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Original Article

Dysmenorrhea among higher secondary schoolgirls


of Imphal West district, Manipur: A cross-sectional study
Sathish Kumar K, Shantibala Konjengbam, Hanjabam Sanayaima Devi
Department of Community Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India

Abstract
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 treatment-seeking 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.
Key Words: Absenteeism, dysmenorrhea, prevalence, treatment

INTRODUCTION worldwide ranges 15.8-89.5%, with higher prevalence


rates reported in the adolescent population.[2] A similar
Adolescence is a period of transition from childhood to scenario exists in India. The prevalence of dysmenorrhea
adulthood and is characterized by a spurt in physical, was found to be 78.69% in a study conducted in Gwalior
endocrinal, emotional, and mental growth, with a change among higher secondary schoolgirls.[1]
from complete dependence to relative independence.[1]
One of the major physiological changes that take place Dysmenorrhea is frequently associated with sickness
in adolescent girls is the onset of menarche, which is absenteeism, decrease in academic performance, and
often associated with problems of irregular menstruation, decrease in physical and social activities in adolescents.
excessive bleeding, and dysmenorrhea. Of these, In spite of the frequency and severity of dysmenorrhea,
dysmenorrhea is one of the most common problems most girls do not seek medical treatment for this
experienced by adolescent girls.[1] condition because they feel it is a normal part of the
menstrual cycle.[3] Therefore, dysmenorrhea affects not
Dysmenorrhea is defined as difficult menstrual flow or
painful menstruation. The prevalence of dysmenorrhea This is an open access article distributed under the terms of the
Creative Commons Attribution-NonCommercial-ShareAlike 3.0
Access this article online License, which allows others to remix, tweak, and build upon the
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new creations are licensed under the identical terms.
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For reprints contact: reprints@medknow.com

How to cite this article: Kumar KS, Konjengbam S, Devi HS.


DOI: 10.4103/0972-4958.175849 Dysmenorrhea among higher secondary schoolgirls of Imphal West
district, Manipur: A cross-sectional study. J Med Soc 2016;30:38-43.

Address for correspondence: Dr. Sathish Kumar K, Department of Community Medicine, Regional Institute of Medical Sciences, Lamphelpat,
Imphal - 795 004, Manipur, India. E-mail: kumarsathish16@gmail.com

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Kumar, et al.: Dysmenorrhea among higher secondary schoolgirls

only the untreated person but also her family, her social The selection of schools and study participants is
life, and national economics as well. shown in Figure 1. For this study, clusters identified
were institutions providing higher secondary education.
Although dysmenorrhea is an important health problem,
The schools were first stratified into government and
there have, to our knowledge, not been any data
private schools. There were 2016 girls (40%) studying
published from Manipur. In order to lay the groundwork
in 22 private schools and 2940 girls (60%) studying
for such an undertaking, studies are needed to establish
in 19 government schools. After excluding those
the prevalence of dysmenorrhea in adolescent girls of
schools with less than 70 girls in classes XI and XII,
Manipur.
13 government schools and 9 private schools were listed
Therefore, this study was conducted with the following in the sampling frame. In the first stage, 6 government
objectives: schools and 4 private schools were selected by simple
1. To determine the prevalence of dysmenorrhea among random sampling (SRS) with probability proportionate to
adolescent girls. size (PPS). In the second stage, 421 students (60%) were
2. To determine the association between dysmenorrhea and selected from 6 government schools and 282 students
selected variables of interest. (40%) were selected from 4 private schools by randomly
3. To assess the effect of dysmenorrhea on quality of life. selecting 70 girls within each cluster.
4. To assess the treatment-seeking practices for
Data were collected using a self-administered
dysmenorrhea.
questionnaire after explaining to the students the nature
of the questions and how to fill in the questionnaire.
MATERIALS AND METHODS
The questionnaire had questions on sociodemographic
characteristics of the respondents, their food habits,
This was a cross-sectional study conducted among
physical activity, menstrual history, prevalence and severity
schoolgirls of classes XI and XII studying in institutions
of dysmenorrhea, and quality-of-life–related questions
providing higher secondary education to girls in Imphal
such as on the perceived effects of dysmenorrhea
West district, Manipur from December 2012 to September
on school attendance, academic performance, daily
2014. Manipur is one of the states in Northeast India,
physical activities, and treatment-seeking practices
which has a diverse ethnic population speaking different
for dysmenorrhea. As all the students were taught in
languages and dialects, practicing different religions such
English and the students were more familiar in English,
as Hinduism, Christianity, Sanamahism, and Islam. The
questionnaires were used in the English version, which
majority of Manipuris are Meiteis, inhabiting the valley
was pretested prior to the initiation of the study.
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= 4P(1-P)/L2,
where P = 79 (taking prevalence as 79% from a previous
study),[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. Figure 1: Flow chart showing selection of schools and study participants

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Kumar, et al.: Dysmenorrhea among higher secondary schoolgirls

Data collected were checked for consistency and Table 1: Sociodemographic characteristics
completeness. The data were then entered in IBM SPSS of the study population
for Windows version 20 (Armonk, New York, USA). Data Characteristics Frequency Percentage (%)
were presented in percentages and mean with standard
Age
deviation. Analysis was done using chi-square test and
15 years 28 4.0
chi-square test for trend. A P value of less than 0.05 was
16 years 259 36.8
considered as statistically significant.
17 years 291 41.4
Operational definition 18 years 89 12.7
Dysmenorrhea 19 years 36 5.1
Those who had had painful menstrual periods within the Standard
past 6 months were considered as having dysmenorrhea. 11 319 45.4
12 384 54.6
For the severity of dysmenorrhea, a 10-point numerical
Religion
rating scale (NRS) was used to represent the continuum
Hindu 404 57.6
of the female students’ perception of the degree of pain. Christian 190 27.0
One extremity of the scale (0) represents no pain at all Sanamahi 68 9.7
and the other extremity (10) represents unbearable pain. Muslim 31 4.4
The participants were asked to rate the degree of pain by Others 9 1.3
encircling the number. Residence
The scores received from the scale were classified as Urban 445 63.3
follows: Rural 258 36.7
Mild dysmenorrhea: 1-3. Type of school
Moderate dysmenorrhea: 4-7. Government 421 59.9
Severe dysmenorrhea: 8-10. Private 282 40.1

This scale has well-established validity and reliability


(Cronbach’s α = 0.94)[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 (±0.90) years.
Figure 2: Distribution of dysmenorrheics by severity of dysmenorrhea
A majority (57.6%) of the respondents were Hindus
and about three-fourth (63.3%) of the respondents were 6 months. About one-fourth (26.8%) of the students with
urban residents[Table 1]. dysmenorrhea said that painful menstruation affected
The prevalence of dysmenorrhea was 76%. Among those their exam grades.
who had dysmenorrhea, menstrual pain was mild in About three-fifth (63.7%) of the respondents were
about one-third (32.8%) and severe dysmenorrheic pain of the opinion that treatment was not required for
was experienced by about one-fifth (21.2%) [Figure 2]. painful menstruation. About one-third (34.6%) of the
A majority of the respondents with dysmenorrhea respondents who felt that treatment was required wanted
reported that concentration during class hours (57.7%), treatment because pain was unbearable and they were all
interpersonal relationships with friends and family dysmenorrheics. Among those who said that treatment
(44.2%), and daily physical activities (36.5%) were affected was not needed for painful menstruation, more than
due to painful menstruation. More than half (57.3%) of three-fifth (62.3%) of them, which included nearly
the dysmenorrheic students had been absent from school half (48.2%) of the dysmenorrheics, said that painful
for at least 1 day due to painful menstruation in the past menstruation was a natural phenomenon and hence

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Kumar, et al.: Dysmenorrhea among higher secondary schoolgirls

treatment was not required, while about 8.5% of them higher secondary schoolgirls in Gwalior, MP. In studies
(all of them having dysmenorrhea) felt too ashamed to conducted outside India, the prevalence rates varied,
tell others and hence avoided treatment. with the lowest prevalence of 48.4% being reported in
Mexico.[9] Kindy et al.[10] reported the highest prevalence
Increased physical activity and regular intake of fruits and
of 94% among Omani high school students. The wide
vegetables and fish was protective against dysmenorrhea.
variation in these estimates may be attributed to the use
There was a significant association of dysmenorrhea with of differently selection methods for groups of subjects[11]
long menstrual periods (>6 days), heavy menstrual flow and the absence of both a universally accepted definition
(>80 mL), positive family history, and irregular menstrual of dysmenorrhea and a system for grading its severity.[12]
cycle [Table 2].
With increase in the severity of dysmenorrhea, the Table 2: Association between dysmenorrhea and
number of respondents who reported school absenteeism selected variables
(P = 0.00), poor exam grades (P = 0.00), decrease in Characteristics Dysmenorrhea No N (%) P value
class concentration (P = 0.00), limited interpersonal Yes N (%)
relationships with friends and family (P = 0.00), and
Regular physical activity
decrease in daily physical activities (P = 0.00) also
Yes 194 (71.6) 77 (28.4) 0.03
increased, and this was found to be significant[Table 3].
No 340 (78.7) 92 (21.3)
Among those who had dysmenorrhea, only 37.5% were Food habit
receiving treatment for painful menstruation. Medication Vegetarian 134 (74.1) 48 (25.9) 0.48
was the most common treatment practice adopted by Nonvegetarian 397 (76.6) 121 (23.4)
nearly one-fifth (19.9%) of the respondents with painful Fruits and vegetables
menstruation, followed by hot bath (13.3%), heating intake(at least once
pad (6.6%), and hot tea (0.7%). Only 13.1% of the a day)
dysmenorrheics had consulted a physician, and the rest Yes 262 (72.8) 98 (27.2) 0.04
No 272 (79.3) 71 (20.7)
were taking medication on the advice of their mother,
Fish intake (at least
friend, pharmacist, or sister. Only two-fifth (39.5%) of the
once in a week)
dysmenorrheics reported that their pain was fully relieved
Yes 288 (72.5) 109 (27.5) 0.02
after the treatment [Figure 3]. No 246 (80.4) 60 (19.6)
Age of menarche
DISCUSSION 11-12 years 221 (75.7) 71 (24.3) 0.42
13-14 years 284 (75.3) 93 (24.7)
The prevalence of dysmenorrhea was 76.0%. Prevalence 15-16 years 29 (85.3) 5 (14.7)
was higher compared to studies conducted among school Cycle length
and college girls in other parts of India such as Tamil Less than 21 days 12 (80.0) 3 (20.0) 0.60
Nadu,[5]Andhra Pradesh,[6] Karnataka,[7]and Madhya (short)
Pradesh (MP),[8] where the prevalence rates were 51%, 22-35 days (normal) 466 (75.8) 149 (24.2)
56.2%, 65%, 67.5%, and 73.8%, respectively. Only Agarwal More than 35 days 59 (80.8) 14 (19.2)
et al.[1] reported a higher prevalence rate of 79.7% among (long)
Bleed length
Less than 2 days 16 (72.7) 6 (27.3) 0.03
(short)
2-6 days (normal) 303 (72.7) 114 (27.3)
More than 6 days 215 (81.4) 49 (18.6)
(long)
Bleed amount
Less than 20 mL 75 (72.8) 28 (27.2) 0.04
(scanty)
20-80 mL 354 (74.4) 122 (25.6)
(moderate)
More than 80 mL 105 (84.7) 19 (15.3)
(heavy)
Family history
Yes 328 (86.5) 51 (13.5) 0.00
No 140 (58.6) 99 (41.4)
Don’t know 66 (77.6) 19 (22.4)
Figure 3: Treatment practices for dysmenorrhea

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Kumar, et al.: Dysmenorrhea among higher secondary schoolgirls

Table 3: Association between severity of dysmenorrhea and quality of life


Characteristics Total N (%) Dysmenorrhea P value*
Mild N (%) Moderate N (%) Severe N (%)
School absenteeism
0 day 228 (42.3) 137 (78.3) 84 (34.1) 7 (3.1) 0.00
1-3 days 247 (46.3) 36 (20.6) 142 (57.7) 69 (61.1)
More than 3 days 59 (11.0) 2 (1.1) 20 (8.2) 37 (32.8)
Exam grades
Affected 143 (26.8) 9 (5.1) 59 (24.0) 75 (66.4) 0.00
Not affected 391 (73.2) 166 (94.9) 187 (76.0) 38 (33.6)
Class concentration
Affected 308 (57.7) 62 (51.4) 152 (61.8) 94 (83.2) 0.00
Not affected 226 (42.3) 113 (48.6) 94 (38.2) 19 (16.8)
Interpersonal relationships
Affected 236 (44.2) 40 (22.9) 114 (46.3) 82 (72.6) 0.00
Not affected 298 (55.8) 135 (77.1) 132 (53.7) 31 (27.4)
Daily physical activity
Affected 195 (36.5) 23 (70.3) 90 (36.6) 82 (72.6) 0.00
Not affected 339 (63.5) 152 (29.7) 156 (63.4) 31 (27.4)
*
Analysis done using Chi-square test for trend

Another reason for the variation could be associated with various gradients of pain and the absence of a universally
ethnic and sociocultural factors.[13] accepted system for grading its severity.[20,21]
Similar to the findings observed in other studies,[3,13,14] As seen in studies all around the world,[10,16,22] most of
increased physical activity and regular intake of fruits and the respondents with dysmenorrhea said that painful
vegetables and fish were protective against dysmenorrhea. menstruation led to decreased class concentration,
There was a significant association of dysmenorrhea with poor interpersonal relationships with friends and family
long menstrual periods, heavy menstrual flow, and positive members, poor exam grades ,and decreased daily physical
family history, as reported by many studies.[11,13,15-17] Lee activity, and they were found to be significantly associated
et al.[18] reported that dysmenorrhea was significantly with increase in the severity of dysmenorrhea.
associated with irregular cycle length (either short or The most worrying finding was that even though the
longer menstrual cycle), and similar finding was also prevalence of dysmenorrhea was high, only 38% of the
observed in this study. girls with dysmenorrhea received treatment for painful
About 57% of the girls suffering from dysmenorrhea menstruation. This percentage was lesser than those
were absent from school due to painful menstruation at seen in other studies, such as in Karnataka[7] (86.9%),
least for 1 day in the past 6 months, and this increased Oman[10] (73%), and Egypt[16] (56%). Medication was the
significantly with increase in the severity of pain. most common method of treatment, as seen in other
Given these findings, school officials and school health studies.[7,10,16,23] The physician consultation rate was only
program coordinators may benefit from considering 13%, and the rest were taking treatment on the advice of
dysmenorrhea in the context of improving their school their mother, friend, pharmacist, or sister. Even though
attendance rates and the academic performance of the use of medication for treatment was low, the physician
their students. Except in a study in Thailand[19]where consultation rate was higher as compared to other studies
the absenteeism rate was 80.6%, the absenteeism rate in Egypt[16](9%), Oman[10](3%), Tamil Nadu[5](9.7%), and
in this study was higher than those observed in studies Thailand[19](7%), except in two studies done in Mexico[9]
all around the world. In MP[20] it was 31.6%. Anandha (28%) and USA[23](14%).
Lakshmi et al.[5] reported an absenteeism rate of 31.2%, The other nonpharmacological methods used for
and it increased significantly with increase in the severity treatment are hot bath, heating pad, and hot tea, as
of dysmenorrhea. Comparing school absenteeism rates seen in other studies.[7,10,16,23] Treatment-seeking behavior
in these studies was difficult because different time increases significantly as the severity of pain increases.
frames were used for estimating the same. Even then, Anandha Lakshmi et al.[5] reported a similar finding in
the variation in school absenteeism rates among these Tamil Nadu. Nearly two-fifth of the respondents, which
studies may be related to the existence of different included 27.34% of the dysmenorrheics, said that painful
cultural perceptions and difference in responses to menstruation was a natural phenomenon and hence

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Kumar, et al.: Dysmenorrhea among higher secondary schoolgirls

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