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RESEARCH
AFP VOL.45, NO.11, NOVEMBER 2016© The Royal Australian College of General Practitioners 2016
Prevalence and severity of
dysmenorrhoea, and management
options reported by young
Australian women
Asvini K Subasinghe, Lina Happo, Yasmin L Jayasinghe, Suzanne M Garland, Alexandra Gorelik, John D Wark
ysmenorrhoea, or painful menstruation, is a common
symptom of menses.
1,2
Dysmenorrhoea is defined as a painful,
cramping sensation in the lower abdomen or back associated
with menstrual periods
3
and is classified into primary and secondary
types. Primary dysmenorrhoea is painful menstrual periods, not due
to other diseases, and often occurs soon after menarche. Secondary
dysmenorrhoea is due to an underlying pelvic abnormality, such
as endometriosis, and can be either new-onset or a change in the
nature of the dysmenorrhoea (intensity, duration) over time.
4
Dysmenorrhoea has been examined in Australian women in
only a small number of studies, mostly involving adolescent girls
recruited from secondary schools.
2,5
The national prevalence of
dysmenorrhoea is 70–90%,
2
which is comparable to that reported
worldwide. Although dysmenorrhoea is a common problem faced by
women, many are reluctant to consult their doctor about it.
6
We evaluated the prevalence and severity of dysmenorrhoea using
online questionnaires at two time points in a cohort of women aged
16–29 years. We assessed the impact of menstrual pain and its
severity on relationships, productivity, health and wellbeing. We also
sought to determine the level of concern in young women regarding
dysmenorrhoea, and their use of available treatments.
Methods
Study design
The Young Female Health Initiative (YFHI)
7
and Safe-D studies
8
are
the first comprehensive prospective studies in which clinical and
self-reported data are collected relating to sexual and mental health,
lifestyle and wellbeing in young Australian women.
Ethics
The YFHI study was approved by the Human Research and Ethics
Committee (HREC) at the Royal Women’s Hospital (approval number
Background
Little is known about the severity of dysmenorrhoea and
attitudes towards its management in young females.
Objective
The aim of this study was to evaluate the prevalence and
severity of dysmenorrhoea in women aged 16−25 years.
Method
Participants were recruited via targeted Facebook advertising
and asked to complete an online questionnaire covering
medications, menstruation and lifestyle-related themes.
A follow-up questionnaire on dysmenorrhoea was also
administered.
Results
The prevalence of dysmenorrhoea was 88% (n = 247, mean age
21.5 years, SD 2.6). Only 34% of participants reported consulting
a healthcare provider about their pain, whereas 86% consulted
other sources. Pain medication was used by 58% of the
participants. Dysmenorrhoea was associated with interference
with daily activities (
P
<0.001).
Discussion
Dysmenorrhoea is highly prevalent among these women, with
most indicating moderate to severe pain and a significant
adverse impact on daily activities. Most women did not obtain
information about dysmenorrhoea from healthcare providers,
indicating the need for general practitioners to provide accurate
information about dysmenorrhoea to young females.
D
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RESEARCH DYSMENORRHOEA
AFP VOL.45, NO.11, NOVEMBER 2016 © The Royal Australian College of General Practitioners 2016
11/14), and the Safe-D study by Melbourne
Health HREC (approval number 2013.007).
Procedures followed were in accordance
with the Helsinki Declaration of 2000 as
revised in 2002.
Recruitment and inclusion criteria
Eligible participants were females
aged 16−25 years and living in Victoria,
Australia.
7, 8
Advertisements were posted
on Facebook to recruit women into two
general health studies called YFHI and
Safe-D.
Clicking on the advertisement directed
respondents to secure websites containing
more information and where expressions
of interest were registered. Prospective
participants were then contacted by
investigators and consented into the study.
Participation included the completion
of a web-based questionnaire, using
SurveyMonkey (www.surveymonkey.com)
or Limesurvey (www.limesurvey.org),
covering demographics, mental health,
lifestyle and reproductive health. Existing
participants from YFHI and the Safe-D study
who had consented to be contacted for
future studies were invited to fill in a follow-
up dysmenorrhoea questionnaire.
Collection of dysmenorrhoea data
Dysmenorrhoea was defined as ‘period
pain’ of any severity in the six months
preceding questionnaire completion.
The nature of the dysmenorrhoea was
ascertained according to time of onset
in relation to menarche (‘primary onset’
at menarche, versus ‘secondary onset’
some years after menarche). This is not a
reflection of whether the dysmenorrhoea
itself was primary or secondary, as
information on underlying disease was not
ascertained for all participants.
The severity of pain and level of
interference with daily activities were
measured on a Likert scale (1 [little] to 10
[severe]). This rating was used to categorise
participants according to the Numerical
Rating Scale (NRS) for pain, which is useful
in the assessment of dysmenorrhoea.
9
A
rating of 1–3 was considered mild pain, 4–6
as moderate pain and 7–10 as severe pain.
Statistical analyses
Statistical analyses were performed
using Stata version 11.1 (StatCorp LP,
College Station, TX, USA). Analyses for
associations between dysmenorrhoea
and categorical variables were performed
using Fisher’s exact test. Ordered logistic
regression was performed to determine
the risk of interference on aspects of daily
living. A two-sided P <0.05 was defined as
statistically significant.
It is important to note that there were
missing data from participants for various
questions (4−10%). Therefore, we present
prevalence estimates using different
denominators for a number of questions.
Results
Baseline questionnaire data were available
from 250 YFHI respondents and 228 Safe-D
participants. Follow-up questionnaires
were completed by 247 participants
(YFHI n = 141, Safe-D n = 106; Figure 1).
This represented a 69% response rate
(247/359).
A difference in age was found between
YFHI and Safe-D participants who
completed the follow-up questionnaire
(Figure 1). However, after adjustment for
a delay in the inclusion of participants
aged 16–17 years in the YFHI study, no
differences in age were obser ved. Thus,
the two data sets were collated and the
results of pooled data are presented in this
paper.
Descriptive statistics
Dysmenorrhoea was reported by 88%
(n = 207/236) of respondents who
completed the follow-up dysmenorrhoea
questionnaire and had had a period
in the past 12 months. This was
comparable to the prevalence found in the
respondents who completed the baseline
questionnaires (86%, n = 369/431).
Those who reported dysmenorrhoea at
baseline did not differ, with respect to
age, marital status or education level,
from those not reporting dysmenorrhoea.
However, a greater proportion of those
who experienced dysmenorrhoea reported
depression (32% versus 19%, P = 0.04)
and had experienced a pregnancy (24%
versus 4%, P = 0.02; Table 1).
At follow-up, 19% reported mild
dysmenorrhoea, 49% moderate and 32%
severe. Dysmenorrhoea commenced
at menarche for 70% (n = 144/207)
of respondents (‘primary onset’
dysmenorrhoea), while for 30% (n =
63/207) dysmenorrhoea commenced
some years after menarche (‘secondary
onset’ dysmenorrhoea).
Primary versus secondary onset
dysmenorrhoea
No significant differences were obser ved
between those who reported primary
onset of dysmenorrhoea and secondary
onset of dysmenorrhoea with regards
to age (21.8 ± 2.5 versus 21.4 ± 2.6;
P = 0.02), current use of hormonal
contraceptives (60% versus 51%; P = 0.2)
and severity of dysmenorrhoea (P = 0.7).
Reported management options
for dysmenorrhoea
At follow-up, use of pain medication
was reported by 58% (n = 120/206) of
respondents with dysmenorrhoea. Pain
medication included paracetamol, aspirin,
mefenamic acid and ibuprofen. Those with
severe dysmenorrhoea were more likely to
use pain medication when compared with
those who experienced moderate or mild
period pain (73% versus 56% and 30%,
respectively; P = 0.001).
Hormonal contraception was used by
57% (n = 140/247) of women, with 74%
using the combined oral contraceptive pill
(COCP), 13% etonogestrel implant, 9%
levonorgestrel intrauterine device, 2%
progestogen-only oral contraceptive pill,
and 2% medroxyprogesterone acetate
injection. Period pain was the reason for
using hormonal contraception in 36%
(n = 45/117). There was no significant
difference in hormonal contraceptive use
between respondents who experienced
dysmenorrhoea and respondents who did
not (P = 0.6).
Most respondents with dysmenorrhoea
(92%; n = 190/207) indicated using non-
pharmacological measures, either alone
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DYSMENORRHOEA RESEARCH
AFP VOL.45, NO.11, NOVEMBER 2016© The Royal Australian College of General Practitioners 2016
or in conjunction with analgesics, to relieve
period pain. The use of heat packs was
most popular, with 54% (n = 112) reporting
their use, followed by hot baths (37%; n =
77), meditation (7%; n = 15) and exercise
(2%; n = 3).
Association between
dysmenorrhoea and consultations
Only 34% (n = 71/207) of those with
dysmenorrhoea had ever consulted a
healthcare provider about period pain.
Participants with severe dysmenorrhoea
(53%; n = 34/64) were more likely to
consult their healthcare provider than
those with mild (13%; n = 5/39) or
moderate (31%; n = 30/98) dysmenorrhoea
(P <0.001). Approximately 86% (n =
176/206) who experienced dysmenorrhoea
had sought information about period pain
from other sources (eg internet, social
media, friends, magazines), including 34%
(n = 69/206) who obtained information from
family members.
Impact of dysmenorrhoea on
quality of life
More severe dysmenorrhoea was
associated with greater risk of interference
in numerous aspects of daily living (work/
study attendance and productivity;
relationships with family, friends and
partners; exercise; sexual activity [P <0.001;
Table 2]). Among respondents experiencing
dysmenorrhoea, 24% (n = 50/207) required
time off work or study in the preceding six
months because of the pain. Taking time off
because of period pain was associated with
the severity of dysmenorrhoea (52% [n =
33/64] in severe dysmenorrhoea, 15% [n
= 15/98] in moderate and 3% [n = 1/39] in
mild; P <0.001).
Discussion
The very high prevalence of dysmenorrhoea
among the study participants falls within
the range reported in a systematic
review conducted by the World Health
Organization.
10
A greater proportion of
those who experienced dysmenorrhoea
also reported depression, compared with
those who did not. This finding is supported
by that reported in a case-control study
comprising 424 adolescents,
11
and is
intuitive as dysmenorrhoea may have a
negative impact on quality of life.
While a large proportion of
women reported moderate to severe
dysmenorrhoea, approximately 60% of
these used pain medication for relief. By
contrast, 82% of women with moderate
or severe dysmenorrhoea reported using
non-pharmacological measures, such
as heat therapy, despite the limited and
inconsistent evidence for their efficacy
in dysmenorrhoea.
12
The discrepancy
between the use of pharmacological
and non-pharmacological measures may
suggest inherent resistance in young
women towards the use of pharmacological
analgesics. Alternatively, there may be
a lack of knowledge of pharmacological
treatments for dysmenorrhoea. Further
research may shed more light on these
issues.
It is surprising that there was no
relationship between COCPs and
Figure 1. Sample derivation for follow-up dysmenorrhoea questionnaire from Young Female Health
Initiative (YFHI) and Safe-D participants
YFHI eligibility
criteria:
• Female
• Lives in Vic,
Australia
• 16–25 years old
Completed initial YFHI
questionnaire
n = 250
Completed initial Safe-D
questionnaire
n = 228
Data analysis
YFHI participants who
consented to further studies
n = 212
SAFE-D participants who
consented to further studies
n = 147
Completed follow-up
dysmenorrhoea questionnaire
n = 141 (66.5%)
Completed follow-up
dysmenorrhoea questionnaire
n = 106 (72.2%)
• Uncontactable (n = 2)
• Withdrew interest (n = 2)
• No response (n = 36)
• Incomplete
questionnaire (n = 1)
• Uncontactable (n = 3)
• Withdrew interest (n = 1)
• No response (n = 35)
• Incomplete
questionnaire (n = 5)
Subsequent analysis performed separately on data
obtained from YFHI and SAFE-D participants revealed
results of no signicant difference
Characteristic YFHI participants
n = 141*
SAFE-D participants
n = 106*
P value
Age (years), n (%)
16–20
21–25
21 (15.2)
117 (74.8)
45 (42.9)
60 (57.1) <0.001
Educational level, n (%)
<Year 12
<Year 12
9 (6.6)
128 (93.4)
28 (26.7)
77 (73.3) <0.001
Socio-economic index
†
, n (%)
Not lowest quartile
Lowest quartile
111 (86.1)
18 (14.0)
90 (85.7)
15 (14.3) 0.942
Menarche
Median (min–max) 13.0 (10–20) 12.8 (8–16) 0.688
Days of menstrual bleeding, n (%)
<4 days
4–6 days
>6 days
12 (8.5)
102 (72.3)
27 (19.2)
9 (8.5)
67 (63.2)
30 (28.3) 0.236
Hormonal contraception, n (%)
Currently using
81 (57.1) 59 (55.7) 0.0796
*Numbers may not add up to total due to missing data.
†
As determined by Socio-Economic Indexes for Areas (SEIFA) 2011 developed by the Australian Bureau of
Statistics. Ranks areas in Australia according to relative socioeconomic advantage and disadvantage based
on ve-yearly census data.
Invited to complete follow-up dysmenorrhoea questionnaire
Ongoing recruitment
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AFP VOL.45, NO.11, NOVEMBER 2016 © The Royal Australian College of General Practitioners 2016
dysmenorrhoea, given the high prevalence
of dysmenorrhoea in our cohort and that
COCPs are widely used for the treatment
of dysmenorrhoea in both sexually active
and non–sexually active women.
13
This
unexpected finding may reflect the
wide variety of indications for the use of
hormonal contraception in young women,
regardless of whether they experienced
dysmenorrhoea. Indeed, approximately
one-third of women using hormonal
contraception stated that dysmenorrhoea
was the reason for use of these agents.
We did not assess the level of alleviation
women with dysmenorrhoea achieved with
the use of hormonal contraception. Data
pertaining to their use and effectiveness
was not obtained in this study and
represents an avenue for further research in
this group of women.
Although severe pain was more likely to
prompt a consultation than milder pain, the
majority of women with moderate to severe
dysmenorrhoea had never sought medical
attention for dysmenorrhoea. The low
frequency with which women seek medical
attention for dysmenorrhoea has been
previously described.
6
This is particularly
relevant in young women who perceive
dysmenorrhoea to be a common menstrual
complaint that needs to be tolerated, and
thus find difficulty determining if and when
to seek medical attention.
6
By contrast, 86%
of women with dysmenorrhoea had sought
information about period pain from other
sources such as the internet and family
members. These sources may be perceived
as ‘more accessible’ to young women than
a healthcare practitioner, but represent a
greater potential for misinformation. These
findings highlight the need for accessible,
reliable and helpful information with which
young women are comfortable.
A three-pronged approach could be
taken to better inform young women of
dysmenorrhoea and associated support
services. First, informative leaflets could
be handed out to girls in schools by the
school nurse so that adolescent females
are familiar with the symptoms for
dysmenorrhoea, which they can obser ve,
and for which they can contact their GP if
they require prescription pain medication.
Second, health professionals could be
more proactive in asking about this
sensitive topic so that if young women
have dysmenorrhoea they may be more
likely to discuss their pain. Third, given the
information-seeking behaviours reported
in this sample, health professionals and
schools could promote the use of reliable
websites on which accurate information on
dysmenorrhoea is published.
Dysmenorrhoea significantly affects the
quality of life of females in our sample.
Approximately 50% of women with
Table 1. Characteristics of respondents who experienced dysmenorrhoea versus
those who did not at baseline
Topics
Dysmenorrhoea*
n = 369
No
dysmenorrhoea*
n = 62
P
value
Age (years) mean ± SD 21.5 ± 2.7 21.4 ± 2.4 0.8
Marital status
Never married 315 (87.3) 53 (85.5) 0.7
Married/de facto 44 (12.7) 9 (14.5)
Level of education
No tertiary qualication 105 (28.8) 18 (29.0) 0.7
Undergraduate (or equivalent) 231 (63.3) 41 (66.1)
Postgraduate (or equivalent) 29 (8.0) 3 (4.8)
Employment
No paid employment 103 (28.2)
37 (10.1)
22 (35.5)
5 (8.1)
0.2
Labourer or related work 81 (22.2)
144 (39.5)
7 (11.3)
28 (45.2)
Managerial or professional occupation
Clerical or related work
SEIFA quartiles†
Not lowest quartile 309 (84.7) 47 (77.1) 0.1
Lowest quartile 56 (15.3) 14 (23.0)
Current smoker 40 (11.3) 8 (13.3) 0.6
Alcohol consumption in the last 12 months
≤Once a month 91 (32.2) 19 (39.6) 0.5
2–3 days a month 70 (24.7) 11 (22.3)
1–2 days a week 92 (32.5) 16 (33.3)
≥3 days a week 30 (10.6) 2 (4.2)
Depression 117 (32.1) 12 (19.4) 0.04
Experienced a pregnancy 24 (8.8) 4 (8.5) 0.02
Current hormonal contraception use 134 (36.4) 24 (38.7) 0.7
SEIFA, Socio-Economic Indices for Areas.*n (%) unless specied otherwise; †As determined by Socio-Eco-
nomic Indexes for Areas (SEIFA) 2011 developed by the Australian Bureau of Statistics. Ranks areas in
Australia according to relative socioeconomic advantage and disadvantage based on ve-yearly census data.
There were missing data for information regarding the prevalence of dysmenorrhoea for 47 participants.
Numbers may not add up to 100% due to missing values.
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AFP VOL.45, NO.11, NOVEMBER 2016© The Royal Australian College of General Practitioners 2016
Table 2. Relationship between severity of dysmenorrhoea and impact on normal daily activities
Interference Mild n (%) Moderate n (%) Severe n (%) P value OR† (95% CI‡)
Daily activities
None 8 (20.5) 7 (7.2) 0 (0)
Mild 31 (79.5) 70 (72.2) 26 (41.9) <0.001 7.1
(4.2–12.0)
Moderate 0 (0) 19 (19.6) 12 (19.4)
Major (0) 1 (1.0) 24 (38.7)
Work/study attendance
None 3 (37.5) 9 (19.2) 3 (6.0)
Mild 5 (62.5) 26 (55.3) 15 (30.0) <0.001 3.1
(1.3–7.6)
Moderate 0 (0) 10 (21.3) 15 (40.0)
Major 0 (0) 2 (4.3) 12 (24.0)
Work/study productivity
None 6 (46.2) 9 (14.8) 4 (7.7)
Mild 6 (46.2) 34 (55.7) 20 (38.5) <0.001 3.7
(2.1–6.5)
Moderate 1 (7.7) 16 (26.2) 11 (21.2)
Major 0 (0) 2 (3.3) 17 (32.7)
Friendships
None 3 (60.0) 14 (26.4) 6 (14.3)
Mild 2 (40.0) 28 (52.8) 14 (33.3) 0.002 3.9
(1.9–7.7)
Moderate 0 (0) 11 (20.8) 15 (35.7)
Major 0 (0) 0 (0) 7 (16.7)
Family relationships
None 6 (66.7) 13 (24.1) 5 (12.2)
Mild 3 (33.3) 30 (55.6) 14 (34.2) <0.001 4.7
(2.4–9.0)
Moderate 0 (0) 11 (20.4) 15 (36.6)
Major 0 (0) 0 (0) 7 (17.1)
Relationship with partner
None 3 (30.0) 9 (16.1) 3 (8.1)
Mild 7 (70.0) 26 (46.4) 12 (32.4) 0.004 3.2
(1.7–5.9)
Moderate 0 (0) 18 (32.1) 12 (32.4)
Major 0 (0) 3 (5.4) 10 (27.0)
Sexual activity
None 1 (5.6) 3 (4.3) 1 (2.2)
Mild 9 (50.0) 23 (32.9) 7 (15.6) 0.005 2.7
(1.6–4.6)
Moderate 4 (22.2) 18 (25.7) 6 (13.3)
Major 4 (22.2) 26 (37.1) 31 (68.9)
Exercise
None 7 (26.9) 5 (5.8) 2 (3.6)
Mild 16 (61.5) 37 (43.0) 12 (21.4) <0.001 4.9
(3.0–7.9)
Moderate 3 (11.5) 30 (34.9) 12 (21.4)
Major 0 (0) 14 (16.3) 30 (53.6)
CI, condence interval; OR, odds ratio
†Odds ratio, as determined by ordinal logistic regression analyses
‡95% condence interval
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severe dysmenorrhoea reported time
off, compared with only 2.6% with mild
dysmenorrhoea. Given that 80% of
women in our study reported moderate to
severe dysmenorrhoea, this represents a
significant recurrent burden not only for
the women themselves, but also for the
workforce and economy.
A major strength of this study is that
we were able to gain an insight into
the experience of young women with
dysmenorrhoea in a representative general
population of young females. When
compared with national data for this age
group, a greater proportion of participants
in our study had attained tertiary
education. However, no other significant
differences were obser ved. Therefore,
our findings should be generalisable to a
general population of young females.
There were a number of potential
limitations. The sample size only allowed
an estimation of dysmenorrhoea
prevalence. Additionally, the definitions
of primary onset and secondary onset
dysmenorrhoea were from self-report
rather than proven pathology.
Conclusion
The prevalence of dysmenorrhoea is
critically high in this sample of young
females, with many indicating that pain
had a significant adverse impact on
numerous daily activities. However, a large
proportion did not use pain medication and
obtained information about dysmenorrhoea
from sources other than health
professionals, which poses a large risk of
misinformation and a potential barrier to
seeking early medical advice. Therefore,
educational materials, information on
reliable websites and guidance about
dysmenorrhoea and treatment options
should be made readily available to young
women in schools as well as by health
professionals.
Implications for general practice
Dissemination of accurate information
about treatment options for
dysmenorrhoea in Victoria may improve
the quality of life of young females.
Authors
Asvini K Subasinghe PhD, Research Fellow,
Department of Microbiology and Infectious
Diseases, Royal Women’s Hospital, Parkville,
Vic; Infection and Immunity, Murdoch Childrens
Research Institute, Parkville, Vic. asvini.
subasinghe@gmail.com
Lina Happo PhD, medical student, Department of
Medicine, University of Melbourne, Parkville, Vic
Yasmin L Jayasinghe MBBS, FRANZCOG,
PhD, Paediatric and Adolescent Gynaecologist,
Department of Obstetrics and Gynaecology,
University of Melbourne, Royal Women’s Hospital,
Parkville, Vic; Department of Gynaecology, Royal
Children’s Hospital, Parkville, Vic
Suzanne M Garland MBBS, MD, FRCPA,
FAChSHM, FRANZCOG, Professor, Director of
Microbiology and Infectious Diseases, Department
of Microbiology and Infectious Diseases, Royal
Women’s Hospital, Parkville, Vic; Infection and
Immunity, Murdoch Childrens Research Institute,
Parkville, Vic; Department of Obstetrics and
Gynaecology, University of Melbourne, Royal
Women’s Hospital, Parkville, Vic
Alexandra Gorelik MSc, Biostatistician, Department
of Medicine, University of Melbourne, Parkville, Vic;
Melbourne EpiCentre, Royal Melbourne Hospital,
Parkville, Vic
John D Wark MBBS, FRACP, PhD, Professor,
Endocrinologist, University of Melbourne
Department of Medicine and Bone & Mineral
Medicine, Royal Melbourne Hospital, Parkville, Vic
Competing interests: Dr Garland reports
grants from Merck, GSK, CSL, Commonwealth
Department of Health, and non-financial support
from Merck, outside the submitted work; and has
delivered lectures and received speaking fees from
MSD and SPMSD for work performed in personal
time.
Provenance and peer review: Not commissioned,
externally peer reviewed.
Acknowledgements
We thank the YFHI and Safe-D research teams and
participants for their time. YFHI was supported by
an Australian NHMRC program grant (568971) and
Safe-D study by a NHMRC project grant (1049065).
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