Epidemiology of dysmenorrhea among adolescent students in Mansora, Egypt

Abstract

To examine the prevalence, determinants, impact and treatment practices of dysmenorrhoea, we studied 664 female students in secondary schools in urban and rural areas. Data was collected through a self-administered questionnaire. About 75% of the students experienced dysmenorrhoea (mild 55.3%, moderate 30.0%, severe 14.8%). Most did not seek medical advice although 34.7% treated themselyes. Fatigue, headache, backache and dizziness were the commonest associated symptoms. No limitation of activities was reported by 47.4% of student with dysmenorrhoea, but this was significantly more reported by students with severe dysmenorrhoea. Significant predictors of dysmenorrhoea were older age, irregular or long cycle and heavy bleeding.

Full text

Eastern Mediterranean Health Journal, Vol. 11, Nos 1/2, 2005 155
Epidemiology of dysmenorrhoea
among adolescent students in
Mansoura, Egypt
A-H. El-Gilany,
1
K. Badawi
2
and S. El-Fedawy
2
1
Department of Community Medicine, Faculty of Medicine;
2
Students’ University Hospital, University of
Mansoura, Mansoura, Egypt (Correspondence to A-H. El-Gilany: ahgilany@hotmail.com).
Received: 21/04/03; accepted: 23/03/04
ABSTRACT To examine the prevalence, determinants, impact and treatment practices of dysmenorrhoea,
we studied 664 female students in secondary schools in urban and rural areas. Data was collected through
a self-administered questionnaire. About 75% of the students experienced dysmenorrhoea (mild 55.3%,
moderate 30.0%, severe 14.8%). Most did not seek medical advice although 34.7% treated themselves.
Fatigue, headache, backache and dizziness were the commonest associated symptoms. No limitation of
activities was reported by 47.4% of student with dysmenorrhoea, but this was significantly more reported by
students with severe dysmenorrhoea. Significant predictors of dysmenorrhoea were older age, irregular or
long cycle and heavy bleeding.
Épidémiologie de la dysménorrhée chez des élèves adolescentes à Mansoura (Égypte)
RÉSUMÉ Pour examiner la prévalence, les déterminants, l’impact et les pratiques de traitement de la
dysménorrhée, nous avons mené une étude auprès de 664 élèves d’écoles secondaires en zone urbaine et
rurale. Des données ont été recueillies à l’aide d’un auto-questionnaire. Environ 75 % des élèves ont eu une
dysménorrhée (légère 55,3 %, modérée 30,0 %, sévère 14,8 %). La plupart d’entre elles n’ont pas recher-
ché un avis médical bien que 34,7 % se soient soignées elles-mêmes. Fatigue, céphalées, dorsalgies et
vertiges étaient les symptômes les plus courants qui y étaient associés. Aucune limitation des activités n’a
été rapportée par 47,4 % des élèves souffrant de dysménorrhée, mais ce point était signalé significative-
ment plus souvent par les élèves souffrant de dysménorrhée sévère. Les facteurs prédictifs de la dysmé-
norrhée étaient l’âge plus avancé, un cycle menstruel irrégulier ou long et des menstrues abondantes.
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Introduction
Dysmenorrhoea, or painful menstruation,
is defined as a severe, painful cramping
sensation in the lower abdomen [1]. It may
be accompanied by headache, dizziness, di-
arrhoea, a bloated feeling, nausea and vom-
iting, backache and leg pains. Primary
dysmenorrhoea occurs in the absence of
recognizable pelvic pathology and com-
monly begins when the ovulatory menstru-
al cycle starts. The pain starts a few hours
before menstruation and lasts for up to 72
hours. It is usually most severe on the first
day of menstruation and gradually dimin-
ishes. It is caused by increased endometrial
prostaglandin production and almost al-
ways first occurs in women younger than
20 years [1–4].
Secondary dysmenorrhoea, on the oth-
er hand, is associated with pelvic condi-
tions or pathology that cause pelvic pain in
conjunction with the menses. This usually
appears later in a woman’s reproductive life
and can occur with anovulatory cycles. It
often lasts for 5 to 7 days each month, and
progressively increases in severity [1–4].
Dysmenorrhoea has a negative effect
on a woman’s life. It may be so severe as to
confine the woman to bed. During adoles-
cence, dysmenorrhoea leads to high rates
of absence from school and non-participa-
tion in activities. Mild to moderate cases
can usually be treated by reassurance and
paracetamol [1,2,5].
Population studies on dysmenorrhoea
are scarce for Egyptian women, and practi-
cally non-existent for adolescent girls. In
this study, therefore, we aimed to estimate
the prevalence of dysmenorrhoea and to
study its determinants and impact as well
as treatment practices among adolescent
students in Mansoura, Egypt.
Methods
This study was carried out during the peri-
od November 2001–April 2002 in Mansou-
ra district, Egypt. A cross-sectional survey
was carried out. The target population was
female secondary-school students enrolled
in government schools. Approval of the lo-
cal directorate of education was obtained.
The eastern and western educational zones
(municipal subdivisions of the city) as well
as the rural sector were represented. Both
general and technical secondary schools
were represented. One general secondary
school was randomly selected from each
of the eastern and western zones (the num-
ber of schools is similar in each zone) as
well as 1 school from the rural sector. One
technical commercial school and 1 nursing
school were selected from Mansoura city.
All social strata as well as the urban and
rural sectors of the community were repre-
sented in this distribution. From each se-
lected school, 1 class (cluster) from each
grade was randomly selected. A total of 15
classes were studied. A total of 694 stu-
dents were registered in the chosen class-
es. Of these, 664 (95.7%) participated in
the study. Others were either absent
(3.6%) or refused to complete the ques-
tionnaire (0.7%).
In cooperation with the school authori-
ties, female investigators spent about 45–
60 minutes in each class. The students
were briefed about the study, encouraged
to participate and motivated to express their
experiences. It was emphasized that all data
collected were strictly confidential. Stu-
dents were requested to complete a self-
administered, anonymous questionnaire
covering family background, age at me-
narche, duration and amount of bleeding,
cycle length, pain during menstruation
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Eastern Mediterranean Health Journal, Vol. 11, Nos 1/2, 2005 157
(dysmenorrhoea) during the previous 3
months, severity of the pain (mild, moder-
ate or severe, subjectively assessed), dura-
tion of pain, any associated symptoms,
impact on daily activities and treatment tak-
en, if any. Dysmenorrhoea was defined as
lower abdominal pain associated with men-
strual periods. The social score and family
social class were calculated according to
Fahmy and El-Sherbiny [6].
Data were analysed using SPSS, version
9. The chi-squared test was used as a test
of significance. Factors significantly af-
fecting prevalence of dysmenorrhoea on
univariate analysis were entered into multi-
variate logistic regression analysis. P
≤ 0.05 was considered to be statistically
significant.
Results
The sociodemographic characteristics of
the students in the study are shown in Table
1. The majority (96.7%) ever menstruated.
The mean and median ages at menarche
were 12.9 years and 13.0 years respective-
ly. The vast majority of the students
(98.0%) were Muslim. Just over half
(53.2%) were from an urban residence.
The overall prevalence of dysmenor-
rhoea (assumed to be primary dysmenor-
rhoea, as secondary is rare at this age) was
74.6%; it was significantly more frequent
among students from a rural residence, in
those from low and very low social class-
es, those of older age, those who said they
had an irregular cycle, those who stated
they had heavy bleeding, those with long
duration of bleeding (≥ 6 days) and those
with long cycles (≥ 30 days) (Table 2).
On logistic regression analysis, the sig-
nificant determinants of dysmenorrhoea
were older age, cycle irregularity, heavi-
ness of menstrual flow and longer cycle
length (Table 3).
Table 1 Sociodemographic characteristics of
secondary school students in Mansoura
Variable No. %
Residence
Urban 353 53.2
Rural 311 46.8
Family social class
High 175 26.4
Middle 124 18.7
Low & very low 365 55.0
Religion
Muslim 651 98.0
Christian 13 2.0
Age (years)
a
14 109 16.4
15 217 32.7
16 240 36.1
17+ 98 14.8
Ever menstruating
Yes 642 96.7
No 22 3.3
Age at menarche (years)
b,c
< 12 47 7.1
12 178 26.8
13 244 36.7
14+ 173 26.1
Total 664 100
a
Range 14–18 years; mean 15.5 years (standard
deviation 0.99).
b
Range 10–16 years; median 13.0 years; mean
12.9 years (standard deviation 1.03).
c
Among ever menstruating adolescents.
Dysmenorrhoea was mild in the majori-
ty of cases; only 14.8% of students with
dysmenorrhoea reported having severe
forms. In the majority of cases, the dura-
tion of the pain was less than 24 hours. The
most frequent symptoms associated with
dysmenorrhoea were fatigue, headache,
backache, dizziness and anorexia/vomiting.
In 23.8% of cases there were no associated
symptoms. About half the students with
dysmenorrhoea did not take any medica-
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tion; the others reported using herbs/home
remedies (36.7%) and analgesics/non-
steroidal anti-inflammatory drugs
(NSAIDs)/antispasmodics (34.7%) (Table
4). These drugs were mostly self-pre-
scribed; only 13 students (2.7%) consulted
a physician or pharmacist.
The impact of dysmenorrhoea on daily
activities is shown in Table 5. No limitation
was reported by 47.4% overall, but by only
2.8% of those who stated they had severe
dysmenorrhoea. The activities the students
reported as most often being limited were
daily home chores (42.8%), going out of
Table 2 Prevalence and determinants of dysmenorrhoea among ever
menstruating adolescents in Mansoura
Variable Total Dysmenorrhoea Significance test
No. %
Residence
Urban 335 233 69.6 χ
2
= 9.5; P = 0.002
Rural 307 246 80.1
Family social class
High 163 107 65.6 χ
2
= 12.5; P = 0.002
Middle 119 85 71.4
Low & very low 360 287 79.7
Age (years)
14 97 60 61.9 χ
2
= 31.4; P < 0.001
15 210 142 67.6
16 237 187 78.9
17+ 98 90 91.8
Age at menarche (years)
< 12 47 38 80.9 χ
2
= 1.8; P = 0.6
12 178 133 74.7
13 244 184 75.4
14+ 173 124 71.7
Cycle regularity
a
Regular 429 298 69.5 χ
2
= 18.1; P < 0.001
Irregular 213 181 85.0
Bleeding amount
a
Drops 28 11 39.3 χ
2
= 25.6; P < 0.001
Average 503 373 74.2
Heavy 111 95 85.6
Bleeding duration (days)
< 4 63 40 63.5 χ
2
= 6.8; P = 0.033
4–5 400 296 74.0
≥ 6 179 143 79.9
Cycle length (days)
< 30 245 166 67.8 χ
2
= 9.8; P = 0.002
≥ 30 397 313 78.8
Overall 642 479 74.6
a
Subjectively reported.
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Eastern Mediterranean Health Journal, Vol. 11, Nos 1/2, 2005 159
the home (41.5%), participation in social
activities (39.0%) and participation in
sports (34.4%). Limitations on activities
were significantly more frequently reported
among students who reported having se-
vere dysmenorrhoea.
Discussion
Over the past decade there has been a para-
digm shift in the field of population studies,
moving from a relatively singular focus on
family planning to a broader focus on re-
productive health. Menstrual problems are
generally perceived as only minor health
concerns and thus irrelevant to the public
health agenda. Data on the frequency of
menstrual dysfunction and its impact on
health status, quality of life and social inte-
gration among women in developing coun-
tries are scant. The lack of data and the
private nature of menstruation perpetuate
the belief that menstrual complaints do not
warrant the attention of the public health
community [7,8].
Dysmenorrhoea is the commonest gy-
naecologic disorder among female adoles-
cents and is one of the commonest
gynaecologic complaints in young women
who present to doctors today [3,9,10].
Dysmenorrhoea among adolescents is usu-
ally of the primary type [1–4,11,12 ].
In our study, 74.8% of adolescent stu-
dents reported pain with menstruation dur-
ing the previous 3 months. This is
comparable to previously reported preva-
Table 3 Logistic regression analysis of factors affecting
dysmenorrhoea among ever menstruating adolescent students (n
= 642)
Variable
ββ
ββ
β P OR 95% CI
Age (years)
14
a
–1
15 0.28 0.3 1.32 0.78–2.23
16 0.78 0.005 2.18 1.27–3.72
17+ 1.89 < 0.001 6.59 2.82–15.4
Cycle regularity
Regular –0.61 0.009 0.54 0.34–0.86
Irregular
a
–1
Menstrual flow
Drops
a
–1
Average 1.31 0.002 3.71 1.63–8.47
Heavy 1.88 0.0002 6.54 2.47–17.29
Cycle length (days)
<30
a
–1
≥ 30 0.39 0.048 1.48 1.00–2.19
Constant –0.61
–2 log likelihood 657.7
Model
χ
2
69.7; P < 0.001
OR = odds ratio, CI = confidence interval.
a
Reference group.
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lence in both industrialized and developing
countries that ranged from 20% to 93% for
the same age group [2,3,5,7,13–19]. The
severity of dysmenorrhoea varied greatly.
In our study 14.8% of adolescents with
dysmenorrhoea reported their pain as se-
vere. In other countries, severe dysmenor-
rhoea was reported by 15%–53% of
adolescents [7,10,14,17,18,20]. These dif-
ferences in the degree of pain severity may
be related to cultural differences in pain
perception and variability in pain threshold.
Correlation between ethnicity and pain per-
ception has previously been reported [10].
Duration of pain was less than 24 hours
in 64.9% of cases and only 8.6% of adoles-
cents reported pain lasting for more than 48
hours. Banikarim, Chacko and Kelder re-
ported that 90% of adolescents had men-
strual cramps lasting for 48 hours or less
[10]. In 23.8% of cases, dysmenorrhoea
was not associated with other symptoms
(fatigue, headache, backache, dizziness,
anorexia/vomiting, abdominal pain/disten-
sion and diarrhoea). Most of the studies we
reviewed reported the same duration of
pain as in our study but the associated
symptoms occurred with different fre-
quencies [2,3,10,13,15].
It has been reported that the risk of dys-
menorrhoea is higher in women with irreg-
ular, prolonged or heavy menstrual flow as
well as early age of menarche [2,14,
16,20]. In our study we found that preva-
lence of dysmenorrhoea was significantly
higher among adolescents aged 16 and 17
years compared to those aged 14 years,
those who had irregular cycles and those
reporting heavier menstrual flow or a pro-
longed cycle (≥ 30 days).
Treatment of dysmenorrhoea should be
directed at providing relief from the cramp-
ing pelvic pain and associated symptoms.
Non-steroidal anti-inflammatory drugs and
oral contraceptives are reported as provid-
ing the most effective treatment [7]. The
use of oral contraceptives by unmarried
girls is, however, culturally unacceptable in
our traditional and conservative communi-
ty.
In our study, only 2.7% of adolescents
consulted a physician or pharmacist. This
is consistent with other findings that most
adolescents with dysmenorrhoea self-
medicate with the over-the-counter prepa-
rations; few consult health care providers
Table 4 Clinical presentation and treatment of
dysmenorrhoea among ever menstruating
adolescent students in Mansoura
Characteristic No. %
Severity
Mild 265 55.3
Moderate 143 30.0
Severe 71 14.8
Duration of pain
< 24 hours 311 64.9
24–48 hours 127 26.5
> 48 hours 41 8.6
Associated symptoms
a
None 114 23.8
Fatigue 339 70.8
Headache 297 62.0
Backache 272 56.8
Dizziness 144 30.1
Anorexia/vomiting 66 13.8
Abdominal distension/
bloating 39 8.1
Diarrhoea 18 3.8
Treatment
a
None 237 49.5
Rest/relaxation 204 42.6
Herbs/home remedies 166 36.7
Analgesics/NSAIDs/
antispasmodics
b
176 34.7
Total 479 74.6
a
Categories are not mutually exclusive.
b
Self-prescribed in 166 (97.3%).
NSAIDs = non-steroidal anti-inflammatory drugs.
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Eastern Mediterranean Health Journal, Vol. 11, Nos 1/2, 2005 161
[5,10]. We found that rest/relaxation, herb-
al/home remedies and/or drugs were used
by 42.6%, 36.7% and 34.7% of partici-
pants respectively. The drugs included an-
algesics, NSAIDs and antispasmodics,
mostly self-prescribed.
Banikarim, Chacko and Kelder reported
that treatment for dysmenorrhoea in His-
panic adolescents included rest (58%),
medication (52%), heating pad (26%), tea
(20%), exercise (15%) and/or herbs (7%)
[10]. It has been reported that the most
common medications used by women with
dysmenorrhoea were analgesics (53%) and
NSAIDs (42%) [17].
Although not life threatening, dysmen-
orrhoea can be particularly disruptive to a
woman’s daily life and productivity. In the
absence of appropriate pain relief, women
with severe dysmenorrhoea may not be
able to carry out their normal activities
[7,8].
In our study, 47.4% of students with
dysmenorrhoea reported no limitation of
daily activities. Activities most commonly
limited due to dysmenorrhoea were daily
home chores, going out of the home, par-
ticipation in social events, participation in
sports, concentration in class, homework
tasks and attending school. All the limita-
tions were significantly more frequent
among students with severe dysmenor-
rhoea compared to those with mild or mod-
erate pain. Banikarim, Chacko and Kelder
reported that activities limited by dysmen-
orrhoea among adolescents included con-
centration in class (59%), sports (51%),
class participation (50%), socialization
(46%), homework (35%), test-taking skills
(36%) and grades (29%) [10]. In a study in
Morocco, menstrual pain was often cited
as the main single cause of school absen-
teeism among adolescent girls [16].
Reproductive health information and
education programmes for adolescents are
being introduced in many countries, and
these could be an important means of pro-
viding information about treatment options
Table 5 Impact of dysmenorrhoea on daily activities
Activity limited
a
Dysmenorrhoea Total
χχ
χχ
χ
2
Mild Moderate Severe
No. % No. % No. % No. %
No limitation 169 63.8 56 39.2 2 2.8 227 47.4 89.0
Daily home chores 73 27.5 72 50.3 60 84.5 205 42.8 79.0
Going out of the home 60 22.6 71 49.7 68 95.8 199 41.5 128.6
Participation in social
events 51 19.2 66 46.2 70 98.6 187 39.0 152.5
Participation in sports 47 17.7 49 34.3 69 97.2 165 34.4 156.5
Concentration in class 28 10.6 32 22.4 57 80.3 117 24.4 147.9
Homework tasks 16 6.0 38 26.6 49 69.0 103 21.5 134.7
School attendance 13 4.9 41 28.7 43 60.6 97 20.3 116.4
Total 265 100 143 100 71 100 479 100
a
Categories are not mutually exclusive.
P < 0.001.
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for menstrual disorders [8]. Young girls
may be more open than older women to
discussing menstruation.
The introduction of a reproductive
health component into school health educa-
tion programme could help in providing in-
formation, education and support to
students regarding reproduction in general
and menstrual problems in particular. It is
essential to make treatment available for
girls. Many girls may feel shameful and re-
luctant to report dysmenorrhoea and con-
sequently, do not seek medical advice. It is
one of the roles of school health care pro-
viders to ask about and screen for dysmen-
orrhoea and offer treatment if necessary.
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Adolescent health and development
One in every five people in the world is an adolescent – defined by
WHO as a person between 10 and 19 years of age. Out of 1.2 billion
adolescents worldwide, about 85% live in developing countries and
the remainder live in the industrialized world. Adolescents are gen-
erally thought to be healthy: by the second decade of life, they have
survived the diseases of early childhood, and the health problems
associated with ageing are still many years away. Yet adolescents
are still a vulnerable sector of the population and many do die pre-
maturely. WHO, along with its partners, UNICEF and UNFPA, advocate
an accelerated approach to promoting the health and development
of young people in the second decade of life. Further information
on the work of the Adolescent Health and Development Team within
the WHO Department of Child and Adolescent Health and Develop-
ment is available at: http://www.who.int/topics/adolescent_health/
en/
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