Prevalence, risk factors, and management practices of premenstrual syndrome among female university students in Lebanon: An observational cross-sectional study.

Premenstrual syndrome (PMS) is a common gynecological condition affecting women of reproductive age [ 1 , 2 ]. According to the American College of Obstetricians and Gynecologists (ACOG), PMS is characterized by a combination of physical, emotional, and behavioral symptoms that occur during the five days prior to menstruation and resolve within four days after the onset of menstrual flow, persisting for at least three consecutive menstrual cycles [ 3 ]. These symptoms vary widely and may include mood changes, anxiety, irritability or anger, sleep disturbances, fatigue, and physical complaints such as abdominal cramps and bloating [ 1 , 3 ]. PMS is associated with a significant decline in quality of life, affecting both functional and psychosocial well-being [ 4 , 5 ]. Women experiencing PMS often report increased absenteeism from work or university as well as reduced academic or occupational performance, largely due to difficulties in concentration, decreased productivity, and fatigue [ 5 , 6 ]. PMS severity is determined by symptom intensity and functional impairment [ 1 , 4 , 7 ]. PMDD represents the severe end of the premenstrual symptom spectrum and is associated with substantial impairment in quality of life [ 1 , 4 , 5 ]. Globally, PMS affects 20–30% of reproductive-aged women [ 8 ]. However, reported prevalence differs markedly by region: approximately 85% in Africa, 60% in South America, 46% in Asia, and 40% in Europe [ 9 ]. Country-specific data further illustrate this variability, ranging from 92.3% in Jordan [ 10 ], 80.2% in Egypt [ 11 ], 71.9% in Palestine [ 12 ], and 66.3% in Syria [ 13 ]. In Lebanon, the prevalence of PMS has been reported to be approximately 63% among university students, indicating a high local burden [ 14 ]. The etiology of PMS is multifactorial and involves neurochemical and hormonal mechanisms [ 15 , 16 ]. Evidence suggests that symptoms may reflect increased sensitivity to cyclical hormonal changes rather than abnormal progesterone levels [ 2 , 16 ]. Fluctuations in estrogen, progesterone, serotonin, and the progesterone metabolite allopregnanolone may contribute to affective symptoms through altered GABAergic transmission during the luteal phase [ 15 , 16 ]. Several sociodemographic factors, including age, marital status, educational level, and body mass index (BMI), have been identified as risk factors for PMS [ 17 ]. In addition, menstrual pattern characteristics such as age at menarche, cycle length and flow, and duration of menstruation are strongly implicated in PMS, reflecting underlying hormonal fluctuations that contribute to symptom development [ 1 , 18 , 19 ]. Meal skipping, which is common among teenagers, and high consumption of fast food have been linked to PMS [ 19 , 20 ]. Apart from that, the increasing use of social media, especially among university students, raises concern since excessive social media consumption is associated with PMS symptoms [ 3 ]. Other modifiable factors, including physical inactivity, smoking, stress, and sleep disturbances, are also associated to a higher risk and greater severity of PMS [ 18 , 21 ]. Management of PMS includes lifestyle modifications, pharmacological treatment, and complementary therapies, with the aims of reducing symptoms, improving functioning, and enhancing quality of life [ 22 , 23 ]. Non-pharmacological approaches, including smoking cessation, regular exercise, dietary modifications, stress management, behavioral therapy, and selected complementary therapies, are commonly recommended for mild-to-moderate symptoms; however, evidence for herbal remedies and supplements remains variable [ 23 – 26 ]. Pharmacological treatment is generally reserved for persistent or more severe symptoms and may include NSAIDs, SSRIs, hormonal contraceptives, anxiolytics, and, in selected cases, SNRIs [ 7 10 ]. SSRIs are considered particularly effective for mood-related symptoms and may be used continuously or during the luteal phase, while combined oral contraceptives containing drospirenone and ethinyl estradiol may help alleviate physical symptoms by suppressing ovulation and reducing hormonal fluctuations [ 7 , 10 – 13 ]. Studies from Saudi Arabia and Turkey suggest that many women with PMS rely on self-management rather than professional consultation. Pharmacological treatment, particularly NSAIDs and other pain relievers, is commonly used, whereas non-pharmacological approaches such as rest and warm compresses also remain frequent [ 1 , 27 , 28 ]. Despite its burden, PMS remains under-recognized in Lebanon, and local evidence regarding management-seeking behaviors and the perceived effectiveness of management strategies among female university students is limited. Therefore, this study aimed to estimate the prevalence of moderate-to-severe PMS and symptoms consistent with PMDD among female university students in Lebanon, identify associated factors, and describe management practices and their perceived effectiveness.

A total of 1,345 female participants completed the electronic questionnaire. Of these, 283 participants were excluded for not meeting the inclusion criteria, including participants with PCOS (n = 152), history of psychiatric illness (n = 37), hypothyroidism or hyperthyroidism (n = 36), pregnancy or breastfeeding (n = 30), amenorrhea (n = 13), endometriosis (n = 9), uterine fibroids (n = 5), and chronic pelvic inflammation (n = 1). Therefore, 1,062 participants were included in the final analysis. The electronic questionnaire required completion of all mandatory items before submission; thus, no questionnaires were excluded because of incomplete responses or missing data. Further details regarding participant enrollment and analysis are presented in Fig 1 . BSMAS: Bergen Social Media Addiction Scale; PCOS: Polycystic Ovary Syndrome; PMS: Premenstrual Syndrome; PSST: Premenstrual Symptoms Screening Tool; PMDD: Premenstrual Dysphoric Disorder; PSS-4: Perceived Stress Scale-4. The mean age of the participants was 22.09 ± 4.58 years, with ages ranging from 18 to 45 years. Nearly half of the participants were aged between 18 and 20 years (n = 499, 47.0%), followed by those aged 21–24 years (n = 361, 34%). Concerning the academic specialization, more than half of the participants were enrolled in non-medical faculties (n = 565, 53.2%). As for the academic level, almost half of the participants were registered in the second (n = 238, 22.4%) and third academic years (n = 243, 22.9%), with a notable portion also pursuing a Master’s degree (n = 158, 14.9%). The majority of participants were single or engaged (n = 969, 91.2%). The mean BMI was 23.92 ± 4.21 kg/m 2 , with more than half of the participants having normal weight (56%), while 29.2% were overweight and 7.7% were obese ( Table 1 ). Note: Academic level: “Freshman” refers to students enrolled in the preparatory foundation year before entry into an undergraduate degree program, whereas “First year” refers to the first year of an undergraduate degree program. The mean age at menarche was 12.35 ± 1.29 years, with most participants reporting normal menarche between 12 and 13 years (n = 628, 59.1%). The mean menstrual cycle duration was 28.26 ± 3.57 days, and the majority had a normal cycle duration of 24–38 days (n = 956, 90%). Regarding menstrual flow, the mean duration was 6.16 ± 1.29 days, with most participants reporting a normal flow duration of 4.5–8 days (n = 944, 88.9%). In terms of menstrual bleeding intensity, moderate bleeding (more than 1 pad soaked in 3 hours) was the most reported pattern (n = 748, 70.4%) ( Table 2 ). When participants were asked whether they believed they might have PMS, the majority acknowledged this fact (n = 946, 89.1%). S1 Table demonstrates the frequency and severity of premenstrual symptoms experienced by participants assessed using the PSST. Physical symptoms, including breast pain, headache, muscle pain, swollen stomach, and weight gain, had the highest mean score (1.94 ± 0.92) out of 4, with nearly two-thirds of participants reporting moderate-to-severe symptoms (n = 740, 69.7%). Fatigue or lack of energy, and depressed mood/hopelessness were also highly reported symptoms, with 68.8% and 67.8% of the participants reporting moderate-to-severe symptoms, respectively. Additionally, overeating or food craving were commonly reported, with 66.2% of participants experiencing moderate-to-severe symptoms. In contrast, insomnia had the lowest mean score (0.8 ± 0.92), with nearly half of the participants reporting no insomnia symptoms (n = 509, 47.9%). S2 Table presents the extent to which premenstrual symptoms interfered with participants’ daily life activities. Home responsibilities showed the greatest level of interference, with a mean score of 1.48 ± 0.97 out of 4, where 50.5% reported moderate-to-severe interference. Social life activities and study efficiency or productivity were also commonly affected, where 44.6% and 43.2% of the participants reported moderate-to-severe interference, respectively. Relationships with colleagues demonstrated the lowest interference score (1 ± 0.86), with one-third of participants reporting no interference at all (n = 356, 33.5%). According to the PSST classification criteria, nearly half of the participants screened positive for moderate-to-severe PMS based on the PSST (n = 497, 46.8%), while 390 participants (36.7%) were classified as having no/mild PMS. Notably, 175 participants (16.5%) met the criteria for PMDD, as illustrated in Fig 2 . When participants were asked about the academic absenteeism related to PMS symptoms, more than one-third reported missing academic activities due to their premenstrual symptoms (n = 395, 37.2%). As shown in Table 3 , out of 1,062 participants, one-third were current smokers (n = 340, 32%), while 35 were ex-smokers (3.3%). Concerning the type of smoking, more than half of the smokers reported smoking hookah (n = 209, 61.5%), whereas 27 participants (7.9%) reported smoking cigarettes. In terms of cigarette consumption, 25.9% smoked 6–10 cigarettes per day, while 37% smoked more than 11 cigarettes per day. Among the hookah smokers, 18.7% of the participants reported smoking 3 hookah sessions, whereas 6.7% reported smoking 4 sessions per day. More than half of the female participants reported either not engaging in physical exercise or exercising only occasionally (n = 610,57.5%). Moreover, the mean sleep duration was 7.57 ± 1.68 hours, ranging from 3 to 15 hours. Short sleep duration (9 hours). Furthermore, 430 participants (40.5%) experienced sometimes skipping meals, whereas 202 participants (19%) reported frequent meal skipping. In addition, nearly half of the participants reported sometimes consuming fast food (n = 472, 44.4%), whereas 178 participants (16.8%) reported frequent fast-food consumption. a Out of the total number of current smokers 340 The mean BSMAS score was 16.16 ± 5.71, while the mean PSS-4 score was 8.04 ± 2.10. Fig 3 and Fig 4 present the distribution of participants’ responses to the individual items of the BSMAS and PSS-4, respectively. Responses are presented as percentages for each response category (Very rarely, Rarely, Sometimes, Often, and Very often). Higher frequencies of “Often” and “Very often” indicate greater endorsement of social media addiction-related behaviors. BSMAS = Bergen Social Media Addiction Scale. Responses are presented as percentages of participants for each PSS-4 item. Table 4 presents the univariate analysis of potential predictors associated with moderate-to-severe PMS/PMDD among female university students. Compared with students aged 18–20 years, those aged 25–30 years (UOR = 0.49, 95% CI = 0.34–0.72, P < 0.001) and those older than 30 years (UOR = 0.46, 95% CI = 0.27–0.79, P < 0.001) had significantly lower odds of moderate-to-severe PMS/PMDD. Academic level was also significantly associated with the outcome, with advanced undergraduate/professional students (UOR = 0.75, 95% CI = 0.57–0.98, P = 0.04) and postgraduate students (UOR = 0.63, 95% CI = 0.44–0.89, P = 0.01) showing lower odds compared with early undergraduate students. Ever- students were also less likely to have moderate-to-severe PMS/PMDD compared with single/engaged students (UOR = 0.56, 95% CI = 0.37–0.86, P = 0.01). CI , confidence interval; UOR , unadjusted odds ratio. a Percentages for the column. b Percentages for the row. c Univariate binary logistic regression was conducted to assess associations with moderate-to-severe PMS/PMDD. d Statistically significant ( p  < 0.05). e Independent t-test was utilized. † Retained in the final model. Note: Collapsed variables were defined as follows: early undergraduate included freshman, first-year, and second-year students; advanced undergraduate/professional included third-, fourth-, fifth-, sixth-year, and PharmD students; postgraduate included Master’s/MBA and PhD/DBA students. Ever married included married, divorced, and widowed participants. Regular exercise included participants exercising at least 1–2 times per week. Low meal skipping included rarely/never and sometimes, while high meal skipping included occasionally and frequently. Low fast-food consumption included rarely/never and sometimes, while high fast-food consumption included occasionally and frequently. Any war-related impact included displacement from home, financial difficulties due to war, damage or destruction of workplace or home, or loss/injury of a family member. Regarding menstrual characteristics, heavy menstrual bleeding was significantly associated with higher odds of moderate-to-severe PMS/PMDD compared with moderate bleeding (UOR = 1.70, 95% CI = 1.17–2.47, P < 0.001). Menstrual cycle duration and menstrual flow duration were not significantly associated with the outcome. For lifestyle-related factors, current smokers had significantly higher odds of moderate-to-severe PMS/PMDD compared with never smokers (UOR = 1.93, 95% CI = 1.45–2.56, P < 0.001), while regular exercise was associated with lower odds (UOR = 0.62, 95% CI = 0.45–0.85, P  9 hours/day) was associated with increased odds of moderate-to-severe PMS/PMDD compared with normal sleep duration (UOR = 1.73, 95% CI = 1.17–2.55, P = 0.01). High meal skipping (UOR = 1.56, 95% CI = 1.20–2.03, P < 0.001) and high fast-food consumption (UOR = 1.61, 95% CI = 1.24–2.08, P < 0.001) were also significantly associated with increased odds of moderate-to-severe PMS/PMDD. Psychosocial factors were strongly associated with moderate-to-severe PMS/PMDD. Higher BSMAS score was significantly associated with increased odds of moderate-to-severe PMS/PMDD (UOR = 1.14, 95% CI = 1.11–1.16, P < 0.001), as was higher PSS-4 total score (UOR = 1.30, 95% CI = 1.21–1.39, P < 0.001). Multivariable binary logistic regression identified several independent predictors of moderate-to-severe PMS/PMDD ( Table 5 ). Compared with moderate menstrual bleeding, light bleeding was independently associated with lower odds of moderate-to-severe PMS/PMDD (AOR = 0.65, 95% CI = 0.43–0.98, P = 0.04), whereas heavy bleeding was associated with higher odds (AOR = 1.58, 95% CI = 1.05–2.38, P = 0.03). Current smoking remained independently associated with higher odds of moderate-to-severe PMS/PMDD (AOR = 1.61, 95% CI = 1.17–2.21, P = 0.003). High meal skipping (AOR = 1.38, 95% CI = 1.03–1.86, P = 0.03) and high fast-food consumption (AOR = 1.34, 95% CI = 1.00–1.79, P = 0.04) were also independently associated with increased odds of moderate-to-severe PMS/PMDD. In addition, higher BSMAS total score (AOR = 1.31, 95% CI = 1.28–1.34, P < 0.001) and higher PSS-4 total score (AOR = 1.48, 95% CI = 1.38–1.59, P < 0.001) remained significant independent predictors. In contrast, age, academic level, marital status, menarche age, menstrual cycle duration, menstrual flow duration, physical exercise, and sleep duration were not independently associated with moderate-to-severe PMS/PMDD after adjustment. AOR , adjusted odds ratio; B , B, logistic regression coefficient; CI , confidence interval; SE , standard error; UOR , unadjusted odds ratio; Wald , Wald chi-square test that tests the null hypothesis. a Multivariable binary logistic regression using the Enter method. b Statistically significant ( p  < 0.05). Univariate associations with PMDD are presented in Table 6 . In the multivariable analysis, heavy menstrual bleeding, current smoking, regular exercise, higher BSMAS total score, and higher PSS-4 total score were independently associated with PMDD ( Table 7 ). CI , confidence interval; UOR , unadjusted odds ratio. a Percentages for the column. b Percentages for the row. c Univariate binary logistic regression was conducted to assess associations with PMDD. d Statistically significant ( p  < 0.05). † Retained in the final model. Note: Collapsed variables were defined as follows: early undergraduate included freshman, first-year, and second-year students; advanced undergraduate/professional included third-, fourth-, fifth-, sixth-year, and PharmD students; postgraduate included Master’s/MBA and PhD/DBA students. Ever married included married, divorced, and widowed participants. Regular exercise included participants exercising at least 1–2 times per week. Low meal skipping included rarely/never and sometimes, while high meal skipping included occasionally and frequently. Low fast-food consumption included rarely/never and sometimes, while high fast-food consumption included occasionally and frequently. Any war-related impact included displacement from home, financial difficulties due to war, damage or destruction of workplace or home, or loss/injury of a family member. AOR , adjusted odds ratio; B , logistic regression coefficient; CI , confidence interval; SE , standard error; UOR , unadjusted odds ratio; Wald , Wald chi-square test that tests the null hypothesis. a Multivariable binary logistic regression using the Enter method. b Statistically significant ( p  < 0.05). Among participants with moderate-to-severe PMS or PMDD (N = 672), 319 (47.5%) reported using at least one non-pharmacological strategy to manage symptoms. The most commonly reported approaches were sleep or rest (n = 229/319, 71.8%), increased water intake (n = 164/319, 51.4%), regular physical activity (n = 125/319, 39.2%), caffeine reduction (n = 90/319, 28.2%), hot baths (n = 87/319, 27.3%), and magnesium supplementation (n = 86/319, 27.0%). Herbal beverages and other complementary approaches were used less frequently. Most participants perceived lifestyle modifications as slightly effective (46.4%) or moderately effective (28.8%), whereas 5.6% considered them very effective and 19.1% reported no benefit. Pharmacological treatment was used by 262 participants (n = 262/672, 39%). Pharmacists were the most frequently reported source of medication recommendation (n = 89/262, 34.1%), followed by family members or friends (n = 78/262, 29.9%) and self-initiated use (n = 67/262, 25.5%); physician recommendations accounted for 7.3%. Analgesics were used by 254 medication users (96.9%), most commonly ibuprofen, mefenamic acid, paracetamol, and diclofenac. Two-thirds of analgesic users reported use during every menstrual cycle, with a mean duration of 2.04 ± 0.91 days per cycle ( Table 8 ). Antidepressants and hormonal therapies were used less frequently, by 6.1% and 1.5% of medication users, respectively. Overall, 45.8% of medication users considered pharmacological treatment very effective and 36.6% considered it moderately effective. Pain or cramps were the most frequently improved symptoms (92.7%), followed by back pain, general discomfort, and headache. Adverse effects were reported by 9.2% of medication users, most commonly stomach pain, sweating, nausea, and weight gain; one-third of those reporting adverse effects discontinued treatment.

This study showed that PMS was common among female university students in Lebanon, with a substantial proportion experiencing moderate-to-severe symptoms and symptoms consistent with PMDD. Premenstrual symptoms were not only frequent but also functionally relevant, as they interfered with daily activities and contributed to academic absenteeism among a considerable proportion of participants. Physical symptoms, fatigue, depressed mood or hopelessness, and food cravings were among the most commonly reported moderate-to-severe symptoms. Several factors were independently associated with moderate-to-severe PMS, including heavy menstrual bleeding, current smoking, frequent meal skipping, high fast-food consumption, higher social media addiction scores, and higher perceived stress scores. These findings highlight the multifactorial nature of PMS and suggest that both biological and modifiable lifestyle as well as psychosocial factors may contribute to symptom burden among university students. The findings also emphasize the importance of addressing stress, unhealthy dietary behaviors, smoking, and problematic social media use as part of comprehensive PMS awareness and management strategies. Given the high burden observed, universities should consider implementing targeted educational and counseling interventions to improve students’ awareness of PMS, encourage appropriate health-seeking behavior, and promote evidence-based symptom management. Future studies using prospective symptom tracking and multicenter designs are warranted to confirm these findings and further explore the effectiveness of different PMS management approaches among university students in Lebanon.

An observational cross-sectional study using convenience sampling was conducted among female students at Beirut Arab University, Lebanon, from April 20 to May 8, 2026. Beirut Arab University has four campuses distributed across Lebanon, and data were collected from students at all four campuses. The university enrolls students from diverse Lebanese regions and socioeconomic and cultural backgrounds. The inclusion criteria were female students enrolled at Beirut Arab University, aged 18–45 years. Participants were excluded if they reported gynecological conditions such as endometriosis, uterine fibroids, uterine polyps, polycystic ovary syndrome (PCOS), chronic pelvic inflammatory disease, or amenorrhea. Additionally, females reporting medical conditions, including thyroid disorders or diagnosed mental health conditions (e.g., anxiety or depression), as well as those currently using hormonal medications for contraception, were excluded. Pregnant or breastfeeding women were also excluded. A self-administered questionnaire was developed by the research team following a review of relevant literature [ 4 , 5 , 7 , 29 ]. It consisted of 39 closed-ended questions covering sociodemographic characteristics, menstrual history, premenstrual symptoms, lifestyle and psychosocial factors, and PMS management practices. The questionnaire was administered in English, and the PSST, BSMAS, and PSS-4 were used in their original English versions. The full questionnaire is provided in S1 Appendix . Premenstrual symptoms were assessed using the Premenstrual Symptoms Screening Tool (PSST), a validated instrument for screening PMS and PMDD [ 29 ]. The PSST includes 14 symptom items and 5 functional-impairment items, each rated on a 4-point Likert scale from 0 (“not at all”) to 3 (“severe”). PMS and PMDD were classified according to the established PSST criteria based on symptom number, severity, and functional impairment [ 29 ]. Social media addiction severity was assessed using the 6-item Bergen Social Media Addiction Scale (BSMAS), with total scores ranging from 6 to 30 and higher scores indicating greater risk of addictive social media use [ 30 , 31 ]. Perceived stress was measured using the 4-item Perceived Stress Scale (PSS-4), with total scores ranging from 0 to 16 and higher scores indicating greater perceived stress [ 32 , 33 ]. The final section assessed healthcare consultation, non-pharmacological strategies, medication use, perceived effectiveness, and safety. Five experts in clinical pharmacy, pharmacy practice, and pharmacology reviewed the questionnaire for face and content validity. A pilot test was conducted among 20 university students to assess clarity, organization, completion time, and reproducibility; pilot data were not included in the final analysis. The sample size was calculated using the standard formula for cross-sectional studies developed by Daniel et al., where n was the required sample size, Z was the Z-value corresponding to a 95% confidence level (1.96 at α = 0.05), P was the estimated prevalence of PMS (63%) [ 14 ], and d was the desired precision (4%) [ 34 ]. Based on this calculation, the minimum required sample size was 358. Three trained researchers recruited eligible female students from university common areas. After receiving information about the study and providing electronic informed consent, participants completed an anonymous self-administered questionnaire on a tablet device. Participation was voluntary, and participants could withdraw before submission. The questionnaire required approximately 10 minutes to complete. All submitted questionnaires contained complete responses to mandatory items. Data were screened for consistency and eligibility before coding and analysis. Data were coded and analyzed using IBM SPSS Statistics version 24. Categorical variables are presented as frequencies and percentages, and continuous variables as means ± standard deviations. Analyses of PMS management practices and perceived effectiveness were restricted to participants with moderate-to-severe PMS or PMDD. Associations with moderate-to-severe PMS/PMDD were initially assessed using Pearson’s chi-square test. Variables with P < 0.20 in univariate analyses and clinically relevant variables were entered into a multivariable binary logistic regression model using the Enter method. Model fit was assessed using the Hosmer–Lemeshow test. Adjusted odds ratios with 95% confidence intervals were reported, and P < 0.05 was considered statistically significant. Academic specialization: Participants enrolled in various faculties and majors were classified as either medical or non-medical students. Medical students (from the faculties of pharmacy, medicine, nursing, dentistry and applied health sciences) were expected to possess medical knowledge regarding common health conditions. In contrast, non-medical students included those studying in faculties outside the medical field. The study was designed and conducted in accordance with the ethical principles outlined in the World Medical Association Declaration of Helsinki [ 35 ]. Ethical approval was obtained from the Institutional Review Board (IRB) at Beirut Arab University on April 17, 2026. No approval code was issued at the time of approval. The IRB confirmed that the study was reviewed and approved in accordance with institutional regulations and guidelines, and that data collection was authorized to proceed. Participants were provided with a clear explanation of the purpose and procedures of the study prior to participation. Participants who agreed to take part provided electronic informed consent via a tablet-based questionnaire before completing the survey. Participation was entirely voluntary, and participants were informed that they could refuse or withdraw at any time prior to submission of their responses without any consequences. Confidentiality, anonymity, and non-traceability were strictly maintained throughout the study.

Self-administered questionnaire used to collect sociodemographic, menstrual, lifestyle, psychosocial, and premenstrual syndrome management-related data from female university students in Lebanon. (PDF) De-identified individual-level dataset underlying the findings reported in this study. (XLSX) (DOCX) (DOCX)