ABSTRACT

CORRESPONDING AUTHOR:
Dr. Jayun Joshi,
24,  Jagatjanani  Society,
Behind Polytechnic, Ambawadi,
Ahmedabad - 380015.
E-mail: drjmjoshi@gmail.com
Ph: 0091 9427711313

ABSTRACT: Dysmenorrhea  is  the  painful  menstruation  mostly accompanied  by  the number of other symptoms which are disturbing to herself.  The purpose of the study was to determine the prevalence of dysmenorrhea in first year medical students and its impact on their academic and personal activities. STUDY DESIGN: Cross sectional study MATERIALS AND METHODOLOGY: Subjects are asked to complete the given questionnaire handed out by researcher. The predesigned and pretested questionnaire included questions regarding socio-demographic information, menstrual pattern, severity with grading, associated symptoms and impact of dysmenorrhea. RESULTS: The prevalence of dysmenorrhea was 87%. The most common symptoms were mood changes, backache and stomach cramps. Only 2.7% had severe dysmenorrhea. The most common management strategy practiced was the rest (93.7%). Only 17.4% had consulted doctors for their complaints. CONCLUSION AND RECOMMENDATION: Dysmenorrhea is the significant public health problem in women’s life. It has great impact on personal and social life. Adolescent girls should be motivated to consult the doctor for their disturbing menstrual problems.
KEY   WORDS:  Dysmenorrhea,   premenstrual syndrome (PMS), first year medical students.

INTRODUCTION : Dysmenorrhea  is  a  painful  and  cramping  sensation  in  the  lower  part  of  the  abdomen  often  accompanied  with the  other  biological  symptoms  including  fatigue, dizziness,  sweating,  headache,  backache,  nausea,  vomiting,  diarrhea and other symptoms  just  before  or  during   menses. Dysmenorrhea   could  be  primary  and  secondary  on  the  basis  of  presence  or  absence  of  pathology. Primary  dysmenorrhea  is  seen  only  in  ovulatory  cycles  usually  developing  within 6 to 12 months  of  menarche  with  no  pathology  or  organic  base. The  pain  in the  Primary  dysmenorrhea   and  the systemic   symptoms  that  may  be associated  with  it  are  due  to  high  prostaglandin  level.
The  level  of  the  prostaglandin F2α  are  high  during  the  first  two  days  of  menstruation  in  women  found  to  be  higher  in  women  with  severe  menstrual  pains  than  in  women  who  experience  mild  or  no  menstrual  pain.
      Secondary   dysmenorrhea  is  usually  due  to  pelvic  pathology  and  it  is  not  common  in  adolescent  girls. However some girls may suffer secondary   dysmenorrhea   following pelvic inflammatory disease. The  mechanism  responsible  for  pain  in  the  secondary   dysmenorrhea   varies  and  may  not  involve  the  high  level  of prostaglandins. The diagnosis of dysmenorrhea is generally clinical. Accurate history and examination can make the diagnosis easier.
Some of the symptoms  associated  of  the  severe  form  of  dysmenorrhea  are  common  to premenstrual  syndrome(PMS) as both   the  condition  have  no  organic  base. Premenstrual  syndrome(PMS)  is  recurrent  variable  somatic,  psychological  and  emotional  symptoms  that  develop  during    the  7-14  days  before  onset  of  menstruation  in  women  who  are  mainly  aged  20-40 years. Over  150  different  symptoms  have  been  linked   to   premenstrual  syndrome (PMS)  but  the  most  common  are  fatigue,  headache,  mood  changes,  inability  to  concentrate  etc. the  symptoms  in  the  premenstrual  syndrome (PMS)   are  due  to  variation  in  the  sex  steroids  and  low  circulation  serotonin  levels  which  differs  from  the  high  levels  of   prostaglandins  seen  in  primary  dysmenorrhea.  
MATERIAL  AND  METHODS : The  cross  sectional   study  was  conducted  in  the  specific  group  consisting of  first   year  medical  students  of  various  medical  colleges  of  Ahmedabad. The  target  group  was  chosen   to  determine  the  prevalence  of  dysmenorrhea  in  that  group, impact  of  dysmenorrhea  on  their  routine  activities, treatment  modalities  they   prefer  and  also  to  give  them  related  education  regarding  menstrual  problems.  
After  choosing  the  target  group  the  necessary  permission  was  taken  from  concerned  authority  for  conducting  this  study.  The  meeting  was  held  and  the  questions  were  discussed  with  them. As  the  target  group  was  medico,  the  study  was  easier  and  accurate. They  had  given  15  minutes  to  voluntarily  complete  the  questionnaires.
 
The    questionnaire
1.    Form No. :
2.    Age :
3.    Age of Menarche :
4.    Duration of cycle :                                  (1) <3 days   (2) 3 - 5 days     (3) > 5 days
5.    Interval b/w two periods :                    (1) <21 days (2) 21-34 days   (3) >34 days
6.    Bleeding  amount (pads used/day):     (1) 1/day      (2) 2-4/day        (3) >4/day
7.    Grading of severity in dysmenorrhea :
1) No dysmenorrhea
2) Mild (painful   but not inhibits normal activity)
3) Moderate (daily activity affected and required analgesics which gives relief)
4) Severe (activity clearly inhibited and poor effect of analgesics)
       8.    Associated symptoms:
I.    Stomach cramps
II.    Backache
III.    Mood changes
IV.    Fatigue
V.    Diarrhea
VI.    Headache
VII.    Nausea
VIII.    Edema
9.     Effect of dysmenorrhea on activities :
1)    No activity limited
2)    Sleep disturbed
3)    Adversely affects mood
4)    Miss the class
5)    Affects other activities
10.    Management strategies :
1.    Rest
2.    Treatment  and  drugs  as  per doctor’s advice   
3.    Self medication
4.    Hot bags
5.    Other  measures
The  sample  size  was  143  and  all  the  students  had  completed  the   questionnaires  completely  within  given  time. The response rate was 100%. The  student  with  history  of  recent  surgery  and  the  pelvic  inflammatory  disease(PID)  were  excluded.  
A  complete  questionnaires  were  coded  and  entered   in the  statistical  package  of  social  science (SPSS) software  version 10.0. Descriptive  statistics was  used to  determine  mean  age  of  participants,  age  at  menarche,  prevalence  of  dysmenorrhea,  management  options  and  activities  affected  by  the  condition.
The  categorical  data  were  analyzed   by  the  chi-square   test  and  P  value  was  calculated  to  determine  the  significant  association.

OBSERVATIONS  AND  RESULTS : The  mean  age of  the  participants  was  19.1 years  and mean  age  of  the  menarche  was  13.2 years.

Table 1:  Grading of severity of dysmenorrhea

The  severity  of   dysmenorrhea   was  determined  by  the  multidimensional  scoring  system  based  on  the  pain, activities  limited  and  medications  taken.

Table 2:  Impact of dysmenorrhea on daily activities

Table  2  shows  effect  of  dysmenorrhea  on  activities  of  affecting  women. Sleep  disturbance, mood  change, missing  the  class  and  other  daily  activities  were  affected  significantly  as  the  severity  of  dysmenorrhea  increases.  The  p  value  is  <0.0001 (chi  square 73.663)  suggests  the  test is  significant. 

Table 3:  Management strategies and grading of the dysmenorrhea

Table 3  shows  the  relationship  between  the  grading  of  dysmenorrhea  and  the  management  strategies  to  alleviate  their  symptoms.  Chi-square value is 43.753(p value < 0.0001).

DISCUSSION : The  mean  age  of  menarche  was  13.2%  which  correlates  with  the Kishan  Verma  study(1) . This  study  showed  the  high  prevalence  of  dysmenorrhea  among  the  medical students  in 87% (n = 143). The  study  correlates  with  the  previously  done  study  in  adolescent  girls  by  Banikarim  et al (85%) (2). There  is  some  difference  from other  studies which might be due to highly  selected  subject  group. The  other  issues  regarding  this  study  is that  there  is  no  any  universally  accepted  and  properly  defined  grading  of  dysmenorrhea.  Moreover  pain  associated  with  dysmenorrhea  is  difficult  to  measure  as it  is  usually  accompanied  by  other  unpleasant  sensations  and  also  the  reaction  component  affects  the  judgement  of  pain.  It should be regarded as multidimensional phenomenon.
This  syndrome  of  dysmenorrhea   encompass  a  wide  variety  of  physical  as  well  as  psychological  symptoms. In  our  study  the  mood  change  was  the  most  frequently  reported  complain  among  the  sufferers. Backache , stomach  cramps, fatigue,  headache, nausea,  diarrhea , edema  were  the  other  associated  symptoms  in  descending  order  noticed  in  our  study.  There  was  no  relationship  between  the  age  of menarche  and  the  prevalence  and  severity  of  dysmenorrhea  this  is  contrast  findings  by  the  Sundell  et  al in  which  prevalence  and  severity of  dysmenorrhea  and  significantly  affected  by  the  age  of  menarche(3).
Dysmenorrhea  is  the  cause  of  recurrent  short  term  class  absenteeism  and  restriction  in  the  daily  activities  in  adolescent  girls(4,5). Around  15%  of  women  experience  monthly  menstrual  pain  severe  enough  to  prevent  the  normal  daily  activities at  home, class  and  workplace. In our study 16.7% of respondents with dysmenorrhea missed classes. 29.3%  reported  limitation  of  sleep  and  34.2% had  mood  changes  which    affected  concentration  in  class  and  the  future  performance. Though  dysmenorrhea  is  not  the  life  threatening  condition, monthly  recurrence  of  severe  symptoms  represent  a  significant  morbidity  with  profound  negative  impact  on  day  to  day  life  with  compounding  emotional  distress  brought  on  by  the pain.  
The   overall  physician  consultation  rate  was  17.4% .  This  low  rate  specially  in  the  medicos  showed  that  still  most  of  the  women  believe  that  the  painful  periods  are  normal  female  phenomena(6). Rest  was  the  commonest  option  for  overcoming  the  situation  which correlates with the  loss  of  daily  activities  and  weak  performance. The  practice  of  self  medication  is also  common  (7).
There were some limitations of our study. The   major  limitation  was  that  the  study  was  done  in  first  year  medical  students  so  the  findings  may  not  be  the  same  for  girls  from  the  other  segment  of  group. The  physical  examination  was  not  done  to  identify  the  secondary  dysmenorrhea  and  so  secondary  dysmenorrhea   was  not  included  in  our  study.

CONCLUSION AND RECOMMENDATION :  High  prevalence  rate  of  dysmenorrhea  among  the  medical  students  requires  attention. Though  the  subject  group  was  medicos,  education  is  vital  in  ensuring  that  dysmenorrhea  should   no  longer be considered  as  a  normal  female  exercise. Physician   consultation must be promoted for dysmenorrheic women. Self   medication practices should be minimized. Further   studies  among  the  other  group  of  population  should  be  conducted  to understand  its   prevalence  as  well as  impact  at  individual  and  social  level. Adolescent girls should be encouraged   to consult   the   doctor   for their disturbing   various   menstrual   problems.

REFERENCES:
1.    Kishan  Verma ; annals  of  human  biology  1990 : vol 17 :159 -162.
2.    Banikarim  C, Chackro MR, KeldeR  SH,  Prevalence  and  impact of  dysmenorrheal in adolescents. Arch  pediatric  adolescent  medicine  2000 : 154 :1226 – 9.
3.    Sundell  G  Millstone, Andersch B. Factors  influencing  prevalence  and  severity of  dysmenorrhea   in  young  women. Br J obs gyn1990; 97 : 588-594.
4.    Dawood  MY, Primary dysmenorrhea  :  Advance  in  pathogenesis  and  management. Am  J Obst –gyn 2006; 108, 428-444.
5.    French  L. Dysmenorrhea. Am  fam  physician 2005; 71 : 285 – 291.
6.    Johnson  J .Level of  knowledge  among  the  adolescent  girls  regarding  treatment  effectiveness in  dysmenorrheal. J of  adolescent  health  care 1988 ;9 : 198-402.
7.    Ohde  S Takuda. Dysmenorrhea  among  Japanese  women. Int  J  Gyn Obs 2008 ;100 : 13 – 17.

Graph 1 : Percentage  wise  distribution  of  dysmenorrheal  grade

Graph  1  shows  the  prevalence  of  dysmenorrhea  was  87%  while 13%  experienced  no  dysmenorrhea (n = 143).  The  most  common  type  of   dysmenorrhea  was  grade1(  57.3%)  and  least  common  type  was  grade  3 ( 2.7%. )

Graph 2 :  Percentage  of  dysmenorrheic  women  who  suffered  from  associated  symptoms

Graph 2  shows  reported  symptoms  associated  with  the  dysmenorrhea.  The  most  common  symptoms  were  mood  change(64.3%), backache(63.6%), stomach  cramps(61.5%)  and  fatigue(46.1%).

Graph 3:  percentage of management strategies choose

Graph  3  shows  that Rest was the  most  common  management  strategy   practiced  (93.7%), while 17.4%of girls  had  consulted  the  doctor  for medication and  11.1%  relied on self medication..Hot bags were also popular in 13.2%.