The reproductive system of females, unlike males, shows regular cyclic changes [1]. Over 200 psychological, physiological, and behavioral alterations occur in the female body due to the menstrual cycle [2]. During the menstrual cycle, sex hormones are responsible for physiological changes in the reproductive organs, as well as changes in the female’s physical and mental condition [3]. The majority of females go through at least one of these changes, such as irritation, mental instability, and physical symptoms like headache or bloating, particularly during the luteal phase. Premenstrual Dysphoric Disorder (PMDD) is a diagnosis given when a patient's mental symptoms are severe enough to affect their ability to function in social situations and other areas of their life, such as their ability to work efficiently [4]. In 20-40% of females, these symptoms may indicate a psychopathology that can significantly affect a female’s quality of life [5].

Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD) are two forms that characterize the changes in the mental health status of females due to hormonal disturbances, as aforementioned [6]. PMS refers to a set of emotional, somatic, and behavioral symptoms that occur cyclically only in the luteal phase and subside with the onset of menstrual bleeding. In contrast,PMDD is a severe form of PMS manifested by more intensified emotional symptoms affecting a subset of menstruating women with a disease burden compared to other depressive disorders [7]. Premenstrual Dysphoric Disorder (PMDD) criteria are mentioned in section II (Diagnostic Criteria and Codes) in the DSM-5TR, under the depressive disorders part of this section. The female must have premenstrual dysphoric symptoms during the majority of menstrual periods in the past year. These symptoms should begin five days before menses, improve during menses, and fade away after three days of menses. The female must have at least five premenstrual dysphoric symptoms to be diagnosed as a case of PMDD. At least one of the five symptoms must be one of the following: labile mood, irritability or anger, depressed mood and anxiety and tension. Other symptoms include decreased interest, concentration difficulties, fatigue, change in appetite, change in sleep habits, instability, and physical symptoms. The physical symptoms include breast tenderness, swelling, joint or muscle pain, and weight gain. These symptoms do not attribute to other physical or psychological disorders or medications and interfere significantly with social and work life [8]. Treatment of PMDD may take the pharmacological and nonpharmacological options. The last option is preferable among females [9]. Nonpharmacological strategies are cognitive behavioral therapy, dietary modification (restricted salt, restricted caffeine, and restricted alcohol), moderate regular exercise, stress management, and supportive therapy [9].

Studies showed that PMDD predisposes the onset and exacerbation of other mental health disturbances, such as depression, dysthymia, and generalized anxiety disorder, and increases the risk of antenatal peri-menopausal depression [10]. Studies showed that the 12-month prevalence of PMDD is 1.8–5.8% among menstruating women [5]. However, the severity of symptoms may vary among women suffering from PMDD, which has also been addressed by the literature, leading to higher rates of PMS and PMDD: 15.0-20.0% and 3.0-8.0%, respectively. Such rates are also dependent on the developmental phase of the female. For example, in a study targeting female university students during their exam time, we found that PMS was 92.3% and that PMDD was 7.7% [11]. Such figures are considered alarming to mental health and reproductive health professionals due to serving consequences on quality of life and functionality [12]. Thus, healthcare professionals need to be aware of and well-equipped with knowledge and skills to detect and manage PMS and PMDD.

The figures of PMS and PMDD indicate the need to be aware of the impact of the long-term effects of the situation and the attitude of women towards seeking psychological counseling as needed. Previous reports showed that women suffering from PMS or PMDD rarely seek medical counseling and that among those who do, a sufficient response to their needs is not obtained in a large proportion of cases [13, 14].]. Such a negative attitude and low tendency to seek appropriate counseling may delay treatment and contribute to the exacerbation of symptoms, leading to further biological, psychological, and social problems. Attitude however, largely depends on the level of knowledge of women and considered the keystone to appropriate practice. Lack of knowledge could be one significant reason for not considering psychological and medical counseling [15]. This would suggest that assessing females' attitudes, knowledge and practices utilizing the KAP model would enlighten the health professionals about the severity of such a mental situation and enable them to manage it appropriately.

Egypt is a highly populated country that suffers unequal distribution of health services. Mental health problems among females are considered one of the significant issues in Egypt; however, this requires females themselves to beware and very literate about female-related mental health problems such as PMS and PMDD. Globally, mental disorders are stigmatized, and people do not explicitly declare their mental health needs. This situation is much more evident among the Egyptian population and might contribute to further obstacles to seeking mental health services. Nevertheless, efforts are directed toward the enhancement of mental health literacy as one proving step toward improving the use and access to mental health services. Investigating the knowledge, attitudes, and practices of Egyptian females is one cornerstone to improving mental health literacy, use and access to mental health services. This study came to respond to this important need and steps and attempt to extend our understanding regarding the knowledge, attitudes, and practices of Egyptian females toward PMS and PMDD in Egypt.

This study emphasized the significant contribution of PMDD by evaluating the prevalence and assessing the knowledge, attitude, and practices concerning PMS. We found that the prevalence of PMDD was 10%. The results of this study agree with other previous reports that found that PMDD ranges from 4.8% to 18.0% [19-21]. Such variation might be related to methodological issues such as the difference in sample and sampling and the cultural context of the selected sample. In the present study, approximately half of the participants reported having good knowledge about PMDD. Although women in Egypt, similar to other neighboring countries, do suffer from a lack of health literacy in many health-related issues, they were able to identify and prove that they have the appropriate knowledge regarding one significant female mental illness [22, 23]. Different explanations can be proposed here that might explain the good knowledge among women. For example, almost half of the women are working and have a higher level of education. This might have contributed to having them more exposed to different resources of information and provided them with the opportunity to be more oriented to symptoms that could explain their changes in mood. Being well-educated would suggest that they could seek and find information about what they feel from different resources. The results suggest that education and being an active worker would enhance women's awareness and be more literate about their mental health status, connecting that to their philological functions. The results support previous reports that women with higher levels of education had higher levels of PMDD knowledge [21], who discovered that higher education was an independent predictor of PMDD symptoms. As a result, raising awareness among persons with limited education is critical, as they may not have enough access to information about PMDD symptoms.

The study of Delelegn et al. [24] revealed that PMDD symptoms were connected with increased severity of stress, which is consistent with the current study's finding that most females (80%) reported that PMDD symptoms are caused by life stress.

One significant contribution of this study to the body of knowledge is the high level of awareness about seeking psychological care for PMDD when needed. Almost two-thirds of women expressed that they do not mind receiving medical advice, psychiatrist consultation, and seeking out family support on PMDD. Such a high level of awareness is considered antistigma behavior that would enhance the general community's mental well-being. Unfortunately, no comparative studies have been found within the same cultural context that have been published in spite of the knowledge that stigma among Arabs, in general, is one of the most significant negative factors that contribute to delay in seeking treatment and exacerbate the health and wellbeing of those suffering mental health problems and illnesses [24-27]. The good knowledge and awareness among women in this study also contributed reflected in their practices, where we found that most of them reported talking to their family about PMDD symptoms and did not receive help with such initiation of communication with family members.

One limitation of this study is related to the settings of data collection in which two medical centers have been included in our study. Therefore, the study findings cannot be generalized to all women in Egypt. The PSST, which is a screening rather than a diagnostic tool, was used to evaluate PMDD. This may also contribute to the high prevalence of PMDD among the current sample.

This study reveals that around 10% of the women who participated in this study have PMDD, and the majority of those women believe that PMDD awareness is important and advocate seeking medical advice. Higher educational level is the only significant predictor of good PMDD knowledge in the present study. Talking to family members, especially the husband, is helpful to overcome the symptoms of PMDD. The results indicate that mental health literacy is one significant factor that needs to be sustained among women. Orientation and early intervention mental health screening are required at the obstetrics and gynecology outpatient unit. This will enable assessing and intervening earlier to prevent the development of symptoms of mental disorders if not treated and managed well. Further longitudinal research is needed larger sample size to address the long-term consequences of PMDD and identify skills of management among women when they suffer symptoms. Variables such as social support and psychological well-being have to be addressed at every visit to maternal and child health care centers.