|Shrotriya Charu1*, Ray Amita2, Ray Sujoy3 and George Aneesh Thomas4
|Related article at Pubmed, Scholar Google|
Background: A common gynecological problem encountered among female medical students is dysmenorrhea, which also appears to be a leading cause of absenteeism from college. Hence arises a need to evaluate the menstrual characteristics, prevalence of dysmenorrhoea and its effect on daily routine activities and quality of life of medical students. Aims: This is a cross sectional descriptive study, conducted on 560 female medical students with the objectives to evaluate the menstrual characteristics ,prevalence and severity of dysmenorrhoea and its effects on the quality of life, particularly absenteeism from college. Methods: Three medical colleges in Mangalore (Karnataka, India) provided the setting of our study. These were representative of a cosmopolitan nature of the study population. A total of 560 students were interviewed by the investigators. All participants were given a preformed questionnaire to complete. Besides menstrual characteristics the questionnaire included gradation of pain and quality of life based on the American Chronic Pain Association (ACPA) which was modified according to needs of our study. Chi-square test and logistic regression were used for statistical analyses. Results: The average age of the participants was 20.57 years +/- 1.208 years (ranging from 17-24 years). The mean BMI of the participants was 21.69 +/-3.27 kg/m2 (ranging from 14.7 kg/m2 to 33.54kg/m2 ). The average age of menarche was 12.67+/-1.10years, (9 to 16 years). The average menstrual cycle duration of the participants in the study group was 29.52+/- 3.37days. 97.2 %( 533), family history of dysmenorrhea was present in 40% participants (n=560). Of the total , 86.96 % (487) participants reported to have physical premenstrual symptoms and 55.71% (312) reported to have psychological premenstrual symptom. There is a significant association between Quality of Life and severity of dysmenorrhea . Conclusion: Our study shows a significant association of dysmenorrhoea with the age of menarche, family history and both physical and psychological premenstrual symptoms. Although there was an association of dysmenorrhoea with chronological age, BMI and cycle length, these associations were not found to be statistically significant. The most significant conclusion of our study was found to be high prevalence of dysmenorrhoea, having a significant effect on the routine activities and a detrimental effect on the quality of life. The alarming prevalence of self-medication in the form of NSAID's, easily available over the counter was also highlighted in our study.
|Dysmenorrhoea, Menstrual characteristics, Quality of life|
|Dysmenorrhoea is defined as painful menstrual cramps of uterine origin. It is common gynecological condition that can affect as many as 50% of women 1. 10% of these women suffer severely enough to render them incapacitated for one to three days each menstrual cycle 2 . This situation not only has a significant effect on quality of life and personal health but also has a global economic impact 3 .|
|Two categories of dysmenorrhoea are defined, primary and secondary.|
|Primary is a menstrual pain without any organic pathology 4. The initial onset of primary dysmenorrhoea is usually at or shortly after menarche, when ovulatory cycles are established.|
|When the pelvic pain is associated with an identifiable pathological condition, such as endometriosis, ovarian cysts, pelvic inflammation, myomas or intrauterine devices it is considered to be secondary dysmenorrhoea. This category is more likely to occur years after the onset of menarche and can occur premenstrually as well as during menstruation.|
|As described above, dysmenorrhoea with an identifiable cause is termed as secondary, where as one without any identifiable cause are primary. In vivo and in vitro research has identified the overproduction of prostaglandins as a substantial contributing factor to the painful cramps.5|
|Several longitudinal studies have found a positive association of primary dysmenorrhea with duration of menstrual flow, younger age at menarche, increased BMI and cigarette smoking.6, 7.There is also some evidence of a dose–response relationship between exposure to environmental tobacco smoke and increased incidence of dysmenorrhoea7. Childbirth, in contrast, appears to relieve dysmenorrhoea6.|
|This is a cross sectional descriptive study, conducted on 560 female medical students with the objectives to evaluate the menstrual characteristics, prevalence and severity of dysmenorrhoea and its effect on the quality of life, particularly absenteeism from college.|
|Mangalore is a city situated in the state of Karnataka in South India. It has a population of 484,785 as per the 2011 census of India8. There are significant disparities in the socio-economic characteristics in the different quarters of the city. The city includes several universities and professional colleges and has a cosmopolitan structure in terms of student population. This study was conducted in Father Muller Medical College, Yennopoya Medical College, and Kasturba Medical College, Mangalore.|
|This cross-sectional study was conducted between March 2011 and October 2011. A total of about 600 subjects were accessible, out of which 560 agreed to be a part of the study, others were either absent or refused to fill the questionnaire.|
|The ‘quality of life’ scale, devised by American Chronic Pain Association was modified as per the activities most suited for the college students most commonly limited to attending classes and mild to moderate form of exercise.|
|All 560 participants surveyed at colleges completed the questionnaires and inventories during a class period. After distributing the questionnaires to students at the college, they were informed as to how the questionnaires were to be filled and were then requested to make the best choice that was applicable to them during past 1 year. The participants completed questionnaires in the presence of a member of the research team. All participants were told that participation in the investigation was strictly voluntary, and that the data collected would not be used for anything except for this research study. The duration for completing the questionnaire was between 15-20 min per participant. The principal investigator checked the data to ensure its quality.|
Development of Questionnaires
|Dysmenorrhoea was said to be present if the participant reported pain in the abdomen on the day before and /or the first day of the menstrual period.|
|The participants were provided with a visual analogue scale of 0-4, to assess their pain. (where zero referred to least intensity of pain and 4 referred topain severe enough to confine a participant to home / bed)|
|(Original scale- APPENDIX I)|
|MODIFICATION OF QUALITY OF LIFE SCALE|
|If the participant experienced menstrual bleeding in equal intervals between 21 and 35 days, it was evaluated as normal 9; if the menstruation interval was less than 21 days, it was considered to be short; if the menstruation interval was more than 35 days, it was considered to be long.|
|The presence of dysmenorrhea in an adolescent’s mother or sister was accepted as a positive family history of dysmenorrhea.|
|BMI were calculated by measuring their height and weight. Each participant’s body weight was measured with domestic scales and height with a meter rule. As per the "WHO The International Classification of adult underweight, overweight and obesity according to BMI", those who had a BMI of 18.0–24.9 kg/m2 were classified as normal weight, participants with BMI values that corresponded to a BMI of 25.0–29.9 kg/m2 were classified as overweight (pre-obese), participants with BMI values that corresponded to an adult BMI of 30.0 kg/m2 were classified as obese, and with BMI values that corresponded to <18.0 kg/m2 as underweight 10.|
|Frequently, women of reproductive age experience symptoms during late luteal phase of their menstrual cycle, and collectively these complaints are termed premenstrual symptoms, and typically include both psychological and physical symptoms 11.|
|Physical symptoms were broadly divided into abdominal symptoms (abdominal bloating, hypogastric pain), breast symptoms (breast heaviness/tenderness) and other symptoms (headache, pain in thighs, backache).|
|Psychological symptoms, on the other hand, were classified as uneasiness, anxiety and disturbed sleep.|
|Ethical approval was taken from the hospital’s ethics committee.|
|Chi-square test and logistic regression were used for statistical analyses.|
|Baseline characteristics (Figure 1, 2)|
|The average age of the participants was 20.57 years +/- 1.208 years (ranging from 17-24 years). 23% (114) were found to be less than 20 years of age whereas only 4% (22) were above 22 years of age. Most of the responders, 73% (409) fell within the age group of 20-22.|
|The mean BMI of the participants was 21.69 +/- 3.27 kg/m2 (ranging from 14.7 kg/m2 to 33.54 kg/m2).|
|Majority of the participants had a normal BMI (18.5-25) which was around 67% of the total participants. The underweight and overweight categories had almost equal distribution with 15% were and 18% respectively.|
|The prevalence of dysmenorrhea was very high with 67.5% (378) with around 34% of the women who experienced pain rating their pain as ‘slightly severe’.|
|Age of Menarche (Figure 3, table 1)|
|The average age of menarche was 12.67+/- 1.10years, (9 to 16 years). Most of the participants, i.e. 84.2% (472), had started menstruating between 12-14 years of age.|
|Association with dysmenorrhoea|
|There is a significant association between age of menarche and dysmenorrhea (χ² = 11.36 df= 2 and p value =0.003). After taking the age group of 12-14 years as the reference category the bivariate analysis found that girls who had menarche at 15 years and above had a 30% higher chance of reporting dysmenorrhea when compared to girls who had menarche at 12-14 years and the difference was found to be statistically significant (RR: 1.30 ; 95% CI: 1.06-1.60). Similarly we also found that girls who had menarche at 11 years or below had a 23% higher chance of reporting dysmenorrhea when compared to girls who had menarche at the reference age group and this difference was also found to be statistically significant ( R.R :1.23; 95% CI; 1.13-1.45).|
|Length of the menstrual cycle|
|Among the 548 respondents the average duration of the menstrual cycle was 29.52+/- 3.37days (20-45 days). A large chunk of students had menstrual cycle duration of 28 to 35 days; 97.2% (533), which is considered as normal. Since a very small number (2.8%) had cycle length <21 days and >35 days, we did not endeavor to find any association between cycle length and dysmenorrhea.|
|Family History (Figure 4,5, table 2)|
|Most of the interviewees did not have complaints of dysmenorrhea among their immediate family members; 60.5% (339).|
|Association with dysmenorrhoea|
|Of the 39.5% (221) participants who had some family history of dysmenorrhoea, 81.9% (181) experiences the condition themselves. The bivariate analysis performed proved to be statistically significant (χ² = 34.5 df=1 and p value =0.000). Thus we concluded that participants whose family members (sisters or mothers) had a history of dysmenorrhoea had a 1.41 times greater chance of having the same problem when compared to participants without a family history of the same (RR: 1.41; 95% CI =1.26 -1.57).|
|As per our methodology, premenstrual symptoms were classified as physical and psychological (while considering the percentages, please note there are participants who have reported both physical and psychological symptoms)|
|• PMS - PHYSICAL SYMPTOMS (Figure 6, table 3)|
|Of the total 560, 86.96% (487) participants reported to have physical premenstrual symptoms. These were broadly classified into abdominal symptoms (abdominal pain, bloating), breast heaviness, and other symptoms (headache, backache, pain in thighs). Abdominal symptoms were reported by 67.9%( 380) while breast heaviness was reported by only 21.1% (118) of the women.|
|Association with dysmenorrhoea|
|Our analysis showed an association between PMS (physical) and dysmenorrhea (χ² = 167.34 df=1 and p value =0.000). We found that women who had PMS had 56.1 times more chance of having dysmenorrhea when compared to women in whom PMS was absent and the difference was found to be statistically significant (RR 56.51, 95% CI= 8.06 TO 396.06). The nature of the result is due to the obvious fact that most responders (except one) that had dysmenorrhea experienced some form of PMS.|
|• PMS - PSYCHLOGICAL SYMPTOMS (Figure 7)|
|44% (245) of the 557 participants did not report any psychological symptoms (3 responses could not be analyzed) but a majority, 56% (312) of the surveyed women reported to have experienced some form of psychological premenstrual symptom. Out of these, 46% (146) of the subjects had experienced uneasiness whereas 42% (131) reported anxiety as the main problem.|
|Association with dysmenorrhoea|
|As a standard procedure, women who did not experience any form of PMS (psychological) were taken as the reference category and other categories of the problem were compared to this.|
|Our results were as follows: women who experienced uneasiness were 1.75 times more likely to have dysmenorrhea when compared to women who had no PMS and the difference was statistically significant (RR:1.75,95% CI:1.48-2.07). Women who experienced anxiety were 2.17 times more likely to have dysmenorrhea when compared to women who had no PMS and the difference was statistically significant (RR: 2.17, 95%CI: 1.88-2.52). Women who had disturbed sleep as their main PMS were 2.3 times more likely to have dysmenorrhea when compared to women who had no PMS and this too was statistically significant (RR: 2.30, 95% CI:1.99-2.65).|
|Treatment (any) and Dysmenorrhea (Figure 8, table 4)|
|• 86.9% (320/368) of women who had dysmenorrhea took treatment. Among these|
|• 73.4% (270/368) women took allopathic medicines: (168/270 took Analgesics, 148/270 took Antispasmodics and 46/270 took both).|
|• 57.8% (213/368) women took Physiotherapy. (91 %(194/213) used hot water bag)|
|• 39.94% (147/368) women took both Allopathic and Physiotherapy treatment.|
|• 19.83% (73/368) women made use of home remedies|
|• 6.79% (25/368)women made use of other means|
|Quality of Life and Dysmenorrhoea (Figure 9, table 5)|
|Again in this bivariate analysis ‘normal’ QOL (376; 67.1%) was taken as the reference category and all other analysis was done with respect to this; participants who had dysmenorrhea were 6.6 times more likely to stay in bed all day when compared to women who had normal quality of life with respect to their menstrual cycle and the difference was found to be statistically significant ( RR: 6.6, 95% CI:4.48 to 8.45). We also found that participants who had dysmenorrhea were 6.16 times more likely to stay at home all day when compared to women who had normal quality of life with respect to their menstrual cycle and the difference was found to be statistically significant (RR :6.16, 95% CI:4.48 to 8.45). In addition to this participants who had dysmenorrhea were 6.06 times more likely to attend college after taking medication (with no other outdoor activities) when compared to women who had normal quality of life with respect to their menstrual cycle and the difference was found to be statistically significant (RR:6.06, 95% CI :4.41 to 8.34). Lastly, we found that participants who had dysmenorrhea were 5.62 times more likely attend college without taking medication (with no other outdoor activities) when compared to women who had normal quality of life with respect to their menstrual cycle and the difference was found to be statistically significant ( RR: 5.62, 95% CI:4.08 to7.75).|
|According to the bivariate analysis, significant differences were revealed between the existence of dysmenorrhea and age of menarche, family history, different grades of PMS (psychological) and the presence of PMS (physical) among women in the study population. Logistic regression was performed using ‘Enter method’ for the above mentioned variable, the results are as given in the table below.|
|Age at menarche (15 years and above, 11 years and below), presence of dysmenorrhea in the immediate family, presence of PMS (uneasiness and anxiety) and the presence of physical Premenstrual Syndrome (PMS) were considered to be important risk factors for dysmenorrhoea in the study population. However, the last category of PMDD (disturbed sleep) was found not to be a precipitating factor for dysmenorrhoea. This might be due to the comparatively less number of participants who reported this as one of their problems.|
|The presence dysmenorrhoea seemed to be an important factor in determining the different subcategories of the quality of life as well as the need to take any form of treatment, in the bivariate analysis. However, because these variables were considered to be the effects rather than the causes of dysmenorrhoea they were analyzed separately using logistic regression and were not combined with the other variables. Attending college with or without medications (without any outdoor activities) were the only variables among all the sub categories of the Quality of Life that were significantly associated with dysmenorrhea. The wide confidence intervals were due to the low and unequal respondents in these categories. Both the sub categories: “in bed all day” and “unable to attend college” were not associated with dysmenorrhoea, this might be again due to the comparatively unequal distribution of respondents in these two categories. Seeking treatment (in any form) was also independently associated with dysmenorrhea.|
|Dysmenorrhea is the most common gynecological problem worldwide. In our study, 67.5% of girls reported dysmenorrhoea in past 1 year. Other studies conducted in the developing countries reported a prevalence ranging from 71% to 75% (12, 13, and 14). A Cochrane systematic review of studies in developing countries reported prevalence of dysmenorrhea in 25% to 50% of adult women. (15) On the other hand, studies from the developed world reports a wide range of 60% to 73% (16, 17, 18)|
|The prevalence of dysmenorrhoea varies with age of menarche.|
|The students’ average menarche age was 12.67+/-1.10 years.Of the total participants found to have dysmenorrhoea, 82.69% of the participants had attained menarche by the age of 11 (early menarche). There is a significant association between early age of menarche and dysmenorrhoea, (p=0.003). Participants who had menarche at 11 yrs and below, had a 23% higher chance of having dysmenorrhoea when compared to participants who had menarche at an age above 11 yrs and the difference was found to be statistically significant. This finding is found consistent with several other studies (12, 19,20). However, none of these references give an explanation for the same. This could probably be explained by the fact that girls who attain menarche early have longer exposure to uterine prostaglandins, leading to higher prevalence of dysmenorrhoea.|
|Variation in prevalence of dysmenorrhoea and BMI|
|The mean BMI of the students was 21.69 +/-3.27 kg/m2 (ranging from 14.7 to 33.54). 67.1% of the women had a normal BMI, which falls between 29.5 to 25 kg/m2 . Although not significantly associated, it was found that participants who were underweight were 0.002 times less likely, whereas those overweight and obese are more likely to suffer from dysmenorrhoea when compared to participants with normal BMI. Another study conducted in India, under similar set up, finds no correlation between BMI and dysmenorrhoea14. Similarly, no association was found between prevalence of dysmenorrhoea and height or weight 21. Our findings were consistent with those reported in the literature, i.e. severity of dysmenorrhoea is positively associated with increased BMI. 20|
|Length of cycle|
|The average menstrual cycle duration of the students in the study group was 29.52+/-3.37days. 97.2%, (533), of the subjects have a normal cycle length of around 20-35 days. Normal length of cycle is considered 21-35 days long 22. This is in view of fact that the cycles are already regularized by this age. We did not find the association between length of cycle and dysmennorhoea. Different studies suggest that dysmenorrhoea is more prevalent in women with longer cycles. (13, 23)|
|Frequently, women of reproductive age experience symptoms during late luteal phase of their menstrual cycle, and collectively these complaints are termed premenstrual symptoms and typically include both psychiatric and physical symptoms.11 .Our study reports a significant association between the premenstrual symptoms (both physical and psychological) and dysmenorrhoea. We cannot say if the anticipation of dysmennorhoea might be the reason of the premenstrual symptoms or the psychological symptoms like anxiety and disturbed sleep, which may also decrease the pain threshold, might be responsible for increased severity of dysmenorrhoea. The findings are consistent with other study12 where the symptoms associated with dysmenorrhoea are graded as lethargy and tiredness (first), depression (second) and inability to concentrate in work (third).|
|In another study from India, (14) subjects suffering from dysmenorrhoea (n=79), presented with following symptoms i.e., backache (62.0%), headache (26.58%), fatigue (70.88%) and vomiting/diarrhea (6.32%) were reported. In 107 participants, 60.74% were presented with PMS, symptoms consist of: breast heaviness (17.75%), abdominal bloating (12.14%), backache (25.23%), headache (13.08%), uneasiness (22.42%), and anxiety (8.41%).|
|The most frequent symptoms associated with dysmenorrhoea were fatigue, headache, backache, dizziness and anorexia/vomiting. In 23.8% of cases there were no associated symptoms 13|
|In this study it was found that 39.46% participants have a positive familial correlation, i.e. either mother or sibling has similar complaints. This is in accordance to other similar study conducted in similar setup in Pakistan 24. Another study finds a strong correlation between familial predisposition and dysmenorrhoea. 18|
|Effect on daily routine|
|Dysmenorrhea is found to have significant effect on day to day activities, limiting daily activities(13), having negative effect on quality of life18, leading to absenteeism in work place or taking medication to carry out daily activities(14,21). Similar findings appear in our study, most of the participants, most commonly limited to attending classes and mild to moderate form of exercise.|
|86.9% (320/368) of the participants who had dysmennorhoea took treatment.|
|Where most (91%=194/213) common mode of treatment was evaluated to be the application of heat in the form of hot water bag, a large number of participants (73.4%) relied on easily available over the counter analgesics. These drugs (NSAIDs) have considerable side effect and its effluent use needs to be checked.|
|Dysmenorrhoea is found to be highly prevalent among female medical students and is found to be a leading cause of absenteeism in medical colleges. A positive association between dysmenorrhoea and the age of menarche, family history, both physical and psychological premenstrual symptoms. Although there was an association of dysmenorrhoea with chronological age, BMI and cycle length, these associations were not found to be statistically significant.|
|Most women experience a number of physical and emotional symptoms associated with dysmenorrhea.|
|Dysmenorrhoea is also found to have an adverse effect on the quality of life.|
Conflict of interest
|The findings of this study thus indicate the magnitude of the problem and the need for appropriate intervention through a change in lifestyle.|
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FIGURE : 9
|1-Weisman A M, Hartz A J et al “The natural history of primary dysmenorrhoea: a longitudinal study, Br J Obstet Gynaecol 111, 345, 2009
2- Dawood MY. Ibuprofen and dysmenorrhea. Am J Med 1984; 77(1A):87–94.
3-Dawood MY. Dysmenorrhea. Clinical Obstetrics and Gynecology 1990;33(1):168– 78.
4-Lichten EM, Bombard J. Surgical treatment of primary dysmenorrhea with laparoscopic uterine nerve ablation. Journal of Reproductive Medicine 1987; 32:37–41
5-Dawood MY. Primary Dysmenorrhea - Advances in pathogenesis and management. Obstetrics Gynaecology 2006; 108:428–41.
6-Sundell G, Milsom I, Andersch B. Factors influencing the prevalence and severity of dysmenorrhoea in young women. Br J Obstet Gynaecol 1990; 97:588–594. [PubMed]
7- Chen C, Cho SI, Damokosh AI, et al. Prospective study of exposure to environmental tobacco smoke and dysmenorrhea. Environ Health Perspect 2000; 108:1019–1022.
8- "Population of Corporation/CMC/TMC/TP (Population 2001 Census)". Directorate of Municipal Administration, Bangalore. Retrieved 2008- 04-16.
9-.Berek JS.Berek and Novak's gynecology. Lippincott William and wilkins.wolters kluwer health (India) pvt ltd., New Delhi; 14; 2007:461
10. World Health Organization. Obesity: preventing and managing the global epidemic Report of a WHO consultation on obesity. Technical report series, No 894. Geneva: World Health Organization; 2000.
11- Schorge JO, Schaffer JI, Halvorson LM, et al. Williams’s gynecology. Printed in china; 2008:296
12. Agarwal Ak, Agarwal A. A Study of Dysmenorrhea during Menstruation in Adolescent Girls. Indian J Community Med. 2010 January; 35(1): 159–164.
13-. El-Gilany A-H, Badwai k, El-Fedway s. Epidemiology of dysmenorrhoea among adolescent students in Mansoura, Egypt. WHO HEALTH JOURNAL Volume 11 Nos 1&2 January - March, 2005
14. Singh A, Kiran D, Singh H, et al. Prevalence and severity of dysmenorrhea: A problem related to menstruation, among first and second year female medical students. Indian J Physiol Pharmacol 2008; 52 (4):389– 397
15. Harlow S, Campbell O. Epidemiology of menstrual disorders in developing countries: A systematic review. British Journal of Obstetrics and Gynaecology 2004; 111:6–16.
16- Burnett MA, Antao V, Black A, et al. Prevalence of primary dysmenorrhea in Canada. J Obstet Gynaecol Can
17- Andersch B, Milsom I. An epidemiologic study of young women with dysmenorrhea.Am J Obstet Gynecol 1982; 144:655–660. [PubMed]
18- Unsal A, Ayranci U, Tozum M, et al: Prevalence of dysmenorrheal and its effect on quality of life among a group of female university students Ups J Med Sci 2010:115; 138-45
19.P Latthe, L Mignini, R Gray, R Hills and K Khan, Factors predisposing women to chronic pelvic pain: systematic review. BMJ, 332 (2006), pp. 749–755.
20. Schorge john o, schaffer Joseph I, Halverson Lisa m, et al. Williams gynecology. Printed in China 2008; 257-258
21. Ortiz, M.I. (2010). Primary dysmenorrhea among Mexican university students: prevalence, impact and treatment. Eur. J. Obstet. Gynecol. Reprod. Biol. 152: 73–77.
22. MÜNSTER, K., SCHMIDT, L. and HELM, P. (1992), Length and variation in the menstrual cycle—a cross-sectional study from a Danish county.Br J Obstet Gynaecol 99:422–429.
23. SUNDELL, G., MILSOM, I. and ANDERSCH, B. (1990), Factors influencing the prevalence and severity of dysmenorrhoea in young women. Br J Obstet Gynaecol 97:588–594.
24. Parveen N, Majeed R, Rajar Udm. Familial predisposition of dysmenorrhoea among medical students. Pak j med sci 2009; 25(5):857-860.