An observational population based study on dysmenorrhea and its risk factors

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  • ABSTRACT

    Dysmenorrhea is the most common gynecological disorder in women of reproductive age. The prevalence of menstrual pain is relatively high and has been shown to be related to many factors like age, age at menarche, menstrual cycle regularity, parity, cigarette smoking, and dietary habits etc. This study was conducted to determine the possible link between dysmenorrhea and the factors related to it. We investigated the associated risk factors that could influence menstrual pain. This Cross Sectional Study was conducted at Dept. of OBG, NIUM, Bangalore. The study consisted of 230 women between the ages of 20 - 49 years. Included volunteers were newly married, nulliparious and parous women. The detailed reproductive history was recorded and was analyzed statistically. It was observed that there were only two factors that were influencing Dysmenorrhea namely the early age at menarche and increase parity. It was hypothesis that earlier start to reproductive life in some way decreases the sensitivity of the uterus to prostaglandin, whereas delayed menarche and postponing reproductive life increase sensitivity of the uterus to prostaglandins and cause severe menstrual pain. It is concluded that early age at menarche and high parity decrease menstrual pain.


  • KEYWORD

    prevalence , dysmenorrhea , risk factors , observation

  • INTRODUCTION

    Dysmenorrhea, spasmodic or congestive is the most frequently occurring symptom, for which women consult gynecologist. Every woman experiences this pain, more or less in her life. The cause for primary dysmenorrhea is yet to be established while secondary dysmenorrhea is due to some pelvic pathology and hence is curable. The pain in primary dysmenorrhea is attributed to uterine ischemia, release of prostaglandin, vasopressin and forceful irrhythmic contraction of uterus (Akerlund et al., 1995; Bossmar et al., 1995; Kennedy, 1997; Rosenwaks and Seegar-Jones, 1980). In some women severity of the pain is sufficient enough to enforce them for absence from work place or school. (2, 36) Dysmenorrhea is taken differently by different socio economic groups and so is response and reporting. Because of this, different social groups present variable statistics. The overall prevalence of dysmenorrhea is reported to be 28% (Loto et al., 2008).

    Risk factors associated with dysmenorrhea are increase age, early age at menarche, parity, longer menstrual cycles, increase duration and amount of flow, smoking, alcohol consumption, diet, body weight, physical activity, positive family history and psychological etc (Andersch and Milsom, 1982; Banikarim et el., 2000; Balbi et al., 2000; Juang et al., 2006; Klein and Litt, 1981).

    It is hypothesized that an earlier start to reproductive life in some way decreases the sensitivity of the uterus to prostaglandin. But there is also the possibility that those who had a relatively earlier birth of first child have relatively higher progesterone levels. The other hypothesis is that higher level of prostaglandin is a risk factor for miscarriage. In this case, women with higher levels of prostaglandin and or higher sensitivity to them could have given their first live birth relatively later (Rosenwaks and Seegar-Jones, 1980; Weissmann et al., 2004).

    In several studies higher prevalence of dysmenorrhea with early onset of menarche and in teen age is attributed to anovulatory cycles (Bossmar et al., 1995; Rosenwaks and Seegar-Jones, 1980). Decreasing trend of dysmenorrhea with advancing age has been reported (Weissman et al., 2004). Contrary to earlier belief studies confirmed unresponsiveness of Dysmenorrhea to vaginal delivery and to pregnancy. Age dependency of Dysmenorrhea has been shown in many studies as in multiparous women severity of pain decreased after the age of 40 years (Ju et al., 2010). Longer or irregular menstrual cycles (Zukri et al., 2009) and longer duration of menstrual flow (Solomon et al., 2013) also cause menstrual pain. Postponing the start of reproductive life to mid twenties is a mean that the number of menstrual cycles for women with earlier menarche is quite high. Thus, the period of time between first menstruation and conception might be a better predictor of menstrual pain in parous women than the age of menarche itself. The length of time after puberty in which uterus is exposed to prostaglandins and the number of menstruations can influence the prevalence of menstrual pain in adult reproductive life, but pregnant or lactating women experienced a less number of cycles (Sterasam, 1997).

      >  Objective

    To investigate the associated risk factors that could influence menstrual pain.

      >  Methodology

    The present Cross Sectional Study was conducted at Dept. of OBG, National Institute of Unani Medicine, Bangalore during the year of 2014. The study consisted of 230 women with the ages between 20 - 49 years with complaint of dysmenorrhea. All newly married, nulliparous and parous women were included. The detailed reproductive history like age, age at menarche, duration of cycle, duration and amount of flow, pain during menstruation and its intensity and number of abortions, number of pregnancies were recorded. Some women could not reveal the information about their menstrual symptoms or age of menarche. The collected data were analyzed statistically.

      >  Study design

    Cross sectional study.

      >  Duration of Study

    2 months.

      >  Sample size

    230.

      >  Method of collection of data

    By history.

      >  Inclusion criteria

    All married women complaining of pain abdomen during menstruation.

      >  Exclusion criteria

    Menopausal women.

    RESULTS AND DISCUSSION

    The present study was conducted to observe the relationship between dysmenorrhea and associated factors whether they relieve the dysmenorrhoic pain or not. The study consisted of 230 cases of dysmenorrhea. The data observed were as:

      >  Age

    Age has a significant effect on the severity of dysmenorrhea. Older women are more like to experience less severity and prevalence of dysmenorrhea. Primary dysmenorrhea frequently occurs in women aged 15 - 24 years and then declines as women age advances to 25 to 34 years (Walraven et al. 2002). Similarly the international association of the study of pain reported that primary dysmenorrhea is most common between ages of the 15 - 19 years and declines thereafter.

    The present study revealed that according to age distribution analysis this disease was prevalent throughout reproductive life i.e. 20 - 49 years of age, but higher prevalence was observed in middle age i.e. 30 - 39 years (Table 1) and it was concordant with the finding of Weissman et al. (2004). Out of 230 cases of dysmenorrhea 79 cases were between the age of 20 - 29 years, 95 cases were between 30 - 39 years of age and 56 cases were between 40 - 49 years of age (Table1), in a longitudinal study of the natural history of Primary Dysmenorrhea it was reported that older age was associated with less severe dysmenorrhea (Walraven et al. 2002). Furthermore in another study found that the severity of primary dysmenorrhic pain decreased significantly after the age of 40 years in nulliparous women (Juang et al., 2006)

    In their study Rebecca et al. and Harlow and Park concluded that it is an age related disease and that the symptoms gradually decrease with increase in age. The incidence also tends to decrease with age (Harlow and Park et al., 1996).

      >  Early age of Menarche

    Studies on the prevalence of menstrual pain have shown that many factors are related to this disorder. The relationship between age at menarche and dysmenorrhea is contradictory. In present study it was observed that out of 230 cases 175 cases were found between the age of menarche of 11 - 13 years (Table 2) and this finding was concordance with the finding of Andersch and Milsom (1982). In their study they documented that early age at menarche was associated with an increase in the severity and duration of dysmenorrhea (Harlow and Park, 1996; Montero et al., 1999; Patel et al., 2006; Pawlowski, 2004). Conversely Derman et al. (2004) could not observe clear relationship between age at menarche and dysmenorrheal.

      >  Duration and amount of menstrual flow

    Duration and amount of menstrual flow as risk factor for dysmenorrhea are controversial. Longer or irregular menstrual cycles (Derman et al., 2004) and duration of menstrual flow (Montero et al., 1999) also cause menstrual pain. In present study 29 patients had frequent cycles, 161 patients had normal length of cycles and 40 patients had longer menstrual cycles (Table 3). Regarding the duration of flow 156 patients had 2 - 4 days of flow, 57 patients had 5 - 10 days and 17 patients had more than 10 days of menstrual flow (Table 4), whereas 53 patients had scanty flow, 133 patients had moderate flow and 44 patients had heavy menstrual flow (Table 5). According to many studies long and heavy menstrual flow has been associated with an increased risk of dysmenorrhea (Solomon et al., 2002). Conversely, Tangchai et al. (2004) reported that dysmenorrhea was not associated with the duration of the menstrual cycle and amount of bleeding in each cycle. In some studies severity of pain has been correlated with menstrual flow (Vink et al., 2006).

      >  Parity

    Epidemiological studies have revealed so many associated factors responsible for dysmenorrhea. Primary dysmenorrhea occurs more frequently in unmarried than in married even of advanced age (61% versus 51% respectively). Although primary dysmenorrhea tends to improve and to decrease with age more rapidly in married than in unmarried women and pregnancy, vaginal delivery do not necessarily cure it (Klein and Litt, 1981).

    Childbearing is said to relieve dysmenorrhea, but this does not always occur. One study revealed that in nulliparous women with Dysmenorrhea, the severity of menstrual pain decreased significantly after the age of 40 years (Vink et al., 2006). Another study indicated that dysmenorrhea was present in 36.4% of participants and was significantly associated with lower age and lower parity (Juang et al., 2006). In other study it was reported that parity also plays a role. Both the prevalence and severity of Dysmenorrhea reduced after the first delivery and in women who were parous than women who had never been pregnant or women who had experience a medical or spontaneous abortion (Solomon et al., 2002; Sundell et al., 1990; Weissmann et al., 2004). Regarding the parity in present study out of 230 cases 60 patients had a history of abortion, 13 were nulliparous, 46 were of parity one, 68 were of parity two, 49 were of parity three, 34 were of parity four, 09 were of parity five and only one case each was found of parity seven, eight, twelve and no patient was found of parity six, nine, ten and eleven (Table 6). Out of 230 cases severe dysmenorrhea was found in patients of parity one, moderate dysmenorrhea was seen in patients with parity two to four, whereas mild dysmenorrhea was seen in patients of parity five and above as the prevalence of high parity was also low. Often primary dysmenorrhea becomes of less severe with age or after childbirth (Andersch and Milsom, 1982; Wong et al., 2009). Parity was also reported negatively related to dysmenorrhea from Singapore (Ng et al., 1992) and from Poland (Skierska et al., 1996).

    SUMMARY AND CONCLUSION

    The present study was carried out to observe how the Dysmenorrhea is associated with risk factors like age, age at menarche, menstrual cycle irregularities, parity etc. It was observed that early age at menarche increases severity and duration of menstrual pain, whereas its prevalence decreases with advancing age and parity.

    On the basis of the above observation, it is concluded that large sample would accurately determine strength of the association of under study risk factors with Dysmenorrhea.

  • 1. Akerlund M, Melin P, Maggi M 1995 Potential use of oxytocin and vasopressin via antagonists in the treatment of preterm labor and labor and primary dysmenorrhea [Adv Exp Med Biol] Vol.395 P.595-600 google
  • 2. Andersch B, Milsom I 1982 An epidemiologic study of young women with dysmenorrhea [Am J Obstet Gynecol] Vol.144 P.655-660 google
  • 3. Balbi C, Musone R, Menditto A, Di Prisco L, Cassese E, D'Ajello M, Ambrosio D, Cardone1 A 2000 Influence of menstrual factors and dietary habits on menstrual pain in adolescence age [Eur J Obstet Gynecol Reprod Biol] Vol.91 P.143-148 google doi
  • 4. Banikarim C, Chacko MR, Kelder SH 2000 Prevalence and impact of dysmenorrhea on hispanic female adolescents [Arch Pediatr Adolesc Med] Vol.154 P.1226-1229 google doi
  • 5. Bossmar T, Akerlund M, Szamatowicz J, Laudanski T, Fantoni G, Maggi M 2004 The pain intensity level in adolescence with primary dysmenorrhea [The Pain Clinic] Vol.16 P.349-352 google doi
  • 6. Derman O, Kanbur NO, Baltaci G, Akbayrak T, Tokur T 2004 The pain intensity level in adolescence with primary dysmenorrhea [The Pain Clinic] Vol.16 P.349-352 google doi
  • 7. Harlow SD, Park M 1996 A longitudinal study of risk factors for the occurrence, duration and severity of menstrual cramps in a cohort of college women [Br J Obstet Gynaecol] Vol.103 P.1134-1142 google doi
  • 8. Ju H, Jones M, Mishra G 2014 The prevalence and risk factors of dysmenorrhea [Epidemiol Rev] Vol.36 P.104-113 google doi
  • 9. Juang CM, Yen MS, Horng HC, Cheng CY, Yuan CC, Chang CM 2006 Natural progression of menstrual pain in nulliparous women at reproductive age: an observational study [J Chin Med Assoc] Vol.69 P.484-488 google doi
  • 10. Kaprio J, Rimpela A, Winter T, Viken RJ, Rimpela M, Rose RJ 1995 Common genetic influences on BMI and age at menarche [Hum Biol] Vol.67 P.739-753 google
  • 11. Kennedy S 1997 Primary dysmenorrhoea [Lancet] Vol.349 P.1116 google doi
  • 12. Klein JR, Litt IF 1981 Epidemiology of adolescent dysmenorrhea [Pediatrics] Vol.68 P.661-664 google
  • 13. Latthe P, Mignini L, Gray R, Hills R, Khan K 2006 Factors predisposing women to chronic pelvic pain: systematic review [BMJ] Vol.332 P.749-755 google doi
  • 14. Locke RJ, Warren MP 1999 Curbside consult: What is the effect of exercise on primary dysmenorrhea? [West J Med] Vol.171 P.264-265 google
  • 15. Loto OM, Adewumi TA, Adewuya AO 2008 Prevalence and correlates of dysmenorrhea among Nigerian college women [Aust N Z J Obstet Gynaecol] Vol.48 P.442-444 google doi
  • 16. Montero P, Bernis C, Loukid M, Hilali K, Baali A 1999 Characteristics of menstrual cycles in Moroccan girls: prevalence of dysfunctions and associated behaviours [Ann Hum Biol] Vol.26 P.243-249 google doi
  • 17. Ng TP, Tan NC, Wansaicheong GK 1992 A prevalence study of dysmenorrhoea in female residents aged 15-54 years in Clementi Town, Singapore [Ann Acad Med Singapore] Vol.21 P.323-327 google
  • 18. Padhye S, Karki C, Padhye SB 2003 A profile of menstrual pain among nulliparous women in a private set up [Kathmandu Univ Med J (KUMJ)] Vol.1 P.20-26 google
  • 19. Patel V, Tanksale V, Sahasrabhojanee M, Gupte S, Nevrekar P 2006 The burden and determinants of dysmenorrhoea: a populationbased survey of 2262 women in Goa, India [BJOG] Vol.113 P.453-463 google doi
  • 20. Pawlowski B 2004 Prevalence of menstrual pain relation to the reproductive life history of women from the Mayan Rural community [Ann Hum Biol] Vol.31 P.1-8 google doi
  • 21. Rosenwaks Z, Seegar-Jones G 1980 Menstrual pain: its origin and pathogenesis [J Reprod Med] Vol.25 P.207-212 google
  • 22. Skierska E, Leszczy?ska-Bystrzanowska J, Gajewski AK 1996 Risk analysis of menstrual disorders in young women from urban population [Przegl Epidemiol] Vol.50 P.467-474 google
  • 23. Solomon CG, Hu FB, Dunaif A, Rich-Edwards JE, Stampfer MJ, Willett WC, Speizer FE, Manson JE 2002 Menstrual cycle irregularity and risk for future cardiovascular disease [J Clin Endocrinol Metab] Vol.87 P.2013-2017 google
  • 24. Sterasam BI 1997 The Biology of Menstruation in Homo Sapiens: Total Lifetime Menses, Fecundity, and Nonsynchrony in a Natural-Fertility Population [Current anthropology] Vol.38 P.123-129 google doi
  • 25. Sundell G, Milsom I, Andersch B 1990 Factors influencing the prevalence and severity of dysmenorhoea in youg women [BJ of OBG] Vol.97 P.123-129 google
  • 26. Tangchai K, Titapant V, Boriboonhirunsarn D 2004 Dysmenorrhea in Thai adolescents: prevalence, impact and knowledge of treatment [J Med Assoc Thai] Vol.87 P.S69-S73 google
  • 27. Vink CW, Labots-Vogelesang SM, Lagro-Janssen AL 2006 Menstruation disorders more frequent in women with a history of sexual abuse [Ned Tijdschr Geneeskd] Vol.150 P.1886-1890 google
  • 28. Walraven G, Ekpo G, Coleman R, Scherf C, Morison L, Harlow SD 2002 Menstrual disorders in rural Gambia [Stud Fam Plann] Vol.33 P.261-268 google doi
  • 29. Weissman AM, Hartz AJ, Hansen MD, Johnson SR 2004 The natural history of primary dysmenorrhoea: a longitudinal study [BJOG] Vol.111 P.345-352 google doi
  • 30. Wong CL, Farquhar C, Roberts H, Proctor M 2009 Oral contraceptive pill for primary dysmenorrhoea [Cochrane Database Syst Rev] Vol.7 google
  • 31. Zukri SM, Naing L, Hamzah TNT, Hussain NHN 2009 Primary dysmenorrhea among medical and dental university students in Kelantan: prevalence and associated factors [IMJ] Vol.16 P.93-99 google
  • [Table 1.] Age wise distribution of patients.
    Age wise distribution of patients.
  • [Table 2.] Age of Menarche.
    Age of Menarche.
  • [Table 3.] Duration of menstrual cycle.
    Duration of menstrual cycle.
  • [Table 4.] Duration of menstrual flow.
    Duration of menstrual flow.
  • [Table 5.] Amount of flow.
    Amount of flow.
  • [Table 6.] Dysmenorrhea and parity.
    Dysmenorrhea and parity.