Comparing the Effects of Yoga & Oral Calcium Administration inAlleviating Symptoms of Premenstrual Syndrome in Medical Undergraduates

Introduction

Premenstrual syndrome (PMS), a common cyclic disorder of young and middle-aged women, ischaracterized by physical, emotional and behavioral symptoms such as bloating, mastalgia,insomnia, fatigue, mood swings, irritability, and depression, that consistently occur duringthe luteal phase of the menstrual cycle; disappearing within a few days of the onset ofmenstruation.¹

Although evidence for a hormonal abnormality has not been established, the symptoms of thepremenopausal disorders are related to ovarian hormones. The progesterone metabolites maybind to a neurosteroid binding site on the membrane of the neurotransmitters.²

Prevalence of PMS is difficult to establish because of its variable clinicalmanifestations and interpretations. Nevertheless, a general consensus based on thequestionnaire data is that 80%-95% of the female population admit to recurrent premenstrualsymptoms, of which 5% suffer from symptoms severe enough to disrupt their lives.³

Since the symptoms are diverse, there is a wide array of the theories proposed and theapproaches offered to manage PMS. The milder cases that constitute the major group mayrespond well to non-pharmacological approaches like counseling, stress management,complementary approaches like acupuncture, relaxation techniques, yoga, and consumption ofmicronutrients like calcium, magnesium, zinc etc. On the other hand, some cases can only bemanaged by drugs like serotonergic antidepressants and selective serotonin reuptakeinhibitors are the agents that constitute well-established, highly effective and first-linepharmacologic therapy.⁴

Stress appears to be one of the accepted causes of premenstrual syndrome. Thus, stressrelaxation techniques like yoga can be of reasonable value. Properly performed yogasanas areassociated with not only relaxation of the related muscles as shown by EMG changes, but alsoare associated with relaxation of mind and body by increasing parasympathetic activity.Regular elicitation of relaxation response results in decreased norepinephrine sensitivityand hence decrease in PMS symptoms like irritability and anxiety.^5,6

Literature states that women with mild to moderate luteal phase symptomatology have someunderlying calcium dysregulation⁷with asecondary hyperparathyroidism and vitamin D deficiency.⁸ There is evidence that this calcium deficiency is unmasked with the risein ovarian steroid hormone levels during the menstrual cycle.^8,9

Medical Undergraduates are heavily burdened by their packed curriculum. The females, inaddition, suffer from affective or somatic premenstrual syndrome (PMS) symptoms thatadversely affect their quality of life. The present study was thus, proposed to attenuatethe symptoms of PMS by practicing yoga and oral calcium administration in medicalundergraduates.

Materials and methods

This qusi-experimental study was conducted on 78 young female medical students of agegroup 18-22 years from JLN Medical College, Ajmer and Rajasthan, India. In each batch of 100medical undergraduates, there were around 30-35 girls. Amongst all the girls, 78 volunteeredfor the study.

We selected healthy females with a menstrual cycle ranging from 21-35 days and not varyingmore than 4 days. The females having a past or present history of some psychiatric illness,prolonged medication, chronic backaches or usage of oral contraceptives were excluded fromthe study.

Sixty-five females out of 78 volunteers were recruited for the study. To sensitize them tothe study, they were given a lecture on the physiology of normal menstrual cycle; thehormonal and endocrinal changes during different phases of the menstrual cycle andpremenstrual syndrome.

All the subjects were required to record the number of symptoms, along with theirseverity, in a predesigned, validated questionnaire, prospectively for two consecutivemenstrual cycles. The questionnaire was designed on the diagnostic criteria for thediagnosis of PMS given by American College of Obstetricians and Gynaecologists (ACOG).Symptoms must appear in three consecutive menstrual cycles:

The questionnaire included a list of somatic symptoms such as breast tenderness, abdominalbloating, headache and swelling of extremities. The affective symptoms listed weredepression, angry outbursts, irritability, anxiety, confusion, and socialwithdrawal.¹⁰

The presence of at least one somatic and one affective listed symptoms occurring from fivedays before the menstrual phase and relieving within 4 days of the onset of menstruationwere the diagnostic criteria of PMS. The severity of the symptoms was assessed byself-rating, the number of days of discomfort & whether any medication was taken forrelief of the symptoms.¹⁰

Fifty-eight subjects were found to have PMS. After recording weight, pulse, BP, they weredivided into three groups. One group of 20 girls who volunteered for yoga, constituted yogagroup; another group of 20 chose to take oral tablets of calcium carbonate. Rest 18, whoshowed their unwillingness for yoga or oral calcium administration, served as controls.

The yoga group underwent yoga training, one hour daily, five days a week for a period ofthree months under the supervision of an expert and trained instructor. The plan wastailored by a yoga instructor of the institute. It was a general yoga plan for all agegroups; not specific only for PMS group. The schedule included “OM”‏) is a mantra orvibration coming from Hinduism and yoga chanting‏ ‏(; various yogasanas in standing, sittingand lying down positions; pranayama and bhramari gunjan. The session was concluded withShavasana.¹¹

Twenty girls that constituted the calcium group, were given 500 mg of calcium carbonateorally, for a period of 3 months. The students were made to take calcium tablets in front ofthe researcher, to ensure adherence to the dosage.

The control group of 18 subjects was neither given yoga training, nor oral calcium. After3 months, the assessment of the symptoms & severity of PMS was again done by the samequestionnaire.

We received the approval from the institutional ethical committee of JLN Medical College,Ajmer for conducting the study. This study was done as a part of MD Physiology Thesis. Wewere supposed to present our work before a committee of members and were asked to makeamendments, if any, during that time.

The study was hence conducted and thesis approved by permission of the members of theinstituteAlso, a written informed consent was taken from all the participants, after clearlyexplaining them the purpose of the study.

Flowchart of the study showed as figure 1.

Figure 1Flowchart of the study

Results

Fifty eight medical undergraduates with a mean age of 19.4 (1.07) years participated inthe study. The mean weight of control group was 51.2 kg at the beginning which declined to51 kg at the end of the study (P>0.05). In calcium group, the mean weight was 53.9 kg and52 kg at the commencement and completion of the study, respectively (P<0.05).

The yoga group showed a maximal decline in weight from mean weight of 48.8 kg at the startand 46.6 kg at the end of three months of yoga training (P< 0.01).

The effect of interventions on the pulse rate of all the three groups is shown in Table 1. The result showed that both systolic anddiastolic BP in all the three groups was not significantly different (P > 0.05).

The number of symptoms in yoga ranged from 3-12 prior to the commencement of the studythat declined to 1-7 after yoga training (P<0.05). Eighteen out of 20 (90%) subjects alsoreported a decrease in the severity of the existing symptoms (P<0.05).

Eleven out of 20 subjects (55%) in calcium group showed a decline in the severity ofsymptoms. The number of symptoms declined from a mean value of 5.3 at the beginning of thestudy to 4.3 at the end of intervention (P< 0.05).

In the control group, there was no significant changes in the number and severity ofsymptoms. 38.89% of subjects showed a decrease in the symptoms, while the severity increasedin 33% (P> 0.05).

The mean number of PMS symptoms in different groups is shown in Figure 2.

On comparing the effects of the yoga and calcium groups, a Kruskal-Wallis test showed thatthere was a statistically significant decrease in PMS symptoms between these groups(χ² = 10.654, P = 0.004).

Discussion

The premenstrual syndrome is a physioclinical entity, afflicting a large segment of thefemale population of reproductive age group, severely hampering their lifestyle andefficiencies.²

The precise etiology of this multifactorial, psychoneuroendocrinal disorder remainsunclear but lifestyle, nutrition, and general health considerations seem to be importantissues in the management of menstrual symptoms. Severe intensity of symptoms is seenassociated with young age or students, lower education, unemployment, smoking, sedentarywork, poor health, stress, and dysmenorrhea.¹²In the present study, a significant reduction in weight in calcium group(P<0.05) and yoga group was seen. A decrease in water retention and weight was seen inwomen fed high calcium diet in a study.¹³Yoga is known to reduce weight by burning calories, boosting metabolism and also byimproving thyroid functions.^14,15

Figure 2Mean number of PMS symptoms in different groups

A significant reduction in pulse rate was found in the yoga group (P<0.05). A declinein heart rate after yogic exercises was reported by Telles et al.,¹⁶Literature states that there occurs a decrease in noradrenergicreceptor sensitivity by yoga.⁵

‏ There was no significant change in the BP in none of the three groups. Probably oursamples was a group of healthy young females whom none of them had hypertension.

However, we found a highly significant reduction in the number of symptoms of PMS in theyoga group. Prior studies have reported that relaxation techniques like 61-PR which is atype of hatha yoga reduces the stress among women with PMS.¹⁷ Wu et al., performed a study to evaluate the efficacy of yogain PMS. It was revealed that the alpha brain wave percentage was higher immediately afteryoga exercise in the PMS group. This suggests that the participants felt more relaxed orwere in a more peaceful mental condition after yoga exercise.^18,19

To evaluate the strength of evidence for treatments for premenstrual syndrome, Sue Douglasperformed an advanced MEDLINE search from January 1990 to December 2001.

The Cochrane Library and personal contacts were also used. The author concluded thatcalcium carbonate should be recommended as first-line therapy for women withmild-to-moderate PMS.²⁰ There is evidencethat a daily intake of 1,000 mg of calcium in women with premenstrual syndrome havedecreased 61% of their physical and 62% of psychiatric symptoms.⁹ There is scientific evidence supporting cyclic fluctuations ofcalcium and vitamin D during the menstrual cycle that may help explain some features of PMSlike depression, anxiety and the dysphoric states.⁸ Calcium and vitamin D may influence the development of PMS through theirrelationship to endogenous estrogens. Calcium, parathyroid hormone, and vitamin D levelshave been observed to fluctuate across the menstrual cycle in response to changes inestradiol at ovulation and during the luteal phase in several studies.^8,21,12 Buchanan et al., concluded that endogenousestrogen elevation promotes the formation of 1,25 (OH) 2D from 25 (OH) D and that it mayreciprocally inhibit synthesis of 24,25 (OH) 2D. Thus, Calcium supplementation is a highlyeffective method to relieve symptoms of PMS.²²

At the end of the study, students, motivated & encouraged with the results ofintervention. They stated that they will include yoga or calcium as a lifestyle measureregularly. However, we didn’t follow the participants regarding adherence to thischange.

The limitations of the present study are its small sample size and non-randomizedallocation of the participants to various groups.²³

Conclusion

According to the result, yoga offers a natural and effective way to alleviate PMS symptomsand serves as an alternative to painkillers and hormonal supplements.

Besides stress reduction, it also provides a moderate degree of exercise or toning to thebody and hence can be adopted as a healthy lifestyle adjunct. Calcium is also relativelyinexpensive, simple, safe, and effective approach to alleviate the symptoms of PMS and isalso important in preventing osteoporosis. Since the decrease in number and severity ofsymptoms was more in yoga than calcium group, yoga seems to be more effective than calciumsupplementation in relieving PMS symptoms.

Physical distress is known to cause absenteeism from work, hence, it would be reasonableto state that if a girl is free from her monthly distress, her well-being and workefficiency would increase. Thus encouraging a regular practice of yoga or taking a tablet ofcalcium daily in the medical schools can improve psychological well-being and workefficiency of students.

Acknowledgments

The author would like to appreciate the contribution of all the students who participatedin the study.

Ethical issues

None to be declared.

Conflict of interest

The authors declare no conflict of interest in this study‏.