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Premenstrual symptoms - severity,

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international cross-sectional study
Torbjörn Bäckström

Menopause International

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Menopause International 2009; 15: 120–126. DOI: 10.1258/mi.2009.009030

Original article

Premenstrual symptoms – severity,

duration and typology: an international
cross-sectional study
Lorraine Dennerstein,* Philippe Lehert,* Torbjörn Carl Bäckström† and
Klaas Heinemann‡
*Department of Psychiatry, The University of Melbourne, Victoria, Australia; †Umea Neurosteroid Research Center,
Department of Clinical Sciences, Obstetrics and Gynecology, Norrlands University Hospital, Umea, Sweden;
‡
Bayer Schering Pharma, Women’s Health Care, Berlin, Germany
Correspondence: Professor Lorraine Dennerstein, Department of Psychiatry, The University of Melbourne, Parkville, VIC 3010, Australia.
Email: ldenn@unimelb.edu.au

Abstract
Objectives. Determine women’s experiences of premenstrual symptoms.
Study design. Cross-sectional survey.
Sample. In all, 4085 women aged 14–49 years recruited by random telephone digit dialing in France,
Germany, Hungary, Italy, Spain, UK, Brazil and Mexico.
Main outcome measures. Telephone interview checklist of 23 premenstrual symptoms, sociodemographic
variables and lifestyle variables.
Results. The most prevalent symptoms were abdominal bloating, cramps or abdominal pain, breast tender-
ness, irritability and mood swings. Severity of symptoms is directly proportional to duration (R ¼ 0.79).
Hierarchical clustering found the following mental and physical domains and a typology: ‘Mild’ type (40.8%)
with minimal symptoms; ‘Moderate M’ type (28.7%) with moderately severe, mostly mental symptoms;
‘Moderate P’ type (21.9%) with moderately severe, mostly physical symptoms; and ‘Severe’ type (8.6%) with
severe intensity of both mental and physical symptoms. Multiple stepwise regression found significant effects
on symptom duration severity index of age (linear and quadratic effects), current smoking and country.
Conclusions. Further research is needed on the impact of premenstrual symptoms on quality of life,
and whether a brief symptom list could be developed as a valid and reliable tool globally.

Keywords: Premenstrual symptoms, premenstrual syndrome, epidemiological

Introduction The current study utilizes population-based sampling in

There have been few attempts to elucidate models that
best describe women’s experiences of symptoms associ-
ated with the premenstrual phase of the menstrual cycle.
Models of significant premenstrual syndromes have been
proposed.1–3 Some prevalence studies of these clinical
syndromes were based on clinic samples or convenience
groups and were subject to bias.4–6 Other studies carried
out population-based sampling,7–9 but studies are often
not comparable between countries because of the use of
different measures, methods and criteria.10 Endicott11
reported that premenstrual symptoms are not culture
specific, although particular symptoms may be reported
more frequently in one culture compared with another.
They recommend further epidemiological work in other
cultures to resolve the issue.
a study carried out concurrently in different countries in
Europe and Latin America. The broad objectives are to
describe women’s experiences of the severity and fre-
quency of premenstrual symptoms and to determine
whether there are symptom patterns or a typology classi-
fication suggested.
Materials and methods
Design
During June and July 2003, computer-assisted telephone
interviews, consisting of a series of questions about pre-
menstrual symptoms, were conducted with 4085 women
of reproductive age in European countries (Germany

120 Menopause International Vol. 15 No. 3 September 2009

 L Dennerstein et al. Premenstrual symptoms – severity, duration and typology
n ¼ 531, Italy n ¼ 505, France n ¼ 501, UK n ¼ 500,
Spain n ¼ 500 and Hungary n ¼ 500) and Latin American
countries (Brazil n ¼ 548 and Mexico n ¼ 500).
Subjects
Based on government national statistics in each country,
a representative sample of women aged 14–49 years
(16–49 in France and the UK), who were not pregnant
at the time of the interview, were randomly recruited
according to demographic quotas primarily for age and
secondly for region (urban or rural) and education
(data sources for random recruitment: MA 2002
Pressemedien and Statistisches Bundesamt [Germany],
Census 2001/National Statistics and Labour Force Survey
autumn 2002 [UK], INSEE 1999 [France], EGM 2002
[Spain], ISTAT Census 2001 [Italy], HCSO Census 2001
[Hungary], IBGE Census 2002 and Callbus AC Nielson
Omnibus [Brazil] and INEGI Census 2000 [Mexico]).
Recruitment was based on telephone calls using
numbers derived from different sources: Germany: ADM-
Telefonstichprobe; UK: White pages; Spain: CETESA tele-
phone directories; Italy: Italy Phone Database; Brazil:
Yellow pages; Hungary: database of all private telephone
subscribers of Hungary; France: data file from France
Telecom; and Mexico: phone book.
Measures
When contacted by telephone, women were asked their
ages and whether they were willing to take part in a
telephone interview. Those who qualified and agreed
participated in telephone interviews, with pretrained
female interviewers, which lasted approximately 10
minutes for women with no premenstrual symptoms and
30 minutes for women who had experienced premen-
strual symptoms. Participating women did not receive
any payment for completing the survey.
The women who were currently taking prescription or
non-prescription medication that had been effective in
reducing or relieving symptoms in the days before menses
were asked about their symptoms ‘before starting medi-
cation’. All other women were asked about their current
symptoms.
Women were asked about 23 symptoms. The symptoms
were those on the lists of the classificatory systems used in
the diagnosis of premenstrual dysphoric disorder (PMDD)
according to Diagnostic and Statistical Manual of Mental
Disorders-IV1 and of premenstrual syndrome (PMS)
according to the American College of Obstetricians and
Gynecologists criteria.2 To ensure that women were only
referring to symptoms occurring in the days before their
menstrual periods, symptom questions were introduced
with the following statement: ‘in the following interview we
would like to focus only on the symptoms which might
occur within the days before your menstrual period starts
and which disappear as soon as, or a few days after, the
period begins. This point was reiterated with each question’.
Women who reported any of the premenstrual symptoms
were asked (for each symptom) questions on symptom
severity (mild, moderate or severe) and duration of
Menopause International Vol. 15 No. 3 September 2009
symptom (during how many of the menstrual cycles in the
last 12 months was the symptom experienced). The order of
symptoms in each group was changed between interviews.
Women who experienced any of the premenstrual symp-
toms were also asked a single question on overall severity
of these symptoms (mild, moderate or severe).
Sociodemographic variables
These included age, country and region, education level,
age at first occurrence of premenstrual experiences, marital
status, working status (full time, part time and no paid
work), smoking habits, income level, sport participation,
and use of oral contraceptive pill and other medications.
Statistical analysis
Measuring intensity and frequency
In this survey, symptoms were measured by their per-
ceived severity (ordinal scale – none, mild, moderate or
severe) and duration or frequency (during how many
menstrual cycles was the symptom experienced in the last
12 months). A common way of summarizing symptoms is
a sum-score of severity of symptoms (severity index, SI),
of duration of symptoms (duration index, DI), and even
more accurately as the sum of the products (duration 
severity: duration severity index, DSI). Using three
different indexes renders the analysis complex. Our first
analysis objective was to simplify the analysis, in exami-
ning whether one of these indexes would summarize the
knowledge of the others. We used a mixed generalized
model ( proportional odds model for ordinal data on
random coefficients) to assess the relationship between
severity and duration of symptoms.
Classification of symptoms
We attempt to classify the symptoms according to their
observed intercorrelation, under the assumption that cor-
related prevalence between any two symptoms provides
some evidence of a common cause. We carried out hier-
archical clustering (Ward algorithm) based on the inter-
symptom matrix of distances estimated by the reciprocal
of the Kendall ordinal correlation matrix (1–R 2). As tree
classification usually provides several solutions, the candi-
date items’ classifications were compared by confirmatory
factor analysis, in carrying out bootstrap samples and eval-
uating for each the root mean square residual mean discre-
pancy between implied and observed correlations.12
Explanatory model of premenstrual symptom
experience
In studying symptom classification, we confirm the
existence of a general component of severity, and a
differentiation between mental and physical symptoms.
We attempted to explain these two endpoints (overall
severity and mental/physical profile) according to all the
available variables, sociodemographic ( partner, income,
work, parity, country), lifestyle (smoking habits, sport)
and age at which symptoms started.
The statistical analysis was performed with the help of SAS
9.2 software. Given the large sample size, a level of P values
,0.001 were considered to be significant. When calculated
on the whole sample, the half-confidence interval or
121
L Dennerstein et al. Premenstrual symptoms – severity, duration and typology

precision of the proportions is 1.5% and is not mentioned,
except for small proportions.
Results
Sample description
A total of 4085 women from Latin American (n ¼ 1048)
and European (n ¼ 3037) countries participated in the
study. The response and refusal rates are not known.
The distribution of sociodemographic variables across
countries reveals differences (Table 1). Brazilian and
Mexican samples are characterized by a slightly younger
age. French and German women have a higher education
level than women from other countries. Important dis-
parities exist in work participation, in particular the pro-
portions of women in home duties (1% in UK–36% in
Mexico). Income was also very different among countries
with more than 40% reporting high income in the UK as
compared with 1% in Mexico.
Premenstrual symptom prevalence,
severity and duration
For each individual symptom (Table 2), we report in
decreasing importance the median of symptom severity
(S) (level 0 ¼ nil and 3 ¼ severe), duration (D) (mean
number of affected menstrual cycles in the last 12
months) and the product (severityfrequency).
We found a strong relationship between symptom dur-
ation and severity for all the symptoms; mean coefficient
of Kendall correlation coefficient R ¼ 0.79, mean coeffi-
cient of determination ¼ 0.570, and range ¼ 0.502–
0.781. Thus, the severity of a symptom is directly pro-
portional to the duration. This relationship is true for all
the symptoms studied (minimum R ¼ 0.71). Moreover,
throughout a mixed model assuming correlation between
all the symptoms, we confirmed that the relationship
between duration and severity was not statistically
different among symptoms, and not dependent on any
sociodemographic variables (age, educational level,
country).
Classification of symptoms
We attempt to classify the symptoms according to
their observed intercorrelation, under the assumption
that correlated prevalence between any two symptoms
provides some evidence of a common cause. The
Kendall correlation matrix of the symptoms was charac-
terized by a mean between-item correlation of R ¼ 0.23
with constantly positive correlations ranging from
R ¼ 0.08–0.69, and all the coefficients are significantly
higher than zero (P . 0.001). We carried out a
hierarchical clustering (Ward tree algorithm) based
on the correlation matrix. Five groups emerged from
the tree:
(1) Depressed mood, anger, irritability, mood swings;
(2) Anxiety, not in control, restlessness, hopelessness,
tension;
(3) Confusion, social withdrawal, sleep disturbances,
poor concentration, lack of energy;

Table 1 Sample profile – between-countries comparison

Germany UK Italy Spain France Brazil Hungary Mexico Total

Age (mean) 33.18 32.09 32.03 32.23 32.28 29.64 31.47 28.65 31.44
Parity (mean) 1.20 1.36 1.07 1.10 1.14 0.87 0.97 1.24 1.12
Married (%) 79.5 80.8 79.8 79.7 78.6 65.7 75.8 65.2 75.6
Education (%)
Low 29.9 30.4 27.7 41.4 24.6 16.1 26.2 36.2 28.9
Middle 37.1 51.2 54.1 37.2 33.9 65.0 57.4 42.2 47.4
High 33.0 18.4 18.2 21.4 41.5 19.0 16.4 21.6 23.7
Work (%)
Full-time 31.8 29.8 27.2 35.3 43.7 30.7 52.8 17.2 33.5
Part-time 27.8 33.6 17.1 16.7 17.8 18.4 6.2 16.0 19.2
Student 16.8 16.8 24.0 20.2 22.2 20.3 24.6 29.2 21.7
Unemployed 4.7 18.4 2.2 7.9 4.4 10.9 3.8 2.0 6.8
Housewife 18.9 1.4 29.6 20.0 12.0 19.7 12.6 35.6 18.7
Income (%)
Low 42.0 17.3 37.8 10.0 47.4 55.0 24.2 72.8 40.9
Middle 42.4 39.1 54.4 71.3 43.4 34.8 55.0 26.2 44.0
High 15.6 43.6 7.8 18.7 9.2 10.2 20.8 1.0 15.0
Sport (%)
Never 27.6 21.8 57.1 42.7 51.5 54.2 39.2 43.2 42.2
Occasionally 62.8 53.4 35.5 31.6 39.5 28.3 49.4 33.0 41.7
Daily 9.6 24.8 7.4 25.7 9.0 17.5 11.4 23.8 16.1
Smoking (%)
No 66.5 72.2 72.3 61.4 70.1 83.6 66.8 86.2 72.5
Moderate 25.8 22.0 23.2 29.4 24.4 10.9 23.4 13.2 21.4
Severe 7.7 5.8 4.6 9.2 5.6 5.5 9.8 0.6 6.1

(Age SD was close to 10.05 for every country)

122 Menopause International Vol. 15 No. 3 September 2009

 L Dennerstein et al. Premenstrual symptoms – severity, duration and typology

Table 2 Prevalence, severity and duration of symptoms

Median Duration (D) DS [0–10]
severity (S) (no. of cycles)
[0–4] [0–12] Mean SD

Abdominal bloating 1.08 5.63 2.79 3.24

Cramps/abdominal pain 0.99 4.08 2.29 3.29
Breast tenderness 0.93 4.51 2.19 3.00
Irritability 0.95 4.19 1.96 2.69
Mood swings 0.82 3.54 1.78 2.84
Headaches 0.75 2.86 1.65 2.96
Lack of energy 0.74 3.45 1.64 2.67
Joint/muscle/back pain 0.68 2.89 1.54 2.82
Change in appetite 0.60 2.82 1.47 2.78
Anger 0.70 2.74 1.37 2.51
Depressed mood 0.66 2.83 1.29 2.30
Weight gain 0.42 2.37 1.06 2.31
Tension 0.47 2.16 1.01 2.18
Restlessness 0.43 1.97 0.89 2.04
Anxiety 0.39 1.63 0.80 2.05
Social withdrawal 0.38 1.49 0.71 1.86
Skin disorders 0.28 1.51 0.69 1.92
Sleep disturbances 0.28 1.17 0.61 1.91
Poor concentration 0.28 1.19 0.56 1.69
Not in control 0.20 0.80 0.39 1.45
Swelling of extremities 0.16 0.76 0.36 1.42
Hopelessness 0.18 0.70 0.34 1.33
Confusion 0.13 0.50 0.22 1.06

SD ¼ standard deviation

(4) Breast tenderness, abdominal bloating, swelling of Typology of experience of premenstrual

extremities, weight gain, changes in appetite;
(5) Headaches, skin disorders, joint/muscle/back pain,
symptoms
cramps, abdominal pain. Based on the 23 symptoms, we attempt to divide the
women into homogeneous and well-separated clusters
according to their values on the perceived symptoms.
Through a K-means clustering algorithm on the whole set
However, at a higher stage, the three groups 1, 2 and 3 and
of the 23 symptoms, we consistently identified a four-
the two other groups 4 and 5 merged into two main clusters.
group clustering: (1) the most prevalent ‘Mild’ type
The first was constituted by mental and behavioural symp-
(n ¼ 1666, 40.8%) characterized by no or very small
toms, and the second by physical symptoms. The stability of
global indexes in all dimensions; (2) a ‘Moderate M’ type
these classifications was assessed through a factor analysis
(n ¼ 1174, 28.7%) with a profile of moderately severe
with orthogonal rotation. The first two factors were associ-
symptoms in general, but dominated by mental symp-
ated with 41% and 25% of the whole variance. Factor 1 was
toms; (3) the ‘Moderate P’ type (n ¼ 894, 21.9%) defined
invariably associated with overall severity, while factor 2
by a moderately severe profile but a marked tendency
differentiated mental and physical symptoms.
towards physical symptoms; and (4) finally a ‘Severe’ type
We tested the relevance of the two alternative classifi-
(n ¼ 351. 8.6%) characterized by severe intensity of both
cations (two- or five-domains) by using confirmatory
physical and mental symptoms. This typology was found
factor analysis on bootstrap selections. The five-domain
to be reasonably stable independently of the use of
classification, although more detailed, did not appear to
severity SI as well as DI or DSI indexes.
be significantly more informative than the simpler two
domains of mental and physical. We estimated the
homogeneity of the two mental and physical domains.
The coefficients of internal consistency on mental and Explanatory models of premenstrual
physical clusters were 0.86 and 0.88, and thus well above symptom experience
the minimum value of 0.7.
We tested the stability of this classification using We used all the available variables, sociodemographic
alternatively the SI (severity), DI (duration) and DSI (partner, income, work, parity, country), lifestyle (smoking
(duration  severity) indexes. Our results remain habits, sport), current use of the oral contraceptive pill and
unchanged, irrespective of the index. We also assessed age at which symptoms started, as potential predictors of
stability of the results by carrying out the same analysis the intensity of symptoms, in using the summed or total
for each country. There were extremely small differences, duration  severity symptom index (TDSI) as the depen-
and we conclude that this classification remains invariant dent variable. We carried out a multiple stepwise regression
for index and irrespective of the country. on all the available variables. The age effect was not

Menopause International Vol. 15 No. 3 September 2009 123

L Dennerstein et al. Premenstrual symptoms – severity, duration and typology

observed as linear, and we added a quadratic term. Only four regions. The majority of women experienced their first
significant predictors were found. The first predictor was age symptom before the age of 20 years (EU 67.7%; Latin
with a linear and quadratic effect, producing an inverse America 70.2%). Only a small percentage of women
u-curve where younger and older women were characterized in both regions experienced their first premenstrual
by a smaller intensity, with a maximum reached around 35 symptom over the age of 40 years (EU 2.2%; Latin
years (Exact value 34.5, 95% confidence interval [32.1, America 1.5%). We carried out a linear stepwise regression
36.9]). After age, the next important predictor was smoking in which no covariate among the available variables
habits: smokers are associated with an increase of 1.8 (1.18, showed a significant effect. No difference was found
2.42). Lastly, we found differences between countries, with between countries.
an increasing order from Germany, Spain, Italy, Hungary,
Mexico, France, Brazil and the UK. The range of change from
Germany (22.57) to the UK (4.04) is 6.67. Our final model is
characterized by a poor determination (R 2 ¼ 0.047), Discussion
underlying that many specific predictors of premenstrual
symptoms were not documented in this study (Table 3). We found that across all countries studied, physical
We studied the difference in symptom profile, calculating symptoms were the most prevalent symptoms reported,
the difference between the sum of mental domain symp- as assessed by severity and number of cycles affected.
toms (duration  severity index) (DSIM) and the sum of Wittchen et al. 13 used data from a prospective longitudi-
physical domain symptoms DSIP divided by TDSI following nal community survey of 1488 German women aged
the expression (DSIM–DSIP)/TDSI. This ratio is always ,1, 14–24 years and found that physical complaints were the
and is positive or negative reflecting that the symptom most frequently endorsed premenstrual symptoms at
profile is predominantly physical or mental. We used a baseline and over all three waves of assessments (experi-
multiple stepwise linear regression to identify the main enced by 45% of the women). Physical symptoms were
predictors. The only variables with an effect on the mental– the most frequently reported premenstrual symptoms in a
physical domain difference were the following: (a) age with Japanese sample5 and among Australian twin registry
a decrease of 0.03 [20.05, 20.01], thus a relative increase of sample women,14 but not among two USA samples.11,15
physical symptoms compared with mental symptoms when The most prevalent symptom (abdominal bloating or
age increases; (b) work with an increase of 0.16 [0.05, 0.28] abdominal swelling) was greater than 10 times more
of mental symptoms for no paid work or housewife and, at important than the least prevalent (confusion). The
the opposite end, an increase in physical symptoms for standard deviations of the DSI index are large, which
women with full-time employment; (c) age at first suggests a large between-women variability. It remains to
symptoms seems to have an important increase of 0.40 be understood how this variability is distributed.
[0.21, 0.60] for each increasing year of the first symptoms; We found a strong relationship between severity and
(d) after adjustment for these first covariates, the country duration for all the symptoms. This indicates that severity
effect remains significant (P , 0.001) with mental com- of a symptom is directly proportional to the duration or
ponents highest for the UK and lowest for Germany. how many cycles were affected. In principle, a woman
reporting severe symptoms is also suffering from these
symptoms for most menstrual cycles. Thus, when
Variables associated with age at first approximation is needed, the severity level can be used
alone. It should be noted that in this survey women were
symptoms not asked how many days per cycle the symptoms lasted.
The age at which women experienced a premenstrual A discussion on the effects of predictors must take into
symptom for the first time was comparable between two account how the considered endpoint of the summed
or total TDSI has been constituted and measured to
appreciate the clinical relevance of possible effects. In this
Table 3 Predicting total duration  severity index (TDSI)
context, there was only a very limited influence of the
Coeff. CI DF MS P value available covariates. It should be noted that oral contra-
ceptives prescribed in 2003 were not associated with the
Constant 2.847 [20.792, 6.486] 1 322.630 0.121 prevalence of premenstrual symptoms. Age has an
Age 0.560 [0.312, 0.808] 1 2688.552 ,0.001 obvious effect, with less symptoms found before 20 and
Age2 20.008 [20.012, 20.004] 1 2381.495 ,0.001
after 45 and a maximum around 35 years. However, the
Smoker 1.808 [1.185, 2.431] 1 4438.913 ,0.001
Country 7 3225.058 ,0.001
clinical relevance of the difference is modest, with a
Germany 22.539 [23.477, 21.601] slightly larger contribution from heavy smoking.
Spain 22.483 [23.447, 21.520] The residual variability is mainly taken into account by
Italy 21.549 [22.505, 20.594] country, but from Germany to Mexico the difference is
Hungary 20.705 [21.666, 0.256] not clinically significant. In this respect, Brazil and the UK
Mexico 20.390 [21.362, 0.581] are the only countries to have a significantly larger impact
France 0.178 [20.781, 1.137] on symptom prevalence. It is apparent that countries
Brazil 3.333 [2.406, 4.260] cannot be separated in their effect on premenstrual
UK 4.157 [3.198, 5.116] symptoms by cultural or geographical classifications.
Error 4074 137.110
The only conclusion is that premenstrual symptoms
CI ¼ confidence interval; DF ¼ degrees of freedom; MS ¼ mean square severity is likely influenced by many other variables not
(R 2 ¼ 0.054) documented here.

124 Menopause International Vol. 15 No. 3 September 2009

 L Dennerstein et al. Premenstrual symptoms – severity, duration and typology
The finding that certain symptoms vary significantly by
country suggests that cultural or other factors may sig-
nificantly contribute to awareness of these symptoms or
to variability in perception of severity of some symptoms.
Of interest, the UK was more likely to report mental
symptoms and to report more severe symptoms than
other European countries. In this respect, UK women are
similar to US women as there are reports that US women
are also more likely to report affective symptoms.11 These
findings suggest an area for further research.
A major strength of the current study is that the same
sampling, method and measures were used across conti-
nents and that the results were not constrained to one of
the classificatory systems. Another important strength of
the current study is that it is a population-based study
with racial diversity. Of the numerous studies previously
conducted on premenstrual symptoms, only a few have
been population based and these have usually been
limited to one particular country. Many studies have used
convenience samples such as those of white women
attending a US university or seeking treatment at health
clinics. Results from such studies are not generalizable to
other more diverse populations of women. The current
study also incorporated all symptoms listed by the current
classificatory systems and did not limit symptom experi-
ence to those required for PMDD, which is very much
weighted to psychological symptoms with only one
somatic group of symptoms among 11 symptom groups.
A major limitation to the study is reliance on retro-
spective self-report. Self-report measures can introduce
bias, as interpretations can vary between women. The
retrospective approach to PMS studies has been criticized
as discrepancies have been found between retrospective
and prospective ratings in the same population of
patients.16 However, daily charting is difficult with up to
50% of women refusing.7,17 Some recent studies have
shown that retrospective reports can be accurate, even for
PMDD diagnosis.18,19
The current study was also limited in the information
collected on variables that may affect the prevalence of
premenstrual symptoms. A further limitation is the lack of
record keeping on response rates, which limits the infer-
ences that can be drawn about the generalizability of the
data. However, other surveys have found similar results to
the present survey: that over 90% of women have at least
one premenstrual symptom20 and that around 6–9% of
women are reported as having severe symptoms.21,22
Thus, this suggests that the level of symptom severity
reported in our study does not differ from that of other
major studies.
Conclusions
Physical symptoms are the most prevalent premenstrual
symptoms experienced by women. Thus, these symptoms
are an important component of premenstrual syndromes
that are psychobiological in nature. A significant number
of women in both continents report moderate/severe
premenstrual symptoms, and these vary with age, country
and smoking status. Further research should establish the
impact on quality of life, the relationship to existing
classificatory systems and whether a brief symptom list
Menopause International Vol. 15 No. 3 September 2009
can be developed that will be a valid and reliable tool for
all countries studied.
Acknowledgments: We would like to acknowledge the
assistance of TNS/EMNID, Germany, in the development of the
questionnaire and the following fieldwork agencies: OPERA, the
UK; PLM, France; Demoscopia, Spain; Nomesis, Italy; MASMI,
Hungary; AC Nielsen, Brazil; Analitica, Mexico. Institutional
review board approval was not sought as this was a questionnaire
survey with no intervention. Women were asked to consent
verbally to answer questions in the telephone-administered
questionnaire survey about their menstrual cycle experience.
All results were stored without any identification data. This study
was supported by Bayer Schering Pharma, Women’s Health Care,
Germany. Data were analysed independently of the company by
the first two authors.
Competing interests: Lorraine Dennerstein: expert advisory
board/speaker honoraria from Boehringer Ingelheim and Wyeth
Pharmaceuticals, speaker honoraria Bayer Schering; Philippe
Lehert: regular Senior Consulting Statistician for the following
laboratories: Merck Kgaa, Sanofi-Aventis, Ipsen, Serono, Bayer
Schering; Torbjorn Backstrom: Bayer Schering Pharma speaker
honoraria and Schering Plough grant application referee; Klaas
Heinemann: Bayer Schering Pharma employee.
Accepted: 16 June 2009
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