Prevalence, severity and correlates of dysmenorrhea among postpartum women in Western Kenya: A cross-sectional study

Dysmenorrhea is the most prevalent menstrual disorder globally with the highest disease burden of any gynecological issue in low- and middle-income countries (LMICs) [ 1 ]. The global prevalence of dysmenorrhea ranges from 20% to 90% across different populations, depending on the method of assessment [ 2 , 3 ]. Approximately 10–15% of women experience dysmenorrhea severe enough to prevent normal daily functioning [ 1 , 2 , 4 – 7 ]. Dysmenorrhea presents as lower abdominal pain or cramping commonly accompanied by backache, nausea and vomiting, headache, dizziness, diarrhea, loss of appetite, bloating, leg pains, and irritability [ 8 ]. Dysmenorrhea symptoms especially when moderate to severe, often negatively impact women’s quality of life, work productivity, and healthcare utilization [ 9 – 12 ]. Yet, there are limited data on the frequency and severity of dysmenorrhea in LMICs, particularly in Sub-Saharan Africa (SSA) [ 9 , 12 ]—a region with persisting gaps in women’s health. Data on dysmenorrhea in this context could inform clinical and public health interventions and improve health and quality of life for those impacted. Factors associated with dysmenorrhea include age, parity, marital status, menstrual bleeding characteristics, cigarette smoking, and alcohol consumption [ 9 , 10 , 12 , 13 ]. Hormonal contraceptive use may protect against dysmenorrhea symptoms [ 11 , 5 ]. Furthermore, experiences of dysmenorrhea are associated with anxiety, embarrassment, discomfort, and depression among women, especially younger women and adolescents [ 11 ]. Several studies demonstrate an increased risk of depression in women with dysmenorrhea, especially in the period after pregnancy, when postpartum depression is a health concern [ 14 ]. There is a dearth of data on dysmenorrhea among women in SSA [ 15 ]. Particularly, data are sparse regarding dysmenorrhea during the postpartum period in SSA, where high fertility rates in many countries mean many women spend a substantial proportion of their reproductive years in pregnant or postpartum states [ 16 , 17 ]. Understanding the burden and risk factors for dysmenorrhea up to 24 months post-delivery can inform postpartum health services to alleviate the negative impacts of dysmenorrhea and improve the quality of life. We conducted a secondary analysis to determine the prevalence, severity, and correlates of moderate-to-severe dysmenorrhea at 24 months post-delivery, using data from a large cohort of women in Kenya. We hypothesized that the prevalence of moderate-to-severe dysmenorrhea would be high, and be associated with low parity, younger age, and irregular menstrual cycles, while hormonal contraceptive use would be inversely associated.

A total of 277 women met the inclusion criteria and were included in the final analysis ( Fig 1 ). The participants had a median age of 27 years [interquartile range (IQR) of 24–31, absolute range: 15–41, and most were aged between 25–35 years (59%)]. The majority were married or living with a partner (94%), in monogamous relationships (82%), and had completed more than eight years of education (77%). Nearly all had more than one child (93%) and reported a vaginal delivery (94%) for their most recent birth. At the time of data collection, nearly half were still breastfeeding (44%) and 97% were on contraception; the most commonly reported contraceptive methods were injectables (32%), followed by implants (28%) and other non-permanent methods (e.g., condoms; 26%). Psychosocial distress factors were relatively rare. Only 2% of women reported depressive symptoms, 4% reported elevated stress, and less than 1% reported IPV. However, 27% reported exposure to six or more ACEs, and 16% had lower levels of mother-infant engagement. A full description of participant characteristics is provided in Table 1 . PrEP = Pre-exposure prophylaxis for HIV prevention; OCP = Oral contraceptive pills; IUD = Intrauterine device; LAM = Lactational amenorrhea method; 1 Polygamous marriage was evaluated among those who are married. 2 Regular employment was evaluated as participants reported engaging in an economic activity to earn a living wage. 3 Pregnancy and obstetric history assessed among those with a history of prior pregnancy at enrollment. 4 Non-permanent contraceptive type used was evaluated among those reporting currently using contraceptives; Other = None, abstinence, periodic abstinence, withdrawal, and emergency contraception. 5 Assessed at 24 months post-delivery. 6 Depression symptoms were assessed using the CESD and dichotomized as low (depression <10) and high (depression score ≥10). 7 Stress symptoms were assessed using the perceived stress scale and dichotomized as low (pss < 14) and high (pss score ≥14). 8 Adverse Childhood Experiences (ACEs) were assessed using the ACEs questionnaire and dichotomized as low (ACE score <6) and high (ACE score ≥6). 9 Alcohol use was defined as consuming a drink containing alcohol at least once in the past month. 10 Intimate Partner Violence using the HITS scale and dichotomized as low (negative score<10) and high (positive score ≥10). 11 Mother and child engagement using the Multiple Indicator Cluster Survey (MICS) scale and dichotomized as Yes/No for High, and Low. 12 Moderate-to-severe dysmenorrhea was defined as reporting at least one menstrual symptom that was moderately to very severely bothersome on the CMSS; dichotomized into Yes/No. 13 Menstrual experiences in the last 6 months among those who reported menstruation. 14 Additional time spent in bed was defined as extra bed rest by those experiencing menstrual problems throughout the last period; dichotomized as Yes (>0 hours)/No (0 hours). 15 Pills taken for menstrual relief were evaluated among those who reported taking any kind of pills for menstrual relief over the number of days of medication (Yes/No). Overall, the median dysmenorrhea total score was 2 (IQR: 0–6), with 24% (n = 67) of mothers reporting moderate-to-severe dysmenorrhea symptoms defined as having at least one moderate to very severely bothersome symptom that lasted at least one full day on the CMSS. Over half of the women reported regular cycles (51%), and most had menstrual bleeding lasting 3–5 days (68%). The majority reported moderate flow levels (63%), while a smaller proportion spent additional time in bed (21%) or used painkillers to manage menstrual symptoms (18%) ( Table 1 ). Among those reporting any experience of individual dysmenorrhea symptoms, the most commonly experienced dysmenorrhea symptoms were cramps (46%), followed by abdominal pains (34%), headaches (13%), weakness (8%), and dizziness (8%), that varied in duration and typically lasted 3–7 hours or longer, with approximately 19% (n = 44) reporting symptoms that persisted for an entire day or more ( Table 2 ). Among women with severe dysmenorrhea, 17% of women reported cramps, followed by abdominal pain (12%), headaches (4%), and weakness (3%) ( Table 3 ). 1 Experience of dysmenorrhea symptoms assessed among those reporting menstrual bleeding since the most recent pregnancy ended using the Cox MSS; dichotomized as “any experience of symptom”, Yes/No 2 Duration of symptom occurrence evaluated among those who reported experiencing any of the symptoms based on the total amount of time one experienced a condition during her last period 1 Severity of symptom occurrence evaluated using the Cox MSS among those who reported experiencing any of the symptoms based on the average level of pain or distress of the condition when it did occur in the last menstrual period In the univariate analysis, several factors were significantly associated with moderate-to-severe dysmenorrhea ( Table 4 ). Women who reported higher scores of ACEs were more likely to have moderate-to-high dysmenorrhea than those with fewer ACEs (36.0% vs. 19.8%, prevalence ratio [PR]=1.82, 95% confidence interval [CI]: 1.10–2.95, p = 0.02). Women who were still breastfeeding at 24 months post-delivery had a higher risk of moderate-to-severe dysmenorrhea compared to those not breastfeeding (32.2% vs. 19.2%, PR = 1.68, 95% CI: 1.04–2.74, p = 0.04). Likewise, each unit increase in depressive symptom score was associated with a higher risk of moderate-to-severe dysmenorrhea (PR = 1.10, 95% CI: 1.01–1.18, p = 0.02). Moderate-to-severe dysmenorrhea was also related to pain relief behaviors: women with moderate-to-severe symptoms were more likely to use painkillers (67.3% vs. 14.9%, PR = 4.52, 95% CI: 2.79–7.30, p < 0.001) and spend additional hours in bed (55.2% vs. 16.0%, PR = 3.45, 95% CI: 2.13–5.58, p < 0.001) for symptom relief compared to those with less severe dysmenorrhea. PR=Prevalence ratio; CI=Confidence interval. 1 Moderate-to-severe dysmenorrhea was defined as reporting at least one menstrual symptom that was moderately to very severely bothersome; dichotomized into Yes/No. *Adjusted for age (continuous). **Adjusted for age (continuous) and breastfeeding. Although age, irregular menstrual cycles, and hormonal contraceptives were not significantly associated with having moderate-to-severe dysmenorrhea as hypothesized, they demonstrated trends in the expected direction, warranting further investigation. Being ≤24 years (20.0%, PR = 0.74, 95% CI: 0.42–1.26, p = 0.28) or >35 years (20.8%, PR = 0.77, 95% CI: 0.27–1.77, p = 0.58) compared to 25–35 years (27.0%) was associated with a lower risk of moderate-to-severe dysmenorrhea. Similarly, using oral contraceptive pills compared to other methods such as abstinence or periodic abstinence was associated with a slightly lower risk of moderate-to-severe dysmenorrhea (21.4% vs. 23.1%, PR = 0.93, 95% CI: 0.22–2.69, p = 0.90), while injectable or implants use showed a slightly higher risk of moderate-to-severe dysmenorrhea (24.8% vs. 23.1%, PR = 1.08, 95% CI: 0.64–1.86, p = 0.78). Irregular menses posed a greater risk of moderate-to-severe dysmenorrhea than regular menses (29.4% vs. 19.1%, PR = 1.54, 95% CI: 0.95–2.53, p = 0.09). In multivariate analyses, several associations remained statistically significant after adjusting for maternal age and current breastfeeding. Participants who reported higher ACEs more frequently experience moderate-to-severe dysmenorrhea than those with fewer ACEs (adjusted PR [aPR]=1.71, 95% CI: 1.04–2.79, p = 0.03). Women who were breastfeeding at 24 months post-delivery had a higher likelihood of reporting moderate-to-severe dysmenorrhea compared to those who were not breastfeeding (aPR = 1.66, 95% CI: 1.02–2.71, p = 0.04), after adjustment for age. Pain relief behaviors were also significantly associated with severity: women with moderate-to-severe dysmenorrhea reported using painkillers more frequently (aPR = 4.12, 95% CI: 2.52–6.73, p < 0.001) and spending additional hours in bed than those without moderate-to-severe dysmenorrhea (aPR = 3.11, 95% CI: 1.88–5.14, p < 0.001).

This study assessed the prevalence, severity, and correlates of dysmenorrhea among postpartum women in Western Kenya. Nearly 1 in 4 women in this cohort experienced moderate-to-severe dysmenorrhea, with abdominal cramps and pain being the most commonly reported symptoms. Moderate-to-severe dysmenorrhea was associated with psychosocial and behavioral factors, including extended breastfeeding, high scores of ACEs, and coping behaviors such as additional time spent in bed and use of painkillers. These results highlight the complex biopsychosocial dimensions of menstrual pain and underscore the need for targeted, context-specific interventions to address dysmenorrhea.

We conducted a secondary cross-sectional analysis, leveraging data from women enrolled in the Pre-Exposure Prophylaxis (PrEP) Implementation for Mothers in Antenatal Care (PrIMA) Extension (PrIMA-X) Study (R01 HD100201), a longitudinal observational cohort study assessing the safety of PrEP during pregnancy and postpartum. PrIMA-X enrollment was conducted at four maternal and child health (MCH) clinics in Western Kenya between October 26, 2020, and June 6, 2023, and eligible participants were at least 15 years old, living without HIV, and were receiving MCH services at the study sites. Mother-child pairs were followed prospectively for up to 60 months postpartum. In September 2022, data collection for dysmenorrhea symptoms was incorporated into study procedures. Data were included in the present analysis among women who had menstruation data recorded at their 24-month post-delivery visit from the time that dysmenorrhea measurement was activated through Dec 2, 2024. Among 1,191 women enrolled in PrIMA-X, 277 participants met the inclusion criteria for this analysis. Ethical approval was obtained from the University of Washington Institutional Review Board (STUDY00008710) and the Kenyatta National Hospital, University of Nairobi Ethics and Research Committee (KNH-UoN ERC: P921/11/2019). All participants provided written informed consent. Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information ( S1 Checklist ). Data were collected by trained study nurses using tablet-based Research Electronic Data Capture (REDCap) questionnaires [ 18 ]. Questionnaires were administered in English, Swahili, or Dholuo based on participant preference. All measures or variables used in this analysis were collected at various time points, including at 24 months post-delivery. They included items related to sociodemographic characteristics (age: ≥ 24 vs. 25–35 vs. > 35 years, marital status, employment, education level: ≥ 8 vs. < 8 years, etc.), obstetric information (pregnancy outcomes, breastfeeding, mode of delivery, non-permanent birth control methods, etc.), psychosocial characteristics (alcohol/tobacco, etc.) and menstrual patterns (length of menstrual cycle, bleeding days per period, nature of menstrual flow, hours spent on bed and/or pills taken in last menstrual period for menstrual relief). We used the Cox Menstrual Symptom Scale (CMSS) to measure duration and severity of physical and emotional dysmenorrhea symptoms [ 19 ]. The CMSS evaluates 18 symptoms of dysmenorrhea in terms of duration and severity, respectively, including general aching, headaches, stomachaches, backaches, cramps, leg aches, dizziness, facial blemishes, flushing, nausea, vomiting, loss of appetite, diarrhea, weakness, insomnia, gloominess, irritability, and nervousness, using a 5-point Likert scale. Duration is rated from 0 (“did not occur”) to 4 (“lasted several days”), and severity from 0 (“not noticeable”) to 4 (“very severely bothersome”). Item-level scores for duration and severity are summed to produce a total score ranging from 0 to 144, where higher scores indicate more severe symptoms [ 20 ]. Although the CMSS has not been formally validated in Swahili or Dholuo, the scale was translated and back-translated by bilingual experts and pilot-tested with local women to ensure conceptual clarity and linguistic appropriateness. In the present analysis, the primary outcome was moderate-to-severe dysmenorrhea, defined as reporting at least one menstrual symptom that was moderately to very severely bothersome (CMSS severity score ≥2 vs. score <2). Depressive symptoms were assessed using the 10-item Center for Epidemiologic Studies Depression Scale (CESD-10), a shortened version of the original CESD that has been validated in diverse populations, including adolescents and adults in SSA [ 21 , 22 ]. The CESD-10 includes 10 items rated on a 4-point Likert scale ranging from 0 (“rarely or none of the time”) to 3 (“most or all of the time”) based on symptom frequency in the past week. Total scores range from 0 to 30, with higher scores indicating greater severity of depressive symptoms. Consistent with prior research, scores were dichotomized as low (<10) and high (≥10) depressive symptoms to identify clinically meaningful distress [ 23 , 24 ]. Perceived stress was measured using the 10-item Perceived Stress Scale (PSS-10), a widely used psychological instrument designed to measure the degree to which individuals perceive life situations as stressful during the past month, on a 5-point Likert scale ranging from 0 (“never”) to 4 (“very often”) [ 25 ]. Four positively worded items were reverse-scored, and total scores ranged from 0 to 40, with higher scores indicating greater levels of perceived stress. For this analysis, perceived stress was dichotomized as low (<10) and high (≥10), with the threshold of 10 reflecting elevated stress in population-based studies [ 26 ]. ACEs were measured using the 31-item of Adverse Childhood Experiences International Questionnaire (ACE-IQ), capturing exposure to a range of adversities during childhood and adolescence, including physical, emotional, and sexual abuse; neglect; household dysfunction (e.g., caregiver substance use, incarceration, mental illness, death, or separation); bullying; and exposure to violence in the home, school, or broader community [ 27 , 28 ]. These items were grouped into 13 domains based on established ACE frameworks, with each domain coded as either present or absent. A cumulative ACE score (range: 0–13) was then calculated by summing the number of domains experienced. For analysis, ACE exposure was dichotomized as high (≥6) and low (<6), thresholds supported by evidence linking higher ACE burden to increased risk of adverse mental, behavioral, and physical health outcomes [ 28 , 29 ]. IPV was assessed using the Hurt, Insult, Threaten, and Scream (HITS) scale, a validated 4-item screening tool designed to measure the frequency of physical and emotional abuse by a partner [ 30 ]. The scale includes the items: Hurt, Insult, Threaten, and Scream, each rated on a 5-point Likert scale ranging from 1 (“never”) to 5 (“frequently”), yielding a total score range of 4–20. Higher scores indicate greater IPV exposure. We defined IPV based on thresholds established for identifying individuals at risk of IPV in clinical and research settings (HITS score ≥10 vs. < 10) [ 30 ]. Mother-child engagement was measured using items from the Multiple Indicator Cluster Survey (MICS) Early Childhood Development module, which assesses the frequency and quality of developmental stimulation activities provided by caregivers [ 31 ]. Mothers were asked whether they engaged in key activities with their child in the past three days, such as reading, storytelling, singing songs, playing, or naming/counting objects. Responses were used to create a binary variable indicating high engagement (if the mother participated in at least four of the six recommended activities) and low engagement (if fewer than four activities were reported), consistent with global early childhood development benchmarks [ 31 ]. Descriptive statistics were used to summarize symptom duration and severity. Poisson regression with robust variance estimation, clustered by facility level, was used to assess the associations between moderate-to-severe dysmenorrhea and potential correlates. For the adjusted analyses, we selected age (as a continuous variable) and current breastfeeding status (Yes/No) as a priori confounders based on previous literature and a conceptual model of dysmenorrhea etiology [ 5 ]. Each variable with p ≤ 0.05 in univariate analysis was then entered into a separate multivariable Poisson model controlling for these covariates. R software (version 4.3.1, 2023-06-16) was used for analysis.

Inclusivity in global research checklist. (DOCX) Dataset used for analysis. (CSV)