{"paper_id":"912e8337-a94f-4d22-9ec0-fb30ad480df4","body_text":"Self-help and Prescription Therapies for Menstrual Burden in a \nUniversity Population \n \nZimberg SE,1,2 Castejon AM,2 del Mazo N,3 Murphy C.1,2 \n \n1AutoNation Institute of Breast Cancer and Care, Nova Southeastern University, Fort Lauderdale, FL  \n33314 \n2Barry and Judy Silverman College of Pharmacy, Nova Southeastern University, Fort Lauderdale, FL. \n33314 \n3Department of Gynecology, Cleveland Clinic Florida, Weston, FL.  33331 \n \nCorresponding author:  Stephen E Zimberg, MD, MSHA, MCST, PhD (candidate).  Sz312@nova.edu. \n \nAbstract: \n \nBackground \nIt is known that cyclic menstruation imposes significant burdens on a large portion of the \nfemale population with a plethora of symptoms, including pelvic pain, dysmenorrhea, \nmenorrhagia, and psychological distress.  The effects are widespread, impacting the \nquality of life, ability to work and function, finances, and education.  For the most part, \nprevious studies have been surveys administered through social media channels such \nas pelvic pain and endometriosis societies, which, by definition, introduce bias.  There is \na need to evaluate the female population regarding female health issues in a less \nbiased manner to assess the actual disease burden and response. \n \nMethods \nA cross-sectional, IRB-approved study of the Nova Southeastern University \nundergraduate (2022) and graduate female population cohort was conducted using a \nself-administered, anonymous survey to assess the prevalence of menstrual pain and \ndisability (menstrual burden).  This included the use of prescription and non-prescription \nmedications, self-help interventions, and cannabis use (either medicinal or recreational) \nfor symptoms associated with menstruation.  All students who identify as female at the \nuniversity were invited via campus email to participate in this survey, hosted securely on \nthe SurveyMonkey website.  One initial invitation was sent, followed by two reminder \ninvitations at 2-week intervals.  A descriptive analysis was performed. \n \nResults \n14,024 email invitations were sent to the entire university population that identified as \nfemale to the registrar, with a response rate of 15.8% (similar to the response rate in \nmost university surveys at this institution).  18.23% of the cohort reported bleeding that \nrestricted the student’s ability to function, and 13.2% were so severely affected by \nmenstrual symptoms that bed rest was required to cope adequately.  Primary symptoms \nof bloating/swelling/constipation were reported in over 77%, mood swings/moodiness in \napproximately 74%, and pelvic or back pain was noted in over 70% of the respondents. \nIn an assessment of treatment regimens, approximately 80% used over-the-counter \nmedications, 55% reported using heating pads, 25% used oral contraceptive products, \n29.6% engaged in exercise or meditation, and fully 14.76% used cannabis in its various \n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\nforms as treatment adjuncts (in addition to other regimens). In the evaluation of multiple \nefficacies, the respondents reported that 72% of those that used OTC medications for \nrelief found them very or moderately effective, 66.2% of those that used a heating pad \nfound it very or moderately effective, 54.2% of those that used exercise and meditation \nfound it very or moderately effective, and cannabis was found to be very or moderately \neffective by 82% of the cohort that reported using it as an adjunct.  Unexpectedly, there \nwere some racial/ethnic differences in disease burden, the types of treatment modalities \naccessed, and perceived effectiveness.  There were minimal differences between age \ngroups. \n \nConclusion \nMenstruation in female college students represents a significant challenge for 40.2% of \nthis South Florida population, causing moderately severe to extremely severe \nsymptoms. This study supports previous findings by Schoep\n2 on the impact of \nmenstruation on the quality of life of Dutch women and by Munro’s global systematic \nreview\n3, which documented a significant menstrual burden and its implications for \neducation.   We found a high burden among college women when the entire female \nuniversity population was invited to participate in this survey.  This study’s emphasis on \nthe menstrual burden and its impact on quality of life expands on previous studies. Our \nresults should pave the way for a policy review of how the menstrual burden is \napproached in university settings, particularly regarding efforts to encourage gender \nequality. \n \n \nIntroduction \n \nAs of 2021, there were approximately 2 billion girls and women of reproductive age \n(ages 14 to 50) worldwide.1  Monthly menstruation imposes significant burdens with a \nplethora of symptoms, including pelvic pain, dysmenorrhea, menorrhagia, and \npsychological distress affecting a large portion of this population.  The effects are \nwidespread, impacting the quality of life, ability to work and function, finances, and \neducation.  A recent Dutch study (Schoep et al. 2019)\n2 explored the impact of menstrual \nsymptoms among 42,879 subjects who were reached through social media over a \nseveral-month period in 2017, using a cross-sectional survey. The mean age of \nrespondents was 28.7 years (SD 8.6), and 96.8% were Dutch.  The most common \ncomplaints were abdominal pain during the period (87.4%), perimenstrual psychological \ncomplaints (77.3%), and tiredness (70.7%), with heavy bleeding, back pain, and \nheadache accounting for 53.7%, 59.2%, and 56.2% respectively, significantly affecting \nthe respondents’ quality of life.  More than 33% of the women were limited in their \nfunctioning during menstruation, and the annual costs surpassed $2,000 (US) per \npatient, primarily secondary to lost work and productivity. \n \nTo contextualize the effects of menstruation on university students, Munro et al. (2021)\n3 \nconducted a systematic review (83 studies included) of the respondents’ experiences \nand the impact on education worldwide.  In general, they reported negative experiences \nprimarily from dysmenorrhea, difficulties containing the menstrual flow, and the shame \n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \n\nand stigma associated with the flow. Most respondents reported missing school, poor \nsocial engagement, and decreased academic performance monthly.  Some societies \n(very few) reported positive experiences in reinforcing womanhood, though many cited \na lack of sanitary utilities to accommodate personal care of the menstrual flow.  \nBecause studies have indicated that improved education is linked to stronger \neconomies in which women work and to improved social and family standing, \ndocumenting the barriers contributing to their failure is a public policy imperative.\n4  \n \nOne of the common disease states impacting menstrual burden is endometriosis.  \nEndometriosis is a disease affecting up to 10% of reproductive-age women, sometimes \ncausing diffuse and often severe pelvic pain and dyspareunia. The prevalence can \nreach 50% in women with a history of infertility.\n5  The disease is defined as the \npresence of endometrial tissue located outside the uterine cavity. It can involve the \novaries, bladder, rectum, pelvic peritoneum, and even distant areas such as the bowels \nand lungs. The varying locations are responsible for the multitude of disparate \nsymptoms (primarily pain) and infertility.6  The global endometriosis market is forecast to \nreach $2.42 billion by 2026, encompassing medical, holistic, and surgical treatments. \nThe market is projected to grow significantly during the forecast period, with one notable \nfactor being the rising incidence of the condition.7  Treatment for the disease is \ndependent on the severity of the disease, symptoms, and the patient’s desire to have \nchildren. Medication is usually tried first when pain is the primary problem; however, \nmedical treatment (such as Non-Steroidal Anti-Inflammatory Drugs - NSAIDs) is often \ninsufficient to treat the symptoms, and therefore, hormonal and/or surgical intervention \nis required.\n8 \n \nIn the general population, it is estimated that between 16% and 91% of women \nexperience pelvic pain and dysmenorrhea (painful menses) regularly.9  There have \nbeen several exploratory studies in the recent past, notably in Europe, South Africa, \nAustralia, and New Zealand, regarding self-treatment and management of \nendometriosis and menstrual-associated pelvic pain. Armour et al. (2019) reported on \nself-management strategies among Australian women with endometriosis.\n5 Of the 484 \nusable responses documenting self-management of symptoms, 70% used heat (heating \npads), 68% used bodily rest, 47% used meditation and breathing, and 14% and 13% \nused alcohol and cannabis, respectively. Of all the various interventions, women in this \nstudy rated cannabis with tetrahydrocannabinol (THC) as the most effective adjunctive \ntherapy, with 56% able to reduce their endometriosis medications by more than 50%. \nOnly 1/3 of CBD (cannabidiol) users achieved a 50% reduction of medications, and the \neffectiveness of the other interventions ranked far behind cannabis and CBD.\n5 Recent \nsystematic reviews of the effectiveness of dietary interventions on endometriosis and \npelvic pain showed positive effects. Still, the assessment of bias risk was high.10  \nSimilarly, though women widely practice changes in lifestyle for the treatment of \nmenstrual pain and endometriosis, the world’s scientific literature is conflicting on its \nvalue.\n11  Several studies based on surveys indicate that cannabis with THC, more so \nthan CBD, may also be helpful in the treatment of pain associated with \nendometriosis.\n12,13  Additionally, recent reviews have focused on the endocannabinoid \nsystem as a primary nexus of the pain and other symptoms associated with menstrual \n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \n\npain and endometriosis: nociceptive, inflammatory, and neuropathic. This implies that \ncannabis may play a significant role in the treatment of endometriosis with fewer side \neffects compared to conventional treatment and possibly delay the need for invasive \nmanagement (Ahmad 2021, p. 344-345), and is complemented by the expression of \ncannabinoid receptors, hormones, enzymes, and ligands.\n13,14  The endocannabinoid \nsystem (ECS) modulation then presents a reasonable strategy to combine all the factors \nabove to treat the symptoms of menstrual pain and endometriosis. Cannabis is a readily \navailable modulator that can then be used as an adjunct treatment.  \n \nThe purpose of this study is to evaluate the current state of menstrual burden and \nadjunctive therapeutic modalities in a college-age cohort, including cannabis, to \nameliorate the symptoms of menstruation, menstrual pain, and endometriosis, and to \nassess the perceived effectiveness of said interventions.  Most previous studies have \nused social media-based tools through websites dedicated to menstrual pain and \nendometriosis, which, by design, can introduce an inherent bias into the findings.  A \n2021 study from six Fellowship of Minimally Invasive Gynecologic Surgery sites (AAGL) \ndocumented that patients with gynecologic pain were more likely than those without \npain to use social media and the internet to understand and manage their condition. \nPatients with pain engaged in and trusted social media at a higher level, with \nengagement rising directly with the menstrual burden.\n15  Additionally, the placebo effect \nand media expectations of efficacy weigh heavily in studies assessing the effectiveness \nof cannabis therapy for pain.\n16  Although bias can never be eliminated, using an entire \nuniversity cohort that identifies as female should mitigate much of it and is a unique \napproach among current studies.  We documented a high menstrual burden on the \nfemale university population when the entire female university college student body was \ninvited to respond, rather than focusing on pain and endometriosis groups from social \nmedia platforms.   \n \n \nMethods \n \nStudy Design \nThis is a cross-sectional study of the Nova Southeastern University undergraduate and \ngraduate female population cohort using an anonymous survey to collect data about the \nprevalence of menstrual pain and disability, as well as the use of various treatment \nmodalities, including cannabis (either medicinal or recreational) for pelvic pain \nassociated with cyclic menstruation and endometriosis.  The study was approved by the \nNova Southeastern University Institutional Review Board (Study on Women's Menstrual \nSymptoms and Treatment– NSU IRB Protocol Number 2021-544). It also explored the \ndosage forms and formulations used, as well as the perceived effectiveness of the \ndifferent modalities in relieving symptoms. This was a 12-question survey taking less \nthan 5 minutes (average 3 minutes) to complete online. All students who identified as \nfemale to the university registrar were invited via campus email to participate in this \nsurvey, hosted securely on SurveyMonkey.  One initial invitation was sent, followed by \ntwo reminders sent at 2-week intervals.  The survey stopped collecting responses on \n2/15/22. \n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \n\n \nNSU had 20,888 students enrolled for the 2021-2022 academic year (of whom 6,314 \nwere undergraduates, and 14,574 were graduate students). The number of graduate \nand undergraduate students varies significantly on the university website. Of the total \nenrollment (20,888), 70% were female, and 30% were male (2.3 to 1 ratio).\n17  The \nracial/ethnic breakdown was 6,447 Hispanic, 6,105 White, 3,676 Black or African \nAmerican, 1,752 Asian, 938 International, 1,057 Unknown, 577 Multi-ethnic, 24 Native \nAmerican or Pacific Islander.  Of note, the NSU student population does not mirror the \nUS general population in terms of race and ethnicity, though practical conclusions can \nstill be drawn from this cohort.\n18  The survey is included as Addendum 1 at the end of \nthis manuscript after the references.  The enrollment statistics were from self-\nidentification to the university registrar. \n \nInclusion/Exclusion Criteria \nAll subjects were included if they were female graduate or undergraduate students at \nNSU between the ages of 18 and 50 who responded to the survey. As an enrolled NSU \nstudent, it was assumed that the subjects had access to a computer and basic English \nproficiency.  No one who responded was excluded from the analysis. \n \nRecruitment and Data Collection \nSubjects were recruited via an online letter explaining the purpose of the study, sent via \nthe university email system to graduate and undergraduate students, with an email link \nto a secure SurveyMonkey data collection form. Response reminders were sent twice to \nencourage participation. Results were collected anonymously using SurveyMonkey \nforms that offered secure socket layer encryption. The survey link was closed after two \nmonths, and the results were analyzed. A contact email was provided to subjects for \nquestions, and options were offered to receive an executive summary after publication \nof the results. Results are stored securely on the Survey Monkey site. No personal \nidentification was collected; only general demographics were collected. \n \nOutcomes \nThis survey provides insight into the prevalence and degree of menstrual burden, \nmenstrual symptom treatment preferences, and cannabis use as an adjunct for treating \nmenstrual pain in female college students. It also assesses the prevalence of cannabis \ninhalation (smoking and vaping), edibles (gummies, foods, beverages), topical (cream, \ngel, patch), and other (spray, suppository) for treatment. Formulation data were \ncollected on THC-dominant, CBD-dominant, and balanced THC/CBD mix popularity, \nand the perceived efficacy of various adjuncts noted in previous papers, including \ncannabis, for relieving symptoms, such as pelvic pain, cramps, bloating, and fatigue. \nDemographic information was collected to assess racial/ethnic differences in use and \nthe perceived effectiveness of the various modalities used for relief.  \n \n \nResults \n \n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \n\nAn invitation to complete the 12-question survey (with an embedded link) was sent to all \ngraduate and undergraduate students who identify as female at Nova Southeastern \nUniversity (n=14,024). The university sent 14,024 invitations from its separate \nenrollment records, which are 1.7% higher than what is published on the university \nwebsite.  This was over a 7-week span in January and February of 2022.  Reminder \nletters were sent two weeks and four weeks after the initial request. There were 2,216 \nresponses for a total response rate of 15.8%.  A review of the University’s response to \nits annual surveys has hovered around 16% (personal communication, NSU Office of \nInstitutional Effectiveness), which is comparable to this survey experience.  There was \nan immediate response on the first day after the email invitation was sent, then a rapid \ndrop-off over the following week, as seen in Figure 1.  The initial response was 7.9% on \nthe day following the initial invitation, followed by 4.2% on the day following the first \nreminder, and 3% on the day following the second reminder, as seen below. \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 . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \n\nFigure 1\n \n \nFigure 1.  Display of survey responses by date, with January 2 corresponding to the initial email survey \nrequest, January 16th to the second reminder, and January 30th to the third reminder.  The responses a \nweek out from each are also listed.  4 responses came in late, bringing the total to 2216. \n \nDemographics \n \nThe responses were divided into graduate (59.38%) and undergraduate (40.61%), as \nshown in Table 1 below. \n \n \n \n \n \n \n \n \n \n \n \n \nTable 1 \nResponses vs. Date\nResponses\n0\n200\n400\n600\n800\n1000\n1200\n1110\n40\n594\n26\n419\n23\nJanuary 2 January 9 January 16 January 23 January 30 February 6\nDate\nResponses\n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \n\nAcademic Level of Respondents \nEducation Level of \nRespondents \nRaw Response Number Percent of Responses \n(n=2238) \nUndergraduate Freshman 275 12.29% \nUndergraduate \nSophomore \n199 8.89% \nUndergraduate Junior 221 9.87% \nUndergraduate Senior 214 9.56% \n1st Year Graduate School 475 21.22% \n2nd Year Graduate School 418 18.68% \n3rd Year Graduate School 210 9.38% \n4th Year Graduate School 118 5.27% \nBeyond 4th Year (PG5-\nPG7) \n108 4.83% \nTotal 2,238 99.99% \n \nTable 1.  Breakdown of academic levels among all respondents.  Nova Southeastern University \ncurrently has 6,314 undergraduate and 15,531 graduate students (the total graduate varies on the \nuniversity website from 14,574 to 15,531), making up the total student body for a 1 to 2.3 ratio \n(undergraduate to graduate).  Survey responses were 40.61% undergraduate and 59.38% graduate, for a \n1:1.46 response ratio.  The differences between the total responses in Figure 1 and Table 1 reflect \nvariations in responses to the various questions. \n \nFrom an age perspective, 81.96% of the respondents were under 30.  This reflects the \nnature of the university undergraduate and graduate students, with younger \nrespondents making up the bulk.  The breakdown is shown in Table 2. \n \n \n \n \n \n \n \n \n \n \n \n     \n \n \n \n \n \n \n \n \n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \n\nTable 2 \n    Age Distribution of Respondents \nAge Range of \nRespondents \nRaw Response Number Percent of Responses \n(n=2216) \n17 to 20 579 26.13% \n21 to 25 838 37.82% \n26 to 30 399 18.01% \n31 to 35 146 6.59% \n36 to 40 90 4.06% \n41 to 45 73 3.29% \n46 to 50 45 2.03% \n51 and over 46 2.08% \nTotal 2,216 100.01% \n \nTable 2.  The age distribution of the respondents.  81.96% were age 30 or younger.  There are 22 fewer \nrespondents to this query than to the Academic Level question in Table 1. \n \nFor the entire (male and female) university student population in general per the \nregistrar, the demographic makeup (2021) was Native American (0.11%), Asian (8.8%), \nBlack/African American (17.6%), Hispanic (32.2%), Hawaiian or Pacific Islander (0.1%), \nCaucasian (29.7%), Mixed (3%), International (3.79%), and Unknown (4.7%).\n19  The \nracial/ethnic distribution of the respondents (just the female respondents) to this survey \nis presented in Table 3 and Figure 2. \n \n   Table 3 - Racial/Ethnic Distribution \n \nRacial/ethnic group \nTotal University \nPercentage Respondent Percentage \nAsian 8.80%  9.90% \nBlack/African American 17.60% 15% \nCaucasian 29.70%  41% \nHawaiian or PI 0.10% 0.20% \nHispanic 32.20%  25% \nMixed 3%  6.40% \nNative American 0.11% 0.50% \nUnknown 4.70%  2.00% \nInternational 3.79%    \n \n \n     \n \n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \n\n \nFigure 2 \n \nTable 3 and Figure 2.  Respondent demographic percentages.  There is an overrepresentation of \nCaucasian responses compared to the general student body (41% study vs 29.7% general) and an \nunderrepresentation of Hispanic responses (25% study vs 32.2% general).  There was no choice for \ninternational respondents in this study; 13 respondents did not answer this query out of 2,216. \n \nMenstrual Characteristics \n \nThe subjects reported normal cycling in 70.98% (1,573) of cases, irregular cycling in \n21.30% (472), no cycling due to medications for endometriosis or oral contraceptives in \n9.48% (210), no cycling due to previous gynecologic surgery (hysterectomy or ablation) \nin 1.04% (23), and no cycling due to menopause in 1.49% (33) of subjects.  The top \nthree symptoms reported by the study population were bloating/swelling/constipation \n(77.66%; 1,721), mood swings/moodiness (74.1%; 1,642), and pelvic or back pain \n(71.57%; 1,586).  Of note is that 18.23% (404) reported bleeding that restricted the \nsubject’s ability to function.  The entire display is featured in Table 4.   \n  \n \n      \n \n \n \nTable 4 \nMenstrual Symptoms of the Respondents \n0.00%\n5.00%\n10.00%\n15.00%\n20.00%\n25.00%\n30.00%\n35.00%\n40.00%\n45.00%\nRespondent Demographics\nTotal University Percent Respondant Percentage\n \n) \n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \n\nTable 4.  The array of symptoms reported by respondents (more than one choice per person).  Only \n2.71% had no symptoms. \n \n When asked how severely their menses affect them, approximately 1 in 6 women \n(15.75%; 349) reported minimal to no issues. In contrast, 56.32% (1,248) had minimal \nto moderate issues that kept them from perform\ning some of their daily routines, but they \nfelt they could cope well.  Almost 27% of the women (26.94%, 597) felt that their \nmenses caused moderate to severe symptoms, keeping them from doing many things \nand interfering with their lifestyles.  Severe symptoms that required the subjects to stay \nin bed and greatly restricted activities to cope were reported by 10.97% (243), and \n2.26% (50) had unbearable symptoms and could not function during menses.  \nInterestingly, 7.08% (157) were told that they had endometriosis by their doctor, by \nhaving surgery, or by a family member (not a physician).  Fully 93.55% (2,073) had not \nbeen diagnosed with this disease across the entire cohort. \n \n \nSymptom Treatments and Efficacy\n \n \nNumerous treatments have been used over the years to alleviate menstrual issues with \nvarying success rates.  In this survey, almost 80% used over-the-counter medications, \nand 12.82% did not need anything for treatment.  The full responses are shown in Table \n4 below. \n \n \n \n \n \n \n     Table 4 \n   Treatment Regimens for Menstrual Cycle Symptoms \n \ny \nle \n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \n\nTable 4.  Reported treatments used for menstrual symptoms in the cohort.  12.82% didn’t need \nanything, and only 1.99% used menstrual devices such as TENs or Jovi. (more than one choice was \npermitted).  79.29% used over-the-counter medications.  The total number of respondents was 2,216; the \npercentages were established from the responses listed. \n \nOne of the more important questions revolved around the perceived effectiveness of the \nvarious treatment categories respondents reported using in Table 4 \n.   \n1. Prescription pain medications: of the 185 respondents who use them, 32.4% \nfound them very effective, 37.8% moderately effective, and 29.8% only mildly \neffective or ineffective. \n2. Over-the-counter pain relievers – among the 1,757 respondents who use them, \n27.3% found them very effective, 44.7% moderately effective, and 28% only \nmildly effective or ineffective. \n3. Over-the-counter menstrual pain devices: of the 44 respondents who use them, \n14% found them very effective, 33.2% moderately effective, and 52.7% only \nmildly effective or ineffective. \n4. Oral contraceptives/hormonal management – of the 556 respondents who use \nthis, 36.2% find it very effective, 33.6% find it moderately effective, and 30.2% \nfind it only mildly effective or not effective at all. \n5. Cannabis/Marijuana/THC/CBD – of the 327 respondents who use this, 51.7% \nfind it very effective, 30.3% find it moderately effective, and 18% find it only mildly\neffective or not effective at all. \n6. Alternative medicine/acupuncture/herbal medicine – of the 125 respondents who \nreport using this, 20.3% find it very effective, 35.7% find it moderately effective, \nand 44% find it only mildly effective or ineffective. \n7. Exercise/meditation: used by 656 respondents; of these, 17.5% find it very \neffective, 36.7% moderately effective, and 45.8% only mildly effective or not \neffective. \n \ne \ne \nly \no \n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \n\n8. Alcohol – this is reported by 49 as a treatment, and of this group, 8.1% found it \nvery effective, 11.5% found it moderately effective, and 80.3% found it only mildly \neffective or not effective at all. \n9. Sexual relations – of the 202 respondents who engage in this as a treatment \nadjunct, 12.5% find it very effective, 32.8% find it moderately effective, and \n54.7% find it only mildly effective or not effective at all. \n10. Antidepressants are used as a treatment by 70 respondents, and of these, 5.9% \nfound them very effective, 20.1% found them moderately effective, and 74% \nfound them only mildly effective or not effective at all. \n11. Heating pad – 1,207 respondents use this as a treatment for menstrual cycle \nsymptoms.  Of that, 24.5% found it very effective, 41.7% found it moderately \neffective, and 33.8% found it minimally effective or ineffective. \n \n \n \nFigure 3 \n \n \n \n \n \nCannabis/marijuana\n \nly \n \n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \n\n \nOf the 14.76% (327) of respondents who reported the use of cannabinoids for menstrual \ncycle symptoms, 89.91% (294) use smoking or vaping as a delivery system, 30.58% \n(100) use edibles/gummies, and 9.5% (31) use topicals, creams, or oils. Only one \npatient used a nasal or oral spray system, and one used a suppository system.  In the \nnext survey question related to cannabis/marihuana use, there were 412 respondents \nrather than 327.  The “n” of 412 responses reflects that 18.6% of respondents used \ncannabis for menstrual symptoms, with 49.51% using conventional THC (delta 9 THC) \ndominant strains, 15.53% using a CBD (cannabidiol) dominant strain, 26.46% using an \nequal mix of THC and CBD strain (50/50 mix), and 8.5% using the delta 8 TCH \nproducts, with the rest of respondents stating that they did not use cannabinoids.  The \ndirect question of what was used seems to have engendered more responses.  \nRecently, there have been reports of statistically significant pain reduction using \ncannabidiol (CBD) infused tampons to control dysmenorrhea, though the literature is \nsparse on this option.\n20 \n \nThe respondents reported on the perceived effectiveness of the cannabis delivery \nsystems in Figure 4. \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nFigure 4 \n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \n\n \n \n \n \nRacial/ethnic differences\n \n \nSome racial differences in responses regarding treatments were noted.  The \nrespondent’s age range did not appear to affect their responses. \n \n1. Black/African American – A greater number of respondents did not need \ntreatment for menstrual symptoms (16.92% vs. a mean of 12.82% for all other \nraces/ethnicities), and a greater number required prescription pain relievers \n(15.11% vs. a mean of 8.35% for all other races/ethnicities). Further, compared \nto all other races and ethnicities, Black/African Americans reporte\nd less usage of \noral contraceptives (13.9% vs. a mean of 25.9%), cannabis (8.76% vs. a mean of \n14.76%), and exercise/meditation (20.54% vs. a mean of 29.6%).  \n2. Caucasian – There was a greater number of respondents using oral \ncontraceptives (33.0% vs. a mean of 25.9% for all other races), and no significant\ndifferences for other treatments used compared to other racial/ethnic groups. \n3. Hispanic – There was a lower number using antidepressants (1.44% vs. a mean \nof 3.16% for all other races), with similar usage of other treatments compared to \nall other groups. \n4. Asian – Similarly, fewer respondents used antidepressants (1.83% vs. \na mean of \n3.16% (all other races)), with different treatments showing similar usage patterns \ncompared to other races/ethnicities. \n \nf \nof \nnt \nn \nof \ns \n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \n\n5. Mixed – those with mixed racial ancestry reported more use of cannabis \n(23.57%) compared to a mean of 14.76% for all other groups, and more use of \nexercise and meditation (38.57%) vs. a mean of 29.6% for all other groups. \n \n \nDiscussion \n \nFor the female population, the burdens of menstruation, including symptoms of pelvic \npain and psychological distress, are widespread, significantly impacting the quality of \nlife, finances, education, and ability to work and function. Though previous studies have \nused social media channels, there is an inherent bias in recruiting through self-help \nchannels.  In this study, we included all individuals who identified as female from the \nentire university population to address this bias.  Further, by including those with \nendometriosis, we tried to evaluate the disease burden and the various coping \nmechanisms used by this young female sample to alleviate their symptomatology. The \nsurvey response was 15.8%, similar to the standard response rate for other NSU \nuniversity surveys.  The study was weighted toward younger subjects, as might be \nexpected in a university study, with 63.95% of participants aged 18 to 25. \nDemographically, Caucasians were overrepresented as respondents compared to the \ngeneral student body (41% vs. 29.7%), and Hispanics were underrepresented (25% vs. \n32.2%).  \n \nIt was noted that 18.23% of the university’s female population reports pain and bleeding \nthat restricts the student’s ability to function, and 13.2% were so severely affected by \nsymptoms that bed rest was required, impacting academics and advancement, which \nhas significant policy implications.  Recently released guidelines on cannabis use \nthroughout women’s lifespans from the Society of Obstetricians and Gynecologists \nCanada (SOGC) focused on several essential statements on cannabis use in the \nfemale population. \n21,22 Canada legalized cannabis for recreational use countrywide on \nOctober 17, 2018 (Cannabis Act), and they have now had experience with large swaths \nof the population using it over time.23  This prompted the SOGC to issue its \nrecommendations, shown below, with its confidence in the scientific evidence \nsupporting each statement. \n \n1. Cannabis use is increasing, and women are commonly using cannabis for \nrecreational and medical reasons (high confidence).  In the US, for the first time \nin 2023, 19- to 30-year-old female respondents reported a higher prevalence of \npast-year cannabis use than male respondents in the same age group, reflecting \na reversal of the gap between sexes. Conversely, male respondents 35 to 50 \nyears old maintained a higher prevalence of past-year cannabis use than female \nrespondents of the same age group, consistent with what’s been observed for \nthe past decade. \n24 \n2. The use of cannabis, especially products containing tetrahydrocannabinol, can \ninduce or worsen psychosis and depression (high confidence). \n3. Study results concerning the association between cannabis and anxiety are \nconflicting, and this association requires further study. (High confidence). \n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \n\n4. There is limited evidence that frequent cannabis use may affect female fertility \n(moderate confidence), but frequent use can diminish male fertility (moderate \nconfidence). A recent study by Duval et al. (2025) revealed significant effects on \noocyte maturation, transcriptomic profiles, meiotic spindle organization, and \noocyte ploidy. Collectively, this data presents compelling evidence that cannabis \nconsumption may negatively impact female fertility.\n25 \n5. No evidence exists that cannabis products improve chronic pelvic pain (low \nconfidence). \n6. The effects of prenatal cannabis exposure on long-term outcomes through \nchildhood, adolescence, and adulthood have not been conclusively defined. Still, \nrecent data suggest that there are persistent neurocognitive effects into \nadulthood (moderate). \n \nOur study seems to support findings of increased use of cannabis for self-treatment of \nmenstrual symptoms, at least in the university female population we sampled. \nMoreover, Cannabis/Marijuana/THC/CBD had the highest perceived level of \neffectiveness against these symptoms among female users compared to other \ntraditional treatments such as over-the-counter medications and oral contraceptives. \nThis justifies further research into possible mechanisms that may explain this perceived \nbenefit in a recurrent condition that females face regularly throughout their reproductive \nlives. Implications of cannabis use for women’s health, fertility, and its impact on \noffspring’s health must also be investigated. \n \nConclusion: \n \n Menstruation and its associated symptoms in this college female population represent \na significant challenge.  Even though we did not evaluate the impact of menstrual \nburden on academic performance, the fact that 40.2% of the female college population \nhad a significant impairment in their ability to function, with 13.23% being incapacitated \nentirely, makes menstruation a significant barrier compromising university life. Various \nadjuvants include the array of self-treatment modalities used by this population for \nsymptom relief, including reliance primarily on over-the-counter medications for a \nsubstantial percentage of respondents with varying perceived efficacies.  Additionally, \ncannabis is used by up to 18.6% as an adjunct with 80% perceived efficacy, deserving \nfurther studies.  In addition to this study, the previous data cited on the effects of \nmenstrual burden on academics, advancement, and quality of life should inform a policy \nreview of how menstrual burden is addressed in university settings, particularly \nregarding efforts toward gender equality.  The prevalence of cannabis use by nearly one \nin 5 students for menstrual burden is a reality that may elicit a policy review in many \ninstitutions, both at the university and secondary school levels.  An awareness of the \nextent of the burden may help adjust testing schedules and teaching formats to \naccommodate this large portion of our population. \n \n \nAdvantages \n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \n\nThe entire university body that identified as female was invited to participate, regardless \nof social media platforms and the biases they entail. \n \nLimitations \nThe 15.8% response rate is disappointing, though that rate (about 16%) is commonly \nencountered in this university’s surveys, and the 2,216 responses are certainly one of \nthe larger ones published on this subject.  Response bias is a possibility, as in all \nstudies, and the cited placebo effects may compromise questions on cannabis and \nother treatment modalities. \n \n \n                                           \n \n1 Gender ratio in the World, UN (World Population Prospects 2019), \nhttps://statisticstimes.com/demographics/world-sex-ratio.php  accessed 2/20/2022. \n2 Schoep ME, Nieboer TE, van der Zanden M, et al. The impact of menstrual symptoms on everyday life: \na survey among 42,879 women. Am J Obstet Gynecol 2019;220:569.e1-7.  \n3 Munro, A. K., Hunter, E. C., Hossain, S. Z., & Keep, M. (2021). A systematic review of the menstrual \nexperiences of university students and the impacts on their education: A global perspective. PloS \none, 16(9), e0257333. https://doi-org.ezproxylocal.library.nova.edu/10.1371/journal.pone.0257333 \n4 Gumà, J., Solé-Auró, A., & Arpino, B. (2019). Examining social determinants of health: the role of \neducation, household arrangements and country groups by gender. BMC public health, 19(1), 699. \nhttps://doi-org.ezproxylocal.library.nova.edu/10.1186/s12889-019-7054-0 \n5 Armour M, Sinclair J, Chalmers KJ, Smith CA. Self-management strategies amongst Australian women \nwith endometriosis: a national online survey. BMC Complement Altern Med. 2019;19(1):17. Published \n2019 Jan 15. doi:10.1186/s12906-019-2431-x. accessed 2/20/22. \n6 Geukens EI, Apers S, Meuleman C, D'Hooghe TM, Dancet EAF. Patient-centeredness and \nendometriosis: Definition, measurement, and current status. Best Pract Res Clin Obstet Gynaecol. \n2018;50:11-17. doi:10.1016/j.bpobgyn.2018.01.009. accessed 2/20/22. \n7 Reports and Data. Endometriosis Market To Reach USD 2.42 Billion By 2026. Endometriosis Market \nSize – USD 1.93 Billion in 2018, CAGR of 2.8%, Endometriosis Industry Trends –The increasing focus on \nclinical trial. https://www.globenewswire.com/news-release/ 2020/03/05/1996125/0/en/Endometriosis-\nMarket-To-Reach-USD-2-42-Billion-By-2026- Reports-And-Data.html. accessed 2/20/22. \n8 Hirata, T., Koga, K., Kai, K., Katabuchi, H., Kitade, M., Kitawaki, J., Kurihara, M., Takazawa, N., Tanaka, \nT., Taniguchi, F., Nakajima, J., Narahara, H., Harada, T., Horie, S., Honda, R., Murono, K., Yoshimura, K. \nand Osuga, Y. (2020), Clinical practice guidelines for the treatment of extragenital endometriosis in \nJapan, 2018. J. Obstet. Gynaecol. Res., 46: 2474-2487. https://doi-org.proxy-\nhs.researchport.umd.edu/10.1111/jog.14522 accessed 2/20/22. \n9 Ju H, Jones M, Mishra G. The prevalence and risk factors of dysmenorrhea. Epidemiol Rev. \n2014;36:104-113. doi:10.1093/epirev/mxt009. Accessed 2/20/22. \n10 Nirgianakis K, Egger K, Kalaitzopoulos DR, Lanz S, Bally L, Mueller MD. Effectiveness of Dietary \nInterventions in the Treatment of Endometriosis: a Systematic Review [published online ahead of print, \n2021 Mar 24]. Reprod Sci. 2021;10.1007/s43032-020-00418-w. doi:10.1007/ s43032-020-00418-w. \nAccessed 2/20/22. \n11 Tsonis O, Gkrozou F, Barmpalia Z, Makopoulou A, Siafaka V. Integrating Lifestyle Focused \nApproaches into the Management of Primary Dysmenorrhea: Impact on Quality of Life. Int J Womens \nHealth. 2021;13:327-336. Published 2021 Mar 17. doi:10.2147/IJWH.S264023 accessed 2/20/22. \n12 Reinert A, Hibner M. Self-Reported Efficacy of Cannabis for Endometriosis Pain. The Journal of \nMinimally Invasive Gynecology. 2019;26(7):S72. doi:10.1016/j.jmig.2019.09.682 accessed 2/20/22. \n13 Bouaziz J, Bar On A, Seidman DS, Soriano D. The Clinical Significance of Endocannabinoids in \nEndometriosis Pain Management Cannabis Cannabinoid Res. 2017; 2(1): 72–80. Published online 2017 \nApr 1. doi: 10.1089/can.2016.0035 accessed 2/20/22. \n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \n\n                                                                                                                                          \n14 Ahmad S, Hill KP. Medical Marijuana : A Clinical Handbook. First edition. Wolters Kluwer; \n2021.http://search.ebscohost.com.proxy-hs.researchport.umd.edu/login.aspx? \ndirect=true&db=cat01362a&AN=hshs.006203833&site=eds-live accessed 2/20/22. \n15 Piszczek CC, Foley CE, Farag S, Northup M, Overcarsh P, Wiedrick J, Yunker AC, Ecker AM. Social \nmedia utilization, preferences, and patterns of behavior in patients with gynecologic pelvic pain. Am J \nObstet Gynecol. 2022 Apr;226(4):547.e1-547.e14. doi: 10.1016/j.ajog.2021.10.039. Epub 2021 Nov 6. \nPMID: 34752735. \n16 Gedin F, Blomé S, Pontén M, Lalouni M, Fust J, Raquette A, Vadenmark Lundquist V, Thompson WH, \nJensen K. Placebo Response and Media Attention in Randomized Clinical Trials Assessing Cannabis-\nBased Therapies for Pain: A Systematic Review and Meta-analysis. JAMA Netw Open. 2022 Nov \n1;5(11):e2243848. doi: 10.1001/jamanetworkopen.2022.43848. PMID: 36441553; PMCID: PMC9706362. \n17 NUS Florida Demographics and Diversity Report. https://www.collegefactual.com/colleges/nova-\nsoutheastern-university/student-life/diversity/#overview  accessed 2/20/22. \n18 US Census 2020. https://www.census.gov/quickfacts/fact/table/US/PST045219. Accessed 2/20/22. \n19 Nova Southeastern Student Population. https://www.univstats.com/colleges/nova-southeastern-\nuniversity/student-population/ accessed 3/24/22. \n20 Milanova, V., Mihaylova, K., Lazarova, I., Georgieva, T., Baxter, H., Dobreva, D. (2024) Efficacy and \nusability of a cannabidiol-infused tampon for the relief of primary dysmenorrhea. Journal of Endometriosis \nand Uterine Disorders. Volume 5, 2024, 100057, ISSN 2949-8384.  \nhttps://doi.org/10.1016/j.jeud.2023.100057. \n21 Robert, M., Graves, L. E., Allen, V. M., Dama, S., Gabrys, R. L., Tanguay, R. L., Turner, S. D., Green, \nC. R., & Cook, J. L. (2022). Guideline No. 425a: Cannabis Use Throughout Women's Lifespans - Part 1: \nFertility, Contraception, Menopause, and Pelvic Pain. Journal of obstetrics and gynaecology Canada : \nJOGC = Journal d'obstetrique et gynecologie du Canada : JOGC, 44(4), 407–419.e4. https://doi-\norg.ezproxylocal.library.nova.edu/10.1016/j.jogc.2022.01.012 accessed 4/13/22 \n22 Graves, L. E., Robert, M., Allen, V. M., Dama, S., Gabrys, R. L., Tanguay, R. L., Turner, S. D., Green, \nC. R., & Cook, J. L. (2022). Guideline No. 425b: Cannabis Use Throughout Women's Lifespans - Part 2: \nPregnancy, the Postnatal Period, and Breastfeeding. Journal of obstetrics and gynaecology Canada : \nJOGC = Journal d'obstetrique et gynecologie du Canada : JOGC, 44(4), 436–444.e1. https://doi-\norg.ezproxylocal.library.nova.edu/10.1016/j.jogc.2022.01.013 accessed 4/13/22 \n23 Kourgiantakis T, Edwards T, Lee E, Logan J, Vicknarajah R, Craig SL, Simon-Tucker M, Williams CC. \nCannabis use among youth in Canada: a scoping review protocol. BMJ Open. 2022 Jun \n20;12(6):e061997. doi: 10.1136/bmjopen-2022-061997. PMID: 35725253; PMCID: PMC9214380. \n24 NIDA. Cannabis and hallucinogen use among adults remained at historic highs in 2023. National \nInstitute on Drug Abuse website. https://nida.nih.gov/news-events/news-releases/2024/08/cannabis-and-\nhallucinogen-use-among-adults-remained-at-historic-highs-in-2023. August 29, 2024 Accessed \nDecember 27, 2025. \n25 Duva l, C., Wyse, B.A., F uch s Weizma n, N . et al. Cannabis impact s fema le ferti li ty as  eviden ced by an in \nvitro in vest igati on a nd a case-co ntro l st u dy. Nat Com mun 16, 8185 (2025). \nhttp s:// do i.org/1 0.1038/s 41467-025-6301 1-2.  \n \n \n \n \n \n \n \n \n \n \nAddendum 1 \n \nSurvey - www.surveymonkey.com/share/ec01779f-d9ac-46a0-9aa0-663d746220ca \n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint \n\n                                                                                                                                          \n \n \n \n \n \n \n \n . CC-BY-ND 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted December 31, 2025. ; https://doi.org/10.64898/2025.12.30.25343226doi: medRxiv preprint","source_license":"CC0","license_restricted":false}