Relation of Primary Dysmenorrhea with BMI and Associated Risk Factors among Medical Students of Rawalpindi

Relation of Primary Dysmenorrhea with BMI and Associated Risk Factors among Medical Students of Rawalpindi | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Relation of Primary Dysmenorrhea with BMI and Associated Risk Factors among Medical Students of Rawalpindi Wasia Ahmad, Hanan Ahmed, Muhammad Bilal Ali Khan Yazdani This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4637677/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Primary dysmenorrhea (PD) is one of the most common gynecological complaints in women of childbearing age, which severely impacts their quality of life. Objective The study aims to investigate the prevalence of dysmenorrhea among women of different ranges of Body Mass Index (BMI) and its associated risk factors. Methodology: 250 students (aged 18–24) from three medical colleges; Army Medical College, Foundation University Medical College, and Rawalpindi Medical University, participated in this cross-sectional survey. They were subjected to a pretested and structured questionnaire comprising 30 questions regarding their menstrual characteristics, risk factors of dysmenorrhea, and their weights and heights. BMI was calculated. Descriptive and analytical statistics were conducted using chi-square and ANOVA. A p-value of < 0.05 was considered statistically significant. Results Based on this study, 88.4% of the students had PD, with 19% having mild, 45.2% having moderate, and 35.7% having severe dysmenorrhea. 78% of the students stated that dysmenorrhea makes it difficult for them to go about their everyday lives. Among the risk factors, family history, and intensity of bleeding were statistically significant. Any relation between age at menarche and duration of menstruation was not established. Among the modifiable factors i.e. diet, sleep, stress, and exercise, only sleep was considered statistically significant. Chiefly, no association was found between BMI and intensity of dysmenorrhea. Conclusion A high prevalence of PD was detected among young women between 18–24 years of age. Family history, intensity of bleeding, and an inactive lifestyle were found to be the important risk factors for PD. However, no correlation was observed between BMI and PD. Obstetrics & Gynecology primary dysmenorrhea prevalence BMI risk factors dysmenorrhea Figures Figure 1 Figure 2 INTRODUCTION Dysmenorrhea poses a greater burden than other gynecological complaints [ 1 ] . Dysmenorrhea is defined as pain during menstruation and has 2 types: primary and secondary. Primary dysmenorrhea (PD) is described as menstrual pain that is not associated with an underlying organic disorder. It normally starts six to twelve months after menarche and lasts till menopause. Conversely, secondary dysmenorrhea typically appears beyond the age of 25 and is brought on by an underlying gynecological disease such as endometriosis, uterine fibroids, or pelvic adhesions [ 2 ] . It is the most common female problem, affecting 90% of adolescent girls and more than half of menstruating women [ 3 ] . In some women (3–33%), the pain is severe enough to restrict their daily activities, causing absence from school [ 4 ] , lower academic performance [5] , reduced quality of sleep, and adversely affects mood, causing stress and anxiety [ 6 ] , ultimately causing a major decrease in the quality of life of those affected. The global prevalence of dysmenorrhea varies significantly by region, ranging from 50–90% [ 7 ] . This variation is due to the lack of a uniform operational definition for dysmenorrhea to be used in epidemiological studies and the way it is measured. Despite its high prevalence, studies have reported that women being affected by PD do not report it, or seek medical help [ 8 ] . Many studies have shown that a variety of risk factors, including biological, psychological, social, and lifestyle factors, can be linked to PD. Biological factors include a positive family history, heavy and prolonged menstrual bleeding, menarche at an early age [ 9 ] , and menstrual cycle irregularity [ 10 ] . Somatization, psychological disturbance, and poor mental health, such as stress, anxiety, and depression come under psychological factors [ 11 , 12 ] . A lack of social support is one of the social factors [ 13 ] . Other factors include age < 20 years, null parity, smoking, lack of exercise, and a stressful lifestyle [5, 14] . In terms of student dietary habits, it was discovered that a higher intake of fish, eggs, milk, fruits, and vegetables as sources of minerals, and a lower intake of wine, was linked to a lower prevalence of dysmenorrhea [ 14 ] . Coffee intake was identified as a significant risk factor for dysmenorrhea in a study conducted at Dumlupinar University [5] . PD is also linked with Body Mass Index (BMI). A study conducted in Saudi Arabia has shown that underweight subjects had a greater prevalence of moderate and severe dysmenorrhea than did obese subjects [ 15 ] . However, the evidence of how BMI affects PD is still controversial [ 16 ] . A few studies find no correlation between BMI and dysmenorrhea [ 16 , 17 ] , whereas others find a higher prevalence of PD in underweight women [ 18 , 19 ] , still other data points to a connection between raised BMI and PD [ 20 ] . Additionally, the results of Hong et al. indicate a U-shaped relationship between BMI and PD, indicating that females who are underweight or obese have an increased chance of experiencing PD [ 21 ] . As the evidence currently available is inconclusive to support the impact of BMI on PD, and the risk factors associated with it, which have been thoroughly researched on other populations, particularly stress, physical activity, family history, and diet, among university students of Pakistan, this study is designed to help provide some data to try to fill this existing gap. MATERIALS AND METHODS A pre-tested and structured online questionnaire prepared with reference to previous studies in the literature including the questions concerning women’s menstrual characteristics, and the risk factors of PD was used for the survey. The questionnaire was divided into 3 parts beginning with the written informed consent from all the participants in which they were assured of the confidentiality of their responses to the succeeding questionnaire followed by socio-demographic and lifestyle characteristics of the women including name, age, gender, university, level of education, date of birth, marital status and place of residence. Elements related to reproductive and menstrual characteristics such as the age of menarche, duration of the cycle, estimated pain experienced by the women during menstruation, approximate daily flow, history of dysmenorrhea in the immediate family, and quantification of the degree of pain on Numeric Pain Relating Scale (NPRS) classifying mild dysmenorrhea between 1–3 points, moderate between 4–7 points and severe between 8–10 points were also included in this segment of the questionnaire. The subsequent part is comprised of questions specifying the characteristics of PD such as the location of the pain, the character of the pain, the effect of dysmenorrhea on daily activities, and modifiable risk factors; diet, physical activity, stress, and sleep. The third portion included the calculation of BMI. The height and weight were self-reported and BMI was calculated using the formula weight in kg divided by height in meters squared. Based on the BMI recommendations from the World Health Organization, it was categorized into four groups underweight (< 18.5), normal (18.5–24.9), overweight (25-29.99), or obese (≥ 30). Inclusion Criteria Women belonging to the age group 18–24, from 3 medical colleges, namely Army Medical College, Foundation University Medical College, and Rawalpindi Medical University, were included. Exclusion Criteria Women diagnosed with any gynecological pathologies like uterine fibroids, endometriosis, or pelvic adhesions were excluded. Statistical Analysis Data analysis was done with IBM SPSS 25. For all BMI groups, frequencies and percentages of the severity of dysmenorrhea were computed. The chi-square test of association and analysis of variance (one-way ANOVA) was applied. A value of p less than 0.05 was considered statistically significant. Table 1 ; History and Characteristics of Dysmenorrhea(n = 250) Frequency Percent History Of dysmenorrhea Yes 221 88.4 No 29 11.6 Pain Location Lower Abdomen 71 32.1 Lower Abdomen and back 148 67.0 Right side of abdomen 1 0.5 Left side of abdomen 1 0.5 Identify the character of pain Spasmodic 126 57.0 Sharp 60 27.1 Stinging 35 15.8 First experience of menstrual pain From first period 97 43.9 After 1–2 years 88 39.8 After 3–4 years 20 9.1 After 5–6 years 16 7.2 Length of pain 1 day 65 29.4 2 days 126 57.1 3 days 16 7.2 Entire period 14 6.3 Effect on daily activities Yes 174 78.7 No 47 21.3 Pain starts for each period Previous day 91 41.2 First day 83 37.6 First or second day 47 21.3 Do any of the following activities affect pain? Type of Diet 34 15.4 Exercise 45 20.4 Sleep 73 33.0 Stress 69 31.2 Pain associated with any autonomic reaction? Nausea 56 25.3 Vomiting 19 8.6 Diarrhea 39 17.6 None 107 48.4 Pain is relieved by NSAIDS 103 46.6 Injections 2 0.9 Hot packs 98 44.3 Anti-spasmodic 18 8.2 RESULTS This study explored that 221 (88.4%) students were suffering from dysmenorrhea, with 42 (19%) having mild, 100 (45.2%) moderate, and 79 (35.7%) having severe dysmenorrhea. Several PD characteristics are shown in Table 1 . The lower back and abdomen were indicated by the majority of participants (67%) as the most common sites of pain. For 44% of the individuals, the pain began with their first menstrual cycle. Of the respondents, 57.1% reported that their menstrual pain lasts for two days. For 46.6% of the participants, NSAIDS were beneficial for pain relief. Figure 1 shows the relation of pain intensity with the intensity of bleeding. The intensity of pain increased with heavy menstrual flow. Statistical significance was established. Figure 2 highlights the factors that influence pain. Pain was either relieved or aggravated by the type of diet in 16% of the subjects. 31% reported that stress increased pain intensity, while in 20% of the subjects, exercise affected pain. 33% revealed that sleep relieved pain. The distribution of mild, moderate, and severe dysmenorrhea in underweight, normal weight, overweight, and obese groups is shown in Table 2 . The prevalence of mild, moderate, and severe dysmenorrhea was greater in patients with a normal BMI (52.4%, 53%, and 53.2%, respectively) compared to other BMI groups. However, a statistical significance could not be established (p-value 0.06). Table 2 ; Relation between Body Mass Index (BMI) and Primary Dysmenorrhea (n = 250) BMI Dysmenorrhea P-value No Pain, n (%) Mild Pain, n (%) Moderate Pain, n (%) Severe Pain, n (%) 0.06 Underweight 2 (6.9) 11 (26.2) 24 (24) 27 (34.2) Normal 24 (82.8) 22 (52.4) 53 (53) 42 (53.2) Overweight 2 (6.9) 7 (16.6) 20 (20) 8 (10.1) Obese 1 (3.4) 2 (4.8) 3 (3) 2 (2.5) P-value < 0.05 is considered statistically significant DISCUSSION In this study, which involved 250 students between the ages of 18 and 24, it was explored that 221 (88.4%) had PD, of whom 42 (19%) had mild, 100 (45.2%) had moderate, and 79 (35.7%) had severe dysmenorrhea. The results align with recent review articles that suggest 16–90% of young females experience dysmenorrhea, with 2–29% experiencing pain severe enough to restrict their daily activities [ 16 ] . For young females, PD is one of the most common reasons for class absenteeism. 78.7% of the students in our study reported that having dysmenorrhea had a detrimental impact on their everyday activities and academic performance. These findings support earlier research that shows that class absenteeism and lack of concentration and focus influence the educational performance of the majority of dysmenorrheic females (60.4 percent) [ 4 ] . Furthermore, Minaleshewa et al. found that 51.4% of their PD respondents had a decline in academic performance, and 63% of them experienced social withdrawal [ 22 ] . Lower abdomen and back were the most frequently reported sites of dysmenorrheic pain (67%) among the study participants. For 43.9% of the participants, pain began a year after menarche, while another 39.8% started experiencing pain 1–2 years after their first menstruation. For 57.1% of the participants, menstrual pain persists for two days. For each menstrual period, 41.2% of the subjects reported that pain starts a day before, while 37.6% feel it on the first day. 57% of the participants reported having spasmodic pain, whereas 27.1% reported sharp pain. 34% of participants in Kural et al.'s study reported diffuse lower abdomen pain, with the majority (68%) reporting spasmodic pain [ 23 ] . Uterine contractions caused by increased prostaglandin production in the menstruating uterus may cause spasmodic discomfort in these subjects [ 24 ] . Pain was associated with nausea in 25.3% and diarrhea in 17.6% of the subjects, while 48.4% reported that it was not associated with any autonomic reactions. Pain relief was achieved in 44.3% of our subjects with hot packs and 46.4% of our subjects by the use of NSAIDs. This result supports the substantial correlation between prostaglandins and PD, as NSAIDs reduce pain by inhibiting the production of prostaglandins [ 24 ] . Many studies in the current literature have shown that a variety of modifiable and non-modifiable risk factors can be linked to PD. In our study, age at menarche, family history, average daily flow, duration of menstruation, and lifestyle factors are the considered risk factors. Early menarche, i.e. menarche before 11 years of age, was reported by 3.2% of the subjects. Some studies [ 7 ] [ 14 ] reported a higher dysmenorrhea frequency in women who had menarche at an early age. However, in our study, the age of menarche was not independently associated with dysmenorrhea (p > 0.05). This might be due to the reason that only 8 subjects out of 221 had an early menarche, so the results cannot be generalized. Burnett et al. have reported similar results [ 25 ] . There was a positive association between a history of dysmenorrhea in the immediate family and the severity of PD in the current study (p = 0.016). Results of previous studies also support this association [ 16 ], [ 7 ], [ 9 ], [ 13 ] . There are two possible reasons for this association; the first points to the girls' behavioral modeling after their mothers or sisters, and the second reason can be explained by genetic factors. The findings of a study conducted by Silberg et al. on 1200 pairs of monozygotic and dizygotic twin sisters indicated that PD was caused by both genetic and environmental factors [ 26 ] . A longer duration of menstruation (more than 7 days) was reported by 6.4% of the subjects, while 93.6% had normal duration i.e. 3–7 days. Statistical significance was not established between the duration of menstruation and the intensity of dysmenorrhea (p-value 0.6). The significant difference between the percentages of subjects with normal and prolonged duration of menstruation may have distorted the results. In contrast, some studies in the literature reported a positive association between longer duration of menstruation and intensity of dysmenorrhea [ 9 ] [ 13 ] [ 14 ] . Subjects who frequently engage in physical activities and have an active lifestyle reportedly feel less pain, as compared to those who have a sedentary lifestyle, with little to no physical activity. A positive association was established between an active engagement in physical activity and lesser intensity of pain (p = 0.015). This finding is consistent with the previous studies [ 27 ] [ 28 ] and furthers the fact that maintaining a healthy and active lifestyle can reduce the intensity of PD. In the current study, 9.6% of subjects reported light flow, 83.2% moderate, and 7.2% heavy bleeding. A heavier intensity of bleeding was associated with a higher severity of PD (p = 0.009). Similar results were reported in previous studies [ 7 ] [ 10 ] [ 14 ] . In contrast, no correlation was found between the duration of the menstrual cycle and the intensity of pain, in a study conducted among 276 Japanese women aged 19 to 24 years [ 29 ] . The use of different scales for grading the severity of dysmenorrhea can explain this disparity. The study explored that pain during menstruation was influenced by four factors; diet, exercise, sleep, and stress. 34 subjects (15.4%) reported that the type of diet during menstruation either aggravated or relieved their pain. Hot beverages like tea, warm foods, fruits, vegetables, and eggs reportedly relieved pain, while cold beverages like soft drinks, ice cream, and caffeinated products like coffee aggravated pain. Faramarzi et al. reported that dysmenorrhea was two times higher in women with high caffeine intake [ 13 ] , while a study conducted among Spanish university students revealed that consumption of cola drinks was a statistically significant risk factor [ 9 ] . Some studies [ 6 ] in the literature have established association of dysmenorrhea with poor mental health, stress, anxiety, and depression. 69 subjects (31.2%) mentioned increased intensity of pain during stress. Results of a study by Hong Ju et al. revealed a positive association between perceived stress, related to work or general life events, and the risk of dysmenorrhea [ 16 ] . The molecular mechanisms linking work stress to dysmenorrhea are not completely understood, however, it potentially includes a cascade of neuroendocrine reactions. Stress-related hormones, including adrenaline and cortisol, appear to influence prostaglandin synthesis and/or binding in the myometrium [ 11 ] . In the current study, 45 students (20.4%) reported that their pain was influenced by exercise, while 73 (33.0%) revealed that their pain was relieved during sleep. Among diet, sleep, stress, and exercise, only sleep was statistically significant (p = 0.047). Pain is a perception rather than a sensation, and during sleep, the pain sensitivity might be lowered in the case of mild pain. Some studies reported that severe dysmenorrheic pain significantly reduced the quality of sleep, therefore, sleep was not a relieving factor in that case. However, some studies reported that inconclusive evidence was found for these modifiable factors [ 16 ] . The present study revealed that the severity of dysmenorrhea was not associated with body mass index (pvalue 0.06). This finding is in line with a few previous studies [ 17 ] [ 12 ] . Sundell et al [ 12 ] found that the severity of dysmenorrhea was not associated with either height or weight. However, a limitation of the present study was that, out of all study participants, 56.4% were females of normal weight, 25.6% underweight, 14.8% overweight, and only 3.2% obese. There may have been a bias in the results due to this unequal distribution of subjects in different BMI groups. On the other hand, previous studies have reported different associations with BMI. Studies by Mohapatra et al. [ 19 ] and Rafique et al. [ 15 ] show a significant association between PD and low BMI. However, the exact pathophysiological mechanisms behind this link remain unclear. Given that a certain amount of body fat is necessary for healthy menstrual cycles and ovulation, and that a lack of fat can cause ovulatory, menstrual, and reproductive issues, it is possible that irregular menstruation and disturbed ovulation can change the estrogen/progesterone ratio, which in turn can increase prostaglandin production and cause PD [ 15 ] . Snehalata et al. found a positive correlation between PD and higher BMI in their subjects and showed that the severity of PD increased with increasing BMI [ 20 ] . A U-shaped association between BMI and PD was found in Hong et al.'s prospective study, indicating that females who are underweight or overweight/obese are more likely to experience PD [ 21 ] . This study assessed the severity of PD using the NPRS, associated it with BMI, and investigated additional PD risk factors. However, this study's cross-sectional design meant that it was unable to determine the impact of either increasing or decreasing BMI on PD. Additionally, no medical examinations or investigations were performed; the diagnosis of PD was made solely based on the patient's history. The impact of additional confounding variables, such as irregular menstrual cycles, oral contraceptive pill use, parity, smoking, and alcohol intake, was not taken into account. Furthermore, the study of pain is challenging because firstly, pain is a subjective matter, and people's perceptions of pain are influenced by a variety of circumstances when determining its intensity. Secondly, different studies on dysmenorrhea used different scales to score its intensity, and so comparison of the results with other studies can be affected. CONCLUSIONS This study concludes that PD affects a significant percentage of young females, negatively impacting their everyday activities and academic performance. Additionally, it was shown that the majority of respondents' pain was reduced by NSAIDs, therefore, confirming that PD is caused by increased prostaglandin synthesis. Our results showed that family history of dysmenorrhea and heavy intensity of menstrual bleeding are the important risk factors. In addition, we did not find any correlation between BMI and PD. However, concerning lifestyle and eating habits, based on our results and previous reports, further studies are necessary to provide or confirm recommendations on the most advisable diets or lifestyle changes for reducing the risk of suffering from dysmenorrhea. Declarations This research project, titled "Relation of Primary Dysmenorrhea with BMI and Associated Risk Factors among Medical Students of Rawalpindi", has been reviewed and approved by the Army Medical College Ethical Review Committee. The committee has evaluated the study's ethical considerations, ensuring that it complies with established guidelines for research involving human subjects. References Patel V, Tanksale V, Sahasrabhojanee M, et al.: The burden and determinants of dysmenorrhoea: a population-based survey of 2262 women in Goa, India. BJOG. 2006, 113(4):453-63. 10.1111/j.1471- 0528.2006.00874.x Kumar P, Malhotra N. : Jeffcoate’s Principles of Gynecology. Jaypee Brothers Medical Pub, India; 2014. 10.5005/jp/books/11155 Berkley KJ.: Primary dysmenorrhea: an urgent mandate . Pain . 2013, 1(1):8. Derseh BT, Afessa N, Temesgen M : Prevalence of dysmenorrhea and its effects on school performance: A cross-sectional study. J Womens Health Care . 2017, 6:361. 10.4172/2167-0420.1000361 Unsal, Alaettin : Prevalence of dysmenorrhea and its effect on quality of life among a group of female university students . Upsala Journal of Medical Sciences . 2010, 115,2:138-145. 10.3109/03009730903457218 Dorn LD, Negriff S, Huang B : Menstrual symptoms in adolescent girls: association with smoking, depressive symptoms, and anxiety . J Adolesc Health. 2009, 44(3):237-43. 10.1016/j.jadohealth.2008.07.018 Habibi N, Huang MSL, Gan WY, Zulida R, Safavi SM: Prevalence of Primary Dysmenorrhea and Factors Associated with Its Intensity Among Undergraduate Students: A Cross-Sectional Study. Pain Manag Nurs. 2015, 16:855-861. 10.1016/j.pmn.2015.07.001 Fisher C, Adams J, Hickman L, Sibbritt D: The use of complementary and alternative medicine by 7427 Australian women with cyclic perimenstrual pain and discomfort: a cross-sectional study. BMC Complement Altern Med. BioMed Central. 2016, 16:129. 10.1186/s12906-016-1119-8 Fernández-Martínez E, Onieva-Zafra MD, Parra-Fernández ML: Lifestyle and prevalence of dysmenorrhea among Spanish female university students. PLoS ONE . 2018, 13:8. 10.1371/journal.pone.0201894 Abdel-Salam DM, Alnuman RW, Alrwuaili RM, Alrwuaili GA, Alrwuaili EM: Epidemiological aspects of dysmenorrhea among female students at Jouf University, Saudi Arabia. Middle East Fertil Soc J. 2018, 23(4):435-9. 10.1016/j.mefs.2018.08.001 Wang L, Wang X, Wang W, et al.: Stress and dysmenorrhoea: a population based prospective study . Occup Environ Med. 2004, 61:12. Sundell G, Milsom I, Andersch B: Factors influencing the prevalence and severity of dysmenorrhoea in young women. Br J Obstet Gynaecol. 1990, 97-7. 10.1111/j.1471-0528.1990.tb02545.x Faramarzi, Mahbobeh, and Hajar Salmalian: Association of psychologic and nonpsychologic factors with primary dysmenorrhea.. Iranian Red Crescent medical journal vol. 16,8. 2014:16307. 10.5812/ircmj.16307 Balbi C, Musone R, Menditto A, et al.: Influence of menstrual factors and dietary habits on menstrual pain in adolescence age. Eur J Obstet Gynecol Reprod Biol. 2000, 91:143-148. 10.1016/S0301-2115(99)00277-8 Rafique, Nazish, and Mona H. Al‐Sheikh: Prevalence of primary dysmenorrhea and its relationship with body mass index.. Journal of Obstetrics and Gynaecology Research. 9:1773-1778. 10.1111/jog.13697 Ju H, Jones M, Mishra G: The prevalence and risk factors of dysmenorrhea . Epidemiol Rev. 2014, 36:104-113. 10.1093/epirev/mxt009 Davaneghi S, Dahri M: Association between body mass index, diet and physical activity with primary dysmenorrhea severity pain in university students. Nutr Food Sci Res. 2014, 1:250. Rafique N, al-Sheikh M: Prevalence of menstrual problems and their association with psychological stress in young female students studying health sciences. Saudi Med J. 2018:67-73. 10.15537/smj.2018.1.21438 Mohapatra D, Mishra T, Behera M, Panda P: A study of relation between body mass index and dysmenorrhea and its impact on daily activities of medical students. Asian J Pharm Clin Res. 2016, 9:297-299. 10.22159/ajpcr.2016.v9s3.14753 Snehalata T, Mahesh MA: Relationship between body mass composition and primary dysmenorrhoea . Indian J Physiother Occup Ther. 2016, 10:76-81. 10.5958/0973-5674.2016.00017.4 Ju H, Jones M, Mishra GD: A U-shaped relationship between body mass index and dysmenorrhea: A longitudinal study. PLoS One. 2012, 134187:10. 10.1371/journal.pone.0134187 Gebeyehu MB, Mekuria MB, Tefera YG : Prevalence, impact, and management practice of dysmenorrhea among University of Gondar Students, Northwestern Ethiopia: A cross-sectional study. Int J Repro Med. 2017:8. 10.1155/2017/3208276 Kural, MoolRaj: Menstrual characteristics and prevalence of dysmenorrhea in college going girls. . Journal of family medicine and primary care vol. 4,3. 2015:426-31. 10.4103/2249-4863.161345 Chan WY, Yusoff Dawood M, Fuchs F: Prostaglandins in primary dysmenorrhea: comparison of prophylactic and nonprophylactic treatment with ibuprofen and use of oral contraceptives. Am J Med. 1981, 70:535-541. 10.1016/0002-9343(81)90576-3 Burnett MA, Antao V, Black A: Prevalence of primary dysmenorrhea in Canada . J Obstet Gynaecol Can. 2005, 27:765-70. 10.1016/s1701-216330728-9 Silberg, J.L., Martin, N.G. & Heath, A.C: Genetic and environmental factors in primary dysmenorrhea and its relationship to anxiety, depression, and neuroticism. Behav Genet. 17, 363:383. 10.1007/BF01068137 Dehnavi, Zahra Mohebbi : The Effect of aerobic exercise on primary dysmenorrhea: A clinical trial study. . Journal of education and health promotion vol. 7. 3-10. 10.4103/jehp.jehp_79_17 Gamit KS, Sheth MS, Vyas NJ: The effect of stretching exercise on primary dysmenorrhea in adult girls . Int J MedSci Public Health. 2014, 3:10.5455/ijmsph.2014.210220142 Nagata C, Hirokawa K, Shimizu N : Associations of menstrual pain with intakes of soy, fat and dietary fiber in Japanese women. Eur J Clin Nutr. 59:88-92. 10.1038/sj.ejcn.1602042 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4637677","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":318936540,"identity":"e0b88ac6-5c96-47d8-96dd-ff37409fd6d5","order_by":0,"name":"Wasia Ahmad","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYJCCA2DEkNj44AOQYmMnXktys+EMkBZmoi1iSG+T5gGxCWkxOH784YEfNXei+dsT26Rtfm2T52NmYPzwMQePljM5Bgd7jj3LnXHmYbN1bt9twzZmBmbJmdtwazE7kMNwgIftcG7DjcTG27k9txmBWtiYefFpOf/8wcE//w7nzr+R2CBt2XPbnrCWGwkGh3nbDuduuJHYJM3w43YiQS32N94YHJbtO5y7EegXw96G28ltzIzNeP0i2Z/++OObb4dz5x1Pf/jgx5/btvPbmw9++IhHCypgbAOTDcSqB4E/pCgeBaNgFIyCkQIAOKVhwZ+WkLUAAAAASUVORK5CYII=","orcid":"","institution":"Army Medical College","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Wasia","middleName":"","lastName":"Ahmad","suffix":""},{"id":318936541,"identity":"4ef7e262-4e9f-4414-bfe9-2a1dc3fef87c","order_by":1,"name":"Hanan Ahmed","email":"","orcid":"","institution":"Army Medical College","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hanan","middleName":"","lastName":"Ahmed","suffix":""},{"id":318936542,"identity":"11da4bbf-364d-4bf4-80d2-e63712e5be21","order_by":2,"name":"Muhammad Bilal Ali Khan Yazdani","email":"","orcid":"","institution":"Army Medical College","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Muhammad","middleName":"Bilal Ali Khan","lastName":"Yazdani","suffix":""}],"badges":[],"createdAt":"2024-06-25 15:53:11","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false,"coiExplicitlySet":false},"doi":"10.21203/rs.3.rs-4637677/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4637677/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59257274,"identity":"15cfb861-334e-434c-9d8d-a03eb99dad63","added_by":"auto","created_at":"2024-06-28 09:00:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":21569,"visible":true,"origin":"","legend":"\u003cp\u003eRelation between intensity of bleeding and pain\u003c/p\u003e","description":"","filename":"figure.png","url":"https://assets-eu.researchsquare.com/files/rs-4637677/v1/968900047cc690399c1080b9.png"},{"id":59257273,"identity":"1f7809a0-9082-4934-b9df-bb64ee928855","added_by":"auto","created_at":"2024-06-28 09:00:23","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":53472,"visible":true,"origin":"","legend":"\u003cp\u003eFactors affecting pain\u003c/p\u003e","description":"","filename":"Screenshot20240625004147.png","url":"https://assets-eu.researchsquare.com/files/rs-4637677/v1/ba48b3cebea62fd0a0437626.png"},{"id":59257276,"identity":"ad15c824-b6a7-425c-a2da-8936e9371897","added_by":"auto","created_at":"2024-06-28 09:00:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":542248,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4637677/v1/c2b4aa0b-3ebe-484e-90f7-1d924c063b1c.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eRelation of Primary Dysmenorrhea with BMI and Associated Risk Factors among Medical Students of Rawalpindi\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eDysmenorrhea poses a greater burden than other gynecological complaints \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Dysmenorrhea is defined as pain during menstruation and has 2 types: primary and secondary. Primary dysmenorrhea (PD) is described as menstrual pain that is not associated with an underlying organic disorder. It normally starts six to twelve months after menarche and lasts till menopause. Conversely, secondary dysmenorrhea typically appears beyond the age of 25 and is brought on by an underlying gynecological disease such as endometriosis, uterine fibroids, or pelvic adhesions \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. It is the most common female problem, affecting 90% of adolescent girls and more than half of menstruating women \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. In some women (3\u0026ndash;33%), the pain is severe enough to restrict their daily activities, causing absence from school \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e, lower academic performance \u003csup\u003e[5]\u003c/sup\u003e, reduced quality of sleep, and adversely affects mood, causing stress and anxiety \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e, ultimately causing a major decrease in the quality of life of those affected. The global prevalence of dysmenorrhea varies significantly by region, ranging from 50\u0026ndash;90% \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. This variation is due to the lack of a uniform operational definition for dysmenorrhea to be used in epidemiological studies and the way it is measured. Despite its high prevalence, studies have reported that women being affected by PD do not report it, or seek medical help \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Many studies have shown that a variety of risk factors, including biological, psychological, social, and lifestyle factors, can be linked to PD. Biological factors include a positive family history, heavy and prolonged menstrual bleeding, menarche at an early age \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e, and menstrual cycle irregularity \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Somatization, psychological disturbance, and poor mental health, such as stress, anxiety, and depression come under psychological factors \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. A lack of social support is one of the social factors \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Other factors include age\u0026thinsp;\u0026lt;\u0026thinsp;20 years, null parity, smoking, lack of exercise, and a stressful lifestyle \u003csup\u003e[5, 14]\u003c/sup\u003e. In terms of student dietary habits, it was discovered that a higher intake of fish, eggs, milk, fruits, and vegetables as sources of minerals, and a lower intake of wine, was linked to a lower prevalence of dysmenorrhea \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Coffee intake was identified as a significant risk factor for dysmenorrhea in a study conducted at Dumlupinar University \u003csup\u003e[5]\u003c/sup\u003e. PD is also linked with Body Mass Index (BMI). A study conducted in Saudi Arabia has shown that underweight subjects had a greater prevalence of moderate and severe dysmenorrhea than did obese subjects \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. However, the evidence of how BMI affects PD is still controversial \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. A few studies find no correlation between BMI and dysmenorrhea \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e, whereas others find a higher prevalence of PD in underweight women \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e, still other data points to a connection between raised BMI and PD \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Additionally, the results of Hong et al. indicate a U-shaped relationship between BMI and PD, indicating that females who are underweight or obese have an increased chance of experiencing PD \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. As the evidence currently available is inconclusive to support the impact of BMI on PD, and the risk factors associated with it, which have been thoroughly researched on other populations, particularly stress, physical activity, family history, and diet, among university students of Pakistan, this study is designed to help provide some data to try to fill this existing gap.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eA pre-tested and structured online questionnaire prepared with reference to previous studies in the literature including the questions concerning women\u0026rsquo;s menstrual characteristics, and the risk factors of PD was used for the survey. The questionnaire was divided into 3 parts beginning with the written informed consent from all the participants in which they were assured of the confidentiality of their responses to the succeeding questionnaire followed by socio-demographic and lifestyle characteristics of the women including name, age, gender, university, level of education, date of birth, marital status and place of residence. Elements related to reproductive and menstrual characteristics such as the age of menarche, duration of the cycle, estimated pain experienced by the women during menstruation, approximate daily flow, history of dysmenorrhea in the immediate family, and quantification of the degree of pain on Numeric Pain Relating Scale (NPRS) classifying mild dysmenorrhea between 1\u0026ndash;3 points, moderate between 4\u0026ndash;7 points and severe between 8\u0026ndash;10 points were also included in this segment of the questionnaire. The subsequent part is comprised of questions specifying the characteristics of PD such as the location of the pain, the character of the pain, the effect of dysmenorrhea on daily activities, and modifiable risk factors; diet, physical activity, stress, and sleep. The third portion included the calculation of BMI. The height and weight were self-reported and BMI was calculated using the formula weight in kg divided by height in meters squared. Based on the BMI recommendations from the World Health Organization, it was categorized into four groups underweight (\u0026lt;\u0026thinsp;18.5), normal (18.5\u0026ndash;24.9), overweight (25-29.99), or obese (\u0026ge;\u0026thinsp;30).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eInclusion Criteria\u003c/h2\u003e \u003cp\u003eWomen belonging to the age group 18\u0026ndash;24, from 3 medical colleges, namely Army Medical College, Foundation University Medical College, and Rawalpindi Medical University, were included.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eExclusion Criteria\u003c/h2\u003e \u003cp\u003eWomen diagnosed with any gynecological pathologies like uterine fibroids, endometriosis, or pelvic adhesions were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData analysis was done with IBM SPSS 25. For all BMI groups, frequencies and percentages of the severity of dysmenorrhea were computed. The chi-square test of association and analysis of variance (one-way ANOVA) was applied. A value of p less than 0.05 was considered statistically significant.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e; History and Characteristics of Dysmenorrhea(n\u0026thinsp;=\u0026thinsp;250)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eHistory Of dysmenorrhea\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e221\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePain Location\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower Abdomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower Abdomen and back\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight side of abdomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft side of abdomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIdentify the character of pain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpasmodic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSharp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStinging\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFirst experience of menstrual pain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrom first period\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter 1\u0026ndash;2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter 3\u0026ndash;4 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter 5\u0026ndash;6 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLength of pain\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1 day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEntire period\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEffect on daily activities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e174\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePain starts for each period\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst or second day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDo any of the following activities affect pain?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Diet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExercise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePain associated with any autonomic reaction?\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNausea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVomiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePain is relieved by\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNSAIDS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInjections\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHot packs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnti-spasmodic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThis study explored that 221 (88.4%) students were suffering from dysmenorrhea, with 42 (19%) having mild, 100 (45.2%) moderate, and 79 (35.7%) having severe dysmenorrhea. Several PD characteristics are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The lower back and abdomen were indicated by the majority of participants (67%) as the most common sites of pain. For 44% of the individuals, the pain began with their first menstrual cycle. Of the respondents, 57.1% reported that their menstrual pain lasts for two days. For 46.6% of the participants, NSAIDS were beneficial for pain relief.\u003c/p\u003e \u003cp\u003eFigure 1 shows the relation of pain intensity with the intensity of bleeding. The intensity of pain increased with heavy menstrual flow. Statistical significance was established.\u003c/p\u003e\n\u003cp\u003eFigure 2 highlights the factors that influence pain. Pain was either relieved or aggravated by the type of diet in 16% of the subjects. 31% reported that stress increased pain intensity, while in 20% of the subjects, exercise affected pain. 33% revealed that sleep relieved pain.\u003c/p\u003e\u003cp\u003eThe distribution of mild, moderate, and severe dysmenorrhea in underweight, normal weight, overweight, and obese groups is shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The prevalence of mild, moderate, and severe dysmenorrhea was greater in patients with a normal BMI (52.4%, 53%, and 53.2%, respectively) compared to other BMI groups. However, a statistical significance could not be established (p-value 0.06).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e; Relation between Body Mass Index (BMI) and Primary Dysmenorrhea (n\u0026thinsp;=\u0026thinsp;250)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003eDysmenorrhea\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo Pain, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMild Pain, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate Pain, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSevere Pain, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnderweight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (26.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 (34.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (82.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (52.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53 (53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42 (53.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverweight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (16.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8 (10.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObese\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (2.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eP-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 is considered statistically significant\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this study, which involved 250 students between the ages of 18 and 24, it was explored that 221 (88.4%) had PD, of whom 42 (19%) had mild, 100 (45.2%) had moderate, and 79 (35.7%) had severe dysmenorrhea. The results align with recent review articles that suggest 16\u0026ndash;90% of young females experience dysmenorrhea, with 2\u0026ndash;29% experiencing pain severe enough to restrict their daily activities \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFor young females, PD is one of the most common reasons for class absenteeism. 78.7% of the students in our study reported that having dysmenorrhea had a detrimental impact on their everyday activities and academic performance. These findings support earlier research that shows that class absenteeism and lack of concentration and focus influence the educational performance of the majority of dysmenorrheic females (60.4 percent) \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Furthermore, Minaleshewa et al. found that 51.4% of their PD respondents had a decline in academic performance, and 63% of them experienced social withdrawal \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLower abdomen and back were the most frequently reported sites of dysmenorrheic pain (67%) among the study participants. For 43.9% of the participants, pain began a year after menarche, while another 39.8% started experiencing pain 1\u0026ndash;2 years after their first menstruation. For 57.1% of the participants, menstrual pain persists for two days. For each menstrual period, 41.2% of the subjects reported that pain starts a day before, while 37.6% feel it on the first day. 57% of the participants reported having spasmodic pain, whereas 27.1% reported sharp pain. 34% of participants in Kural et al.'s study reported diffuse lower abdomen pain, with the majority (68%) reporting spasmodic pain \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. Uterine contractions caused by increased prostaglandin production in the menstruating uterus may cause spasmodic discomfort in these subjects \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. Pain was associated with nausea in 25.3% and diarrhea in 17.6% of the subjects, while 48.4% reported that it was not associated with any autonomic reactions. Pain relief was achieved in 44.3% of our subjects with hot packs and 46.4% of our subjects by the use of NSAIDs. This result supports the substantial correlation between prostaglandins and PD, as NSAIDs reduce pain by inhibiting the production of prostaglandins \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMany studies in the current literature have shown that a variety of modifiable and non-modifiable risk factors can be linked to PD. In our study, age at menarche, family history, average daily flow, duration of menstruation, and lifestyle factors are the considered risk factors. Early menarche, i.e. menarche before 11 years of age, was reported by 3.2% of the subjects. Some studies \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e7\u003c/span\u003e] [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e reported a higher dysmenorrhea frequency in women who had menarche at an early age. However, in our study, the age of menarche was not independently associated with dysmenorrhea (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). This might be due to the reason that only 8 subjects out of 221 had an early menarche, so the results cannot be generalized. Burnett et al. have reported similar results \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThere was a positive association between a history of dysmenorrhea in the immediate family and the severity of PD in the current study (p\u0026thinsp;=\u0026thinsp;0.016). Results of previous studies also support this association \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e16\u003c/span\u003e], [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e7\u003c/span\u003e], [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e9\u003c/span\u003e], [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. There are two possible reasons for this association; the first points to the girls' behavioral modeling after their mothers or sisters, and the second reason can be explained by genetic factors. The findings of a study conducted by Silberg et al. on 1200 pairs of monozygotic and dizygotic twin sisters indicated that PD was caused by both genetic and environmental factors \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA longer duration of menstruation (more than 7 days) was reported by 6.4% of the subjects, while 93.6% had normal duration i.e. 3\u0026ndash;7 days. Statistical significance was not established between the duration of menstruation and the intensity of dysmenorrhea (p-value 0.6). The significant difference between the percentages of subjects with normal and prolonged duration of menstruation may have distorted the results. In contrast, some studies in the literature reported a positive association between longer duration of menstruation and intensity of dysmenorrhea \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e9\u003c/span\u003e] [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e13\u003c/span\u003e] [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSubjects who frequently engage in physical activities and have an active lifestyle reportedly feel less pain, as compared to those who have a sedentary lifestyle, with little to no physical activity. A positive association was established between an active engagement in physical activity and lesser intensity of pain (p\u0026thinsp;=\u0026thinsp;0.015). This finding is consistent with the previous studies \u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e27\u003c/span\u003e] [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e and furthers the fact that maintaining a healthy and active lifestyle can reduce the intensity of PD.\u003c/p\u003e \u003cp\u003eIn the current study, 9.6% of subjects reported light flow, 83.2% moderate, and 7.2% heavy bleeding. A heavier intensity of bleeding was associated with a higher severity of PD (p\u0026thinsp;=\u0026thinsp;0.009). Similar results were reported in previous studies \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e7\u003c/span\u003e] [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e10\u003c/span\u003e] [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. In contrast, no correlation was found between the duration of the menstrual cycle and the intensity of pain, in a study conducted among 276 Japanese women aged 19 to 24 years \u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. The use of different scales for grading the severity of dysmenorrhea can explain this disparity.\u003c/p\u003e \u003cp\u003eThe study explored that pain during menstruation was influenced by four factors; diet, exercise, sleep, and stress. 34 subjects (15.4%) reported that the type of diet during menstruation either aggravated or relieved their pain. Hot beverages like tea, warm foods, fruits, vegetables, and eggs reportedly relieved pain, while cold beverages like soft drinks, ice cream, and caffeinated products like coffee aggravated pain. Faramarzi et al. reported that dysmenorrhea was two times higher in women with high caffeine intake \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e, while a study conducted among Spanish university students revealed that consumption of cola drinks was a statistically significant risk factor \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Some studies \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e in the literature have established association of dysmenorrhea with poor mental health, stress, anxiety, and depression. 69 subjects (31.2%) mentioned increased intensity of pain during stress. Results of a study by Hong Ju et al. revealed a positive association between perceived stress, related to work or general life events, and the risk of dysmenorrhea \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. The molecular mechanisms linking work stress to dysmenorrhea are not completely understood, however, it potentially includes a cascade of neuroendocrine reactions. Stress-related hormones, including adrenaline and cortisol, appear to influence prostaglandin synthesis and/or binding in the myometrium \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. In the current study, 45 students (20.4%) reported that their pain was influenced by exercise, while 73 (33.0%) revealed that their pain was relieved during sleep.\u003c/p\u003e \u003cp\u003eAmong diet, sleep, stress, and exercise, only sleep was statistically significant (p\u0026thinsp;=\u0026thinsp;0.047). Pain is a perception rather than a sensation, and during sleep, the pain sensitivity might be lowered in the case of mild pain. Some studies reported that severe dysmenorrheic pain significantly reduced the quality of sleep, therefore, sleep was not a relieving factor in that case. However, some studies reported that inconclusive evidence was found for these modifiable factors \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe present study revealed that the severity of dysmenorrhea was not associated with body mass index (pvalue 0.06). This finding is in line with a few previous studies \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e17\u003c/span\u003e] [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Sundell et al \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e found that the severity of dysmenorrhea was not associated with either height or weight. However, a limitation of the present study was that, out of all study participants, 56.4% were females of normal weight, 25.6% underweight, 14.8% overweight, and only 3.2% obese. There may have been a bias in the results due to this unequal distribution of subjects in different BMI groups.\u003c/p\u003e \u003cp\u003eOn the other hand, previous studies have reported different associations with BMI. Studies by Mohapatra et al. \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e and Rafique et al. \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e show a significant association between PD and low BMI. However, the exact pathophysiological mechanisms behind this link remain unclear. Given that a certain amount of body fat is necessary for healthy menstrual cycles and ovulation, and that a lack of fat can cause ovulatory, menstrual, and reproductive issues, it is possible that irregular menstruation and disturbed ovulation can change the estrogen/progesterone ratio, which in turn can increase prostaglandin production and cause PD \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. Snehalata et al. found a positive correlation between PD and higher BMI in their subjects and showed that the severity of PD increased with increasing BMI \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. A U-shaped association between BMI and PD was found in Hong et al.'s prospective study, indicating that females who are underweight or overweight/obese are more likely to experience PD \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study assessed the severity of PD using the NPRS, associated it with BMI, and investigated additional PD risk factors. However, this study's cross-sectional design meant that it was unable to determine the impact of either increasing or decreasing BMI on PD. Additionally, no medical examinations or investigations were performed; the diagnosis of PD was made solely based on the patient's history. The impact of additional confounding variables, such as irregular menstrual cycles, oral contraceptive pill use, parity, smoking, and alcohol intake, was not taken into account. Furthermore, the study of pain is challenging because firstly, pain is a subjective matter, and people's perceptions of pain are influenced by a variety of circumstances when determining its intensity. Secondly, different studies on dysmenorrhea used different scales to score its intensity, and so comparison of the results with other studies can be affected.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThis study concludes that PD affects a significant percentage of young females, negatively impacting their everyday activities and academic performance. Additionally, it was shown that the majority of respondents' pain was reduced by NSAIDs, therefore, confirming that PD is caused by increased prostaglandin synthesis. Our results showed that family history of dysmenorrhea and heavy intensity of menstrual bleeding are the important risk factors. In addition, we did not find any correlation between BMI and PD. However, concerning lifestyle and eating habits, based on our results and previous reports, further studies are necessary to provide or confirm recommendations on the most advisable diets or lifestyle changes for reducing the risk of suffering from dysmenorrhea.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThis research project, titled \u0026quot;Relation of Primary Dysmenorrhea with BMI and Associated Risk Factors among Medical Students of Rawalpindi\u0026quot;, has been reviewed and approved by the Army Medical College Ethical Review Committee. The committee has evaluated the study\u0026apos;s ethical considerations, ensuring that it complies with established guidelines for research involving human subjects.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePatel V, Tanksale V, Sahasrabhojanee M, et al.: The burden and determinants of dysmenorrhoea: a population-based survey of 2262 women in Goa, India. BJOG. 2006, 113(4):453-63. 10.1111/j.1471- 0528.2006.00874.x\u003c/li\u003e\n\u003cli\u003eKumar P, Malhotra N. : Jeffcoate\u0026rsquo;s Principles of Gynecology. Jaypee Brothers Medical Pub, India; 2014. 10.5005/jp/books/11155\u003c/li\u003e\n\u003cli\u003eBerkley KJ.: Primary dysmenorrhea: an urgent mandate . Pain . 2013, 1(1):8.\u003c/li\u003e\n\u003cli\u003eDerseh BT, Afessa N, Temesgen M : Prevalence of dysmenorrhea and its effects on school performance: A cross-sectional study. J Womens Health Care . 2017, 6:361. 10.4172/2167-0420.1000361 \u003c/li\u003e\n\u003cli\u003eUnsal, Alaettin : Prevalence of dysmenorrhea and its effect on quality of life among a group of female university students . Upsala Journal of Medical Sciences . 2010, 115,2:138-145. 10.3109/03009730903457218\u003c/li\u003e\n\u003cli\u003eDorn LD, Negriff S, Huang B : Menstrual symptoms in adolescent girls: association with smoking, depressive symptoms, and anxiety . J Adolesc Health. 2009, 44(3):237-43. 10.1016/j.jadohealth.2008.07.018\u003c/li\u003e\n\u003cli\u003eHabibi N, Huang MSL, Gan WY, Zulida R, Safavi SM: Prevalence of Primary Dysmenorrhea and Factors Associated with Its Intensity Among Undergraduate Students: A Cross-Sectional Study. Pain Manag Nurs. 2015, 16:855-861. 10.1016/j.pmn.2015.07.001\u003c/li\u003e\n\u003cli\u003eFisher C, Adams J, Hickman L, Sibbritt D: The use of complementary and alternative medicine by 7427 Australian women with cyclic perimenstrual pain and discomfort: a cross-sectional study. BMC Complement Altern Med. BioMed Central. 2016, 16:129. 10.1186/s12906-016-1119-8\u003c/li\u003e\n\u003cli\u003eFern\u0026aacute;ndez-Mart\u0026iacute;nez E, Onieva-Zafra MD, Parra-Fern\u0026aacute;ndez ML: Lifestyle and prevalence of dysmenorrhea among Spanish female university students. PLoS ONE . 2018, 13:8. 10.1371/journal.pone.0201894\u003c/li\u003e\n\u003cli\u003eAbdel-Salam DM, Alnuman RW, Alrwuaili RM, Alrwuaili GA, Alrwuaili EM: Epidemiological aspects of dysmenorrhea among female students at Jouf University, Saudi Arabia. Middle East Fertil Soc J. 2018, 23(4):435-9. 10.1016/j.mefs.2018.08.001\u003c/li\u003e\n\u003cli\u003eWang L, Wang X, Wang W, et al.: Stress and dysmenorrhoea: a population based prospective study . Occup Environ Med. 2004, 61:12.\u003c/li\u003e\n\u003cli\u003eSundell G, Milsom I, Andersch B: Factors influencing the prevalence and severity of dysmenorrhoea in young women. Br J Obstet Gynaecol. 1990, 97-7. 10.1111/j.1471-0528.1990.tb02545.x\u003c/li\u003e\n\u003cli\u003eFaramarzi, Mahbobeh, and Hajar Salmalian: Association of psychologic and nonpsychologic factors with primary dysmenorrhea.. Iranian Red Crescent medical journal vol. 16,8. 2014:16307. 10.5812/ircmj.16307\u003c/li\u003e\n\u003cli\u003eBalbi C, Musone R, Menditto A, et al.: Influence of menstrual factors and dietary habits on menstrual pain in adolescence age. Eur J Obstet Gynecol Reprod Biol. 2000, 91:143-148. 10.1016/S0301-2115(99)00277-8\u003c/li\u003e\n\u003cli\u003eRafique, Nazish, and Mona H. Al‐Sheikh: Prevalence of primary dysmenorrhea and its relationship with body mass index.. Journal of Obstetrics and Gynaecology Research. 9:1773-1778. 10.1111/jog.13697\u003c/li\u003e\n\u003cli\u003eJu H, Jones M, Mishra G: The prevalence and risk factors of dysmenorrhea . Epidemiol Rev. 2014, 36:104-113. 10.1093/epirev/mxt009\u003c/li\u003e\n\u003cli\u003eDavaneghi S, Dahri M: Association between body mass index, diet and physical activity with primary dysmenorrhea severity pain in university students. Nutr Food Sci Res. 2014, 1:250.\u003c/li\u003e\n\u003cli\u003eRafique N, al-Sheikh M: Prevalence of menstrual problems and their association with psychological stress in young female students studying health sciences. Saudi Med J. 2018:67-73. 10.15537/smj.2018.1.21438\u003c/li\u003e\n\u003cli\u003eMohapatra D, Mishra T, Behera M, Panda P: A study of relation between body mass index and dysmenorrhea and its impact on daily activities of medical students. Asian J Pharm Clin Res. 2016, 9:297-299. 10.22159/ajpcr.2016.v9s3.14753\u003c/li\u003e\n\u003cli\u003eSnehalata T, Mahesh MA: Relationship between body mass composition and primary dysmenorrhoea . Indian J Physiother Occup Ther. 2016, 10:76-81. 10.5958/0973-5674.2016.00017.4\u003c/li\u003e\n\u003cli\u003eJu H, Jones M, Mishra GD: A U-shaped relationship between body mass index and dysmenorrhea: A longitudinal study. PLoS One. 2012, 134187:10. 10.1371/journal.pone.0134187\u003c/li\u003e\n\u003cli\u003eGebeyehu MB, Mekuria MB, Tefera YG : Prevalence, impact, and management practice of dysmenorrhea among University of Gondar Students, Northwestern Ethiopia: A cross-sectional study. Int J Repro Med. 2017:8. 10.1155/2017/3208276\u003c/li\u003e\n\u003cli\u003eKural, MoolRaj: Menstrual characteristics and prevalence of dysmenorrhea in college going girls. . Journal of family medicine and primary care vol. 4,3. 2015:426-31. 10.4103/2249-4863.161345\u003c/li\u003e\n\u003cli\u003eChan WY, Yusoff Dawood M, Fuchs F: Prostaglandins in primary dysmenorrhea: comparison of prophylactic and nonprophylactic treatment with ibuprofen and use of oral contraceptives. Am J Med. 1981, 70:535-541. 10.1016/0002-9343(81)90576-3\u003c/li\u003e\n\u003cli\u003eBurnett MA, Antao V, Black A: Prevalence of primary dysmenorrhea in Canada . J Obstet Gynaecol Can. 2005, 27:765-70. 10.1016/s1701-216330728-9\u003c/li\u003e\n\u003cli\u003eSilberg, J.L., Martin, N.G. \u0026amp; Heath, A.C: Genetic and environmental factors in primary dysmenorrhea and its relationship to anxiety, depression, and neuroticism. Behav Genet. 17, 363:383. 10.1007/BF01068137\u003c/li\u003e\n\u003cli\u003eDehnavi, Zahra Mohebbi : The Effect of aerobic exercise on primary dysmenorrhea: A clinical trial study. . Journal of education and health promotion vol. 7. 3-10. 10.4103/jehp.jehp_79_17\u003c/li\u003e\n\u003cli\u003eGamit KS, Sheth MS, Vyas NJ: The effect of stretching exercise on primary dysmenorrhea in adult girls . Int J MedSci Public Health. 2014, 3:10.5455/ijmsph.2014.210220142\u003c/li\u003e\n\u003cli\u003eNagata C, Hirokawa K, Shimizu N : Associations of menstrual pain with intakes of soy, fat and dietary fiber in Japanese women. Eur J Clin Nutr. 59:88-92. 10.1038/sj.ejcn.1602042\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Army Medical College","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"primary dysmenorrhea, prevalence, BMI, risk factors, dysmenorrhea","lastPublishedDoi":"10.21203/rs.3.rs-4637677/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4637677/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePrimary dysmenorrhea (PD) is one of the most common gynecological complaints in women of childbearing age, which severely impacts their quality of life.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThe study aims to investigate the prevalence of dysmenorrhea among women of different ranges of Body Mass Index (BMI) and its associated risk factors.\u003c/p\u003e\u003ch2\u003eMethodology:\u003c/h2\u003e \u003cp\u003e 250 students (aged 18\u0026ndash;24) from three medical colleges; Army Medical College, Foundation University Medical College, and Rawalpindi Medical University, participated in this cross-sectional survey. They were subjected to a pretested and structured questionnaire comprising 30 questions regarding their menstrual characteristics, risk factors of dysmenorrhea, and their weights and heights. BMI was calculated. Descriptive and analytical statistics were conducted using chi-square and ANOVA. A p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBased on this study, 88.4% of the students had PD, with 19% having mild, 45.2% having moderate, and 35.7% having severe dysmenorrhea. 78% of the students stated that dysmenorrhea makes it difficult for them to go about their everyday lives. Among the risk factors, family history, and intensity of bleeding were statistically significant. Any relation between age at menarche and duration of menstruation was not established. Among the modifiable factors i.e. diet, sleep, stress, and exercise, only sleep was considered statistically significant. Chiefly, no association was found between BMI and intensity of dysmenorrhea.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eA high prevalence of PD was detected among young women between 18\u0026ndash;24 years of age. Family history, intensity of bleeding, and an inactive lifestyle were found to be the important risk factors for PD. However, no correlation was observed between BMI and PD.\u003c/p\u003e","manuscriptTitle":"Relation of Primary Dysmenorrhea with BMI and Associated Risk Factors among Medical Students of Rawalpindi","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-28 09:00:19","doi":"10.21203/rs.3.rs-4637677/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"78858747-6048-4740-ae4d-67aa8e844643","owner":[],"postedDate":"June 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":33852117,"name":"Obstetrics \u0026 Gynecology"}],"tags":[],"updatedAt":"2024-06-28T09:00:19+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-28 09:00:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4637677","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4637677","identity":"rs-4637677","version":["v1"]},"buildId":"CiT4i_kKBbxQbnFL0ufpk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}