Dysmenorrhea in adolescents and young adults: a review in different country.

Dysmenorrhea is one of the most common gynecological disorders among adolescent girls. The syndrome of dysmenorrhea is known to encompass a wide variety of physical (and affective) symptoms ( 1 - 6 ). Dysmenorrhea can be divided into 2 broad categories of primary and secondary. Primary dysmenorrhea (PD) is defined as recurrent, crampy pain occurring with menses in the absence of identifiable pelvic pathology. It is unusual for symptoms to start within the first six months after menarche. Affected women experience sharp, intermittent spasmodic pain usually concentrated in the suprapubic area. Pain may radiate to the back of the legs or the lower back. Mood changes, fatigue, headache, nausea and edema during menstruation are reported with dysmenorrhea ( 1 - 6 ). Negative consequences of dysmenorrhoea may include impaired quality of personal and social life, mood disorders, sleep disturbance and limitation of usual daily activities ( 3 , 4 - 6 ). Pain usually begins somewhere between several hours before and a few hours after the onset of the menstrual bleeding. Symptoms peak with maximum blood flow and usually last less than one day, but pain may continue up to 2 to 3 days ( 3 , 4 - 6 ). Symptoms are comparatively reproducible from one menstrual period to the other ( 1 , 2 ). Pain intensity may be mild, moderate or severe based the adolescent’s description, degree of limitation of activities, and requirement for medication ( 1 , 2 ). Secondary dysmenorrhea (SD) is menstrual pain associated with an underlying pelvic pathology such as endometriosis, pelvic inflammatory disease, congenital müllerian anomalies and ovarian cysts. Its onset may be many years after the onset of menarche ( 1 , 2 , 5 ). A variety of physiological, environmental and behavioural factors might influence SD. Early onset of menarche ( 7 - 9 , 12 ), smoking ( 8 , 10 , 11 ), higher body mass index (BMI) ( 12 ), null parity ( 13 ), longer and heavier menstrual flow ( 9 , 12 , 14 ) and family history of dysmenorrhea ( 15 - 17 ) are among these factors. Depression and stress increase the risk of dysmenorrhea ( 18 ). Physical exercise, fish intake and use of oral contraceptives are protecting. ( 8 , 9 , 16 ). Other common factors, such as education and alcohol consumption show largely negative or inconclusive results ( 8 , 9 , 11 , 15 ). The association between dysmenorrhea and economic factors still need further research. The exact cause of the disorder is not completely understood. However, there are many known factors that play significant roles in the pathogenesis of dysmenorrhea. The most important are: excessive uterine contractility, disturbances in uterine blood supply, increased synthesis of prostaglandins (PG) and anatomical abnormalities of the female reproductive tract ( 19 - 21 ). It was shown that women with dysmenorrhea have higher levels of PG in their plasma and menstrual effluent than women without dysmenorrhea ( 19 - 21 ). Most of the release of prostaglandins during menstruation occurs within the first 48 hrs, which coincides with the greatest intensity of the symptoms ( 22 ). PG stimulates myometrium contractility and local vasoconstriction that cause the menstrual effluent to be expelled from the uterine cavity. Additionally, elevated serum vasopressin, nitric oxide and interleukin-6 levels have been reported in women with PD ( 23 - 25 ). Moreover, increased lipid peroxidation and elevated concentrations of free radicals occur during dysmenorrhea ( 26 - 28 ).

In the present literature review, two instruments were mainly used to measure the participants’ severity of dysmenorrhoea: Multi dimensional Scoring system (MSS) and a Visual Analog Scale (VAS). The first scoring system measured pain severity and took into account the impact of pain on daily activities, systemic symptoms and analgesic requirements. The MSS grading of pain is as follows: Grade 0: Menstruation is not painful and daily activities are not affected. Grade 1 (mild): Menstruation is painful but seldom inhibits normal activity. Pain killers are rarely required. Grade 2 (moderate): Menstruation is moderately painful and it affects daily activities. Pain killers are required; however they give sufficient relief so that absence from class is unusual. Grade 3 (severe): Menstruation is extremely painful and associated with vegetative symptoms (headache, fatigue, vomiting and diarrhea). Daily activities are clearly inhibited. Pain killers provide no relief. VAS was assessed with a linear analogue scale. This scale involves the use of a 10 cm line on a sheet of paper and represents the girls’ continuum of severity of pain beginning with “ no pain at all’’ and ending with “unbearable pain.” The participants were asked to rate the degree of pain by making a mark on line. The scores obtained from the scale were classified into mild dysmenorrhea if it was between 1-3 points, moderate between 4-7 points and severe between 8-10 points. Participants were instructed to evaluate their pain for the 6 menstrual days ( Table 1 , no. 49). Dysmenorrhea was found to be significantly associated with older age, earlier menarche, irregular or long cycle and heavy bleeding ( Table 1 , no. 9). However, in one study no significant correlation was found between age at menarche and severity of dysmenorrhea ( Table 1 , no. 41). One study reported that menstrual pain was related to stress, high temperature and humidity, age, BMI and number of births ( Table 1 , no. 28). The correlation between age and various degrees of dysmenorrhea was found to be statistically significant (χ 2 =5.32; p < 0.05). The highest percentage of the participants (32%) were 21 years of age followed by 20 years (29%) and than 22 years (16%) ( Table 1 , no. 41). About 50% of students (53.7%-47.4%) reported a family history of dysmenorrhea ( Table 1 , no. 16, 24,28,33 and 46). When logistic regression analysis was done, the risk of dysmenorrhea was 0.97 times lower as age increased (p <0.006) ( Table 1 , no. 50). In another study, univariate logistic regression analysis showed that eating chocolate, using oral contraceptive pills, age at first menstruation, menstrual frequency, and sister’s dysmenorrhea status affected participants’ dysmenorrhea status (p<0.05). The multivariate logistic regression model showed that those whose sister experienced dysmenorrhea were 0.2 times more likely to experience dysmenorrhea themselves than those whose sister did not have dysmenorrhea, and this finding was statistically significant ( Table 1 , no. 49). Certain diets may cause an increase in the symptoms and in the intensity of menstrual discomfort. The severity of dysmenorrhea was significantly correlated with daily meal pattern and the total daily protein intake (p<0.05) ( Table 1 , no.41). A good protein intake can help to reduce the symptoms of dysmenorrhea.

Published studies in English providing relevant information on dysmenorrhea were identified by searching PubMed, Embase and Google restricting the population to adolescents and young adult women and the year of publishing from 2010 to August 2015, based on the keywords ‘dysmenorrhea’, ‘adolescents’ and ‘epidemiology’. In addition, the reference lists of the selected articles were examined. Only a limited number of studies have been included in this review, instead of a meta-analysis, because of the profound heterogeneity in study populations, definition of dysmenorrhea and measurements of risk factors among the included studies.

Despite the high prevalence of dysmenorrhea in adolescents, many girls did not receive professional help or treatment ( Table 1 ). Mothers were the most important persons the girls turned to for answers regarding menstruation, followed by peers (52.9%) and school nurse ( Table 1 , no. 9 and 34). Wong and Khoo in their study reported that in spite of the high prevalence and enormous impact of dysmenorrhea on the lives of participants, 76% believed that dysmenorrhea was a normal part of the female menstrual cycle and only 14.8% sought medical treatment ( Table 1 , no. 35). This suggested that culture may influence the experience and interpretation of symptoms such as pain and the way in which they are treated. Several remedies were used to reduce pain and duration of dysmenorrhea. Household remedies were used by 43% of the students ( Table 1 , no. 37). Methods such as herbal remedies, traditional Chinese medicine, hot drinks, or sports, herbal tea, coffee, physiotherapy massage, heat application, rest and distraction for pain management have been also reported ( Table 1 , no. 5, 9, 14, 21, 24, 37, 41 and 48). From 21% to 96% practised self-medication either by pharmacological or non pharmacological interventions ( Table 1 , no. 14, 24, 37). The most common strategies reported were resting (65.1%), taking an analgesic (54.6%), locally applying heat packs (63.2%), drinking herbal tea (32.2%), taking a hot shower (37.1%), and walking (21.6%). On the other hand, 19.1% applied to an emergency department ( Table 1 , no. 49). When dysmenorrhea was severe, analgesics, nonsteroidal anti-inflammatory drugs (NSAID), aspirin, antispasmodics or “calmative drugs” were used by a high proportion of subjects. However, only few girls reported seeking medical advice ( Table 1 , no. 9, 13, 14, 15, 24, 34, 35, 37 and 43). The use of oral contraceptives for menstrual problems was minimal. Medication dosing was often sub-therapeutic. Effect of the analgesics used on menstrual blood flow was studied. One hundred and seventy-seven (88.5%) of the students reported no effect on blood flow, 22 (11%) had decreased blood and 1 (0.5%) reported increase in blood flow when using aspirin as a pain-killer.

Morbidity due to dysmenorrhea represents a substantial public health burden because it is one of the leading causes of absenteeism from school and work and is responsible for significant loss of earnings and diminished quality of life ( 29 - 34 ). A number of recent studies have determined the prevalence of dysmenorrhoea with estimates ranging from 20-90%, probably depending on variable methods of data collection, different definitions of dysmenorrhea and diverse study populations ( Table 1 ). The wide prevalence variation may also be due to the focus on selected groups of subjects instead of a representative sample from the population of women in the local community ( 35 , 36 ). The limitation of these studies was that they did not distinguish between PD and SD, and most of the them did not evaluate the degree of menstrual pain ( 37 , 38 ). In approximately 10% of adolescents and young adults with severe dysmenorrhea pelvic abnormalities such as endometriosis or uterine anomalies were found. Adolescents received information regarding menstruation from variable sources. Mothers were the major source while only few received information about menstruation and related symptoms from their healthcare providers. Therefore, it has been recommended that adolescent care providers should be able to care for these girls in a more efficient way ( 39 - 42 ). In our survey, many adolescent girls self-medicate with paracetamol or NSAIDs. Some girls even go to the extent of using these medications in nontherapeutic doses for quick pain relief. The negative aspect of self-medication is that most people are not cognizant of the side effects and it is also possible that correct dosage may not be used. Appropriate counselling and management should be instituted among female students to help them cope with the challenges of dysmenorrhea. Information, education and support should also be extended to parents, school peer leaders, and hostel administrators in order to address the reproductive health needs of the female students. In summary, studying the epidemiology and natural progression of menstrual pain is an interesting issue that deserves further attention because of its high prevalence and possible significant negative consequence on women health. In order to reach this goal, the following recommendations have been reported in the literature: Dysmenorrhea is one of the most common complaints among adolescents and women of young reproductive age. Morbidities, including school absenteeism, are higher among those with severe dysmenorrhea. Since only 2% of adolescents received information regarding menstruation from their health care provider, it is imperative that health care providers increase their anticipatory guidance regarding normal menstruation. This may aid in the prompt diagnosis and treatment of menstrual disorders to minimise the impact on school, sports, social and daily activities and decrease their associated morbidities ( 30 , 42 ). Earlier age at menarche, long menstrual periods, heavy menstrual flow, smoking, positive family history, obesity and alcohol consumption are associated with more severe episodes of dysmenorrhea. Therefore, lifestyle modifications and promoting healthy eating habits should be highlighted in school health education programs to improve menstrual health ( 9 , 43 ) Information, education and support should also be extended to parents in order to address the reproductive health needs of the female students ( 44 ). Clinicians need to identify menstrual abnormalities as early as possible in order to minimize their possible consequences and to promote proper management (48,49). We recommend encouraging adolescents to chart their menstrual frequency and regularity prospectively from menarche onwards ( 45 , 46 ). Those adolescents who do not respond to simple medical management should be considered for further investigation for possible underlying pathology, such as endometriosis ( 47 ).

The main aim of this paper is to review the epidemiology of dysmenorrhoea in different countries, the methods used for the assessment of dysmenorrhea and its effect on this public health burden.

We found 50 studies that met our inclusion criteria. The majority were cross-sectional studies on 41,140 adolescents and young women published from 2010 onward ( Table 1 ). Summary of studies on dysmenorrhea in different countries from 2010 to 2015 The prevalence of dysmenorrhea varied greatly from 94% (Oman), 59.8% (Bangladesh), 34% (Egypt) ( Table 1 , no. 8 and 36) to 0.9% (Korea) ( Table 1 , no. 3 and 33). Menstrual pain frequently occurred on the first day of menstruation (77.8%) ( Table 1 , no. 49). Mid-cycle pain was reported by 30.9% and 33.9% experienced dysmenorrhea every month ( Table 1 , no. 31 and 19). 42.6% of students showed menstrual cramps lasting between 24 and 48 hours ( Table 1 , no. 5). The most common dysmenorrhea symptoms were abdominal cramps (53.2%), low-back pain (34.2%) and fatigue (21.6%) ( Table 1 , no.28). The most common associations were nervousness and depression (70%), followed by sleeplessness (50%) and headache (42%). Nausea and vomiting were observed only in 15% of adolescents. ( Table 1 , no. 41). Some participants had dysuria with the dysmenorrhoea and hence they felt reluctant to pass urine ( Table 1 , no. 13).

Adolescents who missed school due to dysmenorrhoea were from 7.7% to 57.8% ( Table 1 , ref. 3, 10) and 140 (21.5%) missed social activities ( Table 1 , no. 44). School absenteeism was due to lack of class concentration during their period 209 (79.4%), poor class attendance 72 (27.3%) and concentration on pain 52 (19.7%). During menstruation days students didn’t come to school or even if they came, they didn’t attend class attentively thinking of the sudden leakage or the pain associated with menstruation. They didn’t come to school even if they have an exam or didn’t do the test with concentration when menstruation days coincided with exam days. They didn’t stand in front of students to answer questions or to write on the board fearing the sudden leakage of blood and staining of their clothes ( Table 1 , no. 10). Academic performance was affected by menstruation in several ways; mainly study time (76%), concentration (65.8%), participation in group activities (58.1%), examination performance (51.8%) and class attendance (40.8%) ( Table 1 , no. 2). Some participants could not undertake their normal activities during the pain, they became irritable and were not able to relate well with friends and family. Over half (53.6%) of the students preferred to be alone, 2.7% became more sociable and the social life of the remaining (43.7%) was not affected during menstruation ( Table 1 , no. 2 and 40). Furthermore, short sleeping hours (< 6/day) were associated with moderate-severe dysmenorrhea (OR = 3.05, 95%CI: 1.06-8.77), and sports activity levels were associated with severe dysmenorrhea (p for trend= 0.045) ( Table 1 , no.30). Sleep disturbance (26%) was also observed in 26% of University students in Hong Kong ( Table 1 , no. 14). Only 79 girls (32%) had a bath on the first day of their menstrual period. Furthermore, 162 girls (65%) did not have a bath in the early days of their menstruation cycle, out of which 85 girls (51.5%) did not have a bath even after eight days from the beginning of their menstrual period ( Table 1 , no. 38). Dietary intake changed in 73.9% of the students with almost equal proportions reporting eating more (36.4%) and eating less (37.3%). There was a high tendency to eat more chocolate (59.4%) and other sweets (43.9%) while consumption of savouries, soft drinks, tea/coffee, dairy products and junk food were not that affected ( Table 1 , no. 2).There were statistically significant differences by medical year for the intake of chocolate and soft drinks only. The proportions of students increasing their chocolate intake during the menstrual period were 61.5% (year 1), 54.1% (year 2), 60.0% (year 3), 70.7% (year 4), 38.2% (year 5) and 68.4% (year 6). For soft drinks, the corresponding percentages were 28.9%, 16.2%, 14.7%, 15.4%, 6.2% and 10.8%, respectively ( Table 1 , no. 2).

Dysmenorrhoea (76%), premenstrual symptoms (PMS, 69%) and irregularity of cycles (29%) were the most frequent menstrual abnormalities observed in one study. The duration of pre-menstrual syndrome was 1.5± 0.7 days ( Table 1 , no. 18). The increase in BMI was shown in a study to have a highly significant association with PMS (p< 0.001). This study also showed a highly significant association between physical activity and PMS (p: 0.01) ( Table 1 , no. 7). The duration of pre-menstrual syndrome was 1.5± 0.7 days. The students were questioned regarding work days lost due to dysmenorrhoea and 50 (25%) reported losing 1.5±1.0 days ( Table 1 , no. 49).