Prevalence of Premenstrial Disphoric Disorder Associated Factors among Students of Tabor Secondary and Preparatory School in Hawassa City, Ethiopia Cross Sectional

Background: Premenstrual dysphoric disorder (PMDD)-is a severe and disabling form of premenstrual Syndrome affecting 3-8% of menstruating women. The disorder consists of a cluster of affective, behavioral and somatic symptoms that recur monthly during the luteal phase the menstrual cycle. Premenstrual dysphoric disorder (PMDD) was added to the list of depressive disorders in the diagnostic and statistical manual of mental disorders in 2013. The exact pathogenesis of the disorder is still unclear. Objective: To assess the prevalence of PMDD and its associated factors among students of Hawassa tabor secondary and preparatory school. Method: A cross sectional institutional based was conducted among 351 randomly selected female students of Hawassa tabor school. Data was collected by three students were facilitate the works with closed ended structured questionnaire and they was trained on how to collect the data. The collected data was entered, analyzed and cleaned by SPS. Results: prevalence of premenstrual dysphoric disorder in this study was 76.9%. Of each symptom is more than ninety present or 324 (92.3%) respondents can’t have experience unpleasant physical or emotional symptoms peculiar to the ve days before the onset of menses & 27(7.7%) participants have show the symptoms. Among those 26 (7.4%) have present for the past ≥ 3 consecutive cycles. 46 (13.1%) have family history of such symptoms. Conclusions: These ndings have implications for both women and medical providers, who should be aware that PMS symptoms are prevalent and often distressing, yet also understand that the severity of symptoms may remit over time.


Background
Premenstrual dysphoric disorder (PMDD)-is a severe and disabling form of premenstrual Syndrome affective 3-8% of menstruating women. The disorder consists of a cluster of Affective behavioral and somatic symptoms that recur monthly during the luteal phase the menstrual cycle. Premenstrual disphoric disorder (PMDD) was added to the list of depressive disorders in the diagnostic and statistical manual of mental disorders in 2013. The exact pathogenesis of the disorder is still unclear. Most reproductive women appear to experience recurrent premenstrual physical and/or emotional symptoms. It is appearance of physical, psychological symptoms recurring periodically. ( J psychol 1998).
At least 80% of menstruating woman have some premenstrual symptoms. About 40% of menstruating women have premenstrual syndrome and 10% have severe symptoms, a condition called premenstrual Dimorphic disorder (PMDD). Nine million women or approximately ve to seven (5-7%) present of women of child bearing age have PMDD. Due to the fact that there are no adequate pathophysiologic explanation for PMDD and no consistently effective therapy available, the issue is confusing. Different researchers agreed on the following criteria to diagnose PMDD. The diagnosis of PMDD is based on ful lling the following criteria:-Presence of one or more of the following somatic symptoms (abdominal bloating, breast fullness and tenderness, perceived weight gain, headache, low back pain and arthralgia. Psychobehavioral symptoms (anxiety, irritability, confusion, depression, di culty in concentration, fatigue, emotional liability and sleep disturbance).Three or more cyclic recurrence during the ve days prior to menses, and symptoms so severe and debilitating the social and / or occupational function. (Philip's LS, 2003 ).
Risk factors for PMDD include advancing age (beyond 30 years) and genetic factors. However, as indicated above, PMS symptoms are identified in adolescents and can begin aroundage14,or 20 years post-menarche, and persist until menopause.
Premenstrual dysphoric disorder related to long time frame work and loss of e ciency in work place, high suicidal and accident rates, poor academic performance and acute psychiatric problems (Philip's LS,

2003).
Lack of school health service, inadequate adolescent reproductive health education, lack of published standardized diagnostic criteria for PMDD and other related factors makes the problems worse in developing countries. In our country adequate studies are not done to overcome the previously mentioned problems and on the study area no recent and reliable study has been done on PMDD. For this reason this study has been designed. (Li Chaoyang, 2008).

Methods
The study was conducted in Hawassa tabor senior secondary school, female students. Tabor senior secondary school is established in 1968 E.C .It is one of the biggest public schools in south Ethiopia. Hawassa is one of the capital city of SNNPR and 272 km far from Addis abeba. A facility based cross sectional study was conducted after stratifying students based on their class and section.
All female students of Hawassa tabor school where the source of population. Samples were selected randomly by sections from sections selected female students were selected for the study and those who have seen their menses at least three times consecutively included in the study.
The sample size was calculated by using single population proportion formula with the following parameters:-n=minimum sample size q=1-p=0.5, regarding this case p=50% = 0.5 and margin of error = 5% (0.05%). The structured and well organized questionnaire that was prepared after reviewing similar literature and modi ed to our context was used to collect data.

Data collection
The study participants were given a general introduction to the study as well as the opportunity to ask questions about the study and questionnaire were distributed. The principal investigator and the supervisor had checked the completed questionnaires for consistency and completeness on a daily basis.

Data Analysis and Presentation
After the data were collected it was sorted, entered, cleaned and analyzed by using manual scienti c calculator and tally sheet and presented by table and graphs.

Data Quality Assurance
To increase the quality of data; pre-testing of questionnaire, training of data collectors, consistent supervision during data collection by the coordinator, cross checking of questionnaire for their completeness and double entry of data to assure data quality will done.

Ethical Consideration
O cial letter was written from HU ethical bored was shown to the school head and then to the individual respondent students who were participating in the study. In addition to this, informed verbal consent taken from each participant. During data collection time the name of the participant were not taken to keep their con dentiality

Socio demographic characteristics of respondents
The total response rate was 351, from those total respondents 192 (54.7%) of the respondents were between the age of 20-24year and 137 (39.0%) respondents were between the age group of 13-19. As shown (table 1)

Discussion
Apart from our previous study epidemiological studies have revealed a high prevalence of PMDD in adolescents: The prevalence of PMDD was 3.7% according to DSM IV-TR and 91% according to International Classi cation of Diseases, 10 th edition criteria. The symptoms commonly reported were "fatigue/lack of energy," "decrease interest in work," and "anger/irritability." The most common functional impairment item was "school/work e ciency and productivity." PSST have 90.9% sensitivity, 57.01% speci city, and 97.01% predictive value of negative test. The rate of PMDD in east Asia (1.3-2.8%) appear to be lower than that seen in the western literature (3.8%). many of the risk factors of PMDD were the same in the eastern and western literature although same key differences were found. This result supports the recent ndings of studies in which premenstrual disorders were shown to be major problems in adolescence that markedly interfered with school and social activities. Signi cant differences were observed in the prevalence of all premenstrual symptoms between the 'absent' group and the 'non-absent' group in the present study. This result indicated that premenstrual symptoms may lead to school absenteeism in any girl that has menses and ovulates. An analysis of factors interfering with work, activities, and relationships showed that 'reduced social life activities' was a risk factor for school absenteeism, conversely indicating that girls in the 'absent' group were having problems not only in their school lives but also in other social activities, such as hobbies or after-school activities. A limitation of our study Was a being cross-sectional study design, it will not show cause and effect analysis.
Self-reporting design, therefore, recall bias should be considered.

Conclusions
Our results suggest that a greater proportion of women than previously identi ed may experience a negative impact of PMS symptoms on their daily lives. However, these women appear to vary greatly in their assessment of the burden of their PMS symptoms over time. These ndings have implications for both women and medical providers, who should be aware that PMS symptoms are prevalent and often distressing, yet also understand that the severity of symptoms may remit over time. Our ndings call for close monitoring of women for PMS symptoms, frequent reassessment of women who report distressing PMS symptoms, and careful consideration before initiation of long-term treatment.
In total, 65.6 % of female students were absent from school due to premenstrual symptoms.
Premenstrual symptoms, such as tender breasts, feeling bloating, headache, joint or muscle pain, and weight gain' were risk factors for school absenteeism. In addition, 'a preference for salty food' and 'lack of regular exercise' was risk factors of absence. Considering the di culty of medical treatment in adolescents, education on proper exercise and eating habits is important and may lead to an improvement in premenstrual symptoms and the life qualities of adolescents. According to DSM-5 criteria 27 (7.7%) respondents have with PMDD and 324(92.3%) have not. Among those 17 (63.0%) respondents have 20-24 age group, 7 (25.9%) have 13-19 age group and 3(11.1%) have 25 and above age group.

RECOMMENDATION
Health Education programs on PMDD for adolescent school girls.
Health care professionals give Health Education programs to create awareness of PMDD and educated more women.
Health care professionals should encourage women to track their cycles by keeping a diary and recommended that PMDD patents join online support group.

Declaration
Ethics approval and consent to participate Ethical clearance was obtained from the Institutional Review Board of Hawassa University College of medicine and health science .Formal letter was obtained from the school of Nursing. Permission was obtained from concerned bodies (Zonal and Educational Bauru). The con dentiality of respondents was kept by not writing their name on the questioners' sheet. Before questionnaires administered to any eligible participant, written consent was obtained from study participant after the study was explained to them in detail .Any participants who are not willing to participate in the study were not forced to participate.
Competing Interest

None declared
The authors declare no competing interest.

Funding
No Funding was received for this research work.

Missing Availability of data and materials
No data missed Authors'contribution MG, YI, DD, participated in the conception, design of the study, reviewing proposal and data analysis MG has participated in supervising and writing manuscript. All authors read and approved the nal manuscript.