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Prevalence of, and Risk Factors for Dysmenorrhea among Female Medical Students at the University of Ibadan, Nigeria

Oluwabunmi Victoria Adeyeye*1, Yusuf Olatunji Bello*2,3, Mary Mofiyinfoluwa Adeyeye1, Olajumoke Aishat Oladosu1, Oluwagbemisola Motunrayo Oderemi1 Nasirat Ibukun Akinlade1, Millicent Magdalene Maduka1, Gloria Onyinyechi Madu4, Imran Oludare Morhason-Bello3,5


1.Department of Medicine and Surgery, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Oyo State, Nigeria. 2. Department of Statistics, Faculty of Science, University of Ibadan, Oyo State, Nigeria. 3. Institute 

for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Oyo State, Nigeria. 4. Department of Medicine and Surgery, Faculty of Clinical Sciences, College of Medicine, Abia State University, 

Abia State, Nigeria. 5. Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, 

College of Medicine, University of Ibadan, Oyo State, Nigeria

ABSTRACTS

Aim: This study investigates the prevalence and factors associated with dysmenorrhea among medical students at the University of Ibadan, Nigeria.Settings and Design: A cross-sectional study was conducted among female medical students that were regularly menstruating.  Methods and Material: A structured questionnaire validated by expert independent observers was used for data collection. Information collected included socio-demographic characteristics, pattern of menstruation including dysmenorrhea, and related reproductive health explanatory variables.  Statistical analysis used: The association between dysmenorrhea and selected explanatory variables status was assessed with the chi-square test. Poisson regression with robust variance was used to examine the significant factors that affect the prevalence of dysmenorrhea. Results: In total, 171 female medical students participated. Majority 163 (96.45%) of participants reported having lower abdomen pain during menstruation. There was a statistically significant difference in the average monthly allowance between participants with and without a history of dysmenorrhea (p<.001). A higher percentage of participants 99 (61.88%) with a history of dysmenorrhea stated that a family member had experienced cyclical pain. Participants who were unsatisfied with their relationship with their parents had 1.04 (95% CI 1.01 - 1.08) times more likely to experience dysmenorrhea than participants who felt satisfied with their parents. Conclusion: There is a high prevalence of dysmenorrhea amongst medical students with those having an increased average monthly allowance and feeling satisfied with their parents at a decreased risk.   

 Keywords: Dysmenorrhea, Menstruation, Pain, Female Medical Student, Nigeria

Correspondence 

 Imran O. Morhason-Bello, MD, PhD 

Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Medicine, University College Hospital, University of Ibadan, Ibadan,  PMB 5116, Oyo State, Nigeria. imranmorhasonbello@gmail.com. Phone number: +2348034784402

Introduction

During a woman's reproductive life, menstruation is often a universal and normal occurrence. Menstruation is a cyclical shedding of blood and mucosal tissue from the uterine lining through the vagina every month. This process is initiated by a fall in progesterone levels and serves as an indication that conception has not taken place. The onset of menstruation is described as menarche, usually occurs around 12 to 13 years.1 Menarche's onset is marked by a variety of abnormalities. In various Western populations, post-menarchial irregularity was reported by 43 to 62% of girls during the first year of menstruation, and in some cases, it continued for 3 to 5 years. 1-4 Menstrual disorder can become a serious gynecological complaint in adolescence and adulthood particularly when it becomes persistent and it sometimes disrupts routine activities such as missing exercise and outdoor events. 5 Menstrual disorders could be a disorder of cycle length, a disorder of flow, or both. Examples of such disorders include oligomenorrhea (light, irregular, or delayed menstruation), menorrhagia (excessive or prolonged flow), dysmenorrhea (painful menstruation), Pre-menstrual Syndrome (PMS) and amenorrhea (lack of menstruation). 

Generally, dysmenorrhea affects 50% to 90% of the general population making it one of the most commonly reported menstruation disorders in adolescent girls and adult women. 6 A study reported that women older than 20 years tend to have higher prevalences of dysmenorrhea than those of younger age.7 Dysmenorrhea is characterized by a cramping sensation that occurs in the lower abdomen or pelvic discomfort that generally radiates to the back or thighs. It is sometimes accompanied by other symptoms, such as headache, breast tenderness, anxiety, vomiting, and anorexia, all of which occur shortly before or during the period of menstruation.8 Dysmenorrhea could be primary or secondary.  Primary dysmenorrhea has no evident pathological pelvic illnesses and has been present since the commencement of menarche. Young females and adolescents are most likely to experience it. 9 On the other hand, secondary dysmenorrhea describes painful menstruation brought on by a known pelvic pathology, such as a pelvic inflammatory disease, adenomyosis, or fibroid. 10

Although dysmenorrhea is not a life-threatening condition, it negatively affects the quality of life for women.11 There are reports of a strong association between dysmenorrhea and mental health manifestations.12 The intellectual, social, and emotional well-being may be greatly compromised in women complaining of persistent dysmenorrhea.13 For example, a study showed that 10 to 15% of women experienced monthly menstrual pain that makes the completion of normal daily home, work, or school duties difficult. 13

Several studies on risk factors associated with dysmenorrhea have reported mixed results7. Most studies conducted among college students consistently showed an earlier age at menarche as a risk factor for dysmenorrhea, perhaps, this could be a result of hormonal imbalance in the hypothalamus-pituitary-ovarian axis. 14-17 Other associated risk factors include having a positive family history of dysmenorrhea, 18,19 having a longer menstrual cycle, 17,19, and older age at getting pregnant or delivering a child.20 Studies that assessed the role of smoking, alcohol consumption, coffee intake, and risk of dysmenorrhea had contradictory findings.7 For example, some studies showed smokers having a higher risk of dysmenorrhea18,21,22 while other studies did not find any association with smoking history. 15, 19, 23

Several studies have explored dysmenorrhea across diverse populations, including adolescents and adult women. However, the distinct stressors and rigorous demands inherent in medical education create a unique context for female medical students. Understanding the prevalence and risk factors of dysmenorrhea within this specific group is especially relevant. Exploring these factors within this specific demographic could reveal unique contributors to the development or exacerbation of dysmenorrhea, thereby facilitating the development of tailored interventions and support services. Moreover, insights gained from studying dysmenorrhea among medical students can also inform strategies applicable to the wider female population, both within academic settings and beyond. This study therefore aims to investigate the prevalence of, and risk factors associated with the report of dysmenorrhea among female medical students as a sample of young people in Ibadan. The female medical students were chosen based on our assumption that they would have learnt about the subject in class and fully understood the term dysmenorrhea. Secondly, the female medical students were believed to be able to openly discuss their menstrual health challenges compared to young ladies who might not have had medical training. 

SUBJECTS AND METHODS 

Study Design

This was a cross-sectional study that was conducted among female medical students at the College of Medicine, University of Ibadan (UI). UI is the premier University in Nigeria, established in 1948 together with the Medical School. A structured questionnaire was administered to the participants to collect the quantitative data.

Study Settings

Data were collected from female medical students (years 1-6) in the College of Medicine, UI.

Inclusion Criteria

Female medical students with a history of regular menstruation 

Exclusion Criteria

Any participants with abnormal bleeding, pelvic inflammatory diseases, lower abdominal pain, or pelvic pain due to other causes and those that refused to consent were excluded.

Sampling Technique  

The student records at the College of Medicine, University of Ibadan showed that there were 40, 68, 93, 63, 58, 57, and 40 female students at each level from Year 1 to Year 6, making a total of 419 students. There was a set of students delayed by an academic year due to industrial actions by labour unions. A stratified random sampling technique was used to select potential participants to minimize bias and reduce error. Each academic year was taken as a stratum, and a random sample was selected proportionate to the absolute population of female medical students in each year. 

Sample Size

The sample size was calculated using a formula for cross-sectional design;

image

Where:

n = sample size

image=value of z at image(level of significance)

p = prevalence of dysmenorrhea from a previous study and 

d = precision of the study, set at 5%.

The sample size was 167. Four additional participants were added to the sample size, nevertheless, to account for nonresponse bias making a total of 171.  

Study Instrument and Data Collection

A structured questionnaire comprising five sections with closed-ended questions was developed following a review of literature and discussions with Obstetrician and Gynaecologists at the College of Medicine, UI. After the design, another set of independent experts (Obstetricians and Gynaecologists) reviewed the questions before we conducted a pilot among young people in the community. Members of the research team distributed the questionnaire to selected students from the sampling frame of each class and were given a week to complete it and for collection. Students who declined consent were excluded from participation.

Data Management and Analysis

Response Variable: The primary outcome was a history of dysmenorrhea.

Explanatory Variables: The explanatory variables considered include the socio-demographic characteristics, pattern of menstruation, and family history.

The statistical analysis was performed using STATA (StataCorp L.L.C.). Descriptive statistics (mean and standard deviation) and frequency distribution were used to summarize the continuous and categorical variables. The median and interquartile range were used where the continuous variables were not normally distributed. The association between the categorical variables and the status of dysmenorrhea was examined using the chi-square test. The risk ratio was obtained for the study variables on the participants' dysmenorrhea history using Poisson regression with robust variance. Statistical significance was determined using the 95% confidence interval and a p-value of less than or equal to 0.05.

Ethical Consideration

Ethical approval was obtained from the UI/UCH ethics committee with reference number UI/EC/22/0266. Before each participant completed the questionnaire, informed consent was obtained to gain their voluntary participation. An introductory and consent note was attached to the questionnaire, and the participants were encouraged to seek clarification before signing the consent form.

RESULTS

A total of 171 medical students participated in the study. The descriptive analyses of participants by their history of dysmenorrhea are shown in Table 1. Six (3.55%) out of 171 participants had never experienced dysmenorrhea, while 163 (96.45%) of them had lower abdomen pain during menstruation. The average age of participants with dysmenorrhea was 22.09±0.18 compared to those without a history of dysmenorrhea (21.80±0.73). Most participants 167 (97.66%) were single and 143 (85.12%) lived on campus. All participants without a history of dysmenorrhea engaged in regular communication and enjoyed a positive relationship with their parents. The average monthly allowance for participants without a history of dysmenorrhea was two times higher than those 


Text Box: Table 1: Distribution and Test of Association between Respondent Characteristics and Dysmenorrhea History


Text Box: Table 2: Dysmenorrhea History and Lifestyle Changes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

with a history of dysmenorrhea. A higher percentage of participants 99 (61.88%) with a history of dysmenorrhea reported a positive family history of dysmenorrhea/cyclical abdominal pain. Menstrual discomfort was reported by two-thirds 111 (67.68%) each month, followed by participants who reported it every three months (Figure 1). 

There was no significant association between history of dysmenorrhea and selected categorical characteristics. However, there was a significant difference in the average monthly allowance between participants with and without a history of dysmenorrhea [t (150) = -3.898, p .001]. There was also a significant difference in menstrual cycle length between participants in the two groups [t (160) = 2.840, p = 0.005], with participants with a history of dysmenorrhea having a longer average menstrual cycle length (27.94±0.39) than those without dysmenorrhea (21.4±4.73).

Table 2 displays the participants' lifestyle changes and history of dysmenorrhea. Over a third, 59 (36.42%) of participants rated their pain as severe to prevent them from performing their daily activities without taking medication. The majority 102 (64.56%) reported feeling discomfort at the beginning of menstruation, while 10 (6.33%) reported history of pain throughout the duration of menstruation. Figure 2 shows the pharmacological and non-pharmacological pain relief methods used by the participants. Most of them took paracetamol and hot water as pharmacological and non-pharmacological treatment regimens, respectively (Figure 2). 


Table 3 shows the Poisson regression with robust variance of factors associated with history of dysmenorrhea. The results of the crude risk ratio showed that participants who communicated with their parents fortnightly or monthly were 1.04 (95% CI 1.01 - 1.07) times more likely to experience dysmenorrhea than those who did not communicate with their parents weekly. Additionally, participants who were unsatisfied with their relationship with their parents were 1.04 (95% CI 1.01 - 1.08) times more likely to experience dysmenorrhea than participants who felt satisfied with their parents. Accommodation, religion, marital status, family structure, parent divorce, and use of sanitary products were other factors associated with history of dysmenorrhea. However, these explanatory factors were not statistically significant after adjusting for other variables in the model.

DISCUSSION

This study showed that dysmenorrhea is highly prevalent among medical students as nearly all participants gave a history of having experienced symptoms suggestive of pain during menstruation. We also found that participants with a history of dysmenorrhea had a longer average menstrual cycle length, a positive family history, and most used paracetamol and hot water as treatment regimens.  

The high prevalence of dysmenorrhea observed in this study is similar to studies by Gumanga and 

 

 

Text Box: Table 3: Risk Factor Analysis of Dysmenorrhea among Participants Using Poisson Regression


image

Figure 1: Bar Plot of the Frequency of Menstrual Pain

 

image

Figure 2: Dysmenorrhea Pain-Relieving Techniques 

 

Kwame-Aryee, 2012 in Ethiopia and Ghana that reported prevalence rates of 85.4% and 74.4% respectively. 24 The high proportion of dysmenorrhea was also reported in other studies across different geopolitical regions of Nigeria but at a slightly lower level than our study. For example, a study in Anambra, Southeast region found 82.2% of participants reporting dysmenorrhea while another study in Southwest Nigeria found 73% of adolescents with dysmenorrhea. A similar study in Kwara state showed that 71.8% of adolescents had a history of dysmenorrhea. 25 However, two studies among adolescents in Enugu (51.1%) and Kano (42.5%) found relatively lower prevalences of dysmenorrhea. 26,27   The variation in the prevalences of reported dysmenorrhea might be due to differences in the operational definition used, methods of data collection (self-versus interviewer-administered) and age range of study population recruited. 

In this study, we observed that participants who did not experienced dysmenorrhea had a higher monthly income than those with history of dysmenorrhea. It is plausible that monthly income could be a maker of the socioeconomic state of participants as some studies have reported this association. 28  This causal relationship will need to be explored using a longitudinal study design. School absenteeism due to dysmenorrhea is another previously reported factor because of its potential to negatively affect their academic performances. In this study, more than a third of participants with dysmenorrhea said their menstrual pain were severe enough to affect their daily activities if they did not use any pain relief medications. Although this study did not assess the previous academic performances of participants in relation to school absenteeism or its effects on other daily activities, the impact of dysmenorrhea could be enormous as students may miss examinations or perform poorly in their academic pursuits. A study by Ezebialu et al. in Nigeria had previously reported an association between severe dysmenorrhea and poor academic performances. 29

Interestingly, we observed that a significant proportion of participants were using non-pharmaceutical regimens including drinking or bathing with hot water. This strange attitude of medical students requires further exploration to understand the sources of this traditional treatments and their perceived belief about the potency of such treatments.  Furthermore, most of the participants used mild analgesics whereas a lot of them described their pain as severe. It is possible that participants might have overrated the severity of their pain or they were self-medicating instead of seeking for medical consultation and prescription from experts. 

The interpretation of findings from this study might be limited due to the following reasons. This was a cross-sectional design that made it difficult to define causality on any of the identified risk factors of dysmenorrhea. We limited the sampling to medical students who were in different academic years. It is possible that students in the clinical year might have a better understanding of dysmenorrhea than those in the preclinical year of their study. This analysis did not differentiate between primary and secondary dysmenorrhea and their associated risk factors. Additionally, we utilized self-reported scores to assess the severity of dysmenorrhea pain, rather than a pain score index, due to the absence of standardized dysmenorrhea pain assessment tools. This approach may introduce subjectivity and variability in pain reporting.

CONCLUSION   

In conclusion, this study showed a relatively high prevalence of dysmenorrhea amongst medical students compared to previous studies in Nigeria. We described risk factors associated with history of dysmenorrhea and recommended a future mixed methods design that could explore reasons why people use non-orthodox methods of treatment for dysmenorrhea. 

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 

Conflict of Interest: The authors declare that they have no competing interests. 

REFERENCES

  1. Rubin C, Maisonet M, Kieszak S, Monteilh C, Holmes A, Flanders D, et al. Timing of maturation and predictors of menarche in girls enrolled in a contemporary British cohort. Paediatric and perinatal epidemiology. 2009;23(5):492-504.
  2. Demir SC, Kadayýfçý TO, Vardar MA, Atay Y. Dysfunctional uterine bleeding and other menstrual problems of secondary school students in Adana, Turkey. Journal of Pediatric and Adolescent Gynecology. 2000;13(4):171-5.
  3. Lee LK, Chen P, Lee K, Kaur J. Menstruation among adolescent girls in Malaysia: a cross-sectional school survey. Singapore medical journal. 2006;47(10):869.
  4. Cakir M, Mungan I, Karakas T, Girisken I, Okten A. Menstrual pattern and common menstrual disorders among university students in Turkey. Pediatrics International. 2007;49(6):938-42.
  5. Joshi T, Kural M, Agrawal DP, Noor NN, Patil A. Primary dysmenorrhea and its effect on quality of life in young girls. Int J Med Sci Public Health. 2015;4(3):381.
  6. Margaret A, Manjubala D. Relationship between BMI (body mass index) and dysmenorrhea among adolescents in a college of nursing at Puducherry, India. Int Res J Med Sci. 2016;4(3):4-6.
  7. Ju H, Jones M, Mishra G. The prevalence and risk factors of dysmenorrhea. Epidemiologic reviews. 2014;36(1):104-13.
  8. Harel Z. Dysmenorrhea in adolescents and young adults: an update on pharmacological treatments and management strategies. Expert opinion on pharmacotherapy. 2012;13(15):2157-70.
  9. Fajrin I, Alam G, Usman AN. Prostaglandin level of primary dysmenorrhea pain sufferers. Enfermería Clínica. 2020;30:5-9.
  10. Janssen E, Rijkers A, Hoppenbrouwers K, Meuleman C, d'Hooghe T. Prevalence of endometriosis diagnosed by laparoscopy in adolescents with dysmenorrhea or chronic pelvic pain: a systematic review. Human reproduction update. 2013;19(5):570-82.
  11. Kabukcu C, Başay BK, Başay Ö. Primary dysmenorrhea in adolescents: Association with attention deficit hyperactivity disorder and psychological symptoms. Taiwanese Journal of Obstetrics and Gynecology. 2021;60(2):311-7.
  12. Alonso C, Coe CL. Disruptions of social relationships accentuate the association between emotional distress and menstrual pain in young women. Health Psychology. 2001;20(6):411.
  13. Sharma A, Taneja DK, Sharma P, Saha R. Problems related to menstruation and their effect on daily routine of students of a medical college in Delhi, India. Asia Pacific Journal of Public Health. 2008;20(3):234-41.
  14. Hossain MG, Sabiruzzaman M, Islam S, Hisyam RZ, Lestrel PE, Kamarul T. Influence of anthropometric measures and socio-demographic factors on menstrual pain and irregular menstrual cycles among university students in Bangladesh. Anthropological Science. 2011;119(3):239-46.
  15. Yamamoto K, Okazaki A, Sakamoto Y, Funatsu M. The relationship between premenstrual symptoms, menstrual pain, irregular menstrual cycles, and psychosocial stress among Japanese college students. Journal of physiological anthropology. 2009;28(3):129-36.
  16. Loto OM, Adewumi TA, Adewuya AO. Prevalence and correlates of dysmenorrhea among Nigerian college women. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2008;48(4):442-4.
  17. Chia C, Lai JH, Cheung P, Kwong L, Lau FP, Leung K, et al. Dysmenorrhoea among Hong Kong university students: prevalence, impact, and management. Hong Kong Medical Journal. 2013.
  18. Ozerdogan N, Sayiner D, Ayranci U, Unsal A, Giray S. Prevalence and predictors of dysmenorrhea among students at a university in Turkey. International Journal of Gynecology & Obstetrics. 2009;107(1):39-43.
  19. Unsal A, Ayranci U, Tozun M, Arslan G, Calik E. Prevalence of dysmenorrhea and its effect on quality of life among a group of female university students. Upsala journal of medical sciences. 2010;115(2):138-45.
  20. El Gilany A, Badawi K, El Fedawy S. Epidemiology of dysmenorrhoea among adolescent students in Mansoura, Egypt. EMHJ-Eastern Mediterranean Health Journal. 2005.
  21. Parazzini F, Tozzi L, Mezzopane R, Luchini L, Marchini M, Fedele L. Cigarette smoking, alcohol consumption, and risk of primary dysmenorrhea. Epidemiology. 1994;5(4):469-72.
  22. Harlow SD, Park M. A longitudinal study of risk factors for the occurrence, duration and severity of menstrual cramps in a cohort of college women. Bjog: An International Journal Of Obstetrics & Gynaecology. 1996;103(11):1134-42.
  23. Seven M, Güvenç G, Akyüz A, Eski F. Evaluating dysmenorrhea in a sample of Turkish nursing students. Pain Management Nursing. 2014;15(3):664-71.
  24. Gumanga S, Kwame-Aryee R. Menstrual characteristics in some adolescent girls in Accra, Ghana. Ghana medical journal. 2012;46(1).
  25. Femi-Agboola DM, Sekoni OO, Goodman OO. Dysmenorrhea and its effects on school absenteeism and school activities among adolescents in selected secondary schools in Ibadan, Nigeria. Nigerian Medical Journal: Journal of the Nigeria Medical Association. 2017;58(4):143.
  26. Nwankwo TO, Aniebue UU, Aniebue PNJJop, gynecology a. Menstrual disorders in adolescent school girls in Enugu, Nigeria. 2010;23(6):358-63.
  27. Rabiu A, Abubakar IS, Garba I. Dysmenorrhea and menstrual patterns among adolescent school girls in 
    Kano. New Nigerian Journal of Clinical Research. 2019;8(13):30.
  28. Hailemeskel S, Demissie A, Assefa N. Primary dysmenorrhea magnitude, associated risk factors, and its effect on academic performance: evidence from female university students in Ethiopia. International journal of women's health. 2016;8:489-96.
  29. Ezebialu I, Ezenyeaku C, Umeobika J. Prevalence of dysmenorrhea and its contribution to school absenteeism among Nigerian undergraduate students. Annals of Health Research. 2021;7(1):59-66.