Menstruation marks an important milestone in women^,s reproductive and endocrine health. Although it is a natural phenomenon many girls face problems of menstruation such as irregular bleeding, excessive bleeding, and painful menstruation¹. Painful menstruation or dysmenorrhea is a common gynecologic disorder among young females. It is defined as pelvic pain directly related to menstruation and is associated with various other symptoms. Dysmenorrhea is classified into two categories: primary when pelvic examination and ovulatory function are normal and secondary when there is an identifiable gynecological pathology. Primary dysmenorrhea characteristically begins when adolescents attain their ovulatory cycles; generally, within the 1st year after menarche^2,3.

Dysmenorrhea is considered the most common symptom of all menstrual complaints and poses a greater burden of disease than any other gynecological complaint in developing countries⁴. Pain or cramping sensations in the lower abdomen may be accompanied by headaches, dizziness, diarrhea, a bloated feeling, nausea and vomiting, backache, and leg pains^5,6. The high prevalence of dysmenorrhea among adolescents (50%–70%)^6,7,8, especially in the 1st year of their reproductive life influences their daily activities,^1,5,9,10 and is thus a major public health problem^7,8.

Although menstrual irregularity can be normal during the first few years after menarche, other menstrual signs and symptoms such as amenorrhea, excessive uterine bleeding, dysmenorrheal, and premenstrual syndrome may indicate a pathological condition which requires prompt attention and referral⁷.

Despite being the common gynaecological problem, there are limited studies in and around Aligarh. It’s unclear to what extent young girls are bearing severity of dysmenorrhoea. Hence this study is done to estimate the magnitude of dysmenorrhoea.

AIMS & OBJECTIVES:

The study aims to assess the prevalence of primary dysmenorrhoea, evaluate associated risk factors and self-management techniques practiced among adolescent girls in Aligarh.

MATERIAL AND METHODS:

The present study was a Community based Cross-Sectional study conducted in Secondary and higher Secondary Schools (Girls) of Aligarh Muslim University (AMU), Aligarh. The study was conducted among the students of class 6th to 12thstandard from each of the university girl schools namely Senior Secondary School Girls, AMU Girls High School and AMU ABK High School (Girls) using systematic random sampling with population proportionate to size.

The sample size was calculated by using the single population proportion formula with the assumptions of 95% confidence interval (CI), 5% margin of error, the anticipated prevalance 50%¹¹, and 10% non response rate. Based on this, our final calculated sample size was 420. For the selection of 422 students, the Population proportionate to size technique was used to calculate the required sample from each of the school and respective classes. Out of total of 422, 97 girls were taken from Senior Secondary school girls, 200 from AMU Girls High school and 125 from AMU ABK High school Girls. In different classes, every 8th (sampling interval) student was taken. In case that student was absent then the next one was taken.

All students studying in class 6th to 12th standard from the selected schools and had attained menarche as well as a student who gave consent were included in study whereas students who were absent on the day of data collection were excluded from the study.

A pre-designed and pretested questionnaire was used for data collection in a face to face interview. Weight and height was used to calculate Body mass index (BMI) using formula BMI = weight in Kg/height in m2. BMI was classified into four groups based on the cut off points recommended by World Health Organization¹². Pattern of menstruation was assessed by length of menstrual cycle and duration of menstruation. Cycle with an average rhythm of 28±7 days and 3-6 days of bleeding is a regular menstruation¹³. Pictorial blood assessment chart was used to assess heavy menstrual bleeding¹⁴.  Numerical Pain Rating Scale was used in the study to grade intensity of pain in dysmenorrhoea¹⁵. It is developed by Mc Caffery M, Pasero C.  It is an 11-point scale for self-reporting of pain consisting of vertical or horizontal line that is anchored by number 0 on the bottom or left side and number 10 on the top or the right side. 0 indicates no pain and 10 indicates worst pain imaginable.

Data were entered and analyzed using  (IBM SPSS version 20 Armonk, NY) Descriptive statistics such as frequency and percentages for categorical variables were used. Both bivariate and multivariable logistic regression analyses (backward stepwise) were used to determine factors associated with premenstrual syndrome. P ≤ 0.05 was considered statistically significant

The study was approved by Institutional Ethics Committee, JNMCH, AMU, Aligarh. In addition written informed consent from the participating schools and informed oral assent was taken from all the participants, after explaining the purpose of the study and prior consent from parents was taken.

RESULT:

Table 1 shows the socio-demographic details of study subjects. Majority of the respondents, (54.0%), were aged between 10-14 years, while remaining in the age range of 15-19 years (46.0%). Nearly one-third of the respondents were students of class 6th to 8th  (33.6%) while the remaining students were studying in 9th -10th  (41.5%) and 11th -10th  (24.9%). Almost two-fifth of respondents, mother (41.2%) had completed graduation while 29.1% of respondents mother were educated till high school. 75% of the mother were housewife while 25% were working. Again two-fourth of respondents father(41.2%) had completed graduation. Majority of respondents father (39.3%) belong to service class. Majority of study participants were in the normal BMI range (53.1%) while one-fourth of population i.e. 113 (26.8%) were underweight as per WHO Classification.

Table 1: Background characteristics of study population:

Table 2: Menstruation related Information

Table 3: Distribution of adolescent girls based on dysmenorrhoea characteristic

Table 4: Bivariate and multivariable analysis of risk factors associated with dysmenorrhea

Table 5: Self- Management techniques to get pain relief

*Multiple response

As per table 2, more than one-third (36.5%) of the respondents experienced early menarche, before celebrating their 12th birthday. Out of the total study population, 63(14.9%) girls had a menstrual cycle length shorter than 21 days, 119 (28.2%) had cycle longer than 35 days and 240(56.9%) had a cycle length between 21 and 35 days. Majority 259(50.9%) of the subjects experienced normal duration of bleeding (3-5 days), 37(8.8%) reported shorter duration of bleeding (<3 days) and 126(29.9%) had longer duration of bleeding (>5 days). It was observed that majority 237(56.2%) experienced regular cycle while 185(43.8%) reported irregular cycle. Nearly one-third (33.6%) of the participant reported heavy bleeding during menstruation.

In Table 3, information related with dysmenorrhoea is presented. Dysmenorrhoea was reported by 180 (42.7%) of the study population. Out of 180 girls who complained of dysmenorrhoea, 58.3% had most severe pain on first day, 21.5% on second day, 22.7% on one day before menstruation and 13.3% on any other day. Regarding location of pain, most of the girls (33.3%) were having lower abdomen, back and leg pain, 27.8% were having lower abdomen and back pain and 25% had pain in lower abdomen. As per numerical pain rating scale, 80(44.5%) girls reported moderate pain while  30.5%  and 25% had mild and severe pain respectively. Dysmenorrhoea affected daily routine activities of 38.9% of the females and 34.4% complained of disturbance in sleep. Dysmenorrhoea affected academic performance of 91% of the students in various ways. Most of the girls (44.5%) felt weak and tired, 32.2% complained of lack of concentration, 14.4% girls preferred school absenteeism. 8.9% girls reported no effect on academics due to dysmenorrhea

During the multivariate analysis of Dysmenorrhoea in relation to all exploratory variables, only six of the most contributing factors remained to be statistically significant and independently associated with the presence of dysmenorrhoea (at 0.05 level of significance). In this study, the existence of dysmenorrhoea had a statistically significant association with low income, AOR (95%CI) 2.85(1.51-5.35), underweight , AOR (95% CI) 3.19(1.74-5.84), early menarche AOR (95%CI)  3.11(1.29-7.49), longer duration of menses (>5 days), AOR (95%CI) 3.37(1.19-6.49), heavy menstrual bleeding AOR (95% CI) 2.06(1.25-3.41)  and irregular cycle, AOR (95% CI) 1.64(1.02-2.64) (Table 4). Cox and Snell R2 was 0.2 and Nagelkerke R2 was 0.3.

Of various self management techniques opted by study groups, 51% took bedrest, 18.3% opted for hot applications, 10% took help of massage, 25.1% opted medicine to get relief from pain while 22.3% did not take any measure as showed in table 5

DISCUSSION:

This study aimed to determine prevalence of dysmenorrhoea, risk factors contributing to dysmenorrhoea, pain severity and different management practices. This study has established certain risk factors associated with dysmenorrhoea.

The current study showed the prevalence of dysmenorrhoea was relatively high (42.7%) among school going adolescent girls of Aligarh. This result was in agreement with the 45% among young college nursing students in vadodara by shah et al¹⁶, 46.8% by Rana et al¹⁷ in Gujrat, 49.13% by Mohite et al¹⁸ in Maharastra. Another cross-sectional study among chinese female university students in Hunan, China reported prevalence of 41.7%¹⁹. However, in our study population, the prevalence was lower than 78.2% in Mysore²⁰, 67.2% in Delhi²¹, 85.1% in Ethiopia²², 89.1% in Iran²³. The variations of prevalence rates of dysmenorrhea across the world may be due to absence of a standardized definition of Dysmenorrhoea and objective assessment methods used to determine this condition, ethnic and sociocultural factors of study population.

More than two third of the girls (69.5%) described their dysmenorrhea as moderate to severe. Pain is extremely subjective symptom and it has been very difficult to quantify pain. In our study, it was revealed that 30.5%, 44.5% and 25% of girls had mild, moderate and severe pain, respectively. In a study conducted by Ortiz in 1539 students of Mexican University, author concluded that dysmenorrhea was mild in 36.1%, moderate in 43.8% and severe in 20.1%²⁴. Maitri shah et al., have found that 18%, 40% and 42% of students had mild, moderate and severe pain respectively²⁵. This indicates dysmenorrhea is still an important public health problem which may have a negative impact on health, social environment, academic performance and psychological status.

Primary dysmenorrhoea usually begins at either the first day of menstruation or the day before²⁶. In our study majority of girls (58.3%) reported pain on first day of menses. As far as effect of pain on academics was concerned, majority complained of weakness and tiredness (44.5%) and lack of concentration (32.2%).  The current finding was supported by an exploratory survey conducted by Anil K Agarwal²⁷ and a descriptive survey by George et al²⁸.

Our study showed that risk of dysmenorrhoea is more in low income group. This was consistent with other studies that have shown that socioeconomic status influences the severity of menstruation pain^29,30. For instance, a study performed in 581 women aged 18-45 years in central North Carolina indicated that low income increased the development of dysmenorrhea and dyspareunia³¹.

Another student among 440 female university students showed that the risk of PD was nearly 5 times higher among students whose monthly income was less than 9 USD than those whose monthly income was greater than 18 USD³². In contrast, a prospective study conducted in 823 enrolled Japanese women reported no distinct relationship between dysmenorrhea and household income³³. The mixed results could be explained by the differences in the study population and different definitions of various economic situations and require further understanding.

According to our study girls with early menarche and irregular cycle are at risk of dysmenorrhoea. Chauhan et al in Karnataka reported a significant association between age of menarche and dysmenorrhoea³⁴. Omidvar et al found that higher percentage of girls who encompassed menarche at an earlier age experienced dysmenorrhoea more than those who had late menarche²⁰. However, Pawlowski et al did not find any difference in the ages of menarche between dysmenorrheic and non‑dysmenorrheic girls³⁵. A systematic review that included 63 studies and 64,286 women showed that earlier menarche and an irregular cycle increased the risk of dysmenorrhea by 54% and 102%, respectively³⁶. Although the underlying etiologic mechanisms of these associations are not well understood, the mechanism is probably related to ovulatory efficiency, higher levels of uterine activity during menstruation, and the increased production of uterine PGs^37,38

Our study showed that adolescent girls who were underweight were associated with increased risk of dysmenorrhea compared with those who had a normal BMI. These results are compatible with other research findings ^39,34. A meta-analysis that included 5 trials showed that a BMI of less than 20 increased the risk for dysmenorrhea by 42%³⁶. However, the association between BMI and Dysmenorrhoea is still controversial. Many studies have revealed no relationship between BMI and dysmenorrhea,^33,40 whereas other studies have shown an increased prevalence of PD in overweight or obese subjects^41,42. Despite that the pathophysiological mechanisms are still unclear, a possible hypothesis is that a lower amount of body fat affects normal ovulation and menstrual cycles and thus leads to excessive release of prostaglandin (PGs) which results in dysmenorrhoea⁴³.

Menstrual bleeding duration of 5 days and over was an important risk factor for dysmenorrhoea. Bleeding duration was found to be significantly associated with dysmenorrhea in the present stud. This finding is compatible with the result showing that the risk of dysmenorrheal is higher in women with long menstrual flows^44,45.

CONCLUSION:

To conclude, dysmenorrhea is found to be highly prevalent among school going girls. Dysmenorrheal pain  may affect the daily activities and academic performance of the students. Findings suggest low income, underweight, early menarche, long menstrual bleeding, irregular cycle and heavy menstrual bleeding  as significant risk factors for dysmenorrhea in these girls. Majority of girls were suffering from dysmenorrhea indicating the magnitude of problem and thus, need an appropriate medical intervention and lifestyle modification.

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