Silent struggles: association between primary dysmenorrhea and health-related quality of life among adolescent girls in Lusaka District, Zambia.

This cross-sectional study design was conducted between June and August 2023, building on our previous work that focused on the prevalence and associated factors of primary dysmenorrhea among adolescent girls in the same area. The study design was well suited for this research, as it allowed for the collection of data at a single point in time [ 17 ], providing a snapshot of the association between primary dysmenorrhea and quality of life (QoL) among adolescent girls. The study was carried out in Lusaka District, Zambia, across 8 selected schools. Lusaka was chosen because of its unique demographic characteristics, including a rapidly growing youth population and varying access to healthcare services, which makes it a suitable area for understanding the prevalence and effects of dysmenorrhea among adolescent girls. The schools included a mix of private and public schools located in both urban and peri-urban settlement areas. The selection of these schools was purposeful, aiming to capture diverse samples of adolescent girls from different socioeconomic backgrounds. This inclusion also allowed for a comprehensive understanding of the impact of primary dysmenorrhea across different environments. In this study, we included adolescent girls who met the following eligibility criteria; (i) had experienced menarche, (ii) were aged between 10 and 19 years, (iii) who provided informed asset (and parental consent if under 18 years) and (iv) had the ability to speak and understand English. The following exclusion criteria were applied to ensure data validity and participant safety; (i) presence of known secondary causes of dysmenorrhea (e.g., endometriosis, pelvic inflammatory disease, or uterine anomalies), based on self-reported diagnosis, (ii) use of hormonal contraceptives for menstrual pain management at the time of data collection, (iii) incomplete or inconsistent questionnaire responses that compromised data quality. To achieve a minimum statistical power of 80%, the sample size for this study was calculated using a 95% confidence interval and an absolute precision of 5%. Owing to a lack of data regarding the prevalence of primary dysmenorrhea and its association with quality of life among school adolescent girls in Zambia, this study used a prevalence rate of 42.9% drawn from a 2019 study among urban adolescent girls in Zimbabwe as the basis for sample size calculation [ 18 ]. This led to the determination of a sample size of 376. However, 400 adolescents were ultimately recruited for the study. The study employed a combination of purposive and simple random sampling methods to select schools and participants. At the time of the study, Lusaka District had a total of 169 primary schools and 196 secondary schools [ 19 ]. Given the age range of interest (10–19 years) and the requirement that participants be post-menarche and English-literate, the sampling frame was restricted to 65 primary schools (those with Grades 6–7) and 196 secondary schools, yielding a total eligible pool of 261 schools. To ensure representation across school levels and socioeconomic contexts, purposive stratification was first applied by: (i) school level (primary vs. secondary), and (ii) location (urban vs. peri-urban), resulting in four strata. A target of 2 schools per stratum was set to balance feasibility and diversity, giving a planned sample of 8 schools. Consequently, the final sample comprised 8 secondary schools with 4 urban (2 public, 2 private) and 4 peri-urban (2 public, 2 private), selected via computer-generated simple random sampling from their respective strata. A total of 400 adolescent girls were enrolled, with 50 participants per school, ensuring proportional representation across school types and minimizing clustering bias. This sample size exceeded the minimum requirement ( n  = 376), enhancing statistical power. With permission from the Ministry of Education (REF MOE4/15/156), eligible adolescent girls were selected from grades 6 to 12 across 8 secondary schools. To ensure age-appropriate representation across the adolescent spectrum (10–19 years), a stratified random sampling approach was applied within each school. First, the total number of eligible girls (post-menarche, English-literate, aged 10–19) was obtained per grade. Then, proportional allocation was used to determine the number of participants per grade, based on the school’s grade-level enrolment. Within each grade, eligible students were assigned unique identification numbers by their class teachers. These numbers were entered into a sealed box, and 50 numbers per school were drawn blindly (lottery method), ensuring each eligible girl had an equal probability of selection. This procedure yielded a final sample of 50 participants per school (total n  = 400). This process was conducted only after obtaining the necessary approval from the ministry, ensuring adherence to proper protocols. A data collection tool was developed on the basis of a review of relevant literature on primary dysmenorrhea. The questionnaire was then designed to collect information on demographic characteristics and menstrual history. The questionnaire was piloted with a small group of participants to assess its clarity and reliability before the main study. A 10-point Visual Analogue Scale (VAS), where 0 = “no pain” and 10 = “worst imaginable pain”, was used to support the self-reported diagnosis of primary dysmenorrhea. Participants reporting menstrual pain in the absence of known secondary causes (e.g., endometriosis, pelvic inflammatory disease) and a VAS score ≥ 4 (moderate to severe pain) were classified as having primary dysmenorrhea; those reporting no or minimal pain (VAS ≤ 3) were classified as non-cases. Importantly, pain severity categories (mild/moderate/severe) were not used as exposure variables in regression analyses; the focus remained on the binary presence or absence of clinically meaningful dysmenorrhea (VAS ≥ 4), consistent with our objective to assess population-level burden rather than dose–response relationships. This approach aligns with screening-oriented public health studies where binary classification enhances feasibility and interpretability [ 20 ]. The values can be used to track pain progression for a person [ 21 ]. The QoL of the adolescents was assessed via the SF-36 questionnaire [ 22 ]. The questionnaire consists of 36 items and eight subscales, which are summarized in two summary domains: the physical (PCS) and mental component summary (MCS) measures. The eight subscales included physical functioning (PF, 10 items), role-physical functioning (RP, 4 items), bodily pain (BP, 2 items), general health (GH, 5 items), vitality (VT, 4 items), social functioning (SF, 2 items), role emotional functioning (RE, 3 items) and mental health (MH, 5 items). All the items in each subscale were scored so that a high score would define a more desirable QoL [ 22 ]. The PCS domain consists of physical functioning, bodily pain, general health and role-physical functioning subscales, whereas the MCS domain consists of role emotional functioning, vitality, social functioning and mental health subscales. The score of each summary domain is the sum of these four subscales. Two trained research assistants with experience in fieldwork who underwent specific training in quantitative data collection procedures for this study were responsible for data collection within the selected schools, ensuring quality assurance throughout the process. The data were analysed via STATA version 18 SE (Stata Corp, College Station, TX, USA). Descriptive statistics such as frequencies and percentages were used to summarize the sociodemographic and menstrual characteristics of the study participants. Furthermore, descriptive statistics such as medians and interquartile ranges (IQRs) were used to summarize each of the eight subscales of the SF-36 questionnaire (PF, RP, BP, GH, VT, SF, RE, and MH), which are presented via box plots. The eight subscales were later put into two summary domains, with each domain having four subscales: the PCS (PF, BP, GH, and RP) and the MCS (RE, VT, SF, and MH). The scores for each of the two domains were calculated by adding the scores for the subscales in a particular domain and dividing by the total number of subscales in the same domain. The PCSs and MCSs were also summarized using medians and interquartile ranges (IQRs) and are presented in box plots. Data management was carried out with strict control measures. All the collected data were securely stored and regularly backed up to ensure confidentiality. Data cleaning was performed prior to analysis to identify and address missing or inconsistent data. The two data collectors performed data entry individually to minimize errors, and any discrepancies were resolved through verification with the original source. The overall poor quality of health was measured on the basis of the two-component summary scores as follows: Yes, if both the PCS and MCS are below 50 or if one of the two (PCS or MCS) is below 50, this score was coded as 1; otherwise, it was coded as 0. Poor quality of health was then compared across the different participants’ sociodemographic characteristics via chi-square tests and Fisher’s exact tests on the basis of the assumptions of each test. To assess the association between primary dysmenorrhea and poor-quality health among adolescents, generalized linear models (GLMs) with family (binomial) and link (identity) variables were used. Poor quality of health was taken as the outcome variable (“Yes” coded = 1, “Otherwise” coded = 0), whereas dysmenorrhea was regarded as the primary exposure of interest. This was performed for both adjusted and unadjusted analyses. For adjusted analysis, the Bayesian information criterion (BIC) and Akaike information criterion (AIC) were used to select the best-fit model (variables to adjust for). Robust standard errors were adjusted for the clustering of adolescents within schools. All the analyses were performed at the 5% significance level.

In this section, the findings from a study on the impact of primary dysmenorrhea on quality of life (QoL) among school-aged adolescent girls in Zambia are presented. The following subsections provide a detailed breakdown of the data, illustrating the pervasive impact of dysmenorrhea on the lives of adolescent girls. A total of 400 adolescent girls from eight secondary schools participated. The majority (68.3%, n  = 273) were aged 15–19 years. Most (79.3%, n  = 317) experienced menarche at the typical age of 12–14 years, and 82.5% ( n  = 330) reported a menstrual duration of 3–5 days. Over half (57.5%, n  = 230) described their menstrual flow as moderate, and the most common cycle length was 26–30 days (26.0%, n  = 104). Pads were the predominant menstrual material used (87.8%, n  = 351), and most participants (89.0%, n  = 356) had received some education about menstruation—primarily from their mothers (41.3%, n  = 165). Notably, 63.5% ( n  = 254) reported a history of primary dysmenorrhea (Table  1 ). Table 1 Descriptive statistics of the sociodemographic and menstrual characteristics of the study participants Characteristic Frequency Percentage n (%) Age group  10–14 years 127 31.8  15–19 years 273 68.3 Live with  Father and Siblings 8 2  Mother and Siblings 72 18  Parents and Siblings 207 51.7  Parents, Siblings and Extended Family 57 14.2  With other family 56 14 Age at menarche  10–11 (Early menarche) 63 15.8  12–14 (typical menarche) 317 79.3  15–16 years (late menarche) 20 5 Duration of menses  1–2 days 8 2  3–5 days 330 82.5  6–8 days 57 14.2  > 8 days 5 1.3 Menstrual Materials  Cloths (Traditional Chitenge Material) 44 11  Cotton wool 3 0.8  Diapers 2 0.5  Pads 351 87.8 Access to menstrual materials  No 75 18.8  Yes 325 81.3 Affordability of Menstrual Materials  No 213 53.3  Yes 187 46.8 Menstrual cycle length  16–20 Days 76 19  21–25 Days 79 19.8  26–30 Days 104 26  31–35 Days 90 22.5  36–40 days 5 1.3  Irregular 46 11.5 Menstrual flow intensity  Light 81 20.3  Moderate 230 57.5  Heavy 89 22.3 Product change frequency (Per day)  1–3 times 329 82.3  4–6 times 70 17.5  7–9 times 1 0.3 Education about menstruation  No 44 11  Yes 356 89 Person who gave information  Aunty 33 8.3  Grandmother 83 20.8  Mother 165 41.3  Sister 30 7.5  Teacher 49 12.5  Missing 40 10 Dysmenorrhea  No 253 65.8  Yes 137 34.3 Total sample size N  = 400. Values are n (frequency) and column % Descriptive statistics of the sociodemographic and menstrual characteristics of the study participants Total sample size N  = 400. Values are n (frequency) and column % The overall percentage of adolescent girls who experienced poor quality of life was 60.5% (242/400). Bivariate analysis revealed that a significant majority (62.6%, 223/356) of the adolescents reporting poor quality of life had some level of education about menstruation ( P  < 0.013). Notably, primary dysmenorrhea was significantly associated with poor quality of life, at 86.9% (119/137). These findings were statistically significant ( P  < 0.001) (Table  2 ). Table 2 Bivariate analysis of primary dysmenorrhea against the sociodemographic and menstrual characteristics of the study participants Characteristic Total N Poor Quality of Health n (%) p value No Yes Overall 400 158 (39.5) 242 (60.5) Age group 0.13 1  10–14 years 127 57 (44.9) 70 (55.1)  15–19 years 273 101 (37.0) 172 (63.0) Live with 0.70 2  Father and Siblings 8 3 (37.5) 5 (62.5)  Mother and Siblings 72 24 (33.3) 48 (66.7)  Parents and Siblings 207 87 (42.0) 120 (58.0)  Parents, Siblings and Extended Family 57 24 (42.1) 33 (57.9)  With other family 56 20 (35.7) 36 (64.3) Age at menarche 0.30 1  10–11 (Early menarche) 63 28 (44.4) 35 (55.6)  12–14 (typical menarche) 317 125 (39.4) 192 (60.6)  15–16 years (late menarche) 20 5 (25.0) 15 (75.0) Period duration 0.11 2  1–2 days 8 0 (0.0) 8 (100.0)  3–4 days 220 86 (39.1) 134 (60.9)  5–7 days 162 67 (41.4) 95 (58.6)  >=8 days 10 5 (50.0) 5 (50.0) Menstrual cycle length 0.37 1  16–20 days 76 28 (36.8) 48 (63.2)  21–25 days 79 30 (38.0) 49 (62.0)  26–30 days 104 37 (35.6) 67 (64.4)  31–35 days 95 46 (48.4) 49 (51.6)  Irregular 46 17 (37.0) 29 (63.0) Menstrual flow intensity 0.56 1  Light 81 29 (35.8) 52 (64.2)  Moderate 230 90 (39.1) 140 (60.9)  Heavy 89 39 (43.8) 50 (56.2) Menstrual material 0.95 2  Cloths (Traditional Chitenge Material) 44 16 (36.4) 28 (63.6)  Cotton wool 3 1 (33.3) 2 (66.7)  Diapers 2 1 (50.0) 1 (50.0)  Pads 351 140 (39.9) 211 (60.1) Access to menstrual material 0.34 1  No 75 26 (34.7) 49 (65.3)  Yes 325 132 (40.6) 193 (59.4) Affordability of Menstrual materials 0.40 1  No 213 80 (37.6) 133 (62.4)  Yes 187 78 (41.7) 109 (58.3) Product change frequency 0.78 1  1–3 times 329 131 (39.8) 198 (60.2)  4–6 times 71 27 (38.0) 44 (62.0) Education about menstruation 0.013 1 *  No 44 25 (56.8) 19 (43.2)  Yes 356 133 (37.4) 223 (62.6) Source of menstruation information 0.66 1  Aunty 33 10 (30.3) 23 (69.7)  Grandmother 83 31 (37.3) 52 (62.7)  Mother 165 70 (42.4) 95 (57.6)  Sister 30 11 (36.7) 19 (63.3)  Teacher 49 17 (34.7) 32 (65.3) Dysmenorrhea < 0.001 1 *  No 263 140 (53.2) 123 (46.8)  Yes 137 18 (13.1) 119 (86.9) 1 Chi-square, 2 Fisher’s exact, n Sample, % Percentage * Statistically significant at the 5% significance level Bivariate analysis of primary dysmenorrhea against the sociodemographic and menstrual characteristics of the study participants 1 Chi-square, 2 Fisher’s exact, n Sample, % Percentage * Statistically significant at the 5% significance level This analysis highlights the disparities in quality of life (QoL) components between adolescents with and without primary dysmenorrhea. For each domain, the median score and interquartile range (IQR) were reported to describe central tendency and variability. The distribution of quality of life (QoL) components revealed notable differences between adolescents with and without primary dysmenorrhea. In the Physical functioning domain, girls without primary dysmenorrhea had a median score of 80 (IQR:50–100) indicating generally good physical capacity. In contrast, those with primary dysmenorrhea had a significantly lower median score of 20 (IQR: 0–40). Role Physical domain reported a median score was 78 (IQR: 0–100) for girls without primary dysmenorrhea, compared to 0 (IQR: 0–0) for those with primary dysmenorrhea, reflecting near-universal limitations in daily activities due to pain. Bodily Pain domain showed that median scores were 70 (IQR: 30–100) for the non- primary dysmenorrhea group versus 10 (IQR: 0–30) for the primary dysmenorrhea group, reflecting that suggesting most experience consistently high pain level that significantly disrupt functioning. General Health domain showed that median scores were 78 (IQR: 58–90) for the non- primary dysmenorrhea group versus 42 (IQR: 40–45) for the primary dysmenorrhea group indicating a shared, pessimistic self-assessment of health, likely influenced by the chronic and recurrent nature of menstrual pain. Vitality domains showed median scores were 75 (IQR: 60–89) for the non- primary dysmenorrhea group versus 63 (IQR: 60–65) for the primary dysmenorrhea group, suggesting persistent fatigue or low energy that is uniformly experienced, possibly due to pain, sleep disruption, or anaemia from heavy flow. Social Functioning domain shoed median scores were 70 (IQR: 22–100) for the non- primary dysmenorrhea group versus 15 (IQR: 0–22) ) for the primary dysmenorrhea group, with half scoring ≤ 15 (near floor), indicating frequent avoidance of social interactions. Role Emotional domains showed median scores were 70 (IQR: 40–100) for the non- primary dysmenorrhea group versus 0 (IQR: 0–0) for the primary dysmenorrhea group, this suggests dysmenorrhea exerts a profound emotional toll, directly impacting schoolwork, chores, or responsibilities. And lastly, Mental Health domains showed median scores were 67 (IQR: 37–75) for the non- primary dysmenorrhea group versus 37 (IQR: 30–40) for the primary dysmenorrhea group, indicating elevated psychological distress, likely exacerbated by unpredictability and stigma around menstrual pain (Fig.  1 ). Fig. 1 Distribution of Quality-of-Life components by Primary Dysmenorrhea Distribution of Quality-of-Life components by Primary Dysmenorrhea The following four components, “physical functioning”, “role physical”, “body pain” and “mental health,” give the overall score for the summary component called the “physical component summary (PCS)”. The distribution of the PCS revealed that for adolescents without severe primary dysmenorrhea, the median score was 77, indicating generally high levels of physical health, with an IQR of 45–90, which suggests moderate variability. On the other hand, for adolescents who experience primary dysmenorrhea, the figure reveals a much narrower distribution of lower scores. The majority of the adolescents had relatively lower PCS scores. The presence of the upper whisker and upper quartile at the same value [ 21 ] suggests that the upper half of these groups’ scores were very similar, indicating consistently low physical health. Furthermore, the four components “vitality”, “social functioning”, “role emotional” and “mental health” make up the “mental component summary (MCS)”. The distribution of the MCS revealed that for adolescents without primary dysmenorrhea, the median score was 70, and the IQR was 29, suggesting that there is considerable variability in the MCS scores. On the other hand, for adolescents who experience severe primary dysmenorrhea, the figure shows a much lower range of scores. The IQR of 5 indicates that the middle 50% of scores for participants with dysmenorrhea fall between 30 (the lower quartile) and 35 (the upper quartile). This narrow range suggests that most participants reported similar levels of mental health, indicating limited variability among this group. The dashed line at 50 indicates the clinical threshold used to define poor physical/mental component summary (PCS/MCS) scores (Fig. 2 ). Fig. 2 Distribution of Quality-of-Life Component Summary by Primary Dysmenorrhea Distribution of Quality-of-Life Component Summary by Primary Dysmenorrhea The association between primary dysmenorrhea and poor quality of life was assessed among adolescents who reported either no primary dysmenorrhea 123 (46.8%) or yes to having primary dysmenorrhea 119 (86.8%). The unadjusted analysis revealed that there was a significant association between primary dysmenorrhea and poor quality of life, with an odds ratio of 7.54 (95% CI 4.33, 13.06; p  < 0.001) for adolescents with primary dysmenorrhea. After adjusting for potential confounders, age, age at menarche, period duration, menstrual flow intensity and education about menstruation, the association remained robust, with an adjusted odds ratio of 8.52 (95% CI: 4.74, 15.30; p  < 0.001). These findings indicate that primary dysmenorrhea is strongly associated with reduced quality of life among adolescent girls in this sample (Table  3 ). Table 3 Association between primary dysmenorrhea and poor quality of life Primary characteristics Poor Quality of Life n (%) Unadjusted 1 Adjusted OR (95% CI) p value OR (95% CI) p value Dysmenorrhea  No 123 (46.8) Ref - Ref -  Yes 119 (86.9) 7.52 (4.33, 13.06) < 0.001 8.52 (4.74, 15.30) < 0.001 1 Adjusted for age, Age at menarche, Period duration, Menstrual flow intensity and Education about menses Association between primary dysmenorrhea and poor quality of life 1 Adjusted for age, Age at menarche, Period duration, Menstrual flow intensity and Education about menses

This study provides evidence of a strong association between primary dysmenorrhea and reduced health-related quality of life among school-going adolescent girls in Lusaka District, Zambia, particularly across physical, emotional, and social domains. The near-universal role limitations and markedly lower mental health scores among affected girls suggest that dysmenorrhea may contribute substantially to psychosocial distress in this population. While these findings highlight the potential burden of untreated menstrual pain in this setting, the cross-sectional design precludes causal inference, and the school-based sample limits generalizability beyond urban/peri-urban secondary-school adolescents. Nonetheless, the observed patterns warrant further investigation into contextually appropriate, multi-level interventions, including menstrual education, pain management support, and school-based accommodations that could be explored in future longitudinal or implementation research. Given the centrality of cultural norms in shaping menstrual experiences, culturally grounded approaches, such as engaging mothers and female caregivers as trusted sources of support may hold promise and merit evaluation in the Zambian context.

This study aimed to explore the association between primary dysmenorrhea and quality of life (QoL). The majority of the participants reported limitations to their overall physical and mental health. These findings indicate that not only their physical aspects but also their psychological and social aspects are associated with primary dysmenorrhea. Studies have shown that girls complain that dysmenorrhea affects their physical life [ 16 , 23 ]. Notably, primary dysmenorrhea was a significant factor associated with QoL in this study, as 86.9% of the adolescents who experienced primary dysmenorrhea reported poor QoL, with a significant association ( p < 0.001). These findings indicate that primary dysmenorrhea is not only associated with physical health but also the overall quality of life of adolescent girls. This study revealed that adolescents suffering from primary dysmenorrhea are more likely to report reduced physical functioning and increased body pain, as evidenced by lower median scores according to multiple QoL components. These findings align with those of a study conducted in Australia, which revealed that girls with dysmenorrhea have lower physical functioning scores for quality of life than those with other menstrual problems [ 24 ]. These findings suggest that primary dysmenorrhea can substantially affect the daily lives and overall well-being of affected adolescent girls. Reduced physical functioning may also hinder participation in physical activities, academic performance, school attendance and social interactions. This could lead to a cycle of reduced quality of life and increased psychosocial stress. Additionally, the mental health implications of primary dysmenorrhea were also evident in this study, particularly the near-floor scores in Role Emotional (median = 0) and low Mental Health (median = 37 underscores that primary dysmenorrhea is not merely a physical complaint, but a psychosocial phenomenon. These findings suggest that primary dysmenorrhea not only affects physical health but also contributes to emotional distress among affected adolescents and aligns with growing evidence that menstrual pain is experienced within culturally mediated frameworks of silence, stigma, and gendered expectations [ 10 , 25 ]. In many Zambian households, menstruation remains a taboo topic, discussed discreetly or only after menarche, often by older female relatives [ 26 ]. While mothers were the primary source of menstrual information in our sample (42.4%) only 89% of girls reported receiving any education on menstruation, suggesting that informational awareness is insufficient without emotional validation and structural support. Cross-culturally, the psychosocial impact of dysmenorrhea varies significantly. A qualitative study in China reported that adolescents with severe dysmenorrhea frequently experienced increased familial attentiveness, especially from mothers, including reassurance, rest permission and pain-relief assistance suggesting culturally embedded coping mechanisms [ 13 ]. This culturally rooted support system may mitigate some mental health impacts, highlighting the importance of social support in managing dysmenorrhea. Conversely, in settings where pain is normalized or dismissed as just part of being a woman, adolescents may internalize suffering, potentially contributing to delayed help-seeking and social withdrawal [ 27 ]. In Zambia, emerging qualitative work highlights that girls frequently conceal pain to avoid being labelled “weak” or “unproductive” [ 28 ]. While silence plays a passive role, a more insidious dynamic may be the active discouragement of pain expression, whether by teachers admonishing girls for “complaining,” peers mocking absenteeism as “excuse-making,” or caregivers advising stoicism (“every woman suffers, just endure”). Such responses not only invalidate lived experience but may teach girls that their pain is illegitimate, reinforcing internalised stigma and delaying help-seeking. This aligns with emerging evidence that pain normalisation, the framing of primary dysmenorrhea as an inevitable rite of passage, functions as a form of structural gaslighting, particularly when coupled with limited access to safe, affordable analgesia or menstrual leave policies in schools [ 27 , 28 ]. In this study, the near-floor Role-Emotional scores (median = 0) among affected girls may reflect not just physical incapacity, but this learned resignation, a belief that expressing distress is futile or shameful. Similarly, a study performed at a Turkish University revealed that an explanation for why only some but not all the parameters are affected could be that since dysmenorrhea is an important illness that primarily affects physical health, domains of the SF-36 related to physical health could only be affected. Social and psychological parameters such as social functioning, role–emotional, and mental health could not be affected because of this fact [ 16 ]. These varying perspectives emphasize that the experience of dysmenorrhea can differ widely on the basis of cultural context and social support availability. Furthermore, the findings of this study underscore the urgent need for comprehensive interventions that address menstrual health management, which include not only educational initiatives but also support mechanisms that empower adolescent girls to manage primary dysmenorrhea effectively. While a relationship between education about menstruation and QoL was observed, with 62.6% of those who received some level of education on menstruation experiencing poor quality of life ( P  < 0.013), education alone may not be enough to mitigate the negative impacts of menstrual-related issues, such as primary dysmenorrhea. This suggests that while educational programs are vital, they must be part of a broader framework that includes psychological support, access to healthcare services, and resources that facilitate effective pain management. The study also revealed the absence of significant associations between QoL and factors such as menstrual cycle length and flow intensity, which might indicate that individual variations in pain perception could play a more crucial role in determining QoL. However, research has shown that dysmenorrhea and heavy menstrual bleeding are associated with poor quality of life among women, particularly in athletic populations [ 29 ]. This variation could be due to the difference in study participants, as this study focused on adolescent girls. Although the adjusted model controlled for several sociodemographic variables, the intersection of primary dysmenorrhea with material deprivation warrants further reflection. Over half (53.3%) of participants reported menstrual materials as unaffordable, even among pad users (87.8%), many may ration usage, increasing discomfort and anxiety, particularly during heavy-flow days. For girls with primary dysmenorrhea, this adds a dual burden of managing pain while fearing leakage, odour, or school absenteeism due to lack of supplies. Similarly, living arrangements (e.g., with extended family or non-parental guardians) may constrain access to emotional or financial support for pain management. While our bivariate analysis did not find statistically significant associations between QoL and product access or living situation, the direction of effect (65.3% poor QoL among those with no access vs. 59.4% among those with access) hints at a socially patterned vulnerability, one where primary dysmenorrhea compounds existing inequities. This resonates with the social determinants of health framework, pain is universal, but suffering is distributed unequally [ 30 ]. This study is subject to several limitations. While our cross-sectional design provides robust evidence of the association between primary dysmenorrhea and poor HRQoL, it does not capture the dynamic, cyclical nature of menstrual pain and its fluctuating impact on daily functioning. For instance, QoL may vary significantly across the menstrual cycle, declining during menses and recovering in inter-menstrual phases and individual pain perception may be modulated by contextual stressors such as examination periods, food insecurity, or acute experiences of stigma. Without repeated measures, we cannot discern whether reported poor QoL reflects a persistent deficit (or episodic disruption, a distinction critical for designing effective interventions. Future mixed-methods cohort studies could employ ecological momentary assessment (EMA) or symptom diaries to map within-person variation and identify modifiable triggers of QoL deterioration. Additionally, although the study observed a consistently high burden of poor QoL among adolescents with dysmenorrhea across both early [ 10 – 14 ] and late [ 15 – 19 ] adolescence in descriptive checks, future studies employing age-stratified or longitudinal designs are needed to explore how dysmenorrhea-related QoL impacts evolve across developmental stages and interact with contextual factors. Given the profound association of primary dysmenorrhea with physical, emotional, and academic functioning, the study proposes a tiered, school-level response framework grounded in feasibility and dignity. (i)A Nurse-led menstrual health and pain literacy workshop, co-facilitated with trained peer educators and incorporating girl-centered storytelling, to demystify primary dysmenorrhea and promote help-seeking. (ii) Designated rest spaces like quiet, private rooms where girls experiencing acute pain can rest without stigma or penalty, aligned with UNESCO’s WASH-in-Schools guidelines for menstrual health management [ 31 ]. (iii) Safe, guided access to NSAIDs via school health personnel (ibuprofen 200–400 mg, with parental opt-in consent), as recommended by WHO for adolescent pain management where contraindications are screened [ 32 ] and (iv) Teacher sensitisation modules, integrated into in-service training, to reframe menstrual absenteeism not as truancy but as a health equity issue, equipping educators to respond with empathy, flexibility, and referral pathways. Critically, all interventions must be co-designed with adolescent girls, caregivers, and school leadership to ensure cultural relevance and sustainability.

Primary dysmenorrhea is common in girls who have begun menstruating [ 1 ]. It is categorized as a painful menstrual cycle in females with normal pelvic anatomy and generally begins at menarche [ 2 ]. This typically occurs in women aged 20 years or younger [ 3 ]. Symptoms of primary dysmenorrhea include cramping pain that is more concentrated in the lower back or inner thigh and the lower abdomen [ 4 ]. Some have reported other symptoms, such as nausea, vomiting, headache and dizziness [ 5 ]. The global prevalence of primary dysmenorrhea ranges from 45% to 95% in females of reproductive age, with 2% to 29% experiencing severe pain [ 6 ]. In Nigeria, the prevalence of primary dysmenorrhea has been reported to be as high as 92.96% [ 7 ]. Dysmenorrhea has a substantial effect on quality of life (QoL) [ 8 ]. While it is primarily known for causing significant physical discomfort, its impact extends beyond pain alone [ 9 ]. Dysmenorrhea affects various aspects of daily functioning, disrupting the emotional, social and psychological well-being of those affected [ 10 ]. Aside from its impact on physical health, dysmenorrhea significantly affects the QoL of adolescent girls [ 11 ]. QoL encompasses various aspects of an individual’s wellbeing, including physical, social, emotional and mental health [ 12 ]. Research shows that primary dysmenorrhea negatively influences these dimensions [ 13 ]. For example, studies using the 36-item Short-Form (SF-36) QoL scale, which measures domains such as physical functioning, role limitations due to emotional problems and mental health, have reported lower QoL scores in students suffering from dysmenorrhea ( p < 0.05) [ 13 ]. The more severe the pain is, the greater the degree to which QoL is compromised. Similarly, research involving students revealed that those with dysmenorrhea had reduced QoL scores across all domains [ 14 ]. While these studies underscore the pervasive impact of dysmenorrhea on QoL, most of the available evidence is from an international context [ 1 , 15 , 16 ]. There is a dearth of research examining the specific effects of dysmenorrhea on school-going adolescent girls in Zambia. Therefore, this study aimed to investigate the effect of primary dysmenorrhea on the QoL of school-going adolescent girls in Zambia, Lusaka District.

Supplementary Material 1. Supplementary Material 1.