Dysmenorrhea among higher secondary schoolgirls of Imphal West district, Manipur: A

cross-sectional study
K. Kumar, Shantibala Konjengbam and Hanjabam Devi
Journal of Medical Society. 30.1 (January-April 2016): p38. From InfoTrac Health and
Medical Collection 2017.
Copyright: COPYRIGHT 2016 Medknow Publications and Media Pvt. Ltd.
http://www.jmedsoc.org/
Full Text:
Byline: K. Kumar, Shantibala. Konjengbam, Hanjabam. Devi
Background: Dysmenorrhea is one of the common problems experienced by many
adolescent girls after the onset of menarche. Objectives: This study had the following
objectives: 1. To determine the prevalence of dysmenorrhea among adolescent girls; 2.
To determine the association between dysmenorrhea and selected variables of interest;
3. To assess the effect of dysmenorrhea on quality of life; 4. To assess treatmentseeking practices for dysmenorrhea. Materials and Methods: This was a cross-sectional
study conducted among higher secondary schoolgirls of Imphal West district, Manipur
from December 2012 to September 2014. The sample size was calculated to be 660.
Participants were selected by stratified two-stage cluster sampling. Data were collected
using a self-administered questionnaire. Data were entered and analyzed using IBM
SPSS version 20 (Armonk, New York, USA). Analysis was done using chi-square test
and chi-square test for trend. Results: Among the 703 respondents, the prevalence of
dysmenorrhea was 76.0%, and about one-fifth (21.2%) of the respondents were
suffering from severe dysmenorrhea. Painful menstruation caused school absenteeism,
poor exam grades, and poor interpersonal relationships, decreased concentration in
class and affected daily physical activities in the majority of respondents. Only 37.5% of
the dysmenorrheic girls were receiving treatment for painful menstruation, of which
medication was the common, but only 13.1% of the dysmenorrheic girls took medication
on prescription by a doctor. Conclusion: Health education on issues related to
reproductive health should be incorporated early enough in the school curriculum to
prepare girls for menstruation and inform them about available treatment options for
dysmenorrhea.
Introduction
Adolescence is a period of transition from childhood to adulthood and is characterized
by a spurt in physical, endocrinal, emotional, and mental growth, with a change from
complete dependence to relative independence. [sup][1] One of the major physiological
changes that take place in adolescent girls is the onset of menarche, which is often
associated with problems of irregular menstruation, excessive bleeding, and
dysmenorrhea. Of these, dysmenorrhea is one of the most common problems
experienced by adolescent girls. [sup][1]
Dysmenorrhea is defined as difficult menstrual flow or painful menstruation. The
prevalence of dysmenorrhea worldwide ranges 15.8-89.5%, with higher prevalence

rates reported in the adolescent population. [sup][2] A similar scenario exists in India.
The prevalence of dysmenorrhea was found to be 78.69% in a study conducted in
Gwalior among higher secondary schoolgirls. [sup][1]
Dysmenorrhea is frequently associated with sickness absenteeism, decrease in
academic performance, and decrease in physical and social activities in adolescents. In
spite of the frequency and severity of dysmenorrhea, most girls do not seek medical
treatment for this condition because they feel it is a normal part of the menstrual cycle.
[sup][3] Therefore, dysmenorrhea affects not only the untreated person but also her
family, her social life, and national economics as well.
Although dysmenorrhea is an important health problem, there have, to our knowledge,
not been any data published from Manipur. In order to lay the groundwork for such an
undertaking, studies are needed to establish the prevalence of dysmenorrhea in
adolescent girls of Manipur.
Therefore, this study was conducted with the following objectives:
*To determine the prevalence of dysmenorrhea among adolescent girls. *To determine
the association between dysmenorrhea and selected variables of interest. *To assess
the effect of dysmenorrhea on quality of life. *To assess the treatment-seeking practices
for dysmenorrhea.
Materials and Methods
This was a cross-sectional study conducted among schoolgirls of classes XI and XII
studying in institutions providing higher secondary education to girls in Imphal West
district, Manipur from December 2012 to September 2014. Manipur is one of the states
in Northeast India, which has a diverse ethnic population speaking different languages
and dialects, practicing different religions such as Hinduism, Christianity, Sanamahism,
and Islam. The majority of Manipuris are Meiteis, inhabiting the valley region, followed
by Kukis, Nagas, and other smaller tribal communities mainly inhabiting the hilly region.
All the different ethnic groups in Manipur are believed to be of the same mongoloid
origin. Imphal West district is one of the nine districts of Manipur present in the valley
region, consisting mainly of Meiteis and some inhabitants who migrated from the hill
region. As of the 2011 census, it is the most populous district in the state with its
headquarters at Lamphelphat. The female population of Imphal West is 514,683, of
which female literacy rate of Imphal West is 80.17 are literate, and the sex ratio of
Imphal West is 1031 females per 1000 males as per 2011 census.
Those students who had not had a period during the past 6 months and those who were
absent on the day of the visit were excluded from the study. The sample size was
calculated based on the formula: N = 4 P (1- P )/L [sup]2 , where P = 79 (taking
prevalence as 79% from a previous study), [sup][1] L=5 (taking absolute allowable error
as 5%), and 95% confidence level. The calculated sample size was 275. With a design
effect of 2, the estimated sample size was then 550. Estimating a nonresponse rate of

20%, the final sample size was 660. Hence, about 700 girls were targeted for data
collection.
The selection of schools and study participants is shown in [Figure 1]. For this study,
clusters identified were institutions providing higher secondary education. The schools
were first stratified into government and private schools. There were 2016 girls (40%)
studying in 22 private schools and 2940 girls (60%) studying in 19 government schools.
After excluding those schools with less than 70 girls in classes XI and XII, 13
government schools and 9 private schools were listed in the sampling frame. In the first
stage, 6 government schools and 4 private schools were selected by simple random
sampling (SRS) with probability proportionate to size (PPS). In the second stage, 421
students (60%) were selected from 6 government schools and 282 students (40%) were
selected from 4 private schools by randomly selecting 70 girls within each cluster.
{Figure 1}
Data were collected using a self-administered questionnaire after explaining to the
students the nature of the questions and how to fill in the questionnaire. The
questionnaire had questions on sociodemographic characteristics of the respondents,
their food habits, physical activity, menstrual history, prevalence and severity of
dysmenorrhea, and quality-of-life-related questions such as on the perceived effects of
dysmenorrhea on school attendance, academic performance, daily physical activities,
and treatment-seeking practices for dysmenorrhea. As all the students were taught in
English and the students were more familiar in English, questionnaires were used in the
English version, which was pretested prior to the initiation of the study.
Data collected were checked for consistency and completeness. The data were then
entered in IBM SPSS for Windows version 20 (Armonk, New York, USA). Data were
presented in percentages and mean with standard deviation. Analysis was done using
chi-square test and chi-square test for trend. A P value of less than 0.05 was considered
as statistically significant.
Operational definition
Dysmenorrhea
Those who had had painful menstrual periods within the past 6 months were considered
as having dysmenorrhea.
For the severity of dysmenorrhea, a 10-point numerical rating scale (NRS) was used to
represent the continuum of the female students' perception of the degree of pain. One
extremity of the scale (0) represents no pain at all and the other extremity (10)
represents unbearable pain. The participants were asked to rate the degree of pain by
encircling the number.
The scores received from the scale were classified as follows:

Mild dysmenorrhea: 1-3. Moderate dysmenorrhea: 4-7. Severe dysmenorrhea: 8-10.

This scale has well-established validity and reliability (Cronbach's a = 0.94) [sup][4]
Those who were involved in outdoor physical activity daily for 30 min or longer at least 4
times a week were considered as doing regular physical activity.
Ethical approval was obtained from the institutional Ethics Committee before the
beginning of the study. Written permission from all the participating school authorities
and verbal assent or consent from all the participants were obtained.
Results
A total of 703 students participated in the study. The mean age of the respondents was
16.78 ([+ or -]0.90) years. A majority (57.6%) of the respondents were Hindus and about
three-fourth (63.3%) of the respondents were urban residents [Table 1].{Table 1}
The prevalence of dysmenorrhea was 76%. Among those who had dysmenorrhea,
menstrual pain was mild in about one-third (32.8%) and severe dysmenorrheic pain was
experienced by about one-fifth (21.2%) [Figure 2].{Figure 2}
A majority of the respondents with dysmenorrhea reported that concentration during
class hours (57.7%), interpersonal relationships with friends and family (44.2%), and
daily physical activities (36.5%) were affected due to painful menstruation. More than
half (57.3%) of the dysmenorrheic students had been absent from school for at least 1
day due to painful menstruation in the past 6 months. About one-fourth (26.8%) of the
students with dysmenorrhea said that painful menstruation affected their exam grades.
About three-fifth (63.7%) of the respondents were of the opinion that treatment was not
required for painful menstruation. About one-third (34.6%) of the respondents who felt
that treatment was required wanted treatment because pain was unbearable and they
were all dysmenorrheics. Among those who said that treatment was not needed for
painful menstruation, more than three-fifth (62.3%) of them, which included nearly half
(48.2%) of the dysmenorrheics, said that painful menstruation was a natural
phenomenon and hence treatment was not required, while about 8.5% of them (all of
them having dysmenorrhea) felt too ashamed to tell others and hence avoided
treatment.
Increased physical activity and regular intake of fruits and vegetables and fish was
protective against dysmenorrhea. There was a significant association of dysmenorrhea
with long menstrual periods (>6 days), heavy menstrual flow (>80 mL), positive family
history, and irregular menstrual cycle [Table 2].{Table 2}
With increase in the severity of dysmenorrhea, the number of respondents who reported
school absenteeism ( P = 0.00), poor exam grades ( P = 0.00), decrease in class
concentration ( P = 0.00), limited interpersonal relationships with friends and family ( P =

0.00), and decrease in daily physical activities ( P = 0.00) also increased, and this was
found to be significant[Table 3].{Table 3}
Among those who had dysmenorrhea, only 37.5% were receiving treatment for painful
menstruation. Medication was the most common treatment practice adopted by nearly
one-fifth (19.9%) of the respondents with painful menstruation, followed by hot bath
(13.3%), heating pad (6.6%), and hot tea (0.7%). Only 13.1% of the dysmenorrheics
had consulted a physician, and the rest were taking medication on the advice of their
mother, friend, pharmacist, or sister. Only two-fifth (39.5%) of the dysmenorrheics
reported that their pain was fully relieved after the treatment [Figure 3].{Figure 3}
Discussion
The prevalence of dysmenorrhea was 76.0%. Prevalence was higher compared to
studies conducted among school and college girls in other parts of India such as Tamil
Nadu, [sup][5] Andhra Pradesh, [sup][6] Karnataka, [sup][7] and Madhya Pradesh (MP),
[sup][8] where the prevalence rates were 51%, 56.2%, 65%, 67.5%, and 73.8%,
respectively. Only Agarwal et al . [sup][1] reported a higher prevalence rate of 79.7%
among higher secondary schoolgirls in Gwalior, MP. In studies conducted outside India,
the prevalence rates varied, with the lowest prevalence of 48.4% being reported in
Mexico. [sup][9] Kindy et al . [sup][10] reported the highest prevalence of 94% among
Omani high school students. The wide variation in these estimates may be attributed to
the use of differently selection methods for groups of subjects [sup][11] and the absence
of both a universally accepted definition of dysmenorrhea and a system for grading its
severity. [sup][12] Another reason for the variation could be associated with ethnic and
sociocultural factors. [sup][13]
Similar to the findings observed in other studies, [sup][3],[13],[14] increased physical
activity and regular intake of fruits and vegetables and fish were protective against
dysmenorrhea. There was a significant association of dysmenorrhea with long
menstrual periods, heavy menstrual flow, and positive family history, as reported by
many studies. [sup][11],[13],[15],[16],[17] Lee et al . [sup][18] reported that
dysmenorrhea was significantly associated with irregular cycle length (either short or
longer menstrual cycle), and similar finding was also observed in this study.
About 57% of the girls suffering from dysmenorrhea were absent from school due to
painful menstruation at least for 1 day in the past 6 months, and this increased
significantly with increase in the severity of pain. Given these findings, school officials
and school health program coordinators may benefit from considering dysmenorrhea in
the context of improving their school attendance rates and the academic performance of
their students. Except in a study in Thailand [sup][19] where the absenteeism rate was
80.6%, the absenteeism rate in this study was higher than those observed in studies all
around the world. In MP [sup][20] it was 31.6%. Anandha Lakshmi et al . [sup][5]
reported an absenteeism rate of 31.2%, and it increased significantly with increase in
the severity of dysmenorrhea. Comparing school absenteeism rates in these studies
was difficult because different time frames were used for estimating the same. Even

then, the variation in school absenteeism rates among these studies may be related to
the existence of different cultural perceptions and difference in responses to various
gradients of pain and the absence of a universally accepted system for grading its
severity. [sup][20],[21]
As seen in studies all around the world, [sup][10],[16],[22] most of the respondents with
dysmenorrhea said that painful menstruation led to decreased class concentration, poor
interpersonal relationships with friends and family members, poor exam grades ,and
decreased daily physical activity, and they were found to be significantly associated with
increase in the severity of dysmenorrhea.
The most worrying finding was that even though the prevalence of dysmenorrhea was
high, only 38% of the girls with dysmenorrhea received treatment for painful
menstruation. This percentage was lesser than those seen in other studies, such as in
Karnataka [sup][7] (86.9%), Oman [sup][10] (73%), and Egypt [sup][16] (56%).
Medication was the most common method of treatment, as seen in other studies. [sup]
[7],[10],[16],[23] The physician consultation rate was only 13%, and the rest were taking
treatment on the advice of their mother, friend, pharmacist, or sister. Even though the
use of medication for treatment was low, the physician consultation rate was higher as
compared to other studies in Egypt [sup][16] (9%), Oman [sup][10] (3%), Tamil Nadu
[sup][5] (9.7%), and Thailand [sup][19] (7%), except in two studies done in Mexico [sup]
[9] (28%) and USA [sup][23] (14%).
The other nonpharmacological methods used for treatment are hot bath, heating pad,
and hot tea, as seen in other studies. [sup][7],[10],[16],[23] Treatment-seeking behavior
increases significantly as the severity of pain increases. Anandha Lakshmi et al . [sup]
[5] reported a similar finding in Tamil Nadu. Nearly two-fifth of the respondents, which
included 27.34% of the dysmenorrheics, said that painful menstruation was a natural
phenomenon and hence treatment was not required. This may suggest that there was a
significant lack of awareness and knowledge among adolescent girls regarding
treatment for dysmenorrhea. About 5.4% of the respondents felt that it was shameful to
tell others, hence they avoided treatment. This shows the sensitive nature of the
problem among adolescent girls. Improving the girls' knowledge about dysmenorrhea
could therefore positively influence their health care-seeking behavior. Health promotion
in the primary health care setting or at school may be an efficient way of achieving this.
Only two-fifth of the dysmenorrheics reported that the pain was fully relieved after
treatment. Even though this can be explained by considering that treatment will not
entirely relieve pain in everyone, the reasons that some may be taking irregular or
inadequate treatment cannot be excluded.
The strength of the study was that as the questionnaire method was used, participants
could give honest responses for questions regarding menstruation. There were some
limitations to this study. The participants were asked to recall information regarding
menstrual and school absenteeism for the past 6 months, which may have led to recall
bias. In addition, the information on school absenteeism and the effect of dysmenorrhea
on exam grades was obtained by self-reporting, and so there was the possibility of false

information being reported. However, every effort was made to motivate the
respondents to provide true information.
Conclusion
Considering the public health importance of the social and academic limitations
associated with dysmenorrhea, health education on issues related to reproductive
health should be incorporated early enough in the school curriculum to prepare girls for
menstruation and inform them about available treatment options in case they
experience dysmenorrhea.
Acknowledgment
The authors wish to thank all the participants for their cooperation and all the school
authorities for giving their permission to conduct this study.
Financial support and sponsorship
Nil.
Conflicts of interest
The authors declare no conflict of interest.
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Source Citation (MLA 7th Edition)
Kumar, K., Shantibala Konjengbam, and Hanjabam Devi. "Dysmenorrhea among higher
secondary schoolgirls of Imphal West district, Manipur: A cross-sectional study." Journal
of Medical Society 30.1 (2016): 38. PowerSearch. Web. 17 Oct. 2016.
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