In spite of the significant health and economic consequences of dysmenorrhea in adolescent girls, studies of menstrual symptoms and mood variations in adolescents seldom appear in the recent literature. Premenstrual syndrome or premenstrual dysphoric disorder primarily is the focus in today’s literature when considering emotions and problem behaviors,,(6
),. Past studies have demonstrated associations between negative emotions and dysmenorrhea (9
), and between smoking and dysmenorrhea. (4
) However, to our knowledge, this is the first study in adolescents to examine depressive and anxiety symptoms as well as smoking behavior, and their relationship to menstrual symptoms.
The first aim was to describe self reported characteristics of adolescent menstrual symptoms in relation to smoking behavior. The findings document adolescents who smoke also report having more menstrual symptoms. These results held even after controlling for key covariates. Similarly, the Australian Longitudinal Study on Women’s Health showed that 18–23 year old current smokers and ex-smokers had an increased risk of menstrual symptoms compared to non-smokers (13
). Importantly, menstrual symptoms increased in those with a younger age onset of smoking and as cigarette consumption increased. In other studies, smokers had a longer duration of dysmenorrhea,(12
) and smoking increased the risk of dysmenorrhea, which increased as cigarette consumption became higher (14
). Smokers also reported more pain with menses or pain that required medication or time off from work than nonsmokers (28
). Only two studies were found in younger adolescents where dysmenorrhea was positively associated with smoking (29
) whereas smoking was negatively correlated with dysmenorrhea in 19 year olds (31
). Given our findings that adolescent girls who smoke had more menstrual symptoms and the earlier findings of menstrual problems in adult women who smoke, one may want to consider the possibility that smoking may influence adolescent menstrual cycles. Smoking cessation efforts that inform adolescents of this possible relationship may contribute to less smoking in adolescents. Future research will need to confirm such findings in a longitudinal fashion and to examine causation.
The second and third aims of the study were to establish the relation between depressive and anxiety symptoms and menstrual symptoms and if the relation was moderated by smoking. Our study is the first to report that smoking status and depressive symptoms/anxiety are associated with menstrual symptoms in a positive direction and that the impact of depressive symptoms and anxiety is stronger in those who have not had smoking experience. In previous studies depression and anxiety in college age women were positively associated with total menstrual pain using the modified MSQ. Our correlations in the total sample support these previous findings. The fact that both depression and anxiety show a significant relationship with the MSQ may be due to the fact that the two affective variables may have overlapping or associated features.
One novel aspect of our findings is that depressive symptoms and anxiety were more strongly related to higher numbers of menstrual symptoms in the never smoker group than in the ever smoker group of adolescents. This finding initially is counterintuitive. Using it appears that the predicted MSQ Sum scores are relatively equal across the range of depressive symptom scores for the ever smoker group. It may be that this group self-medicates with smoking or other substances as well as pain medication. For example, some individuals smoke to reduce depressive symptoms (32
). The girls in the smoker group were also older and may have had easier access to medications for dysmenorrhea at home or at school. Smokers also were more likely to use hormonal contraceptives (27.7% vs. 3.8% of oral contraceptive use; p ≤ .0001; 49.5% vs. 8.5% of any hormonal contraceptives in the past 12 months, p <.0001) which may improve dysmenorrhea as reported in some studies (23
), but not others (22
). We did however, control for medication use and hormonal contraceptive use in the statistical model. An alternative hypothesis is that dysmenorrhea may be less severe in smokers, as shown by relative stability of dysmenorrhea across depressive symptoms, due to decreased prostaglandin synthesis (33
). This however, cannot be tested in our study. Prostaglandins primarily are responsible for symptoms associated with primary dysmenorrhea and substances found in cigarettes (i.e., nicotine, acrolein) may antagonize prostaglandin synthesis.
Additionally, shows a wider discrepancy in menstrual symptoms by smoking group at the higher end of the depressive symptom distribution. It may be that depressive symptoms in the never smoker group, magnify the intensity of menstrual symptoms (i.e., depression drives menstrual symptoms) whereas low levels of depressive symptoms have no impact on menstrual symptoms allowing smoking to have a greater impact on menstrual symptoms (smoking status drives menstrual symptoms). Longitudinal analyses will be needed to test this hypothesis. In brief, our results show that both depressive symptoms and trait anxiety are significantly correlated with all MSQ factors in a positive direction. Further, there was consistency in the interactions of depressive symptoms and/or anxiety with smoking with the MSQ-sum as well as the MSQ-Spasmodic and Factor 1 (menstrual pain) factors. Significant associations were seen with all MSQ factors with depressive symptoms and anxiety and moderating effects of smoking were seen with many of the factors. However, not all literature supports the use of the two factor model of the MSQ. Future research will need to validate previously defined factor solutions and examine whether other factors exist for the MSQ in this younger age group. Our study examined the same factors that were reported in the literature in order to compare our younger adolescent sample with the results from the standard sample of college age and older women.
An additional reason that some of our findings are contrary to the literature may be related to the variable reflecting smoking behavior. First, although smoking status in studies similar to the current study frequently use a self-report variable, the variable may contain a margin of error. However, in our study girls were asked their smoking history at the screen and then again at their first visit. The kappa coefficient of these two time points was very high (k = .89). The time interval between the two interviews ranged from just a few days to as long as several weeks, thus “disagreement” could also reflect a transition to a higher stage of smoking. If that is the case, our kappa coefficient underestimates agreement. Other studies have shown high reliability in 11 and 12 year olds. Second, dichotomizing smoking status also may limit understanding the full impact of smoking on menstrual symptoms in this age. However, by using a dichotomous variable we minimized the possibility of misclassification of smoking status since any thing more than a puff or two was categorized as “ever smoker”.
Our findings are strengthened by the fact that the study includes a more normative sample of girls with respect to dysmenorrhea; that is girls were not enrolled based on their dysmenorrhea status. We had a range of menstrual symptoms reported but fewer at the high end of severe dysmenorrhea. Earlier studies only enrolled girls who reported dysmenorrhea (20
). Our study also controlled for potentially important confounding variables such as gynecological age, pubertal status, hormonal contraceptive use, and use of medications for dysmenorrhea. Additionally, the sample is relatively large and includes a significant proportion of minorities. However, since our minority population is primarily African American the study cannot be generalized to other minority populations including Hispanics.
This study provides a step towards further understanding menstrual symptoms in adolescent girls and the association that smoking behavior and depressive symptoms or anxiety may have in this academic and socially costly problem. The mechanisms no doubt are complex and dynamic thus calling for more complex models in longitudinal analyses. For example, there is literature that supports that smoking is a risk for future depression,(34
) and that smoking in adolescence is associated with anxiety (36
). But the causal direction is not known (38
). Other studies show that high depressive symptoms in adolescent non-smokers was not predictive of future smoking,(35
) or opposing findings (39
). Similarly, the literature on the association of smoking and dysmenorrhea is not always in a consistent direction (31
) and thus differences must be considered.
Knowing that both smoking and mood are associated with menstrual symptoms has clinical relevance to those providing care for adolescents. Previous research has demonstrated adolescent smokers have thought about or tried quitting (40
). Health care providers may specifically counsel the adolescent female about the mental and functional benefits of smoking cessation, which may be more applicable to their daily life than discussion about future risks of lung cancer and coronary artery disease (atherosclerosis). Earlier research has stressed that more immediate risks from smoking, such as menstrual symptoms, (compared to chronic or long term effects of smoking) may improve the relevance of anti-smoking campaigns focusing on this younger age group (13
). Finally, the findings indicate that the relation between depression or anxiety and menstrual pain begins early in the post-menarcheal years. Therefore, it may be important for providers to give special attention to dysmenorrhea in young adolescents who have depressive symptoms or anxiety or who smoke, as well. In turn, quality of life may be improved and there may be fewer days of school or work absence.
In conclusion, this study shows that moods and smoking are associated with menstrual problems even in young girls. Our finding that girls who have depressive or anxiety symptoms and who smoke may have lower menstrual distress should be accompanied by a note of caution given that the study does not establish causality. Further, the dynamic and complex nature of smoking, moods, and dysmenorrhea cannot be disentangled in a cross-sectional study. Future studies will need to focus on more detailed reports of smoking and the longitudinal changes that occur in the relationships examined in this study. Overall, the findings indicate that efforts to prevent or reduce menstrual symptoms should begin at a younger gynecological age than previously anticipated and that mood and smoking status should be considered.