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 women’s 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 women’s 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 women’s self-definitions. Differences in menstrual symptoms may only be found when definitions of menstrual regularity and irregularity are based on a cross-classification of women’s 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 Cormack’s2 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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if one uses a cycle length of less than 21 days or more than 35 days as the criterion for an irregular cycle. for it is not only a matter of standard reliability.”9 The authors of another major study.21 has been seriously criticized. For example. 63% said that their cycles were regular within a few days. if not most. Unfortunately. Furthermore.17 and 1 of adolescents and their mothers. Several studies have attempted to determine cycle irregularity by self-definition (subjective criteria) by simply asking the women whether they were regular or irregular. which would result in an increased number of symptoms reported by women with irregular cycles. The lack of objective criteria for menstrual irregularity (as we have shown above) stems from the fact. other symptoms.12 20–35 days. Sheldrake and Cormack2 reported that 7% said that their cycles were regular to the day.23 Consequently. women’s self-definitions of their menstrual regularity and irregularity may be highly unreliable. that women’s menstrual cycles are inherently variable and that there is wide variation in cycle length both within the same woman and among women. there were no associations between reported cessation of periods and 5 personality scales.6 24 to 32 days. 2 of college women16. and 21% said that their cycles were fairly or extremely irregular. The use of an improved definition of menstrual regularity and irregularity would be expected to allow for a more sensitive differentiation between the groups. In sum.9. in general19 and of menstrual information in particular. On the basis of their responses. Other studies concerned specifically with regularity and irregularity used assorted criteria. Three standard gynecological texts state that the commonly observed interval between menstrual periods is 26 to 30 days.15 In 3 additional samples. Two main problems are related to the determination of a criterion for cycle irregularity.13 and 22–35 days14). there is no accepted objective criterion of what constitutes regularity or irregularity.MENSTRUAL IRREGULARITY 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. although cessation of periods was significantly related to the sixth scale. the reliability of retrospective reporting. although there is somewhat more latitude in definitions of the lower cut-off point (eg. the reliability of the women’s self-reporting is even more complex. In another study. They reported no significant associations between cessation of menstruation and the following variables: age of menarche.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. the authors of these studies did not find a consistent association between irregularity and menstrual symptoms. and any reported relationship was quite weak. One concerns the number and range of days that constitute a regular or an irregular cycle. but also because of the inherent ambiguity of the concept itself.9 17% of the 20. Apparently. With regard to menstrual regularity and irregularity.22. used 35 days as the cut-off point separating regular and irregular periods. All of these studies relied on the respondents’ self-definitions for designating menstrual regularity and irregularity. pain. many.to 24-year age group reported being irregular and 83% reported being regular. and incapacity.20.” specify in the text and make salient in their tables that the average cycle length varies between 25 and 31 days. age of establishment of regular periods. In a study of college women. the author designated which of the women showed any interruption in their periods. usual duration of the cycle. Overall. 25–35 days. but the agreement was considerably lower for the irregular 174 Behavioral Medicine . self-definition of amount of blood loss.8 One major study used less than 21 or more than 35 days as the criterion of “unusual menstrual cycle lengths.11. They found no differences between these 2 groups of women on 14 other premenstrual symptoms and none on 16 menstrual symptoms. An almost identical finding was reported in Israel for university women (82% regular) and for mothers (83% regular). 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. In a 1992 study of Danish women.7 and 24 to 35 days. We are aware of only 1 study that examined the extent to which women’s self-definitions of their menstrual regularity and irregularity were consistent with an objective criterion based on self-reported prospectively collected menstrual data. 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 21.10 who did not use the term “unusual or irregular cycle lengths.4 Paige5 reported no association between regularity and menstrual symptoms in her sample of 298 unmarried university women.10. 211 student nurses completed a questionnaire on menstruation and other items. 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. attested by all of the major studies of women’s menstrual cycles. extraversion.18 cycle irregularity was reported by about one fourth of the women. not only because of the standard problems of recall and retrospective reporting.24 Eighty-two percent of the women self-defined as regular were also deemed so by the objective criterion. it seems then that about 20% of college-age women report having irregular cycles.

During the last 2 weeks of classes. and 15% 9 or 10 menstrual dates. During the last week of October and the first week of November. 20 of the 217 women participating in the study left the dormitories and were not replaced. We suggest. At the beginning of the study. 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. factors were being examined that might affect one’s period. which lasted about 2 months (during which time not all the women recorded their menstrual dates). Instruments The cover page of the questionnaire explained that the major purpose of the study was to determine menstrual symptoms. 48% were 20. the average age is somewhat higher than for first-year students in the United States. Of these. Subjective Criterion In the context of a number of menstrual questions. the percentages were similar: 74% were classified as being regular and 26% as Vol 27. then. The data collected from this sample have been used previously to examine menstrual synchrony25. 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. we asked the students to complete another questionnaire. During the school year. all of the students were asked to complete a questionnaire.24 The menstrual symptoms reported from this sample have not been analyzed previously. and religiosity might influence a woman’s reaction to her menstruation. headaches. Thus. Because most Israeli Jewish women serve in the army for 2 years. The criterion for irregularity was based on reports9. and tiredness). we asked the women. The academic school year in Israel started on October 17 and was supposed to end on June 9. 189 returned menstrual calendars and the second set of questionnaires.26 and the congruence between women’s self-definitions of menstrual regularity-irregularity with objective criterion of regularity and irregularity. the mean age was 20. marital status. At the beginning of the study (the research lasted 8 months). Participants were assured that their responses were confidential. but because of a countrywide university strike it was extended to June 23. an extension of research performed previously in the United States. how different ages. for example. 34% 7 menstrual dates.21). stomachaches. p < . Thus. Definitions of Irregularity Objective Criterion A women’s 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. “Do you have regular periods?” Yes. Seventeen of the 234 women refused to participate in this study. No. 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. Because of some movement in and out of the dormitories and because of the university strike. The respondents were also asked to respond on a 5-point scale from never have this symptom to always have this symptom (eg. 3 personality scales. the occurrence of 3 such cycles would clearly indicate an irregular pattern. In a previous article24 we reported that 68% of the women said their cycles were regular and 32% said that they were irregular. Of the remaining 197 women. and during the menstrual period. 40% 8 menstrual dates. at which time we also collected the menstrual calendars. METHOD Participants The participants were first-year university students who lived in university residence halls. 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.01.WELLER & WELLER women: only 44% of those who defined themselves as irregular were also so defined by the objective criterion. The questionnaire contained questions on demographics and on menstruation and related issues. 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. back pains. Winter 2002 175 . Therefore. Also excluded were the data from 13 women who reported using oral contraceptives. during the first day of. the total number of women for whom we report menstrual data is 114. 11% had recorded 6 menstrual dates. 18% were 21. we would expect to find that women with irregular cycles have more menstrual symptoms than women with regular cycles. 234 women were living in these university housing units.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. For the objective criterion. and a 24-item menstrual symptom inventory27 that asked about symptoms before.3 years (SD = 1. Using this combined definition. Thus. It further explained that in the study. 22% were aged 19 years. and 11% were 22 or older (1% rounding error).

and crossclassification of the 2.03 2. we showed twice as many menstrual symptoms reported by women with irregular menstrual periods as women with regular periods.001 2. First. and during the entire menses (see Table 1).17 2. Our research— the only study that did not rely solely on women’s self-definitions—found that women with irregular cycles experienced more menstrual symptoms than women with regular cycles.31 1.66 .17 2. dizziness Lower back pain Continuous aching pain Used aspirin Self-definition Regular Irregular p Objective criterion Regular Irregular p 2. the critical significance level was p = . 1 item during the first day. and 3 items during the menstruation period. 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. first-day.68 .71 3. and another during the entire menstrual period.29 2.22 .83 irregular.04 .81 1.66 2.07 3.43 2. For the objective criterion of regularity. The number of significant menstrual symptoms was identical for the subjective (self-definition) and the objective criteria of irregularity.05 1.02 . We analyzed these separately according to each of the 3 criteria of regularity-irregularity: self-definition.04 .93 2.76 2.05 . 2 of them in the premenstrual stage.0005 2.52 2. objective.18 .001 2.15 3. but this seems less likely).50 2.89 2. For the self-definition criterion of regularity. 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).035 . In all instances. the irregular women reported more menstrual distress than did the regular women. a woman whose cycle length shifted from 176 Behavioral Medicine . That is.05 . the women who reported irregular cycles indicated distress more frequently than the women who reported regular cycles. we found significant differences in 4 of the 24 menstrual-distress items.80 3. COMMENT The weak relationship reported in the literature between menstrual irregularity and menstrual symptoms may reflect the empirical reality. The relatively few differences reported in the literature would seem to be the result of relying solely on self-definition of irregularity.01 . Alternatively.21 2.015 2. The reason the differences were not greater for the objective criterion may lie in our definition of regularity and irregularity.21 1.91 1.79 3. in employing what we regard as a more valid measure of menstrual irregularity.00 . 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 periods—premenstrual. On these items.19 2.05.04 . 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.003 . Four items were significant for the menstruation stage. 1 in the premenstrual stage and the other 3 during the menstrual period.65 . we also found 4 significant items.77 2. 1 during the first day.20 3. the irregular women reported significantly more menstrual distress.65 2. Only significant items are presented in the table. it may stem from the particularly difficult conceptual problem of defining menstrual regularity and irregularity (symptom reporting could also be biased. For 8 symptoms.MENSTRUAL IRREGULARITY 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.97 1.003 .

Macisco JJ Jr. we24 described different patterns of cycles. 29 days. or prostaglandins. The additional apprehension of women who regard their cycles as irregular may then affect their reactions during their menses.99:422–429. report the following cycle lengths: 26 days. Brayer FT. in fact. Sheldrake P. DiSaia PJ.WELLER & WELLER 21 to 34 days then back to 28 days may very well consider herself as irregular. 32. for example. Parker MP. In an article on menstrual variability. Abnormal Uterine Bleeding. 1974. Second. Philadelphia: Lippincott. A woman with this pattern might nevertheless consider herself irregular because.19:131–137. in contrast to women with regular cycles who might be less likely to perceive this stage of the menses as stressful.6 Thus. Dery GK. 1982. Burnett LS. Clinical Gynecologic Endocrinology and Infertility. eds. Duffy BJ. Bar-Ilan University. Schmidt L. 7. Women learn to sing the menstrual blues. eds. women with irregular cycles may not be more aware of their symptoms than women with regular cycles. 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.biu. we defined regularity when less than one third of the cycles were extra long or extra short. 1973:4–46. Baltimore: Williams & Wilkins. 32 days. During the premenstrual stage. Chiazze L Jr. a woman who gradually arrived at a 34-day cycle could jump back to a 24. Br J Obstet Gynaecol. Wentz AC. Spellacy WN. 10. menstruation being more salient for irregular women may lead them to search for and produce associations between specific cues.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. It is possible that each pattern of irregularity reflects a different physiological/hormonal state. McCormick WO. Speroff L. 26). Variations in menstrual cycle symptom reporting. They may perceive and react differently to their menses and menstrual symptoms and thus may be more apprehensive about their menses. Winter 2002 177 . Novak’s Textbook of Gynecology. JAMA. Length and variation in the menstrual cycle—A cross-sectional study from a Danish county. Premenstrual symptoms and symptoms during the menses are equally represented. 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