Clinical Context

Data suggests that more than two-thirds of premenstrual disorders (PMDs) have symptom onset during the teen years. Premenstrual disorders can include premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). PMDD is more disabling due to the predominant psychological symptoms and social functioning problems. Few risk factors in early life have been identified for PMD development.

Higher body mass index (BMI) may be a consequence of premenstrual symptoms rather than a contributor. Prospective data are needed to clarify a potential causal relationship between childhood BMI and subsequent risk for PMDs.

Study Synopsis and Perspective

Above-normal body mass in childhood is a risk factor for premenstrual disorders in adulthood, a new study has found.

The results suggest that maintaining a normal weight as a preadolescent may lower the burden of premenstrual disorders later on, according to the researchers, whose study was published online March 8 in JAMA Network Open.^[1]

"Healthcare providers should be aware of the risk of premenstrual disorders among children with bigger body mass and educate the girls and their parents about the premenstrual symptoms," such as mood swings, hypersensitivity, insomnia, fatigue, and food cravings, said Donghao Lu, MD, PhD, from the Karolinska Institute in Stockholm, Sweden, who led the study.

Although prior cross-sectional studies have shown correlations between BMI and premenstrual disorders, whether one condition leads to the other has been unclear.

"The thinking was that premenstrual disorders might contribute to weight gain because premenstrual syndrome usually includes cravings and mood changes," Chighaf Bakour, MD, PhD, University of South Florida, Tampa, who authored an accompanying editorial, told Medscape Medical News.^[2]

To examine the association between childhood body size and the risk for premenstrual disorders in young adulthood, Dr Lu and colleagues analyzed data from 6,524 US women participating in the Growing Up Today Study (GUTS), which includes children of participants in the Nurses' Health Study II.

The investigators enrolled more than 16,800 children aged 9 to 14 years in the first phase of GUTS in 1996. In a second phase in 2004, researchers recruited nearly 11,000 other children aged 9 to 16 years. Participants reported their height and weight on questionnaires. In 2013 they completed a questionnaire about premenstrual symptoms.

About 15% met criteria for premenstrual disorders, including premenstrual syndrome and premenstrual dysphoric disorder, a more disabling form in which psychologic symptoms predominate and impair social functioning.

Baseline BMI, at an average age of 12.7 years, was positively associated with the risk for premenstrual disorders at a mean age of 26 years, with a risk ratio of 1.09 per unit of BMI z score (95% confidence interval [CI], 1.03-1.15).

The researchers also found a trend of increasing premenstrual symptom severity across BMI categories.

"Obesity was associated with a higher burden of premenstrual symptoms (β = 0.27; 95% CI, 0.09-0.44) compared with normal BMI for age," they write. After adjusting for potential mediators like age at menarche, obesity's association with symptoms remained significant but "slightly attenuated," they say.

Women with premenstrual disorders experienced menarche slightly earlier, on average, than women without the conditions (12.7 vs 12.8 years). They also were more likely to report experiences of childhood abuse (27.8% vs 21.3%), to smoke, and to have anxiety, depression, and disordered eating based on self-reported diagnoses, medication use, or reported symptoms.

Prior studies have shown that early menarche and adverse childhood experiences also are associated with increased risk for premenstrual disorders, Dr Lu noted.^[3,4]

The researchers speculated that the interplay between fat and sex hormones could contribute to the increased risk. Another possibility, they added, is that an inflammatory response to obesity somehow triggers the development of premenstrual disorders.

But many women with PMDs may have had normal body mass as children. "Of course, we don't believe larger body size is the only player here," Dr Lu told Medscape Medical News.

The study does not establish that overweight or obesity causes premenstrual disorders, Dr Bakour writes in her commentary to the study. Other, unmeasured variables related to adverse childhood environments or diet, for example, might contribute to the development of both weight gain and premenstrual syndrome.

The next step, she said, would be to look at what might contribute to both disorders: "Something like depression, mental illness, or toxic stress would contribute to overweight and also increase premenstrual disorders," she told Medscape Medical News. The study also paves the way for interventional studies to test whether weight management can reduce the incidence or burden of premenstrual disorders.

The study was supported by Swedish Research Council grants. The Growing Up Today Study was supported by the National Institutes of Health. Study coauthors disclosed grants from the National Institutes of Health and work on a study for the Swedish Inflammatory Bowel Disease Register, which receives funding from Janssen. Dr Bakour has disclosed no relevant financial relationships.

JAMA Netw Open. Published online March 8, 2022.

Clinical Implications

• Childhood BMI was associated with PMD risk and premenstrual symptoms in young adulthood, particularly for probable PMDD and early-onset PMDs.
• As the study could not prove causality, prospective studies starting in early childhood with follow-up through young adulthood and interventional studies examining the association of sustained weight loss in childhood and adolescence with PMD incidence and burden are still needed.
• Implications for the Health Care Team: Childhood obesity may also result in early menarche, which is associated with increased risk for PMDs. The overall pubertal timing could mediate the association between childhood BMI and PMDs, but associations with BMI mostly remained significant even after accounting for age at menarche. It was found that maintaining normal BMI in childhood may be considered a measure to prevent development of PMDs and other health conditions in adulthood, clinician’s and members of the health care team must share this information with their patients and care holders.

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