Menstrual-related symptoms as red flags for school absenteeism among Norwegian adolescents (MINA): A cross-sectional study.

Oline Friestad Gravdahl contributed to data curation, formal analysis, investigation, visualization of the results, and the writing of the original draft. Rune Svenningsen contributed to the conceptualization of the research, supervision of the research, visualization of the results, and writing of the original draft. Peter Majak contributed to the writing of the original draft. Guri Majak contributed to the conceptualization of the research, acquisition of funding, administration and supervision of the research, data curation, formal analysis, investigation, visualization of the results, and writing of the original draft.

The study was approved by the Head of the Department of Gynecology, the institutional Personal Data Officer at Oslo University Hospital, as well as the Regional Committee for Medical and Health Research Ethics in Southeast Norway (date of approval October 22, 2022, case number 2022/521616). Although the study was anonymous, written consent was obtained from each student before granting access to the questionnaire.

This research was funded by Foundation Dam (grant number HEL‐437940).

Eleven out of 25 eligible high schools agreed to participate in the study. Of the estimated 4001 eligible students attending participating high schools, 1020 (25%) responded to the questionnaire. The response rate between schools varied from 7% to 60%. Data from the 987 students who completed the full questionnaire were included in the study (Figure  1 ). A total of 33 students did not report age and were thus excluded from the data set. The median age at menarche for the study population was 12 years (IQR: 1). And twelve students (1.2%) indicated that they had not yet experienced menarche and were excluded from all analyses including menstrual symptoms. Due to a predominance of uncertain and inconsistent responses regarding weight and height, the analysis of BMI is excluded from the study. Population characteristics are presented in Table  1 . Flowchart illustrating the inclusion process. *The total number of female students in Norway is unknown, as students are not registered by sex or gender. Based on reports indicating a 50–50 distribution of male and female students, we opted to estimate the number of female students by dividing the total number of registered students by two. Population characteristics, including demographics and menstrual‐related symptoms in the total study population. Of the participants, 789 (80.3%) experiencing dysmenorrhea, with a median pain level of 7 (IQR: 4). Among participants with dysmenorrhea, 300 (38.1%) reported a pain score of ≥8 on the NRS, classifying them as experiencing severe dysmenorrhea. 5 , 6 , 9 Of these, 91.3% indicated experiencing severe dysmenorrhea monthly. A total of 487 participants (61.9%) reported pain scores of 1–7 on the NRS, classifying them as experiencing mild‐to‐moderate dysmenorrhea. About 130 participants reported a pain score >1 but did not classify this as dysmenorrhea. In the total study population, 89% of participants reporting absenteeism due to menstruation stated that it was specifically due to menstrual pain (data not shown). This proportion was even higher in the subgroup of participants with a minority background, where 96% attributed their absenteeism to menstrual pain (data not shown). Participants with severe dysmenorrhea reported a significantly higher degree of absenteeism than those with mild‐to‐moderate dysmenorrhea, both in school (85.0% vs. 53.1%, p  < 0.001) and social settings (84.3% vs. 53.9%, p  < 0.001) (Table  2 ). Dysmenorrhea and its association with academic and social absenteeism ( p ‐values from Chi‐square tests). Abbreviations: NRS, numeric rating scale. Students with severe dysmenorrhea experienced significantly more headaches than those with mild‐to‐moderate dysmenorrhea (79.2% vs. 56.0%, p < 0.001 ) (Table  3 ). Similar results were noted for vomiting, menorrhagia, syncope, fatigue, dyschezia, dysuria, polyuria, and urinary incontinence (Table  3 ). Dysmenorrhea, academic absenteeism, and associated symptoms ( p ‐values from Chi‐square tests). Abbreviation: NRS, numeric rating scale. Considering all possible menstrual‐related predictors assessed in the survey, dysmenorrhea severity (odds ratio [OR] = 1.35 [1.24;1.47], p  < 0.001), menorrhagia (OR = 1.55 [1.10; 2.18], p  = 0.012), dyschezia (OR = 1.63 [1.14; 2.33], p  = 0.007), vomiting (OR = 1.97 [1.19; 3.266], p  = 0.009), and fatigue (OR = 1.97 [1.08; 3.57], p  = 0.026) were significant predictors of academic absenteeism. Among these, vomiting showed the highest OR in predicting academic absenteeism. The logistic regression model indicated that, after controlling for all other symptoms, students who reported vomiting had nearly twice the odds of academic absenteeism compared with those who did not. This underscores the importance of healthcare professionals specifically inquiring about menstrual‐related vomiting to better identify students at risk of school absenteeism (Table  4 ). Menstrual‐related headaches were marginally above the conventional 5% significance threshold (OR = 1.41 [0.99; 1.99], p  = 0.051). Other possible predictors, including urinary incontinence, dysuria, fainting, and cycle‐independent stomach aches, were not significant when analyzed together with the other symptoms in the model (Table  4 ). Fitted multivariate logistic regression model for academic absenteeism ( N  = 872). Abbreviations: CI, confidence interval; OR, odds ratio. Participants with severe dysmenorrhea reported seeking healthcare significantly more often than those with mild‐to‐moderate dysmenorrhea (Table  5 ). Of all participants, 82.9% used over‐the‐counter analgesics, including NSAIDs and paracetamol, during menstruation. Of these, 16.9% reported that the analgesics provided no pain relief. Higher usage of analgesics and opioids was observed among participants with severe dysmenorrhea (Table  5 ). Fewer than one‐third of the participants reported using hormonal contraception to manage pain (28.3%). The use of hormonal contraception for pain management was significantly more prevalent among participants with severe dysmenorrhea (Table  5 ). Dysmenorrhea and associated actions taken to manage pain ( p ‐values from Chi‐square tests). Abbreviation: NRS, numeric rating scale. Higher rates of absenteeism from both social and academic activities were observed among students of non‐Norwegian ethnicity (Table  6 ). Furthermore, students with a minority background appeared to report higher rates of absenteeism than those of Norwegian ethnicity for mild‐to‐moderate dysmenorrhea (Figure  2 ; Tables  S1 and S2 ). This is consistent with the significant effect of ethnicity observed in the logistic regression model, with pain and minority background emerging as predictors of academic absenteeism (OR = 1.64, p  = 0.003) (Tables  S1 and S2 ). Figure  2 illustrates the association between academic absenteeism, pain level, and ethnicity, depicting the proportion of students reporting absenteeism for each pain level (from 0 to 10), with ethnicity (minority yes/no) indicated by two differently colored lines. Dysmenorrhea, absenteeism, healthcare‐seeking behavior, use of analgesics, and use of hormonal contraception in subgroups based on ethnicity and municipality ( p ‐values from Chi‐square tests). Abbreviation: NRS, numeric rating scale. Minority background in relation to academic absenteeism and level of dysmenorrhea. The horizontal axis gives the pain level, and the vertical axis gives the raw proportion of students reporting absenteeism, among students of majority background (blue) and minority background (red). There is a significant effect of ethnicity as a predictor of academic absenteeism (OR = 1.64, p = 0.003 ). The sensitivity analysis, which split the study population into schools with response rates of 30%, indicated a tendency toward greater severity of dysmenorrhea in the low‐response group. However, the relationships between absenteeism, dysmenorrhea, and accompanying symptoms were not affected (Tables  S2a and S2b ).

This study indicates a high prevalence of severe dysmenorrhea, 38.1%, among high school students in Norway. This aligns with the 36% reported in Sweden 5 and 33% reported in Finland ‐ and is consistent with global rates, further supporting the generalizability of our data. 2 , 5 , 9 In this population of adolescents, significant associations were found between severe dysmenorrhea and several menstrual‐related complaints, including menorrhagia, fatigue, headache, dyschezia, dysuria, polyuria, urinary incontinence, vomiting, and syncope. Several of these symptoms were very strong independent predictors of absenteeism, even after controlling for the severity of dysmenorrhea, and could therefore serve as additional red flags. We found a high rate of self‐medication with over‐the‐counter analgesics, including NSAIDs and paracetamol, during menstruation, with 95.9% of participants with severe dysmenorrhea reporting such use (Table  5 ). Prior studies suggest that adolescents lack knowledge of proper dosages, leading to undertreatment. 1 , 2 , 11 , 12 While dosage accuracy was not assessed in this study, 30% of those with severe dysmenorrhea reported insufficient pain relief, possibly due to under‐medication. The challenge of undertreatment is further underlined by our findings showing that nearly half of the participants with severe dysmenorrhea did not seek any healthcare, including visiting the school nurse. Various explanations for this are proposed in the literature, such as assuming that symptoms are “normal,” financial concerns, doubt about provider assistance, and lack of awareness of treatment options. 4 Our findings highlight the importance of educating and empowering adolescents about what constitutes normal and abnormal menstruation to encourage them to seek and receive appropriate care. We also recommend accessible educational resources on effective self‐medication and guidance on seeking assistance when standard medication fall short. Only one‐third of the participants with severe dysmenorrhea reported using hormonal contraception despite the proven efficiency in treating primary dysmenorrhea alone or alongside analgesics. 1 , 3 , 11 , 12 This may be due to reluctance from adolescents or parents, age‐related caution from healthcare providers, 5 as well as the low rates of participants seeking healthcare. 3 Significant differences in hormonal contraception use as a treatment for dysmenorrhea were found between participants with different ethnic background, despite similar rates of healthcare‐seeking and dysmenorrhea prevalence, indicating menstrual inequity. 13 Adolescents raised with minority backgrounds also reported a significantly higher prevalence of menstrual‐related absenteeism from both academic and social activities. These disparities may be systemic and preventable, 13 , 14 , 15 , 16 , 17 , 18 highlighting the need to understand the factors contributing to higher absenteeism among minority adolescents, as it can significantly impact their education and future job prospects. 15 , 16 , 17 Key limitations of this study include potential selection bias and overestimation of the measured variables given the varied response rates between schools, with some schools having very low response rates. Despite these limitations, the large sample size ( N  = 1020) and the similarity of findings with those from neighboring countries mitigate this risk. Sensitivity analysis between schools with high and low response rates indicated that the symptomatic red flags were consistent. Regardless of any overestimation, the proportion of adolescents experiencing dysmenorrhea remains high and concerning. The questionnaire was evenly distributed to all participating schools in Oslo and intended for classroom administration. However, some schools citing time constraints and competing survey demands, declined to allocate class time. This led to variations in distribution both between and within schools, which may explain the differing response rates. Our findings showed balanced participation of adolescents across ethnicities and the eastern and western municipalities, indicating even participation across the city. However, since the study was conducted in an urban setting, the results need to be validated in a rural context.

Severe dysmenorrhea is highly prevalent among adolescents, yet adequate medical treatment and healthcare‐seeking remain concerningly low, especially among those from minority backgrounds. This study identifies predictors that alongside dysmenorrhea, act as red flags for high absenteeism and could promote a better identification of at‐risk adolescents. Future research should focus on targeted interventions to reduce absenteeism, as well as highlight social and clinical practices that may reduce the high prevalence of severe and recurrent dysmenorrhea symptoms among adolescents.

Dysmenorrhea, or menstrual pain, is common among women of reproductive age. The prevalence of dysmenorrhea varies worldwide, ranging from 50% to 90%. 1 Many women tend not to seek help for menstrual pain, as society often views dysmenorrhea as a natural response to menstruation and the menstrual cycle. 2 , 3 , 4 This might be particularly true for adolescents, who are at a vulnerable stage of life. Dysmenorrhea is not only associated with physical symptoms but also impacts psychological, cognitive, and social aspects, severely impacting the daily lives of those affected. 2 , 5 , 6 , 7 Thus, menstrual pain can be a considerable cause of short‐term absenteeism from academic and social activities among adolescents. 2 , 5 , 6 Absenteeism is moreover linked to anxiety and depression, making it crucial to identify students needing intensified follow‐up to protect their social and academic well‐being. 8 No data are available on the prevalence or severity of dysmenorrhea among Norwegian adolescents. Furthermore, information regarding the accompanying symptoms most related to dysmenorrhea and absenteeism is lacking. Thus, this study aimed to evaluate the prevalence of severe dysmenorrhea and investigate accompanying symptoms, as well as absenteeism caused directly or indirectly by severe dysmenorrhea among adolescents in Oslo, Norway. Further, we sought to assess potential differences in subgroups based on ethnicity and municipality of origin. The overall goal of the study was to investigate whether symptoms significantly related to severe dysmenorrhea could be identified and used as red flags, aiding teachers and healthcare professionals in identifying adolescents in need of intensified follow‐up, treatment, and further referral to or within the healthcare system.

Rune Svenningsen received speaker fees from Astellas. Guri Majak received speaker fees from Ferring, Gedeon Richter, Intuitive Surgical, and Medtronic.

This collaborative cross‐sectional study, conducted between Oslo University Hospital and the University of Oslo, targeted female high school students in Oslo aged 16–19 (born 2004–2006). A web‐based anonymous questionnaire (Appendix  S1 ) was developed, aligned with previous Scandinavian studies, and included questions based on literature and clinical practice. 1 , 2 , 5 , 9 The questionnaire comprised 67 questions covering demographics, dysmenorrhea, menstrual‐related symptoms, and consequences and actions due to these symptoms (Appendix  S1 ). The questionnaire was distributed to all public high schools, inviting them to participate in a classroom setting in April 2023. Schools received a link and QR code for the survey, with instructions to facilitate responses during class. Participation was voluntary, anonymous, and required digital consent. The cut‐off age for inclusion in the study was set at 16 years, allowing participation without permission from a legal guardian. Consequently, responses from participants who did not indicate their age were excluded. The study had two primary outcomes: (1) the prevalence of dysmenorrhea was assessed using a numeric rating scale (NRS) ranging from 0 to 10 in this age group, where mild‐to‐moderate and severe dysmenorrhea was defined as scores of 1–7 and ≥8, respectively; and (2) to identify any association between menstruation in general and dysmenorrhea specifically and academic or social absenteeism. In the questionnaire, we asked about absenteeism both in general due to menstruation and specifically due to menstrual pain. Among participants reporting absenteeism due to menstruation, 9 out of 10 stated that menstrual pain was the primary reason (data not shown). Based on this, we chose to use absenteeism due to menstruation as our primary measure, as it encompasses the largest group of affected individuals. The secondary outcome was to examine the symptoms associated with dysmenorrhea, that might predict academic absenteeism, identifying red flags for students in need of more extensive follow‐up. We inquired about the severity and frequency of accompanying symptoms, including irregular menstruation, menorrhagia, fatigue, headaches, dyschezia, dysuria, urinary incontinence, vomiting, and fainting. Additionally, we also inquired about the measures that respondents took to manage dysmenorrhea, including seeking healthcare, using contraceptives as medical treatment, and the use of analgesics. Lastly, the study also aimed to assess whether ethnicity and socioeconomic factors influence the prevalence of severe dysmenorrhea, its accompanying symptoms, and its impact on social and academic absenteeism. Participants reported if they or their parents were from a country outside Norway, defined as “minority background,” in addition to stating their residential municipality. Eastern municipalities of Oslo, known for higher socioeconomically deprivation and a greater minority population were used as a proxy for socioeconomic factors. 10 Statistical analyses were conducted using IBM SPSS Statistics for Windows, version 29.0 (IBM Corp., Armonk, NY, USA). Chi‐square tests were used to test independence between pairs of categorical variables. Multivariate logistic regression was used to study the association between the probability of academic absenteeism, pain level, and accompanying symptoms. The response variable was the occurrence of academic absenteeism for each student (binary), while the covariates included dysmenorrhea measured on a scale from 0 to 10 and the following binary accompanying symptoms: headaches, regular bleedings, menorrhagia, urinary incontinence, dysuria, polyuria, dyschezia, vomiting, syncope, cycle‐independent stomach aches, and fatigue. A similar model was used to study the association between the probability of academic absenteeism, pain level, and ethnicity. Bias related to variability in the response rate between schools was assessed through a sensitivity analysis, comparing schools with response rates of >30% with those with response rates of <30%.

Appendix S1. English version of the originally distributed questionnaire. Table S1. Multivariate logistic regression model of academic absenteeism, minority background, and pain ( N  = 931). Table S2a. Fitted multivariate logistic regression model for academic absenteeism among participants in the high response rate group ( N  = 435). Table S2b. Fitted multivariate logistic regression model for academic absenteeism among participants in the low response rate group ( N  = 424).