Impact of dysmenorrhea on academic performance and quality of life among female medical students: A pilot study

Dysmenorrhea is one of the most common gynecological conditions affecting women of reproductive age and is characterized by painful uterine contractions during menstruation that can significantly disrupt daily activities and overall wellbeing.[ 1 2 ] Beyond physical pain, dysmenorrhea has been associated with emotional distress, sleep disturbances, reduced productivity, and impaired quality of life, making it an important yet often underestimated public health issue.[ 3 4 5 ] Recent research increasingly recognizes dysmenorrhea not merely as a transient menstrual symptom but as a condition with broader psychosocial and functional consequences, particularly among adolescents and young adults.[ 6 ] University students, especially those enrolled in medical programs, may be particularly vulnerable to these effects. Medical education is inherently demanding, requiring prolonged study hours, sustained concentration, and frequent assessments under considerable psychological pressure.[ 7 ] In this context, menstrual pain and its associated symptoms can negatively affect class attendance, academic engagement, and examination performance, ultimately compromising both educational outcomes and quality of life.[ 8 9 ] From a health promotion standpoint, menstrual health among medical students warrants special attention as this group represents future healthcare providers who will play a critical role in patient education and advocacy.[ 10 ] Although dysmenorrhea has been widely studied worldwide, much of the available evidence originates from high-income settings, with comparatively limited data from the Middle East.[ 11 12 ] In Iraq, menstrual health—particularly among female medical students—remains under-represented in the literature. The novelty of the present study lies not in establishing the global prevalence of dysmenorrhea but in contextualizing its impact within Iraqi female medical students and examining how menstrual pain intersects with academic performance and quality of life in a highly demanding educational environment.[ 13 ] By addressing both academic and psychosocial dimensions, this study provides locally relevant evidence that is largely absent from regional research. Despite their medical knowledge, several studies have shown that medical students often underutilize professional healthcare services for menstrual problems, relying instead on self-medication or informal coping strategies.[ 14 15 ] This paradox—where future healthcare professionals avoid seeking care for a common and treatable condition—may reflect time constraints, normalization of pain, perceived stigma surrounding menstruation, or a culture of self-reliance embedded within medical training.[ 16 ] Exploring these behaviors is essential for developing institution-based health promotion strategies that encourage appropriate care-seeking and effective self-management. Figure 1 illustrates the conceptual framework guiding this study. Drawing on biopsychosocial and health promotion models, the framework proposes that dysmenorrhea severity contributes to physical symptoms and emotional distress, which in turn affect daily functioning, academic engagement, coping behaviors, and health-seeking practices. Together, these pathways influence overall quality of life and academic performance among female medical students.[ 17 ] Clinical burden profile of dysmenorrhea among participants. Distribution of pain severity, recurrence pattern, duration, and commonly reported associated symptoms Therefore, to address the existing gap in local evidence, this pilot study aimed to assess the prevalence of dysmenorrhea and to evaluate its impact on academic performance, quality-of-life-related domains, coping strategies, and health-seeking behavior among Iraqi female medical students.

A total of 100 female medical students participated in the study. Participants were aged 18–25 years, with most in the 18–19 (44%) and 20–21 (43%) year groups. Students from all academic years were represented, and all participants were unmarried. The distribution of age and year of study is shown in Table 1 . Distribution of participants by year of study and age group Dysmenorrhea was reported by 89% of participants. Menstrual cycles were regular in 57%, occasionally irregular in 34%, and irregular in 9%. The most common duration of menstrual bleeding was 6–7 days (50%), followed by 3–5 days (45%). Pain intensity was high, with 72% reporting severe pain, 22% moderate pain, and 6% mild pain. Pain occurred during every menstrual cycle in 42% and during most cycles in 35%. The duration of pain was typically 1–2 days (66%), although one quarter of participants reported pain lasting more than 4 days. The lower abdomen was the most frequent pain location, followed by the lower back and thighs [ Table 2 ]. Menstrual and dysmenorrhea characteristics of participants ( n =100) *”Multiple responses allowed” Overall, the clinical burden of dysmenorrhea was substantial, combining high severity, recurrent occurrence, and multiple associated symptoms [ Figure 1 ]. Dysmenorrhea was associated with noticeable academic impairment, although absenteeism remained limited. While 62% reported difficulty attending classes, most students continued attending lectures. Twenty-nine percent missed one to two classes per menstrual cycle, and 9% missed three to four classes. Reduced concentration during lectures was highly prevalent (92%). The degree of impairment was slight in 29%, moderate in 44%, and severe in 19% of participants. Missed or postponed examinations occurred in 18% of students. Additional academic effects included increased academic stress (35.3%), difficulty completing assignments (22.1%), and self-reported lower grades (9%). Only a small minority (1.6%) reported no academic impact. Detailed academic outcomes are summarized in Table 3 . Academic functioning outcomes associated with dysmenorrhea ( n =100) Dysmenorrhea affected multiple aspects of daily life. Moderate-to-severe impairment was reported in daily activities (65%), emotional wellbeing (73%), and sleep quality (79%). These findings indicate a broad effect extending beyond pain to psychological and behavioral functioning [ Figure 2 ]. Multidimensional quality-of-life impairment associated with dysmenorrhea. Proportion of participants reporting moderate-to-severe impairment in daily activities, emotional wellbeing, and sleep quality Most participants used at least one method to manage menstrual pain. The most common strategies were rest (31.5%), over-the-counter analgesics (27.9%), and heat therapy (18.8%). Less frequently reported approaches included herbal remedies, exercise, dietary modification, and prescription medication. A small proportion (4.6%) reported no pain-relief method. Despite the high prevalence and severity of symptoms, only 13% sought medical consultation, while the majority relied on self-management. Most participants reported no specific barriers to care, although some cited lack of information, embarrassment, access limitations, or cost concerns. Adequate social support was reported by 73% of students [ Table 4 ]. Coping strategies and health-seeking behavior among participants

Dysmenorrhea represents a substantial yet underaddressed health concern among Iraqi female medical students, with clear adverse effects on academic performance, daily functioning, and quality-of-life-related domains. The findings of this study demonstrate that the burden of dysmenorrhea extends beyond physical pain to include emotional distress, impaired concentration, absenteeism, and reduced academic engagement, highlighting its relevance as both a health and educational issue. From a health promotion and policy perspective, these results underscore the need for institution-level interventions aligned with international benchmarks such as the World Health Organization’s framework on adolescent and young adult health and wellbeing, which emphasizes early identification, health education, and accessible care within educational settings. Integrating menstrual health education into medical curricula, establishing student-friendly gynecological consultation services, and promoting evidence-based pain management strategies are essential steps to mitigate the academic and psychosocial consequences identified in this study. Given the paradoxical finding that medical students—despite their health knowledge—often rely on self-management and underutilize professional care, universities should adopt proactive, campus-based health promotion programs that address informational gaps, time constraints, and cultural attitudes toward menstrual health. Such measures are consistent with global health promotion priorities that advocate for supportive learning environments and equitable access to healthcare for students. In conclusion, addressing dysmenorrhea among medical students is not solely a clinical matter but a strategic investment in student wellbeing, academic success, and future healthcare workforce performance. Policymakers, academic institutions, and student health services should collaboratively prioritize menstrual health as part of comprehensive student support systems. This study addresses an important yet underexplored public health issue by focusing on dysmenorrhea among Iraqi female medical students, a population underrepresented in regional and international literature. The study’s strengths include its focus on academic performance and quality-of-life domains, which are highly relevant to health promotion in educational settings. The use of a structured questionnaire informed by validated menstrual health and quality-of-life frameworks enhances content validity. Additionally, examining coping strategies and health-seeking behaviors provides actionable insights for institutional interventions, aligning well with the scope of the Journal of Education and Health Promotion . Several limitations should be acknowledged. First, the cross-sectional design precludes causal inference between dysmenorrhea and academic impairment. Second, the diagnosis of primary dysmenorrhea relied on self-reported symptoms without clinical confirmation, which may introduce misclassification bias; however, this approach is common and acceptable in epidemiological surveys of student populations. Third, data were collected through self-administered questionnaires, which may be subject to recall and reporting bias. Finally, as the study was conducted in a single academic setting, the findings may not be fully generalizable to all medical students in Iraq or the wider Middle East. The findings highlight the need for institutional health promotion strategies targeting menstrual health among medical students. Universities should consider integrating menstrual health education, accessible gynecological counseling services, and evidence-based pain management guidance into student health programs. Future research should employ multicenter designs, include clinical confirmation of dysmenorrhea, and explore longitudinal outcomes to better understand causal pathways between menstrual health, academic performance, and psychosocial wellbeing. Qualitative studies may also help elucidate cultural and systemic barriers to health-seeking behavior among medical students. The authors declare that AI tools were used solely for language editing and clarity enhancement during manuscript preparation. No AI tools were used in data collection, data analysis, interpretation of results, or generation of tables and figures. The authors take full responsibility for the content of the manuscript and affirm that the use of AI complied with ethical standards and publication guidelines. CI: Confidence interval; JEHP: Journal of Education and Health Promotion; OR: Odds ratio; QoL: Quality of life; SPSS: Statistical Package for the Social Sciences. The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request. All data were anonymized to protect participant confidentiality. The authors declare no conflicts of interest.

The present study provides locally relevant evidence on the burden of dysmenorrhea among Iraqi female medical students and its implications for academic performance, quality of life, coping strategies, and health-seeking behavior. The findings demonstrate that dysmenorrhea is highly prevalent and frequently severe in this population, with substantial effects on concentration, daily functioning, emotional wellbeing, and sleep quality. These results support the study hypothesis that dysmenorrhea represents not only a clinical concern but also an educational and health-promotion issue within medical training environments. The high prevalence of dysmenorrhea observed in this study is consistent with international literature reporting rates exceeding 70% among young women and university students.[ 1 5 6 ] Similar findings have been reported among medical and health-science students in other regions, where dysmenorrhea has been shown to significantly disrupt academic activities and overall wellbeing.[ 8 11 12 ] However, the severity distribution in the present study—where nearly three-quarters of participants reported severe pain—appears higher than that reported in several previous studies,[ 1 6 ] highlighting a potentially greater burden among Iraqi medical students. Differences in pain perception, stress levels, and cultural normalization of menstrual pain may partly explain this finding. Consistent with earlier research, dysmenorrhea in this study was strongly associated with academic impairment, particularly reduced concentration during lectures, increased academic stress, and difficulty completing assignments.[ 8 9 14 ] Although class absenteeism was reported, many students continued attending lectures despite significant discomfort, reflecting a pattern of academic presenteeism. This finding aligns with previous reports indicating that students often prioritize attendance over wellbeing, even when experiencing significant pain.[ 11 15 ] Such behavior may negatively affect learning efficiency and academic performance and underscores the need for supportive institutional policies. The impact of dysmenorrhea on quality-of-life domains was substantial, with sleep disturbance and emotional distress being particularly prominent. These findings are consistent with studies showing impaired quality of life in university students with dysmenorrhea.[ 3 4 6 ] The conceptual framework proposed in this study supports a biopsychosocial pathway whereby physical pain leads to emotional and functional impairments, ultimately affecting educational outcomes and health behaviors.[ 17 ] Despite the high prevalence and severity of symptoms, the majority of participants relied on self-management strategies rather than seeking professional medical care. Over-the-counter analgesics and rest were the most commonly reported coping methods, while formal healthcare consultation was infrequent. This pattern mirrors findings from other studies among medical and university students, where self-medication is common and professional care-seeking is limited.[ 14 15 16 ] Nonpharmacological strategies, including physical activity and lifestyle modifications, have demonstrated beneficial effects in reducing dysmenorrhea severity and improving functional outcomes, as supported by recent systematic reviews.[ 16 ] The paradox of low healthcare utilization among medical students may be explained by time constraints, perceived trivialization of menstrual pain, embarrassment, or a culture of self-reliance ingrained in medical training.[ 16 ] Addressing these barriers is essential from a health-promotion perspective. From an institutional standpoint, these findings highlight the need for targeted health promotion interventions within medical schools. Integrating menstrual health education into student wellness programs, improving access to student health services, and fostering a supportive academic environment may help mitigate the negative impact of dysmenorrhea on academic performance and quality of life. Such interventions are supported by global health promotion strategies emphasizing preventive care, student wellbeing, and educational equity.[ 10 ]

This study employed a cross-sectional analytical design and was conducted among female medical students at a medical college in Iraq during the academic year 2024–2025. The study setting represents a demanding educational environment where academic workload and clinical exposure may influence students’ physical and psychological wellbeing. The study was designed and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The study population consisted of female undergraduate medical students enrolled across different academic years. Eligible participants were students who had attained menarche and reported experiencing menstrual cycles during the study period. Students with known gynecological disorders (such as endometriosis or pelvic inflammatory disease) or chronic medical conditions that could confound menstrual symptoms were excluded. A convenience sampling technique was used due to the exploratory nature of the study and logistical constraints. Participation was voluntary, and informed consent was obtained electronically prior to questionnaire completion. As a pilot exploratory study, a formal sample size calculation was not performed; a target of approximately 100 participants was considered adequate to estimate prevalence and assess feasibility. Data were collected using a self-administered structured questionnaire distributed electronically. The questionnaire comprised four sections: Sociodemographic and academic characteristics. Menstrual characteristics and dysmenorrhea severity. Impact of dysmenorrhea on academic performance and daily activities. Quality-of-life domains, coping strategies, and health-seeking behavior. The quality-of-life and functional impact items were adapted from validated frameworks, including constructs from the Menstrual Distress Questionnaire (MDQ) and short-form quality-of-life instruments commonly used in student health research. Content validity was assessed through expert review by faculty members in obstetrics and gynecology and community medicine. A pilot test was conducted among a small group of students to assess clarity and comprehensibility, and minor wording modifications were made accordingly. Internal consistency of the questionnaire domains was evaluated using Cronbach’s alpha, demonstrating acceptable reliability. Questionnaires with incomplete key outcome variables were excluded from analysis; remaining missing values were handled using pairwise deletion. Ethical approval for the study was obtained from the Institutional Review Board of Al-Kindy College of Medicine (approval date: May 25, 2025). Participation was voluntary, anonymity was ensured, and no identifying information was collected. All procedures were conducted in accordance with the Declaration of Helsinki. Participants were informed of their right to withdraw at any stage without any academic or personal consequences. Data were coded and analyzed using Statistical Package for the Social Sciences (SPSS) software, version 28. Descriptive statistics were used to summarize participant characteristics and study variables. Categorical variables were presented as frequencies and percentages, while continuous variables were summarized using means and standard deviations where appropriate. Inferential analysis was conducted to assess associations between dysmenorrhea severity and academic impairment. Chi-square tests were applied for categorical comparisons. Results were reported as odds ratios (ORs) with 95% confidence intervals (CIs). Statistical significance was set at P < 0.05, and exact P values were reported throughout.