{"paper_id":"5787d9eb-dde1-4d8c-81f7-98af61e32549","body_text":"Cyclic perimenstrual pain and discomfort and Australian women’s associated use of complementary and \nalternative medicine: a longitudinal study. \nCarole Fisher BSc \nLouise Hickman PhD \nJon Adams PhD \nDavid Sibbritt PhD \n \nCorresponding author –  Professor Jon Adams \n    Faculty of Health \n      University of Technology Sydney \n      Australia \nTel.:     +61 2 9514 4821 \nEmail:  Jon.Adams@uts.edu.au    \n    \n        \n \n \n \n \n \n \n \n \n \n \n \n \nA longitudinal analysis of CAM use and CPPD. \n  \n\nCyclic perimenstrual pain and discomfort and Australian women’s associated use of complementary and \nalternative medicine: a longitudinal study. \n \nAbstract \nObjective \nTo examine the longitudinal change in Australian women’s prevalence of cyclic perimenstrual pain and discomfort and \nthe association between their symptoms and use of complementary and alternative medicine (CAM). \nMethod \nData on endometriosis, premenstrual syndrome (PMS), irregular periods, heavy periods and severe period pain were \ncollected over a seven-year period from the Australian Longitudinal Study on Women’s Health, for women aged 28 to 33 \nyears in 2006, and at three year follow-ups.  Changes in symptoms and patterns of CAM practitioner and \ntherapy/product use associated with these symptoms were analysed using longitudinal regression modelling. \nResults \nOver the seven-year period, prevalence rates of PMS and heavy periods increased, whilst prevalence rates of \nendometriosis, irregular periods, and severe period pain remained stable. The most common use of CAM longitudinally \nassociated with the perimenstrual symptoms were use of vitamins/minerals, yoga/meditation, massage therapy, herbal \nmedicine and aromatherapy.  \nExcluding consultation with a naturopath/herbalist, over the 7-year survey women’s use of all other CAM practitioners \nincreased as did their use of vitamin/minerals, yoga/meditation and Chinese medicines, whilst aromatherapy use \ndeclined. \nConclusion \n\nOnly the prevalence of PMS and heavy periods increased with aging in this sample of women. Whilst overall use of CAM \npractitioner and self-prescribed products/therapies increased over time, CAM was chosen by women mainly to treat \nendometriosis and PMS. The extent to which this use reflects treatment efficacy is uncertain. \nKeywords: endometriosis, premenstrual syndrome, irregular periods, heavy periods, severe dysmenorrhoea, \ncomplementary and alternative medicine, longitudinal study.  \n\nCyclic perimenstrual pain and discomfort and Australian women’s associated use of complementary and \nalternative medicine: a longitudinal study. \nIntroduction \nIn 2002 the Association of Women’s Health, Obstetric and Neonatal Nurses organized the diverse symptoms associated \nwith perimenstrual symptoms into the concept of cyclic perimenstrual pain and discomfort (CPPD).1 This term \nencompasses a cluster of symptoms commonly experienced by many women which were  treated as single menstrual \nissues, predominantly premenstrual syndrome (PMS) and dysmenorrhoea.1  It is now well established that between 80-\n97% of women experience at least one CPPD symptom between ages 12-50 years. 2, 3 For some 40% of women the \nsymptoms are moderate2, for up to 10% they are severe enough to interfere with normal educational, professional \nand/or social functions according to their menstrual cycles.3 These life-changing disadvantages have serious \nramifications for a minority of women.3-6 Symptoms of CPPD, estimated to number over 300, may be ‘affective’ \n(emotional/mental such as irritability, anxiety and depression), physical (commonly breast tenderness, bloating, \nheadache and cramping) or a combination.1, 7 Symptom patterns may vary in nature, frequency, severity and/or over \ntime for each woman. Whilst disturbances in sex hormones and their effect on neurotransmission are implicated, no \nsingle aetiology satisfactorily explains all CPPD manifestations.2, 5, 8   \nComplementary and alternative medicine (CAM) is broadly defined by the World Health Organisation as those therapies \nnot routinely taught or used in conventional medical settings.9 CAM use has increased world-wide10, 11 with women \nidentified as predominant users.12-14 Conventional medical treatment for CPPD is wide-ranging and symptom-related, \nencompassing pharmaceutical, surgical and psychological treatments, none of which are wholly effective alone or in \ncombination1, 7, benefitting up to  60% of sufferers.15 Indeed, studies consistently indicate that most women with CPPD \nseek no medical help.16-18 At the same time various CAM clinical trials have reported benefits in  CPPD treatment \nincluding herbal medicine for PMS19, 20 and acupuncture21 and herbs for dysmenorrhoea.22 Data from 20 cross-sectional \nstudies conducted since 2007 indicate prevalence of CAM use for CPPD of between 7-70% (mean=30%).17, 23-41 Whilst \nthese studies represent a significant increase in research into CAM use for CPPD, the data lack coherence due to \nenormous variations in design and methodology. Additionally, few studies have tracked changes in CPPD symptoms with \naging and to-date none have examined CAM use over time amongst women experiencing CPPD. This present study \n\ninitiates the process of analysing age-related changes in CPPD and associated changes in CAM use, an important but \nunder-studied area of research. \nMaterials and Methods \nSample \nThe Australian Longitudinal Study on Women’s Health (ALSWH), initiated in 1996, aimed to assess and monitor women’s \nhealth, including their health-seeking behaviour using surveys conducted at 3-yearly intervals. Over 58,000 women in \nthree age groups (‘young’, 18-23 years; ‘mid-age’, 45-50 years; ‘older’, 70-75 years) were randomly selected from the \nnational Medicare database and invited by mail to participate. The current analysis was based on the ‘young’ cohort of \nwomen, born between 1973 and 1978, as they represented women in the middle of the menstruating period of their \nlives.  The baseline response rate for this cohort of 41-42% was estimated, due to uncertainty over the original Medicare \ndatabase’s accuracy42, however the demographic profile indicated responders were a  representative sample when \ncompared to 1996 census data.43  Data from surveys 4, 5 and 6, conducted in 2006, 2009 and 2012 respectively, \nobtained via questionnaires, were analysed. The response rates over the three surveys were 68% (n=9145) for survey 4 \nand 62% (n=8200) for surveys 5 and 6 (n=8010).  \nEthical approval for the ALWSH was granted by the Human Ethics Committee at the University of Queensland and \nUniversity of Newcastle and written consent was obtained from all participants. \nCyclic Perimenstrual Pain and Discomfort (CPPD) symptoms \nQuestions to participants included being diagnosed with endometriosis in the previous 3 years and the frequency of \nexperiencing the following undefined conditions, premenstrual tension, irregular periods, heavy periods and severe \nperiod pain for 12 months prior to each survey, using the grades ‘never’, ‘rarely’, ‘sometimes’ or ‘often’.  The term \n‘premenstrual tension’ has been used consistently in these surveys, its original reference relating to emotional changes \nthat occurred prior to menstruation. ‘Premenstrual syndrome’, suggested in 1953 to take into account the physical and \nbehavioural changes that also occur at this time, is the current terminology.44 \nComplementary and alternative medicine (CAM) use \n\nIn each survey, for the previous 12 month period, women were asked to respond to the question of whether they had \nconsulted with a chiropractor, osteopath, massage therapist, acupuncturist and/or naturopath/herbalist for their own \nhealth. Participants were also questioned about CAM therapy and products used for their own health in the previous 12 \nmonths. Specific categories listed were ‘vitamins/minerals’, ‘yoga/meditation’, ‘herbal medicines’, ‘aromatherapy oils’ \nand ‘Chinese medicine’; with answers graded by frequency of use as ‘never’, ‘rarely’, ‘sometimes’ or ‘often’.   \n \nConfounders \nThe demographic factors ‘area of residence’, ‘educational status’, ‘ability to manage on income’ , ‘marital status’, ‘body \nmass index’ (BMI)  calculated from height and weight, without shoes, ,’ parity’ based on live births, ‘stress’, ‘exercise \nlevel ’ , ‘contraceptive use’ (oral and/or implant) and ‘ethnicity’  as well as the co-morbidities ‘insulin-dependent (Type \n1) diabetes ’, ‘non-insulin dependent (Type 2) diabetes’, ‘low iron (iron deficiency or anaemia)’, ‘depression’, ‘anxiety \ndisorder’, ‘asthma’  and ‘hypertension (high blood pressure)’ were ascertained from the survey and identified as \npotential confounders. All co-morbidities were coded in the affirmative if diagnosed or treated in the previous 3 year \nperiod. Women who had been diagnosed with cancer in the previous three years, totalling 261 over the three surveys, \nwere excluded from all analyses as the disease and/or its treatment may have affected symptom reporting and CAM \nuse. \nArea of residence was categorised as either urban or rural. Educational status was categorised as: (1) ‘No formal \nqualifications’/’Year 10 or equivalent (e.g. School Certificate)’/ ’Year 12 or equivalent (e.g. Higher School Certificate)’; (2) \n‘Trade / apprenticeship’/ ‘Certificate/diploma’; and (3) ‘University/Higher university degree’.  Ability to manage on \navailable income was categorised as: (1) ‘It is impossible’/’It is difficult all of the time’; (2) ’It is difficult some of the \ntime’; and (3) ‘It is not too bad’/’It is easy’. Marital status was categorised as: (1) ‘Never married’; (2) ‘Married/De facto \n(opposite and same sex)’; and (3) ‘Separated/Divorced/Widowed’.  BMI was categorised as: \n1)’<18.5kg/m2’(underweight); (2) ‘18.5-<25.0kg/m2’ (normal); (3) ‘=>25-<30 kg/m2’(overweight); (4) ‘=>30 \nkg/m2’(obese). Parity was categorised as: (1) ‘none’; (2) 1-2; (3) 3 or more.  The mean stress level, defined, validated and \ncalculated by ALSWH, based on stress felt in the last 12 months around 11 life domain items was categorised as: (1) ‘Not \napplicable/Not at all stressed’; (2) ‘Somewhat stressed’; (3) ‘Moderately stressed’; (4) ‘Very stressed’; (5) ‘Extremely \nstressed’. Level of exercise was calculated using an algorithm based on time in last week spent in ‘Walking briskly’, \n\n‘Moderate leisure activity’ and ‘Vigorous leisure activity’ data, derived from Active Australia’s National Physical Activity \nSurvey, categorised as: (1) ‘Sedentary’; (2) ‘Low’; (3) ’Moderate’; (4) ‘High’. Current contraceptive use had a binary code, \nbased on a positive response to any of the following, ‘I use the oral contraceptive pill’ (survey 4) and ’I use a combined \noral contraceptive pill’/I use a progestogen only oral contraceptive pill/I use the oral contraceptive pill but I don’t know \nwhat type’ (surveys 5 &6) and/or ‘I use an implant’ (all surveys).  Ethnicity was categorised according to country of birth \nas: (1) ‘Australia’; (2) ‘Other English speaking background’; (3) ‘Europe’; (4) ‘Asia’ (excluding the Middle East); (5) ‘Other’. \n \n Statistical Analysis \nLongitudinal regression modelling was conducted using generalised estimating equations (GEEs). GEEs are an extension \nof generalised linear models that allow for the analysis of data longitudinally, thus reflecting the relationship between \nthe longitudinal development of the association between CPPD symptom and CAM practitioner or CAM therapy use in \nnon-pregnant respondents over the different survey timeframes, taking into account the significant confounding \nvariables identified. Analyses were achie ved using the statistical package STATA 14.0 and due to the large sample size, \nstatistical significance was set at p < 0.005. The Wald statistic was used to assess the fit of the multivariable models.  \nNo interactions were examined. \n \nResults \nThe prevalence rates for endometriosis (mean = 4.0%), irregular periods (mean = 20.9%) and severe period pain (mean = \n23.7%) recorded over the three surveys appeared largely unaffected by age change (Table 1). Prevalence of PMS was \nhighest in 2012, averaged 36.0% between 2006 and 2009 and rose to 41.4% in 2012. Similarly, the prevalence of heavy \nperiods showed little change between 2006 and 2009 (mean = 22.8 %) but increased to 29.9% by 2012. \n \nAll multivariate analyses were adjusted for co-morbidities of diabetes, hypertension, anaemia, asthma, depression, and \nanxiety and for demographics of area of residence, marital status, educational status, ability to manage on income, \nbody-mass index, parity, stress, exercise level, oral/implant contraceptive use and ethnicity. Over the seven year time \nperiod women with endometriosis were more likely to have consulted with a massage therapist (OR=1.26; 95% CI: 1.08, \n1.47), nearly twice as likely to have consulted with an acupuncturist (OR=1.88; 95% CI: 1.51, 2.35) and over 50% more \n\nlikely to have consulted a naturopath/herbalist (OR=1.54; 95% CI: 1.26, 1.88), compared to women who had not been \ndiagnosed with endometriosis (Table 2).  \nStatistically significant associations were found between PMS and consultation with a naturopath/herbalist only. \nSpecifically, these consultations were more likely for women who sometimes (OR=1.23; 95% CI: 1.09, 1.40) or often \n(OR=1.48; 95% CI: 1.27, 1.74) suffered PMS, compared to non-sufferers (Table 2). \nWomen who had irregular periods were no more likely to have consulted with any CAM therapist compared to those \nwho never had irregular periods whilst those who often had heavy periods were less likely to consult with an osteopath \n(OR=0.64; 95% CI: 0.49, 0.83) compared to those who never had heavy periods.  Women who sometimes had severe \nperiod pain were less likely to consult with a naturopath/herbalist (OR=0.78; 95% CI: 0.67, 0.91) than those women who \nreported they never had this symptom. \nThe likelihood that any woman consulted with a CAM practitioner increased from 2006 to 2009 for a chiropractor \n(OR=1.25; 95% CI: 1.15, 1.36), an osteopath (OR=1.64; 95% CI: 1.42, 1.90), a massage therapist (OR=1. 36; 96% CI: 1.27, \n1.46) and/or an acupuncturist (OR=1.84; 95% CI: 1.59, 2.12). In 2012, across the cohort, the likelihood of CAM \npractitioner consultation increased for a chiropractor (OR=1.28; 95% CI: 1.17, 1.41), an osteopath (OR=1.71; 95% CI: \n1.48, 1.98), a massage therapist (OR=1.41; 95% CI: 1.30, 1.52) and/or an acupuncturist (OR=1. 59; 95% CI: 1.37, 1.85) \ncompared to 2006 data. The prevalence data for use of CAM practitioners by women with CPPD in 2012 showed that a \nchiropractor, an osteopath, a massage therapist, an acupuncturist and a naturopath/herbalist had been visited by 0.9%, \n0.4%, 1.9%, 0.6% and 0.7% respectively by women with endometriosis; 8.4%, 3.8%, 18.8%, 4.3% and 5.8%  respectively \nfor women who sometimes or often had PMS;  4.8%, 1.7%, 10.0%, 2.2% and 3.1%, respectively for those who \nsometimes or often had irregular periods; 5.8%, 2.5%, 12.5%, 2.8% and 4.0% respectively  for those who sometimes or \noften suffered heavy periods and 4.8%, 2.2%, 10.4%, 2.6% and 3.1% respectively for those who sometimes or often \nreported painful periods (Table 3). \nWomen with endometriosis were significantly more likely to have used vitamins/minerals (OR=1.40; 95% CI: 1.17, 1.67), \nyoga/meditation (OR=1.35; 95% CI: 1.13, 1.60), herbal medicines (OR=1.34; 95% CI: 1.13, 1.60) and Chinese medicines \n(OR=1.99; 95% CI: 1.53, 2.58) compared to those without endometriosis (Table 4).  \n\nCompared to never sufferers of PMS those who rarely had symptoms were more likely to use herbal medicines \n(OR=1.21; 95% CI: 1.09, 1.34), with the likelihood increasing for sometimes sufferers (OR=1.33; 95% CI: 1.21, 1.48). \nWomen who reported they sometimes experienced PMS were also more likely to have used yoga/meditation (OR=1.16; \n95% CI: 1.05, 1.28) and aromatherapy (OR=1.26; 95% CI: 1.14, 1.40) than those who never had PMS. Most CAM \ntherapies/products were more likely to be used by women who reported having PMS often compared to those who \nnever suffered; specifically vitamins/minerals (OR=1.21; 95% CI: 1.08, 1.37), yoga/meditation (OR=1.27; 95% CI: 1.12, \n1.45), herbal medicines (OR=1.48; 95% CI: 1.30, 1.69), and/or aromatherapy (OR=1.26; 95% CI: 1.11, 1.44). \nWomen who indicated sometimes or often having had irregular periods or heavy periods were not more or less likely to \nuse any CAM therapies/products. Women who often suffered severe period pain were more likely to use aromatherapy \n(OR=1.34; 95% CI: 1.13, 1.58) compared to those who had not suffered from severe period pain. \nFrom 2006, for all women, the likelihood increased in 2009 and 2012 of using vitamins/minerals (OR=1.21; 95% CI: 1.13, \n1.31) and (OR=1.26; 95% CI: 1.15, 1.37) respectively, yoga/meditation (OR=1.15; 95% CI:1.05,1.26) and (OR=1.21; 95% \nCI:1.10,1.32) respectively and Chinese medicines (OR=1.61; 95% CI: 1.35, 1. 93) and (OR=1.49; 95% CI: 1.24, 1.79) \nrespectively. Herbal medicine use increased slightly in 2009 only, when compared to 2006 (OR=1.17; 95% CI:1.08, 1.28). \nHowever, for aromatherapy this likelihood decreased in 2009 (OR=0.83; 95% CI: 0.76, 0.90) and declined still further in \n2012 (OR=0.70; 95% CI: 0.64, 0.77), compared to 2006. Prevalence data showed that vitamins/minerals, yoga \n/meditation, herbal medicines, aromatherapy and Chinese medicines were used by 2.9%, 1.3%, 1.1%, 0.7% and 0.4% \nrespectively by women with endometriosis. For those women who sometimes or often had PMS the respective \nprevalences of use were 29.7%, 10.9%, 10.2%, 8.3% and 2.7%; for those who sometimes or often had irregular periods \nthese were 15.8%, 5.5%, 5.3%, 4.0% and 1.6%; for those who sometimes or often suffered heavy periods these were \n20.9%, 7.1%, 7.2%, 5.8% and 1.8% and for those who sometimes or often reported painful periods these were 17.3%, \n6.2%, 6.2%, 5.4% and 1.6% (Table 5). \nDiscussion \nOur study, based on a large, representative sample of young Australian women, was the first as far as we are aware, to \nhave analysed changes of CAM use in relation to various menstrual problems spanning the age range from 28-33 years \nthrough to 34-39 years.  CAM use by women suffering CPPD reflected the general growth in interest and information \n\nregarding CAM, much likely derived from non-professional sources45, over a seven year timeframe and represents \nimportant data for health care providers and policy makers.46 \nOur findings confirmed the high prevalence and consequent significance of CPPD for women’s health previously \nreported.1, 3, 47 Data from our young cohort, aged over the seven year time–frame, represent a valuable insight into \npossible changes in CPPD with age during this relatively young period of women’s lives but  as previous studies have \nlargely employed longer time frames corroboration awaits further research. \nPrevalence of CPPD \nAcross 2006 to 2012 the consistent prevalence of endometriosis (mean=4.0%) accords with a reported level of 4.8%46, \nhowever the choice for a diagnosis made in the previous 3 years rather than the currently accepted 5-year span  may \nhave under-estimated its prevalence and may complicate comparisons. Whilst not equivocal the relationship between \nincreasing age and endometriosis according to recently published data suggest no correlation exists.48   \nOur cohort’s prevalence of irregular periods (mean=20.9%) accorded with a reported level of 25.6%49 again showing no \nconsistent age-related trend. Menstrual cycle irregularity may decrease with age49 although a large European study \nfound a consistent  prevalence across age groups, rising after 42 years of age, around peri-menopause.50  \nSevere dysmenorrhoea levels over the three surveys in our study appeared unaffected by aging, the mean=23.7% \ncompared to 2-29%  previously reported.51  Dysmenorrhoea has a high prevalence in under 30-year olds usually \ndiminishing with age.51 Variations in definition of ‘severity’, (‘interfering with daily activity or efficiency’52, ‘activity \ninhibited and lack of relief from analgesics’6, ‘absenteeism from work’53)  and reliance on subjective pain assessment \ncomplicates comparisons across studies relating age to dysmenorrhoea severity.51 In addition, the scant published data \non severe dysmenorrhoea reported largely on younger women than our cohort. Nevertheless,  factors such as parity, \nage at menarche, lifestyle and weight appear to be significant determinants of changes in dysmenorrhoea, prevalence \nbeing age-related for women under 30 years old, a group mostly younger than our cohort.52, 6, 54, 55 A longitudinal US \nstudy into dysmenorrhoea in women comparable in age with our cohort estimated severe dysmenorrhoea prevalence at \n2%, and whilst it declined with age, again parity was a more significant factor.52  \nWith regard to prevalence of heavy periods, a systematic review estimated this ranged between 10-30%56, consistent \nwith our mean of 25.2%. We found menorrhagia prevalence increased with age,  supported by a French College of  \n\nObstetricians and  Gynaecologists guideline review suggesting a prevalence peak of 24%  in women aged 36-40 years.57  \nPooled data from a systematic review of PMS prevalence, averaged it at 47.8%,  albeit with an extremely broad range \n(10 -98%).58 This average is higher than that found in our surveys, 2006 and 2009, but comparable with the 41.4% \nreported by the 2012 survey. Scant current prevalence data exists relating PMS to ageing but reported  patterns of \nhigher PMS levels with age59, 60 and a recent, large general population study of UK women aged 12-50 years having a \npeak prevalence in the 35-39 year age-group61 support our observed age increase.  \nCAM use and CPPD  \nOver time, our study found women with endometriosis may have been more likely to visit a massage therapist, an \nacupuncturist and/or a naturopath/herbalist and with the exception of aromatherapy, may also have been more likely \nto have used all CAM and in particular Chinese medicine, compared to those without endometriosis. Scientific validation \nexists for benefits from acupuncture62 and Chinese herbal medicine63, 64 in treating pain and poor fertility associated \nwith endometriosis, but none to-date for therapeutic massage or naturopathic/western herbalist treatment. However a \nsmall cross-sectional study into endometriosis associated leg pain found 79%, 67% and 50% of women using massage, \nacupuncture and herbs respectively reported improvement in pain level.26     \nFrom our analysis, women with PMS appeared more likely, over time, to visit a naturopath/herbalist compared with \nnon-sufferers.  Compared to non-sufferers of PMS, women who sometimes experienced PMS were also more likely \nusers of yoga/meditation, herbal medicine or aromatherapy, but those often suffering PMS increased their use of all \nCAM self-help therapies and products surveyed except Chinese medicines. CAM  clinical trials have indicated \nsupplements (calcium, magnesium65 and fish oils 66 ), herbs (Vitex agnus castus)65,  yoga67 and aromatherapy \n(lavender)68 are potentially helpful for PMS. Whilst evidence exists that Chinese herbal medicine may be beneficial 69 ,  \nusers of this CAM with PMS  in our study were too few to indicate a significant association. General support for the \nefficacy of CAM in treating PMS has been reported in previous surveys where between 37-97% women estimated an \nimprovement in symptoms.70-74  Indirect support for individual CAM modalities in PMS treatment  exists from cross-\nsectional studies where women reported using osteopathy74, chiropractic74, vitamins/minerals39, 70-73, 75-77, massage29, 70, \n75, 76, yoga/meditation70, 76, Chinese herbs72, acupuncture72, aromatherapy72 and western herbs39, 72, 76 for symptom relief. \nMore research into these CAM as treatment approaches appears warranted.  \n\nNo published clinical evidence relates efficacy of CAM treatment to irregular periods, although national Taiwanese \nhealth database records cited ‘menstruation disorders’ amongst the main reasons for prescribing Chinese herbal \nmedicine.78 Our study found no positive association of CAM use with irregular menses or heavy periods. The physical \nand social discomfort associated with heavy periods may account for the reduced likely visit of women who often \nexperience them to an osteopath, with a non-significant trend away from other forms of CAM that require particular \ndress codes and/or need for personal interaction such as massage therapy, chiropractic, acupuncture and yoga/ \nmeditation. Previous studies on women with self-reported menorrhagia79 and/or gynaecological problems associated \nwith heavy bleeding including general pelvic problems24 and  fibroids31,36, 37, 80, found an associated use of a variety of \nCAM including herbs, acupuncture, dietary supplements and Chinese medicine. Our analyses did not reflect this. \nThe relative lack of CAM use by those in our cohort with either irregular periods and/or heavy periods may be due to \nlack of knowledge in Australia about their potential benefits as in countries where CAM is part of mainstream health \nprovision, such as Taiwan and Korea, there is a strong traditional use and acceptance of Chinese medicine to treat these \nproblems.33, 47 In addition, unlike PMS and dysmenorrhoea which occur commonly, both cycle irregularity and \nmenorrhagia may be perceived as having potentially serious underlying pathologies81, 82 and/or consequences for \nconception and vitality for which diagnosis and treatment are regarded as more appropriately dealt with through \nconventional medicine.  \nScientific evaluation of CAM for dysmenorrhoea is sparse, but support does exist for  yoga83, herbs84 , aromatherapy22  \nand Chinese herbal medicines.27, 85 Cross-sectional studies suggest women use vitamins and minerals17, 24, herbs17, 24, 30, 32, \n33, 41, 47 and massage28, 40 regardless of scientific validation. Our study showed no associated CAM use by women with \ndysmenorrhoea except an apparent reduction in association between dysmenorrhoea sometimes experienced and visits \nwith a naturopath/herbalist.  This finding contrasted with more widespread CAM use for endometriosis sufferers \nbecause although dysmenorrhoea is a predominant symptom it is secondary to the disease whereas primary \ndysmenorrhoea may be normalised in menstruation and therefore tolerated16 and/or treated using non-CAM self-help \nremedies such as hot drinks, heat and exercise.17, 24, 40, 70 The only CAM therapies and products associated with \ndysmenorrhoea experienced often was the use of aromatherapy, a practice for which some clinical evidence exists.86  \nRegular, monthly severe pain relief may be considered too expensive for regular CAM practitioner treatment and given \n\nits uncertain aetiology self-treatment with a wide-range of both non-pharmacological and pharmacological strategies is \nknown to commonly occur.16, 72  \nPrevalence of CAM use   \nFrom 2006 to 2012 the significant increased visits to a chiropractor, an osteopath and an acupuncturist, by all women in \nour study, may relate to their subsidized coverage by Medicare and private health insurers to which an increasing \nnumber of Australians have subscribed.87, 88 Referrals from medical practitioners to osteopaths, chiropractors, \nacupuncturists and massage therapists88, 89, the relative decreased cost from 2007 to 2012 for chiropractor visits87, \nincreased practice of both acupuncture and massage therapy by medical  professionals88,90 and the high accessibility of \nmassage therapists who far outnumber other CAM therapists91 are also likely to have increased their uptake.  \nOver the study period visits decreased overall by 13% to a naturopath/herbalist, a practitioner-based CAM requiring \neither private health insurance or out-of-pocket funding in Australia and for which over-the-counter products are easily \nself-prescribed. Against this background, women with endometriosis and/or PMS in our study were more likely to have \nincreased their visits to a naturopath/herbalist compared to women not suffering these symptoms, strongly suggesting \nsignificant treatment benefits associated with women receiving this professional guidance. An anomalous UK finding \nnoting prescription-related PMS diagnoses by general practitioners decreased four-fold between 1993-1998, whilst PMS \nwas the second most common condition treated by UK herbalists in 1998, led its authors to suggest women were by-\npassing conventional medicine in favour of CAM treatment.92 An updated survey showed levels of conventional \nprescriptions in the UK for CPPD-related problems were still declining 61,indicating women may be continuing to self-\ntreat or to seek help beyond conventional medicine. It is possible that herbal medicine has been an effective option for \nPMS, explaining its increased uptake. Whilst aromatherapy use declined substantially over the timeframe of our study, \nthis was not mirrored by women suffering PMS, suggesting it too may be an effective treatment. Clearly more research \nis needed into the role of these CAM in PMS treatment. \nAccording to data from our study, the use of self-prescribed CAM was higher than the use of CAM practitioner services, \nbehaviour identified elsewhere.13,76,78 Chinese medicine practitioners’ registration by the Australian government in \n200593, officially ‘recognising’ this modality, may explain our finding that Chinese medicine use increased. \n\nAcupuncture use is possibly under-reported in our data. Two-thirds of Chinese Medicine Board of Australia registered \npractitioners use acupuncture with Chinese herbal medicine, a category not identified in ALSWH surveys. Additionally \nother practitioners such as osteopaths,  chiropractors, medical doctors and physiotherapists also administer \nacupuncture but may have been unidentified by survey respondents  as acupuncture-orientated visits.94 \nHealth policy implications \nCAM use is higher amongst chronic ill-health sufferers, women and those whose medical problems are not well \naddressed by conventional treatment.95 Women suffering CPPD clearly satisfy these criteria and are likely to continue \nusing CAM. Medical reviews acknowledge that CPPD treatment is largely functional or symptomatic relying on hormone \nreplacement therapy, surgery, angiogenesis inhibitors, immune modulators, anti-depressants and/or analgesics with \nlimited efficacy, possible side-effects and most importantly perhaps, for this cohort, are often unsuitable for women \nintending to conceive.96, 97 Over 300 treatment strategies are currently offered by conventional health practitioners for \nCPPD indicating their complexity and individual nature.7, 92 At the same time traditional Chinese27, 78 and Western \nconventional medical practitioners recommend CAM such as vitamin B6, herbal, homeopathic and nutritional \nsupplements, to their CPPD patients.70, 72, 92, 98 It is therefore in the interest of women, health providers and health policy \nmakers to investigate the role of CAM in this significant area of women’s health.  \nStudy limitations \nWhen interpreting these study findings, readers should be mindful of some limitations. Whilst the demographic profile \nof ‘young’ age participants initially recruited by ALWSH was considered representative when compared to 1996 \nconsensus data it is possible, due to the relatively poor retention rate from the original sample, that some bias has been \nintroduced and that our cohort may be viewed as unrepresentative thereby reducing the generalizability of our results \nand possibly distorting prevalence of CPPD data and the associated CAM use.  Retrospective reporting by ALSWH \nparticipants regarding both CPPD symptoms and CAM use raises possible recall bias. Reporting of CPPD symptoms was \nsubjective and the lack of standardised instruments and CAM terminology in the surveys may have resulted in \nclassification errors and difficulties in cross study comparisons. In particular PMS was used interchangeably with PMT \nwhich may have led to its under-estimation or incorrect classification.  Also, the use of other contraceptive devices and \nmedications that could potentially alter menstrual symptoms could not be assessed as these data were not collected. \nSome response bias is recognised in baseline recruitment because women with tertiary education were over-\n\nrepresented and some ethnic groups under-represented. Due to lack of relevant data the study was unable to track \ndirect changes in CPPD symptoms after CAM use. However, the large, representative sample and data tracking this \nimportant timeframe in women’s reproductive lives provide strong support for the validity of our findings.  \nConclusion \nLarge numbers and proportions of women suffer CPPD with prevalence of PMS and heavy periods apparently increasing \nwith age. This study demonstrates many women with CPPD symptoms are self-medicating, using a range of CAM, \npossibly without professional oversight. Increasing use of specific CAM by women with CPPD from 2006 to 2012 \nsuggests some CAM has untapped potential to significantly benefit these prevalent, disruptive health problems. Given \nthe large cost to women, their families and society it is important for health carers and policy makers to gain \ninformation into the types of alternative treatments being adopted, their efficacy and risk factors. CAM is a promising \narea of treatment for chronic CPPD and there is much to be gained by further research. \nEthics approval and consent to participate \nEthical approval for the ALSWH was gained from the Human Ethics Committees at the University of Queensland and \nUniversity of Newcastle. The study participants provided written consent. \nAcknowledgements \nWe are grateful to Professor Gita Mishra for reviewing the manuscript and to all the women who provided the survey \ndata. \nFunding \nThe ALSWH is funded by the Department of Health and Ageing, Australian Government (DOHA). \nAuthor Disclosure Statement \nNo competing financial interests exist.\n\nReferences \n \n1. Sharp BA, Taylor DL, Thomas KK, Killeen MB, Dawood MY. Cyclic perimenstrual pain and discomfort: the \nscientific basis for practice. Journal of obstetric, gynecologic, and neonatal nursing : JOGNN / NAACOG. \n2002;31(6):637-649. \n2. Milewicz A, Jedrzejuk D. Premenstrual syndrome: From etiology to treatment. Maturitas. 11/1/ 2006;55, \nSupplement 1:S47-S54. \n3. Wittchen HU, Becker E, Lieb R, Krause P. Prevalence, incidence and stability of premenstrual dysphoric \ndisorder in the community. Psychological Medicine. 2002;32(1):119-132. \n4. Nevatte T, O’Brien P, Bäckström T, et al. 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Archives of Gynecology and Obstetrics. 2013;288(3):569-576. \n98. Gordon NP, Sobel DS, Tarazona EZ. Use of and interest in alternative therapies among adult primary care \nclinicians and adult members in a large health maintenance organization. Western Journal of Medicine. \n1998;169(3):153-161. \n \n \n \n \n \n\n \n \n Professor Jon Adams \n    Faculty of Health \n      University of Technology Sydney \n      Australia \nTel.:     +61 2 9514 4821 \nEmail:  Jon.Adams@uts.edu.au    \n \n \n  \n\n Table 1. The Prevalence of Menstrual Problem in non-pregnant women in 2006, 2009 and \n2012. \n  \n  \nMenstrual Problem \n \nSurvey 4 (2006) \n(n=9145) \n \nSurvey 5 \n(2009) \n(n=8200) \n \nSurvey 6 \n(2012) \n(n=8010) \n    \nEndometriosis    \nSample size 7704 6835 7340 \nPrevalence (%) 3.8 4.4 3.7 \nPMS    \nSample size 8105 7286 7426 \nPrevalence (%) 36.9 35.0 41.4 \nIrregular periods    \nSample size 8109 7267 7429 \nPrevalence (%) 21.1 19.3 22.2 \nHeavy periods    \nSample size 8108 7267 7438 \nPrevalence (%) 23.1 22.5 29.9 \nSevere period pain    \nSample size 8117 7279 7436 \nPrevalence (%) 24.7 22.2 24.2 \n \n \n \nPMS – premenstrual syndrome. \n\n**PMS (premenstrual syndrome) - the emotional, physical and behavioural changes that occur in the luteal phase of menstruation and which subside with the onset of, or after, \nmenstruation.  \n \nTable 2. The odds ratio* for association of cyclic perimenstrual pain and discomfort and consultations with complementary and alternative \nmedicine  practitioners. \n \nCyclic Perimenstrual Pain and \nDiscomfort Symptom \n \nChiropractor \n \nOsteopath \n \nMassage Therapist \n \nAcupuncturist \n \nNaturopath/herbalist \n \nOdds Ratio (C.I.) \n(n=9719) \n \nOdds Ratio (C.I.) \n(n=9716) \n \nOdds Ratio (C.I.) \n(n=9717) \n \nOdds Ratio (C.I.) \n(n=9717) \n \nOdds Ratio (C.I.) \n(n=9716) \nEndometriosis \nNo (reference) \nYes C,D,E \n \n1.00 \n1.21 (1.01,1.43) \n \n1.00 \n1.13 (0.86,1.48) \n \n1.00 \n1.23 (1.07,1.43) \n \n1.00 \n1.97 (1.59,2.44) \n \n1.00 \n1.54 (1.27,1.87) \nPMS** \nNever (reference) \nRarely \nSometimes C,E \nOften C,E \n \n1.00 \n1.03 (0.93,1.13) \n0.97 (0.89,1.07) \n0.95 (0.84,1.08) \n \n1.00 \n1.14 (0.98,1.32) \n1.02 (0.88,1.19) \n1.27 (1.04,1.54) \n \n1.00 \n1.11 (1.02,1.19) \n1.14 (1.06,1.23) \n1.25 (1.12,1.38) \n \n1.00 \n1.07 (0.93,1.25) \n1.11 (0.96,1.28) \n1.28 (1.07,1.55) \n \n1.00 \n1.15 (1.02,1.31) \n1.30 (1.15,1.47) \n1.60 (1.38,1.86) \nIrregular cycle \nNever (reference) \nRarely \nSometimes E \nOftenE \n \n1.00 \n0.94 (0.85,1.04) \n1.08 (0.98,1.21) \n0.95 (0.83,1.08) \n \n1.00 \n1.00 (0.85,1.18) \n0.91 (0.76,1.09) \n1.03 (0.84,1.26) \n \n1.00 \n0.95 (0.87,1.03) \n1.06 (0.97,1.16) \n0.99 (0.89,1.10) \n \n1.00 \n1.07 (0.91,1.25) \n1.04 (0.88,1.23) \n1.17 (0.97,1.41) \n \n1.00 \n1.06 (0.93,1.22) \n1.25 (1.09,1.42) \n1.28 (1.10,1.49) \nHeavy periods \nNever (reference) \nRarely \nSometimes  \nOften B,C \n \n1.00 \n1.02 (0.92,1.13) \n0.96 (0.86,1.08) \n0.90 (0.77,1.05) \n \n1.00 \n0.86 (0.73,1.02) \n0.82 (0.68,0.98) \n0.64 (0.49,0.82) \n \n1.00 \n0.97 (0.89,1.06) \n0.91 (0.83,1.00) \n0.80 (0.70,0.91) \n \n1.00 \n0.96 (0.82,1.14) \n0.85 (0.71,1.02) \n0.76 (0.60,0.95) \n \n1.00 \n0.95 (0.83,1.10) \n1.00 (0.86,1.15) \n0.90 (0.75,1.09) \nPainful periods  \nNever (reference) \nRarely C \nSometimes  \nOften  \n \n1.00 \n0.99 (0.90,1.10) \n1.07 (0.95,1.21) \n0.98 (0.82,1.16) \n \n1.00 \n1.01 (0.86,1.18) \n1.02 (0.84,1.24) \n1.38 (1.07,1.78) \n \n1.00 \n1.13 (1.04,1.22) \n1.03 (0.94,1.14) \n1.09 (0.95,1.25) \n \n1.00 \n1.13 (0.97,1.32) \n1.11 (0.92,1.32) \n1.30 (1.02,1.65) \n \n1.00 \n0.98 (0.86,1.11) \n0.83 (0.71,0.96) \n1.13 (0.93,1.37) \nTime \nSurvey 4 (reference) \nSurvey 5 A,B,C,D \nSurvey 6 A,B,C,D,E \n \n1.00  \n1.20 (1.12,1.28) \n1.34 (1.25,1.43) \n \n1.00 \n1.39 (1.24,1.57) \n1.65 (1.46,1.84) \n1.00 \n1.15 (1.09,1.22) \n1.22 (1.15,1.29) \n1.00 \n1.45 (1.28,1.63) \n1.48 (1.31,1.66) \n1.00 \n0.91 (0.83,1.00) \n0.85 (0.78,0.94) \n \nA statistically significant association with chiropractor                                          D statistically significant association with acupuncturist \n B statistically significant association with osteopath   E statistically significant association with naturopath/herbalist \n C statistically significant association with massage therapist  \n \n*Adjusted for co-morbidities of diabetes, hypertension, anaemia, asthma, depression, anxiety and cancer and for demographics of area of residence, marital status, educational status \nand ability to manage on income.  All models have a Wald statistic p value <0.005. \n \n \n\nTable 3. Prevalence of cyclic perimenstrual pain and discomfort symptom and use of complementary and alternative medicine \npractitioners in 2012. \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n  \nCyclic Perimenstrual \nPain and Discomfort \nSymptom \nChiropractor Osteopath \n \nMassage therapist Acupuncturist Naturopath/Herbalist \nNo \n(n=5,980) \nYes \n(n=1,493) \nNo \n(n=6,849) \nYes \n(n=624) \nNo \n(n=4,305) \nYes \n(n=3,168) \nNo \n(n=6,799) \nYes \n(n=674) \nNo \n(n=6,628) \nYes \n(n=845)  \n % % % % % % % % % % \nEndometriosis \nNo \nYes \n \n77.3 \n2.8 \n \n19.0 \n0.9 \n \n88.3 \n3.3 \n \n \n8.0 \n0.4 \n \n \n55.9 \n1.8 \n \n40.5 \n1.9 \n \n87.8 \n3.1 \n \n \n8.5 \n0.6 \n \n \n85.6 \n3.0 \n \n10.7 \n0.7 \nPMS  \nNever \nRarely \nSometimes \nOften \n \n \n30.3 \n16.7 \n22.5 \n10.5 \n \n7.2 \n4.4 \n5.8 \n2.6 \n \n34.7 \n19.3 \n26.0 \n11.6 \n \n2.8 \n1.8 \n2.4 \n1.4 \n \n22.9 \n12.0 \n15.7 \n6.9 \n \n14.6 \n9.1 \n12.7 \n6.1 \n \n34.7 \n19.2 \n25.5 \n11.6 \n \n2.8 \n1. 9 \n2.8 \n1.5 \n \n34.2 \n19.0 \n24.9 \n10.7 \n \n3.2 \n2.2 \n3.5 \n2.3 \nIrregular Periods \nNever \nRarely \nSometimes \nOften \n \n \n49.0 \n13.5 \n10.3 \n7.2 \n \n12.3 \n2.9 \n3.0 \n1.8 \n \n56.0 \n15.1 \n12.3 \n8.3 \n \n5.3 \n1.3 \n1.0 \n0.7 \n \n35.4 \n9.8 \n7.1 \n5.2 \n \n25.9 \n6.6 \n6.2 \n3.8 \n \n56.0 \n14.9 \n12.1 \n8.0 \n \n5.2 \n1.6 \n1.2 \n1.0 \n \n55.0 \n14.5 \n11.5 \n7.7 \n \n6.2 \n2.0 \n1.8 \n1.3 \nHeavy Periods \nNever \nRarely \nSometimes \nOften \n \n42.4 \n13.6 \n15.0 \n9.0 \n \n10.3 \n3.9 \n3.5 \n2.3 \n \n48.1 \n16.2 \n16.9 \n10.5 \n \n4.5 \n1.3 \n1.6 \n0.9 \n \n30.4 \n9.7 \n10.6 \n6.8 \n \n22.2 \n7.8 \n7.9 \n4.6 \n \n48.0 \n16.0 \n16.8 \n10.2 \n \n4.7 \n1.5 \n1.7 \n1.1 \n \n47.4 \n15.4 \n16.2 \n9.7 \n \n5.2 \n2.1 \n2.3 \n1.7 \nPainful Periods \nNever \nRarely \nSometimes \nOften \n \n \n42.5 \n17.9 \n13.2 \n6.3 \n \n10.6 \n4.7 \n3.1 \n1.7 \n \n48.8 \n20.8 \n14.9 \n7.2 \n \n4.3 \n1.8 \n1.4 \n0.8 \n \n31.5 \n12.4 \n9.2 \n4.5 \n \n21.7 \n10.3 \n7.0 \n3.4 \n \n48.8 \n20.5 \n14.7 \n7.0 \n \n4.3 \n2.1 \n1.6 \n1.0 \n \n47.7 \n19.9 \n14.5 \n6.6 \n \n5.4 \n2.8 \n1.7 \n1.4 \n\nTable 4. The odds ratio* for association between cyclic perimenstrual pain and discomfort and use of complementary and alternative \nmedicine therapies and products. \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nA statistically significant association with vitamins/minerals D statistically significant association with aromatherapy oils  \nBstatistically significant association with yoga or meditation E statistically significant association Chinese medicines       \nCstatistically significant association with herbal medicines  \n \n*Adjusted for co-morbidities of diabetes, hypertension, anaemia, asthma, depression and anxiety and for demographics of area of residence, marital status, educational status, ability \nto manage on income, body-mass index, parity, stress, level of exercise, oral/implant contraceptive use and ethnicity. All models have a Wald statistic p value <0.005. \n \n**PMS (premenstrual syndrome) - the emotional, physical and behavioural changes that occur in the luteal phase of menstruation and which subside with the onset of, or \nafter, menstruation.  \n \n \nCyclic Perimenstrual Pain \nand Discomfort Symptom \n \nVitamins/minerals \n \nYoga/meditation \n \nHerbal medicines \n \nAromatherapy \n \nChinese medicines \n \nOdds Ratio (C.I.) \n(n=9268) \n \nOdds Ratio (C.I.) \n(n=9267) \n \nOdds Ratio (C.I.) \n(n=9264) \n \nOdds Ratio (C.I.) \n(n=9264) \n \nOdds Ratio (C.I.) \n(n=9263) \nEndometriosis \nNo (reference) \nYesA,B,C,E \n \n1.00 \n1.43 (1.19,1.71) \n \n1.00 \n1.33 (1.12,1.59) \n \n1.00 \n1.34 (1.12,1.59) \n \n1.00 \n1.12 (0.93,1.35) \n \n1.00 \n1.98 (1.51,2.59) \nPMS**  \nNever (reference) \nRarelyC, \nSometimes,B,C,D \nOften A,B,C,D \n \n1.00 \n0.96 (0.88,1.04) \n1.04 (0.95,1.13) \n1.21 (1.08,1.37) \n \n1.00 \n1.08 (0.98,1.20) \n1.16 (1.05,1.28) \n1.27 (1.11,1.45) \n \n1.00 \n1.21 (1.09,1.35) \n1.34 (1.21,1.49) \n1.49 (1.30,1.69) \n \n1.00 \n1.09 (0.98,1.21) \n1.28 (1.15,1.41) \n1.27 (1.11,1.45) \n \n1.00 \n1.17 (0.95,1.43) \n1.19 (0.98,1.45) \n1.32 (1.04,1.69) \nIrregular Periods  \nNever (reference) \nRarely  \nSometimes  \nOften  \n \n1.00 \n1.08 (0.98,1.18) \n1.11 (1.00,1.23) \n1.10 (0.98,1.25) \n \n1.00 \n0.98 (0.88,1.09) \n1.13 (1.01,1.27) \n1.02 (0.89,1.17) \n \n1.00 \n1.03 (0.93,1.15) \n1.07 (0.95,1.20) \n1.08 (0.94,1.23) \n \n1.00 \n1.04 (0.93,1.16) \n1.09 (0.98,1.23) \n0.95 (0.83,1.09) \n \n1.00 \n1.04 (0.84,1.28) \n1.29 (1.05,1.59) \n1.21 (0.95,1.54) \nHeavy Periods  \nNever (reference) \nRarely \nSometimes \nOften  \n \n1.00 \n1.02 (0.93,1.13) \n0.95 (0.86,1.06) \n0.91 (0.79,1.05) \n \n1.00 \n1.01 (0.90,1.12) \n0.99 (0.88,1.12) \n0.85 (0.72,1.00) \n \n1.00 \n0.97 (0.87,1.09) \n1.04 (0.92,1.17) \n1.05 (0.90,1.23) \n \n1.00 \n0.97 (0.87,1.09) \n0.93 (0.83,1.05) \n0.91 (0.78,1.07) \n \n1.00 \n1.01 (0.81,1.25) \n0.88 (0.70,1.10) \n0.84 (0.63,1.13) \nPainful Periods  \nNever (reference) \nRarely \nSometimes \nOften D \n \n1.00 \n0.90 (0.83,0.99) \n0.96 (0.86,1.07) \n0.96 (0.82,1.12) \n \n1.00 \n0.97 (0.88,1.08) \n1.00 (0.89,1.13) \n1.24 (1.05,1.47) \n \n1.00 \n0.97 (0.87,1.08) \n0.96 (0.85,1.09) \n1.19 (1.00,1.40) \n \n1.00 \n1.02 (0.91,1.13) \n1.10 (0.97,1.24) \n1.33 (1.13,1.58) \n \n1.00 \n1.07 (0.87,1.31) \n1.05 (0.83,1.33) \n1.47 (1.09,1.99) \nTime \nSurvey 4 (reference) \nSurvey 5 A,B,C,D.E \nSurvey 6 A,B,D,E \n \n1.00 \n1.21 (1.12,1.31) \n1.25 (1.15,1.36) \n \n1.00 \n1.16 (1.06,1.27) \n1.20 (1.10,1.32) \n \n1.00 \n1.18 (1.08,1.29) \n1.06 (0.97,1.17) \n \n1.00 \n0.83 (0.76,0.91) \n0.70 (0.64,0.77) \n \n1.00 \n1.63 (1.36,1.95) \n1.51 (1.26,1.81) \n\nTable 5. Prevalence of cyclic perimenstrual pain and discomfort symptom and use of complementary and alternative medicine  \ntherapies and products in 2012. \n \n \n \n \n \nCyclic Perimenstrual \nPain and Discomfort \nSymptom  \nVitamins/Minerals Yoga/Meditation \n \nHerbal medicines Aromatherapy oils Chinese medicines \nNo \n(n=2,384) \nYes \n(n=5,043) \nNo \n(n=5,713) \nYes \n(n=1,714) \nNo \n(n=5,927) \nYes \n(n=1,500) \nNo \n(n=6,224) \nYes \n(n=1,203) \nNo \n(n=7,024) \nYes \n(n=403) \n % % % % % % % % % % \nEndometriosis \nNo \nYes \n \n \n31.2 \n0.8 \n \n65.1 \n2.9 \n \n74.5 \n2.4 \n \n21.8 \n1.3 \n \n77.1 \n2.6 \n \n19.2 \n1.1 \n \n80.8 \n3.0 \n \n15.5 \n0.7 \n \n91.2 \n3.3 \n \n5.1 \n0.4 \nPMS  \nNever \nRarely \nSometimes \nOften \n \n \n13.1 \n7.3 \n8.3 \n3.4 \n \n24.3 \n13.9    \n20.1 \n9.6 \n \n29.9 \n16.5 \n21.4 \n9.1 \n \n7.5 \n4.7 \n7.1 \n3.8 \n \n31.6 \n17.1 \n21.9 \n9.3 \n \n5.8 \n4.1 \n6.5 \n3.7 \n \n32.7 \n18.0 \n23.0       \n10.1 \n \n4.7 \n3.2 \n5.4 \n2.9 \n \n35.7 \n20.1 \n26.8 \n12.0 \n \n1.6 \n1.1 \n1.7 \n1.0 \nIrregular Periods \nNever \nRarely \nSometimes \nOften \n \n \n20.6 \n5.0 \n3.8 \n2.7 \n \n40.6 \n11.5 \n9.6 \n6.2 \n \n47.4 \n12.8 \n9.8 \n6.9 \n \n13.9 \n3.7 \n3.5 \n2.0 \n \n49.8 \n13.1 \n10.1 \n6.9 \n \n11.4 \n3.4 \n3.2 \n2.1 \n \n51.9 \n13.6 \n11.0 \n7.3 \n \n9.3 \n2.9 \n2.4 \n1.6 \n \n58.3 \n15.6 \n12.4 \n8.3 \n \n2.9 \n0.9 \n0.9 \n0.7 \nHeavy Periods \nNever \nRarely \nSometimes \nOften \n \n \n17.6 \n5.5 \n5.6 \n3.4 \n \n35.0 \n12.0 \n12.9 \n8.0 \n \n40.8 \n13.3 \n14.1 \n8.7 \n \n11.8 \n4.2 \n4.5 \n2.6 \n \n43.2 \n13.9 \n14.4 \n8.3 \n \n9.4 \n3.6 \n4.1 \n3.1 \n \n45.0 \n14.6 \n15.0 \n9.1 \n \n7.6 \n2.9 \n3.5 \n2.3 \n \n49.9 \n16.6 \n17.6 \n10.5 \n \n2.7 \n0.9 \n1.0 \n0.8 \nPainful Periods \nNever \nRarely \nSometimes \nOften \n \n \n17.5 \n7.6 \n4.8 \n2.1 \n \n35.6 \n15.1 \n11.4 \n5.9 \n \n41.6 \n17.4 \n12.3 \n5.7 \n \n11.6 \n5.2 \n3.9 \n2.3 \n \n44.0 \n17.9 \n12.5 \n5.5 \n \n9.1 \n4.8 \n3.7 \n2.5 \n \n45.9 \n19.0 \n12.9 \n6.0 \n \n7.2 \n3.6 \n3.4 \n2.0 \n \n50.6 \n21.4 \n15.3 \n7.3 \n \n2.5 \n1.3 \n0.9 \n0.7","source_license":"public-domain-us","license_restricted":false}