Discussion
unawareness
PMS
The results of the study suggested that all three interventions caused a statistically significant decrease in the PMS scores as primary outcome at week 10 compared to the baseline. Positive-oriented counseling had a greater effect on alleviation of PMS than the other two interventions. A review of the literature found no similar study addressing the same interventions examined in the current study. Thus, this section compares the results of the present study with the findings of similar studies. The Results of a study showed that cognitive-behavioral therapy (CBT) mixed with calcium and vitamin D3 pills significantly reduced PMSVitamin D3 level was increased in week 6 and decreased in week 10 in comparison with baseline in current study. A review study showed that taking calcium and vitamin D3 tablet or following a diet rich in these two substances can restore serum levels and eliminate or reduce the PMS symptoms. Calcium and vitamin D3 supplementation are recommended as a cheap, low-risk, acceptable, and available method to reduce the PMS The results of the current study indicated although lifestyle modification training intervention led to a significant reduction in PMS, this reduction was less than the other two interventions. In a study, the web-based lifestyle training could relief PMS in university studentsGeneral reason for effectiveness of three interventions in current study may relate to unawareness of most of women in about PMS and they had not received any treatment before participating in the study. Thus, it seems that all three interventions were effective in informing them about their diseaseAnother primary outcome variable of this study was satisfaction with the intervention method with considerable score of satisfaction in three groups. This finding would be due to short-term intervention that women could feel quick improvement in PMS after 6 weeks. In addition, understandability, acceptability and feasibility of intervention, and popularity of online intervention may be other reasons. The satisfaction with the intervention method differed significantly among the three groups with the most satisfaction in the positive-oriented counseling group and the least satisfaction in the lifestyle modification training group. This can be attributed to healthy lifestyle exercises such as dietary regimens, avoiding stressors, getting enough sleep and rest, which seems to be not easily possible and requires more willpower, practice, and perseverance compared to the two other intervention methodsConsiderable satisfaction with the intervention method (this variable not assessed in other studies), women’s PMS approval using PMS calendar completion prospectively for two consecutive menstrual cycles before initiation of the intervention (it have not been reported in most of similar studies), participation of women with 25-hydroxyvitamin D3 levels less than 30 ng/ml through laboratory measurement before taking vitamin D3 pearl, one month free of intervention follow up after trial completion for reassurance of interventions effectiveness (less mentioned in similar studies), providing content for sessions as educational package for other investigators, and effectiveness of three various short-term interventions may imply strengths of the current study and its clinical application through provide treatment options for women who prefer not to use anti-depressant/hormonal drugs for their side effects or compliance , or would like to use other treatments beside of anti-depressant/ hormonal drugs for more effectiveness on PMS. The authors recommend investigating the impact of such interventions with longer term follow up in the future studies. The impossibility of blinding in intervention due to the nature of the selected interventions and thus the participants were naturally aware of the type of intervention was considered as study limitation. Another study limitation was need to internet literacy for online interventions (except taking vitamin D3 group) that is not applicable for illiterate women.The three non-antidepressant/non-hormonal drugs interventions online positive-oriented counseling, vitamin D3 tablet, and online lifestyle modification training alleviated PMS symptoms, but the positive oriented counseling was more effective than the other two interventions. The women were also satisfied with the allocated intervention method, but more satisfaction observed in positive-oriented counseling group. Superiority of online positive-oriented counseling may imply feasibility of its skills that could be continued individually by women after termination of the counseling, and without leaving the house. It is recommended that health care providers, policymakers, and managers should support and establish interventions for women with PMS in their treatment program and clinical guidelines.