Patterns and associated factors of complementary and alternative therapy use for dysmenorrhea among undergraduate students in North India

Rakhi Mishra: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Aradhna Kumari: Methodology, Formal analysis, Data curation, Conceptualization. Arushi Sumal: Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Ashu Bhardwaj: Methodology, Formal analysis, Data curation, Conceptualization. Ayushi Sharma: Methodology, Formal analysis, Data curation, Conceptualization. Bhawna: Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Chhabi Simran: Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Deep Mala: Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Deepa: Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Deepika: Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Savita Kumari: Validation, Supervision, Conceptualization.

A total of 293 female undergraduate students with dysmenorrhea were included after screening 370 nursing and 50 medical students ( Table 1 ). The mean age was 21.2±1.5 years, with the majority aged 21 to 23 years (64.2%). Most participants were nursing students (98.6%), and students were evenly distributed across the 3rd and 4th years (28% each). The mean age at menarche was 13.8±1.3 years, with most experiencing menarche between 13 and 15 years (76.5%). The predominant menstrual cycle length was 26 to 30 days (87.0%) with a mean of 28.0±2.1 days. Average menstrual flow duration was 4.9±1.2 days, with 71.7% reporting <5 days. Regular menstruation and normal flow were reported by 90.8% and 62.8%, respectively. A small proportion (8.2%) reported gynecologic conditions, such as treated infections or mild cysts, which did not affect participation. Oral contraceptive use was 5.1%. Table 1 Socio-demographic and menstrual characteristics of undergraduate students with dysmenorrhea ( N =293) Table 1 dummy alt text Variable f (%) Age (in y) 21.24±1.47 18–20 93 (31.7) 21–23 188 (64.2) 24–26 12 (4.1) Professional course Nursing 289 (98.6) Medical 04 (1.4) Year of study 1st y 79 (27.0) 2nd y 50 (17.1) 3rd y 82 (28.0) 4th y 82 (28.0) Age at menarche (in y) 13.8±1.3 y 10–12 49 (16.7) 13–15 224 (76.5) 16–18 20 (6.8) Menstrual cycle length (in d) 28.0±2.1 d 21–25 15 (5.1) 26–30 255 (87.0) 31–35 23 (7.8) Duration of menstrual flow (in d) 4.9±1.2 d 8 01 (0.3) Regularity of menses Regular 266 (90.8) Irregular 27 (9.2) Menstrual flow characteristics Scanty 90 (30.7) Normal 184 (62.8) Heavy 19 (6.5) History of gynecological illness Yes 24 (8.2) No 269 (91.8) Oral contraceptive pill use Yes 15 (5.1) No 278 (94.9) Mishra. Patterns and associated factors of complementary and alternative therapy use. AJOG Glob Rep 2026. Socio-demographic and menstrual characteristics of undergraduate students with dysmenorrhea ( N =293) All participants reported experiencing dysmenorrhea within the preceding 6 months. The most frequently reported symptoms and their severity are summarized in Table 2 : tiredness (70.6%), back pain (69.3%), pain radiating to the back or legs (63.8%), suprapubic spasms (49.8%), sharp intermittent pain (31.7%), nausea or vomiting (20.5%), dizziness (19.1%), diarrhea (18.4%), and headache (16.4%). Participants primarily obtained information regarding CAT from family and friends (40.2%), healthcare professionals (29.9%), and online sources (25.3%), with print media (3.4%) and unspecified sources (70.6%) less frequently cited. Home-based remedies such as dietary interventions or hot water application were most frequently employed (22.5%), followed by yoga or exercise (18.4%), whereas acupressure or massage was less frequently reported (1.3%). Table 2 Symptoms experienced, information sources, and use of complementary and alternative therapies among students with dysmenorrhea ( N =293) Table 2 dummy alt text Variable f (%) Experience of dysmenorrhea Yes 293 (100.0) No 00 (00) Source of information on CAT a Family and friends 118 (40.2) Health care professionals 88 (29.9) Online sources 74 (25.3) Print media 10 (3.4) Not specified 207 (70.6) Symptoms experienced during menstruation a Tiredness 207 (70.6) Back pain 203 (69.3) Pain radiating to the back/legs 187 (63.8) Spasms (suprapubic area) 146 (49.8) Sharp intermittent pain 93 (31.7) Nausea and vomiting 60 (20.5) Dizziness 56 (19.1) Diarrhea 54 (18.4) Headache 48 (16.4) Types of CAT used a Home remedies (food, hot water) 66 (22.5) Yoga/exercise 54 (18.4) Acupressure/massage 04 (1.3) a Multiple responses allowed. Mishra. Patterns and associated factors of complementary and alternative therapy use. AJOG Glob Rep 2026. Symptoms experienced, information sources, and use of complementary and alternative therapies among students with dysmenorrhea ( N =293) Multiple responses allowed. Pain severity was assessed using the WaLIDD tool, and findings are summarized in Table 3 . Regarding effects on work ability, pain “almost always” affected work (43.0%) and “always” affected work (13.3%). Pain was reported at a single site (34.8%) or at 2 to 3 sites (43.0%), while a minority of participants reported no specific site of pain (20.8%). On the Wong–Baker FACES Pain Scale, moderate pain was most frequently reported (46.1%), severe pain was reported by 7.5%, and no pain by 9.2%. Overall, dysmenorrhea severity was categorized as mild (29.4%), moderate (51.9%), and severe (14.0%), with pain duration predominantly 1 to 2 days (58.0%). A small proportion of participants reported no dysmenorrhea (4.8%). These responses were self-reported and likely reflect very mild, intermittent, or transient symptoms; to maintain consistency with the assessment tool, these data were retained in the analysis. Table 3 Severity of dysmenorrhea among undergraduate students using the WaLIDD scale ( N =293) Table 3 dummy alt text WaLIDD components f (%) Effect on working ability None 46 (15.7) Almost never 82 (28.0) Almost always 126 (43.0) Always 39 (13.3) Pain location (sites) None 61 (20.8) 1 site 102 (34.8) 2–3 sites 126 (43.0) ≥4 sites 4 (1.4) Pain intensity (Wong–Baker scale) No pain 27 (9.2) Mild 109 (37.2) Moderate 135 (46.1) Severe 22 (7.5) Duration of pain (d) 1 87 (29.7) 1–2 170 (58.0) 3–4 31 (10.6) ≥5 5 (1.7) Overall dysmenorrhea severity None 14 (4.8) Mild 86 (29.4) Moderate 152 (51.9) Severe 41 (14.0) Mishra. Patterns and associated factors of complementary and alternative therapy use. AJOG Glob Rep 2026. Severity of dysmenorrhea among undergraduate students using the WaLIDD scale ( N =293) The utilization of CAT among students with dysmenorrhea is summarized in Table 4 . Among biologically based practices, massage was most common (8.9%), while acupuncture and acupressure were rare (0.7% each). Mind–body therapies included chanting/prayer (9.9%), meditation (8.5%), self-tapping (6.5%), and yoga (5.5%). Manipulative/body-based therapies were less frequent, with reflexology (3.8%) and the Feldenkrais method (1.7%). Whole/alternative medicine use included herbal remedies (2.0%), oral ginger (1.7%), spices (2.0%), and notably, chocolate (59.7%). Other therapies included music therapy (33.1%), local heat (28.0%), hot drinks (27.0%), watching television (12.3%), and aromatherapy (0.3%). Table 4 Use of complementary and alternative therapies for dysmenorrhea among undergraduate students ( N =293) Table 4 dummy alt text CAT domain f (%) Biological-based practices Acupuncture 02 (0.7) Massage 26 (8.9) Acupressure 02 (0.7) Mind–body medicine Yoga 16 (5.5) Self-tapping 19 (6.5) Chanting/prayer 29 (9.9) Meditation 25 (8.5) Manipulative/body-based systems Reflexology 11 (3.8) Feldenkrais method 05 (1.7) Whole/alternative medicine Herbal medicines 06 (2.0) Oral ginger 05 (1.7) Spices (cloves, turmeric, etc.) 06 (2.0) Chocolates 175 (59.7) Other therapies Music therapy 97 (33.1) Local heat therapy 82 (28.0) Hot drinks 79 (27.0) Watching television 36 (12.3) Aromatherapy 01 (0.3) Mishra. Patterns and associated factors of complementary and alternative therapy use. AJOG Glob Rep 2026. Use of complementary and alternative therapies for dysmenorrhea among undergraduate students ( N =293) Association between selected demographic and menstrual characteristics and dysmenorrhea severity is presented in Table 5 . Most variables, including age, course, menstrual regularity, age at menarche, cycle length, duration and flow of menstruation, history of gynecological illness, and oral contraceptive use, were not significantly associated with severity ( P >.05). Year of study was the only variable significantly associated ( P =.035), with higher proportions of moderate–severe dysmenorrhea among 3rd to 4th-year students. Table 5 Association between severity of dysmenorrhea and selected demographic variables ( N =293) Table 5 dummy alt text Variable Severity of dysmenorrhea score Mild ( f ) Moderate–severe ( f ) P value Age (in y) 18–20 47 46 .287 21–23 85 103 24–26 08 04 Professional course Nursing 138 151 .929 Medical 02 02 Year of study 1st y 46 33 .035 ⁎ 2nd y 19 31 3rd y 32 50 4th y 43 39 Regularity of menses Regular 127 139 .968 Irregular 13 14 Age at menarche (in y) 10–12 25 24 .866 13–15 106 118 16–18 09 11 Menstrual cycle length (d) 21–25 04 11 .231 26–30 124 131 31–35 12 11 Duration of menstruation (d) 8 00 01 Menstrual flow Scanty 47 43 .169 Normal 81 103 Heavy 12 07 History of gynecological illness Yes 12 12 .820 No 128 141 Oral contraceptive use Yes 06 09 .536 No 134 144 “Mild”=WaLIDD score 0 to 4 (none+mild); “Moderate–Severe”=WaLIDD score 5 to 12. ⁎ p>0.05 level of Significance. Mishra. Patterns and associated factors of complementary and alternative therapy use. AJOG Glob Rep 2026. Association between severity of dysmenorrhea and selected demographic variables ( N =293) “Mild”=WaLIDD score 0 to 4 (none+mild); “Moderate–Severe”=WaLIDD score 5 to 12. p>0.05 level of Significance. Binary logistic regression showed that students in the 3rd to 4th years had higher odds of moderate–severe dysmenorrhea (adjusted OR=1.82; 95% CI: 1.08–3.05; P =.024). Sharp intermittent pain (OR=2.31; 95% CI: 1.29–4.12; P =.005), massage use (OR=1.96; 95% CI: 1.01–3.80; P =.046), and heat therapy use (OR=2.74; 95% CI: 1.45–5.16; P =.002) were also associated with moderate–severe dysmenorrhea. Utilization of CAT increased with dysmenorrhea severity across domains, including biological-based (20.9% to 46.3%; χ ²=9.12, P =.010), mind–body (16.3% to 36.6%; χ ²=6.47, P =.039), alternative medicine (45.3% to 68.3%; χ ²=8.56, P =.014), and supportive methods (47.7% to 80.5%; χ ²=14.82, P <.001). Reasons for using CAT among students with dysmenorrhea included perceived benefits such as reduction in analgesic use (53.2%), prevention of medication side effects (51.2%), perceived efficacy (43.3%), safety (41.0%), and cost-effectiveness (35.8%). Additional reasons included recommendations from others (33.8%) and easy availability (38.6%). Overall, most responses were in the agree or strongly agree categories, indicating favorable perceptions toward these therapies.

A quantitative descriptive study was conducted from April 25 to 29, 2022, to assess the use of CATs for managing dysmenorrhea among undergraduate students pursuing medical and nursing courses at a tertiary care institute in Uttarakhand, North India. Initially, a sample size estimation was performed using the formula: n = ( Z 1 − α / 2 ) 2 p q / d 2 where Z 1− α /2=1.96 for 95% confidence interval, p =74.4% (expected prevalence of dysmenorrhea), q =1− p , and d =5% margin of error. 11 An additional 10% was added to account for nonresponse due to incomplete or missing questionnaires, resulting in an estimated minimum sample of 314 participants. To ensure complete coverage, all female nursing ( n =370) and medical ( n =50) students were screened using a self-administered questionnaire to identify those experiencing dysmenorrhea in preceding 6 months. Students who reported dysmenorrhea were considered eligible and were further asked detailed questions regarding pain severity, associated symptoms, and use of CAT. Students with amenorrhea or a known diagnosis of gynecological or obstetrical conditions were excluded based on self-reported medical history. This process resulted in 293 participants, who were included in the study using total enumerative sampling of all eligible students. Data were collected using a structured, self-administered questionnaire developed in English. The instrument underwent content validation by a panel of seven experts, including nursing (05) and obstetrics and gynecology (02), and revisions were incorporated based on their recommendations. A pilot study was conducted on 30 students to assess the feasibility and clarity of the questionnaire, and necessary refinements were made before the main study. Tool I: Socio-demographic and menstrual profile : This section consists of participants’ personal and menstrual characteristics, including age, professional course, year of study, age at menarche, regularity of menses, menstrual cycle length, duration and characteristics of menstrual flow, history of gynecological or obstetrical illness, family history of gynecological conditions, oral contraceptive pill use, symptoms during menstruation, and awareness of CAT along with sources of information. Tool II: Dysmenorrhea severity assessment scale (WaLIDD) : Dysmenorrhea severity was assessed using the standardized WaLIDD scale, which comprises four components: effect on work ability, pain location, pain intensity, and duration of pain (in terms of the number of days). Pain intensity was measured using the Wong–Baker FACES Pain Scale (WBFPS), a validated tool widely used for self-reported pain assessment. Each WaLIDD component is scored from 0 to 3, resulting in a total score ranging from 0 to 12. Dysmenorrhea severity is categorized as none (0), mild (1–4), moderate (5–7), or severe (8–12). The WaLIDD scale has demonstrated satisfactory reliability, with a reported Cronbach’s alpha of 0.73. The WBFPS has shown high reliability in clinical settings, with inter-rater reliability coefficients of up to 0.90, indicating consistent pain assessment. Tool III: Likert scale for use of CAT : This tool assessed the frequency and reasons for using CAT in managing dysmenorrhea. It comprised 25 items grouped into five domains: biological-based practices, mind–body medicine, manipulative and body-based systems, whole/alternative medicine systems, and other supportive measures. Eighteen items were rated on a three-point Likert scale (Always, Sometimes, Never), while seven items assessing reasons for CAT use were rated on a five-point Likert scale (Strongly Disagree to Strongly Agree). The internal consistency of this scale was established with a Cronbach’s alpha of 0.82, indicating good reliability. Data were analyzed using SPSS version 23. Descriptive statistics included frequencies, percentages, means, and standard deviations. Associations between categorical variables were examined using the Chi-square test. Variables with P <.20 in bivariate analysis were included in a binary logistic regression model. Adjusted odds ratios with 95% confidence intervals were reported. A P value <0.05 was considered statistically significant. Effect sizes were reported using Cramer’s V to indicate the strength of associations.

The present study demonstrates a substantial burden of dysmenorrhea among undergraduate students, with over half reporting moderate severity and a notable proportion experiencing severe pain. Similar prevalence patterns have been reported among college-going students in India and other low- and middle-income countries, where dysmenorrhea commonly affects daily activities, academic performance, and quality of life. 12 , 13 The predominance of moderate dysmenorrhea aligns with prior institutional surveys among medical and nursing students. 14 , 15 High use of CAT reflects a preference for nonpharmacological approaches due to concerns about side effects and long-term analgesic use. 9 , 10 , 16 The positive association between dysmenorrhea severity and CAT use suggests that students with more intense pain adopt multiple coping strategies. Supportive methods, including local heat therapy, hot drinks, music therapy, and chocolates, were most common and showed the strongest association with severity. Heat therapy is supported by evidence for improving pelvic blood flow and reducing muscle spasm, 17 whereas chocolate likely reflects emotional comfort rather than therapeutic effect. 16 Mind–body practices, such as yoga and meditation, were less frequently used than in other regions of India, where they are more culturally embedded. 18 Higher academic year was associated with increased odds of moderate–severe dysmenorrhea, likely reflecting academic stress and lifestyle disruptions among senior students, 2 , 7 Additionally, the progressive manifestation of underlying gynecological conditions may contribute to increasing pain severity over time. Disorders such as endometriosis or uterine fibroids can become more symptomatic with age and may therefore contribute to greater dysmenorrhea severity among students in higher academic years. 19 Similar associations between stress, academic demands, and menstrual symptoms have been described in student populations, although international findings remain inconsistent. 2 , 16 Several strengths enhance the contribution of this study. First, the use of a total enumerative sampling strategy ensured inclusion of all eligible students with dysmenorrhea within the study population, minimizing selection bias within the institutional setting. Second, dysmenorrhea severity was assessed using the validated multidimensional WaLIDD scale, which captures work ability, location, intensity, duration, and disability, allowing a more comprehensive assessment of menstrual pain than single-item severity measures. Third, the study systematically evaluated a wide spectrum of CAT domains, including supportive, dietary, and mind–body practices, providing detailed insights into real-world coping behaviors among young women. Additionally, evidence on CAT utilization for dysmenorrhea among undergraduate nursing students from North India remains limited; therefore, the findings contribute valuable regional data that may inform student health services and future research. The study also has limitations. The single-center design may limit the generalizability of the findings to other academic institutions or regions. Data were based on self-reported responses and may therefore be subject to recall bias. In addition, the cross-sectional design precludes causal inference regarding the relationship between dysmenorrhea severity and CAT utilization. Furthermore, the clinical effectiveness or outcomes associated with individual CAT methods were not evaluated. These findings underscore the importance of campus health initiatives that promote safe and evidence-based nonpharmacological strategies for menstrual pain management. Interventions such as structured yoga sessions, relaxation training, and education regarding appropriate use of heat therapy may provide accessible and low-cost options for students. Educational programs can also help address misconceptions about self-care practices and guide students toward evidence-supported approaches. Future research should include longitudinal or interventional designs to evaluate the effectiveness and cost-effectiveness of commonly used CAT methods, and multi-institutional studies would improve the generalizability of findings. In summary, among students experiencing dysmenorrhea, greater pain severity was associated with increased utilization of CAT. Understanding these coping behaviors can assist campus health services in designing targeted, evidence-based support strategies to improve menstrual health and overall student well-being.

Artificial intelligence (ChatGPT, OpenAI, 2025) was used only for language editing and formatting assistance; it did not influence the study’s scientific content, data interpretation, or conclusions.

The menstrual cycle is a normal physiological process characterized by cyclical hormonal and physiological changes in the female reproductive system, culminating in menstruation approximately every 28 days. 1 , 2 Despite being a natural phenomenon, menstruation is frequently accompanied by dysmenorrhea, defined as painful uterine cramping during menstrual bleeding. 3 Dysmenorrhea is one of the most common gynecological complaints among adolescents and young women and represents a significant public health concern because of its adverse effects on physical functioning, academic performance, and overall quality of life. 4 Recent studies conducted among adolescents and young adults report that dysmenorrhea affects a substantial proportion of women worldwide, with prevalence estimates ranging from approximately 41% to over 90% depending on the population studied. 5 In India and other low- and middle-income countries, recent research continues to demonstrate a high burden of dysmenorrhea among adolescents and young women, often interfering with academic performance and daily activities. 6 A recent study among female students also highlighted the substantial impact of dysmenorrhea on class participation, absenteeism, and academic productivity. 7 Pharmacological treatments, including nonsteroidal anti-inflammatory drugs and oral contraceptive pills, are commonly used for symptom relief but may be limited by side effects, contraindications, and concerns regarding long-term use. 8 Consequently, many women are increasingly adopting complementary and alternative therapies (CAT), such as hot water applications, exercise, yoga, dietary measures, and herbal remedies, which are perceived as safer and more accessible options. 9 Recent evidence also highlights growing interest in CAT for the management of primary dysmenorrhea because these approaches may provide symptom relief with fewer adverse effects compared with conventional pharmacological treatments. 10 Undergraduate students represent a particularly relevant group for study, as high academic stress, irregular schedules, and lifestyle factors may exacerbate dysmenorrhea and influence CAT utilization. Furthermore, lifestyle and psychosocial factors such as stress, sleep patterns, and physical activity have been identified as important determinants of dysmenorrhea severity among adolescents and young women. 6 However, limited data exist on the patterns of CAT use and predictors of dysmenorrhea severity among undergraduate students in North India. Therefore, this study aimed to assess the use of CAT and its association with the severity of dysmenorrhea among undergraduate students.