B&as.
Rrs. 82 Thcrap).
1975. Vat
THE
13. pp. 237-244
Press. Prmted I” Great Bmarn
DEVELOPMENT OF THE MENSTRUAL SYMPTOM QUESTIONNAIRE MARGARET
Department
Per@mon
of Psychology.
A. CHESNEYand DONALDL. TASTO* Colorado
State University,
(Receked
21 Ocroher
Fort
Collins.
Colorado
80523, U.S.A.
1974)
Summary-The literature has suggested that there are two separate types of primary dysmenorrhea with different physiological bases and different reported symptomatology. The purpose of this study was to construct a questionnaire based on suggestions from Daiton’s (1969) theory of congestive and spasmodic types of primary dysmenorrhea. to obtain test-retest reliabilities of items. and to factor analyze the instrument to empirically investigate the two-type theory. The first set of 51 items had mean test-retest reliabilities of 0.76 and yielded two clearly distinct factors in support of the two-type hypothesis. When items with factor loadings less than +0.35 were discarded. 25 items remained. The-mean test-retest reliabilities of these items was 0.78. Again, two clearly distinct factors emerged defining congestive and spasmodic dysmenorrhea consistent with the literature. The retained items from the first questionnaire and the items from the second questionnaire loaded on the same factors both times. It was concluded that two types of dysmenorrhea do. in fact. exist and that this study has provided a reliable means of differentiating them. From a therapeutic standpoint, accurate diagnosis of type may be a prerequisite for prescribing appropriate treatment.
Dysmenorrhea, or pain during menstruation, has been described as one of the most common complaints encountered in medicine. and probably the most frequent of all symptoms of gynecological disorders (Novak, Jones and Jones, 1965; Ogden et al., 1970). Menstrual pain that is the result of organic pelvic disorders is known as secondary dysmenorrhea, whereas pain occurring in the absence of gross pathological conditions in the pelvic organs is known as primary dysmenorrhea. It is primary dysmenorrhea which constitutes the focus of concern in this study. Described as either short episodes of acute cramplike abdominal pains, or prolonged dull, aching pains, primary dysmenorrhea is often accompanied by nausea, headache, irritability, and gastrointestinai disturbances. The etiology of dysmenorrhea remains obscure and various treatment methods have been developed for this prevalent and debili~t~ng disorder. While there is a lack of agreement on the specific nature of dysmenorrhea, it is generally accepted that a combined psychological and organic approach should be considered (Paulson and Wood, 1966). The psychological influence is apparent in light of the emotional and social references linked to menstruation (Israel. 1967). Consistent with this view of contributing psychological factors. psychological treatments have been shown to be effective. Such treatments include hypnosis (Kroger and Freed, 1943; SchaulIler, 1967) non-directive group therapy (Sturgis. 1962). and most recently, behavior modification (Mullen, 1968, i971; Tasto and Chesney, 1974). The literature which primarily reflects muscular, hormonal, ischemic or psychological explanations presents conflicting findings and actually alternate descriptions of primary dysmenorrhea. Recently, these contradictory findings and alternate descriptions of dysmenorrhea have been integrated in Dalton’s explanation of primary dysmenorrhea (1969). Dalton wrote, “There are two very different, in fact opposite types of (primary) dysmenorrhea known as spasmodic and congestive” (p. 39). The spasmodic type refers to spasms of pain similar to labor pains which begin the first day of menstruation. The congestive type refers to a variation or a symptom of the premenstrual syndrome with dull, aching pains accompanied by lethargy and depression prior to the onset of menstruation. Dalton proposed that dysmenorrhea is related to an hormonal imbalance between the levels of the circulating ovarian hormones-estrogen and progesterone. * Author II.K,T.Ii 1
to whom
c
reprint
requests
should
be directed. 237
238
MARGARET A. CHESNEYand DONALD L.
TAsm
Women with their progesterone levels markedly raised above their estrogen levels are likely to suffer from spasmodic dysmenorrhea. Consistent with Dalton’s theory, research in this field has drawn a relationship between a relative excess of progesterone and an opening of the cervix which is tighter than normal. The cramplike pains are believed to be the result of uterine contractions attempting to force the menstruation through this cervical opening (Tindall, 197 1: Mann, 1963 ; Davis. 1964). On the other hand, those women with their estrogen levels markedly raised above their progesterone levels are likely to suffer from the opposite type. congestive dysmenorrhea. Dalton suggests a relationship among a lack of progesterone. a subsequent lack of corticosteroids and the symptoms of congestive dysmenorrhea which include ischemia and depression. This relationship also emerged from the study and treatment by Janowsky and his associates of a woman whose description of her dysmenorrhea corresponded to the congestive type (Janowsky. Gorney and Mandell. 1967). The importance of determining which of these two types of dysmenorrhea a woman is suffering from is emphasized by Dalton because the therapy, usually hormone treatment, for each type is quite different. Indeed. if the wrong hormone is given. the pain may be increased rather than decreased. Dalton based her theory primarily on clinical observations and personal histories of women. If the two proposed types do exist, then it is essential to develop a reliable and efficient method capable of differentiating between the two types. While the use of prescribed hormones and oral contraceptives constitutes one of the most common treatments for dysmenorrhea. their use is not universally advocated by physicians because of contraindications, such as epilepsy; side effects such as thrombophlebitis, pulmonary embolism, cerebral thrombosis. and neuro-ocular lesions; and nuisances which may accompany use including weight gain. nausea, and breast changes (Tyler, 1973). The incidence of these side effects and nuisances is high. It was estimated. for example, that 40 per cent of women taking oral contraceptives experience some such reactions. In light of these nuisances and effects to hormonal prescriptions. other treatments for dysmenorrhea continue to be explored. including behavior modification. Tasto and Chesney (1974) found that the menstrual symptoms of subjects suffering from primary dysmenorrhea-not differentiated as to sub-type-were differentially affected as a function of behavior modification treatment. If the efficacy of treatment is dependent upon a subject variable such as the type of dysmenorrhea, it is important to diagnose which type before engaging a treatment program. If Dalton’s two proposed types of primary dysmenorrhea and their opposing etiological agents do exist, it might be possible to tailor therapies. medical or behavioral. to each type. If there are two types of primary dysmenorrhea. and if the two types are characterized by different verbal and behavioral symptoms. it should be possible to construct a reliable psychometric instrument capable of differentiating the two types. The purpose of this study is to attempt to develop such an instrument.
METHOD
The Menstrual Symptom Questionnaire. a psychometric test to differentiate between the two proposed types of dysmenorrhea, was constructed by: (I) developing items from the literature that characterize the symptoms of Dalton’s (1969) spasmodic and congestive types of dysmenorrhea; and (2) administering and factor analyzing these items on two separate samples. Step I
For the administration of the questionnaire to the first sample, 51 items were developed from symptoms of the two types of dysmenorrhea discussed in the literature. Forty-two of the 51 items were statements about symptoms with five response choices reflecting the degree to which the symptom is present for the the subject (S) completing the questionnaire. Eight additional items were statements from which an S would select one of five alternative responses most descriptive of herself. The final item had only
Ttte development
of the menstrual
symptom
questionrl~lr~
39
two response choices. This item asked whether or not the S was taking hormonal prescriptions, including oral contraceptives at the present time. The Ss constituting the first sample were 56 volunteer female students from introductory psychology courses at Colorado State University who described themselves as having menstrual discomfort. These Ss were given the 51-item questionnaire once at the beginning and again at the end of a z-week period. After this questionnaire was given the second time. the Ss were read general descriptions of the two types of dysmenorrhea and asked to indicate on their questionnaire the type that best described their experience with menstrual discomfort. The purpose of the two administrations for the first sample was to yield test-retest reliability of the items. Factor analysis was performed on the results of the second administration.
Two types of dysmenorrhea emerged from. and were defined by, the factor analysis of the data from administration of the questionnaire to the first sample. This questionnaire was then revised by eliminating those items which were not correlated with the factors. and by rewriting items (following suggestions from the Ss) for increased clarity. The resulting. revised questionnaire had 25 items (see Table 1). Twenty-four of these 25 items were statements about symptoms with five response choices reflecting the degree to which the symptom is present for the S completing the questionnaire. Twelve of these 24 items were characteristic of spasmodic dysmenorrhea. and 12 were characteristic of congestive dysmenorrhea. The final item consisted of a paragraph describing each of the two types of dysmenorrhea and instructions to the S to select which type she believed was the most accurate description of her experience of menstrual discomfort. This revised questionnaire was administered to a second sample to examine whether or not the items would continue to be reliable. and would continue to generate the same factors as had the first administration of the 51-item questionnaire. The Ss in the second sample were 48 female students from introductory psychology courses at Colorado State University who described themselves as having menstrual discomfort, and who had not participated in the previous administrations of the 51-item questionnaire. These Ss were given the X-item questionnaire once at the beginning and again at the end of a z-week period. This 35item questionnaire (see Table 1) was scored so that each S was given a score of 1-5 for each item. The score of 5 was assigned when the S responded to ‘always’ experiencing a symptom characteristic of s~asi?zQdic dysmenorrhea. A score of I was assigned if an S responded to ‘never’ experiencing this symptom. Conversely. a score of 1 was assigned if an S responded to ‘always’ experiencing a symptom characteristic of coyvsriw dysmenorrhea. and a score of 5 was assigned if another S responded to ‘never’ experiencing this symptom. Thus. the 12 items describing symptoms characteristic of congestive dysmenorrhea were scored in reverse order to those items describing symptoms characteristic of spasmodic dysmenorrhea. The scores of 9, 3. and 4 were assigned in order to correspond to the scoring pattern described above. The twenty-fifth item, having only two choices. was scored so that those Ss who responded that they were most like the description of spasmodic dysmenorrhea were given a score of 5, and those who responded that they were most like the description of congestive dysmenorrhea were given a score of 1. Thus, it was expected that those Ss with spasmodic dysmenorrhea would receive higher total scores while those with congestive dysmenorrhea would receive lower total scores. Since the highest possible score was 12.5 and the lowest possible score was 99. the midpoint between these extremes was 77. RESULTS Step I The 51-item questionnaire first underwent a correlational analysis to examine the reliability of the items over the z-week period of time. All items yielded reliability coefficients equal to or greater than 0.600. and the average coefficient based on Z-score
240
MARGARET Table
A. CHESNEY and DONALD
1. Items on the Menstrual
Symptom
L. TASX) Questionnaire
z
Item* 1. I feel irritable, easily ‘agitated, and am impatient a few days before my period. 2. I have cramps that begin on the first day of my period. 3. I feel depressed for several days heforr my period. pain or discomfort which 4. I have abdominal begins one day before my period. 5. For several days before my period I feel exhausted. lethargic or tired. 6. I only know that my period is coming by
looking at the calendar.
_a
(1
2
E ‘2 E Z ::sa 3 4
N
R
S 0
Z 2 5)
A
period. during
Type of dysmenorrhea:? S = Spasmodic C = Congestive
(0
NRSOA
(9
NRSOA
(Cl
NRSOA
6)
N
R
S
0
A
((3 6)
NRSOA
7. I take a prescription drug for the pain during my period. 8. I feel weak and dizzy during my period. 9. I feel tense and nervous before my period. 10. I have diarrhea during my period. 11. I have backaches several days bqforr my 12. I take aspirin for the pain period. 13. My breasts feel tender and before my period. 14. My lower back, abdomen. of my thighs begin to hurt
&
NRSOA
(9 (8 (C) (3
NRSOA
(Cl
NRSOA
w
NRSOA
(0
NRSOA
(S)
NRSOA NRSOA NRSOA
(S) ((3 ((3
NRSOA
(9
NRSOA
((2
NRSOA N R S NRSOA
0
A
my
sore a few days and the inner sides
or be tender on the first day of my period. 15. During the first day or so of my period. I feel like curling up in bed. using a hot water bottle on my abdomen, or taking a hot bath. 16. I gain weight before my period. 17. I am constipated during my period. 18. Begirnting on the first day of my period, I have
pains which may diminish or disappear for several minutes and then reappear. 19. The pain I have with my period is not intense, but a continuous dull aching. 26. I have abdominal discomfort for more than one
NRSOA day before my period. K) 21. I have backaches which hegirt the same day as N R S 0 A my period. is1 area feels bloated for a few days 22. My abdominal before my period. NRSOA (C) 23. I feel nauseous during the first day or so of my period. NRSOA (C) 24. I have headaches for a few days hqforc my period. NRSOA (S) 25. TYPE I$ The pain begins on the first day of menstruation. often coming within an hour of the first signs of menstruation. The pain is most severe the first day and may or may not continue on subsequent days. Felt as spasms. the pain may lessen or subside for awhile and then reappear. A few women find this pain so severe as to cause vomiting, fainting or dizziness; some others report that they are most comfortabte in bed or taking a hot bath. This pain is limited to the lower abdomen. back and inner sides of the thighs. TYPE
2
is advanced warning of the onset of menstruation during which the woman feels an increasing heaviness, and a dull aching pain in the lower abdomen. This pain is sometimes accompanied by nausea, lack of appetite, and constipation. Headaches, backaches, and breast pain are also characteristic of this type of menstrual discomfort. The type that most closely fits my experience is TYPE -----. There
* On the first 24 items Ss were instructed to indicate the degree to which they experience the symptom by selecting one of five response choices [Never (N), Rarely (R), Sometimes (S), Often (0). and Always (All. *The first 24 items are characteristic of either spasmodic or congestive dysmenorrhea. The type of dysmenorrhea indicates the order of scoring for each item. Items designated as S (Spasmodic), score as indicated by numbers 1-5. Items designated as C (Congestive), reverse scoring. On item 25. if S checks Type 1. score 5: if S checks Type 2, score 1. f On the twenty-fifth item. Ss were instructed to read the descriptions of two types of menstrual discomfort and select the type that most closely fits their experience.
The development
of the menstrual
symptom
questionnaire
241
transformation was 0.76. Following this correlational analysis, a principle components factor analysis (Cooley and Lohnes, 1971) was performed on the second administration of the questionnaire. This was to examine whether or not Ss were responding differently to those items theoreticaily characteristic of spasmodic dysmenorrhea than to those items theoretically characteristic of congestive dysmenorrhea. The requirement that a factor possess an eigenvalue greater than 1 was the criterion for the number of factors (of a limit of ten) to be considered. Using this criterion, the first three factors were extracted from the correlations among items. These three factors accounted for 42.51 per cent of the data’s variance, while the other seven factors accounted for an additional 10.46 per cent of the total variance. Those items with factor loadings greater than t-O.350 were assigned to one of the three factors. For those items meeting this criterion, the highest factor loading determined the factor to which the item was assigned. Using this procedure, no items were assigned to the third factor and 27 items which did not meet criterion were eliminated. The items which were assigned to the first factor were all characteristic of spasmodic dysmenorrhea while those items which were assigned to the second factor were all characteristic of congestive dysmenorrhea. The additional item concerning the type of dysmenorrhea chosen by the S, correlated with the two factors with loadings of 0.489 and -0.389 respectively. The extraction of these two factors, a spasmodic dysmenorrhea factor and a congestive dysmenorrhea. The additional item concerning the type of dysmenorrhea chosen by there are two types of dysmenorrhea. These factors also suggested that a psychometric measure capable of differentiating between these two types could be developed. Step II
The items which-were retained as a result of the first factor analysis included the 12 items which loaded on the spasmodic factor, the 12 items which loaded on the congestive factor, and the 1 item concerning the type of dysmenorrhea chosen by the Ss. This item loaded on both factors as indicated above. These 25 items, listed in Table I, defined the Menstrual Symptom Questionnaire (MSQ). The MSQ underwent a correlational analysis to determine test-retest reliability over the 2-week period. The reliability coefficients for each of the 25 items are presented in Table 2. All the items had reliability coefficients equal to or greater than 0.648, and the average coefficient based on Z-score transformation was 0.78. The twenty-fifth item which consisted of a paragraph describing each of the two types of dysmenorrhea had a high test-retest reliability of 0.933. The test-retest reliability of the Ss total scores on the MSQ was 0.87. A principal components factor analysis (Cooley and Lohnes, 1971) was performed to evaluate the interrelationships among the 25 items. Ten factors were extracted and the requirement that a factor possess an eigenvalue greater than 1 was the criterion for the number of factors to be considered. Using this criterion, three factors again emerged from the correlations among the items. These three factors accounted for 54.56 Tat& -?.MSQ MSQ item number
1
,
; 4 5 6 7 8 9 10 if 12 13
item test-retest
r 0.720 0.82 1 0.782 0.765 0.798 0.689 0.800 0.809 0.745 0.903 0.843 0.739 0.877
reliability
MSQ number
item (cont.)
14 15 16 17 18 19 20 21 22 23 24 25
coefficients
r 0.678 0.720 0.910 0.764 0.809 0.674 0.759 0.793 0.648 0.720 0.825 0.933
MARGARET A. CHESNEYand DONALD L. TASX)
242 Table
3. Factor
Item number
pattern
of the three unrotated
Factor.
- 0.743
15 14 15 16 17 18 19 20 21 22 23 24 25 Per cent total variance accounted for Eigenvalues
0.59?. 0.187 0.4?6 0.3 I7 0.580 0.623 o.Jl)l - 0.265 0.497 0.247 0.5y7 0.303 0.595 0.467 -0.212
0.259 0.611 0.346 0.320 0.518 0.368 0.239 0.385 0.598 25.602 3.47 I
I
MSQ
factors*
Factor 2
Factor 3
0.67y 0.317 o.jo9 0.315 0.513 - 0.263
- 0.289
-
0.245
-0.287 m -0.2x1 o.Jx4 0.315 o.Jg3 0.233
-0.275 o.j94 o.J95 -0.275 0.43? 0.582 0.31X
0.469 0.410 - 0.246 -0.595 21.327 2.899
0.36X - 0.295 -0.343 0.315 -0.221 0.324 -0.314 0.296 - 0.2 IO 0.355 0.327 0.323 0.395 0.410 -O.UIX -0.235 0.403 0.348 0.352 0.315 - 0.247 0.304 - 0.270 0.389
I I .002
7.63
h’
0.67 I 0.535 0.3x I 0.407 0.463 0.459 0.554 0.357 0.479 0.370 0.42 I
0.55I 0.428 0.564 0.463 0.398 0.367 0.61 I
0.318 0.565 0.475 0.353 0.310 0.369 0.X63 54.560
* Principal components techmque. The estimate of communality (h’) was the sum of the squared factor loadings for each variable. Only factors with eigenvalues greater than 1.00 were extracted. The highest factor loadings for each item are underlined.
per cent of the data’s variance, while the other seven factors accounted for an additional 16.14 per cent of the total variance. The factor pattern of the three primary factors is presented in Table 3. The factor loadings and estimates of communality are listed for each of the items. The eigenvalues and the per cent of total variance accounted for by each of the three factors are also included in the lower portion of Table 3. A varimax rotation (Cooley and Lohnes. 1971) was performed to maximize the variance of the squared factor loadings. This rotation resulted in only minor changes in the per cent of variance accounted for by each of the three factors, but did not affect factor loadings. The two factors to which items were assigned were the same as those factors extracted from the first questionnaire. That is, the very same items that loaded on the two factors from the first questionnaire. loaded on the same two factors from the second questionnaire. The 12 items characteristic of spasmodic dysmenorrhea loaded on the first factor while the 12 items characteristic of congestive dysmenorrhea loaded on the second factor. The twenty-fifth item concerning the type of dysmenorrhea chosen by the S. correlated with the two factors with factor loadings of 0.587 and -0.583 respectively. These two factors provide further confirmation of Dalton’s (1969) theory that there are two types of dysmenorrhea. The MSQ scores obtained from the Ss after the Z-week period of time arc presented in Table 4. While the scores generally dropped by one point between Ss, there was a gap of 14 points between the twenty-ninth and the thirtieth rank-ordered Ss. While the midpoint score of 77 had been considered for a line of demarcation between the two types of dysmenorrhea, this midpoint fell within the sizeable 14-point gap. Thus, the ranked scores revealed a relatively continuous dimension within the higher scores (spasmodic) and within the lower scores (congestive). but with a large hiatus existing between these polar dimensions. This pattern of scores suggests that two types of dysmenorrhea can be identified by the MSQ.
The development Table
of the menstrual
4. List of ranked scores pilot administration Ranked
scores
symptom
questionnaire
obtained from of MSQ Ranked
243
second
scores (cont.)
102
83
102 100 98 98 97 96 96 96 95 94 94 93 93 92 91 90 90 89 89 88 88 86 85 83
x3 52 x2 6x 67 66 65 64 63 58 58 56 55 54 52 57 51 51 49 48 46 46 N = 48
DISCUSSION
The extraction of the two factors, the reliability of the items and distribution of the scores into two groups all suggest that the MSQ is a psychometric capable of differentiating between the two types of primary dysmenorrhea. This finding is important for three reasons. First, it substantiates Dalton’s (1969) assertion that there are two types of primary dysmenorrhea. This support of Dalton’s theory indirectly confirms the hormonal imbalance explanation of the two types of primary dysmenorrhea which argues that spasmodic dysmenorrhea is caused by an excess of progesterone compared to estrogen, and congestive dysmenorrhea is caused by an excess of estrogen compared to progesterone. Second. because the two types have different causes and require different treatments, it may be necessary to determine a patient’s type of dysmenorrhea. The endocrine tests which provide such information are quite costly, but the MSQ which also provides this information can be considered as an alternative. Third. the MSQ allows reliable and efficient differentiation between the two types of dysmenorrhea for future research on treatments tailored to each type of dysmenorrhea, spasmodic and congestive. This research is imperative as it is apparent that the hormonal treatments available today are not universally indicated. accepted, or effective. One such possible treatment. behavior modification, which has been shown in three studies to be an effective therapy for dysmenorrhea (Mullen, 1968, 1971; Tasto and Chesney, 1974) might be further explored as a treatment which may be more effective with one of the two types of dysmenorrhea. Research has suggested that one of the physiological effects of muscle relaxation treatment is a reduction in muscle tension (Jacobson, 1938; Paul. 1969; Lehrer. 1972). If, as asserted by Dalton ( 1969), the discomfort in spasmodic dysmenorrhea is related to muscular tension and contractions, while the discomfort in congestive dysmenorrhea is related to an ischemia, then behavior modification treatment may be more effective with spasmodic dysmenorrhea. Further research is necessary to ascertain whether the pairing of muscular relaxation with the onset of menstruation would lead to an alleviation of some of the discomfort experienced by women with spasmodic dysmenorrhea. REFERENCES C~~LEY W. W. and LOHNES P. W. (1971) Multiwriate DALTON K. (1969) Tile Mer~srrucll CT&. Pantheon
Data
Books.
halysis.
New York.
John
Wiley. New York.
244
MARGARET A. CHESNEY and DONALD L. TASTY
DAVIS C. H. (1964) Dysmenorrhea. In Gy,lecology and Obstetrics (Ed. B. CARTER). W. F. Prior. Hagerstown. MD. ISRAEL S. L. (1967) Diagnosis and Trearmwt of Mensrrual Disorders and Sterility. Harper & Row. New York. JACOBSON E. (1938) Progressive Relaxation. University of Chicago Press. Chlcago. JANOWSKY D. S.. GORNEY R. and MANDELL A. J. (1967) The menstrual cycle: Psychiatric and ovarian-adrenocortical hormone correlates: Case study and literature review. Arc/Is gen. Psychiar. 17, 459-469. KROGER W. S. and FREED S. C. (1943) The psychosomatic treatment of functional dysmenorrhea by hypnosis. Am. J. Ohster. Gynec. 46. 817-822. LEHRER P. M. (1972) Physiological effects of relaxation in a double-blind analog of desensitization. Ecllar. Therapy 3. 193-208.MANN E. C. 11963) Primarv dvsmenorrhea. In Progress iu Gwecology (Eds. J. V. M~IGS and S. H. STI’RGIS). Vol. IV, pp. 1-s146. kr;ne and Stratton. New York. _MULLEN F. G. (1968) The treatment of a case of dysmenorrhea by behavior therapy techniques. .I. .Ycrr. Ment. Dis. 147, 371-376. MULLEX F. G. (1971) Treatment of dysmenorrhea by professional and student behavior therapists. Paper presented at F$/I A~rtual Meeting of fhe Association .for fhe Aduanceme,lt qf Behaoror Therap!. September. Washington. D.C. NOVAK E. R., JONESG. S. and JONES H. W.. Jr. (1965) Novak’s Testhook qf Gynecology. 7th Edn. pp. 653-661. Williams and Wilkins, Baltimore. OGDEN J. A., WADE M. E.. ANDERSONG. and DAVIS C. D. (1970) Treatment of dysmenorrhea: A comparative double-blind study. Am. J. Ohstet. Gynec. 106, 838-842. PAUL G. L. (1969) Physiological effects of relaxation training and hypnotic suggestion. J. abuorm. Psychol. 74, 425-437. PAULKIN M. J. and WOOD K. R. (1966) Perceptions of emotional correlates of dysmenorrhea. A~I. J. Ohsret. Gynec. 95. 991-996. SCHAUFFLERG. C. (1967) Dysmenorrhea in and near puberty. N.Y. Acad. Sci. Ann. 142. 794-800. STLIRGISS. H. (1962) Thr G_wtecological Patient: A Psych~e,~docrine Study. Grune and Stratton. New York. TASTO D. L. and CHESNEY M. A. (1974) Muscle relaxation treatment for primary dysmenorrhea. Eellar. Therapy 5, 668-672. TINDALL V. R. (1971) Dysmenorrhea. Br. Med. J. 1, 329-331. TYLER E. T. (1973) Contraception control: The pill is best for most. In Reproducrive E~~docrirlology (Ed. D. P. LAULER). Medcom. New York.
Rrs. 82 Thcrap).
1975. Vat
THE
13. pp. 237-244
Press. Prmted I” Great Bmarn
DEVELOPMENT OF THE MENSTRUAL SYMPTOM QUESTIONNAIRE MARGARET
Department
Per@mon
of Psychology.
A. CHESNEYand DONALDL. TASTO* Colorado
State University,
(Receked
21 Ocroher
Fort
Collins.
Colorado
80523, U.S.A.
1974)
Summary-The literature has suggested that there are two separate types of primary dysmenorrhea with different physiological bases and different reported symptomatology. The purpose of this study was to construct a questionnaire based on suggestions from Daiton’s (1969) theory of congestive and spasmodic types of primary dysmenorrhea. to obtain test-retest reliabilities of items. and to factor analyze the instrument to empirically investigate the two-type theory. The first set of 51 items had mean test-retest reliabilities of 0.76 and yielded two clearly distinct factors in support of the two-type hypothesis. When items with factor loadings less than +0.35 were discarded. 25 items remained. The-mean test-retest reliabilities of these items was 0.78. Again, two clearly distinct factors emerged defining congestive and spasmodic dysmenorrhea consistent with the literature. The retained items from the first questionnaire and the items from the second questionnaire loaded on the same factors both times. It was concluded that two types of dysmenorrhea do. in fact. exist and that this study has provided a reliable means of differentiating them. From a therapeutic standpoint, accurate diagnosis of type may be a prerequisite for prescribing appropriate treatment.
Dysmenorrhea, or pain during menstruation, has been described as one of the most common complaints encountered in medicine. and probably the most frequent of all symptoms of gynecological disorders (Novak, Jones and Jones, 1965; Ogden et al., 1970). Menstrual pain that is the result of organic pelvic disorders is known as secondary dysmenorrhea, whereas pain occurring in the absence of gross pathological conditions in the pelvic organs is known as primary dysmenorrhea. It is primary dysmenorrhea which constitutes the focus of concern in this study. Described as either short episodes of acute cramplike abdominal pains, or prolonged dull, aching pains, primary dysmenorrhea is often accompanied by nausea, headache, irritability, and gastrointestinai disturbances. The etiology of dysmenorrhea remains obscure and various treatment methods have been developed for this prevalent and debili~t~ng disorder. While there is a lack of agreement on the specific nature of dysmenorrhea, it is generally accepted that a combined psychological and organic approach should be considered (Paulson and Wood, 1966). The psychological influence is apparent in light of the emotional and social references linked to menstruation (Israel. 1967). Consistent with this view of contributing psychological factors. psychological treatments have been shown to be effective. Such treatments include hypnosis (Kroger and Freed, 1943; SchaulIler, 1967) non-directive group therapy (Sturgis. 1962). and most recently, behavior modification (Mullen, 1968, i971; Tasto and Chesney, 1974). The literature which primarily reflects muscular, hormonal, ischemic or psychological explanations presents conflicting findings and actually alternate descriptions of primary dysmenorrhea. Recently, these contradictory findings and alternate descriptions of dysmenorrhea have been integrated in Dalton’s explanation of primary dysmenorrhea (1969). Dalton wrote, “There are two very different, in fact opposite types of (primary) dysmenorrhea known as spasmodic and congestive” (p. 39). The spasmodic type refers to spasms of pain similar to labor pains which begin the first day of menstruation. The congestive type refers to a variation or a symptom of the premenstrual syndrome with dull, aching pains accompanied by lethargy and depression prior to the onset of menstruation. Dalton proposed that dysmenorrhea is related to an hormonal imbalance between the levels of the circulating ovarian hormones-estrogen and progesterone. * Author II.K,T.Ii 1
to whom
c
reprint
requests
should
be directed. 237
238
MARGARET A. CHESNEYand DONALD L.
TAsm
Women with their progesterone levels markedly raised above their estrogen levels are likely to suffer from spasmodic dysmenorrhea. Consistent with Dalton’s theory, research in this field has drawn a relationship between a relative excess of progesterone and an opening of the cervix which is tighter than normal. The cramplike pains are believed to be the result of uterine contractions attempting to force the menstruation through this cervical opening (Tindall, 197 1: Mann, 1963 ; Davis. 1964). On the other hand, those women with their estrogen levels markedly raised above their progesterone levels are likely to suffer from the opposite type. congestive dysmenorrhea. Dalton suggests a relationship among a lack of progesterone. a subsequent lack of corticosteroids and the symptoms of congestive dysmenorrhea which include ischemia and depression. This relationship also emerged from the study and treatment by Janowsky and his associates of a woman whose description of her dysmenorrhea corresponded to the congestive type (Janowsky. Gorney and Mandell. 1967). The importance of determining which of these two types of dysmenorrhea a woman is suffering from is emphasized by Dalton because the therapy, usually hormone treatment, for each type is quite different. Indeed. if the wrong hormone is given. the pain may be increased rather than decreased. Dalton based her theory primarily on clinical observations and personal histories of women. If the two proposed types do exist, then it is essential to develop a reliable and efficient method capable of differentiating between the two types. While the use of prescribed hormones and oral contraceptives constitutes one of the most common treatments for dysmenorrhea. their use is not universally advocated by physicians because of contraindications, such as epilepsy; side effects such as thrombophlebitis, pulmonary embolism, cerebral thrombosis. and neuro-ocular lesions; and nuisances which may accompany use including weight gain. nausea, and breast changes (Tyler, 1973). The incidence of these side effects and nuisances is high. It was estimated. for example, that 40 per cent of women taking oral contraceptives experience some such reactions. In light of these nuisances and effects to hormonal prescriptions. other treatments for dysmenorrhea continue to be explored. including behavior modification. Tasto and Chesney (1974) found that the menstrual symptoms of subjects suffering from primary dysmenorrhea-not differentiated as to sub-type-were differentially affected as a function of behavior modification treatment. If the efficacy of treatment is dependent upon a subject variable such as the type of dysmenorrhea, it is important to diagnose which type before engaging a treatment program. If Dalton’s two proposed types of primary dysmenorrhea and their opposing etiological agents do exist, it might be possible to tailor therapies. medical or behavioral. to each type. If there are two types of primary dysmenorrhea. and if the two types are characterized by different verbal and behavioral symptoms. it should be possible to construct a reliable psychometric instrument capable of differentiating the two types. The purpose of this study is to attempt to develop such an instrument.
METHOD
The Menstrual Symptom Questionnaire. a psychometric test to differentiate between the two proposed types of dysmenorrhea, was constructed by: (I) developing items from the literature that characterize the symptoms of Dalton’s (1969) spasmodic and congestive types of dysmenorrhea; and (2) administering and factor analyzing these items on two separate samples. Step I
For the administration of the questionnaire to the first sample, 51 items were developed from symptoms of the two types of dysmenorrhea discussed in the literature. Forty-two of the 51 items were statements about symptoms with five response choices reflecting the degree to which the symptom is present for the the subject (S) completing the questionnaire. Eight additional items were statements from which an S would select one of five alternative responses most descriptive of herself. The final item had only
Ttte development
of the menstrual
symptom
questionrl~lr~
39
two response choices. This item asked whether or not the S was taking hormonal prescriptions, including oral contraceptives at the present time. The Ss constituting the first sample were 56 volunteer female students from introductory psychology courses at Colorado State University who described themselves as having menstrual discomfort. These Ss were given the 51-item questionnaire once at the beginning and again at the end of a z-week period. After this questionnaire was given the second time. the Ss were read general descriptions of the two types of dysmenorrhea and asked to indicate on their questionnaire the type that best described their experience with menstrual discomfort. The purpose of the two administrations for the first sample was to yield test-retest reliability of the items. Factor analysis was performed on the results of the second administration.
Two types of dysmenorrhea emerged from. and were defined by, the factor analysis of the data from administration of the questionnaire to the first sample. This questionnaire was then revised by eliminating those items which were not correlated with the factors. and by rewriting items (following suggestions from the Ss) for increased clarity. The resulting. revised questionnaire had 25 items (see Table 1). Twenty-four of these 25 items were statements about symptoms with five response choices reflecting the degree to which the symptom is present for the S completing the questionnaire. Twelve of these 24 items were characteristic of spasmodic dysmenorrhea. and 12 were characteristic of congestive dysmenorrhea. The final item consisted of a paragraph describing each of the two types of dysmenorrhea and instructions to the S to select which type she believed was the most accurate description of her experience of menstrual discomfort. This revised questionnaire was administered to a second sample to examine whether or not the items would continue to be reliable. and would continue to generate the same factors as had the first administration of the 51-item questionnaire. The Ss in the second sample were 48 female students from introductory psychology courses at Colorado State University who described themselves as having menstrual discomfort, and who had not participated in the previous administrations of the 51-item questionnaire. These Ss were given the X-item questionnaire once at the beginning and again at the end of a z-week period. This 35item questionnaire (see Table 1) was scored so that each S was given a score of 1-5 for each item. The score of 5 was assigned when the S responded to ‘always’ experiencing a symptom characteristic of s~asi?zQdic dysmenorrhea. A score of I was assigned if an S responded to ‘never’ experiencing this symptom. Conversely. a score of 1 was assigned if an S responded to ‘always’ experiencing a symptom characteristic of coyvsriw dysmenorrhea. and a score of 5 was assigned if another S responded to ‘never’ experiencing this symptom. Thus. the 12 items describing symptoms characteristic of congestive dysmenorrhea were scored in reverse order to those items describing symptoms characteristic of spasmodic dysmenorrhea. The scores of 9, 3. and 4 were assigned in order to correspond to the scoring pattern described above. The twenty-fifth item, having only two choices. was scored so that those Ss who responded that they were most like the description of spasmodic dysmenorrhea were given a score of 5, and those who responded that they were most like the description of congestive dysmenorrhea were given a score of 1. Thus, it was expected that those Ss with spasmodic dysmenorrhea would receive higher total scores while those with congestive dysmenorrhea would receive lower total scores. Since the highest possible score was 12.5 and the lowest possible score was 99. the midpoint between these extremes was 77. RESULTS Step I The 51-item questionnaire first underwent a correlational analysis to examine the reliability of the items over the z-week period of time. All items yielded reliability coefficients equal to or greater than 0.600. and the average coefficient based on Z-score
240
MARGARET Table
A. CHESNEY and DONALD
1. Items on the Menstrual
Symptom
L. TASX) Questionnaire
z
Item* 1. I feel irritable, easily ‘agitated, and am impatient a few days before my period. 2. I have cramps that begin on the first day of my period. 3. I feel depressed for several days heforr my period. pain or discomfort which 4. I have abdominal begins one day before my period. 5. For several days before my period I feel exhausted. lethargic or tired. 6. I only know that my period is coming by
looking at the calendar.
_a
(1
2
E ‘2 E Z ::sa 3 4
N
R
S 0
Z 2 5)
A
period. during
Type of dysmenorrhea:? S = Spasmodic C = Congestive
(0
NRSOA
(9
NRSOA
(Cl
NRSOA
6)
N
R
S
0
A
((3 6)
NRSOA
7. I take a prescription drug for the pain during my period. 8. I feel weak and dizzy during my period. 9. I feel tense and nervous before my period. 10. I have diarrhea during my period. 11. I have backaches several days bqforr my 12. I take aspirin for the pain period. 13. My breasts feel tender and before my period. 14. My lower back, abdomen. of my thighs begin to hurt
&
NRSOA
(9 (8 (C) (3
NRSOA
(Cl
NRSOA
w
NRSOA
(0
NRSOA
(S)
NRSOA NRSOA NRSOA
(S) ((3 ((3
NRSOA
(9
NRSOA
((2
NRSOA N R S NRSOA
0
A
my
sore a few days and the inner sides
or be tender on the first day of my period. 15. During the first day or so of my period. I feel like curling up in bed. using a hot water bottle on my abdomen, or taking a hot bath. 16. I gain weight before my period. 17. I am constipated during my period. 18. Begirnting on the first day of my period, I have
pains which may diminish or disappear for several minutes and then reappear. 19. The pain I have with my period is not intense, but a continuous dull aching. 26. I have abdominal discomfort for more than one
NRSOA day before my period. K) 21. I have backaches which hegirt the same day as N R S 0 A my period. is1 area feels bloated for a few days 22. My abdominal before my period. NRSOA (C) 23. I feel nauseous during the first day or so of my period. NRSOA (C) 24. I have headaches for a few days hqforc my period. NRSOA (S) 25. TYPE I$ The pain begins on the first day of menstruation. often coming within an hour of the first signs of menstruation. The pain is most severe the first day and may or may not continue on subsequent days. Felt as spasms. the pain may lessen or subside for awhile and then reappear. A few women find this pain so severe as to cause vomiting, fainting or dizziness; some others report that they are most comfortabte in bed or taking a hot bath. This pain is limited to the lower abdomen. back and inner sides of the thighs. TYPE
2
is advanced warning of the onset of menstruation during which the woman feels an increasing heaviness, and a dull aching pain in the lower abdomen. This pain is sometimes accompanied by nausea, lack of appetite, and constipation. Headaches, backaches, and breast pain are also characteristic of this type of menstrual discomfort. The type that most closely fits my experience is TYPE -----. There
* On the first 24 items Ss were instructed to indicate the degree to which they experience the symptom by selecting one of five response choices [Never (N), Rarely (R), Sometimes (S), Often (0). and Always (All. *The first 24 items are characteristic of either spasmodic or congestive dysmenorrhea. The type of dysmenorrhea indicates the order of scoring for each item. Items designated as S (Spasmodic), score as indicated by numbers 1-5. Items designated as C (Congestive), reverse scoring. On item 25. if S checks Type 1. score 5: if S checks Type 2, score 1. f On the twenty-fifth item. Ss were instructed to read the descriptions of two types of menstrual discomfort and select the type that most closely fits their experience.
The development
of the menstrual
symptom
questionnaire
241
transformation was 0.76. Following this correlational analysis, a principle components factor analysis (Cooley and Lohnes, 1971) was performed on the second administration of the questionnaire. This was to examine whether or not Ss were responding differently to those items theoreticaily characteristic of spasmodic dysmenorrhea than to those items theoretically characteristic of congestive dysmenorrhea. The requirement that a factor possess an eigenvalue greater than 1 was the criterion for the number of factors (of a limit of ten) to be considered. Using this criterion, the first three factors were extracted from the correlations among items. These three factors accounted for 42.51 per cent of the data’s variance, while the other seven factors accounted for an additional 10.46 per cent of the total variance. Those items with factor loadings greater than t-O.350 were assigned to one of the three factors. For those items meeting this criterion, the highest factor loading determined the factor to which the item was assigned. Using this procedure, no items were assigned to the third factor and 27 items which did not meet criterion were eliminated. The items which were assigned to the first factor were all characteristic of spasmodic dysmenorrhea while those items which were assigned to the second factor were all characteristic of congestive dysmenorrhea. The additional item concerning the type of dysmenorrhea chosen by the S, correlated with the two factors with loadings of 0.489 and -0.389 respectively. The extraction of these two factors, a spasmodic dysmenorrhea factor and a congestive dysmenorrhea. The additional item concerning the type of dysmenorrhea chosen by there are two types of dysmenorrhea. These factors also suggested that a psychometric measure capable of differentiating between these two types could be developed. Step II
The items which-were retained as a result of the first factor analysis included the 12 items which loaded on the spasmodic factor, the 12 items which loaded on the congestive factor, and the 1 item concerning the type of dysmenorrhea chosen by the Ss. This item loaded on both factors as indicated above. These 25 items, listed in Table I, defined the Menstrual Symptom Questionnaire (MSQ). The MSQ underwent a correlational analysis to determine test-retest reliability over the 2-week period. The reliability coefficients for each of the 25 items are presented in Table 2. All the items had reliability coefficients equal to or greater than 0.648, and the average coefficient based on Z-score transformation was 0.78. The twenty-fifth item which consisted of a paragraph describing each of the two types of dysmenorrhea had a high test-retest reliability of 0.933. The test-retest reliability of the Ss total scores on the MSQ was 0.87. A principal components factor analysis (Cooley and Lohnes, 1971) was performed to evaluate the interrelationships among the 25 items. Ten factors were extracted and the requirement that a factor possess an eigenvalue greater than 1 was the criterion for the number of factors to be considered. Using this criterion, three factors again emerged from the correlations among the items. These three factors accounted for 54.56 Tat& -?.MSQ MSQ item number
1
,
; 4 5 6 7 8 9 10 if 12 13
item test-retest
r 0.720 0.82 1 0.782 0.765 0.798 0.689 0.800 0.809 0.745 0.903 0.843 0.739 0.877
reliability
MSQ number
item (cont.)
14 15 16 17 18 19 20 21 22 23 24 25
coefficients
r 0.678 0.720 0.910 0.764 0.809 0.674 0.759 0.793 0.648 0.720 0.825 0.933
MARGARET A. CHESNEYand DONALD L. TASX)
242 Table
3. Factor
Item number
pattern
of the three unrotated
Factor.
- 0.743
15 14 15 16 17 18 19 20 21 22 23 24 25 Per cent total variance accounted for Eigenvalues
0.59?. 0.187 0.4?6 0.3 I7 0.580 0.623 o.Jl)l - 0.265 0.497 0.247 0.5y7 0.303 0.595 0.467 -0.212
0.259 0.611 0.346 0.320 0.518 0.368 0.239 0.385 0.598 25.602 3.47 I
I
MSQ
factors*
Factor 2
Factor 3
0.67y 0.317 o.jo9 0.315 0.513 - 0.263
- 0.289
-
0.245
-0.287 m -0.2x1 o.Jx4 0.315 o.Jg3 0.233
-0.275 o.j94 o.J95 -0.275 0.43? 0.582 0.31X
0.469 0.410 - 0.246 -0.595 21.327 2.899
0.36X - 0.295 -0.343 0.315 -0.221 0.324 -0.314 0.296 - 0.2 IO 0.355 0.327 0.323 0.395 0.410 -O.UIX -0.235 0.403 0.348 0.352 0.315 - 0.247 0.304 - 0.270 0.389
I I .002
7.63
h’
0.67 I 0.535 0.3x I 0.407 0.463 0.459 0.554 0.357 0.479 0.370 0.42 I
0.55I 0.428 0.564 0.463 0.398 0.367 0.61 I
0.318 0.565 0.475 0.353 0.310 0.369 0.X63 54.560
* Principal components techmque. The estimate of communality (h’) was the sum of the squared factor loadings for each variable. Only factors with eigenvalues greater than 1.00 were extracted. The highest factor loadings for each item are underlined.
per cent of the data’s variance, while the other seven factors accounted for an additional 16.14 per cent of the total variance. The factor pattern of the three primary factors is presented in Table 3. The factor loadings and estimates of communality are listed for each of the items. The eigenvalues and the per cent of total variance accounted for by each of the three factors are also included in the lower portion of Table 3. A varimax rotation (Cooley and Lohnes. 1971) was performed to maximize the variance of the squared factor loadings. This rotation resulted in only minor changes in the per cent of variance accounted for by each of the three factors, but did not affect factor loadings. The two factors to which items were assigned were the same as those factors extracted from the first questionnaire. That is, the very same items that loaded on the two factors from the first questionnaire. loaded on the same two factors from the second questionnaire. The 12 items characteristic of spasmodic dysmenorrhea loaded on the first factor while the 12 items characteristic of congestive dysmenorrhea loaded on the second factor. The twenty-fifth item concerning the type of dysmenorrhea chosen by the S. correlated with the two factors with factor loadings of 0.587 and -0.583 respectively. These two factors provide further confirmation of Dalton’s (1969) theory that there are two types of dysmenorrhea. The MSQ scores obtained from the Ss after the Z-week period of time arc presented in Table 4. While the scores generally dropped by one point between Ss, there was a gap of 14 points between the twenty-ninth and the thirtieth rank-ordered Ss. While the midpoint score of 77 had been considered for a line of demarcation between the two types of dysmenorrhea, this midpoint fell within the sizeable 14-point gap. Thus, the ranked scores revealed a relatively continuous dimension within the higher scores (spasmodic) and within the lower scores (congestive). but with a large hiatus existing between these polar dimensions. This pattern of scores suggests that two types of dysmenorrhea can be identified by the MSQ.
The development Table
of the menstrual
4. List of ranked scores pilot administration Ranked
scores
symptom
questionnaire
obtained from of MSQ Ranked
243
second
scores (cont.)
102
83
102 100 98 98 97 96 96 96 95 94 94 93 93 92 91 90 90 89 89 88 88 86 85 83
x3 52 x2 6x 67 66 65 64 63 58 58 56 55 54 52 57 51 51 49 48 46 46 N = 48
DISCUSSION
The extraction of the two factors, the reliability of the items and distribution of the scores into two groups all suggest that the MSQ is a psychometric capable of differentiating between the two types of primary dysmenorrhea. This finding is important for three reasons. First, it substantiates Dalton’s (1969) assertion that there are two types of primary dysmenorrhea. This support of Dalton’s theory indirectly confirms the hormonal imbalance explanation of the two types of primary dysmenorrhea which argues that spasmodic dysmenorrhea is caused by an excess of progesterone compared to estrogen, and congestive dysmenorrhea is caused by an excess of estrogen compared to progesterone. Second. because the two types have different causes and require different treatments, it may be necessary to determine a patient’s type of dysmenorrhea. The endocrine tests which provide such information are quite costly, but the MSQ which also provides this information can be considered as an alternative. Third. the MSQ allows reliable and efficient differentiation between the two types of dysmenorrhea for future research on treatments tailored to each type of dysmenorrhea, spasmodic and congestive. This research is imperative as it is apparent that the hormonal treatments available today are not universally indicated. accepted, or effective. One such possible treatment. behavior modification, which has been shown in three studies to be an effective therapy for dysmenorrhea (Mullen, 1968, 1971; Tasto and Chesney, 1974) might be further explored as a treatment which may be more effective with one of the two types of dysmenorrhea. Research has suggested that one of the physiological effects of muscle relaxation treatment is a reduction in muscle tension (Jacobson, 1938; Paul. 1969; Lehrer. 1972). If, as asserted by Dalton ( 1969), the discomfort in spasmodic dysmenorrhea is related to muscular tension and contractions, while the discomfort in congestive dysmenorrhea is related to an ischemia, then behavior modification treatment may be more effective with spasmodic dysmenorrhea. Further research is necessary to ascertain whether the pairing of muscular relaxation with the onset of menstruation would lead to an alleviation of some of the discomfort experienced by women with spasmodic dysmenorrhea. REFERENCES C~~LEY W. W. and LOHNES P. W. (1971) Multiwriate DALTON K. (1969) Tile Mer~srrucll CT&. Pantheon
Data
Books.
halysis.
New York.
John
Wiley. New York.
244
MARGARET A. CHESNEY and DONALD L. TASTY
DAVIS C. H. (1964) Dysmenorrhea. In Gy,lecology and Obstetrics (Ed. B. CARTER). W. F. Prior. Hagerstown. MD. ISRAEL S. L. (1967) Diagnosis and Trearmwt of Mensrrual Disorders and Sterility. Harper & Row. New York. JACOBSON E. (1938) Progressive Relaxation. University of Chicago Press. Chlcago. JANOWSKY D. S.. GORNEY R. and MANDELL A. J. (1967) The menstrual cycle: Psychiatric and ovarian-adrenocortical hormone correlates: Case study and literature review. Arc/Is gen. Psychiar. 17, 459-469. KROGER W. S. and FREED S. C. (1943) The psychosomatic treatment of functional dysmenorrhea by hypnosis. Am. J. Ohster. Gynec. 46. 817-822. LEHRER P. M. (1972) Physiological effects of relaxation in a double-blind analog of desensitization. Ecllar. Therapy 3. 193-208.MANN E. C. 11963) Primarv dvsmenorrhea. In Progress iu Gwecology (Eds. J. V. M~IGS and S. H. STI’RGIS). Vol. IV, pp. 1-s146. kr;ne and Stratton. New York. _MULLEN F. G. (1968) The treatment of a case of dysmenorrhea by behavior therapy techniques. .I. .Ycrr. Ment. Dis. 147, 371-376. MULLEX F. G. (1971) Treatment of dysmenorrhea by professional and student behavior therapists. Paper presented at F$/I A~rtual Meeting of fhe Association .for fhe Aduanceme,lt qf Behaoror Therap!. September. Washington. D.C. NOVAK E. R., JONESG. S. and JONES H. W.. Jr. (1965) Novak’s Testhook qf Gynecology. 7th Edn. pp. 653-661. Williams and Wilkins, Baltimore. OGDEN J. A., WADE M. E.. ANDERSONG. and DAVIS C. D. (1970) Treatment of dysmenorrhea: A comparative double-blind study. Am. J. Ohstet. Gynec. 106, 838-842. PAUL G. L. (1969) Physiological effects of relaxation training and hypnotic suggestion. J. abuorm. Psychol. 74, 425-437. PAULKIN M. J. and WOOD K. R. (1966) Perceptions of emotional correlates of dysmenorrhea. A~I. J. Ohsret. Gynec. 95. 991-996. SCHAUFFLERG. C. (1967) Dysmenorrhea in and near puberty. N.Y. Acad. Sci. Ann. 142. 794-800. STLIRGISS. H. (1962) Thr G_wtecological Patient: A Psych~e,~docrine Study. Grune and Stratton. New York. TASTO D. L. and CHESNEY M. A. (1974) Muscle relaxation treatment for primary dysmenorrhea. Eellar. Therapy 5, 668-672. TINDALL V. R. (1971) Dysmenorrhea. Br. Med. J. 1, 329-331. TYLER E. T. (1973) Contraception control: The pill is best for most. In Reproducrive E~~docrirlology (Ed. D. P. LAULER). Medcom. New York.
