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Productivity loss due to menstruation-related symptoms: A nationwide cross-sectional survey among 32 748 women

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Objective To evaluate age-dependent productivity loss caused by menstruation-related symptoms, measured in absenteeism (time away from work or school) and presenteeism (productivity loss while present at work or school). Methods Design/setting: internet-based, cross-sectional survey conducted in the Netherlands from July to October 2017. Participants: 32 748 women aged 15–45 years, recruited through social media. Outcome measures: self-reported lost productivity in days, divided into absenteeism and presenteeism; impact of menstrual symptoms; reasons women give when calling in sick; and women’s preferences regarding the implications of menstruation-related symptoms for schools and workplaces. Results A total of 13.8% (n=4514) of all women reported absenteeism during their menstrual periods with 3.4% (n=1108) reporting absenteeism every or almost every menstrual cycle. The mean absenteeism related to a woman’s period was 1.3 days per year. A total of 80.7% (n=26 438) of the respondents reported presenteeism and decreased productivity a mean of 23.2 days per year. An average productivity loss of 33% resulted in a mean of 8.9 days of total lost productivity per year due to presenteeism. Women under 21 years were more likely to report absenteeism due to menstruation-related symptoms (OR 3.3, 95% CI 3.1 to 3.6). When women called in sick due to their periods, only 20.1% (n=908) told their employer or school that their absence was due to menstrual complaints. Notably, 67.7% (n=22 154) of the participants wished they had greater flexibility in their tasks and working hours at work or school during their periods. Conclusions Menstruation-related symptoms cause a great deal of lost productivity, and presenteeism is a bigger contributor to this than absenteeism. There is an urgent need for more focus on the impact of these symptoms, especially in women aged under 21 years, for discussions of treatment options with women of all ages and, ideally, more flexibility for women who work or go to school.
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SchoepME, etal. BMJ Open 2019;9:e026186. doi:10.1136/bmjopen-2018-026186
Open access
Productivity loss due to menstruation-
related symptoms: a nationwide cross-
sectional survey among 32 748 women
Mark E Schoep,1,2 Eddy M M Adang,3 Jacques W M Maas,4 Bianca De Bie,5
Johanna W M Aarts,1 Theodoor E Nieboer1
To cite: SchoepME,
AdangEMM, MaasJWM,
etal. Productivity loss due
to menstruation-related
symptoms: a nationwide
cross-sectional survey among
32 748 women. BMJ Open
2019;9:e026186. doi:10.1136/
bmjopen-2018-026186
Prepublication history and
additional material for this paper
are available online. To view
please visit the journal (http://
dx. doi. org/ 10. 1136/ bmjopen-
2018- 026186).
Received 22 August 2018
Revised 8 March 2019
Accepted 12 March 2019
1Department of Obstetrics and
Gynaecology, Radboudumc,
Nijmegen, The Netherlands
2Department of Obstetrics and
Gynaecology, Hospital Rijnstate,
Arnhem, The Netherlands
3Department of Health Evidence,
Radboudumc, Nijmegen, The
Netherlands
4Obstetrics & Gynaecology,
Maxima Medical Centre locatie
Veldhoven, Veldhoven, The
Netherlands
5Dutch Patient Endometriosis
Foundation, Numansdorp, The
Netherlands
Correspondence to
DrTheodoor ENieboer;
bertho. nieboer@ radboudumc. nl
Research
© Author(s) (or their
employer(s)) 2019. Re-use
permitted under CC BY-NC. No
commercial re-use. See rights
and permissions. Published by
BMJ.
ABSTRACT
Objective To evaluate age-dependent productivity loss
caused by menstruation-related symptoms, measured
in absenteeism (time away from work or school) and
presenteeism (productivity loss while present at work or
school).
Methods Design/setting: internet-based, cross-sectional
survey conducted in the Netherlands from July to October
2017. Participants: 32 748 women aged 15–45 years,
recruited through social media. Outcome measures: self-
reported lost productivity in days, divided into absenteeism
and presenteeism; impact of menstrual symptoms;
reasons women give when calling in sick; and women’s
preferences regarding the implications of menstruation-
related symptoms for schools and workplaces.
Results A total of 13.8% (n=4514) of all women reported
absenteeism during their menstrual periods with 3.4%
(n=1108) reporting absenteeism every or almost every
menstrual cycle. The mean absenteeism related to a
woman’s period was 1.3 days per year. A total of 80.7%
(n=26 438) of the respondents reported presenteeism
and decreased productivity a mean of 23.2 days per
year. An average productivity loss of 33% resulted in a
mean of 8.9 days of total lost productivity per year due
to presenteeism. Women under 21 years were more
likely to report absenteeism due to menstruation-related
symptoms (OR 3.3, 95% CI 3.1 to 3.6). When women
called in sick due to their periods, only 20.1% (n=908)
told their employer or school that their absence was due
to menstrual complaints. Notably, 67.7% (n=22 154) of
the participants wished they had greater exibility in their
tasks and working hours at work or school during their
periods.
Conclusions Menstruation-related symptoms cause a
great deal of lost productivity, and presenteeism is a bigger
contributor to this than absenteeism. There is an urgent
need for more focus on the impact of these symptoms,
especially in women aged under 21 years, for discussions
of treatment options with women of all ages and, ideally,
more exibility for women who work or go to school.
BACKGROUND
Menstruation-related symptoms (MRSs)
are diverse and widespread among women.
Symptoms include dysmenorrhoea, heavy
menstrual bleeding and premenstrual mood
disturbances with reported prevalence of
45%–90%, 14%–25% and 20%–29%, respec-
tively.1–3 Studies show that women with MRSs
have lower scores on several domains of quality
of life such as general health and physical,
mental, social and occupational functioning
during their periods.1 4–7 Furthermore, these
symptoms may create considerable financial
burdens on patients and their families as well
as on society.5 6 8–12 Such financial burdens are
related to the costs of visits to the doctor, over-
the-counter drugs and medical or surgical
treatment. However, costs related to produc-
tivity loss could be the largest cost driver.
Productivity costs are defined as costs asso-
ciated with paid and unpaid production loss
and the replacement of productive people
due to illness or disability.13 Productivity costs
can be divided into costs related to absen-
teeism and costs related to presenteeism.
Absenteeism represents the total amount
of time off work or away from school, and
presenteeism represents the loss of produc-
tivity while present at a job or school.
Although the literature is scarce and the
results are variable, studies on specific patient
groups generally show that MRSs can cause
absenteeism.14–16 Research on the association
between MRSs and presenteeism is even more
Strengths and limitations of this study
This is the largest cohort study to analyse the im-
pact of menstruation-related symptoms on work
and school productivity.
The survey was performed among the general fe-
male population and is consequently not per se re-
lated to one specic gynaecological condition.
Due to the way of recruitment of participants, there
may have been some degree of selection bias.
Outcomes are based on self-reported data and
consequently lack objectivity regarding productivity
loss.
The generalisability of the study may be limited to
employment and school systems comparable with
the Dutch.
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Open access
limited. It has been suggested that research into possible
impairments in quality of life caused by menstrual symp-
toms should not focus on single symptoms but rather on
a complex of symptoms that vary widely but that are all
related to the menstrual cycle. This complex includes
both standard symptoms, like heavy menstrual bleeding
and abdominal cramps, and also less common symptoms,
like nausea and cold sweats.17 18
Taking all symptoms into account, it seems likely that
the real impact of MRSs is underestimated in the general
population. Despite being almost two decades into the
21st century, discussions about MRSs may still be rather
taboo. This survey-based exploratory study aimed to
quantify the burden of MRSs in the general female popu-
lation, with burden defined as the number of lost days
at work or school due to absenteeism and presenteeism.
Furthermore, it was aimed to study the impact of specific
symptoms on absenteeism and presenteeism.
METHODS
This cross-sectional study consisted of an online survey
that was distributed from 12 July to 11 October 2017. All
data were anonymously collected and stored under the
privacy rules of the Radboud University Medical Center.
Patients gave informed consent when they initiated the
questionnaire.
Patient and public involvement
A group of women, among which were several members
of the Dutch Patient Endometriosis Foundation, women
with a linguistic education and women with a medical
origin, was involved in the conduct of this study at several
stages, that is, in the development and dissemination of
the questionnaire and in the analysis and interpretation
of the results. One of the authors of this manuscript, BDB,
is the chair of the Dutch Patient Endometriosis Founda-
tion. Additional contributions are noted in the Acknowl-
edgements section.
Questionnaire development
The questionnaire had several parts, and online supple-
mentary appendix 1 provides details about the questions.
Part 1 consisted of questions about each woman’s basic
characteristics. Part 2 had questions about menstrual
symptoms, and part 3 had questions related to absen-
teeism and presenteeism. Adaptive questioning was used
with a maximum of six questions per page. Participants
were asked in a lay manner how long their menstrual
cycle was and what the exact meaning of a menstrual cycle
was. The duration of the cycle was divided in five catego-
ries (25 days or less, 26–30 days, 31–35 days, 36–40 days
and 41 days or more). Furthermore, participants could
indicate if they had an irregular cycle, meaning more
than 10 days difference per cycle, if they were amenor-
rhoeic due to the use of an intrauterine device (IUD) or
the continuous use of oral contraceptives, or the option
‘I do not know’. Additional questions about absenteeism
and presenteeism were included that were based on
the Productivity Cost Questionnaire from the Institute
for Medical Technology Assessment (iMTA-PCQ).19 We
modified the iMTA-PCQ-recommended recall period of
4 weeks to 3 months so that it was in line with the rele-
vant time period for this study and so we could include
multiple menstrual periods. We assumed the amount
of presenteeism to be larger than the amount of absen-
teeism. Therefore, the recall period for absenteeism
was extended to 6 months to maintain accuracy. Visual
analogue scales (VAS) were used to quantify the amount
of pain, or the intensity of the symptom, and the impair-
ment due to pain or the other symptom. Presenteeism
was measured by asking women to what extent they were
able to be as productive as possible compared with a day
without MRSs. This was scored on a scale from 0 to 10,
with 0 being totally unproductive and 10 fully productive.
In separate questions, participants were asked to quantify
their absenteeism that was related to MRSs and absen-
teeism for any other reason than MRSs. For the latter, we
did not specifically ask the underlying reason.
Target population and recruitment
The study population comprised women between 15 and
45 years old. The upper age limit was chosen to avoid
interference from menopausal symptoms; the lower
to have a time margin after the average menarche age,
since it is known that the first periods are irregular and
often accompanied with discomfort and uncertainty.
A large number of women were approached with the
aim of obtaining a cohort that was representative of the
general female population in terms of level of education,
medical history and/or gynaecological diagnosis. Women
were invited to complete a survey using an online ques-
tionnaire tool20 through a campaign on social media
platforms Facebook and Twitter. Patient organisations,
colleagues and visitors of the Facebook page of one of the
authors (TN) were asked to share the link to the ques-
tionnaire in order to reach the widest possible audience.
On 12 July 2017, a link to the questionnaire was posted
on Facebook and Twitter through the account of one
of the authors (TN). In the post, both women with and
without MRSs were encouraged to fill in the question-
naire. Within 24 hours of the first posting on social media,
over 6000 respondents had filled in the questionnaire,
and by July 18, there were 15 000 respondents, which
was announced by a repost of the link to the question-
naire. A third post was made on Facebook and Twitter on
16 September 2017, to reach women who may have been
on holiday when the first posts were created.
Data analysis
The outcome measures were presented in a descriptive
way; we used valid percentages in case of missing values
where necessary. We distinguished between women who
were mainly working or mainly studying. Therefore, we
present these data for two groups, that is, for women who
worked more than 5 hours per week (‘working group’)
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and for women who studied more than 5 hours per week
(‘studying group’).
We used binary logistic regression to calculate ORs.
Absenteeism and presenteeism were used as dependant
variables. As independent variables, we used the following
parameters: women younger than 21 versus women aged
21 and older, smoking yes or no, reports of absenteeism
not related to MRSs, educational level, the use of oral
contraception and the use of an levonorgestrel-releasing
IUD. All independent variables were used in an univariate
as well as a multivariate analysis. We also studied the asso-
ciation between pain scores and both absenteeism and
presenteeism, given that the literature shows that pain
scores of 0–4, 5–6 and 7 or higher have a different impact
on activity, mood and sleep.21 22 Analyses were performed
using IBM SPSS Statistics V.22.00.
Assumptions and transformation of the original data
To present data on level of education in an international
format, we had to transform the original data, which was
based on the Dutch school system.23 The categorical data
of participants’ length of menstrual cycle were trans-
formed into averages.
With regard to the evaluation of absenteeism and
presenteeism, ‘the guideline for economic evaluations
in healthcare in the Netherlands’ was used.24 A work day
accounts for 8 hours. For most sectors in the Netherlands,
a full-time work-week is 36 hours. The maximum amount
of working hours per year was set at 1558 when they were
working full time. We asked women to report their absen-
teeism due to MRSs per cycle and used a recall period of
6 months.
To calculate the percentages for absenteeism, 1 day of
absenteeism accounted for 8 hours of lost productivity.
When a woman reported to study or work more than
40 hours per week, we transformed these hours to 40 for
reasons of clarity in the calculations and comparability
with the data of the Dutch Central Bureau of Statistics
(CBS). We made a few other transformations for cate-
gorical data. For absenteeism related to MRSs, the cate-
gory ‘more than three days per cycle’ was considered to
be 4 days per cycle. For absenteeism that was not related
to MRSs, the category ‘more than ten days in the past
six months’ was considered to be 11 days in the past
6 months.
To present yearly data, we multiplied some of these data
based on the original recall period. The number of days
for absenteeism related to MRSs was based on days per
cycle, which were therefore multiplied by 12.7 based on
the reported average menstrual cycle of 28.8 days (see
table 1). These values were then multiplied by one if the
woman reported that she called in sick ‘every period’, 0.75
if she reported ‘almost every period’, 0.5 if she reported
‘half of all periods’ and 0.25 if she reported calling in sick
‘only once in a while’. Values for absenteeism that was not
related to MRS were based on a recall period of 6 months
and were therefore multiplied by two in order to obtain
the number of days per year. The values for presenteeism
Table 1 Basic characteristics of study participants
(n=32 748)
Number
(percentage) Mean±SD Median
Age, years 28.6±8.6 28
15–19 6141 (18.8)
20–24 6118 (18.7)
25–29 5825 (17.8)
30–34 5483 (16.7)
35–40 4687 (14.3)
41–45 4494 (13.7)
Level of education
Low 4020 (12.3)
Medium 12 335 (37.9)
High 16 229 (49.8)
Hours/week
Paid work 21.7±14.7 24
Study 7.4±13.6 0
Voluntary work 0.8±3.1 0
Menstrual cycle
Regular cycle 25 717 (78.5)
Duration 28.8±3.0 28
Amenorrhoea due
to LG-IUD/OC
3675 (11.2)
Irregular,
variation>10 days
per cycle
2495 (7.6)
Do not know 861 (2.6)
Days with blood
loss per cycle
5.4±1.6 5
Visited a doctor for
MRSs
No 17 873 (54.6)
Yes, general
practitioner
10 141 (31.0)
Yes, gynaecologist 4698 (14.4)
Diagnosis for MRSs*
No 29 731 (90.8)
Yes 3017 (9.2)
Endometriosis 1120 (3.4)
PCOS 588 (1.8)
Adenomyosis 103 (0.3)
Fibroids 275 (0.8)
Other 1901 (5.8)
Contraception*
Hormonal
contraception
11 993 (36.6)
OC 8650 (26.4)
LG-IUD 2752 (8.4)
Continued
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were based on a recall period of 3 months and were there-
fore multiplied by four.
RESULTS
A total of 44 173 women initiated the questionnaire. We
excluded participants who did not report a date of birth
or whose age did not fulfil the inclusion criteria (figure 1).
There were no duplicates of IP addresses. Women who
did not answer questions related to absenteeism and
presenteeism were excluded. Furthermore, cases with
impossible results (eg, 10 000 000 days of presenteeism
in 3 months or 140 changes of sanitary pads a day) were
excluded. This resulted in a total of 32 748 women in the
final analysis.
Table 1 summarises the basic characteristics of the
participants. We found that 45.4% (n=14 839) had visited
a doctor for menstrual complaints in the past, with a
total of 3017 (9.2%) women reporting a diagnosis of a
menstrual disorder, such as endometriosis or fibroids.
The mean age of women in the working group was
higher than the mean ager of women in the studying
group. The mean number of working hours per week
in the working group was 27.0 (SD 11.4), and the mean
number of study hours in the studying group was 27.4
(SD 12.1). A total of 7335 women (22.4%) reported both
working and studying more than 5 hours per week. In this
group, 3001 women were working more than 16 hours a
week, and 5284 women in the study group were studying
more than 16 hours a week.
Absenteeism
Table 2 shows the results on absenteeism due to MRSs.
Although 13.8% of the women (n=4514) reported absen-
teeism due to MRSs, only 1108 women (3.4%) reported
absenteeism every cycle or almost every cycle. The
percentage of absenteeism in every cycle or almost every
cycle was 2.4% in the working group and 4.5% in the
studying group. The mean absenteeism due to MRSs was
Number
(percentage) Mean±SD Median
Other hormonal:
injection,
transdermal and
so on
882 (2.7)
No hormonal
contraception
20 755 (63.4)
Cu-IUD 771 (2.4)
Female
sterilisation
423 (1.3)
No female
contraception
19 639 (60.0)
Nulliparous 21 585 (66.0)
Paid work>5 hours
a week
26 104 (79.7)
Age 29.7±8.3 29
Hours of paid
work/week
27.0±11.4 28
Hours spent on
study/week
7.5±13.4 0
>40 hours of paid
work/week
1047 (3.2)
Study>5 hours a
week
8764 (26.8)
Age 22.0±6.2 20
Hours spent on
study/week
27.4±12.1 30
Hours of paid
work/week
15.5±11.3 12
>40 hours spent
on study/week
322 (1.0)
Mean duration of cycle based on women with a regular cycle.
*More than one answer possible.
Cu-IUD, copper intrauterine device; LG-IUD, levonorgestrel-
releasing intrauterine device; MRSs, menstruation-related
symptoms; PCOS, polycystic ovary syndrome; OC, oral
contraceptive.
Table 1 Continued
Figure 1 Flow chart for the respondents.
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0.9 days per year for the working group and 1.6 day per
year for the study group.
We also calculated the mean total absenteeism that was
not related to MRSs. For the entire group, this was 3.3 days
per year; for the working group, it was 3.5 days, and for
the studying group, it was 4.3 days. The mean percentage
of absenteeism that was not related to MRSs was 3.5%
in the working group and 3.7% in the studying group.
Consequently, absenteeism due to MRSs in our cohort
accounted for, on average, 22% of the total absenteeism
in the working group and 24% in the studying group.
Presenteeism
Table 3 shows the numbers reported for presenteeism.
Over 80 % of all women reported presenteeism during
their periods. The differences between the working group
and the study group were not large in terms of prevalence
and lost productivity. The mean number of lost produc-
tive days per year due to presenteeism was more than
sevenfold greater than the mean number of lost produc-
tive days due to absenteeism.
Factors associated with absenteeism and presenteeism
Figure 2 shows the association between reported pain
or discomfort scores and both absenteeism and presen-
teeism. As seen in detail in table 4, high VAS scores were
significantly associated with higher levels of absenteeism
and presenteeism. The strongest relationship was found
for abdominal pain scores that were seven or higher on
Table 2 Reported absenteeism caused by menstruation-
related symptoms
Number
(percentage) Mean±SD
All (n=32 748)
Absenteeism 4514 (13.8)
≤0.5 day 538 (1.6)
1 day 2259 (6.9)
2 days 1171 (3.6)
3 days 349 (1.1)
>3 days 184 (0.6)
Total days of
absenteeism per year
1.3±5.9
Work (n=26 104)
Absenteeism 2926 (11.2)
≤0.5 day 374 (1.4)
1 day 1476 (5.7)
2 days 757 (2.9)
3 days 211 (0.8)
>3 days 98 (0.4)
Total days of
absenteeism per year
0.9±3.9
Study (n=8764)
Absenteeism 1715 (19.6)
≤0.5 day 234 (2.7)
1 day 921 (10.5)
2 days 423 (4.8)
3 days 92 (1.0)
>3 days 41 (0.5)
Total days of
absenteeism per year
1.6±5.0
Women were asked to report the average amount of days on which
they were absent due to menstruation-related symptoms per cycle.
The total days of absenteeism per year was calculated. The added
numbers of women in the work and study group exceed the total
amount of participants, since 2120 women reported to both study
and work more than 5 hours/week.
Table 3 Reported presenteeism caused by menstruation-
related symptoms
Number
(percentage) Mean±SD Median
All (n=32 748)
Presenteeism 26 438 (80.7)
Number of days in
the past 3 months
5.8±5.3 5.0
Percentage of
productivity loss
per day
33.0±24.8 30.0
Days/year of lost
productivity
8.9±11.0 5.6
Work (n=26 104)
Presenteeism 21 252 (81.4)
Number of days in
the past 3 months
5.7±5.2 5.0
Percentage of
productivity loss
per day
31.7±24.7 30.0
Days/year of lost
productivity
8.4±10.6 4.8
Study (n=8764)
Presenteeism 7385 (84.3)
Number of days in
the past 3 months
6.3±5.3 5.0
Percentage of
productivity loss
per day
36.8±24.2 40.0
Days/year of lost
productivity
10.5±11.8 7.2
Women were asked to report the amount of days on which they
were less productive and to what extent. The total days of lost
productivity per year was calculated. The added numbers of
women in the work and study group exceed the total amount of
participants, since 2120 women reported to both study and work
more than 5hours/week.
Note that the values presented in days/year of lost productivity
do not add up exactly, since these data were calculated on an
individual basis and are not the result of merely multiplying the two
averages.
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a scale from 0 to 10. ORs were 5.6 for absenteeism (95%
CI 5.0 to 6.2) and 8.8 for presenteeism (95% CI 8.1 to
9.5). Figure 3 shows the association between age and both
presenteeism and absenteeism. As shown in both figure 3
and table 4, we found that younger women showed signifi-
cantly higher rates of absenteeism and presenteeism. A
levonorgestrel-releasing IUD is associated with especially
less presenteeism.
Menstruation and suggested implications for schools and
workplaces
From the respondent who had been calling in sick due
to MRSs, 20.1% (n=908) told their employer or school
menstrual symptoms were the reason, 46.4% (n=2092)
only mentioned the presenting symptom. No reason was
given by 27.7% (n=1250), while 5.8% (n=260) made up
another reason. Comparing women aged below 21 years
with women aged 21 years and above, we found that
younger women were less open about their MRSs being
the reason for calling in sick (12.0%) versus women
older than 21 (27.0%). Women were asked to report
suggestions on how work places and conditions could
be changed in order for them to function better during
their menstrual periods. There were 32 708 responses
to this multiple-choice question, to which each woman
could give more than one answer. The majority of women
(67.7%, n=22 154) preferred more flexibility during their
periods, such as the possibility of doing less physical work
(32.1%, n=10 499), the ability to work from home (39.5%,
n=12 917), more time for personal care (28.3%, n=9241)
or the ability to take a day off and make up for it later
(11.5%, n=3756). In addition, 32.9% wished they could
take a complete day off without any consequences. A
percentage of 27.2 (n=8890) did not wish for any changes
in policy. Many women (79.7%, n=26 072) were open to
discussing MRSs with their company doctor, and 56.7%
(n=18 579) thought that doing so would draw more atten-
tion to MRS-related matters.
DISCUSSION
This survey-based study showed that menstruation-re-
lated absenteeism and, to a greater extent, presenteeism
are widespread in the general female population. In our
cohort, MRSs accounted for up to 24% of total absen-
teeism for women who were working and studying. The
annual productivity loss due to presenteeism was seven-
fold times more than the annual productivity loss due to
absenteeism, and women younger than 21 years experi-
ence the largest burden. Symptom severity scores showed
significant and strong associations with both absenteeism
and presenteeism. When women called in sick due to
MRSs, only one in five stated openly that menstrual symp-
toms were the main reason. A majority of women prefers
more flexibility during their periods when it comes to
work or school.
There have been few studies on absenteeism and presen-
teeism related to MRSs in the general female population.
To our knowledge, Tanaka’s study25 is the only other
published study on absenteeism and presenteeism due to
MRSs in the general female population. In a cohort of
19 254 Japanese women, a total of 3311 (17.2%) reported
work productivity lost in the prior 3 months, mostly in the
form of decreased efficiency (62.0%, n=2052). Of these
2052 subjects, the mean number of workdays lost due to
decreased efficiency was 5.7 days in 3 months. After recal-
culation, this accounts for 2.4 days per year for the entire
population. This is fewer days than the 8.9 days per year
in our cohort. However, the numbers for absenteeism
were more similar, with a mean of 1.0 day of absenteeism
per year in the entire Japanese cohort compared with 1.3
days in our cohort. Differences in regulations of social
services, a difference in attitude towards sick leave and a
different method of data collection might explain these
differences. It has been suggested in research on muscu-
loskeletal symptoms that rates of absenteeism might be
lower in Japan compared with European countries and
the USA. Consequently, presenteeism might therefore be
a more representative variable.26 27
More data are available regarding the impact of dysmen-
orrhoea on quality of life and absenteeism. De Sanctis
et al reviewed studies on dysmenorrhoea in multiple
countries, some of which included menstruation-related
absenteeism data.14 They found that the prevalence of
school absences in adolescents that was due to dysmenor-
rhoea varied between 7.7% and 57.8%. Since the review
included 41 140 women in 27 countries, and there was a
high degree of heterogeneity in the outcome measures,
no firm conclusions could be drawn. Hailemeskel et al
evaluated 440 female university students in Ethiopia.28
Figure 2 The relationship between pain and intensity
scores, related to absenteeism and presenteeism, in lost
days per year.
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Table 4 ORs and 95% CIs for factors related to absenteeism and presenteeism
Absenteeism Presenteeism
OR (95% CI)
OR after correction
(95% CI) OR (95% CI)
OR after correction
(95% CI)
Age<21 years* 3.7 (3.4 to 3.9) 3.3 (3.1 to 3.6) 1.4 (1.3 to 1.5) 1.3 (1.2 to 1.4)
Smoking† 1.3 (1.2 to 1.5) 1.3 (1.2 to 1.4) 1.5 (1.3 to 1.6) 1.4 (1.3 to 1.6)
Absenteeism not related
to MRSs in the past
6 months‡
2.2 (2.1 to 2.4) 1.7 (1.6 to 1.9) 1.4 (1.3 to 1.5) 1.3 (1.2 to 1.4)
Level of education§
Low 4.5 (4.1 to 4.9) 2.7 (2.4 to 3.0) 1.3 (1.2 to 1.4) 1.1 (1.0 to 1.2)**
Medium 2.2 (2.1 to 2.4) 1.7 (1.5 to 1.8) 1.3 (1.2 to 1.4) 1.2 (1.1 to 1.2)
High 1.0 (n/a) 1.0 (n/a) 1.0 (n/a) 1.0 (n/a)
Oral contraception¶
No 1.0 (n/a) 1.0 (n/a) 1.0 (n/a) 1.0 (n/a)
Yes 1.2 (1.1 to 1.3) 1.0 (0.9 to 1.1)†† 0.9 (0.9 to 1.0) 0.9 (0.8 to 0.9)
LG-IUD¶
No 1.0 (n/a) 1.0 (n/a) 1.0 (n/a) 1.0 (n/a)
Yes 0.7 (0.6 to 0.8) 0.9 (0.8 to 1.0) 0.5 (0.5 to 0.6) 0.5 (0.5 to 0.6)
Abdominal pain score¶
0–4 1.0 (n/a) 1.0 (n/a) 1.0 (n/a) 1.0 (n/a)
5–6 2.6 (2.3 to 2.9) 2.2 (1.9 to 2.4) 5.2 (4.8 to 5.7) 5.3 (4.9 to 5.7)
>7 7.0 (6.4 to 7.8) 5.6 (5.0 to 6.2) 8.7 (8.0 to 9.4) 8.8 (8.1 to 9.5)
Headache pain score¶
0–4 1.0 (n/a) 1.0 (n/a) 1.0 (n/a) 1.0 (n/a)
5–6 1.5 (1.3 to 1.6) 1.5 (1.4 to 1.6) 3.0 (2.7 to 3.3) 3.1 (2.8 to 3.4)
>7 2.0 (1.8 to 2.1) 2.3 (2.1 to 2.5) 3.5 (3.2 to 3.9) 3.7 (3.4 to 4.1)
Backache pain score¶
0–4 1.0 (n/a) 1.0 (n/a) 1.0 (n/a) 1.0 (n/a)
5–6 1.6 (1.5 to 1.7) 1.4 (1.3 to 1.5) 3.5 (3.2 to 3.9) 3.5 (3.2 to 3.8)
>7 2.7 (2.5 to 2.9) 2.2 (2.1 to 2.4) 4.7 (4.2 to 5.2) 4.5 (4.0 to 5.0)
Tiredness intensity
score¶
0–4 1.0 (n/a) 1.0 (n/a) 1.0 (n/a) 1.0 (n/a)
5–6 1.8 (1.7 to 2.0) 1.8 (1.6 to 2.0) 3.3 (3.1 to 3.6) 3.3 (3.1 to 3.6)
>7 3.0 (2.8 to 3.2) 2.8 (2.6 to 3.1) 5.1 (4.7 to 5.6) 5.2 (4.7 to 5.7)
Psychological
complaints intensity
score¶
0–4 1.0 (n/a) 1.0 (n/a) 1.0 (n/a) 1.0 (n/a)
5–6 1.6 (1.5 to 1.7) 1.5 (1.4 to 1.7) 2.7 (2.5 to 2.9) 2.6 (2,5 to 2.9)
>7 2.2 (2.0 to 2.4) 2.1 (2.0 to 2.3) 4.4 (4.0 to 4.7) 4.3 (4.0 to 4.7)
ORs>1 correlate with a higher prevalence of absenteeism or presenteeism. ORs<1 correlate with a lower prevalence of absenteeism or
presenteeism.
*Correction for smoking and absenteeism that was not related to menstruation-related symptoms (MRSs).
†Correction for age, absenteeism that was not related to MRSs and level of education.
‡Correction for age, smoking and level of education.
§Correction for age, smoking and absenteeism that was not related to MRSs.
¶Correction for age, smoking, absenteeism that was not related to MRSs and level of education.
**P=0.26, ††p=0.73 for all other ORs, p<0.05.
LG-IUD, levonorgestrel-releasing intrauterine device.
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Among students with dysmenorrhoea, 66.8% reported a
loss of concentration in class, and 56.3% reported class
absences during the last month. In a questionnaire-based
study of 706 Hispanic female adolescents, 38% reported
missing school due to dysmenorrhoea during the 3
months prior to the survey, and 59% reported a decrease
in concentration in class due to dysmenorrhoea.29
Absenteeism and presenteeism due to endometriosis
in other studies was greater than in our study, which was
not surprising.9 14 30 However, some interesting parallels
can be drawn to findings from a recent study by Soliman
et al.14 They found that the average number of hours of
presenteeism, 5.3 hours per week, was far greater than
the number of hours of absenteeism, which was 1.1 hours
per week. Furthermore, younger women had significantly
higher levels of lost productivity than their older coun-
terparts, and more severe symptoms were associated with
more absenteeism and presenteeism. This was in line with
our findings, since we also found higher rates of both
absenteeism and presenteeism in younger women. A
taboo on talking openly about MRS, undertreatment and
less flexibility at school might be possible explanations for
these differences. Comparing our outcomes with studies
on other non-gynaecological conditions is hard due to
differences in methods and presentation of findings and
the cyclic character of MRSs. However, the incidence of
presenteeism seems to be as high as it is in patients with
inflammatory bowel disease.31 Moreover, the amount of
impairment is comparable with severe gastro-oesopha-
geal reflux (31.9%), moderate irritable bowel syndrome
(36.6%) and allergic rhinitis (33.4%–39.8%)%).32
Our finding that only 20.1% of women were open
about their menstrual symptoms as a reason for calling
in sick may confirm the general idea that women tend
not to speak openly about MRSs. Wong et al found that
in a cohort of schoolgirls in Malaysia, 76.1% considered
dysmenorrhoea a normal part of the menstrual cycle.15
In the context of the findings noted above, our study
also suggests there is a taboo for women in terms of
discussing menstrual problems with their employers. The
latter may therefore conclude that the impact of MRSs
on their employees is negligible. Considering the fact
that we also found that 68% of women wish that they had
greater flexibility during their periods, either at school
or at work, more openness about MRSs in the employ-
ment setting seems desirable. The reasons underlying
this taboo are likely to have a historical basis; indeed,
since ancient times, menstruation has been surrounded
with mythical stories and has not been well understood.
However, in recent years, the lay literature in developed
countries has focused more attention on MRSs.33–35 The
prevalence and the impact of MRSs on the general popu-
lation and the number of women who are asking for a
different approach all reflect the need to change the view
of menstrual symptoms and the way they are addressed
in society.
This study consisted of a large cohort, and it reached
a large number of women within the age range that was
aimed for. The questionnaire was developed in collabora-
tion with patient representatives to make it understand-
able by and relevant to most women. The cohort appeared
to be a representative sample of the general female popu-
lation based on the number of working hours.33 When
we compare our data with the national registries, the
total amount of absenteeism is found to be comparable,
regardless of whether it was related to MRSs.36 37 It is
difficult to compare our numbers on women with a diag-
nosis explaining their MRSs with numbers found in other
studies. We found that only 9% of the participants had
such a diagnosis, which seems about as expected or even
somewhat low.3 38–40 In contrast, 45% of the women in the
study reported consulting a physician for their MRSs. This
number was relatively high compared with other studies
in which, for example, the percentage of women with
dysmenorrhoea who sought medical advice was approxi-
mately 15%.15 16 An important factor might be the Dutch
health system in which general practitioners are available
free of charge. Women with a low level of education were
relatively under-represented.41 As our results show, espe-
cially absenteeism related to MRSs is associated with a low
level of education, and this might have biased our results.
We expect women with lower educational levels to do
more physical jobs or jobs with less flexibility. Therefore,
our findings on work productivity loss might be under-
estimated. However, our finding could be overestimated
due to the possibility that women with more MRSs might
be more likely to respond to a questionnaire, as it may
seem more relevant to them. Moreover, we were not able
to provide data on presenteeism not related to MRSs nor
were we able to correct for comorbid health conditions.
Thus, these results must be interpreted with caution. Due
to the way that the questionnaire was distributed through
Figure 3 The relationship between age and average
absenteeism and presenteeism.
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social media, there may have been some selection bias.
However, a recent review stated that Facebook is a useful
recruitment tool for healthcare research.42 Although we
did not use a validated questionnaire, our most important
outcomes were based on questions derived from the PCQ,
which itself is based on validated questions and which is
recommended by guidelines for cost research.24 Self-re-
ported absenteeism generally shows a good correlation
with official records, although accuracy decreases with
increasing recall period.43 This might have initiated a
recall bias in our cohort. It is unknown to what extend
recall bias affects reports on presenteeism.44 In general,
although results vary among studies on premenstrual
complaints, a prospective collection of data on symp-
toms is advisable.45 46 Furthermore, an extrapolation
of a 3-month and 6-month timeframe to a yearly basis
may intrinsically imply some degree of uncertainty, for
example, when the influenza season is not included
in the original analysis. Finally, these results may not
be generalised internationally due to variability in the
regulation of social services in different countries, and
this is also a limitation of our study. In he Netherlands,
wages are paid during sick leave that has duration of less
than 1 year, but women in other countries may not have
this benefit. Since we know that many factors influence
menstrual symptoms, including biological, cultural, and
environmental factors, these differences might well influ-
ence both absenteeism and presenteeism.6 14 47
In conclusion, we have found that the impact of MRSs
on work and school productivity is considerable and that
presenteeism contributes significantly more to the matter
than absenteeism. Future research should identify how
women affected by MRSs could be helped best and how
their productivity can be improved in order to reduce the
societal impact regarding absenteeism and presenteeism.
Acknowledgements The authors would like to thank Reinoud Oomen, Peter de
Vroed, Steven Giesbers, Elsbeth Teeling, Paula Kragten and Annemarie Haverkamp
for their valuable contributions in the development and dispersion of the
questionnaire.
Contributors TEN, BDB and JWMA conceived the study. MES wrote the rst and
successive drafts of the manuscript. MES, TEN and EMMA modelled and analysed
the data. TEN, EMMA, JWMM, BDB and JWMA contributed to study conception and
design. MES and TEN collected the data. All authors revised the manuscript for
important intellectual content. MES and TEN had full access to the data and take
responsibility for the integrity of the data and the accuracy of the data analysis. TEN
is the guarantor.
Funding The authors have not declared a specic grant for this research from any
funding agency in the public, commercial or not-for-prot sectors.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval Approval for this study was obtained from the local medical
ethics committee ‘Commissie Mensgebonden Onderzoek (CMO)’ under number le
number 2017–3387 on 12 July 2017.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data from this study are available from a
repository. Data are available on request from the corresponding author.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
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... The burden of menstruation comprises difficulties that affect female participation, especially regarding reduced capacity and work ability [40]. The prevalence and severity of the symptoms are also confirmed by quantitative studies [41][42][43]. However, two quantitative articles from the USA concluded that menstruation explains the gender gap in sickness absence to a very little extent [44] or not at all [45]. ...
... However, two quantitative articles from the USA concluded that menstruation explains the gender gap in sickness absence to a very little extent [44] or not at all [45]. Endometriosis was studied in 13 articles, of which 10 were quantitative studies and 1 used a mixed method, showing prevalence and significant risk for absenteeism, presenteeism and reduced work ability [43,[46][47][48][49][50][51][52][53][54][55]. The included studies showed that endometriosis can affect the quality of daily working life but is also associated with impairment of professional life from a broader perspective, affecting career choices [55]. ...
... The included studies showed that the hormonal system can cause symptoms that influence work participation [39,41,43,58,59]. Menstruation affects most women, and almost half of them experience pain or physical or psychological tension before or during the period, which can amount to a significant burden at the work place [24,27]. ...
Article
Full-text available
Women’s health matters for participation in working life. The objective of this study was to explore female physiology in a work–life context and to investigate possible associations between women’s health, sickness absence and work ability. A scoping review was conducted to develop a systematic overview of the current research and to identify knowledge gaps. The search strategy was developed through a population, concept and context (PCC) model, and three areas of women’s health were identified for investigation in the context of work. A total of 5798 articles were screened by title and abstract and 274 articles were screened by full text; 131 articles were included in the review. The material included research from 19 countries; the majority of the studies used quantitative methods. The results showed an impact on the occupational setting and an association between sickness absence, work ability and all three areas of women’s health, but a holistic and overall perspective on female biology in the work context is missing. This review calls for more knowledge on health and work and possible gender differences in this regard. Women’s health and working life involve a complex connection that has the potential to develop new knowledge.
... Scientific evidence supports the assumption that period pain strongly affects the quality of life and daily activities Nguyen et al., 2015). Dysmenorrhea is a prevalent cause of short-term work or school absence, particularly among young adults Nguyen et al., 2015) and has been linked to a decrease in self-perceived productivity at work (Schoep et al., 2019). However, there are few scientific insights into how people with period pain manage their symptoms at work and little evidence on how organizations and managers can improve work life and self-management of people with menstrual pain. ...
... Accompanying the public stigma around menstruation are several beliefs about menstruation, menstruating people, and how people should behave during menstruation (O'Flynn, 2006) as well as stereotypes and beliefs regarding the effects of menstruation on cognitive ability and emotional stability (Forbes et al., 2003;Marván et al., 2006Marván et al., , 2014Tschacher et al., 2022). The stigma and beliefs might provide a barrier for people with dysmenorrhea to be absent from work when experiencing pain as they do not want to disclose menstrual problems as a reason for their absence (Levitt & Barnack-Tavlaris, 2020) which could explain why presenteeism contributes more greatly to productivity losses due to menstruation symptoms than absenteeism (Schoep et al., 2019). ...
... Menstruation-related symptoms can lead to productivity loss: In a large cohort study including 32748 women between the ages of 15 and 45 (Schoep et al., 2019), menstruation symptoms and particularly abdominal pain were significantly associated productivity loss due to absence from work, but also due to productivity loss despite being present at work (presenteeism). However, productivity loss despite presence seems to be the more significant problem: Whereas the mean absenteeism accounted for 1.3 days of productivity loss a year, being present although having symptoms accounted for 8.9 days of productivity loss. ...
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Although menstrual pain (dysmenorrhea) is common and can have detrimental effects on workability and social functioning, little is known about how people manage dysmenorrhea in their professional life. Existing evidence indicates that people with dysmenorrhea often engage in presenteeism, meaning they work despite experiencing symptoms and report perceptions of social stigma around menstruation. In this study, we investigated individual health-related factors, psychosocial factors, and work factors associated with period pain presenteeism in a cross-sectional survey study including N = 668 employed people with experiences of dysmenorrhea. Our results show that symptom severity, disclosure of menstrual pain to the leader, and remote work are directly associated with period pain presenteeism. Also, we found that disclosure to the leader was associated with leader gender, leader-member exchange (LMX), and the absence of a medical diagnosis, indicating a potential mediating effect. We did not, however, find the perceptions of public beliefs regarding the concealment of menstruation to be related to presenteeism or disclosure. Our findings have important implications for theory building and research on menstruation in occupational contexts, occupational health management and communication, diversity management in organizations, and leadership training.
... 2,3 Although this is a relatively under-researched area, evidence suggests that symptoms women experience during parts of their menstrual cycle may impact their performance at work. 4,5 In a recent survey of approximately 33,000 respondents, 5 13.8% of women reported absenteeism (i.e. failure to report for or remain at work or in school as planned) during their menses and 80.7% reported presenteeism (i.e. the act of showing up for work or school without being productive). ...
... 2,3 Although this is a relatively under-researched area, evidence suggests that symptoms women experience during parts of their menstrual cycle may impact their performance at work. 4,5 In a recent survey of approximately 33,000 respondents, 5 13.8% of women reported absenteeism (i.e. failure to report for or remain at work or in school as planned) during their menses and 80.7% reported presenteeism (i.e. the act of showing up for work or school without being productive). ...
... Nevertheless, previous evidence points to the premenstrual and menstruation phases as the most impactful. 5,14,60 In addition, our sample included only Flo users, who may use Flo to manage their symptoms, whereas previous studies surveyed a more general population of women who may not benefit from app-based symptom management. Similarly, only women who owned and used mobile phones were included, which may limit generalizability. ...
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Objective Mood and physical symptoms related to the menstrual cycle affect women's productivity at work, often leading to absenteeism. However, employer-led initiatives to tackle these issues are lacking. Digital health interventions focused on women's health (such as the Flo app) could help fill this gap. Methods 1867 users of the Flo app participated in a survey exploring the impact of their menstrual cycle on their workplace productivity and the role of Flo in mitigating some of the identified issues. Results The majority reported a moderate to severe impact of their cycle on workplace productivity, with 45.2% reporting absenteeism (5.8 days on average in the previous 12 months). 48.4% reported not receiving any support from their manager and 94.6% said they were not provided with any specific benefit for issues related to their menstrual cycle, with 75.6% declaring wanting them. Users stated that the Flo app helped them with the management of menstrual cycle symptoms (68.7%), preparedness and bodily awareness (88.7%), openness with others (52.5%), and feeling supported (77.6%). Users who reported the most positive impact of the Flo app were 18–25% less likely to report an impact of their menstrual cycle on their productivity and 12–18% less likely to take days off work for issues related to their cycle. Conclusions Apps such as Flo could equip individuals with tools to better cope with issues related to their menstrual cycle and facilitate discussions around menstrual health in the workplace.
... When intrauterine pressures exceed arterial pressure, uterine ischemia develops and anaerobic metabolites stimulate type C pain neurons. 2 Additionally, prostaglandin levels in people with dysmenorrhea are elevated and correlate with the severity of pain. 3 Dysmenorrhea can have a profound impact on the daily lives of women as 38% report inability to perform their normal daily activities and 13.8% report missing school or work due to their symptoms. 4,5 Furthermore, first line medications such as NSAIDs are not always effective as up to 18% of women report no relief at all. 6 The combination of first line treatment ineffectiveness and significant prevalence calls for further investigation into alternative treatments such as Osteopathic Manipulative Treatment (OMT). ...
Article
Introduction Worldwide, menstrual pain affects up to 90% of reproductive-age women. Dysmenorrhea can cause significant disruption to the daily lives of menstruating persons and absenteeism from work or school. The combination of first line treatment ineffectiveness and significant prevalence calls for further investigation into alternative treatments such as Osteopathic Manipulative Treatment (OMT). Methods This meta-analysis aims to aggregate the evidence supporting the use of OMT as a successful treatment option to reduce pain symptoms due to dysmenorrhea. The criteria for accepted articles in our analysis included the studies that mentioned primary dysmenorrhea, the use of a quantitative pain scale, and the inclusion of only patients with regular cycle lengths. Results A total of four studies were compiled to compare the relative improvement that manual manipulative treatments had on reported pain intensity of primary dysmenorrhea, using the Numeric Rating Scale (NRS). Total number of subjects in the experimental group was 88. The mean numeric pain rating scale amongst the studies was 5.4 before treatment and 2.6 after. The p-value of 0.023 is <0.05 and therefore statistically significant. Conclusion The meta-analysis combining data from four studies showed significant improvement of dysmenorrhea when treated with manual manipulative treatments. Findings warrant further investigation with a larger sample size with utilization of standardized OMM regimen.
... Flexibility in hours or the option to work from home may help to alleviate this issue. Still, even for females who do not miss work or school due to menstrualrelated symptoms, the diminished attention and productivity that comes with them significantly impact performance (8). The presence or absence of an underlying cause determines whether dysmenorrhea is classed as primary or secondary (9). ...
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The aim of the study was to compare the effectiveness of acupressure and ice massage treatment methods in the treatment of primary dysmenorrhea. The 210 female students were randomly divided into three groups: acupressure, ice massage and control. In the acupressure group, pressure was performed at the Hugo point by applying medium pressure for 10 minutes of massage. The procedure was repeated five times. In the ice massage group, 2 cm diameter circular ice pieces were used. Massage with ice was carried out rotationally for 10 minutes. Like the acupressure, the procedure was repeated five times. In the control group, glass marbles were applied at the Hugo point with no pressure and massage for 10 minutes. The intensity of pain was measured prior to the intervention, during the intervention and following the intervention using a visual analogue scale. In the beginning, the mean VAS scores were 7.41 ± 1.82, 6.74 ± 2.23, and 7.03 ± 1.72 in the participants in groups control, acupressure and ice massage, respectively (P = 0.13). After the intervention, the mean pain scores were significantly lower at all of the time points in groups acupressure and ice massage than in group control participants (P < 0.001). Although the pain scores showed a more decreasing trend after the intervention in group ice massage than that in group acupressure, the difference between the two groups was not statistically significant (P = 0.97). It was revealed that treatment with acupressure and ice massage could also be recommended as a complementary medicine treatment for the treatment of primary dysmenorrhea with no reported side effects. Keywords: acupressure, ice massage, Hugo point, dysmenorrhea, pain
Article
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Primary dysmenorrhea is one of the most common causes of pelvic pain in women. It can reduce quality of life and interfere with daily activities. The use of combined oral contraceptives in young women with primary dysmenorrhea is an effective and safe treatment option. The article presents a clinical case of the effective use of combined oral contraceptives containing drospirenone in a young woman with primary dysmenorrhea and severe pain syndrome, which is not relieved by analgesics and antispasmodics and significantly reduces the patient's quality of life.
Article
Menstrual poverty has become a global issue, affecting women who do not have access to the menstrual products they need. Most of the related literature is based on low- and middle-income countries’ facts and experiences. Using the 2020 Youth Survey in Barcelona, this cross-sectional study provides novel data on the prevalence and the factors associated with menstrual poverty in an urban context (Barcelona) in a high-income country (Spain) with a randomly selected representative sample of 700 young women aged 15 to 34. Descriptive statistics and logistic regression models were used in the analysis. Results show that 15.3 per cent of young women in Barcelona reported facing financial barriers to accessing menstrual products. Further, those young women with a high level of material deprivation (OR=4.42; CI=2.14–9.16) have a greater probability of suffering from menstrual poverty, whereas those living independently from their parents (OR=0.50; CI=0.28–0.90) and women with a non-EU origin (Latin-Americans: OR=0.54; CI=0.31–0.93; Others: OR=0.06; CI=0.01–0.46) have a lower probability of reporting menstrual poverty. Our findings advocate that the measurement of poverty should consider individual aspects and needs, and not only the household income level as the reference. Further, we would encourage rethinking poverty measurement with a gender perspective, as well as identifying how deprivations overlap to aggravate the experience of poverty.
Article
Introduction Women constitute 62 per cent of UK medical school entries, yet the percentage in higher surgical training is half this (32 per cent), and the proportion of female consultants on the specialist register is only 14 per cent¹. Hidden curricula are subtle value-based lessons with moral undertones; they are absorbed without explicit intention but may perpetuate and boost existing disparities such as gender bias. Gender stereotypes continue to prevail in modern cultures, with female attributes considered warmer and more caring than the colder and more confident male behaviour. Moreover, straying from such traditional dogma can lead to negative perceptions. Microaggression is also prevalent, and defined as subtle insults and hostility toward minority stigmatized groups, including women². Fertility and pregnancy Infertility among doctors is high, with one in four female physicians experiencing conception difficulties, compared with the general population rate of 9–18 per cent³. Challenging on-call rotas and long geographical commutes can make pregnancy daunting. Female surgeons, in particular, have been reported to have significantly higher rates of infertility, with 32 per cent of a cohort of female US residents experiencing difficulties⁴. Arguably, higher infertility may be due to decisions to defer starting families until training has completed, and Rangel et al. reported that 65 per cent of studied female surgeons delayed pregnancy because of training-related concerns⁵. The average age for their first pregnancy was 33 years, compared with 31 years in controls, and the effect of age on fertility is well recognized. Moreover, miscarriage rates among female surgeons have been reported to be 42 per cent, double that of the general population⁵. Rates of pregnancy complications (intrauterine growth retardation, placental abruption, preterm labour, and low birthweight) have also been reported to be significantly higher in female surgeons, with 48 per cent suffering major morbidity, compared with 27 per cent in non-surgeon partners⁶. Pregnant surgeons also suffered higher rates of emergency caesarean section, musculoskeletal disorders, and postnatal depression. Operating for 12 hours or more per week during the third trimester of pregnancy was shown to increase morbidity 1.5-fold⁵. Mohan et al. reported that 27.1 per cent of UK and Republic of Ireland female surgeons felt unsupported during pregnancy⁷.
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The under-representation of females within the labour market, particularly in managerial roles, has sparked a local and global debate on whether women, mostly mothers, face negative discrimination. This study distinctly adopts a field experiment methodology to investigate the presence of gender discrimination and the motherhood penalty against higher education (Bachelor, Master's, and Doctoral degree) females seeking full-time employment in the labour market at the initial stage of the recruitment process, being the call-back to the interview. This study took place in Malta, which was characterised by a low unemployment figure, complemented by strong economic growth at the time, thus enabling a proper analysis of the possible presence of gender-based discrimination even when labour demand is high. Field experiments were chosen as the methodology. This involved sending pairs of fictitious job applications belonging to two fictional male and female candidates (identical to each other except for the demographic characteristics) in response to job vacancies. Then, the employers' behaviour was recorded to assess whether they engaged in discriminatory practices. The analysis of the replies through the use of econometric models shows that there is no statistically significant evidence that employers engage in discrimination at the call-back stage of the recruitment process. Furthermore, during this distribution period, no particular age class was favoured or discriminated against, a finding that contradicts the idea that young female workers are discriminated against due to their maternal responsibilities. Such a study contributes to the growing literature on the subject, by being the first study done in Malta to scientifically test whether the significant gender employment gap present in various industries in Malta is attributed to negative discrimination against women or mothers with young children.
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Background: Primary dysmenorrhea (PD) is the most common gynecologic compliant among adolescent females. There is a wide variation in the estimate of PD, which ranges from 50% to 90%, and the disorder is the most common cause of work and school absenteeism in adolescent females. Objective: To assess the prevalence and associated risk factors of PD among female university students and understand its effects on students’ academic performance. Methods: A cross-sectional study was employed in 440 research participants. A multistage stratified sampling technique was employed to select the study units. Structured and pretested self-administered questionnaires were used and weight and height measurements were conducted. The severity of dysmenorrheal pain was assessed by using a verbal multidimensional scoring system and visual analog scale. The data were double entered in Epi Info version 3.1 and analyzed using SPSS version 17. Descriptive statistics, chi-square test, and logistic regression analysis were performed. Results: A total of 440 students participated in this study. The prevalence of PD was 368 (85.4%). Of these, 123 (28.5%) had mild, 164 (38.1%) moderate, and 81 (18.8%) severe primary dysmenorrheal pain. Among students with PD, 88.3% reported that PD had a negative effect on their academic performance. Of these, 80% reported school absence, 66.8% reported loss of class concentration, 56.3% reported class absence, 47.4% reported loss of class participation, 37.8% reported limited sport participation, 31.7% reported limitation in going out with friends, and 21% reported inability to do homework. Based on the multivariate logistic regression, PD was statistically significant with those who had lower monthly stipends, a history of attempt to lose weight, a history of depression or anxiety, disruption of social network of family, friends or people they love, who consumed more than four glasses of tea per day, who drunk one or more Coca-Cola or Pepsi per day, in nullipara, and students with a family history of dysmenorrhea. Conclusion: PD is more prevalent among female students attending university. It has a significant negative impact on students’ academic performance. Thus, it needs medical attention. There are various identified associated risk factors and considering them in the management of the disorder is fundamental. It is also wise to recommend future studies to better identify risk factors for PD and lighten its effect on students’ academic performance at a larger scale in the country. Keywords: academic performance, risk factors, dysmenorrhea, Ethiopia, adolescents, young, higher institution
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Background: Osteoarthritis (OA) is one of the most common causes of health and work impairment; however, this relationship, especially in Japan, is not well characterized. This study examined work impairment and OA in Japanese workers, specifically the relationship with health-related quality of life (HRQoL) and health status. Methods: This retrospective, cross-sectional observational study included the data of employed adults with a self-reported OA diagnosis from the 2014 Japan National Health and Wellness Survey. Presenteeism and absenteeism were classified using the Work Productivity and Activity Impairment (WPAI) questionnaire for impairment at work in the past week. Outcome variables included health-related quality of life, which was measured with the revised Medical Outcomes Study 36-Item Short Form Survey Instrument Health Survey (SF-36v2), and depression symptom severity, which was assessed using the Patient Health Questionnaire-9 (PHQ-9). Results: The majority (71.2%) of respondents with OA reported presenteeism, and 11.1% reported absenteeism. Presenteeism and absenteeism were both associated with younger age; a lower proportion of respondents with than without presenteeism were married or living with a partner, and a greater proportion of those with absenteeism had comorbid conditions (for all, p < 0.05). Respondents with than without presenteeism reported greater use of medications to relieve OA symptoms (37.3% versus 20.9%, p < 0.05), and those with than without absenteeism reported more frequent arthritis-related problems (p = 0.032). Among those with presenteeism, depression severity was higher (5.8 ± 6.0) than for those with no presenteeism (2.9 ± 4.3; p < 0.001). Presenteeism was associated with impairments in HRQoL on all metrics for patients with OA, with lower mental (6.4 points) and physical (4.8 points) component scores on the SF-36v2 (for all, p < 0.001). Conclusions: Seven out of every 10 patients with OA experienced presenteeism, whereas one out of 10 reported absenteeism. OA respondents with presenteeism also showed greater medication use, lower HRQoL across both mental and physical components, and higher depression severity. Workplace interventions and effective treatment options are necessary strategies for improving the health of workers with OA in Japan.
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Background Social media is a popular online tool that allows users to communicate and exchange information. It allows digital content such as pictures, videos and websites to be shared, discussed, republished and endorsed by its users, their friends and businesses. Adverts can be posted and promoted to specific target audiences by demographics such as region, age or gender. Recruiting for health research is complex with strict requirement criteria imposed on the participants. Traditional research recruitment relies on flyers, newspaper adverts, radio and television broadcasts, letters, emails, website listings, and word of mouth. These methods are potentially poor at recruiting hard to reach demographics, can be slow and expensive. Recruitment via social media, in particular Facebook, may be faster and cheaper. Objective The aim of this study was to systematically review the literature regarding the current use and success of Facebook to recruit participants for health research purposes. Methods A literature review was completed in March 2017 in the English language using MEDLINE, EMBASE, Web of Science, PubMed, PsycInfo, Google Scholar, and a hand search of article references. Papers from the past 12 years were included and number of participants, recruitment period, number of impressions, cost per click or participant, and conversion rate extracted. Results A total of 35 studies were identified from the United States (n=22), Australia (n=9), Canada (n=2), Japan (n=1), and Germany (n=1) and appraised using the Critical Appraisal Skills Programme (CASP) checklist. All focused on the feasibility of recruitment via Facebook, with some (n=10) also testing interventions, such as smoking cessation and depression reduction. Most recruited young age groups (16-24 years), with the remaining targeting specific demographics, for example, military veterans. Information from the 35 studies was analyzed with median values being 264 recruited participants, a 3-month recruitment period, 3.3 million impressions, cost per click of US $0.51, conversion rate of 4% (range 0.06-29.50), eligibility of 61% (range 17-100), and cost per participant of US $14.41. The studies showed success in penetrating hard to reach populations, finding the results representative of their control or comparison demographic, except for an over representation of young white women. Conclusions There is growing evidence to suggest that Facebook is a useful recruitment tool and its use, therefore, should be considered when implementing future health research. When compared with traditional recruitment methods (print, radio, television, and email), benefits include reduced costs, shorter recruitment periods, better representation, and improved participant selection in young and hard to reach demographics. It however, remains limited by Internet access and the over representation of young white women. Future studies should recruit across all ages and explore recruitment via other forms of social media.
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Background: Primary dysmenorrhea (PD) is the most common gynecologic compliant among adolescent females. There is a wide variation in the estimate of PD, which ranges from 50% to 90%, and the disorder is the most common cause of work and school absenteeism in adolescent females. Objective: To assess the prevalence and associated risk factors of PD among female university students and understand its effects on students’ academic performance. Methods: A cross-sectional study was employed in 440 research participants. A multistage stratified sampling technique was employed to select the study units. Structured and pretested self-administered questionnaires were used and weight and height measurements were conducted. The severity of dysmenorrheal pain was assessed by using a verbal multidimensional scoring system and visual analog scale. The data were double entered in Epi Info version 3.1 and analyzed using SPSS version 17. Descriptive statistics, chi-square test, and logistic regression analysis were performed. Results: A total of 440 students participated in this study. The prevalence of PD was 368 (85.4%). Of these, 123 (28.5%) had mild, 164 (38.1%) moderate, and 81 (18.8%) severe primary dysmenorrheal pain. Among students with PD, 88.3% reported that PD had a negative effect on their academic performance. Of these, 80% reported school absence, 66.8% reported loss of class concentration, 56.3% reported class absence, 47.4% reported loss of class participation, 37.8% reported limited sport participation, 31.7% reported limitation in going out with friends, and 21% reported inability to do homework. Based on the multivariate logistic regression, PD was statistically significant with those who had lower monthly stipends, a history of attempt to lose weight, a history of depression or anxiety, disruption of social network of family, friends or people they love, who consumed more than four glasses of tea per day, who drunk one or more Coca-Cola or Pepsi per day, in nullipara, and students with a family history of dysmenorrhea. Conclusion: PD is more prevalent among female students attending university. It has a significant negative impact on students’ academic performance. Thus, it needs medical attention. There are various identified associated risk factors and considering them in the management of the disorder is fundamental. It is also wise to recommend future studies to better identify risk factors for PD and lighten its effect on students’ academic performance at a larger scale in the country. Keywords: academic performance, risk factors, dysmenorrhea, Ethiopia, adolescents, young, higher institution
Article
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Background: Dysmenorrhea is still an important public health problem which may have a negative impact on female health, social relationships, school or work activities and psychological status. Methods: The aim of this review is a better understanding of the epidemiology of dysmenorrhoea and its effect on public health. Published studies in English providing relevant information on dysmenorrhea were identified by searching PubMed, Embase and Google; restricting the population to adolescents and young adult women and the year of publishing from 2010 to August 2015, based on the keywords 'dysmenorrhea', 'adolescents' and 'epidemiology'. In addition, the reference lists of the selected articles were examined. Results: We found 50 studies that met our inclusion criteria. The majority were cross-sectional studies on 41,140 adolescents and young women published from 2010 onward. The prevalence of dysmenorrhea varied from 34 % (Egypt) to 94% (Oman) and the number of participants, reporting very severe pain varied from 0.9 % (Korea) to 59.8% (Bangladesh). Adolescents who missed school due to dysmenorrhoea ranged from 7.7% to 57.8% and 21.5% missed social activities. About 50% of students (53.7%-47.4%) reported a family history of dysmenorrhea. Incidence of dysmenorrhea was 0.97 times lower as age in-creased (p <0.006). Despite the high prevalence of dysmenorrhea in adolescents, many girls did not receive professional help or treatment. Mothers were the most important persons the girls turned to for answers regarding menstruation, followed by peers (52.9%) and school nurse. From 21% to 96% practised self-medication either by pharmacological or non pharmacological interventions. The limitation of these studies was that they did not distinguish between primary dysmenorrhea and secondary dysmenorrhea. Conclusions: The main gynecological complaint of adolescents is dysmenorrhea. Morbidity due to dysmenorrhea represents a substantial public health burden. It is one of the leading causes of absenteeism from school and work and is responsible for significant diminished quality of life. Despite its high prevalence and associated negative effects, many adolescents do not seek medical care for this condition. Appropriate counselling and management should be instituted among female students to help them cope with the challenges of dysmenorrhea. Information, education and support should also be extended to parents, school peer leaders, and hostel administrators in order to address the reproductive health needs of the female students.
Article
Background: Characterized by pain symptoms, endometriosis affects women's productivity in their prime working years. Objective: To evaluate the effect of individual endometriosis symptoms on household chore and employment productivity as measured by presenteeism and absenteeism in a population survey of women with endometriosis. Methods: An online survey of U.S. women was conducted to evaluate the prevalence of endometriosis, as well as symptoms, demographics, and clinical characteristics of the respondents. Women aged 18-49 years (inclusive) with endometriosis completed the Health-related Productivity Questionnaire to assess presenteeism and absenteeism for employed and household work. Descriptive statistics were used to describe the sample, survey responses, and the effect of endometriosis symptom severity on household chore and employment productivity. Regression analyses were performed to examine the effect of individual endometriosis symptoms on employment and household productivity lost because of presenteeism and absenteeism. Results: Of 59,411 women who completed the prevalence screener, 5,879 women (9.9%) met the inclusion criteria for completing the survey; 1,318 women (2.2%) reported endometriosis and at least 1 hour of scheduled household chores in the past 7 days. Of these, 810 women had least 1 hour of scheduled employment in the past 7 days. Mean age was 34.6 years (standard error [SE] ± 0.32); 77.2% of the women were white; 59.3% were married or in a civil union; and 59.1% were employed full or part time. Women with endometriosis had a weekly loss of an average of 5.3 hours (SE ± 0.4) because of employment presenteeism, 1.1 hours (SE ± 0.2) of employment absenteeism, 2.3 (SE ± 0.2) hours of household presenteeism, and 2.5 (SE ± 0.2) hours of household absenteeism. Hourly losses in employment and household chore productivity were significantly greater with increasing symptom severity (mild vs. severe: 1.9 vs. 15.8 total employment hours lost and 2.5 vs. 10.1 total household hours lost; P < 0.0001). Women who experienced 3 endometriosis symptoms concurrently lost a significantly greater number of employment hours because of absenteeism and presenteeism compared with those experiencing 1 or 2 symptoms (P < 0.001). Regression analyses showed that a range of endometriosis symptoms predicted employment and household losses because of presenteeism and absenteeism. Conclusions: There was a significant relationship between the number and patient-reported severity of endometriosis symptoms experienced and hours of employment and household productivity lost because of presenteeism and absenteeism. Study findings indicate a need for guidance strategies to help women and employers manage endometriosis so as to reduce productivity loss. Disclosures: The design and financial support for this study was provided by AbbVie. AbbVie participated in data analysis, interpretation of data, review, and approval of the manuscript. Coyne and Gries are employees of Evidera- Evidence, Value & Access by PPD and were paid scientific consultants for AbbVie in connection with this study. Soliman, Castelli-Hayley, and Snabes are AbbVie employees and may own AbbVie stock or stock options. Surrey is affiliated with Colorado Center for Reproductive Medicine and was paid by AbbVie as a consultant for this project. Surrey serves as a consultant for AbbVie outside of this project. All authors participated in data analysis and interpretation, and contributed to the development of the manuscript. The authors maintained control over the final contents of the manuscript and the decision to publish. Study concept and design were contributed by Soliman, Coyne, Gries, and Castelli-Haley. Soliman, Castelli-Haley, Coyne, and Gries collected the data, and data interpretation was performed by Snabes, Surrey, Soliman, Coyne, and Gries. The manuscript was written and revised by Soliman, Coyne, and Gries, along with the other authors.
Article
Premenstrual disorders include premenstrual syndrome, premenstrual dysphoric disorder and premenstrual worsening of another medical condition. While the underlying causes of these conditions continues to be explored, an aberrant response to hormonal fluctuations that occur with the natural menstrual cycle and serotonin deficits have both been implicated. A careful medical history and daily symptom-monitoring across two menstrual cycles is important in establishing a diagnosis. Many treatments have been evaluated for the management of premenstrual disorders. The most efficacious treatments for premenstrual syndrome and premenstrual dysphoric disorder include serotonin reuptake inhibitors and contraceptives with shortened to no hormone-free interval. Women who do not respond to these and other interventions may benefit from gonadotropin releasing hormone agonist treatment.
Article
The purposes of this study were to determine the prevalence of perimenstrual symptoms among a randomly selected group of Italian women by using a standardized menstrual symptom instrument and to compare them with those from a census-based sample of free-lving American women in the study by Woods et al. (Am J Public Health 1982; 72: 1257–64). Italian menstrual symptom prevalence rates were obtained as part of a 1984 national health screening project using the Moos Menstrual Distress Questionnaire translated into Italian. A total of 306 of the 426 randomly invited women between ages 20 and 49 years participated (71.8% participation rate). After determination of ineligible participants (those who were postmenopausal, posthysterectomy, and pregnant), a total of 239 subjects were interviewed. Italian women reported the highest prevalence of symptoms during the menstrual phase and the lowest prevalence during the remainder of the cycle. The cross-cultural comparison indicates that, overall, Italian women reported higher prevalence of symptoms across the three phases of the cycle than did the American women, even though this difference was the smallest during the premenstrual phase. Prevalence rates of a number of classic premenstrual symptoms (e.g., breast tenderness) and affective symptoms (e.g., tension and avoid social activities) were found to be similar for the Italian and American samples. This study, while it identifies a sodiocutural component to symptom reporting, indicates the presence of premenstrual distress symptoms in diverse cultural settings, even in women who are generally unaware of premenstrual syndrome. These findings lend support to the validity of the premenstrual phase distress experience and suggest the existence of the premenstrual syndrome across diverse cultures.
Article
The differentiation between premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) has been widely discussed. PMDD is listed as a mental disorder in the DSM-5, whereas PMS is not considered as a mental disorder in any diagnostic manual. Consequently, PMS is operationalized in different ways. Keeping a symptom diary is required to diagnose PMDD but is also recommended for PMS. The aim of our study was, therefore, to operationalize PMS and PMDD within a DSM-5-based symptom diary. We developed a symptom-intensity-score (SI-score) and an interference-score (INT-score) to evaluate the symptom diary. Ninety-eight women (aged 20–45 years) completed a symptom diary over two menstrual cycles, a retrospective screening for premenstrual symptoms, and answered additional impairment questionnaires from August 2013 until August 2015. The scores revealed moderate to good reliability (Cronbach’s α = 0.83–0.96). Convergent validity was shown by significant correlations with a retrospective screening, the Pain Disability Index, and the German PMS-Impact Questionnaire. Discriminant validity was indicated by low correlations with the Big Five Inventory-10. These scores may facilitate the evaluation of prospective symptom ratings in research and clinical practice. Future research should focus on continuing to validate the scores (e.g., in an ambulatory setting).
Article
Background: Productivity losses often contribute significantly to the total costs in economic evaluations adopting a societal perspective. Currently, no consensus exists on the measurement and valuation of productivity losses. Objective: We aimed to develop a standardized instrument for measuring and valuing productivity losses. Methods: A group of researchers with extensive experience in measuring and valuing productivity losses designed an instrument suitable for self-completion, building on preknowledge and evidence on validity. The instrument was designed to cover all domains of productivity losses, thus allowing quantification and valuation of all productivity losses. A feasibility study was performed to check the questionnaire's consistency and intelligibility. Results: The iMTA Productivity Cost Questionnaire (iPCQ) includes three modules measuring productivity losses of paid work due to 1) absenteeism and 2) presenteeism and productivity losses related to 3) unpaid work. Questions for measuring absenteeism and presenteeism were derived from existing validated questionnaires. Because validated measures of losses of unpaid work are scarce, the questions of this module were newly developed. To enhance the instrument's feasibility, simple language was used. The feasibility study included 195 respondents (response rate 80%) older than 18 years. Seven percent (n = 13) identified problems while filling in the iPCQ, including problems with the questionnaire's instructions and routing (n = 6) and wording (n = 2). Five respondents experienced difficulties in estimating the time that would be needed for other people to make up for lost unpaid work. Conclusions: Most modules of the iPCQ are based on validated questions derived from previously available instruments. The instrument is understandable for most of the general public.