International Journal of
Nursing Terminologies and Classifications
Perimenstrual Syndrome: Nursing Diagnosis
Among Taiwanese Nursing Students
ijnt_1185
1..7
Han-Fu Cheng, RN, PhD
PURPOSE. To determine the frequency and distribution of
various perimenstrual symptoms experienced by
Taiwanese nursing students.
METHODS. A descriptive “management of menstrual
cramps survey” was utilized to collect information from
2,758 female nursing students in southern Taiwan.
FINDINGS. Of the participants, the most frequently
reported perimenstrual symptom was a combination of
four symptom categories, including mood change, pain,
gastrointestinal disturbance, and functional ability
decline.
CONCLUSIONS. A potentially new nursing diagnosis of
perimenstrual syndrome including four symptom
categories may be established.
PRACTICE IMPLICATIONS. The results are important
for the education of healthcare professionals and the
public. Understanding the interaction among
perimenstrual symptoms may help guide nursing
professionals in women’s health care.
Search terms: Dysmenorrhea, nursing diagnosis,
perimenstrual syndrome, Taiwanese nursing students,
Venn diagram
© 2011, The Author
International Journal of Nursing Terminologies and
Classifications © 2011, NANDA International
doi: 10.1111/j.1744-618X.2011.01185.x
Han-Fu Cheng, RN, PhD, is an assistant professor at the
School of Nursing at Fooyin University, Kaohsiung,
Taiwan.
Background
Dysmenorrhea is the most common gynecological
problem in women of reproductive age (McEvoy,
Chang, & Coupey, 2004). It is a symptom complex that
not only affects quality of life (QOL) but also reduces
productivity (Andersch & Milsom, 1982; Klein & Litt,
1981). Dysmenorrhea is not just pain, and there is evidence that symptoms associated with dysmenorrhea
represent three symptomatic clusters: cyclic pelvic
pain, perimenstrual discomfort, and perimenstrual
negative affect (Collins Sharp, Taylor, Thomas, Killeen,
& Dawood, 2002). In 2002, Collins Sharp et al. referred
to these symptomatic clusters of dysmenorrhea
“nursing diagnoses.” However, dysmenorrhea is currently not part of the nursing diagnoses covered by
NANDA-International. Instead, these three diagnoses
were referred to together as a syndrome, defined as a
“clinical judgment describing a specific cluster of diagnoses that occur together, are best addressed together,
and through similar interventions” (NANDAInternational, 2008, pp. 2–3), and this has been discussed in the nursing literature as perimenstrual
syndrome (PS) (Collins Sharp et al., 2002).
Using the idea of PS and 18 of the 23 symptoms
from the model of Collins Sharp et al. (2002), this
researcher recategorized the diagnostic categories
(symptom clusters) and used them for data collection
purposes. Joint aches, fluid retention, leg/thigh discomfort, breast tenderness, and guilt were not
included because of language issues. For example,
fluid retention, leg/thigh pain, joint pain, and guilt are
not terms commonly used in the description of perimenstrual symptoms among Taiwanese. This is supported by PubMed searches. While there were 66
citations retrieved on November 15, 2009, using the
terms “Taiwan AND dysmenorrhea,” there were no
International Journal of Nursing Terminologies and Classifications Volume ••, No. ••, ••-••, 2011
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Perimenstrual Syndrome: Nursing Diagnosis Among Taiwanese Nursing Students
citations found when the terms “fluid retention,”
“bloating,” “guilt,” “leg OR thigh,” or “joint” were
added to the advanced searches. On the other hand,
“swollen abdomen” and “breast tenderness” were
listed among the top five symptoms mentioned by
adolescents in Taiwan (Chen & Chen, 2005).
While Collins Sharp et al. (2002) had described three
symptom clusters of dysmenorrhea, this researcher
decided upon five symptom clusters: mood change,
pain, functional ability, gastrointestinal (GI) disturbance, and decreased QOL. Collins Sharp et al.’s
symptom cluster of cyclic pelvic pain contained symptoms of nausea, vomiting, diarrhea, and bowel frequency. However, these are not symptoms of pain but
symptoms of GI disturbance. Therefore, they were
placed along with decreased appetite in the GI disturbance category.
Review of the Literature
Literally, dysmenorrhea only refers to menstrual
cycle pain. Some define it more broadly to include
symptoms of abdominal or low back pain, GI disturbances (nausea and vomiting), headache, fatigue,
sweating, lethargy, breast tenderness, and emotional
symptoms, and these symptoms may continue for a
few days during menstruation (Golomb, Solidum, &
Warren, 1998; McEvoy et al., 2004). Some investigators
refer to the signs and symptoms of the menstrual cycle
as premenstrual syndrome. These include anger, irritability, crying spells, decreased energy, decreased
appetite, decreased ability to concentrate, headache,
and cramps (Ghanbari, Haghollahi, Shariat, Foroshani,
& Ashrafi, 2009).
Collins Sharp et al. (2002), in their examination of
cyclic changes, call the entire constellation of related
signs and symptoms PS. This syndrome is divided
into three categories: cyclic pelvic pain, perimenstrual
discomfort, and perimenstrual negative affect. This
is an important development in the description
and classification of the condition. Its importance
becomes apparent when considering how it defined
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dysmenorrhea in the relevant classification. While this
is an important development, the description has limitations. For example, diarrhea was categorized into the
diagnosis of cyclic pelvic pain. Yet diarrhea more properly belongs in the GI disturbance category. For the
purpose of data collection in this study, five perimenstrual categories were generated: mood change, pain,
functional ability, GI disturbance, and decreased
QOL.
Commonly used classifications are also limited in
the definition of dysmenorrhea. NANDA-International
(2009) defines acute pain and chronic pain as a single
diagnosis. It does not include a diagnosis for the cyclic
pain called dysmenorrhea, nor does it include Collins
Sharp et al.’s (2002) three nursing diagnoses of cyclic
pelvic pain, perimenstrual discomfort, and perimenstrual negative affect.
The International Classification of Functioning,
Disability, and Health (ICF, n.d.) lists menstruation
functions and impairments within its body function
category (b650). Among impairments, there is no
mention of dysmenorrheic pain, only premenstrual
tension. While not using the term “dysmenorrhea,”
the ICF does refer to “discomfort associated with the
menstrual cycle, including pre- and post-menstrual
phases” (b6701). Still, this characterization does not
capture the functional impairments associated with PS
as well as that of Chiou and Wang (2008), who indicated that dysmenorrhea may decrease functional
ability, such as inability to attend school, inability to
attend physical education, or a decrease in extracurricular activities.
In the International Classification of Diseases
(ICD-9, n.d.), there are two related diagnoses: dysmenorrhea and premenstrual tension syndrome. The
former is defined as “painful menstruation, excluding
psychogenic.” ICD-9 defines premenstrual tension
syndrome as a combination of distressing physical,
psychological, or behavioral changes that occur during
the luteal phase of the menstrual cycle. These symptoms are diverse, including pain, fluid retention,
anxiety, cravings, depression, irritability, and increased
International Journal of Nursing Terminologies and Classifications Volume ••, No. ••, ••-••, 2011
seizure activity in vulnerable women, and diminish
markedly 2–3 days after the initiation of menses.
Methodology
Research Design
This study utilizes a descriptive survey on a convenience sample of young female students from Taiwan.
The researcher-designed survey, the management of
menstrual cramps survey (MMCS), was distributed to
2,758 nursing students enrolled at the school of nursing
of a university in Kaohsiung in southern Taiwan.
Instrument
The MMCS is a simple checklist with questions in
four different sections over four pages. It requires
about 30 min for completion. The MMCS was developed by this researcher who has worked with women
with PS for 4 years. This survey included a demographic information section. In addition there is a table
listing the perimenstrual symptoms within five categories. The researcher-generated diagnostic categories
constituting PS were:
• Mood change (anger/hostility, tension/anxiety,
irritability/impatience, crying spells, feeling out
of control, depression, decreased sexual desire,
decreased energy, decreased ability to concentrate,
fatigue, nervousness, dizziness, and headache).
• Pain (abdominal pain/cramps, pelvic pain, and low
back pain).
• Functional ability decline (inability to attend school,
inability to attend physical education, or decrease in
extracurricular activities).
• GI disturbance (nausea, vomiting, increased GI
motility/diarrhea, and decreased appetite).
• Decreased QOL.
QOL was included as its own category as it captured the overall experience. Collins Sharp et al. (2002,
p. 640) suggest that “perimenstrual cyclic pelvic pain
can have a significant impact on a woman’s quality
of life.” It is also assumed that the same is true for
other symptoms such as mood, GI symptoms, and
functional ability. Understanding how each of these
affects the overall QOL provides further insight into
the problem.
Content validity was achieved in the following way.
The researcher identified each domain and generated
the items that best reflected each domain through literature review and personal experiences. Three female
clinical experts with advanced degrees in nursing (two
doctoral and one master’s-prepared nurses) were
asked to judge the tool. Each reviewer received a
detailed package that included a description of the
purpose of the measures and instructions for assessing
content validity. The experts were requested to put the
comments and suggestions regarding clarity and readability of each item. Based on this expert opinion, the
researcher made corrections until all three experts
agreed on all items in the tool.
In order to make sure the design was appropriate for
the population, five Taiwanese female nursing students were selected to take part in the pilot study of the
survey before its use in this study. The researcher gave
instructions to the students before conducting the
survey and checked the answers to determine the level
of agreement among different persons using the same
tool. The results showed the inter-rater reliability was
100% consistent.
Results
Participant Background Information
Of all the participants, 2,232 (80.9%) reported experiencing menstrual pain and 2,643 (95.8%) had experienced one or more premenstrual symptoms during
their last menstruation. Out of a total of 2,888 participants recruited to the study, 133 participants were
excluded for failure to return the survey. The remaining 2,758 (95.4%) were enrolled in the study. The mean
International Journal of Nursing Terminologies and Classifications Volume ••, No. ••, ••-••, 2011
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Perimenstrual Syndrome: Nursing Diagnosis Among Taiwanese Nursing Students
age of the study population was 20.5 years (range,
18–55) and SD 4.0.
Table 1. Frequency and Distribution of
Perimenstrual Symptom Categories
Frequency and Distribution of Perimenstrual
Symptoms Within Categories
PS Categories
Perimenstrual symptoms constitute a syndrome,
and are a constellation of symptom clusters. In this
study, the following symptom clusters were used:
mood change, pain, GI disturbance, functional ability
decline, and decreased QOL. QOL was eliminated as a
category within this study, for it was not operational in
this study because its meaning was unclear among
Taiwanese students. For example, some subjects indicated that QOL improved as perimenstrual symptoms
increased. As a result, the meaning of a “yes” response
was not interpretable. Consequently, study results
focus on the remaining four perimenstrual symptom
categories.
Table 1 presents the numbers and percentages of
participants reporting one or more within-category
symptoms. For example, 916 (33.2%) participants
reported at least one symptom from within the mood
change (A), pain (B), GI disturbance (C), and functional
ability decline (D) categories. This was the most frequently reported.
The Venn diagram (Figure 1) is especially useful
in displaying probabilities among interacting/
overlapping sets. Therefore, it was developed to illustrate the proportions of participants reporting
symptom(s) within each category. The legend to
Figure 1 further assists in interpreting the diagram. For
example, the “A alone” space represents the 6.9% who
reported mood change only. The “A + B + C” space
represents the 20.1% who reported mood change, pain,
and GI disturbance.
The Venn display supports the notion that perimenstrual symptom is not just pain, nor a combination of
pain and mood change, but a complex phenomenon
involving the interaction of at least four symptom clusters. Of the participants, 33.2% reported an interaction
of perimenstrual symptoms, representing all four cat4
Frequency
Mood change (A) + pain (B) + GI
disturbance (C) + FA decline (D)
Mood change (A) + pain (B) + GI
disturbance (C)
Mood change (A) + pain (B)
Mood change (A) + pain (B) + FA
decline (D)
Mood change (A) only
No symptom
Mood change (A) + GI disturbance (C)
Pain (B) only
Mood change (A) + FA decline (D)
Mood change (A) + GI disturbance (C)
+ FA decline (D)
Pain (B) + GI disturbance (C)
FA decline (D) only
Pain (B) + GI disturbance (C) + FA
decline (D)
Pain (B) + FA decline (D)
Total
%
916
33.2
555
20.1
546
224
19.8
8.1
190
115
78
64
19
18
6.9
4.2
2.8
2.3
0.7
0.7
18
7
5
0.7
0.3
0.2
3
2,758
0.1
100
FA, functional ability; GI, gastrointestinal.
egories: mood change, pain, GI disturbance, and functional ability decline. This interaction was the most
frequently reported. Next in frequency were the 20.1%
who reported an interaction of perimenstrual symptoms representing three categories (mood change,
pain, and GI disturbance) and the 19.8% who reported
symptoms representing two categories (mood change
and pain).
Discussion
As far back as 1931 (Moline & Zendell, 2000), the
idea was promoted that perimenstrual symptoms are
limited to pain and possibly mood change. The results
reported in this study support perimenstrual symptoms being more complex. Findings shown here indicate that PS is a complex phenomenon, analogous to
those of Collins Sharp et al. (2002).
International Journal of Nursing Terminologies and Classifications Volume ••, No. ••, ••-••, 2011
Figure 1. Venn Diagram: Interaction Among
Symptom Clusters/Categories. A: Mood
Change Only; B: Pain; C: Gastrointestinal
(GI) Disturbance; D: Functional Ability
Decline. A + B: Mood Change + Pain; A +
C: Mood Change + GI Disturbance; A + D:
Mood Change + Functional Ability
Decline; B + C: Pain + GI Disturbance; B +
D: Pain + Functional Ability Decline; C +
D: GI Symptoms + Functional Ability
Decline. A + B + C: Mood Change + Pain +
GI Disturbance; A + B + D: Mood Change
+ Pain + Functional Ability Decline; A + C
+ D: Mood Change + GI Disturbance
+Functional Ability Decline; B + C + D:
Pain + GI Disturbance + Functional
Ability Decline; A + B + C + D: Mood
Change + Pain + Functional Ability
Decline + GI Disturbance
Major differences between this study and that of
Collins Sharp et al. (2002) lie in the distribution of
symptoms within categories and the names of the
categories themselves. Collins Sharp et al. focused on a
broader array of categories including cyclic pelvic pain,
perimenstrual discomfort, and perimenstrual negative
affect. This study focused on pain, mood change, GI
disturbance, and functional ability decline. These
categories were an improvement over Collins Sharp
et al.’s study because they were discrete categories
required of a valid classification (NANDAInternational, 2009) and because “functional ability
decline” was a label consistent with Taiwanese descriptions of perimenstrual complaints (ICF, n.d.).
These four categories were displayed in a Venn
diagram (Figure 1), yielding 15 possible ways in which
perimenstrual symptom categories may interact.
Among these 15 possibilities, 33.2% of the participants
reported symptoms representing all four categories.
This was the most frequently reported interaction.
The idea that PS is a complex phenomenon is also
reflected in the very few subjects who reported perimenstrual symptoms within an isolated category only.
The Venn sets (Figure 1) show 6.9% in the mood
change category only, 2.3% in the pain category only,
0.3% in the functional ability decline only, and 0% in
the GI disturbance category only. This study advances
Venn diagram use in its graphic display of the complexity of the interactions among the signs and symptoms of perimenstrual symptoms. Hence, this study
may be of methodological use in the development in
nursing terminology.
Nursing Implications
Dysmenorrhea is defined as severe menstrual cycle
cramps and pain for at least 2 days (Andersch & Milsom,
1982; Proctor & Murphy, 2001). However, it is important
to distinguish nursing diagnoses from medical diagnoses. In order to make an appropriate nursing diagnosis, work of in-depth assessment is necessary. Nursing
diagnosis provides standards for directing healthcare
International Journal of Nursing Terminologies and Classifications Volume ••, No. ••, ••-••, 2011
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Perimenstrual Syndrome: Nursing Diagnosis Among Taiwanese Nursing Students
providers in nursing interventions. After a diagnosis
is made, the next steps of nursing interventions and
evaluation will be undertaken.
The display of the probabilities associated with
the various interactions among the perimenstrual
symptom clusters helps to explain the complexity of
perimenstrual symptoms as compared with a simpler
medical definition of dysmenorrhea as pain and mood
change only. In addition to being more reflective of the
experience, a more complete explanation is important
for the education of both healthcare professionals and
the lay public, as well as for the purpose of practice,
especially in terms of assessment and research. These
findings have implications for health education regarding menstruation, for clinical assessment of those with
dysmenorrhea complaints, and for researchers studying the effectiveness of treatments to relieve perimenstrual symptoms. The methodology has implications
for terminology developers studying syndromes or
other complex diagnoses.
Limitations
The intrinsic limitation of this survey study is that it
relies on a self-report method of data collection. Therefore, intentional deception, poor memory, or misunderstanding of the question can all contribute to
inaccuracies in the data. Survey research is useful in
gathering information about a particular incident and
emphasizes standardized procedures; however, it
cannot offer insights into cause-and-effect relationships. The use of a self-report inventory presented the
possibility of eliciting a socially desirable response
bias, thereby underreporting certain items. This presents a threat to construct validity. For example, the PS
of decreased sexual desire was the least reported
symptom. This may be because it actually is the least
experienced symptom, or it may be that sexual desire is
not a topic to be discussed in this culture. Despite its
limitations, this study has value.
Ideally, the sample would be chosen randomly from
a cross section of the entire population of young adult
6
women and not limited to nursing students within one
school; however, this study was not randomized
because of limitations in sampling. While nursing
students may be more aware of their body and its
functions, and report perimenstrual symptoms with
greater frequency, it is also possible that such awareness may be common knowledge among all young
Taiwanese women regardless of educational background. Since convenience-sampling techniques
produce a sample that may not be representative of the
greater population, the generalizability of the findings
in this study is thus limited.
Conclusions
The prevalence of perimenstrual symptoms is as
high as 43–90% worldwide in women of reproductive
age. In this study of Taiwanese nursing students of the
same age group, this prevalence was found to be
around 80%. Even though the methodology needs
improvement, this attempt to better understand their
presentations in terms of the ways in which the categories interact has advanced the ability of nursing professionals to describe, assess, teach, and research PS. The
results advance the knowledge underlying nursing
assessment, diagnosis, and management of perimenstrual symptoms. For example, the results showed that
perimenstrual symptom is not only pain, as defined in
the ICD, rather, a cluster of symptoms including mood
change, GI disturbance, and functional ability decline,
in addition to pain. In the sense that dysmenorrhea is
more than just pain and can be described as a syndrome, the results of this study are not dissimilar to
those of Collins Sharp et al. (2002). The display of Venn
diagrams supports the notion that perimenstrual
symptom is, in fact, a complex phenomenon involving
a constellation of symptoms for at least four different
symptom categories.
Acknowledgments. This research was financially supported by Saint Louis University, North American
Nursing Diagnosis Association (NANDA) Scholarship
International Journal of Nursing Terminologies and Classifications Volume ••, No. ••, ••-••, 2011
Fund. Special thanks go to my PhD advisor, Mary Ann
Lavin, for supervising my thesis, part of which is
reported in this study.
Author contact: ns227@mail.fy.edu.tw
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