Ramat-Gan 52900, Israel (e-mail: weller@mail.biu.ac.il). REFERENCES 1. Brooks-Gunn J. The salience and timing of the menstrual flow. Psychosom Med. 1985;47(4):363371. 2. Sheldrake P, Cormack M. Variations in menstrual cycle symptom reporting. J Psychosom Res. 1976;20:169177. 3. Woods NF, Most A, Dery GK. Prevalence of menstrual symptoms. American Journal of Public Health. 1982;72: 12571264. 4. McCormick WO. Amenorrhoea and other menstrual symptoms in student nurses. J Psychosom Res. 1974;19:131137. 5. Paige KE. Women learn to sing the menstrual blues. Psychology 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, Wentz AC, Burnett LS, eds. Novaks Textbook of Gynecology. 11th ed. 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 the menstrual cycleA cross-sectional study from a Danish county. 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.

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11. Jay N, Mansfield MJ, Blizzard RM, et al. Ovulation and menstrual function of adolescent girls with central precocious puberty after therapy with gonadotropin-releasing hormone agonists. J Clin Endocrinol Metab. 1992;75:890894. 12. Dockery P, Li TC, Rogers AW, Cooke ID, Lenton EA, Warren MA. An examination of the variation in timed endometrial biopsies. Hum Reprod. 1988;3:715720. 13. Metcalf MG, Livesey JH. Pregnanediol excretion in fertile women: age-related changes. J Endocrinol. 1988;119: 153157. 14. Kharat I, Nair NS, Dhall K, et al. Analysis of menstrual records of women immunized with anti-hCG vaccines inducing antibodies partially cross-reactive with hLH. Contraception. 1990;41:293299. 15. Weller A, Weller L. Menstrual synchrony between mothers and daughters and between roommates. Physiology & Behavior. 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 premenstrual syndrome. Lancet. 1965;1:11801183. 18. Widholm O, Kantero RL. A statistical analysis of the menstrual patterns of 8000 Finnish girls and their mothers. Acta Obstet Gynecol Scand. 1971;50:136. 19. Nisbett RE, Wilson TD. Telling more than we can know: Ver-

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bal reports on mental processes. Psychol Rev. 1977;84: 231259. Bean JA, Leeper JD, Wallace RB, Sherman BM, Jagger H. Variations in the reporting of menstrual histories. Am J Epidemiol. 1979;109(2):181185. McFarland C, Ross M, DeCourville N. Womens theories of menstruation and biases in recall of menstrual symptoms. J Person Soc Psychol. 1989;57:522531. Treloar AE, Boynton RE, Borghild GB, Brown BW. Variation in the human menstrual cycle through reproductive life. Int J Fertil. 1970;12:77126. Vollman RF. The menstrual cycle. In: Friedman E. eds. Major Problems in Obstetrics and Gynecology. Philadelphia: Saunders; 1977. Weller A, Weller L. Assessment of menstrual regularity and irregularity using selfreports and objective criteria. J Psychosom Obstet Gynecol. 1998;19:111116. Weller L, Weller A, Avinir O. Menstrual synchrony: Only in roommates who are close friends? Physiology & Behavior. 1995;58:883889. Weller L, Weller A. Menstrual variability and the measurement of menstrual synchrony. Psychoneuroendocrinology. 1997;22: 115128. Chesney MA, Tasto DL. The development of a menstrual symptom questionnaire. Behav Res Ther. 1975;13:237244.

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