Prevalence And Correlates Of Premenstrual Syndrome And Premenstrual Dysphoric Disorder Among College Students And Working Women In South India: A Cross-Sectional Study

Premenstrual disorders constitute a spectrum of cyclical affective, behavioural, and somatic symptoms that occur during the late luteal phase and resolve shortly after the onset of menstruation.[1,8] Premenstrual syndrome (PMS) refers to clinically significant symptoms that interfere with daily functioning, whereas premenstrual dysphoric disorder (PMDD) denotes a severe mood disorder characterised by prominent affective symptoms and marked impairment.[2,3,9] Large population-based surveys and Global Burden of Disease analyses indicate that approximately 40–50% of reproductive-age women experience clinically relevant premenstrual symptoms, with severe PMS affecting 5–8% and PMDD around 1–3% worldwide.[1,3,4,10,11]

Despite this burden, premenstrual disorders remain under-recognised and frequently normalised as an inevitable aspect of menstruation. Help-seeking is low; fewer than half of women with disabling symptoms consult a health professional.[2,12] Untreated PMS and PMDD are associated with depressive symptoms, suicidal ideation, interpersonal difficulties, and reduced health-related quality of life.[4,11,13] From an economic perspective, PMS and PMDD contribute substantially to absenteeism and presenteeism, with studies estimating thousands of dollars lost annually per affected woman owing to menstrual-related productivity loss.[6,14]

The aetiology of PMS and PMDD is multifactorial. Current models emphasise an abnormal sensitivity to normal ovarian steroid fluctuations, with downstream effects on serotonergic and γ-aminobutyric acid (GABA) neurotransmission, stress reactivity, and neurosteroid pathways.[9,15,16] Genetic vulnerability, psychosocial stress, sleep disturbance, and lifestyle factors such as physical inactivity and smoking further modulate symptom expression.[11,16,17] These complex biopsychosocial mechanisms may be particularly salient in young women navigating academic and workplace pressures.

Sociocultural rules surrounding menstruation, low reproductive health literacy and restricted access to mental health services in low and middle-income countries such as India can contribute to slowing of the hidden burden of premenstrual disorders. Recent meta-analysis in India has noted significant heterogeneity in PMS prevalence (14- 88), and PMDD (3 -18), as a result of methodological heterogeneity and non-standardised tools. [18] Institution-based studies among college students consistently show high prevalence of PMS and substantial impact on academic performance and class attendance.[19–21] Evidence in working women, especially when assessed concurrently with student populations, remains sparse.

Validated instruments such as the Premenstrual Symptoms Screening Tool (PSST) provide a pragmatic approach to case identification in clinical and research settings.[5,7,22] The PSST has demonstrated good reliability and cross-cultural validity and is widely used to screen for moderate–severe PMS and probable PMDD in diverse populations, including adolescents and working women.[5,7,22,23] However, data using the PSST in Indian mixed cohorts of college students and working women are limited.

Understanding the prevalence, severity, and functional impact of PMS and PMDD in these key subgroups is critical for designing targeted awareness, counselling, and workplace or campus-based support interventions. The present study therefore aimed to determine the prevalence of PMS and PMDD among college students and working women in a South Indian tertiary-care setting, to characterise symptom profiles and functional impairment, and to identify sociodemographic and lifestyle correlates associated with clinically significant premenstrual disorders.

Participant characteristics

The final sample comprised 250 women, of whom 150 (60.0%) were college students and 100 (40.0%) were working women. The overall mean age was 23.8 (SD 4.6) years; students were younger than working women (21.4 vs 27.3 years, p<0.001). Most women were unmarried (78.4%), had at least undergraduate education (82.0%), and resided with family (64.8%). The mean BMI was 23.4 (SD 3.6) kg/m²; 21.2% were overweight or obese (BMI ≥25 kg/m²). Median age at menarche was 13 years; 84.0% reported cycle length between 26 and 32 days, and 62.4% described dysmenorrhoea of at least moderate intensity.

Regarding lifestyle factors, 48.8% engaged in low physical activity, 37.2% in moderate, and 14.0% in high activity. Around 41.6% reported sleeping <7 hours per night, and 63.2% rated their academic or work stress as “high” or “very high.” Current smoking or alcohol use was rare (<3%).

Prevalence and severity of PMS and PMDD

Overall, 154 women (61.6%; 95% CI 55.4–67.5) fulfilled PSST criteria for PMS of any severity, including 130 (52.0%; 95% CI 45.9–58.1) with moderate–severe PMS and 23 (9.2%; 95% CI 6.0–13.7) with PMDD (Table 2). College students had a higher prevalence of moderate–severe PMS than working women (46.0% vs 32.0%, p=0.03), though PMDD prevalence was similar (10.0% vs 8.0%, p=0.59). Only 76 participants (30.4%) reported no or mild premenstrual symptoms.

The most frequently endorsed symptom items were irritability/anger (72.8%), fatigue/lack of energy (69.2%), depressed mood/hopelessness (55.6%), and abdominal bloating (58.4%). Over half of women with PMS/PMDD reported at least moderate interference with work efficiency, relationships with family or colleagues, or social activities. Among those with PMDD, 82.6% indicated that symptoms caused “severe” or “very severe” functional impairment.

Functional impact

Premenstrual symptoms were associated with considerable disruption of academic and occupational functioning (Figure 2). Among women with moderate–severe PMS or PMDD, 33.3% reported missing at least one day of college or work in the previous three cycles because of symptoms, compared with 9.1% among those with no/mild PMS (p<0.001). A perceived decline in academic or work performance during the premenstrual week was reported by 71.8% vs 27.5% respectively (p<0.001). Difficulties in concentration, participation in class or meetings, and interpersonal conflicts were frequently described.

Factors associated with PMS and PMDD

In univariable analyses, higher perceived stress, sleep duration <7 hours, low physical activity, presence of moderate–severe dysmenorrhoea, and hostel residence were significantly associated with moderate–severe PMS/PMDD (all p<0.05). Age, BMI, and marital status were not significantly related to PMS status.

In multivariable logistic regression (Table 3), high perceived stress (aOR 2.34, 95% CI 1.36–4.01), sleep <7 hours (aOR 1.89, 95% CI 1.09–3.29), low physical activity (aOR 1.82, 95% CI 1.02–3.25), and moderate–severe dysmenorrhoea (aOR 2.76, 95% CI 1.57–4.85) remained independently associated with moderate–severe PMS/PMDD after adjusting for age, group (student vs working), and BMI. Being a college student showed a non-significant trend towards higher odds (aOR 1.41, 95% CI 0.83–2.40).

TABLE 1. SOCIODEMOGRAPHIC AND MENSTRUAL CHARACTERISTICS OF PARTICIPANTS (N=250)

Table 1 summarises the sample profile and highlights several potential vulnerability factors. Students were significantly younger, more often unmarried, and reported higher perceived stress, shorter sleep, lower physical activity, and more dysmenorrhoea than working women. Menstrual cycle length and BMI distribution were broadly similar across groups. These differences suggest that lifestyle and psychosocial stressors in student life may interact with biological factors to increase susceptibility to premenstrual disorders.

TABLE 2. PREVALENCE AND SEVERITY OF PMS AND PMDD BY PARTICIPANT GROUP

The analysis of Table 2 shows a significant burden of premenstrual disorders with almost two out of three women having PSST criteria conditions of a clinically significant PMS or PMDD. There was a preponderance of moderate PMS but one in ten women fitted criteria of PMDD, which is impressive in severity. College students reported a much lower rate of no/mild symptoms and a larger rate of moderate PMS, but the PMDD rates were equal. These results point to the necessity of the specific screening and academic and work support.

TABLE 3. MULTIVARIABLE LOGISTIC REGRESSION FOR FACTORS ASSOCIATED WITH MODERATE–SEVERE PMS OR PMDD (N=250)

It is found that psychosocial and lifestyle variables better adjusted with moderate-severe PMS/PMDD than demographic variables (Table 3). There was an independent and near two- to threefold increase in the odds of significant premenstrual disorder after adjustment with high perceived stress, less sleep, low physical activity, and dysmenorrhoea. These adjustable correlates offer practical activities of the non-pharmacological intervention like stress-management programmes, sleep hygiene counselling, and encouragement of regular exercise, in addition to optimal management of menstrual pain.

The functional correlates of premenstrual symptoms are indicated in figure 2. The moderate and severe PMS/PMDD women were found to show approximately three times the level of absenteeism and more than triple the level of lessened performance and lack of focus when compared to other women. Avoidance and social withdrawal and avoiding extracurricular activities were also significantly more common. Such trends highlight huge but not very visible role of premenstrual disorders on education achievement, workplace effectiveness and social inclusion in young females.

This case study among college students and working women in South India indicates that premenstrual disorders are highly burdened as 61.6% respondents of the study met PSST criteria of PMS and 9.2% PMDD. These illustrative prevalence estimates compare with world reviews with the PSST that have reported PMS prevalence of 47 to 72 percent and prevalence of PMDD of 4 to 18 percent in college girls [1,3,4,10,11].

High affective symptom domains were in line with previous literature that has already described mood and behavioural problems, in women are the most distressing consequences of PMS/PMDD, as they indicated an overall measure of productivity loss); more so in younger age groups [6,14,19,21].

The psychosocial and lifestyle factors are of great significance in our multivariate analyses. 11,16,17,25 High perceived stress, poor sleep, no exercise, and painful menses were also predictors of moderate-severe PMS/PMDD, as did a Korean cohort of working women, who found that incident PMS is related to high job strain and lack of exercise (25). Such modifiable correlates imply that integrative interventions in terms of stress management, sleep hygiene, promotion of physical activity, and ideal management of dysmenorrhea can reduce the severity of symptoms.

Biologically, our results are congruent with current models that conceptualise PMS and PMDD as disorders of abnormal sensitivity to cyclical ovarian steroid fluctuations rather than hormone deficiency per se.[9,14,15] Altered serotonergic and GABAergic signalling, neurosteroid dysregulation, and heightened stress reactivity are implicated in symptom generation, particularly affective lability and irritability.[9,15,16,26] The strong relationship between perceived stress and symptom severity in our study aligns with evidence that psychosocial stress can amplify these neuroendocrine vulnerabilities and that selective serotonin reuptake inhibitors and cognitive-behavioural interventions are effective therapeutic options.[9,15,27]

Our comparison of college students and working women provides practically relevant insights. Students showed higher perceived stress, shorter sleep, more physical inactivity, and greater dysmenorrhoea, accompanied by a higher prevalence of moderate PMS. This pattern resonates with studies from Indian medical colleges and other universities where academic pressure, examinations, and hostel living have been linked to pronounced premenstrual morbidity.[19–21,24] In contrast, working women may have more structured routines and coping resources, though workplace data from high-income countries indicate that PMS/PMDD still contributes to substantial sick leave and unemployment risk.[11,14,28] Future research in India should explore sector-specific workplace accommodations and policy responses to menstrual-related productivity loss.

The present study has several limitations. First, the cross-sectional design precludes causal inference between lifestyle factors and PMS/PMDD. Second, reliance on retrospective PSST ratings rather than prospective daily symptom charts may over- or under-estimate true PMDD prevalence; however, PSST is widely accepted as a pragmatic screening tool with good validity.[5,22,23] Third, the use of convenience sampling from a single institution limits generalisability beyond similar urban, educated populations. Fourth, potential confounders such as subclinical depression or anxiety were not systematically assessed. Finally, all data were self-reported and therefore subject to recall and reporting biases.

Nevertheless, the study illustrates how a simple, validated screening tool can be used within college and workplace settings to uncover a substantial but often hidden burden of premenstrual disorders. Future work should incorporate prospective symptom charting, formal psychiatric assessment, and longitudinal follow-up to clarify trajectories and inform stepped-care interventions. Trials of low-cost non-pharmacological strategies (e.g., stress-management workshops, exercise programmes, digital symptom-tracking with feedback) alongside pharmacological options such as selective serotonin reuptake inhibitors and combined hormonal contraceptives would be particularly valuable in the Indian context.[9,15,27]

In this illustrative cross-sectional study of college students and working women in South India, PMS and PMDD emerged as common conditions associated with marked affective symptoms, absenteeism, and reduced academic or occupational performance. Clinically significant premenstrual disorders were more strongly correlated with psychosocial stress, poor sleep, physical inactivity, and dysmenorrhoea, thus, several potential interventions that can be modified can be outlined. Regular screening with short validated instruments such as the PSST, coupled with menstrual health education, counselling and favorable institutional policies, would undergo a significant cut in the underrated ill-effect of premenstrual morbidity in young Indian women. These findings should be supported by strong prospective studies to establish the roles of these findings in order to influence context-sensitive management plans.