1107

RBMO VOLUME 43 ISSUE 6 202 1

ARTICLE

Menstrual Distress Questionnaire (MEDI-Q):

a new tool to assess menstruation-related
distress
BIOGRAPHY
Silvia Vannuccini is a Consultant in Obstetrics and Gynaecology at University Careggi
Hospital, Florence, Italy. Her PhD on molecular medicine focused on uterine disorders
(endometriosis, adenomyosis and uterine fibroids), their imaging diagnosis, hormonal
treatments, stress and effect on quality of life.

Silvia Vannuccini1, Eleonora Rossi2, Emanuele Cassioli2,

Donatello Cirone3, Giovanni Castellini2, Valdo Ricca2, Felice Petraglia1,*

KEY MESSAGE
Menstruation is a physiological event that is often associated with subjective distress. The Menstrual
Distress Questionnaire (MEDI-Q) is a new tool that evaluates menstruation-related distress and provides
a representative score of stress perception to help identify and adequately monitor menstruation-related
disorders and their effect on wellbeing.

ABSTRACT
Research question: Menstruation is a physiological event often associated with subjective distress. Is there a tool that
assesses and objectively evaluates the global distress experienced by women during their period?
Design: An observational cross-sectional study conducted between June 2019 and May 2020 at Careggi University
Hospital, Florence, Italy. A new questionnaire, The Menstrual Distress Questionnaire (MEDI-Q), was developed and
administered to a group of healthy women (n = 418) of fertile age (18–50 years), without known uterine, psychiatric
disorders, or both. The MEDI-Q investigated 25 items, covering the following areas: pain, discomfort, psychic or
cognitive changes, gastrointestinal symptoms and changes in physiological functions. MEDI-Q Total Score and
the three sub-scales, Menstrual Symptoms (MS), Menstrual Symptoms Distress (MSD) and Menstrual Specificity
Index (MESI) were evaluated. The validation of MEDI-Q was achieved by testing test–retest reliability and internal
consistency, convergent and concurrent validity.
Results: The MEDI-Q produced reliable results with good internal consistency, convergent and concurrent validity.
MEDI-Q Total Score, MS and MSD all positively correlated with general psychopathology and premenstrual symptoms.
A receiver operating characteristic analysis was used to determine the cut-off value of 20 (inclusive) and to identify the
women with clinically relevant menstrual distress (area under the curve 0.90, 95% CI 0.86 to 0.93; P < 0.001).
Conclusion: MEDI-Q is a new tool for evaluating menstruation-related distress, and provides a representative score
of stress perception. MEDI-Q may be added to routine women's healthcare to help identify and adequately monitor
menstruation-related disorders, and their effect on wellbeing, promptly.

KEYWORDS
1  Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital
Florence, Italy
2  Psychiatry Unit, Department of Health Sciences, University of Florence Florence, Italy
Distress
3  General Management Staff, Careggi University Hospital Florence, Italy Dysmenorrhea
Menstruation
© 2021 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved. Pain
*Corresponding author. E-mail address: felice.petraglia@unifi.it (F. Petraglia). https://doi.org/10.1016/j.rbmo.2021.08.029 Psychopathology
1472-6483/© 2021 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.
Declaration: The authors report no financial or commercial conflicts of interest.
1108 RBMO VOLUME 43 ISSUE 6 202 1
INTRODUCTION
T
he menstrual cycle is the
main reproductive event
in women, driven by
gonadotrophin releasing
hormone, gonadotrophins and sex
steroid hormones (Farage et al., 2009;
Messinis et al., 2014). The hormonal
fluctuations determine ovarian and
uterine physiology (Baerwald et al.,
2012) but also affect women's health
(cardiovascular and gastrointestinal
function, mood and cognition) (Poromaa
and Gingnell, 2014; Sundström-Poromaa,
2018). Indeed, oestradiol (ERα and
ERβ) and progesterone receptors (PRA
and PRB) are highly expressed in brain
areas associated with reproduction,
neurovegetative and cognitive functions
as well as emotional processing
(Genazzani et al., 1992). Menstruation-
related pain and heavy bleeding
(Iacovides et al., 2015) may embody a
significant source of chronic stress for
women (Schoep et al., 2019), influencing
physical, mental, and social wellbeing
(Edozien, 2006; Critchley et al., 2020).
They may also interfere substantially
with fertility. It is well established that
stress has a negative effect in women
with endometriosis (Reis et al., 2020),
adenomyosis (Nelsen et al., 2018),
abnormal uterine bleeding (Karlsson
et al., 2014), infertility (Bonde et al., 1999)
or undergoing assisted reproductive
technology (Pasch et al., 2012). Stress is a
major factor influencing the development
of psychiatric or psychologic
comorbidities in these patients (Kayhan
et al., 2016).
Stress responses are generally
categorized in terms of eustress and
distress concepts (Ridner, 2004;
American Psychological Association,
2021a; 2021b; 2021c). Eustress
represents the positive component of
the response to a stressor, which benefits
the individual by generating a sense of
fulfilment or achievement, and facilitating
growth and performance (American
Psychological Association, 2021b).
Conversely, distress can be defined as
a non-specific biological or emotional
response to a demand or stressor that
is harmful to the individual (Ridner,
2004). In particular, the maladaptive
response that characterizes distress
involves multiple mind–body changes
(Ridner, 2004; American Psychological
Association, 2021a, 2021c) that are
mirrored by an impairment of the
main domains of daily living, including
socialization and working activities
(Ridner, 2004).
Moreover, several studies have
demonstrated a deep interconnection
between high levels of distress and an
impaired quality of life (Lustyk et al.,
2004; Vitek et al., 2007), defined as the
degree to which an individual is healthy,
comfortable and able to participate in, or
enjoy, life events (Jenkinson, 2021).
Quality-of-life indicators, pain scores and
perceived stress tools are commonly
used in gynaecological settings for
assessing the effect of menstruation-
related alterations (dysmenorrhoea
or heavy menstrual bleeding) (Santer
et al., 2007). A number of instruments,
retrospective questionnaires and
prospective diaries, have been
developed over the years to assess
menstrual cycle symptoms, especially in
the premenstrual phase (Haywood et al.,
2002). The global distress associated
with the multifaced symptomatology
that characterizes menses, however,
including pain and bleeding, and mood
symptoms, alterations of cognitive
functions, emotions, energy, nutrition,
sleeping and sexuality, has been less
investigated.
Menstruation-related distress may
be a useful clinical marker in women
with gynaecological disorders to
investigate possible psychopathological
comorbidities. Therefore, the aim
of the present study was to provide
a comprehensive questionnaire
to investigate the global distress
experienced by women during their
period, resulting in a representative score
of stress perception.
MATERIALS AND METHODS
Participants
An observational cross-sectional study
was conducted at the Obstetrics
and Gynecology Division and at the
Psychiatric Unit of the University of
Florence, Careggi University Hospital,
Florence, Italy. A pre-designed
questionnaire was administered to a
group of healthy women recruited
between June 2019 and May 2020,
aiming to evaluate menstruation-
related distress. The questionnaire was
developed in a digital format for use
on local or online platforms through
computers, smartphones or tablets.
All participants were asked to provide
written informed consent. The
study protocol was approved by the
Ethics Committee of the Institution
(n.14558_oss approved on 28 May 2019).
Participants were recruited according
to the following inclusion criteria:
female gender, age between 18 and 50
years, fluent in Italian and having had
at least three menstruations in the past
12 months. Exclusion criteria were the
presence of known uterine disorders,
known mental disorders and illiteracy or
inability to provide informed consent.
The common recommendations for
sample sizes in the field of questionnaire
validations suggest a range of two to 20
participants per item (Anthoine et al.,
2014); therefore, a minimum of 250
enrolled participants was considered
adequate for the validation of the final
25-item version of MEDI-Q. To obtain a
sufficiently homogeneous sample by age,
enrolment was finalized when at least
84 participants were included in each
of the following age groups: 25 years or
younger, 25–35 years, and 35 years and
older.
Development of the questionnaire
The initial version of the questionnaire
was developed by consulting a panel of
specialists in gynaecology, psychiatry, or
both, after reviewing published research
on this topic and following the COSMIN
standards for content validity (Mokkink
et al., 2010). The questionnaire was
developed in Italian, and the previous
12 months was chosen as the time
range investigated by the questionnaire
(FIGURE 1). A comprehensive list of
symptoms occurring during menstruation
was initially prepared. This phase
allowed 31 symptoms to be identified,
covering the following areas: pain: lower
abdominal pain, urinary pain, pain at
defecation, muscle or osteoarticular pain,
headache, pain during sexual intercourse;
gastrointestinal symptoms: constipation,
diarrhoea, nausea, digestive problems,
blood in the stool; discomfort: breast
tenderness or widespread swelling
sensation, feeling uncomfortable about
the phenomena related to vaginal
blood loss, such as smells, blood spots,
vaginal pads or tampons, difficulties or
embarrassments in sexual intercourse,
feeling of being impure; psychic and
cognitive changes: sadness, emotional
lability, irritability, anger, impulsiveness,
anxiety, concentration impairment; and
other changes in physiological functions:
increased appetite, decreased appetite,
 RBMO VOLUME 43 ISSUE 6 202 1 1109

FIGURE 1  Flowchart for Menstrual Distress Questionnaire design, development and validation.*Items: lower abdominal pain; urinary pain; pain at
defecation; muscle or osteoarticular pain; breast tenderness or widespread swelling sensation; nausea; headache; pain during sexual intercourse;
digestive problems; diarrhoea; constipation; feeling uncomfortable about vaginal blood loss; feeling of being impure; sadness; emotional lability;
irritability and anger; impulsiveness; anxiety; increased appetite; decreased appetite; insomnia; hypersomnia; fatigue; decreased sexual drive;
concentration impairment. Sub-items: frequency score; menstruation distress score; premenstrual phase distress score; and intermenstrual phase
distress score.

insomnia, hypersomnia, fatigue and
decreased sexual drive.
A prototype of the questionnaire was
administered to a group of residents in
psychiatry or obstetrics and gynaecology,
who proofread all items, and to an initial
group of 40 participants (selected with
the same criteria as the participants in
the final validation). At this stage, the
opinions of the participants on face
and construct validity, item relevance,
comprehensiveness and comprehensibility
were collected. This initial feedback led
to the reformulation of several questions
to improve comprehensibility and reduce
misinterpretations (FIGURE 1). Furthermore,
a rearrangement of the items was carried
out, merging into single items symptoms
that were easily confused with each
other, i.e. irritability or anger, or that
belong to the same distress domain, i.e.
all phenomena related to vaginal blood
loss generating discomfort. For each
symptom, a dedicated item was generated
with different sub-items, investigating how
frequently the symptom appeared during
menstruation in the previous 12 months
(A = frequency score), the distress caused
by the symptom (B = menstruation
distress score) and the differences from
non-menstrual days in terms of distress
(C = premenstrual phase distress score;
D = intermenstrual phase distress score)
(TABLE 1).
As previously mentioned, distress can
be defined as a maladaptive response
to a stressor that is mirrored by an
impairment of quality of life and of
various domains of daily living, including
socialization and working activities
(Ridner, 2004; American Psychological
Association, 2021a; 2021c). Accordingly,
the level of distress associated with
menses symptoms was evaluated
by asking how much the symptom
interfered with the person's quality of life,
recreational or work activities, and social
relationships.
To avoid ambiguity, the questionnaire
included explanations on the different
phases of the menstrual cycle.
Experienced clinicians then revised the
questionnaire for clarity, redundancy, and
face and content validity; the final version
of the questionnaire included 25 items
(FIGURE 1). For each item, the distress
score caused by menstrual symptoms
was calculated using the provided
scoring table (TABLE 2). The difference
between B (distress during menstruation)
and D (distress during intermenstrual
days) allows the distress caused by the
exacerbation of the symptom during
menstruation to be measured, excluding
the contribution of any distress present
on other days for the same symptom.
The resulting distress is then combined
with the frequency of the symptom
(TABLE 2), to give greater weight to the
symptoms most frequently reported.
The resulting composite score (distress
score) for each item can assume any
discrete value on a scale between 0 and
5 (TABLE 2).
The MEDI-Q Total Score is obtained
from the sum of all the distress scores
calculated for each item. The minimum
score obtainable is 0, indicating the
absence of any specified symptom
relevant to generate distress during
menstruation in the previous 12 months.
The maximum score is 125, indicating
the presence of all the investigated
symptoms in more than one-half of
menstruations in the past year, each of
them generating severe distress.
1110 RBMO VOLUME 43 ISSUE 6 202 1

TABLE 1  SUB-ITEMS GENERATED FOR EACH ITEM: EACH SUB-ITEM REFERS TO THE PREVIOUS 12 MONTHS

Sub-item Aim Likert scale

A Frequency score To indicate the presence of the symptom 0: the symptom never occurred in any of the menstruations.
exclusively during the days of menstru- 1: the symptom occurred in less than half of the menstruations.
ation. 2: the symptom occurred in more than half of the menstruations.
B Menstruation distress score To evaluate the level of distress associat- 0: no distress.
ed with the symptom, exclusively during 1: slight distress.
menstruation. 2: moderate distress.
3: severe distress.
C Premenstrual phase dis- To evaluate the level of distress associat- 0: no distress (or the symptom never occurred during the premenstrual phase).
tress score ed with the symptom, exclusively during 1: slight distress.
the premenstrual phase.a 2: moderate distress.
3: severe distress.
D Intermenstrual phase To evaluate the level of distress associ- 0: no distress (or the symptom never occurred during the intermenstrual phase).
distress score ated with the symptom during the days 1: slight distress.
between the end of menstruation and 2: moderate distress.
the premenstrual phase. 3: severe distress.
a 
The period immediately preceding menstruation, lasting up to 7 days.

Additional sub-scales of the Menstrual as exacerbated during menstruation Clinical assessment

Distress Questionnaire
The aim of the study was to develop
a questionnaire that evaluated
menstruation-related distress during
the days of menstruation through a
synthetic index (MEDI-Q Total Score);
however, three additional sub-scales were
developed to better characterize the
menstrual-related distress and specifically
to evaluate the following: the number
of menstrual symptoms; the average
distress associated with the symptoms
experienced by the participants; and the
specificity of menstrual symptoms in the
premenstrual phase.
Menstrual Symptoms
Menstrual Symptoms are the total
number of symptoms that generate more
distress during menstruation than in
intermenstrual days. It is represented by
the number of items for which the score
obtained in sub-item B is greater than
that in sub-item D.
Menstrual Symptoms Distress
Menstrual Symptoms Distress relates
to average distress related to menstrual
symptoms, calculated only on the
symptoms indicated by the participant
TABLE 2  MENSTRUAL DISTRESS QUESTIONNAIRE ITEM SCORING TABLE
compared with intermenstrual days, using
the following formula:
MEDI–Q Total Score
MSD = MS
Its range is the same as for each item
(0–5).
Menstrual Specificity Index
The Menstrual Specificity Index (MESI)
calculates the proportion of symptoms
for which the participant has reported
an exacerbation of distress relating to
intermenstrual days and premenstrual
days. This index is useful to distinguish
the participant's menstrual distress from
their premenstrual distress. It is obtained
by counting the number of items for
which both B is greater than D and B
is greater than C conditions are true,
and dividing it by menstrual symptoms.
The MESI ranges between 0 and 1,
with 0 indicating that all the symptoms
experienced during menstruation are
present at least with the same level of
distress even in the premenstrual phase,
and 1 indicating that all the reported
symptoms generate more distress
during menstruation compared with the
premenstrual phase.
After completing the MEDI-Q, face-
to-face psychiatric and gynaecological
clinical evaluations were carried out,
and doctors assessed whether the
participants had clinically relevant
distress during menstruation in the
previous 12 months (FIGURE 1). Criteria
used to define a pathologically distressful
menstruation were as follows: presence
of an impairment in daily activities
(including social, work or recreational
activities) or quality of life caused by
any symptom during menstruation that
was not present during premenstrual or
intermenstrual days or that worsened
pronouncedly while menstruating. Data
collected were also age at menarche,
length of the menstrual cycle, duration
of menstruation and use of hormonal
contraceptives.
Validation of the questionnaire
The MEDI-Q underwent a process of
validation by testing reliability, internal
consistency, convergent and concurrent
validity (FIGURE 1). Descriptive statistics
were reported as means and SD for
continuous variables, and as frequencies
and percentages for dichotomous ones.
Age was always treated as a continuous
variable. Correlations with age were
tested using linear regression model.

Frequency score (sub-item A) Test–retest reliability and internal

0 1
Δ Distress score (B–D) 0 0
1 0
2 0
3 0
If B is less than D, i.e. B–D is less than 0, the item score is 0.
B, menstruation distress score; D, intermenstrual distress score.
2 consistency
0 0
1 2
2 4
3 5
A subsample of 54 participants was
asked to complete the MEDI-Q twice,
within 7 days. Test–retest reliability was
evaluated by computing the Intraclass
Correlation Coefficient between the two
MEDI-Q Total Scores. Cronbach's alpha
method was used to evaluate internal
consistency.

Convergent validity
The convergent validity of the
questionnaire was tested in a sub-sample
of 196 participants by evaluating the
association of MEDI-Q Total Score and
the additional sub-scales (MS, MSD,
MESI) with the following questionnaires:
Shortened Premenstrual Assessment
Form (SPAF) (Allen et al., 1991), a 10-
item scale used for the evaluation of
premenstrual syndrome, with high internal
consistency (Cronbach's alpha ≥0.95) and
test–retest reliability (from 0.60 to 0.70).
Scores can be computed by summing
all items, and range from 10 to 60; Brief
Symptom Inventory (BSI) (Derogatis and
Melisaratos, 1983), a questionnaire for the
assessment of general psychopathology,
with 53 items rated on a five-point scale
(0–4). A global index can be obtained
by averaging all items (Global Severity
Index [GSI]). This scale showed good
psychometric properties (Cronbach's
alpha for all psychopathological
dimensions ranged from 0.71 to 0.85;
test–retest reliability for GSI = 0.90).
The rationale was the possible link
of menstrual distress with general
psychopathology (Ingram and Luxton,
2005) and premenstrual syndrome. All
correlations were tested by multivariate
linear regression model, inserting age as
a covariate.
Concurrent validity
Concurrent validity was assessed by using
the data of clinical evaluation to identify
pathologically distressful menstruation. A
TABLE 3  CHARACTERISTICS OF THE SAMPLE
Characteristics
Age, years
Age of menarche, years
Menstrual cycle interval, days
Menstrual cycle duration, days
Hormonal contraceptive use
BSI GSIa
SPAFa
MEDI-Q Total Score
MS
MSD
MESI
Data presented as mean ± SD or n (%).
Total sample, n = 418.
a  Analysis carried out on a sub-sample of 196 participants.BSI GSI, Brief Symptom Inventory Global Severity
Index; MEDI-Q, Menstrual Distress Questionnaire; MESI, Menstrual Specificity Index; MS, Menstrual Symptoms;
MSD, Menstrual Symptoms Distress; SPAF, Shortened Premenstrual Assessment Form.
receiver operating characteristic (ROC)
analysis was carried out to evaluate the
predictive power of the questionnaire and
to compute the cut-off value indicating
the score that best allowed clinically
distressful menstruation to be identified.
RESULTS
Development and administration of
the questionnaire
The MEDI-Q was administered to a final
sample of 418 participants, of which 190
were aged 25 years or younger, 137 were
aged 25–35 years non-inclusive, and 91
were aged 35 years or older. Baseline
characteristics of the sample, including
characteristics of the menstrual cycle
and use of hormonal contraception,
are presented in TABLE 3. Histograms
illustrating the distributions of MEDI-Q
Total Score and of its sub-scales in the
study sample are presented in FIGURE 2.
Average distress scores computed
for each item using the scoring table
(TABLE 2) are presented in TABLE 4, showing
that lower abdominal pain, feeling
uncomfortable about vaginal blood loss,
sadness, emotional lability, irritability or
anger, and fatigue obtained the highest
scores. The mean scores for each item
were generally low, which was to be
expected as the study population does
not represent a pathological sample.
Clinical assessment
After a face-to-face psychiatric and
gynaecological clinical evaluation, 68
Data
29.41 ± 7.74
12.38 ± 1.36
29.10 ± 6.97
5.11 ± 2.36
146 (34.9%)
0.70 ± 0.64
26.02 ± 11.17
14.94 ± 12.73
7.68 ± 4.45
1.68 ± 0.88
0.61 ± 0.32
RBMO VOLUME 43 ISSUE 6 202 1 1111
(16.3%) women were assessed to have a
clinically relevant distress.
Validation of the questionnaire
The Intraclass Correlation Coefficient
computed for MEDI-Q Total Score over
the two measurements taken 7 days
apart was 0.95 (95% CI 0.90 to 0.98),
showing a good test–retest reliability. The
questionnaire also had a high level of
internal consistency, as determined by a
Cronbach's alpha of 0.85.
In terms of convergent validity, MEDI-Q
Total Score, MS and MSD all negatively
correlated with age (beta coefficients:
–0.14, –0.13 and –0.12, respectively)
and positively correlated with BSI-
GSI (beta coefficients: 0.38, 0.32 and
0.34, respectively) and SPAF score
(beta coefficients: 0.70. 0.62 and 0.51,
respectively) after adjusting for age
(TABLE 5), suggesting an association
of MEDI-Q scores with general
psychopathology and premenstrual
symptoms. On the contrary, the MESI
was inversely related to SPAF scores (β
coefficient = –0.26) (TABLE 5). Results did
not change significantly when inserting
hormonal contraceptive use as a
categorical covariate (data not shown).
Receiver operating characteristic analysis
was used to assess whether MEDI-Q
could identify participants with clinically
relevant menstrual distress to support
concurrent validity. The area under the
curve was 0.90 (95% CI 0.86 to 0.93; P <
0.001). The cut-off value of 20 (inclusive)
was chosen as it had the highest Youden's
J statistic (J = 0.69); therefore, it
maximized sensitivity (0.88), specificity
(0.81) and accuracy (0.82) (FIGURE 3). The
ROC analyses was conducted separately
for participants taking hormonal
contraception and for those not taking it,
and led to the same results and cut-off
values (data not shown).
DISCUSSION
The MEDI-Q is a new tool developed
to assess and score the distress related
to menstruation. The questionnaire
was reliable and showed good
internal consistency, convergent and
concurrent validity. Therefore, it may
be administered to a large population
of women to identify clinically relevant
menstrual distress.
Several areas affected by menstruation
are explored by the MEDI-Q, and the
1112 RBMO VOLUME 43 ISSUE 6 202 1
FIGURE 2  Distributions of Menstrual Distress Questionnaire (MEDI-Q) total score and of its subscales among women included in the study. MS,
Menstrual Symptoms; MSD, Menstrual Symptoms Distress; MESI, Menstrual Specificity Index.
sum of all the distress scores calculated
for each item provides the MED-Q
Total Score, a synthetic index of the
global distress experienced by women,
ranging between 0 and 125. The
clinical assessment of study population,
through a face-to-face psychiatric and
gynaecological clinical evaluation, allowed
participants who had clinically relevant
distress during menstruation in the
previous 12 months to be evaluated. The
ROC analysis was used to test whether
MEDI-Q could discriminate between
participants with menstrual distress and
those without. A MEDI-Q Total Score
equal or higher than the cut-off of 20
indicates a clinically relevant condition.
The MEDI-Q investigates, along with
pain and bleeding, all the potential areas
targeted by menstruation-related distress,
including mood, cognitive function,
energy, nutrition, sleeping and sexuality.
The analysis of average distress score for
each item revealed that lower abdominal
pain, feeling uncomfortable about vaginal
blood loss, sadness, emotional lability,
irritability or anger, and fatigue received
the highest scores. Previous studies have
shown that menstruation influences
mood and cognitive function (Romans
et al., 2012; Poromaa and Gingnell,
2014), and may represent a negative
experience (Szarewski et al., 2012),
leading to menstrual-related concerns
and difficulties in coping with them
(Borjigen et al., 2019).
The presence of a particularly stressful
menstrual phase, with symptoms
significantly compromising daily
activities and quality of life that repeat
regularly for a sustained period, can
be considered a chronic stressor.
The role of stress in the genesis of
psychopathology and mental disorders
is well known, and this is particularly
obvious for chronic stressors (Ingram
and Luxton, 2005). For this reason,
MEDI-Q Total Score, MS and MSD were
found to be positively associated with
general psychopathology, as measured
by BSI-GSI, which evaluates overall
psychological distress. Furthermore, as
premenstrual symptoms often persist
in the very first days of the menstrual
phase, the convergent validity of the
questionnaire was also tested by studying
the associations of MEDI-Q Total Score,
MS and MSD with the SPAF score,
which showed a positive correlation
between menstrual distress and
premenstrual syndrome (Le et al., 2020).
As the MESI indicates the percentage of
symptoms associated with higher levels
of distress during the menstrual phase
compared with premenstrual phase, a
negative correlation with premenstrual
symptomatology was expected and was
indeed confirmed.
As age increases, a negative correlation
was observed with all menstrual distress
indices, which may be explained by an
improvement of primary dysmenorrhoea
and premenstrual symptoms with
increasing age (Freeman et al., 1995;
Knox et al., 2015). Furthermore,
results did not change when entering
hormonal contraceptive as a covariate,
thus suggesting that the assessment of
menstrual distress was not affected by
oestro-progestin or progestin use for
contraception. This implies that MEDI-Q
may be used in all women independently
of hormonal contraception use.
Menstrual health is an integral part of
overall health (Critchley et al., 2020),
and the common physical symptoms of
pain and bleeding during menstruation
may have a relevant effect on stress
perception and quality of life (Matteson
 RBMO VOLUME 43 ISSUE 6 202 1 1113

TABLE 4  AVERAGE DISTRESS SCORES REPRESENTING THE FINAL COMPOSITE SCORES FOR EACH ITEM IN THE
QUESTIONNAIRE, COMPUTED USING THE SCORING TABLE ( TABLE 2)

Item number Item description Mean SD

1 Lower abdominal pain 1.77 1.71
2 Urinary pain 0.05 0.35
3 Pain at defecation 0.15 0.59
4 Muscle or osteoarticular pain 0.86 1.3
5 Breast tenderness or widespread swelling sensation 0.8 1.19
6 Nausea 0.37 0.93
7 Headache 0.86 1.3
8 Pain during sexual intercourse 0.09 0.47
9 Digestive problems 0.36 0.88
10 Diarrhoea 0.56 1.03
11 Constipation 0.17 0.6
12 Feeling uncomfortable about vaginal blood loss 0.98 1.46
13 Feeling of being impure 0.12 0.58
14 Sadness 1.1 1.46
15 Emotional lability 1.31 1.51
16 Irritability or anger 1.19 1.4
17 Impulsiveness 0.24 0.76
18 Anxiety 0.52 1.1
19 Increased appetite 0.76 1.2
20 Decreased appetite 0.1 0.49
21 Insomnia 0.17 0.73
22 Hypersomnia 0.45 1.04
23 Fatigue 1.31 1.53
24 Decreased sexual drive 0.3 0.84
25 Concentration impairment 0.37 0.92

et al., 2013). Furthermore, menstruation-
associated symptoms (Santer et al.,
2007; Bernardi et al., 2017) may
represent, if exacerbated (Deligeoroglou
and Creatsas, 2012), some early signs
of gynaecological diseases, such as
endometriosis, adenomyosis (Chapron
et al., 2020) and uterine fibroids. So
far, many questionnaires have been
used in gynaecology settings to evaluate
quality of life and perceived stress in
pathological conditions (Ghant et al.,
2015; Lazzeri et al., 2015). Most of
them were not specifically designed for
gynaecological disorders and they did not
investigate menstruation and its effects
on physical and mental health. Similarly,
some questionnaires were developed
to assess menstrual pain and bleeding
(Matteson et al., 2015) or to evaluate
quality of life and psychopathology in
uterine disorders (Moradi et al., 2019),
but none of them were specifically
designed to assess menstrual distress as
a whole.
Over the years, a number of instruments
have been developed to evaluate menstrual
symptoms; however, all of them have
their weaknesses and many drawbacks
related to their development or validation
(Haywood et al., 2002). The menstrual
distress questionnaire (MDQ) is one
of the most well-known, and consists
of 47 items, focusing on the severity of
symptoms in the premenstrual, menstrual
and intermenstrual phase of their cycle
(MOOS, 1968). Eight symptom groups
are assessed: pain; concentration; water
retention; behaviour change; negative
affect; autonomic reactions; arousal;
and control. It has, however, been

TABLE 5  CORRELATES OF MENSTRUAL DISTRESS QUESTIONNAIRE SCORES REPORTED AS BETA COEFFICIENTS

MEDI-Q total score MS MSD MESI

Age –0.14 (P = 0.005) –0.13 (P = 0.009) –0.12 (P = 0.013) –0.04 (P = 0.385)
BSI GSIa 0.38 (P < 0.001) 0.32 (P < 0.001) 0.34 (P < 0.001) –0.11 (P = 0.310)
SPAFa 0.70 (P < 0.001) 0.62 (P < 0.001) 0.51 (P < 0.001) –0.26 (P = 0.006)
a 
Correlations with BSI GSI and SPAF are age-adjusted.
BSI GSI, Brief Symptom Inventory Global Severity Index; MEDI-Q, Menstrual Distress Questionnaire; MESI, Menstrual Specificity Index; MS, Menstrual Symptoms; MSD,
Menstrual Symptoms Distress; SPAF, Shortened Premenstrual Assessment Form.
1114 RBMO VOLUME 43 ISSUE 6 202 1
FIGURE 3  Receiver operating characteristic curve analysis to identify the Menstrual Distress
Questionnaire cut-off (20, inclusive) for clinically relevant menstrual distress. Area under the
curve 0.90 (95% CI 0.86 to 0.93; P < 0.001).
subjected to many criticisms because
of its complexity and lack of internal
consistency and validity (Haywood et al.,
2002). A modified MDQ was elaborated
with 35 items, but the scores are only
related to the premenstrual phase (Ross
et al., 2003). Similarly, many instruments
have been developed to investigate the
premenstrual phase symptoms, such
as the premenstrual assessment form
(PAF) (Halbreich et al., 1982) and SPAF
(Allen et al., 1991), designed to measure
changes in mood, behaviour and physical
condition during the premenstrual period.
Recently, a brief web-based instrument
for evaluating the effect of premenstrual
symptoms on health-related quality of
life, the Premenstrual Symptoms Impact
Survey (PMSIS), was also introduced, with
good accuracy in discriminating those at
risk for premenstrual dysphoric disorder
(Wallenstein et al., 2008). The daily
symptom rating scale (DSRS) is different
because it is a prospective measure
providing ratings of women's subjective
daily experience over the premenstrual,
menstrual and intermenstrual phases of the
cycle (Taylor, 1979). On the contrary, the
MEDI-Q provides different information and
allows the distress related to menstruation
itself in a global perspective of women's
health to be measured.
The MEDI-Q was easy to administer
on local or online platforms through
computers, smartphones or tablets, as it
was developed in digital format. This also
reduced the time required for completion,
the complexity of scoring procedures and
saved resources. Participants may easily
access the tool, which has a user-friendly
interface and, as it is self-administered,
users were also more keen to report
their inner feelings, even those they felt
ashamed of (Marcano Belisario et al.,
2015). The advantages of an electronic
tool in this field have been supported
by the use of an electronic personal
assessment questionnaire for menstrual,
pelvic pain and gynaecological hormonal
disorders (ePAQ-MPH), which, similar
to MEDI-Q, provides a comprehensive
assessment of symptomatology associated
with menstruation and gynaecological
disorders and their associated effect on
sexual function and quality of life (Gray
et al., 2019).
One of the strengths of the study is the
rigorous methodology used to develop
and validate the questionnaire. The
selection of study population followed
strict criteria and only healthy women
were included to minimize the bias
caused by the presence of gynaecological
or mental disorders (Nillni et al., 2018),
which may impair the assessment of
distress. In addition, the development
of the tool has profited from the
collaboration of psychiatrists and
gynaecologists, allowing the combination
of both expertise. Physical and mental
symptoms were considered to provide a
complete picture of the average distress
experienced during menstruation.
A meticulous selection of the list of
symptoms, the reformulation of several
questions and a final rearrangement
of the items was carried out to
improve comprehensibility and reduce
misinterpretations. Another strength
of the study is the accurate process of
validation, in which the questionnaire
resulted in reliability if administered
twice to the same sub-group of women
at different time points and provided
internal consistency.
Study limitations include the
generalizability of our findings because
the study was conducted at a single site
and restricted to the Italian language;
additional work will be necessary to ensure
that the MEDI-Q is relevant to other
languages and cultures. Furthermore,
additional research is needed to explore
the contribution of mental health
comorbidities in influencing the menstrual
distress perception, especially among
women with menstruation-related
disorders. In addition, we acknowledge
that the different menstrual phases at the
time of questionnaire administration may
influence the ratings of menstrual distress
score, even though patients were asked to
rate their distress perception during the
menstruations occurring in the past 12
months.
The MEDI-Q may be applicable in several
gynaecological and non-gynaecological
settings as a measure of the global
menstrual distress experienced by
women. As a clinical tool, MEDI-Q
may be used as an early marker of
menstruation-related disorders, such
as endometriosis, adenomyosis, uterine
fibroids or abnormal uterine bleeding.
Moreover, in case of medical or surgical
treatment, MEDI-Q may be used as a
monitoring tool to compare the efficacy
of treatments before and after MEDI-Q
scores assessment. As stress may affect
menstrual cycle regularity and fertility,
the measurement of menstruation
distress may supplement information
on infertile women before or after
assisted reproductive technology. Also,
MEDI-Q may also be applicable in non-
gynaecological settings, with the aim of
testing the effect of systemic diseases on
menstrual distress.
In conclusion, menstruation-related
bleeding, pain, fatigue and mood
changes, together termed menstrual
distress, significantly affect a woman's
physical, social and emotional quality of
life (Matteson and Zaluski, 2019). The
MEDI-Q represents a new tool that may
be added to routine women's healthcare
to help identify and adequately monitor
menstruation-related disorders promptly
and their effect on well-being.
ACKNOWLEDGEMENTS
We thank all the women who participated
in the study and the team of residents
in the Obstetrics and Gynaecology and
Psychiatry Departments who helped to
administer the questionnaire.
 RBMO VOLUME 43 ISSUE 6 202 1 1115

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Received 4 April 2021; received in revised form
15 August 2021; accepted 27 August 2021.