CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
A PREMENSTRUAL SYNDROME
EDUCATIONAL MODEL
A graduate project submitted in partial satisfaction
of the requirements for the degree of
Master of Public Health
by
Catherine L. Marx
I
'
January, 1986
The Project of Catherine L. Marx is a?proved:
Goteti B. Krishnamurty, Dr.JP:H
Michael V. Kline, Dr. P.H.
Committee Chairperson
California State University, Northridge
ii
ACKNOWLEDGEMENTS
I am thankful for the patience and assistance of the many
individuals who were involved in bringing this project to
completion. I am particularly grateful to Dr. Michael Kline for his
ever present guidance and encouragement.
His kind and constructive
help has benefited this project immensely.
My profound appreciation must go to Mary Jorgensen, who started
me on my way, and was always there to offer support and guidance.
A special thanks goes to Dr. G. B. Krishnamurty who has given
freely of his time and expertise.
His interest and gentle
encouragement will always be appreciated.
Finally, I would like to thank my husband and my daughter.
Tneir suoport and encouragement sustained me throughout the
project.
iii
TABLE OF CONTENTS
Page
ACKNOWLEDGEMENTS.
~~1
ABSTRACT . . . • .
V~l.
Chapter
1.
2.
3.
INTRODUCTION. . . . . . . . .
1
Statement of the Problem
4
Purpose of the Project
5
Assumptions
5
Limitations
5
LITERATURE REVIEW
7
Available Instructional Curricula
7
The Lay Literature
8
Summary
10
METHODOLOGY
11
Phase I: Development, Implementation and
Analysis of the Needs Assessment
11
A. Needs Assessment Review of the
Literature . • . . . . . .
11
B. Needs Assessment Interviews
12
Development of the Interview Format. .
12
Implementation of the Interview
Needs Assessment . . . . . . • • .
12
C. Analysis of the Needs Assessment
13
D. Identification of the Target
Population . . . . . . •
13
Phase II: Development of the
Educational Model . . . . .
~v
1.3
A. Design of Curriculum Concept
and Format . . • . .
14
B. Learning Objectives
14
C. Evaluative Criteria
15
D. Content
16
E. Learning Ooportunities and
Resources • . . .
16
Phase III: Validation of the Curriculum
4.
5.
6.
17
A. Selection of a Panel of Experts
17
B. Development of the Validation
Questionnaire
18
RESULTS AND DISCUSSION.
20
Analysis of the Needs Assessment
InterviP-ws. . . . • . . • . .
20
Analysis and Discussion of the
Curriculum Validation Process
21
Validation Questionnaire Results
22
Summary .
26
THE REFINED PREMENSTRUAL SYNDROME
EDUCATIONAL MODEL
27
Introduction
27
Summary of Concepts
27
The Refined Premenstrual Syndrome
Educational Model . • . . . . .
28
CONCLUSIONS AND RECOMMENDATIONS
70
Summary . .
70
Conclusions
70
Recommendations
71
REFERENCES
74
CONSULTED SOURCES.
78
v
APPENDICES
A.
CURRICULUM NEEDS ASSESSMENT
INTERVIEW QUESTIONNAIRE.
79
B.
LETTER OF TRANSMITTAL. •
81
C.
VALIDATION QUESTIONNAIRE
83
D.
VALIDATION EXPERTS . . . •
86
vi
ABSTRACT
A PREMENSTRUAL SYNDROME
EDUCATIONAL MODEL
by
Catherine L. Marx
Master of Public Health
Yne purpose of this project was to develop and validate a
premenstrual syndrome educational model for the health educator to use
in a clinical or classroom setting.
activity were involved in this
Three methodological ryhases of
proc~ss:
Phase I.
Development .
implementation, and analysis of the needs assessment;
Development of the educational model;
Phase II.
Phase III. Validation of the
curriculum.
The needs assessment included a survey of health professionals and
an extensive literature review.
The results of the needs assessment
were used to develop the educational model.
Topics covered in the model
include a definition of the syndrome, the history of the disorder,
anatomy and physiology, diagnosis and current treatment modalities.
vii
The model was designed in curriculum format.
It was validated by
subjecting it to the scrutiny of health care professionals with
expertise in the field of PMS and/or patient/health education.
The
validators assessed the curriculum's validity, clarity, appropriateness,
and utility.
Their suggestions provided a framework for improvement,
and are reflected in the refined curriculum.
Based on analysis of the data, the following conclusions were
reached:
1.
There is a definite need for a comprehensive, unbiased
educational model on Premenstrual Syndrome.
2.
PMS education can impact the welfare of the patient as well as
the family members and significant others.
3.
The proposed model was found to be valid and useful by experts
in the field of Premenstrual Syndrome and health education.
It was recommended that educational programs related to awareness of
the existence of PMS, its signs and symptoms and treatment interventions
be made available to the PMS sufferer, as well as the general public.
viii
CHAPTER I
INTRODUCTION
The identification and acceptance of premenstrual syndrome (PMS) as
a real and serious medical problem has resulted in an emotional and
psychological catharsis for many women.
For centuries women have been placated, cajoled and demeaned into
believing premenstrual difficulties were a product of the imagination,
Alt~ough
an emotional deficiency or a sign of a neurotic personality.
researchers still seem far from consensus regarding the etiology of
premenstrual syndrome (P~B), investi~ation into its consequences as
well as methods of treatment and reduction of symptoms
reported with
increasin~
are now being
frequency.
"Premenstrual Tensim1", first identified by Frank in 1931, was
expanded to "Premenstrual Syndromell in 1953 and included not only
tension related syurptoms, but all recurrent symptoms occurring
exclusively in the premenstrum or early menstration, ;.rith complete
absence of symptoms oost menstruation (Frank,l931; Green and Dalton,
1953).
PMS has been estimated to affect 70 percent to 90 percent of
all women, (Jessop, 1983; Sharma, 1982) and its social impact is far
reaching.
In France, the premenstrual syndrome is legally recognized
as a cause of temporary insanity (Sharma, 1982).
Dalton (1975,1977)
has estimated that up to 50 percent of child battering may be related
to PMS, as we 11 as other forms of family violence.
A study of female
prison inmates found that 62 percent of the violent crimes
committed in the premenstrum (Morton,:!.953).
1
were
Dalton (1964) noted that
2
the suicide rate amoung women
~vas
b.alf of the menstrual cycle.
PMS has also been related to m.?.rital
seven times higher in the second
disharmony (Sharma. 1982), alcoholic bouts (Dalton, 1977), and
increases in accidents (Daltoa,l977), as well as e:Jisodes of asthma
and epilepsy (Dalton ,1977).
T'l.e cost to industry of premenstrual
problems has been estimated at eight percent of the total wage bill 1n
the United States, with similar
indus tr.ialized countries
percenta~es
noted in other
(Dalton, 1979).
Methods of treatment are many and varied and
physician intervention.
oft~n
require
These methods include natural progesterone
therapy (Gonzales, 1981), diuretics (Budoff, 1981), oral
contraceptives (Gonzales, 1981), Vitamb B-6 therapy (Abraham. 1983),
prolactin inhibitors (Andersch, 1979), mineral supplements (Brody,
1981), tranquilizers (Kinch, 1979), and exercise (Brody, 1981).
While
some of these have shown promise in the treatment of PMS symptoms,
biologist
Judith Greene. of William Patterson College, stated:
·~o one aooroach has yet yielded consistent results,
and no single agent has stood out as consistently uBefuL
Uncorit-rolled trials nave been much more d ifEicul t to
demonstrat2 when properly controlled studies have been
done. 11 (Blume, 1983)
The literature indicates that most of the published scientific
material available to the health ;::ducato-.:- is oriented toward the
medical practitioner or resead1er.
The material available to the
public at large has appeared for the most part in women's ma!Sazines.
These sources focus primarily on the women's market and in most cases
neg lee t the male counter.,art, employer, friend or family mernbe r. who
also has a
~ritical
need for accurate information regarding PMS.
3
Also, these articles neither present complete. unbiased and factual
information, nor identify resources available for assistance.
Health
education text books superficially treat the topic of PMS. and 1.n most
cases do not even acknowledge the existence of such an entity.
A
noticable gap that·exists is the absence of an educational
intervention model dealing with PMS.
Four seminars/lectures (1982 - 84) held in the greater Los Angeles
region which were publicized as dealing with PMS provided no formal
curriculum used by any of the presenters.
The presenters were well
known practitioners in the field of PMS and included Katherine Dalton
M.D., sponsored by PMS Action Inc., Guy E. Abraham M.D., of Optimox,
Inc., L.W. Hall M.D., Herald Brundage M.D. and Christopher Pearson
M.D ..
The content of the presentations of Dr. Dalton and Dr. Hall
dealt with their work with progesterone therapy.
Dr. Abraham's
presentation focused on his research with vitamin B-6 therapy.
Drs.
Brundage and Pearson presented a brief overv1.ew of various treatments
available for PMS during a community forum on women's health issues.
Historical, physiological and psychosocial issues were rarely included
in the presentations.
Little information dealing with client
education was presented.
None of the lectures/seminars emoloyed any
method to assess learning; all were handled on strictly an informal
bas is.
In order to obtain clinical information, this Investigator contacted four physicians and one nurse practitioner.
All five health
practitioners worked extensively with gynecological complaints in
their practice.
All had offices located in the Los Angeles area, four
in the San Fernando Valley, one in Santa Monica.
All had been in
4
practice at least four years.
The purpose of the needs assessment was
to identify if there was a need for a curriculum guide which could
provide a model for educational intervention relevant to PMS.
All of the health professionals interviewed stressed that patient
education was a very important segment of total treatment approach
when dealing with PMS.
Discussion about the oroblem was encouraged
during the office visit and was used to to teach the patient about
PMS.
In addition, one practitioner used audiovisual presentations and
recommended the book "Once A Month" (Dalton, 1979) to supplement
information received at the office.
All of those surveyed directed
their educational intervention(s) to the patient only.
Two utilized
counseling services outside of their own practice when they felt that
the situation warrented the intervention.
It is significant to note
that none were aware of an unbiased, comprehensive factual information
reference suitable for the general
publi~.
They felt that
PMS has
psychological, physiological, social and emotional imoact on the PMS
sufferer, as well as family members, friends and employers, and that
educational needs are dramatic.
STATEMENT OF THE PROBLEM
A basic unbiased educational mode 1 for increasing PMS awareness is
needed.
Such a model could be adapted by the health educator
to a
clini•.::al or a classroom setting. and could be used for instruction
specific to the PMS sufferer or more generally to the public at large.
If the cyclic symptoms of P~1S can be recognized, early de teet ion and
intervention may be
achieved, thus inmac ting en the social,
5
psycho logic.<tl and economic difficul tieg related to PMS.
PURPOSE OF THE PROJECT
The major purpose of this project is to develop and validate a
premenstrual syndrome health education model which could be used by
health professionals who deal with those directly and indirectly
affected by PMS.
ASSUMPTIONS
The following assumotions were made in the development of the
educational model:
1. Patient/family education is intergral to the recognition and
management of PMS.
2. Recognition of the cyclic symptoms of PMS can facilitate early
detection and treatment intervention thus reducing the social,
psychological and economic difficulties related to PMS.
3. Although designed specifically for implementation in the San
Fernando Valley. the educational model could be used in health
education settings in other areas.
LIMITATIONS
The major limitations in the develooment of this are:
1. The opinions of the health care practitioners who
wer~
used in
the validation process of the model may not be representative of
other professionals in the field.
2. The educational model was developed to include general informa-
6
tion encompassing the premenstrual syndrome in its entirety; the
curriculum cannot be generalized to include all women '11ith PMS
without regard for cultural and ethnic considerations or
individualized to a specific patient's needs.
3. The 'llodel was primarily designed to meet the needs of the
patient population of the San Fernando Valley area, and m-'ly not
be gene:::-all.zed
to persons
l.n
other geographic areas.
CHAPTER II
LITERATURE REVIEW
There
~s
a paucity of literature which is specifically concerned
with the development of educational interventions for PMS.
In light
of this, this Investigator will present a brief reYiew of relevant
literature on PMS as it has relevance to the conduct of this study.
This Investigator was concerned with determining the type and
extent of information available on Premenstrual Syndrome.
Additionally, there was a need to search for any instructional
curricula available to teach
the public about PMS in either a
classroom. seminar or self learning setting.
All major works available to the public were reviewed as well as
health education texts used by tw·o local colleges, one junior college,
one state un{versity.
A Los Angeles and a Wisconsin PMS clinic were
contacted to obtain instructional information.
The review also
included multi-media information in the form of televis i.on and radio
programs, taues and video pr2sentations.
Finally, the current
approaches in the treatment of PMS were examined, so that
a~?licable
content could be utilized towards the development of a PMS educational
mode 1.
Available Instructional Curricula
An instructional curriculum on Premenstrual Syndrome could not be
located in the literature.
A review of college level health
7
8
education texts used locally identified little if any information
explaining PMS.
(Insel. Roth, 1982) (Jones, S~ainberg, OByer, 1982)
(Combs, Hales, Williams, 1983) (Annual Editions. 1983)
The Lay Literature
There are at least seven reasonably priced paperback books on the
market geared to explaining PMS in easy to understand terms.
For the
purpose of the literature review, five of the most pertinent books
were surveyed (Allen, Fortino, 1983) (Norris, Sullivan, 1984) (Witt,
1984) (Budoff, 1981) (Lever, Brush, 1981).
In PMS:
Wh~§.~~~y_ W~man -~ho~!_r! __ Know
About Premenstrual Syndrome
Witt (198!~) has comniled an overview of PMS which includes an
explanation of the syndrome, the anatomy and physiology of the
menstrual cycle, the physiological, sociological and emotion impact of
PMS.
Medical theories and treatments are excplained, as well as self
determined measures which may control PMS.
The chapters included a
"PMS Update" adding recently acquired information as of January 1984.
In
addition a glossary of terms is included to clarify unfamiliar
words. This book is extremely relevent to the study in that it
presenterl information based on scientific studies in a simple, easy to
understand. straight forward manner.
This book would seem a likely
choice as a required text for the PMS Curriculum.
Norris and Sullivan (1984) provided an aggregation of basic
information about PMS particularly in their section dealing with
historical data tracing "Eve's Curse".
Also included is a full
overview of the psychosocial aspects of PMS, and the historical
personages 'N'ho were likely to have suffered from PMS.
Information :tn
9
this book could be used to reinforce and SU!)p lement that of Witt's
work 1n a classroom setting.
The contents are factual and informative
and the information is broad in its perspective.
However, 1n this
Investigator's view, it is written for a very sophisticated audience.
This book may well be suited as an additional source for the
instructor who might then present the content on a level more suited
to the aptitude of the student population.
A recent work by Budoff (1981) covers a wide range of women's
health problems and issues. including a chapter on PMS.
Information
is clearly stated and primarily covers situations and treatments
pertinent to the author's practice.
This Investigator found that the
limited amount of content allocated to PMS did not provide a broad
enough perspective to be used as a primary text to accompany a
curriculum.
Lever and Brush (1981) focused primarily on the tension aspect of
the syndrome.
While presenting some worthwhile information about
premenstrual symptoms, much of the information is either out of date,
misleading or does not go for enough to clarify the syndrome and
current treatment.
This limitation is apparent since it appears to be
one of the first books published for the general public dealing with
PMS.
Once the syndrome became accepted as a reality, PMS research
mushroomed.
New theories and treatments have sprung up almost
overnight resulting in rapidly outdated information.
Based upon this,
in the Investigator's opinion, this book would not be suitable to
supplement the curriculum.
Allen and Fortino (1983) have ~resented a brief overview in a
chapter on PMS.
The chapter deals with recent
findin~s
and theories
10
and the authors clearly state that "much of the material is
speculative and awaits solid proof or further investigation."
content is brief but straight forward without
medical jargon.
excess~ve
The
unexplained
The section on PMS implications offers a fresh
v~ew
of some of the psychosocial implications so frequently headlined
the press.
~n
Although the focus of the book is on menstruation in
general, it would be worthwhile as a
~eneral
reference for additional
information.
Dalton (1979) has presented a landmark book of information
dealing with PMS symptoms.
The contents cover classical historical
and psvchosocial aspects, as well as case studies.
Data dealing with
hormonal control is clearly explained and illustrated.
limitation of the book
~s
The one
that it deals exclusively with progesterone
therapy, which may not be the treatment of choice
~n
all cases of PMS.
This Investigator believes that the limited focus of the book may
serve to confuse students who are initially learning about PMS.
SUMMARY
This Investigator's assessment of the information available on
premenstrual syndrome indicated that there
1s
no formal educational
structure available to teach the public about PMS in either a
classroom or a
sem~nar
setting.
However, the lay literature review
identified books which r.10uld be useful as student texts to supplen,1ent
the didactic curriculum presentation.
Certain books were also
identified as inappropriate for use based on content bias, outdated
material or too sophisticated a presentation.
Chapter 3
METHODOLOGY
The purpose of this project was to develop and validate a
premenstrual syndrome educational curriculum for use by health education practitioners.
The following methodological phases utilized in
the development and validation of the premenstrual syndrome educational guide are described in this chapter:
Phase I: Development, Imple-
mentation, and Analysis of the Needs Assessment; Phase II: Development
of the Curriculum; and Phase III: Validation of the Curriculum.
Phase I: Development, Implementation, and
Analysis of the Needs Assessment.
A.
Needs Assessment Review of the Literature
A review of the literature was conducted to determine the
existance of published health education materials dealing with PMS.
(See Chapter 2).
Although very little information was found
specifically dealing with educational interventions, the literature
review constituted one of the methodological steps carried out in the
needs assessment process.
The categories of literature wnich were reviewed included
medical journals and publications, nursing journals, current lay
health periodicals, health education texts, exercise physiology texts
and nutritional journals.
In addition, oral and audiovisual
presentations by leaders in the field of PMS were reviewed.
11
12
Q .
B.
Needs Assessment Interviews
The Investigator conducted an informal survey during the Fall
of 1982 to determine the importance placed on client education by
health professionals dealing with PMS, and to identify and investigate
existing PMS patient education programs.
Development of the Interview Format
A formal interview survey was developed by the Investigator
for purposes of determining the importance placed on PMS education.
(See Appendix A)
The interview instrument was pretested utilizing
nursing personnel who had knowledge of this field.
Implementation of the Interview Needs Assessment
Utilizing this instrument, oral interviews were conducted with
physicians and nurses known to the Investigator.
The respondents were
chosen based on their area of practice (women's health) and/or a known
interest and knowledge base regarding PMS.
Such a population consti-
tuted the primary target group involved with the future utilization of
an educational model of this type.
Each respondent was asked for.
information relevant to the importance of patient education,
educational methods employed, and the existence of PMS reference
material suitable to the general public.
Selltiz, Jahoda, Deutsch and Coo (1959) have asserted that a
graded series of response possibilities frequently gives the
investigator additional or more accurate information than a
dichotomous response and presents the question more adequately and
acceptably to the respondent.
The Investigator used such format
13
during the interview.
C.
(See Appendix A).
Analysis of the Needs Assessment
The information gathered during the needs assessment was
analyzed (See Appendix A) in order to determine if patient education
was viewed as important, and what the nature was concerning the level
of formal instruction currently provided to patients.
The needs
assessment process further illustrated the paucity of information
available and confirmed the lack of availability of a comprehensive,
factual, unbiased, educational model for PMS.
D.
Identification of the Target Population
PMS can affect women from puberty through their reproductive
years.
(, 1982)
PMS can also impact others who have close
relationships with the PMS sufferer such as the husband, children,
extended family and employer.
(Dalton, 1979).
(Dalton, 1977)
(, 1982)
As discussed in Chapter 1, a review of pertinent
college level health education texts revealed minimal instruction in
PMS.
The interview conducted during the needs assessment again
identified the lack of general education in PMS.
The Investigator
therefore identified a need to develop a PMS educational model for use
by the health professional to educate the general public regarding
PMS.
Phase II: Development of the Educational Model
A systematic approach that can be repeated or followed by
others has been identified as necessary when structuring and
14
organizing health knowledge for classroom instruction.(Fodor, Dalis,
1981)
Kemp ( 1977) advocates the development of an overall plan
incorporating the interrelated parts of an instructional process in a
sequential pattern.
Both Kemp (1977) and Fodor (1981) focus the
instructional methodologies on learning outcomes.
The strategies
proposed by Fodor and Dalis (1981) dealing with format and curriculum
design were employed in the development of the educational model.
A.
Design of Curriculum Concept and Format
The first step in structuring health knowledge for classroom
instruction is data collection.
The next step is to identify the most
important information to be stressed within a given health information
grouping or category.(Fodor, Dalis, 1981)
These two steps lead to the
establishment of a conceptual framework to support the educational
model.
The conceptual plan
must be comprised of precise statements
based on current points of view which are broad enough to facilitate
organization of related information.
The statements must be valid,
relevant to the target population and nonprescriptive.(Fodor, Dalis,
1981)
B.
Learning Objectives
Once the conceptual framework is determined, learning
objectives can be developed which form the criteria by which the
learners performance can be measured.
a guide to:
Properly stated objectives are
1) specific content to be studied by the learner;
2) specific changes in behavior that are sought in the learner with
respect to content; 3) selection of learning opportunities that best
15
enable the learner to achieve the desired behavioral outcomes; 4) what
to evaluate in terms of the health content studied and the behaviors
sought in the learner; and 5) the evaluation of teacher effectiveness.
(Fodor, Dalis, 1981)
According to Kemp (1977), learning objectives can be grouped
into the following three categories or domains, cognitive, psychomotor
and affective.
The cognitive domain, which includes knowledge,
comprehension, application, analysis, synthesis and evaluation, is
the domain most used in developing educational program objectives.
(Kemp, 1977)
The psychomotor domain includes skills requiring use
and coordination of skeletal muscles.
The affective domain, which
includes attitudes, appreciations and values, is the most difficult
domain to use in constructing objectives. (Kemp, 1977)
The three
domains identified are related in that a single objective can
involve learning in two or more domains, also attitudinal development may precede successful learning in other domains. (Kemp, 1977)
In addition, Fodor (1981) has asserted that when learner attention is
focused on cognitive skill, attitudes about such practice or evolve.
C.
Evaluative Criteria
Evaluation criteria which interface with the Learning
Objectives have been incorporated into the curriculum.
The Evaluative
Criteria identify specific behaviors sought in the learner.
The
Evaluative Criteria can also assist the health educator in developing
an objective criterion based cognitive testing instrument to assess
learner knowledge.
types of questions:
Such an instrument might include the following
multiple choice, short answer, fill in, essay,
16
matching and/or diagram labeling.
If a pre and post test model was used in implementing the
curriculum, the tests should take similar form and treat comparable
content.
D.
Content
The content of the educational model was constructed utilizing
the results of the needs assessment and information obtained through
the literature review.
This included PMS information obtained from
medical and nursing literature, current lay literature and oral and
audiovisual presentations.
Five concepts and fourteen objectives were
developed based on a systematic approach used to define and explain
the premenstrual syndrome and its treatment.
Knowledge, skills and
attitude components were incorporated into the objectives.
E.
Learning Opportunities and Resources
Once the curriculum content and format was determined,
learning opportunities and suggested resources were included to
enhance the learners ability to attain the instructional objectives
identified.
The learning opportunities were tailored to the specific
objectives, as recommended by Fodor and Dalis. (1981)
Instructional
methods were geared to the most efficient use of student time,
facilities and equipment, and were based on Kemp's (1977) recommendations for group presentations.
The recommended resources reflected
the model's objectives and learning opportunities, and provided for
a variety of references as recommended by Fodor and Dalis (1981).
17
Phase III: Validation of the Curriculum
The educational model was validated by subjecting it to the
scrutiny of health care professionals with expertise in the field of
PMS and/or patient/health education.
The validators were requested to
rate the educational model based on 1) the validity of the information, 2) the appropriateness of the content, 3) the clarity of the
presentation, and 4) the usefulness of the model.
provided with a cover letter (See Appendix B),
The validators were
a validation
questionnaire (See Appendix C) and a copy of the educational model.
The questionnaire was pre-tested by submitting it to health education
experts at California State University, Northridge, and at Saint
Joseph Medical Center.
A.
Selection of a Panel of Experts
The Investigator identified the following criteria in
selecting a panel of experts to validate the proposed PMS educational
model:
1) A leadership role in the field of PMS as demonstrated by
publications, interviews and/or extensive practice in the field; and
2) A leadership role in health education, demonstrated by position and
job responsibility.
Members of the panel included:
a nationally
known physician author in the field of PMS, two gynecologists who have
lectured locally on PMS,
a gynecology nurse practitioner in
independent practice, two Directors of Education at Saint Joseph
Medical Center, a Doctor of Education in independent practice, a
Director of Health Education at a women's clinic, and the Health
Educator at California State University, Northridge, Student Health
Service.
18
The panel members were contacted by telephone or in person to
obtain a commitment to participate in the validation process.
In
addition, the initial contact was used to explain the project and to
clarify any questions.
A cover letter, a draft of the educational
model and a validation questionnaire were delivered to each panel
member.
The members were given one month to review the guide before
returning it to the Investigator.
B.
Development of the Validation Questionnaire
The questionnaire was comprised of seven items. (See
Appendix C)
To achieve greater variance of results, a Likert-type
scale was used. (Isaac, Michael, 1984) (Kerlinger,l973)
The scale was
also used to maintain objectivity, uniformity and reliability. (Isaac,
Michael, 1984)
In addition, an open-ended comments section was
provided after each question, to allow for flexibility, depth and
clarification. (Isaac, Michael, 1984) (Kerlinger,1973)
Clarification
was requested for all responses at the low end of the scale.
elaboration was to
This
be placed in the "comments" section.
The questionnaire focused on the following areas: 1) overall
reaction to the curriculum; 2) quality of information, including
clarity, completeness and technical accuracy; 3) appropriateness of
the information for presentation to a lay-audience; and 4) comments
and suggestions for improvement.
The Investigator's intent in determining these areas for
validation was to insure a comprehensive process where major omissions
and/or weaknesses could be identified.
The validators were requested
to judge each item on a scale, which provided for quantifying the
19
~1
results.
In addition, they were allowed to individualize the process
by contributing independent comments, insights and suggestions.
•
Chapter 4
RESULTS AND DISCUSSION
The results of the methodological phases utilized in the development
and validation of the Premenstrual Syndrome Educational Model are
discussed in this chapter.
Eight health care professionals were interviewed.
Analysis of the
responses indicated that, 1n dealing with PMS, patient education was
considered very important bv all individuals interviewed.
Methods used
to teach the patient about PMS were mostly informal and consisted
primarily of oral discussion with the patient during the office visit.
(See Appendi~ A).
One physician recommended a specific book for supplementary patient
reading.
The same physician provided audiovisual ]Jresentations
regarding a specific treatment modality.
primarily at the PMS patient.
Educational efforts were aimed
Educational awareness and therapy >vere
recommended for the spouse/family by one physician. but only in
extenuating circumstances.
None of those interviewed knew of an
unbiased, comprehensive, factual information reference suitable for the
general public.
20
21
Analysis and Discussion of the
Curriculum Validation Process
Nine health professionals received an initial draft of the proposed
educational model, along with a validation questionnaire. (See Appendix
C).
Each panel member •.vas requested to comment, complete the validation
questionnaire and refine the draft where necessary.
Seven o£ the
questionnaires were returned.
The validation questionnaire contained seven questions.
Answers
were rated on a five point scale. If a response was on the low end of
the scale, e.g., "1" or
11
2 11 , a reason for the response was requested to
be included in the ''comments" section.
An additional point on the scale
was provided for questions considered non applicable.
question as well as comments were analyzed.
Response to each
The following table
illustrates the questionnaire results and comments.
Each question will
be presented with the response and comments concerning the refinement of
the model.
Relevence of comments to later refinement of the model will
be noted in the body.
22
TABLE 1
VALIDATION QUESTIONNAIRE RESULTS
Answers were rated on a five point scale. If a response was on the
low end of the scale, e.g., "1" or "2", a reason for the response was
requested to be included in the "comments" section.
This curric1;lum on Premenstrual
Syndrome was designed to provide
unbiased and factual information to
the health educator in the clinical
setting or at the community college
level.
1.
Number of Responses (N
7)
low
na.
l
high
2
3
4
DOES THIS CURRICULUM MEET THE ABOVE
'$)BJECTIVE?
6
5
7
100%
·-----------COMMENTS
Information 1.s accurate.
Informat-ion presented is unbiased.
by the instructor is essential
i~
2. Are the course objectives clearly
stated?
I believe however that a bias
presenting this topic.
Number of Responses-(N
high
low
1
2
3
4
5
7
=
7)-na.
6
100%
COMMENTS
One objective not included is the need to distinguish PMS from
major psychiatric disorders or at least separation of symptoms 1.n
patients with concurrent diseases.
It would be helpful to have a summary of objectives pr1.or to the
beginning of
conte~t
outline.
23
Do not like format.
I prefer to teach from content where each
section outlined: obiectives, evaluation, mode of delivery/teaching
strategies, content outline, resources.
Number of
low
1
3. IS THE CONTENT
IN A
USEFUL MANNER (E.G., GOOD CONTINUITY
AND COHERENCY)?
ORG~~IZED
(N = 7)high
na.
5
6
3
Respon~es
2
3
4
1
14%
1
14%
29%
2
43%
COMMENTS
Content is organized well.
I would place a different emphasis on some aspects of the content
and I feel some content is lacking.
The decimal system of numbering objectives ts hard to follow.
Some (2) of the numbers are
missin~/skipped .
• May be more constructive to discuss reasons women have accepted PMS
suffering in relation to
sociolo~ical
factors, psychological and
psychoanalytic concepts to reduce the negative bias.
Hormones included in Section III are not in Section II.
Nu~b~~-;f Resp;nses-(N~7)-
low
1
4. IS THE CONTENT FACTUAL AND IN LINE
WITH THE MOST CURRENT THINKING?
2
3
4
1
14%
high
5
6
86%
na.
6
COMMENTS
. Content is quite current .
. I think most feel that categorization of PMS by symptom complexes
is useful from a therapeutic aspect and deserves inclusion.
24
. I question some of your resources for recommended diet - "oil of
primrose 11
,
etc .
. Include alcohol related symptoms.
Content may be to extensive.
Number of Res?onses-·TN = 7)
low
high
na.
1
2
1
5. DOES THE CURRICULUM CONTAIN
INFORMATION APPROPRIATE FOR
DISTRIBUTION TO THE LAY PUBLIC
(I.E., THOSE WITH A NON MEDICAL
BACKGROUND)?
14%
-----·--------
3
4
2
29%
5
4
6
57%
--------
COMHENTS
Appropriate and perhaps too complete.
either
elimin~te
I feel a bias 1s needed to
some theories of pathogenesis or at least relegate
them to historic interest only.
Female physiology may be too detailed unless content aimed at
health education students.
Suggest calling PMS a "health problem" rather than a disease.
Use more lay terms in section on causes of PMS.
6. DOES THE COVERAGE OF EACH AREA
PROVIDE AN ADEQUATE INFORMATION
BASE?
Number of Responses-cN~~y­
low
high
na.
1
2
3
5
6
4
4
3
43% 57%
COMMENTS
Emphasis should be expanded to areas that are likely correct or
have theraueutic utility.
25
Cover more under social implications - including the potential bias
towards all women if PMS becomes "non" professionally publicized.
Discuss controversies in treatment.
Discuss court cases in Britain .
. Discuss the difficulty in measuring objectively the self reporting
symptoms.
Discuss placebo success
~n
treatment.
A glossary of terms may be helpful.
Mav be too much in some cases.
---------------
7. IF YOU WERE PRESENTING THIS TOPIC
TO A LAY AUDIENCE, WOULD YOU FIND
THIS CURRICULUM USEFUL IN THE
PREPARATION OF YOUR PRESENTATION?
Number of Responses (N
low
high
1
2
3
4
5
4
3
43%
na.
6
57%
-------------------------------------------------COMMENTS
. Details
~n
the client guide are excellent.
It is very imoortant to emohasize that the disease
var~es
greatly
in severity, because this relates majorly to problems in acknowledgement of
t~e
existence of PMS, appreciation of the reasons for
conflicting results of therapy and also allows for something less
than "cure" with various treatment modalities.
Thorough, however some important factors are not included.
Suggest using related film to enhance specific presentation.
Your model should be used intact, by unbiased instructors, instead
of what we are seeing from professionals today who are not taking
the time for health education.
26
il
Summary
Responses of the validators indicated to the Investigator that the
Educational Model for Premenstrual Syndrome was considered to provide
unbiased, clearly stated, factual information relating to PMS.
In
investigating the reason for the one low response related to question
number three, it was found that two pages of the copv of the curriculum
received by the reviewer were out of sequence.
This accounted for part
of the difficulty cited 1n following the content outline.
Generally,
the content was thought to be well organized, current and appropriate
for distribution to the lay public.
Comments provided by the reviewers
were utilized wherever possible in the fina 1 curriculum mode 1.
.
Chapter 5
THE REFINED PREMENSTRUAL SYNDROME
EDUCATIONAL MODEL
The refined educational model presented in this chapter
represents the results of the needs assessment, the literature review,
and the validation process.
Whenever possible, the recommendations of
the panel of experts used to validate the model were incorporated.
The purpose of the educational model is to provide the health
education practitioner with tonics to be taught to the lay public
regardin~
PMS.
The content is organized into five tonic headings.
The
concepts, objectives, evaluative criteria, content outline, suggested
learning opportunities and resources are presented on the following
pages.
SUMMARY OF CONCEPTS
CONCEPT 1: The premenstrual syndrome (PMS) is a cyclic phenomenon only
recently recognized as a physical disorder.
CONCEPT 2: Knowledge of the anatomy and physiology of the female
reproductive system is essential in the manal?:ement of PMS.
CONCEPT 3: The premenstrual syndrome covers a wide range of physical and
psychological manifestations which occur in relation to the
onset of the menstrual cycle.
CONCEPT 4: Compliance to a medical treatment reg1men can control the
incidence of severe PMS episodes.
CONCEPT 5: Specific behavioral measures can be taken to reduce the
severity of PMS.
27
28
I. PREMENSTRUAL SYNDROME
CONCEPT 1: The premenstrual syndrome (PMS) is a cyclic phenomenon only
recently recognized as a physical disorder.
OBJECTIVE
1.1: Define premenstrual syndrome.
OBJECTIVE
1.2: Discuss the history of PMS.
EVALUATION 1.1: Define premenstrual syndrome 1n your own words.
EVALUATION 1. 2: Discuss two historic explanations of premenstrual
syndrome.
CONTENT
Introduction to the program
A. Purpose
B. Topics
C. Expectations and objectives
I.
Premenstrual Syndrome
A. Definition: Any combination of a
variety of symptoms, physical, psychological or emotional, which are
cyclically manifested just orior
to the onset of menstruation.
1. GenerallY aopear 2-7 days before the onset of menstruation;
2. In some cases PMS may coincide
with ovulation.
3. Usually relieved with the onset
of menses, but in a small percentage of cases, syii!ptoms caa
persist until cessation of the
menstrual flow.
4. May be accelerated or exacerbated by:
a. Post partum depression.
b. Oral contraceptives.
LEARNING OPPORTUNITIES
The instructor distributes
content outline and objectives. Instructor discussion
will include purpose of
course. topics to be covered.
expectations and obiectives.
Instructor lectures and uses
transparencies to define
"nremenstrual syndrome".
29
I. PREMENSTRUAL SYNDROME
CONCEPT 1: The premenstrual syndrome is a cyclic phenomenon only
recently recognized as a physical disorder.
OBJECTIVE
1.2: Discuss the history of PMS.
OBJECTIVE
1.3: Discuss reasons women have so readily accepted suffering
from PMS.
EVALUATION 1.2: Discuss two historic explanations of premenstrual
syndrome.
EVALUATION 1. 3: Discuss three reasons '"omen have so readily accepted
suffering from PMS.
LEARNING OPPORTUNITIES
CONTENT
B. History of PMS:
Instructor lecture.
1. Can be traced back to the First
century A.D ..
a. Menstrual fluid was recounted
to cure boils and epilepsy,
among other complaints;
b. Epilepsy may be precipitated
in the premenstruum.
c. Many women do have skin
eruntions at this time.
2. Many superstitions and taboos
surround menstruation.
a. Greek interpretation was:
1) monthly changes in mood
and behavior attributed
to women being more hot
tempered, volatile and
emotional than men.
2) partially related to the
assessment that women had
a surplus of blood which
needed to be shed monthly.
Instructor obtains student
input regarding the common
facts/myths of menstruation
and PMS. Instructor will list
comments on chalkboard.
30
I. PREMENSTRUAL SYNDROME
CONCEPT 1: The premenstrual syndrome is a cyclic phenomenon only
recently recognized as a physical disorder.
OBJECTIVE
1.2: Discuss the history of PMS.
OBJECTIVE
1.3: Discuss reasons women
from PMS.
~ave
so readily accented suffering
EVALUATION 1.2: Discuss two historic explanations of premenstrual
syndrome.
EVALUATION 1.1: Discuss three reasons women have so readily accepted
suffering from PMS.
LEARNING OPPORTUNITIES
CONTENT
b. Biblical explanation adopted
in the Middle Ages which
continues to find acceptence
1n today's society:
1) menstruation and menstrual
problems seen as a type of
communal atonement for
Eve's original s1n;
2)
~ynecological problems
received little attention
or sympathy, and were
conveniently dismissed as
the "Curse of Eve".
c. A modern exnlanation (1938):
an obstetrical text related
menstruation to the lunar
cycle.
3.
Recent attitudes:
a. Commonly held attitude of
shame towards menstruation.
b. Taught to hide all evidence
of existence of menstruation.
c. Recent medical text books
relate the symptoms of PMS
to a high strung, nervous
The instructor uses script
from "Archie Bunker" to
convey myths and attitudes
typically accompanying menstrual misconceptions:
ARCHIE: Read your bible. Read
about Adam and Eve. They had
it pretty soft out there in
paradise. They didn't even
know they was naked. But Eve
wasn't satisfied. So, going
against direct orders, she
31
I. PREMENSTRUAL SYNDROME
CONCEPT 1: The premenstrual syndrome is a cyclic phenomenon only
recently recognized as a physical disorder.
OBJECTIVE
1.3: Discuss reasons women have so readily accepted suffering
from PMS.
OBJECTIVE
1.4: Identify reasons for the lack of attention
g~ven
to PMS
by the medical profession.
EVALUATION 1.3: Discuss three reasons women have so readily accepted
suffering from PMS.
EVALUATION 1.4: Identify three reasons why little attention has been
paid to premenstrual syndrome until recently.
CONTENT
LEARNING OPPORTUNITIES
makes poor Adam take a bite
or neurotic female; imply
menstrual symptoms used as a out of that apple. So God
refuge from responsibility
got sore and told them to get
and effort.
their clothes on and get outta
t~ere.
So, it was Eve's
d. Over the years physicians,
fault God cursed women with
particularlv obstetricians
this trouble. That's why they
and psychiatrists, have
call it, what do you call it,
cited the following as
the curse.
causing PMS:
1) neuros ~s
MIKE: We 11, there you have it.
Gloria, straight from the
2) emotional disturbance
Reverend Archie Bunker. The
3) hysterical oersonality
true story of menstruation.
4) hostile mother-daughter
ARCHIE:
Ssshhhh ~vith that
relationship
5) rejection of the
kinda word!
feminine role.
Excerpts from ALL IN THE
e. Desoite recent findings to
FAMILY script, Tandem Producthe contrary, some women
tions Inc., March 6,1973.
are still being told that
PMS symptoms are:
Instructor elicits student
1) imaginary
discussion regarding attitudes
2) psychoso~atic
toward the content of the
3) a means to manipulate
script.
others.
4. Little attention was paid to
PMS by the medical profession
as:
Instructor reads excerpt from
Dr. Kinch's article:
"There
is considerable evidence to
32
' .
I. PREMENSTRUAL SYNDROME
CONCEPT 1: The premenstrual syndrome is a cyclic ohenomenon only
recently recognized as a ohysical disorder.
OBJECTIVE
1.3: Discuss reasons women have so readily accepted suffering
from PMS.
OBJECTIVE
1.4: Identify reasons for the lack of attention given to PMS
by the medical orofession.
EVALUATION 1.3: Discuss three reasons women have so readily accepted
suffering from PMS.
EVALUATION 1.4: Identify three reasons why little attention has been
paid to premenstrual syndrome until recently.
LEARNING OPPORTUNITIES
CONTENT
a. PMS is mostly a benign
condition; no obvious harm
will occur to a patient
if left untreated.
b. Symotoms are diverse and
may be variable or inconsistent from one month to
the next, makin~ controlled
scientific research
extremely difficult.
c. Frequently the svmotoms are
common to both men and
women and can be seen
in other health problems.
d. Women have accepted the
condition as inevitable.
support a psychic origin of
the syndrome. Some authorities believe that both the
the onset and exacerbation
of premenstrual tension are
precipitated bv disturbances
that take place in the
patient's life. Patients with
this syndrome are thought to
have hostile, dependent
relationships with their
mothers, with subsequent
strong feelings of guilt.
Or they may repudiate the
female role and have strong
feelings of envy towards men.
I often find that patients
with the most difficulties are
intelli15ent women whose abilities and ambitions to exolore
outside interests are frustrated by child care and other
responsibilities. Many such
patients are married to workaholic professionals businessmen, lawyers,
physicians or clergymen,
for example."
Instructor elicits students'
views of attitudes and beliefs
portrayed in the article.
33
I. PREMENSTRUAL SYNDROME
CONCEPT 1: The premenstrual syndrome is a cyclic phenomenon only
recently recognized as a physical disorder.
OBJECTIVE
1.5: Discuss factors related to determining incidence of PMS.
OBJECTIVE
1.6: Discuss the social aspects related to PMS.
EVALUATION 1.5: Discuss two factors related to
PMS.
determinin~
incidence of
EVALUATION 1.6: Discuss the social aspects related to PMS, includin~ at
least four areas of social interaction effected by PMS.
LEARNING OPPORTUNITIES
CONTENT
C. Incidence/Prevalence.
1.
Epidemiolo~ical
data 1s misleading owing to:
a. The variety of inter?retations of the clinical
manifestations.
b. The difficulty in measuring
the severity of the symptoms.
2. It is generally accented that
70 percent to 90 percent oE
women admit to recurrent
premenstrual symptoms; 20 percent to 40 percent report some
degree of physical or mental
in capacitation.
3. Studies have been conducted to
correlate menstrual traits of
mothers and daughters.
a. 63 percent of daughters of
symptom-free mothers were
also symptom free.
b. 70 percent of daughters of
mothers who had the syndrome
also suffered.
4. PMS has been reported as a
universal phenomenon nl)t related
to:
a. Complexity of society
b. Social or economic factors
c. Ethnicity
Instructor lecture
34
I. PREMENSTRUAL SYNDROME
CONCEPT 1: The premenstrual syndrome is a cyclic phenomenon only
recently recognized as a physical disorder.
OBJECTIVE
1.5: Discuss factors related to determining incidence of PMS.
OBJECTIVE
1.6: Discuss the social aspects related to PMS.
EVALUATION 1.5: Discuss two factors related to determining incidence of
PMS.
EVALUATION 1.6: Discuss the social asuects related to PMS, including at
least four areas of social interaction effected by PMS.
CONTENT
LEARNING OPPORTUNITIES
D. Social Aspects.
1. PMS has been related to
incidence of:
a. Absenteeism from the work
place
b. Aggressive behavior
c. Child battering
d. Other forms of family
violence
e. Marital dishar~onv
f. Alcoholic episodes
g. Crimes of violence including
murder and robbery
h. Suicide
2. The literature has cited PMS
as having been used as a justification in preventing women
from attaining positions of
power.
SUGGESTED RESOURCES
Brahams, D. "Premenstrual syndrome: a disease of the mind" Lancet:
1238 -1240, November 28, 1981.
d'Orban, P.T. and Dalton, J. "Violent crime and the menstrual cycle"
Psychological Medicine (10): 353-359, 1980.
Gonzalez. Elizabeth R. "Premens trua1 syndrome: an ancient woe deserving
of modern scrutiny" JAMA 245:1393- 1396, 1981.
35
I. PREMENSTRUAL SYNDROME
CONCEPT 1: The premenstrual syndrome is a cyclic phenomenon only
recently recognized as a physical disorder.
OBJECTIVE
1. 5: Discuss factors related to determining incidence of PMS.
OBJECTIVE
1.6: Discuss the social aspects related to PMS.
EVALUATION 1.5: Discuss two factors related to determining incidence of
PMS.
EVALUATION 1.6: Discuss the social aspects related to PMS, including at
least four areas of social interaction effected by PMS.
SUGGESTED RESOURCES
----------------
Jones, I.H. "Menstruation: the curse of Eve" Nursing Times: 404-406,
March 6 . 1980.
Kinch, Robert A.H. "Help for patients with premenstrual tension"
Consultant: 187- 191, April, 1979.
Paige, K.E. "Women learn to sing the menstrual blues"
Today:41-46, Seotember, 1973.
Psyc:_~ology
Reid R.L., Yen, S.S.C. "Premenstrual syndrome" Am J Obstet
139(1): 85-104, 1981.
Gyn~~col
Swaffield, Laura "Menstruation: hiding the evidence" Nursing Ti_mes:
414-415, September, 1980.
36
II. ANATOMY AND PHYSIOLOGY OF THE MENSTRUAL CYCLE
CONCEPT 2: Knowledge of the anatomy and ohysiology of the female
reproductive system is essential in the management of PMS.
OBJECTIVE
2.1: List the major organs of the female reproductive system.
OBJECTIVE
2.2: List the endocrine glands involved
cycle and explain their function.
~n
the menstrual
EVALUATION 2.1: List the five major organs of the female reproductive
system.
EVALUATION 2.2: List three endocrine glands involved in the menstrual
cycle and explain their function.
CONTENT OUTLINE
LEARNING OPPORTUNITIES
----
II. ANATOMY AND PHYSIOLOGY OF THE
MENSTRUAL CYCLE
A. Organs of the female reproductive
system:
1. Ovaries
2. Fallopian Tubes (oyiducts)
3. Ute.rus
Each student is requested to
label the reproductive system
as the instructor lectures.
4. Vagina
5. Mammary glands
B. Endocrine glands involved
menstrual cycle:
Instructor discusses the
organs of the menstrual
cycle using overhead transparencies to illustrate the
anatomical structures.
Instructor provides diagram of
the reproductive system to
each student.
~n
the
1. Anterior lobe of the pituitary
gland.
a. Secretes Folical Stimulating
Hormone (FSH) which stimulates growth and development
of ovarian follicle.
b. Secretes Lutenizing Hormone
(LH) which augments the
action of FSH.
2. Ovary
a. Secretes estrogen hormone
b. Secretes progesterone hormone
Instructor uses transparencies
to illustrate gland location
and hormone secretion.
37
II.
k~ATOMY
AND PHYSIOLOGY OF TdE MENSTRUAL CYCLE
CONCEPT 2: Knowledge of the anatomy and physiology of the female
reproductive system is essential in the management of PMS.
OBJECTIVE
2.3: Describe the normal physiology of the menstrual cycle
during the reproductive stage.
EVALUATION 2.3: Describe the normal hormonal activity during the
menstrual cycle, including the activity of FSH, LH.
estrogen and progesterone.
----------------------·CONTENT OUTLINE
----------=~-=-'
LEARNING OPPORTUNITIES
3. Hypothalmus
a. Monitors hormone levels
C. Normal physiology of the menstrual Instructor provides diagram
cycle during the reproductive
depicting hormone and ovary
stage.
activity during the normal
menstrual cycle.
1. Day 1:
a. FSH 1s released in the
venous blood svstem by
the anterior lobe of the
pituitary.
b. FSH stimulates ovarian
follicles to begin to ripen
to develop an egg.
2.
Day 5-10:
a. Estrogen is produced by the
ovarian follicle.
b. Estrogen stimulates the
growth of the uterine lining.
3.
Day 11-15:
a. Anterior pituitary begins
releasing Lutenizing Hormone
(LH).
b. LH causes the Follicle to
rupture releasing the ovum
(ovulation).
Instructor elicits student
discussion on how the various
glands interact with each
other.
38
II. ANATOMY AND PHYSIOLOGY OF THE MENSTRUAL CYCLE
CONCEPT 2: Knowledge of the anatomy and physiology of the female
reproductive system is essential in the management of PMS.
OBJECTIVE
2.3: Describe the normal physiology of the menstrual cycle
during the reproductive stage.
EVALUATION 2.3: Describe the normal hormonal activity during the
menstrual cycle, including the activity of FSH, LH,
estrogen and progesterone.
CONTENT OUTLINE
LEARNING OPPORTUNITIES
c. At ovulation FSH and LH peak
then levels decrease.
d. Once egg is released LH
continues to work causing
the ruptured follicle to
develop into the corous luteum.
e. The corpus luteum produces
progesterone.
4. Day 16-24:
Elevated progesterone level
causes the uterine endometrium to mature and thicken
in preparation for the ovum,
should pregnancy occur.
5. Day 25-28 (if ore~nancy does not
occur):
a. Coruus luteum begins to
degenerate.
b. Progesterone level falls.
c. Estrogen level falls.
d. Menstruation begins.
D. The menstrual cycle usually occurs
only once a month, but can span
any>IThere from 21 to 35 days and
still be considered normal.
39
,, .
II. ANATOMY Al'ID PHYSIOLOGY OF THE MENSTRUAL CYCLE
CONCEPT 2: Knowledge of the anatomy and physiology of the female
reproductive system is essential in the management of PMS.
OBJECTIVE
2.3: Describe the normal physiology of the menstrual cvcle
during the reproductive stage.
EVALUATION 2.3: Describe the normal hormonal activity during the
menstrual cycle, including the activity of FSH, LH,
estrogen and progesterone.
SUGGESTED RESOURCES
·----------------
Allen, P. and Fortino, D. Cycles:_~~erv
New York: Pinnacle Books, Inc., 1983.
Diagram Group. Woman's Body An
1980
~Nners
Woman~_~uide~)ienst_E.l!_ation.
Manual. New York: Bantam Books
Ginsburg;, J. and Fink, R.S. "Premenstrual Syndrome" Nursing (Oxford):
386--388. 1981
Linkie, D.W. "The physiology of the menstrual cycle" Behavior and the
Menstrual ~y~le: 1-21, Edited by Richard C. Friedman, Ne1.r-York-:- Marc;l
Dekker, 1981.
40
II I. PREMENSTRUAL SYNDROME: SYMPTONS AND DIAGNOSIS
CONCEPT 3: The premenstrual syndrome covers a wide range of physical and
psychological manifestations which occur in relation to the
onset of the menstrual cycle.
OBJECTIVE
3.1: Describe the Dhysical and psychological symptoms which
may indicate PMS.
EVALUATION 3.1: Describe six physical and six psychological symptoms
which may indicate PMS.
CONTENT OUTLINE
----------------------LEARNING
OPPORTUNITIES
A. Psychological and Physiological
Symntomatologv
1. Symntoms can range from mild
through severe to incapacitating.
Using overhead transparencies,
the instructor lists and
discusses the various symptoms
of PMS.
2. Symntoms havebeen reported to
occur both in ovulatory and
anovulatory cycles.
3. Symptoms are diverse and can
occur singly or in combination.
a. The number of symptoms as
well as the severity var1es
with each woman.
b. Sometimes patient/family do
not recognize the connection
between symptoms and the
menstrual cycle.
4. No correlation has been
established with symutoms and
age or parity, however, there
has been a correlation established between severity and:
a. age
b. pregnancy.
c. a disruption in cycle.
5. PMS sufferers look physically
well, which often misleads
friends and family into regarding the symptoms as psychosomatic in origin.
The instructor elicits student
discussion of the various
manifestations of PMS, and
emphysizes the cyclic occurences of the symptoms.
41
III. PREMENSTRUAL SYNDROME: SYMPTOMS AND DIAGNOSIS
CONCEPT 3: The premenstrual syndrome covers a wide range of physical and
psychological manifestations which occur in relation to the
onset of the menstrual cycle.
OBJECTIVE
3.1: Describe the physical and psychological symptoms which
may indicate PMS.
EVALUATION 3.1: Describe six physical and s1x psychological symptoms
which may indicate PMS.
CONTENT OUTLINE
6. Common physical symptoms:
a. weight gain
b. abdominal swelling
c. bloating
d. peripheral edema
e. swellin~/tenderness of the
breasts
f. headache/migraine
g. vertigo
h. abdominal/pelvic pain.
1. change 1n bowel habits and
micturation patterns
J. skin changes
k. acne
7. Less common physical symptoms:
a. increased pigmentation
b. eczema
c. uticaria
d. herpatic eruptions
e. rhinitis
f. palpitations
g. nausea
h. thirst
8. Common psychological
manifestations:
a. depression
b. tension
c. anxiety and aggression
d. irrit3.bility
e. lethargy, fatigue
f. change in libido
g. change in sleeping patterns
h. anorexia
1. craving for salty and/or
sweet foods
LEARNING OPPORTUNITIES
42
III. PREMENSTRUAL SYNDROME: SYMPTOMS
-~D
DIAGNOSIS
CONCEPT 3: The premenstrual syndrome covers a wide range of physical and
psychological manifestations which occur in relation to the
onset of the menstrual cycle.
OBJECTIVE
3.2: Discuss how PMS is diagnosed.·
EVALUATION 3.2: Discuss two critical observations necessary to establish
a diagnosis of PMS, and explain how a personal diary may
illustrate the syndrome.
CONTENT OUTLINE
---------------------------------J•
-
LEARNING OPPORTUNITIES
----
loss of concentration
k . c 1urns in e s s
1. sadness and/or weepiness.
9. Positi,,e symptoms sometimes
experienced with PMS:
a. increased sexual drive
b. increased feeling of well
being
c. increased creativity
d. increased energy (frequently
related to increased work
output, e.g., cleaning the
house, scrubbing tile
or floors, baking, etc.)
10. Less is known about the positive
symptoms as they are frequently
not reported.
B. Diagnosis of PMS:
1. There is no laboratory test
diagnostic of PMS.
2. Diagnosis made on basis of
history demonstrating:
a. A recurrent relationship
between the premenstrual
stage and the onset of
symptoms.
b. Relief of symptoms with the
start or cessation of
menstruation.
Instructor lectures on methods
of diagnosing PMS.
43
III. PREMENSTRUAL SYNDROME: SYMPTOMS AND DIAGNOSIS
CONCEPT 3: The premenstrual syndrome covers a wide range of physical and
psycholo~ical manifestations which occur in relation to the
onset of the menstrual cycle.
OBJECTIVE
3.2: Discuss how PMS is diagnosed.
EVALUATION 3.2: Discuss two critical observations necessary to establish
a diagnosis of PMS, and exolain how a personal diary may
illustrate the syndrome.
CONTENT OUTLINE
3. Personal diary/chart maintained by the patient is the most
effective method of diagnosing
the condition.
LEARNING OPPORTlffliTIES
Instructor distributes handout
of a "personal diary" form.
a. Diary should be kept for at
least three (3) cycles.
b. Diary should include:
1) how the patient feels
each day.
2) a record of particular
symptoms.
3) when menstruation begins
and ends.
4) daily weight if fluid
retention related
symptoms are present.
5) basal body temperature
chart. (This should be
kept for at least three
months out of each six).
4. Essential criteria for diagnosis
of PMS:
a. Symptoms occur regularly
b. Symptoms occur in a cyclical
manner in relation to the
onset of menstruation.
Instructor uses overhead
transoarencies to illustrate
s :w:m 1. e diary.
Instructor elicits discussion
regarding the usefullness of
of a journal.
44
III. PREMENSTRUAL SYNDROME: SYMPTOMS AND DIAGNOSIS
CONCEPT 3: The premenstrual syndrome covers a wide range of physical and
psychological manifestations which occur in relation to the
onset of the menstrual cycle.
OBJECTIVE
3.2: Discuss how PMS is diagnosed.
EVALUATION 3.2: Discuss two critical observations necessary to establish
a diagnosis of PMS, and explain how a personal diary may
illustrate the syndrome.
CONTENT OUTLINE
-------------------------LEARNING
OPPORTUNITIES
c. Symptoms may be regularly
irregular, e.g., go away for
months, or be temporarily
replaced by others; but the
symptoms bear a fairly
consistant relationship to
the particular menstrual
cycle where they occur.
SUGGESTED RESOURCES
Ginsburg, J. and Fink, R.S. "Premenstrual Syndrome"
386-388' 1981
~~-~i_ng ~Oxford):
Rose, R .M. and Ab-planalp, J. M. "The premenstrual syndrome"
June, 1983.
~ospi tal
Pra~ice:l29-141,
Sharma, V. "Special reoort: premenstrual syndrome 11 J'he _Pr~~!i tio~er
(226): 1091-1098, June, 1982.
Speroff, L. "Synposium: helping your patients cope with PMS"
Contemoorary OB/GY~: 169 -190, April,1984.
45
III. PREMENSTRUAL SYNDROME: SYMPTOMS AND DIAGNOSIS
CONCEPT 3: The premenstrual syndrome covers a wide range of physical and
psychological manifestations which occur in relation to the
onset of the menstrual cycle.
OBJECTIVE
3.3: Discuss the major theories which pronase the causes of
PMS.
EVALUATION 3.3: Discuss seven theories proposing the cause of PMS, and
accurately identify three methods of treatment which
have been shown effective in the treatment of PMS.
CONTENT OUTLINE
LEARNING OPPORTUNITIES
----------------~-----------------~----------------------
C. Current proposed causes of PMS:
1. Theory: Psychogenic "It's all in her head".
a. Probably the oldest theory;
b. Due to physiolo~ical changes identified has little
validity today.
2. Water retention
a. Theory: Estrogen cau..ses rise
ultimately in aldosterone
resulting in sodium (and
therefore water) retention
and potassium deoletion;
b. Correlation between PMS and
actual increase in body fluid
has not been established,
how·ever a shift in fluid to
the abdomen and other affected sites had been hypothesized;
c. Premenstrual symntoms not
always resolved with administration of a diuretic.
3. Hypoglycemia
a. Theory: Increased progesterone
levels trigger an increased
insulin response to glucose.
Instructor lectures on the
proposed causes of PMS.
Instructor nrovides list of
causes and theoretical
explanation.
46
il
III. PREMENSTRUAL SYNDROME: SYMPTOMS AND DIAGNOSIS
CONCEPT 3: The premenstrual syndrome covers a wide range of physical and
psycholo~ical manifestations which occur in relation to the
onset of the menstrual cycle.
OBJECTIVE
3.3: Discuss the major theories which propose the causes of
PMS.
EVALUATION 3.3: Discuss seven theories oroposing the cause of PMS, and
accurately identify three methods of treatment which
have been shown effective in the treatment of PMS.
CONTENT OUTLINE
LEARNING OPPORTUNITIES
-------···-------------
b. Findings most marked in women
with prominent nervous
symptoms or cravings for
sweets in the premenstruum.
c. May serve to explain jittery feelings, mood swings,
increased fatigue, craving
for sweets.
d. Premenstrual symptoms not always relieved by food intake.
4. Estrogen/progesterone imbaLmce
a. Theory: Too much estrogen,
too little progesterone, or
an imbalance in the ratio of
estrogen to progesterone.
b. The original theory (by Frank
in 1931): Reduced renal
excretion of estrogen was
was the cause of PMS.
c. According to Dalton's theory,
PMS is the result of a droo
in progesterone level just
prior to menstruation.
d. No controlled studies to
prove efficacy, however, progesterone therapy has been
determined effective in noncontrolled situations.
.
47
III. PREMENSTRUAL SYNDROME: SYMPTOMS AND DIAGNOSIS
CONCEPT 3: The premenstrual sy~drome covers a wide range of physical and
psychological manifestations which occur in relation to the
onset of the menstrual cycle.
OBJECTIVE
3.3: Discuss the major theories which propose the causes of
PMS.
EVALUATION 1.3: Discuss seven theories proposing the cause of PMS, and
accurately identify three methods of treatment which
have been shown effective in the treatment of PMS.
CONTENT OUTLINE
LEARNING OPPORTUNITIES
5. Alteration in central nervous
system neurotransmitters:
a. Theory: Decrease 1.n dopamine
level; elevation of prolactin
level.
b. Decreased
have been
retention,
secretion,
levels of dopamine
linked to fluid
altered prolactin
and depression.
c. Elevated prolactin levels
have been related to PMS
(however, studies have not
substantiated its effect);
excessive prolactin not
substantiated as a cause 1.n
any studies.
d. Studies have established some
nositive results of treatment
of PMS with Bromocriptin to
suppress elevated orolactin
oituitary hormone levels;
e. Reported effectiveness for
bromocriptin may not be
related to the prolactin
suppression, but to its
dopamine agonist properties.
48
III. PREMENSTRUAL SYNDROME: SYMPTOMS Al.\l'D DIAGNOSIS
CONCEPT 3: The premenstrual syndrome covers a wide range of physical and
psychological manifestations which occur in relation to the
onset of the menstrual cycle.
OBJECTIVE
3.3: Discuss the major theories which propose the causes of
PMS.
EVALUATION 3.3: Discuss seven theories proposing the cause of PMS, and
accurately identify three methods of treatment which
have been shown effective in the treatment of PMS.
CONTENT OUTLINE
6. Pyridoxal phosphate
LEARNING OPPORTUNITIES
deficie~cy
a. Pyridoxal (vitamin B-6) is a
cofactor necessary in the
synthesis of dooamine and
serotonin;
b. Initial theory: B-6 was
thought to corr~ct a~berant
estrogen metabolism. More
recent theory: oremenstrual
estrogens cause a decrease of
vitamin B-6 that results in PMS.
c. Has been used since the 1940's
as a treatment for PMS; some
studies have shown treatment
effectiveness.
7. Elevated prostaglandin levels.
a. According to Buddoff's
theory, increased levels of
prostaglandin result in
certain congestive types of
PMS sy!llptoms such as breast
tenderness and abdominal
bloating;
b. Some effectiveness has been
reported with the use of
anti prostaglandin medication with certain physical
symptoms.
49
III. PREMENSTRUAL SYNDROME: SYMPTOMS
A.;.~D
DIAGNOSIS
CONCEPT 3: The premenstrual syndrome covers a wide range of physical and
psychological manifestations which occur in relation to the
onset of the menstrual cycle.
OBJECTIVE
3.3: Discuss the major theories which propose the causes of
PMS.
EVALUATION 3.3: Discuss seven theories proposing the cause of PMS, and
accurately identify three met~ods of treatment which
have been shown effective in the treatment of PXS.
-----------------------------------------------:-=-=-c::-=-----·-----CONTENT OUTLINE
LEARNING OPPORTUNITIES
c. caffeine is known to exascerbate PMS; caffeine and
prolactin have been shown to
increase prostaglandin levels.
8. Evolutionary predisposition
a. Rosseinsky and Hall presented
a theory of evolutionary
origin for premenstrual
tens ion:
1) spells of female infertility following ovulation
caused female hostility to
check male ardor.
2) the resulting increased
male ardor during the next
onset of fertility would
enhance the probability of
conception.
3) the effect of species
survival therefore impressed on the menstrual cycle
a oeriodic, programmed
hostility phase of normal
evolutionary origin.
b. Theory purported that oremenstrual tension is intrinsic
and ineradicable and is a
result of genetic inheritance
rather than neuroses.
9. No one theory has been proven in
rig~sly-controlled scientific
clinical studies.
50
III. PREMENSTRUAL SYNDROME: SYMPTOMS At'1D DIAGNOSIS
CONCEPT 3: The premenstrual syndrome covers a 1vide range of physical and
psychological manifestations which occur in relation to the
onset of the menstrual cycle.
OBJECTIVE
3.3: Discuss the major theories which propose the causes of
PMS.
EVALUATION 3.3: Discuss seven theories proposing the cause of PMS, and
accurately identify three methods of treatment which
have been shown effective in the treatment of PMS.
CONTENT OUTLINE
LEARNING OPPORTUNITIES
10. It ia a possibility that the
PMS Syndrome:
a. may well not be a single
entity.
b. may have a multifactorial
etiology.
SUGGESTED RESOURCES
Allen, P. and Fortino, D. Cycles: Evr::ry Womans Guide to Menstruation.
New York: Pinnacle Books, Inc., 1983.
Budoff, Penny W. No More Menstrual Cramos
New York: Penguin Books Ltd. 1981.
~~Othe~Go9~~ew~.
Ginsburg, J. and Fink, R.S. "Premenstrual Syndrome" ~ursi~~L~gxford2:
386-388, 1981
Gonzalez, E. R _ "Premens trua1 syndcome: an ancient T..Yoe deserving of
modern scrutiny"~~ 245: 1393-1.396, 1981.
Reid, R.L., Yen, S.S.C. "Premenstrual syndrome" Am J
139(1): 85-104, 1981
Obste_!_~yn~~£!2_.!.
Rosseinsky, D.R. and Hall, P.G. "An evolutionary theory of premenstrual
tension" ~ancet :1025, October 26,1974.
Sharma, V. "Special report: premenstrual syndrome"
(226): 1091-1098, June, 1982.
'!~-~_Pr~ct~tioneE
Witt, R.L. PMS: What Every Woman Should Know About Premenstrual
Syndrome. New -York: Steinand Day- Publishers, 1984.
51
IV. PREMENSTRUAL SYNDROME: TREATMENT
CONCEPT 4: Compliance to a medical treatment reglmen can control the
incidence of severe PMS episodes.
OBJECTIVE
4.1: Describe the primary medical treatments prescribed for
PMS.
EVALUATION 4.1: List SlX medical treatments prescribed to treat PMS and
describe them in relation to effectiveness, side effects
and precautions.
CONTENT OUTLINE
------------------------
LEARNING OPPORTUNITIES
IV. PREMENSTRUAL SYNDROME: TREATMENT
A. Medical Treatment of PMS:
1. Tranquilizers
a. Meprobamate - use advocated
in the 1950's; then considered to have low toxicity and
no side effects. Also
considered non habit formin~;
this has not proven correct.
b. Diazepam (valium): drug
replacing meprobamate ln the
60's and 70's.
c. Lithium carbonate - not found
effective, not recommended.
d. Phenothiazines: e.g .. compazine,
stelazine, phenergan, increase
prolactin levels. One theory
regarding the cause of PMS is
elevated prolactin levels.
e. Tranquilizers increase the
prolactin level and may thus
decrease the progesterone
leve 1.
f. Tranquilizers and sedatives
have not been found effective
in treatment of PMS, and may
in fact mask or worsen_ symptoms.
52
IV. PREMENSTRUAL SYNDROME: TREATMENT
CONCEPT 4: Compliance to a medical treatment reg1men can control the
incidence of severe PMS episodes.
OBJECTIVE
4.1: Describe the primary medical treatments prescribed for
PMS.
EVALUATION 4.1: List s1x medical treatments prescribed to treat PMS and
describe them in relation to effectiveness, side effects
and precautions.
CONTENT OUTLINE
2.
Bro~ocriptine
LEARNING OPPORTUNITIES
(parlodel) - an
ergot alkaloid
a. Inhibits prolactin secretion.
b. Is also a dopamine antagonist.
c. Effectiveness reported in
controlling premenstrual
breast swelling and soreness.
d. Has severe side effects
including:
1) nausea/vomiting,
2) postural hypotension
3) nasal congestion.
e. In studies, overall therapeutic effect proven to be no
different than placebo.
3. Diuretics
a. Increases sodium and water
excretion.
b. Most useful when symptoms
relate to water retention,
e.g., weight gain, bloated
feeling, breast swelling and
tenderness.
c. May also deolete potassium,
however, two diuretics,
Aldactone (spironolactone)
and Dyrenium (triamterene)
are potassium sparing.
53
".
IV. PREMENSTRUAL SYNDROME: TREATMENT
CONCEPT 4: Compliance to a medical treatment regimen can contra 1 the
incidence of severe PMS episodes.
OBJECTIVE
4.1: Describe the primary medical treatments prescribed for
PMS.
EVALUATION 4.1: List six medical treatments prescribed to treat PMS and
describe them in relation to effectiveness, side effects
and precautions.
-
CONTENT OUTLINE
---------------
LEARNING OPPORTUNITIES
------·---·
----
d. The physician may prescribe a
potassium supplement or
encourage increased intake
in potassium rich foods to
prevent potassium depletion.
e. Side effects of potassium
depletion:
1) ele~trolyte imbalance
2) muscle weakness
4) muscle aches and cramos
3) constipation or diarrhea
5) dizziness
6) headache
7) rapid pulse
f. Precaution:
1) overuse or long term use
of diuretics can lead to
physiological changes in
the way the body excretes
water;
2) the prescribed dose of
diuretic (or potassium
suppliment) should never
be exceeded.
4. Oral Contraceptives.
a. Suppresses gonadotrophin
secretion and ovulation;
induces a relatively constant
hormonal environment throughout the menstrual cycle,
thereby minimizing the
54
IV. PREMENSTRUAL SYNDROME: TREATMENT
CONCEPT 4: Compliance to a medical treatment regimen can control the
incidence of severe PMS episodes.
OBJECTIVE
4.1: Describe the primary medical treatments prescribed for
PMS.
EVALUATION 4.1: List six medical treatments prescribed to treat PMS and
describe them in relation to effectiveness, side effects
and precautions.
CONTENT OUTLINE
usually occurring dramatic
estrogen/progestrone changes.
b. Dalton contends that the
synthetic progestogens (the
progesterone like component
of the contraceptive) causes
a decrease in the already low
natural progesterone level,
therefore worsening the PMS.
c. Some othe researchers have
reported a positive effect on
PMS in some women.
5. Pyridoxine (B-6)
a. Pyridoxine is a cofactor in
the synthesis of the neurotransmitters serotonin and
dopamine; mood and behavior
variables could be effected
pyridoxine deficiency assocciated with lowered serotonin
and dopamine levels.
b. Low serotonin levels have
been related to depression.
c. Decreased dopamine levels
may also serve to increase
prolactin levels; elevated
prolactin has been theorized
as a cause of PMS.
d. Breast tenderness has been
reported to improve on
pyridoxine therapy.
LEARNING OPPORTUNITIES
55
IV. PREMENSTRUAL SYNDROME: TREATMENT
CONCEPT 4: Compliance to a medical treatment regimen can control the
incidence of severe PMS episodes.
OBJECTIVE
4.1: Describe the primary medical treatments prescribed for
PMS.
EVALUATION
L~.l:
List six medical treatments prescribed to treat PMS and
describe them in relation to effectiveness, side effects
and precautions.
-----------------LEARNING
CONTENT OUTLINE
e. Women taking oral contraceptives have been found to have
a functional pyridoxine
deficiency; B-6 has been
incorporated into some brands
of oral contraceptives.
f. Recommended treatment dose:
40 - 100 mg. of pyridoxine
daily for 10 to 14 days prior
to menstruation.
g. Precautions:
1) B-6 has been found to build
up in the blood stream,
thereby becoming toxic.
2) Continued megadose therapy
of B-6 (e.g., 2000 to 6000
mg. per day) can cause loss
of sensation in the extremities, difficulty in
walking and possible loss
of some extremity function.
6. Progesterone Therapy.
a. Manufactured from yams and
soybean plants.
b. Cannot be taken orally as it
is excreted from the body
before becoming effective.
OPPORTUNITIES
56
IV. PREMENSTRUAL SYNDROME: TREATMENT
CONCEPT 4: Compliance to a medical treatment regimen can control the
incidence of severe PMS episodes.
OBJECTIVE
4.1: Describe the primary medical treatments prescribed for
PMS.
EVALUATION 4.1: List s1x medical treatments prescribed to treat PMS and
describe them in relation to effectiveness, side effects
and precautions.
CONTENT OUTLINE
------ - - - - - - - - - - - -
LEARNING OPPORTUNITIES
c. Recommended treatment for
severe PMS: 200 mg of
natural progesterone is
administered vaginally for
at least the five (5) days
before the onset of menses.
d. As pro~es terone is not
immediately effective, and
requires several days of
administration to reach the
required blood level, suppositories should be taken at
least four days before the
expected onset of PMS.
e. Dalton has recommended:
1) 25 to 100 mgs. of proges-
terone given intramuscularly daily every second
day; or
2) up to four 200 to 400 mgs.
of progesterone given in
vaginal suppository form
every day from day 14 of
the cycle; or
3) the subcutaneous implantation of 5 to 12 pellets of
25 or 100 mgs. of progesterone each.
f. Treatment is recommended for
3-4 months, until a beneficial
effect is observed; the dose
57
IV. PREMENSTRUAL SYNDROME: TREATMENT
CONCEPT 4: Compliance to a medical treatment regimen can control the
incidence of severe PMS episodes.
OBJECTIVE
4.1: Describe the primary medical treatments prescribed for
PMS.
EVALUATION 4.1: List s~x medical treatments prescribed to treat PMS and
describe them in relation to effectiveness, side effects
and precautions.
CONTENT OUTLINE
LEARNING OPPORTUNITIES
regimen may then be gradually
reduced, but s~ould be resumed
at a higher level if symptoms
should reoccur.
g. Progesterone treatment has
not been proven effective in
rigid clinically controlled
studies.
h. Side effects:
1) weight change has been
noted, either loss or gain.
2) change in length of the
menstrual cycle has been
noted, either shortened or
lengthened.
7. Progestogen Therapy
a. A synthetic progesterone
prescribed to be taken only
during the premenstrual phase.
b. Is thought to assist in maintaining estrogen/progesterone
balance, however, some studies
have shown progestogens
actually have a tranquilizing
effect.
c. Some English studies have
demonstrated relief of PMS
symptoms, especially headache,
anxiety, irritability, and
hostility.
58
IV. PREMENSTRUAL SYNDROME: TREATMENT
CONCEPT 4: Compliance to a medical treatment regimen can control the
incidence of severe PMS episodes.
OBJECTIVE
4.1: Describe the primary medical treatments prescribed for
PMS.
EVALUATION 4.1: List s~x medical treatments prescribed to treat PMS and
describe them in relation to effectiveness, side effects
and precautions.
CONTENT OUTLINE
----
LEARNING OPPORTUNITIES
d. It is not a universally
accented treatment; it may ~n
fact exacerbate PMS symptoms.
e. Side effects:
1)
2)
3)
4)
Breast tenderness
Menstrual irregularity
Blood clots
Cardiovascular com1)lications.
8. Placebo Therauy
a. When scrutinized under carefully controlled, double blind
Bcientific studies, most treatments have been found to be no
more effective than treatment
with su~ar pills (placebos).
b. Placebo uhilosophy:
"It doesn't matter how it
works or whether it works, as
long as the patient believes
it r,o1orks and gets relief".
c. Over 60 percent of PMS
patients exuerience singificant relief no matter what
the therapy modality.
9. Counseling Therapy
At times family counseling may
be recommended to assist all
members of the family unit in
living with the symptoms of the
PMS sufferer.
59
~1
IV. PREMENSTRUAL SYNDROME: TREATMENT
CONCEPT 4: Compliance to a medical treatment regimen can control the
incidence of severe PMS episodes.
OBJECTIVE
4.1: Describe the primary medical treatments prescribed for
PMS.
EVALUATION 4.1: List s~x medical treatments prescribed to treat PMS and
describe them in relation to effectiveness, side effects
and precautions.
SUGGESTED RESOURCES
Budoff, Penny W. No More Menstrual Cramos And Other
New York: Penguin Books Ltd, 1981.
Goo~~ews.
Ginsburg, J. and Fink, R.S. "Premenstrual Syndrome"
386-383' 1981
Nursi~g__(Oxford):
Gonzalez, E. R. "Premenstrual syndrome: an ancient r.;roe deserving of
modern scrutiny" JAMA 245: 1393-13%, 1981.
Green, J. "Recent trends in the treatment of premenstrual syndrome: a
critical review" Behavior And The Menstrual Cycle: 367 -395, Edited by
Richard C. Friedman, New York: Marcel Dekker, 1982.
Reid, R.L., Yen, S.S.C. "Premenstrual syndrome" Am J Obstet Gynaecol
13 9 ( 1 ) : 85 -104 ; 1 9 81
Sharma, V. "Soecial report: premenstrual syndrome" The Practitioner
(.226): 1091-1098, June, 1982.
Spero££, L. "Synposium: helping your patients cope with PMS"
Contemporary OB/GYN:l69 -190, April,1984.
Witt, R. L. PMS: What Every Woman Should Know About Premenstrual
Syndrome. New York: Stein and Day Publishers, 1984.
•
60
V. PREMENSTRUAL SYNDROME:
COPING WITH PMS:
CLIENT MEASURES
CONCEPT 5: Specific behavioral measures can be taken to reduce the
severity of PMS.
OBJECTIVE
5.1: Describe steps the PMS sufferer can take on her own to
reduce the effects of PMS.
EVALUATION 5.1: Describe at least five steps the PMS sufferer can take
on her own to reduce the effects of PMS.
LEARNING OPPORTUNITIES
CONTENT OUTLINE
V.
PREMENSTRUAL SYNDROME: COPING WITH PHS,
CLIENT MEASURES
A. The first step: Recognition
1. Knowing why the feelings/
symptoms occur ia the first step
to control.
2. Use a chart to track improvement
based on the treatment; positive
results can increase sense of
control.
3. Kno~ing that the symptoms will
occur and being able to predict
when they will occur helps to
control PMS.
B.
Individual management of PMS:
1. Never let blood
low;
su~ar
fall too
a. Five to six light meals per
day are better than ~wo or
three large meals.
b. Decrease intake of concentrated sugar; helps to decrease
symptoms of hypoglycemia.
c. Eat foods high in protein,
low in saturated fats;
protein should reoresent about
20 percent of the total daily
caloric intake.
Q
•
61
V. PREMENSTRUAL SYNDROME:
COPING WITH PMS:
CLIENT MEASURES
CONCEPT 5: Specific behavioral measures can be taken to reduce the
severity of PMS.
OBJECTIVE
5.1: Describe steps the PMS sufferer can take on her own to
reduce the effects of PMS.
EVALUATION 5.1: Describe at least five steps the PMS sufferer can take
on her own to reduce the effects of PMS.
CONTENT OUTLINE
LEARNING OPPORTUNITIES
d. Limit red meat to three ounces
or less oer day; limit dairy
products to two serving~ per
day.
e. Increase intake of complex
carbohydrates to reoresent
about 65 percent of the total
daily calorie intake.
f. Avoid "empty" calories; avoid
most nrocessed and "fast"
foods which are hi~h in SAlt,
sugar and chemicals.
g. Avoid cigarettes and alcohol
as they effect blood sugar
levels.
h. Foods often recommended by
nutritionists and gynecologists include: fresh or frozen
vegetables (canned vegetables
have a higher salt content
and should be avoided); fresh
or frozen fruit juices.
especially oranges and
bananas; yogurt; milk (1-2
cups/day); low salt ccttage
cheese; whole grain breads
and cereals; foods rich in
B vitamins (e.g., beans, rice,
red meat); foods rich in iron,
zinc and magnesium (e.g ..
broccoli, lettuce, mushrooms,
onions, liver); protein
sources of fish, poultry
whole grain and legumes.
62
V. PREMENSTRUAL SYNDROHE:
COPING WITH PMS:
CLIENT MEASURES
CONCEPT 5: Specific behavioral measures can be taken to reduce the
severity of PMS.
OBJECTIVE
5.1: Describe steps the PMS sufferer can take on her own to
reduce the effects of PMS.
EVALUATION 5.1: Describe at least five steps the PMS sufferer can take
on her own to reduce the effects of PMS.
CONTENT OUTLINE
LEARNING OPPORTUNITIES
2. Limit fluids to assist in prevention of water retention, headaches, bloated feeling.
3. Reduce salt intake; helps to
decrease water retention.
a. One team of reasearchers found
that women with PMS consumed
twice as much table salt as
women without PMS;
b. Avoid 11 ins tant 11 foods, prepackaged and canned foods due
to their high salt (and sugar)
content.
c. Avoid smoked, dried pickled
or "salted" foods, commercially
~repared breads, rolls, cereals
(unless salt-free), carbonated
beverages.
d. Avoid carbonated beverages;
soft drinks club soda, tonic
water, diet sodas are high
in sodiu~ benzoate.
e. Read the labels; foods labeled
high in sodium chloride,
sodium citrate, bicarbonate
of soda, and baking powder are
high in salt.
4. Reduce alcohol consumption.
a. Premenstrual 'Y'omen tend to
have a lower alcohol tolerence.
63
V. PREMENSTRUAL SYNDROHE:
COPING WITH PMS:
CLIENT MEASURES
CONCEPT 5: Specific behavioral measures can be taken to reduce the
severity of PMS.
OBJECTIVE
5.1: Describe steps the PMS sufferer can take on her own to
reduce the effects of PMS.
EVALUATION 5.1: Describe at least five steps the PMS sufferer can take
on her own to reduce the effects of PMS.
CONTENT OUTLINE
---------=:---------LEARNING OPPORTUNITIES
b. Less alcohol can cause a
"high" feeling more quickly.
c. limit alcohol intake to one
ounce of hard liquor, four
ounces of wine or 12 ounces
of beer per day.
5. Increase intake of potassium rich
foods.
a. May helr to decrease irritability, lethargy, fatigue.
b. Potassium rich foods include
banannas, dried or fresh
apricots, oranges and
tomatoes.
7. Avoid excessive caffeine intake,
e.g., coffee, tea, cola,
chocolate.
a. Caffeine is a stimulant and
can cause anxiety, insomnia,
nervousness, irritability and
shakiness.
b. May potentiate above syrnotorns
already present due to PMS.
c. Caffeine is a rnethylxanthine;
increased methylxanthines
have been linked to monthly
breast pain.
64
V. PREMENSTRUAL SYNDROME:
COPING WITH PMS:
CLIENT MEASURES
CONCEPT 5: Specific behavioral measures can be taken to reduce the
severity of PMS.
OBJECTIVE
5.1:
Describ~
steus the PMS sufferer can take on her own to
reduce the effects of PMS.
EVALUATION 5.1: Describe at least five steps the PMS sufferer can take
on her o1vn to reduce the effects of PMS.
LEARNING OPPORTUNITIES
CONTENT OUTLINE
d. Caffeine increases the need
for the B vitamins; B-6
deficiency has been proposed
as contributing to PMS.
8. Get adequate rest.
a. If possible a mid-day nao,
or at least a 10-15 minute
break periodically during
the day may helo.
b. Retire earlier during
premenstrual days.
9. Exercise regularly to
sense of well being.
~morave
10. If Dossible reduce stressful
events. avoid known situations
which will cause an upset.
11. Modify demands on self.
12. If water retention is a problem,
an over the counter diuretic
may helo to reduce discomfort.
(A premenstrual headache may
also respond to a diuretic).
a. Some leading brands include
Midol, Pamprin Aqua-Ban,
Femcaps _, Pre-Mens.
65
V. PREMENSTRUAL SYNDROME:
COPING WITH PMS:
CLIENT MEASURES
CONCEPT 5: Specific behavioral measures can be taken to reduce the
s~verity of PMS.
OBJECTIVE
5.1: Describe steus the PMS sufferer can take on her own to
reduce the effects of PMS.
EVALUATION 5.1: Describe at least five steos the PMS sufferer can take
on her own to reduce the effects of PMS.
CONTENT OUTLINE
LEARNING OPPORTUNITIES
b. Low doses of caffeine (under
100 mg.) are described as a
w·eak diuretic, and are used
in some over the counter
preparations for this purpose;
if reducin~ caffeine intake
is a concern, use a product
containing ammonium chloride
or pamabrom as the diuretic
ingredient.
c. Herb diuretics containing
buchu leaves, corn silk,
dandelion, horsetail, juniner
berries and/or w•aterme lon
seeds are also available.
d. Potassium rich foods should
be included in the diet when
a diuretic is taken.
e. Use of the diuretic should be
limited to the premenstrual
phase only, and s~ould be
stopped if side effects occur,
e.~., rapid pulse, diz~iness,
headache, abdominal pain,
diarrhea or vomiting.
13. Increase Vitamin B-6 intake
either through a vitamin supplement or an increase in dietary
intake.
a. B-6 deficiency has been
related to fatigue and
depression.
66
V. PREMENSTRUAL SYNDROME:
COPING WITH PMS:
CLIENT MEASURES
CONCEPT 5: Specific behavioral measures can be taken to reduce the
severity of PMS.
OBJECTIVE
5.1: Describe steps the PMS sufferer can take on her own to
reduce the effects of PMS.
EVALUATION 5.1: Describe at least five steps the PMS sufferer can take
on her own to reduce the effects of PMS.
CONTENT OUTLINE
LEARNING OPPORTUNITIES
b. B-6 is found naturally in
beef liver, brewer's yeast,
wheat germ, brown rice, ~reen
leafy vegetables. and sweet
ootatoes.
c. The body can best absorb and
utilize B-6 when other B
vitamins are present, therefore a combination pill may
be preferential.
14. Aspirin or acetaminophen may be
of use in treatment of headache,
joint and muscle pain exoerienced nremenstrually; avoiding
low blood sugar and/or decreasing
retained water may also gL7e
headache relief in some women.
15. Oil of Evening Primrose has been
recommended by some sources.
a. It is rich in gamma linolenic
acid.
b. Theory:
1) interacts with one type of
prostaglandin to reduce
PMS symptoms.
2) interacts with prolactin to
reduce PMS symDtoms.
c. Method of action and effectiveness has not been proven
by research.
67
V. PREMENSTRUAL SYNDROME:
COPING WITH PMS:
CLIENT MEASURES
CONCEPT 5: Specific behavioral measures can be taken to reduce the
severity oE PMS.
OBJECTIVE
5.1: Describe steps the PMS sufferer can take on her own to
reduce the effects of PMS.
EVALUATION 5.1: Describe at least five steps the PMS sufferer can take
on her own to reduce the effects of PMS.
LEARNING OPPORTUNITIES
CONTENT OUTLINE
d. It is very ex-pensive and
is available only 1n healtl:1
food stores.
16. A craving for chocolate has been
associated with a possible
deficiency.
ma~nesium
a. Research bas shown that some
women with PMS have lower
magnesium levels than women
without PMS.
b. Symptoms associated with
magnesium defeciency include
nervous tension, mood swings,
abdominal bloating, and breast
tenderness.
c. Chocolate is rich in
magnesium, but sl:1ould be
avoided due to the caffeine
and sugar content.
d. Good sources of magnesium
are whole grains, green leafy
vegetables, nuts. legumes,
seeds, cereal and shellfish.
e. Recommended daily allowence
for Magnesium for the non·~regnant/non-lactating woman
is 300 mg.
17. Include the family in education
and
expl.~nation
of PMS.
68
V. PREMENSTRUAL SYNDROME:
COPING WITH PMS:
CLIENT MEASURES
CONCEPT 5: Specific behaYioral measures can be taken to reduce the
severity of PMS.
OBJECTIVE
5.1: Describe ste~s the PMS sufferer can take on her own to
reduce the effects of PMS.
EVALUATION 5.1: Describe at least five steps the PMS sufferer can take
on her own to reduce the effects of PMS.
CONTENT OUTLINE
LEARNING OPPORTUNITIES
a. Families can be adversly
affected by the PMS suffers
symptoms; knowledge of the
uroblem and attempted solutions can reduce family
disharmony.
b. Family members can assist in
the premenstrual period by:
1) reducing stress and demands on the PMS sufferer.
2) increasing support and
understanding.
3) assisting in the treatment
regimen, e.g., assuring
meals are more frequent
and rest requiTements are
met.
c. Family members' guilt feelings may be re 1 ieved by knowing the symotoms manifested,
e.g., anger, hostility,
depression, are due to health
problems.
SUGGESTED RESOURCES
Budo ff, Penny W. No More Mens t:rual Cramus And Other Good News. Net-T
York: Penguin Books-Ltd, -1981-:------Ginsburg, J. and Fink, R.S.
386-388' 1981.
11
Premen,3trual Svnrlr0me 11
~~~(Oxford2:
69
V. PREMENSTRUAL SYNDROME:
COPING WITH PMS:
CLIENT MEASURES
CONCEPT 5: Soecific behavioral measures can be taken to reduce the
severity of PMS.
OBJECTIVE
5.1: Describe steps the PMS sufferer can take on her own to
reduce the effects of PMS.
EVALUATION 5.1: Describe at least five steps the PMS sufferer can take
on her own to reduce the effects of PMS.
SUGGESTED RESOURCES
Hales, Dianne.
July, 1983.
"Flower Power: Evening Primrose Oil" Redbook: 29-30,
Jessop, C. "Medical Staff Conference: Woman's Curse: A General
Internist's Approach To Common Menstrual Problem.s" The Western Journal
of Medicine: 76 -82, January, 1983.
Norris, Ronald V. and Sullivan, Colleen. "The PMS Prescriotion"
Circle: 26-30, 87-88, July 12, 1983.
Norris, Ronald V. and Sullivan, Colleen. PMS
New York: Berkley Books, 1984.
~amily
Preme~~tr~~_Sy:!drome.
Swaffield, Laura "Menstruation: ?re-rnenstrual syndrome" Nursing
Times: 412-413, March 6, 1980.
Witt, R.L. ~:t:!~¥bat Every __ Woman Should Know Abou!:__!.~emen~trual
Svndrome. New York: Stein and Day Publishers, 1984.
--·----
Chapter 6
SUMMARY. CONCLUSIONS AND RECOMMENDATIONS
The development and validation of a premenstrual syndrome
educational model for use by the health educator was the primary
purpose of this project.
The model was developed based upon a survey
of the community and an extensive literature review.
The flexibility
of the model to be adaptated by the health educator to a clinical or a
classroom setting was included in the proiect goal.'
The
Investigator's aim was to provide an instructional tool which could be
used to teach the individual PMS sufferer or the public at large.
Seven experts in the field of PMS and/or health education
provided an evaluation of the accuracy and appropriateness of the
model through the validation process.
su~gestions
for
im~rovement
curriculum model.
Relevant comments and
were incorporated into the refined
This chanter will discuss the conclusions of the
study and recomrnendations for further improvement of the educational
model.
Conclusions
The following conclusions were reached based on an analysis of
the data collected:
70
71
1. There is a definite need for a comprehensive, unbiased
educational model on Premenstrual Syndrome for the health
educator to adapt to the clinical or classroom setting.
2. As there 1.s still no specific treatment for Premenstrual
Syndrome in all cases, a pr1.mary consideration is education.
This education can impact the welfare of the patient as well
as the family members and significant others.
3. The validation process substantiated the validity and utility
of the PMS Educational Model.
There was a positive overall
reaction to the model not only on the part of the validators,
but on the part of others involved 1.n the Needs Assessment and
curriculum development process.
4. True to the nature of the subject matter, the Investigator
found a variety of biases on the part of the panel of experts.
Until
more definative data is available regarding the causes,
effects and treatment of PMS, the topic will continue to
engender a variety of viewpoints and opinions.
Recommendations
1. PMS educational intervention programs should be available to
the PMS sufferer as well as the general public.
health professionals knowledgable of PMS.
There are few
The minimal infor-
72
'
mation currently available in a formal educational setting 1s
often biased and incomplete.
It is hoped that increased
public awareness of this health problem will result in the
implementation of practical, unbiased programs.
2. Education related to awareness of the existence of PMS, its
signs and symptoms and treatment interventions should be made
available to the general pub 1 ic.
Researchers have estimated
as many as 90 percent of the female population suffer from
some form of PMS at some time during their life.
Unless the
PMS is of a severe nature, physician intervention may not be
sought.
An alter'1.ate route for education needs to be
available.
3. There is a need to promote self management of PMS through
educational interventions.
Not all PMS is severe enough to
warrent medical intervention.
There are many self management
alternatives available that can be initiated by the PMS
sufferer that may serve to control the symptoms, or enhance
the therapy prescribed by the physician.
4. The format of the educational model should be modified to
enhance ease of use and clarity.
A summary of ob iec t ives
followed by the content outline would serve to reduce
repetition as well as provide an overview of the content.
'
73
".
5. Content should be modified to be more suitable to the lay
person,
with special attention to medical terms, comolex
explainations, and too extensive a subject matter.
6. As research 1n the field of PMS is constantly bringing new
information to light, ongo1ng evaluation and revision of the
model prior to implementation 1s of critical importance.
74
REFERENCES
1.
Abraham, Guy E. "Nutritional Factors inthe Etiology of the
Premenstrual Tension Syndrome." Journal of_ReE_ro~~_t::!_ive
Medicine: Vol. 28, Number 7: 446 - 464. July. 1983.
2.
Andersch, B .. L. Abrahasson, C. Wendestam. R. Ohman. R. Hahn.
"Hormone Profile in Premenstrual Tension: effects of
Bromocriptine and Diuretics." Clinical Endocrinology (11):
65 7-·664' 1979.
3.
Annual Editions. Health 83/84.
Publishing Group, 1983.
Guilford, Conneticut: Duskin
4.
Allen, P. and Fortino, D. Cycles: Every Womans __Guide_ to
Menstruation. New York: Pinnacle Books, Inc., 1983.
5.
Blume, E. "Premenstrual Syndrome, Depression Linked."
249 (21): 2864-6. June 3, 1983.
6.
Brody, J.E. "Menstrual Problems, Lifting 'The Curse' at Last."
Ladies Home Journal: 40-41, 1981.
7.
Brahams, D.
"Premenstrual Syndrome: A Disease Of The Mind."
Lancet: 1238-1240, November 28, 1981.
8.
Budo ff, Penny W. No More Menstrua 1 Cramps And Other
New York: Penguin Books Ltd, 1981.
9.
Combs. Barbara J., Dianne R. Hales, and Brian K. Williams.
An Invitation to Health, Your Personal Responsibility, Second
Edition-:---Menlo-Park, Callfornfa: B~nj~min~-CunnUTngs Publishing
Company Inc., 1983.
10.
Dalton, Katharina.
One~--~-~~£~~·
House Inc., 1979.
11.
Dalton, Katharina. "Premenstrual Baby Battering."
Medical Journal: 279, May 3, 1975.
JAMA,
Goo~ __ News.
Pomona, California: Hunter
British
75
12.
Dalton, Katharina. The Premenstrual Syndrome.
Illinois: Charles C-.-Thom~~-----r%4-:------
Springfield,
13.
Dalton, Katharina.
The _Pr!:_~~~~ tr~~! __ ~zndr~~~ and Pr~fi~~t:_~_Eone
Ther~el.·
Chicago: Year Book Medical Publishers Inc., 1977.
14.
Diagram Group. Woman ~-~?_dy An Owners Manua 1.
Books , 1980.
15.
d 'Orban, P. T. and J. Dalton. "Violent Crime And The Menstrual
Cycle." ~syc~oloQ;ical___!:'1edi~ir_:~ (10): 353-359, 1980.
16.
Fodor, John T .. and Gus T. Dalis. Health Instruction: Theory
and ~pplic:_~tion. Philadeluhia:
Lea and Febiger,
17.
Frank, R.T. "The Hormonal Causes of Premenstrual Tension."
~rch_iv~~-of -~euro _logy ~~-~--Rsy~~~logy ( 26): 1053, 1931.
18.
Ginsburg, J. and R.S. Fink. "Premenstrual Syndrome."
(Oxford): 386-388, 1981.
1g.
Gonzalez, Elizabeth R.
"Premenstrual Syndrome: An Ancient Woe
Deserving of Modern Scrutiny." JAt'1A, Vol. 245, No. 14:
New York: Bantam
f§sr:------
Nursing_
1393 - 1396, 1981.
20.
Green, J.
"Recent Trends In The Treatment Of Premenstrual
Syndrome: A Critical Review." Behavior And The Menstrual
Cycle: 367-395, Edited by Richard C. Friedman, New York:
M~rcel Dekker, 1982.
21.
Green, R., and K. Dalton. "The Premenstrual Syndrome."
Medical Journal (1): 1007-1014, 1953.
22.
Hales, Dianne. "Flower Power: Evening Primrose Oil. 11 Redbook:
29-30, July, 1983.
23.
Insel, Paul M., and Walton T. Roth.
Core Concepts in Health,
Third Edition. Palo Alto, California:M~yfi~ ld-Pub lishing
Company. 1982.
British
76
24.
Isaac, Stephen. and William B. Michael. Handbook on Research and
Evaluation. Second Edition. San Diego: EdiTS Publi~ers-~--1984.
25.
Jessop, C. "Medical Staff Conference: Woman's Curse: A General
Internist's Approach To Common Menstrual Problems."
The Western Journal of Medicine: 76 -R2, January, 1983.
26.
Jones, T.H. "Menstruation: The Curse Of Eve."
404-406, March 6. 1930.
27.
Jones, Kenneth L .. Louis W. Shainber~, and Curtis 0. Byer.
Dimensions - A Changing Concept of Health, Fifth Edition.
New York: Harp~~ and Row, 1982.
28.
Kemp, Jerrold E. _!nstructio~~"Q_~~ig~.
Fearon and Pitman, 1977.
29.
Kerlinger. Fred N.
Foundations of Behavioral Research,
New York: Rinehart and Winston, 1973.
30.
Kinch, Robert A.H.
"Help For Patients With Premenstrual Tension."
Cons u-1 tan t: 18 7 - 191 , April , 1 9 7 9 .
31.
Lever, Judy, and Michael G. Brush. Pre- Menstrual Tension.
New York: McGraw - Hill Book Company:-1981. ----------
32.
Linkie, D.W.
"The Physiology Of The Menstrual Cycle." Behavior
and the Menstrual Cycle: 1-21, Edited bv Richard C. iriedm;U:
Ne;- York: M;rce lDekk~~. 1981.
33.
Morton, J., H. Additon, R.G. Addison, L. Hunt, and J.J. Sullivan.
"A Clinical Study of Premenstrual Tension." American Journa 1
9i_O£_stet~ics_and Gynecolo~ (65): 1182-1191, 1953.
34.
Norris, Ronald V. and Colleen Sullivan. PMS Premenstrual
Syndrom~. New York: Berkley Books, 1984-.------------
35.
Norris, Ronald V. and Colleen Sullivan.
"The PMS Prescription."
Family Circl~_: 26-30, 87-88, July 12, 1983.
~ursi_(_!_g__'!'i:_mes:
Belmont, California:
77
36.
Paige, K.E.
"Women Le.<J.rn To Sing The Menstrual Blues."
Psychol~gy_Toda~:41-46, September, 1973.
37.
Reid R.L. and S.S.C. Yen. "Premenstrual syndrome." American
Journal of Obstetrics and Gynecology, 139(1): 85-104~981.
38.
Rosseinsky, D.R. and P.G. Hall. "An Evolutionary Theory Of
Premenstrual Tension." Lancet: 1025, October 26, 1974.
39.
Selltiz, Claire, Marie Jahoda. Morton Deutsch and Stuart W. Coo.
Resear~h Methods in Social Relations.
New York: Holt,
Rinehart and Wilson, 1959.
40.
Sharma, V. "Special report: premenstrual syndrome. 11
Practitioner (226): 1091-1098, June, 1982.
41.
Speroff, L.
The
"Synposium: Helping Your Patients Cope With PMS."
169 -190, April, 1984.
~ontemporary O~GYN:
42.
Swaffi~ld,
43.
Swaffield, Laura. "Menstruation: Pre-menstrual Syndrome."
Nursing Times: 412-413, March 6, 1980.
44.
Witt, R.L.
Laura. "Menstruation: Hiding The Evidence."
Times: 414-415, September, 1980.
Nursin~;
PMS: What Every Woman Should Know About Premenstrual
Sy~drom~.-NewYork: -Stein and Day Publishers
,1984-.------
78
MATERIALS FROM THESE SOURCES WERE CONSULTED
IN THE DEVELOPMENT OF THE CURRICULUM.
1.
Dalton, Katharina. "What is this PMS." Journal of th~ Royal
College of General Practitioners: 7I7-722, December, 1982.
2.
Dalton, Katharina. "Cyclical Crimina 1 Acts in Premenstrual
Syndrome." Lancet: 1070-1071, November 15, 1980.
3.
Dalton, Katharina. "Menstrualtion and Crime."
Journal: 1752-1753, December 30, 1961.
4.
Delaney, Janice, Mary Jane Lupton, and Emily Toth.
New York: E.P. Dutton and Company Inc., 1976.
5.
Gonzalez, Elizabeth R. "Even Oral Progesterone may be Effective."
JA.L'1A, Vol. 245, No. 14: 1394, 1981.
6.
Hanna, J. "Defeating the Curse of the Calendar."
Vol. 151, No.14: 36-37, October 2,1980.
7.
Parlee. Mary Brown. "The Premenstrual Syndrome." Psychological_
~ullet~~· Vol. 80, No. 6: 454-465, 1973.
8.
Rose, R.M. and J.M. Abplanalp. "The Premenstrual Syndrome."
Hospital Practice: 129-141, June, 1983.
9.
Sampson, Gwene th A.. and Phi lip Prescott. "The Assessment of the
Symptom and Their Response to Therapy." British Journal of
Psr~~iatry (138): 399-405, 1981.
British_!"!ed~eal
The Curse.
Nu!:sing_Mirror,
10. Sampson, Gweneth A. "Premenstrual Syndrome: A Double-Blind
Controlled Trial of Progesterone and Placebo." British
Journal__ of_~~I~~ia trr ( 135): 209-215, 1979.
11. Stokes, L. and J. Mendels. "Pyridoxine and Premenstrual Tension."
Lane~~: 1177-1178, May 27,1972.
APPENDIX A
CURRICULUM NEEDS ASSESSMENT
INTERVIEW QUESTIONNAIRE
79
80
CURRICULUM NEEDS ASSESSMENT INTERVIEW QUESTIONNAIRE
DATE:
----------------
PERSON INTERVIEWED:
--------------------------------------------POSITION:
------------------------------------------------------1.
In your opinion, how important is patient education in dealing
with PMS?
8
------
Very important.
______ Important.
------Somewhat
important.
Unimportant. Please elaborate:
-----2.
-----------------------------
What method(s) do you use to teach patients about PMS?
8
Oral discussion during office visit.
3
Preprinted material.
--~--
--~--
1 Recommended readings of printed information available at
--~---book stores.
1
Audiovisual presentation.
--~--
____O__Other: (Please list:)_________________________________
3.
In your practice, when dealing with PMS, the educational effort is
geared toward:
7 The
-----1
The PMS patient and spouse/significant other.
1
The PMS patient and family.
--~--
--~--
4.
PMS patient only.
Do you know of an unbiased, comprehensive, factual information
reference suitable for the general public?
Yes
8
No
If yes, please identify: ~N~o~n~e~-----------------------------------
APPENDIX B
LETTER OF TRANSMITTAL
81
82
April 10,1985
Dear
Thank you for agreeing to review the curriculum I have prepared on
premenstrual syndrome. The development of this curriculum is a special
project which will partially meet my requirements for obtaining a
Masters of Public Health degree at the University of California,
Northridge, School of Public Health. The ultimate goal of this
research is to develope a complete, unbiased and factual educational
intervention model dealing with PMS. Although specific books have
been published for the public at large, no PMS educational curriculum
is currently available to the health educator. It is this void which
I hope this curriculum will fill.
As you are a recognized leader in the field of women's health, I am
seeking your assistance to validate the accuracy, clarity and
completeness of the attached curriculum. Your responses are
critically needed to further refine this educational model. I know
there are many other claims on your time, but your thinking will help
to create a body of information which may be adapted by the health
educator to a clinical or a classroom setting. It could be used for
instruction specific to the PMS sufferer, or more generally to the
public at large. A validation questionnaire is enclosed which
specifically identifies what my needs are. Please answer all items.
I would appreciate your response as soon as possible, but before June
30, 1985. If you need clarification about any item, you may contact
me at (818) --- ----, or at my office at (818) -------,extension---.
Since your are an outstanding leader in the field of women's health,
please give this curriculum the benifit of your thinking. Your
thoughts will be extremely valuable, and your contribution will be
acknowledged in the final work. Please take time to respond. Thank
you very much for your assistance.
Yours very truly,
Laurie Marx, R.N.
APPENDIX C
VALIDATION QUESTIONNAIRE
84
VALIDATION QUESTIONNAIRE
Please rate your answers to the following questions by circling the
number which corresponds best to your feelings.
Rating Scale:
1
low
2
3
4
5
high
6
not applicable
(If your response is on the low end of the scale, e.g., 11 111 or "2",
please state your reason for this response under "comments".)
This curriculum on Premenstrual Syndrome was designed to provide
unbiased and factual information to the health educator in the
clinical setting or at the community college level.
1.
Does this curriculum meet the above objective?
1
COMMENTS:
2.
4
5
6
Are the course objectives clearly stated?
COMMENTS:
2
3
4
5
6
--------------------------------------------------------------
Is the content organized in a useful manner (e.g., good continuity
and coherency)?
1
COMMENTS:
4.
3
----------------------------------------------------------------
1
3.
2
2
3
4
5
6
----------------------------------------------------------------
Is the content factual and in line with the most current thinking?
1
COMMENTS:
2
3
4
5
6
--------------------------------------------·--------------------
85
VALIDATION QUESTIONNAIRE
(Continued)
5.
Does the curriculum contain information appropriate for
distribution to the lay public (i.e., those with a non medical
background)?
1
2
3
4
5
6
COMMENTS:
-------------------------------------------------------------
6.
Does the coverage of each area provide an adequate information
base?
1
COMMENTS:
7.
2
3
4
5
6
-------------------------------------------------------------
If you were presenting this topic to a lay audience, would you
find this curriculum useful in the preparation of your
presentation?
1
COMMENTS:
2
3
4
5
6
--------------------------------------------------------------
,,
APPENDIX D
VALIDATION EXPERTS
86
'
87
PANEL OF EXPERTS UTILIZED IN THE VALIDATION OF TdE MODEL
1. Gail Anderson, R.N., M.S.N.
Division Director o~ Nursing/Patient Education
Saint Joseph Medical Center
Burbank, California
2. Herald A. Brundage. M.D.
Obstetrics and Gynecolo~y Practitioner
Saint Joseph Medical Center
Burbank, California
3. Penny Buddoff, M.D.
Gynecology and Woman's Health Practitioner
Woodbury, New York
4. Jan Marquard-Tormey M.P.H.
Health Educator
Addie L. Klotz Student Health Center
California State University, Northridge
5. Rita Marshall, R.N., Ph.D., DIR.
Director of Self Study Services
Ventura, California
6. Gayle Pepper McClean, R.N.C.
Nurse Practitioner
Health Care Center for Women
Sherman Oaks, California
7. Cydney Michaelson, R.N., M.S.N
Director of Nursing Education
Saint Joseph Medical Center
Burbank, California
8. Christopher W.T. Pearson, M.D.
Obstetrics and Gynecology Practitioner
Saint Joseph Medical Center
Burbank, California
9. Lorraine Rothman
Director of Education
Feminist Woman's Health Center
Los Angeles, California