Women who report feeling stressed early in their monthly cycle were more likely than those who were less stressed to report more pronounced symptoms before and during menstruation, according to a study by researchers at the National Institutes of Health and other institutions. The association raises the possibility that feeling stressed in the weeks before menstruation could worsen the symptoms typically associated with premenstrual syndrome and menstruation.

Women who reported feeling stressed two weeks before the beginning of menstruation were two to four times more likely to report moderate to severe symptoms than were women who did not feel stressed.

Premenstrual syndrome (http://www.nichd.nih.gov/health/topics/menstruation_and_the_menstrual_cycle.cfm.) is a group of physical and psychological symptoms occurring around the time of ovulation, which may extend into the early days of menstruation. Symptoms include feelings of anger, anxiety, mood swings, depression, fatigue, decreased concentration, breast swelling and tenderness, general aches, and abdominal bloating.

The study was conducted by researchers in the NIH's , the University of Massachusetts-Amherst, and the State University of New York, Buffalo. The study was published online in the Journal of Women's Health.

"We were interested in identifying factors that might predict who might be most at risk for having more severe symptoms," said Audra Gollenberg, Ph.D., a postdoctoral fellow in NICHD's Division of Epidemiology, Statistics and Prevention Research. "It may be possible to lessen or prevent the severity of these symptoms with techniques that help women to cope more effectively with stress, such as biofeedback, exercise, or relaxation techniques."

The current analysis was part of the NICHD's BioCycle Study, directed by Enrique Schisterman, Ph.D., also an author of the current article. The BioCycle Study seeks to examine ovarian functioning during the course of the menstrual cycle in healthy women. The researchers administered questionnaires to 259 women ages 18-44 who did not have any long-term health conditions, and who were not using oral contraceptives or taking any other hormonal formulations.

Each woman was provided with an at-home fertility monitor to follow the phases of her monthly cycle. The women completed questionnaires about their stress levels for each of the four weeks of their cycle. Items on the survey included: How often have you felt unable to control the important things in your life?; How often have you felt nervous or stressed recently? ; How often have you been able to control interruptions in your life?

Women ranked their responses according to a scale, ranging from never to fairly often. In addition to the weekly questionnaires about stress, the women also responded to questionnaires about their symptoms, in the week coinciding with ovulation, and the following week, during menstruation. Most of the women (250) took part in the study for two menstrual cycles. The remaining nine women participated for only one cycle.

Women whose responses indicated they felt stressed were more likely to report moderate or severe levels of psychological symptoms, such as depression or sadness, crying spells, anger, irritability, and anxiety associated with menstruation. Similarly, women who felt stressed were also more likely to report moderate or severe levels of physical symptoms such as body aches, abdominal bloating, lower back pain, fatigue, abdominal cramping, headache, and cravings for sweet or salty foods. Overall, women reporting high stress levels were two to four times more likely to report moderate to severe psychological and physical symptoms during menstruation than were women who did not report high stress levels.

For the women who took part in the study for more than one cycle, symptoms corresponded with changes in their stress level. For example, women who felt stressed in the weeks preceding one cycle but didn't feel stressed during the other cycle, tended to have more pronounced premenstrual symptoms after the cycle in which they reported stress. Women with high stress preceding both cycles were 25 times more likely to report moderate to severe symptoms than were women with low stress preceding both cycles.

The researchers couldn't rule out that anticipation of pain and other symptoms might add to a woman's stress level and result in more severe symptoms. However, they sought to compensate for this possibility by administering the questionnaires on stress early, during the symptom-free parts of the women's cycles, when they were less likely to be anticipating severe symptoms.

A number of medications are used to treat the symptoms of premenstrual syndrome, said study author Mary Hediger, Ph.D, also of the Division of Epidemiology, Statistics and Prevention research. These include diuretics, pain killers, oral contraceptive pills, drugs that suppress ovarian function, and antidepressants.

"Each woman is an individual, and some women may experience severe symptoms that require medications," Dr. Hediger said. "However, future studies may show that stress reduction techniques can prevent or reduce the severity of premenstrual syndrome, which might provide a cost effective alternative to medications for some women."

The NICHD sponsors research on development, before and after birth; maternal, child, and family health; reproductive biology and population issues; and medical rehabilitation.