Arch Gynecol Obstet (2009) 279:527532 DOI 10.

1007/s00404-008-0750-0

O R I G I N A L A R T I CL E

Prevalence of primary dysmenorrhea in young adult female university students

Aytac Polat Husnu Celik Bilgin Gurates Diren Kaya Mehmet Nalbant Ebru Kavak Fethi Hanay

Received: 9 May 2008 / Accepted: 22 July 2008 / Published online: 26 August 2008 Springer-Verlag 2008

Abstract Objective To determine the prevalence of primary dysmenorrhea and attitudes and behavior toward dysmenorrhea in the female students of an university toward this problem. Materials and methods A total of 1,266 female university students were anonymously surveyed by doctors. Results It was found that mean age of the surveyed students was 21.02 2.13 years, mean menarche age was 13.3 1.4 years, and menstruation frequency was 32.58 19.8 days. Of the students, 45.3% were found to suVer pain in each menstruation, 42.5% in some and 12.2% in none. Of those with primary dysmenorrhea, 66.9% were established to take analgesic drugs. Conclusion Prevalence of primary dysmenorrhea was found higher than that cited in the literature. It was established that although the rate of consultation with health professionals about menstruation and related changes was low, use of agents known to be eVective in primary dysmenorrhea treatment was highly common. Keywords Dysmenorrhea Menstruation Adolescent females Turkey

Introduction Primary dysmenorrhea (PD) is deWned as a cramp-like pain in the lower abdomen at the onset of menstruation without any identiWable pelvic pathology. Pain may be accompanied by back pain, nausea, vomiting and diarrhea [15]. Prevalence of PD, which is the most common gynecological problem among menstruating young adults and adolescents, was reported in many studies to vary between 50 and 90% [6]. PD is typically seen after the start of the ovarian cycles of adolescents. Its prevalence increases in adolescence years, and decreases with age after adolescence [4, 79]. Besides being a gynecological problem, PD is an important health problem concerning public health, occupational health and family practice, as it aVects both the quality of life and the national economy due to short-term school absenteeism and loss of labor [10, 11]. Unfortunately, both the prevalence of PD and the manner in which females attempt to solve this problem are unknown in most of the developing countries. In this study, it was intended to examine the attitudes and behavior of female students of only one university to this problem.

Materials and methods

A. Polat (&) D. Kaya Department of Family Medicine, Firat University, Medical School, Elazig, Turkey e-mail: aytacpolat@hotmail.com H. Celik B. Gurates M. Nalbant E. Kavak F. Hanay Department Obstetric and Gynecology, Firat University, Medical School, Elazig, Turkey e-mail: drhusnucelik@gmail.com

This study was carried out with 1,266 female students at Firat University after the permission of the Ethics Committee of Firat University Medical School was obtained. An anonymous survey was used in the study (Table 1). The survey was carried out within the framework of the permission obtained from the University Rectors OYce and conducted by doctors when the students gathered in class,

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528 Table 1 The questionnaire for the prevalence of primary dysmenorrhea and menstrual pattern in young female university students

Arch Gynecol Obstet (2009) 279:527532

Prevalence of primary dysmenorrhea and menstrual pattern in young female university students 1. How old are you? 2. Your height: (cm) 3. Your weight: (kg) 4. How many siblings do you have? a. I am the only child b. 13 siblings c. 45 siblings d. Six or more siblings 5. What is the educational level of your father? a. Primary school b. Secondary school c. High school d. College or university e. Literate 6. What is the educational level of your mother? a. Primary school b. Secondary school c. High school d. College or university e. Literate 7. Do you smoke? a. Yes, at least one cigarette a day b. Not every day, but occasionally c. I used to, but I quit d. I have never smoked 8. How many cigarettes do you smoke a day? a. I do not smoke b. Less than a cigarette a week c. Less than a cigarette a day d. 15 cigarettes a day e. 610 cigarettes a day f. 1120 cigarettes a day g. More than 20 cigarettes a day 9. Do you exercise? 1-Yes, 2-No 10. Which exercise do you do? Please specify 11. Have you ever taken alcohol? 1-Yes 2-No 12. Do you still take alcohol at least once a week? 1-Yes 2-No 13. Do you have a chronic disease which requires you to use medication regularly? 1-No, 2-Yes (write down the name of your disease) 14. Have you ever had an operation? 1-No 2-Yes (write down the name of the operation you underwent ) 15. What was your Wrst menstruation age? 16. Do you have regular menstruations? 1-Yes 2-No 17. What is the frequency of your menstruations? Every days 18. Write down the duration of your menstruation period? (how many days does your period last?) days 19. Write down the age of your mother, if she is alive: 20. Write down the Wrst menstruation age of your mother, if you know:

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Arch Gynecol Obstet (2009) 279:527532 Table 1 continued

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Prevalence of primary dysmenorrhea and menstrual pattern in young female university students 21. Does your mother have regular periods, as far as you know? a. Yes b. No c. I do not know d. She is in menopause e. She is not alive 22. What is the source of your knowledge about menstruation? a. Mother b. Physician/nurse c. Friend/sibling d. Nobody e. Other (please specify) 23. Mark the complaints you have due to menstruation a. Mood disorders 1-Yes 2-No b. Fatigue 1-Yes 2-No c. Bloated feeling 1-Yes 2-No d. Daily activities 1-Yes 2-No e. Enhanced appetite 1-Yes 2-No f. Loss of appetite 1-Yes 2-No 24. Do you have pain during menstruation? a. Yes, in each period b. Yes in some periods c. No The survey has ended for those who answered NO to question 24 The survey continues for those who answered YES 25. Since when have you been having painful menstruation? a. Since my Wrst period b. For the last months c. For the last years 26. On which day of your period does the pain start and how long does it last? Please specify: 27. Do you take analgesic drug for menstrual pain? 1 No 2 Yes (indicate the name of the drug: ) 28. Does your menstruation pattern change when you take analgesic drug? 1-No 2-Yes (Please specify the change: ) 29. Have you ever seen a doctor for menstrual pain? 1-Yes 2-No 30. Have you ever missed any school day due to menstrual pain in the last year? a. Never b. 1 day c. 2 days d. 34 days e. 56 days f. 7 days or more 31. Have you ever missed any examinations due to menstrual pain in the last year? a. Never b. Once c. Twice d. Three times or more 32. How do you evaluate your school performance when you have painful menstruation? a. Very poor b. Poor c. Average d. Good e. Very good 33. How do you evaluate your life performance when you have painful menstruation? a. Very poor b. Poor c. Average d. Good e. Very good 34. How would you rate your menstrual pain on a scale from 1 to 10 Please indicate 0 1 2 3 4 5 6 7 8 9 10

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before the teacher came in and started the class. Survey forms were collected immediately after they were Wlled out by the students. The survey included questions about the family, like the socioeconomic status, educational level and number of siblings, and questions about PD, without the explicit use of the word dysmenorrhea. The survey also included questions about menstrual pattern, and how and from whom the students asked for information and help in case of painful menstruation. A visual analog scale evaluation was used for students who said that they had painful menstruation. In the concerned scale the students rated the severity of their pain between 1 and 10. Pearson Chi-square test and Fishers exact test were used in the statistical evaluation of data.

Results The mean time that took a student to Wll out the questionnaire was about 8 min (range min: 6, max:10 minutes). Mean age of the students who took the survey was found to be 21.02 2.13 years (1735). Of the surveyed students, 23.6% were at and under 19 years, 75.8% were between 20 and 29 years and 0.6% were at or over 30 years. Of the students, 9.7% were studying in 6-year schools (medical school), 71.8% in 4-year schools (education, science and letters, engineering, technical education, etc.) and 18.5% in 2-year schools (secretarial work, medical documentation, technician work). Mean height of the students was found to be 160.1 22.95 cm and mean weight was found to be 54.17 9.38 kg (3790). Of the students, 1.1% were only child, 43.3% had 13 siblings, 37.4% had four or Wve siblings and 17.9% had six or more siblings. When the students were evaluated in terms of their smoking habits, it was found that 81.2% had never smoked, 8.3% smoked at least one cigarette a day regularly, 6.1% were occasional smokers, while 4.3% had quit smoking. Questions about use of alcohol showed that 86.2% of the students did not use alcohol, 13.7% used alcohol, and 0.2% did not answer this question. Of those who used alcohol, only 0.5% was found to take alcohol regularly every week. When asked about their sporting habits, 69.2% of the students said they did not exercise, 30.5% said they did and 0.3% did not answer the question. An examination of sports activities performed revealed that the most commonly engaged sportive activity was hiking (16.5%). When questioned about whether they had a chronic disease or not, 8.9% of the students said that they did not have any chronic disease, while 0.9% did not answer this question. In the students who reported to have a chronic disease the three most common diseases were migraine, polycystic ovary and gastritis (1.5, 1.1 and 0.9%, respectively).

Students answers to questions about previous operations showed that 85.5% did not undergo any operation. Of the previous operations, the most common three were tonsillectomy, appendicitis and rhinoplasty (2.9, 2.3 and 1.4%, respectively). Mean age for Wrst menstruation was found to be 13.3 1.4 years (min: 9, max: 18). Menstruation age was 911 years in 6.2% of the students, 1215 years in 85.7%, and 16 years and over in 4.9%. Mean menstruation frequency was 32.58 19.8 days. Menstruation frequency was 1321 days in 8.8% of the students, 2235 days in 79.1%, 36 days and over in 5.5%. Menstruation was found to last 13 days in 4.1% of the students, 46 days in 61.7%, 710 days in 32.6% and 11 days and more in 0.9%. When asked whether they had any idea about the menstruation of their mothers, 75.9% of the surveyed students said that they did not know the Wrst menstrual age of their mothers. Of those who did, 20.7% reported the menarche age of their mothers was between 11 and 15 years. When questioned about the menstruation pattern of their mothers, 37.9% of the students said their mothers had regular menstruation, 17.2% said their mothers did not have regular menstruation, 13.5% said they did not know the menstruation pattern of their mothers, 29.9% said their mothers were in menopause and 1.5% did not answer this question. The educational levels of mothers were 47.6, 9.2, 11, 4.8, 13.7, 13.2%, and educational levels of father were 30.3, 15.6, 28.2, 21, 3.2, 1.1% primary school, secondary school, high school, College or University, literate, no literate, respectively (literate: they can read and write only, but have no any educational level, no literate: they can not read and write because of no education). It was learnt from the question about the source of students knowledge about menstruation that the students obtained this information most commonly from their mothers, secondly from their friends and/or siblings, thirdly from physicians and nurses and fourthly from books, magazines and newspapers (29.1, 23.1, 11.8, and 7.0%, respectively). It was found through this question that 7.0% of the students did not acquire any information about this topic from anyone. To the PD question worded as pain during menstruation, 45.3% of the students replied they had pain in each menstrual period, 42.5% replied they had pain in some and 12.2% said they did not have pain during menstruation. An examination of the subgroup who deWned painful menstruation showed that 51.4% of the students suVered from pain since their Wrst menstruation, 4.9% had been having pain for the last 1 year, 6.0% for the last 2 years, 6.2% for the last 3 years and 3.8% for the last 4 years. When asked about the pattern of their pain, 72.9% of the students said their pain started on the Wrst menstrual day, 5.0% said their pain started on the second menstrual day, and 8.1% said they

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had pain before the menstruation started. Exactly 13.7% of the students did not respond to this question. Of the students in whom the pain started on the Wrst menstrual day, 28.8% said their pain lasted for 1 day, 25.1% said their pain lasted for 2 days and 13.8% said their pain lasted for 3 days. Mean pain score in the visual analog scale evaluation of students who said they experienced pain during menstruation was found to be 6.23 3.12. Questions about the drugs which students with PD take for pain demonstrated that 33.1% of the students did not take any drugs, while 66.9% did. It was found that of the drugs taken, 47.4% were single, 8.0% were double and 1.5% were triple analgesics. Of those who took a single agent, 55.9% used Xurbiprofen, 12.7% used naproxen sodium, 12.3% used paracetamol, 4.2% used aspirin and the rest used a random analgesic the name of which they did not know. It was found that the most common double drug combination used was paracetamol + aspirin combination (24.2%). Rate of consultation with a doctor due to menstrual pain is 19.1%. When asked about school absenteeism due to menstrual pain, 60.6% of the students replied they never missed any school days, 19.3% said they were absent a day, 7.5% said they were absent for 2 days, 6.6% said they were absent for 3 or 4 days, 2.2% said they were absent for 5 or 6 days, 3.0% said they were absent for 7 days or more. It was established that of the cases with PD, 5.3% missed one examination, 1.2% missed two examinations and 1.0% missed three or more examinations.

Discussion Primary dysmenorrhea is an important health problem that has a negative impact on the lives of women in the menstrual and premenstrual periods. This survey-based study is the Wrst of its kind in our country and found the total prevalence of PD 88.0%, with 45.3% of females having painful menstruation in each menstrual period and the rest in some. It has been known for a long time that primary PD is associated with an increase in prostaglandin. Symptoms generally appear immediately before menstrual bleeding or with menstruation, but typically in the Wrst 2448 h [6]. Nonsteroid anti-inXammatory (NSAI) drugs are highly eYcient in its treatment. However, it was found that most of the adolescents did not have any information about this eVective treatment in a study from United State [7]. It was also found in our study that about 33.1% of the cases did not use any drugs for this complaint, while 66.9% did. However, rate of consultation with a doctor to obtain medical help was found to be 19.1%. Rate of drug use for pain was found higher than the rates cited in the literature. It is reported in the literature that 54% of the cases have infor-

mation about the drugs and its use in dysmenorrhea [7]. Our study, however, showed that 66.9% of the cases used drugs for pain. This may be due to the fact that analgesics are not prescription drugs in our country. The drug used by the students who participated in the study was analgesics of NSAI type. Low rate of consultation with a doctor due to PD (19.1%) may be attributed to low educational level of the families. In this study, it was established that 26.9% of mothers and 4.3% of fathers did not attend even the primary school. This low rate can explained in the light of the fact that 29.1% of the cases obtained information about menstruation from their families, and that 7.0% did not obtain any information from any source. Students who stated that they used conventional methods for PD treatment did not use any herbal medication. The methods which were stated to be used included rest, application of heat and not minding the pain (pretending there is none). This may be due to programs both by media and medical institutions in our country showing unwarranted and incorrect use of traditional treatment methods. It was demonstrated in the literature that symptoms and severity of PD were positively correlated with early menarche, quantity of menstrual Xow, increased menstrual time, low Wsh consumption and smoking [1216]. PD prevalence in our study was found to be 88%, which is close to the upper limit of the 5090% rate reported in the literature [6]. In our study population, no correlation could be found between PD and such factors as menstruation duration, menarche age and smoking. Rate of smoking in our study was found to be 19.0% and menarche before 11 years of age was found low (6.2%). As reported in the literature, it was established in our study that PD led to a high rate of absenteeism from school (19%), as well as non-attendance to examinations. Considering at least 1 day absenteeism due to pain, the rate of absenteeism from school is about 39.4% and failure to attend at least one examination is 7.5%. Although these rates are lower than the 3450% rates reported in the literature [10, 11], in consideration of the fact that important examinations like university entrance examination are conducted on a single pre-determined date in our country, importance of education about PD and its treatment becomes apparent in case menstruation coincides with important examinations. Likewise, even though this piece of data is subjective, 12% of the students reported that their performance declined during menstruation and the rate of performance decline in students with PD was calculated as 45%. The major weakness of this study is its failure to examine the possible associations between PD and sexual relation. As it is known, evaluation of PD cases should include considerations like sexual activity, sexual abuse history, as

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Arch Gynecol Obstet (2009) 279:527532 prevalence, impact, and knowledge of treatment. J Adolesc Health 25:4045. doi:10.1016/S1054-139X(98)00147-5 Johnson J (1988) Level of knowledge among adolescent girls regarding eVective treatment for dysmenorrhea. J Adolesc Health Care 9:398402. doi:10.1016/0197-0070(88)90036-8 Shapiro SS (1988) Treatment of dysmenorrhoea and premenstrual syndrome with non-steroidalanti-inXammatory drugs. Drugs 36:475490. doi:10.2165/00003495-198836040-00005 Sundell G, Milsom I, Andersch B (1990) Factors inXuencing the prevalence and severity of dysmenorrhoea in young women. Br J Obstet Gynaecol 97:588594 Fedele L, Parazzini F, Bianchi S, Arcaini L, Candiani GB (1990) Stage and localization of pelvic endometriosis and pain. Fertil Steril 53:155158 Marchini M, Tozzi L, Bakshi R, Pistai R, Fedele L (1995) Comparative eYcacy of diclofenac dispersible 50 mg and ibuprofen 400 mg in patients with primary dysmenorrhea. A randomized, double-blind, within-patient, placebo-controlled study. Int J Clin Pharmacol Ther 33:491497 Doty E, Attaran M (2006) Managing primary dysmenorrhea. J Pediatr Adolesc Gynecol 19:341344. doi:10.1016/j.jpag.2006. 06.005 Andersch B, Milsom I (1982) An epidemiologic study of young women with dysmenorrhea. Am J Obstet Gynecol 144:655660 Balbi C, Musone R, Menditto A (2000) InXuence of menstrual factors and dietary habits on menstrual pain in adolescence age. Eur J Obstet Gynecol Reprod Biol 91:143148. doi:10.1016/S03012115(99)00277-8 Deutch B (1995) Menstrual pain in Danish women correlated with low n-3 polyunsaturated fatty acid intake. Eur J Clin Nutr 49:508 516 Hornsby PP, Wilcox AJ, Weinberg CR (1998) Cigarette smoking and disturbance of menstrual function. Epidemiology 9:193198. doi:10.1097/00001648-199803000-00016

well as menarche age, menstrual pattern, characteristics of the menstrual cramps, other symptoms associated with menstruation, use of and response to analgesics [12]. However, it was speculated that such questions would be left blank due to the cultural characteristics of the area where the study was conducted and the participating students, and thus they were not included in the survey. In conclusion, prevalence of PD was found extremely high in the study population. Reliability of the sources from where the information about menstruation is obtained, like mother, sibling, friend and media is dubious, and it is found that professional help about PD treatment is not sought adequately.

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