More Than the Body: A Pilot Study of Psychological Distress in Premenstrual Tension Syndrome Among Married and Unmarried Women
Anakha *, Dr. Raakhee AS 1
*Correspondence to: Anakha, Research Scholar, Department of Psychology, Govt College for Women Thiruvananthapuram, Kerala, India.
Copyright
© 2026 Anakha, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 30 July 2026
Published: 11 August 2026
DOI: https://doi.org/10.5281/zenodo.21887157
Premenstrual Tension Syndrome (PMTS) is often described in physical terms, yet many women say that the hardest part of the premenstrual phase is what happens in the mind rather than in the body. This pilot study was carried out to understand the pattern and severity of PMTS symptoms in a community sample of women and to identify the psychological variables that deserve closest attention in a larger main study. Using a descriptive exploratory design, 64 women aged 21 to 45 years (34 married, 30 unmarried) were recruited through convenience sampling. Participants completed a sociodemographic sheet, the Premenstrual Symptoms Screening Tool, the Depression Anxiety Stress Scales–21, and the Difficulties in Emotion Regulation Scale, married participants also completed the Dyadic Adjustment Scale. Psychological symptoms were reported at clearly higher levels than somatic complaints, and stress, anxiety, and depressive symptoms emerged as the most dominant premenstrual experiences. Married women reported significantly higher psychological distress and greater difficulty regulating their emotions than unmarried women, while the two groups did not differ meaningfully on physical symptoms. Among married women, poorer marital adjustment and greater emotion regulation difficulties were significantly associated with higher distress. The findings suggest that PMTS is not merely a physiological condition, it is closely tied to emotional and stress-related processes, and it appears to weigh more heavily within particular social contexts such as marriage. These results led to the selection of five psychological variables for the main investigation; stress, depression, anxiety, emotional regulation, and marital adjustment.
Keywords: Premenstrual tension syndrome, stress, anxiety, depression, emotional regulation, marital adjustment, married women, pilot study.
Introduction
For a large number of women, the days before menstruation bring a familiar and unwelcome shift. Sleep becomes lighter, patience becomes shorter, and small frustrations begin to feel large. Some women describe bodily discomfort such as bloating, breast tenderness, or headaches, but many others say that the real struggle is emotional: a heaviness of mood, a restlessness that will not settle, and a sense of being stretched too thin. This cluster of recurring physical and emotional changes tied to the menstrual cycle is known as Premenstrual Tension Syndrome (PMTS). Premenstrual difficulties are among the most common health complaints reported by women of reproductive age across the world (Direkvand-Moghadam et al., 2014). In more severe forms, these difficulties are recognised as clinically meaningful conditions that interfere with daily life, work, and relationships (American Psychiatric Association, 2013).
Although premenstrual changes have a clear biological basis in the hormonal rhythm of the cycle, research has repeatedly shown that biology alone does not explain why some women suffer far more than others (Yonkers et al., 2008). The distress that women report is shaped by how they appraise and cope with the demands of their lives, which is why stress theories remain central to understanding this condition (Lazarus & Folkman, 1984). A broader way of seeing PMTS, therefore, is through the biopsychosocial lens, which treats health problems as the joint product of the body, the mind, and the social world a person lives in (Engel, 1977). Within this view, the premenstrual phase may act as a period of lowered emotional reserve, during which the ordinary pressures of life are felt with unusual intensity.
One social context that deserves particular attention is marriage. In many settings, and especially in Indian family life, married women carry a wide set of responsibilities at the same time: managing the household, caring for children and elders, maintaining relationships with the extended family, and often holding paid employment as well. Qualitative work has shown that premenstrual distress is frequently experienced and negotiated within intimate relationships, where a woman's symptoms interact with the expectations of her partner and family (Ussher & Perz, 2013). When emotional resources dip in the premenstrual phase, these relational demands do not pause, and the result can be a sharper experience of stress, irritability, and low mood. Indian studies have documented high rates of premenstrual difficulties among young women, but comparatively less is known about how marital status shapes the psychological weight of these symptoms (Raval et al., 2016).
Two further psychological ideas help to explain why the same symptoms can be bearable for one woman and overwhelming for another. The first is emotional regulation, which refers to the ability to notice, understand, and manage one's feelings rather than being swept away by them (Gross, 1998). If the premenstrual phase temporarily weakens this ability, then ordinary irritations can quickly grow into tears, arguments, or despair. The second is marital adjustment, which describes the overall quality of the marital relationship, including satisfaction, agreement between partners, and the warmth shared between them (Spanier, 1976). A supportive and well-adjusted marriage may soften the impact of difficult premenstrual days, while a strained one may add to the burden precisely when a woman is least equipped to carry it. Both ideas point to processes that could be measured and, importantly, changed through psychological intervention.
The present pilot study was planned as the first step of a larger investigation into a psychological intervention for married women with PMTS.
Review of Literature
A Problem Too Common to Ignore
In a systematic review and meta-analysis that pooled studies from across the world, Direkvand-Moghadam et al. (2014) estimated that nearly half of all women of reproductive age experience premenstrual syndrome in some form, which makes it one of the most widespread health complaints among women anywhere. The picture is no different closer to home. In a study of college students in Gujarat, Raval et al. (2016) found that premenstrual difficulties were common among young Indian women and that a meaningful proportion crossed into the more severe, clinically significant range. Taken together, these studies establish that the problem examined in this pilot is neither rare nor exotic; it sits quietly inside the everyday lives of an enormous number of women.
Stress as a Trigger and an Amplifier
The second theme concerns stress, and one study stands out for the clarity of its design. Gollenberg et al. (2010) followed 259 healthy, regularly menstruating women across two full cycles in the BioCycle Study, measuring perceived stress before the symptoms appeared rather than after. Women who reported high stress in the preceding month were several times more likely to report a large number of moderate to severe symptoms in the perimenstrual period, and stress levels predicted the severity of both psychological and physical complaints. Because stress was measured first and symptoms later, the study makes it hard to dismiss stress as merely a consequence of feeling unwell; it appears to come first and to amplify what follows. The authors themselves concluded that stress reduction may offer a genuine, non-pharmacological route to relief, an idea that speaks directly to the intervention planned in the main study.
The Shadow of Depression and Anxiety
The third theme is the close company that premenstrual distress keeps with depression and anxiety. In a population-based study in Switzerland, Forrester-Knauss et al. (2011) examined the interrelation between premenstrual syndrome and major depression and found that women with severe premenstrual symptoms reported markedly higher levels of depression than women with few or no symptoms, along with poorer general mental health. The relationship ran deep enough that the authors urged clinicians to look for one condition whenever they found the other. Findings of this kind justify treating depressive and anxiety symptoms not as background noise but as central features of the premenstrual experience, which is exactly how they were treated in the present pilot.
When Feelings Become Hard to Manage
The fourth theme moves from what women feel to how they manage what they feel. Eggert et al. (2016) compared women with and without premenstrual syndrome on both self-reported and task-based measures of emotion regulation across the menstrual cycle. Women with the syndrome described clearly greater difficulty in understanding and managing their emotions, and these difficulties were most visible in the premenstrual phase, while differences on the automatic, task-based measures were far weaker. The finding is telling: the struggle appears to lie less in some deep automatic deficit and more in the lived, conscious effort of staying regulated when the premenstrual phase arrives. That is precisely the kind of struggle a psychological intervention can address, and it is the reason emotional regulation earned a place among the variables of the present study.
Symptoms That Live Inside Marriages
The fifth theme is the relational life of premenstrual distress. Ussher and Perz have argued across a series of studies that premenstrual symptoms are not experienced in a vacuum but negotiated within intimate relationships, where partners can either soften or sharpen a woman's distress (Ussher & Perz, 2013). Their randomized controlled trial gave this idea its strongest test: 83 women with premenstrual disorders were allocated to couple-based cognitive behaviour therapy, one-to-one therapy, or a waiting list (Ussher & Perz, 2017). Both therapy formats reduced premenstrual symptoms and distress, but the couple format produced the greatest gains in active coping, and women in that condition described increased understanding and support from their partners. The message for the present work is direct: the marital relationship is not merely a backdrop to premenstrual distress but a live ingredient in it, which is why marital adjustment was measured in this pilot.
From Understanding to Intervention
The final theme offers grounds for hope. Panahi and Faramarzi (2016) tested mindfulness-based cognitive therapy with women suffering from premenstrual syndrome and found that the intervention significantly reduced both depressive and anxiety symptoms. The study matters here for two reasons. It shows that the psychological heart of premenstrual distress responds to structured psychological treatment, and it points specifically toward mindfulness-based cognitive approaches as a promising route, which is the very direction the main investigation takes.
Read together, these six strands of evidence tell a consistent story. Premenstrual distress is common, it is fed by stress, it travels with depression and anxiety, it strains and is strained by the ability to regulate emotions, it is lived out within marriages, and it can be eased by psychological means. What remains less studied, particularly in the Indian context, is how these threads come together in the lives of married women, and that is the gap into which the present pilot steps.
Research Questions
Method
Research Design
The study adopted a descriptive exploratory design. The aim was to describe how PMTS symptoms present themselves in the target population and to explore differences across groups that could guide the main study. A quantitative survey approach was used, with standardised self-report measures administered at a single point in time.
Participants
Participants were recruited through convenience sampling from community settings in Kerala, India. Women were included if they were between 21 and 45 years of age, had regular menstrual cycles, reported experiencing premenstrual symptoms, and were able to read and respond in Malayalam or English. Women who were pregnant or lactating, had undergone hysterectomy, or reported a diagnosed psychiatric or major medical illness were excluded, since these conditions can independently alter mood and menstrual experience. The final sample consisted of 64 women aged 21 to 45 years (M = 31.6 years, SD = 5.8). Of these, 34 were married and 30 were unmarried. Their detailed sociodemographic profile is presented in Table 1.
Measures
A brief sociodemographic sheet prepared for the study collected information on age, marital status, educational qualification, employment status, and type of family. These variables were chosen because each of them can plausibly shape the daily demands a woman faces and the support available to her.
The Premenstrual Symptoms Screening Tool (PSST) was used to assess the pattern and severity of premenstrual symptoms (Steiner et al., 2003). The tool asks women to rate a list of premenstrual experiences on a four-point scale ranging from not at all to severe. For the purpose of this pilot, items were grouped into a psychological symptom domain, covering experiences such as irritability, anxiety or tension, tearfulness, and depressed mood, and a somatic symptom domain, covering physical complaints such as bloating, breast tenderness, headache, and fatigue.
The Depression Anxiety Stress Scales–21 (DASS-21) was used to measure the three psychological states of depression, anxiety, and stress experienced during the premenstrual phase (Lovibond & Lovibond, 1995). Each of the three subscales contains seven items rated on a four-point scale, and subscale scores are doubled so that they can be compared with the full-length version of the instrument. The DASS-21 has been widely used in Indian samples and has shown sound reliability.
The Difficulties in Emotion Regulation Scale (DERS) was used to assess emotional regulation (Gratz & Roemer, 2004). The scale contains 36 items rated from 1 (almost never) to 5 (almost always), and higher total scores indicate greater difficulty in understanding and managing one's emotions. Participants were asked to respond with reference to how they typically feel during the premenstrual phase.
The Dyadic Adjustment Scale (DAS) was administered to the married participants to assess marital adjustment (Spanier, 1976). The scale measures satisfaction, consensus, cohesion, and affectional expression within the relationship, with higher total scores reflecting a better-adjusted marriage. Scores around 100 are conventionally used as a rough dividing line between adjusted and distressed relationships.
Procedure
Permission was obtained from the concerned authorities, and women who expressed willingness were approached individually. The purpose of the study was explained in simple language, and written informed consent was obtained. Participants were assured that their responses would remain confidential and would be used only for research. They were asked to keep the week before their most recent period in mind while answering the questionnaires. Completing all measures took approximately 20 to 25 minutes. The study followed the ethical principles of voluntary participation, informed consent, confidentiality, and the right to withdraw at any point without consequence.
Data Analysis
Data were analysed using IBM SPSS Statistics (Version 29.0). Descriptive statistics, namely frequencies, percentages, means, and standard deviations, were used to summarise the sociodemographic profile and the pattern of symptoms. A paired-samples t test compared psychological and somatic symptom scores within the sample, and independent-samples t tests compared married and unmarried women on the study variables. Within the married subsample, Pearson correlation coefficients examined the relationships of emotional regulation and marital adjustment with distress. The level of significance was set at .05, and Cohen's d was calculated to describe the size of the observed differences.
Results
Sociodemographic Profile
Table 1 summarises the background characteristics of the sample. Most participants were in their twenties and thirties, held at least an undergraduate degree, and lived in nuclear families. The sample was almost evenly divided between married and unmarried women, which allowed a meaningful comparison between the two groups.
Pattern of PMTS Symptoms
The first question of the pilot concerned the overall pattern of symptoms. As shown in Table 2, psychological symptoms were reported at a clearly higher level than somatic complaints. The average rating for the psychological domain fell close to the moderate-to-severe end of the scale, while the average rating for physical symptoms remained near the mild-to-moderate range. The difference between the two domains was statistically significant and large in size. In simple terms, the women in this sample were troubled more by what the premenstrual phase did to their minds than by what it did to their bodies.
The second question asked which psychological experiences stood out most. Table 3 presents the descriptive statistics of the psychological study variables. Stress recorded the highest mean among the DASS-21 subscales, followed by depressive symptoms and anxiety, and all three fell within the moderate range of the instrument. The sample also reported an elevated level of emotion regulation difficulties on the DERS, suggesting that many women found it hard to manage their feelings during the premenstrual phase. Among the married participants, the average marital adjustment score sat just below the conventional cutoff of 100, indicating that a considerable share of these marriages were under some strain. Together, these results indicate that stress, anxiety, and depressive symptoms were the most dominant PMTS-related experiences in this sample, echoing the pattern seen on the psychological domain of the PSST, and that emotional regulation and the marital relationship were far from untroubled.
Comparison of Married and Unmarried Women
The third question concerned marital status. As Table 4 shows, married women reported significantly higher levels of stress, depressive symptoms, and anxiety than unmarried women, with differences of medium size on all three subscales. Married women also reported significantly greater difficulty in regulating their emotions during the premenstrual phase. In contrast, the two groups did not differ significantly on somatic symptoms. The added burden that marriage appeared to carry in this sample was therefore psychological rather than physical.
Emotional Regulation, Marital Adjustment, and Distress Among Married Women
The fourth question asked whether emotional regulation and marital adjustment were meaningfully connected to distress among married women. Table 5 presents the correlations within the married subsample. Greater difficulty in regulating emotions was significantly associated with higher stress, depressive symptoms, and anxiety, with the strongest link seen for stress. Marital adjustment showed the mirror image of this pattern: the better adjusted a woman's marriage, the lower her reported distress on all three subscales. In addition, women in better-adjusted marriages reported fewer emotion regulation difficulties. Although correlations cannot establish cause and effect, the consistency and moderate strength of these relationships indicate that both variables sit close to the heart of premenstrual distress in married women.
Discussion
This pilot study set out to sketch a first picture of PMTS in the target population before launching a larger investigation. Four findings stand out, and each carries a clear message for the main study.
The first finding is that psychological symptoms dominated the premenstrual experience. Although PMTS is often spoken about in terms of bodily discomfort, the women in this sample rated emotional difficulties well above physical ones. This is consistent with the wider literature, which shows that mood-related symptoms are frequently the most impairing part of premenstrual conditions (Halbreich et al., 2003). It also supports the position that premenstrual distress cannot be reduced to hormones alone and must be understood as a condition of the whole person (Yonkers et al., 2008).
The second finding is that stress, anxiety, and depressive symptoms emerged as the most dominant experiences, with stress recording the highest mean score. Seen through the transactional model, this pattern makes intuitive sense: the premenstrual phase seems to lower a woman's coping reserve at the very time when the demands of her life continue unchanged, so ordinary pressures are appraised as heavier and harder to manage (Lazarus & Folkman, 1984). The practical implication is that any psychological intervention designed for this population should place stress and emotion regulation at its centre rather than treating them as side concerns.
The third finding is that married women carried a heavier psychological load than unmarried women, even though the two groups reported similar levels of physical symptoms. Married women reported not only more stress, anxiety, and depressive symptoms, but also greater difficulty in regulating their emotions during the premenstrual phase. This pattern fits the biopsychosocial view that the social context in which symptoms occur shapes how much suffering they cause (Engel, 1977). It also resonates with qualitative accounts showing that premenstrual distress is lived out within relationships, where household responsibilities, caregiving, and the expectations of partners and in-laws leave little room for rest or withdrawal during difficult days (Ussher & Perz, 2013). For many married women in the Indian context, the premenstrual week does not come with any reduction in duties, and the mismatch between depleted inner resources and undiminished outer demands may be precisely what turns symptoms into distress.
The fourth finding sharpens this picture further. Within the married group, emotion regulation difficulties and marital adjustment were both clearly tied to distress: women who struggled more to manage their feelings, and women in more strained marriages, reported the highest levels of stress, anxiety, and depressive symptoms. The two variables were also related to each other, with better-adjusted marriages accompanying steadier emotional functioning. The direction of influence cannot be settled from correlational data; a woman's dysregulated premenstrual days may wear down her marriage just as a difficult marriage may erode her capacity to stay regulated, and in daily life the two likely feed each other. What matters for the present purpose is that both processes are measurable, both are meaningfully connected to distress, and both are, in principle, open to change through psychological intervention (Gross, 1998; Spanier, 1976).
Taken together, these findings shaped the design of the main investigation in three concrete ways. They justified focusing the main study on married women, since this group showed the greater psychological burden. They identified the five psychological variables to be measured and targeted in the main study: stress, depression, anxiety, emotional regulation, and marital adjustment. And they confirmed the relevance of the selected sociodemographic variables, particularly marital status, employment, and family type, as background factors that deserve continued attention.
Limitations
The findings of this pilot should be read with its limitations in mind. The sample was small and recruited through convenience sampling, so it cannot be treated as representative of all women in the region. All data were collected through self-report at a single point in time, and premenstrual symptoms were recalled rather than tracked prospectively across cycles, which is the more rigorous approach for confirming a diagnosis. The grouping of PSST items into psychological and somatic domains was done for exploratory purposes, marital adjustment could naturally be assessed only among the married participants, and the correlational findings cannot speak to cause and effect. These limitations are acceptable in a pilot, whose purpose is to guide rather than to conclude, but they mean that the relationships and group differences reported here should be confirmed in the larger study.
Conclusion
This pilot study suggests that, for the women studied, PMTS is felt first and most strongly in the mind. Stress, anxiety, and depressive symptoms formed the heart of the premenstrual experience, this emotional weight pressed hardest on married women, and it travelled together with difficulties in regulating emotions and with strain in the marital relationship. PMTS, in other words, is not merely a physiological condition; it is intertwined with affective and stress-related processes and with the social settings in which women live, particularly marriage. On this basis, five psychological variables were carried forward into the main investigation: stress, depression, anxiety, emotional regulation, and marital adjustment. These insights provided a firm and well-reasoned foundation for the main study, which examines a psychological intervention for married women living with this condition.
Conflicts of Interests
The authors declare that there are no conflicts of interest among the authors or with any individual or organization concerning the research, authorship and publication of this articles
References