Pediatrics International (2007) 49, 938942

doi: 10.1111/j.1442-200X.2007.02489.x

Original Article

Menstrual pattern and common menstrual disorders among university students in Turkey
MURAT CAKIR,1 ILKE MUNGAN,1 TANER KARAKAS,1 LKNUR GIRISKEN1 AND AYSENUR OKTEN2 Departments of 1Pediatrics and 2Pediatric Endocrinology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
Abstract Background: Menstrual disorders may affect the life of adolescents and young adult women, and may sometimes cause serious problems. The patterns of menstrual cycles were analyzed for association with age of menarche, prevalence of menstrual irregularity, dysmenorrhea, prolonged menstrual bleeding, and effect of menstrual disorders, especially dysmenorrhea, on social activities and school attendance among the female students. Methods: A total of 480 students were randomly selected and asked to complete an the anonymous questionnaire of 25 items. Results: The mean age of the subjects at menarche was 12.8 1.3 years with a range of 917 years. The duration between two periods and the menstrual ow were 27.7 2.5 days and 5.8 1.4 days, respectively. The prevalence of menstrual irregularity, prolonged menstrual bleeding and dysmenorrhea were 31.2%, 5.3% and 89.5%, respectively. Approximately 10% of dysmenorrheic subjects had severe dysmenorrhea; and school absenteeism and need to consult a physician were more common in those subjects. The rst source of their knowledge about menarche and menstruation was their mothers in 211 subjects (54%); only 18 subjects (4.6%) were given a lecture about menstruation and menarche at school. Conclusion: The prevalence of dysmenorrhea and menstrual irregularity was high, and most adolescents have inappropriate and insufcient information about menstrual problems. Hence, an education program is needed at the end of primary school about menarche and menstrual problems. dysmenorrhea, menarche age, menstrual pattern.

Key words

Menarche is a milestone in female puberty that signies the maturation of reproductive potential and physiological growth. It generally occurs approximately 2.3 years after the initiation of puberty, between the ages of 11 and 14 years in 95% of girls depending on race, ethnicity, socioeconomic and nutritional status.1 Menstrual cycles are irregular during the rst year of menarche due to anovulatory cycles. Height, weight and body fat content continue to increase for 12 years following menarche and the cycles become regular within 23 years. Typically a menstrual ow lasts 27 days in 7080% of cases, and changing three to six pads per day suggests normal ow. The duration between two menstrual cycles ranges from 21 to 45 days in the 12 years after menarche. When ovulatory cycles begin, 6080% of the cycles are 2134 days long, which
Correspondence: Murat Cakir, MD, Kazm Dirik Mah., Svari Cad. No: 55, Mutluba lar Apt, Daire: 9, Bornova, Izmir, Turkiye. Email: muratcak@hotmail.com Received 10 January 2006; revised 20 March 2006; accepted 26 October 2006; published online 31 October 2007.

is a similar pattern to that in adults.2 Some variety of menstrual dysfunction occurs in approximately 75% of adolescent girls, and may affect the life of adolescent and young adult women.3,4 Dysmenorrhea is one of the most common gynecologic disorders among adolescent girls. It is dened as pelvic pain directly related to menstruation, and is associated with symptoms ranging from headache and back pain to nausea, vomiting and diarrhea. It is classied into two categories: primary when pelvic examination and ovulatory function are normal; and secondary when there is an identiable gynecological pathology. Primary dysmenorrhea characteristically begins when adolescents attain their ovulatory cycles; generally within the rst year after menarche.5 It is believed that the cause of the pain is excess production of prostaglandins (PG) in the endometrium during the ovulatory cycle. PG stimulate the myometrial contraction and local vasoconstriction that cause the menstrual efuent to be expelled from the uterine cavity. It was shown that women with dysmenorrhea have higher levels of PG in their plasma and menstrual efuent than women without dysmenorrhea.5 Additionally, elevated serum vasopressin,

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Menstrual problems among adolescents

nitric oxide and interleukin-6 levels have been reported in women with primary dysmenorrhea.6,7 Dysmenorrhea is the major cause of activity restriction and school absence in adolescent girls. However, this condition is often considered as physiological pain and ignored by adolescents; and only few adolescents need to consult a physician for menstrual pain and most of them self-medicate with over-the-counter medicines. This cross-sectional study was conducted to determine: (i) the patterns of menstrual cycles associated with the age of menarche; (ii) the prevalence of menstrual disorders; menstrual irregularity, dysmenorrheal and prolonged menstrual bleeding; (iii) source of knowledge and management strategy of menstrual disorders, especially dysmenorrhea; and (iv) the effect of menstrual disorders on social activities and school attendance among female university students.

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Methods
The subjects were student girls from two faculties (Faculty of Medicine and Midwife School) of Karadeniz Technical University, Trabzon. In total there were 506 female students in two faculties during the 20042005 academic years. We aimed to include at least 75% of the female students in the study. A total of 480 students, who were present at the school at time of the study; were asked to complete the anonymous questionnaire of 25 items distributed by the researchers. The aim of the study and the contents of the questionnaire were explained to each subject, and voluntary participation was requested. Subjects who had primary amenorrhea and had a history of abdominal or pelvic surgery were not eligible for the study. All participants gave written informed consent before enrollment, and ethics approval was obtained from the ethics committee. The questionnaire included data regarding demographic features, menarche age, menstrual pattern, severity of dysmenorrhea and associated symptoms, impact of menstrual disorder on social, sport activities and school attendance, management strategy of the pain, the source of their knowledge about menarche and whether they required medical help (from a doctor, nurse or midwife) for menstrual disorder or not. Students were asked to identify the year of their rst period. Questions such as Do you remember which grade you were in when you started having period? were used to help the subjects remember the date. The normal range of menarche age is 1016 years, and we divided the reported menarche age into three groups: early normal menarche age was considered between 10 and 12 years; mid-normal menarche age was between 13 and 14 years; and late normal menarche age was between 15 and <17 years. Dysmenorrhea was dened as any type of pain or discomfort associated with menstrual period. The severity of the dysmenorrhea was measured on multidimensional scoring system.

On the multidimensional scoring system the severity of dysmenorrhea was dened as mild, moderate and severe based on the pain, limitation of activities and medication taken. Severe dysmenorrhea was dened as clearly inhibition of the daily activities associated with systemic symptoms and poor improvement with analgesics.8 In deciding whether the menstrual pattern of the subjects was regular we were cognizant of the normal variation in the menstrual cycle of 2145 days, and that it is variable within this range on a month-to-month basis. Prolonged menstrual ow (PMF) was dened as menstrual bleeding >10 days. The data were analyzed using SPSS for Windows version 9 (SPSS, Chicago, IL, USA). Descriptive statistics were used to determine mean age of the subjects, age at menarche, frequency of menstrual disorders, treatment of dysmenorrhea and activities affected by this condition. The categorical data were analyzed using 2 or Fishers exact test. The continuous data were analyzed using unpaired t-test. P < 0.05 was considered to be statistically signicant.

Results
The questionnaires were distributed to 480 subjects and 391 subjects (81.4%) completed it. The mean age SD of the participants was 20.745 1.823 years (decimal age), with a range of 16.73126.902 years. Menarche age, menstrual pattern and common menstrual problems are listed in Table 1.

Menarche age and menstrual pattern

The mean age of the subjects at menarche was 12.8 1.3 years with a range of 917 years. Eighty-seven subjects (22.2%) had an early menarche age and four subjects were younger than 10 years of age; 273 subjects (69.8%) had a medium menarche and 31 subjects (7.9%) had a delayed menarche and two of them were older than 16 years. The duration between two

Table 1 Menarche age, menstrual pattern and major menstrual problems Parameters Age (years) Menarche age Early menarche, n (%) Medium menarche, n (%) Delayed menarche, n (%) Duration between two periods (days) Duration of menstrual ow (days) Menstrual irregularity, n (%) Prolonged menstrual ow (>10 days), n (%) Dysmenorrhea, n (%) Mean SD 20.745 1.823 12.8 1.3 (917) 87 (22.2) 273 (69.8) 31 (7.9) 27.7 2.5 (1260) 5.8 1.4 (215) 122 (31.2) 21 (5.3) 350 (89.5)

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Table 2 Associated symptoms in dysmenorrheic subjects Symptoms Girls with dysmenorrhea (n = 350) N (%) 270 (77.1) 230 (65.7) 203 (58) 147 (42) 138 (39.4) 125 (35.7) 96 (27.4) 89 (25.4) 65 (18.5) 57 (16.2) 53 (15.1) 40 (11.4) 12 (3.4)

periods and the menstrual ow were 27.7 2.5 days and 5.8 1.4 days, respectively. Two hundred and sixty-nine girls (68.8%) had a regular menstrual pattern. One hundred and twenty-two subjects (31.2%) had irregular menstrual pattern, and 21 of the subjects had PMF. Subjects with irregular menstrual pattern were signicantly younger than the subjects with regular menstrual pattern (20.503 1.882 years vs 20.855 1.788 years, P < 0.05). However, no signicant difference was found in menarche age. PMF was more common in subjects with delayed menarche (5.7%, 3.6% and 19.3%, P < 0.0001) and 10 of the subjects with prolonged menstrual bleeding were hospitalized and evaluated for coagulopathy. These subjects had menstrual ow >2 weeks and were changing approximately 10 pads per day; ve of them had delayed menarche. Two of them were given erythrocyte suspension and iron therapy due to severe anemia, and one of them had immune thrombocytopenic purpura (Fig. 1).

Abdominal pain Backache Nervousness Depression Fatigue Chills Polyuria Increased appetite Diarrhea Loss of appetite Headache Vomiting Other

More than one symptom/girl.

Dysmenorrhea

The prevalence of dysmenorrhea among the subjects was 89.5%, and approximately 10% of them had severe dysmenorrhea. No signicant differences were noted between the subjects with and without dysmenorrhea in terms of age, menarche age, and duration of menstrual ow, menstrual irregularity and duration between the two periods. Nevertheless, only two of 21 subjects with PMF had dysmenorrhea (P < 0.0001). Table 2 shows reported symptoms associated with dysmenorrhea. The most common associated symptoms among the dysmenorrheic subjects were abdominal pain (77.1%), backache (65.7%) and nervousness (58%). Daily activities were limited by dysmen-

orrhea in 104 girls (29.7%), 83 of them reported that their social and sport activities were limited, while 21 subjects missed school because of menstrual pain, for 2 days in 10 of them. More than 50% of the dysmenorrheic girls reported that their class concentration was affected, and approximately 15% of the subjects missed exams or scored a lower grade at least once due to menstrual cramps. Seven subjects (2%) were unable to participate in normal activities and were conned to bed due to menstrual pain. Table 3 shows the comparison of the various factors between the subjects with severe dysmenorrhea and mild to moderate dysmenorrhea. Menarche age was signicantly

Table 3 Comparison of factors according to dysmenorrhea status Severe dysmenorrhea (n = 37) Mean SD Age (years) Menarche age (years) Menstrual irregularity, n (%) Menstrual cycle (days) Menstrual ow (days) Limited social activities, n (%) School absenteeism, n (%) Admitted to a physician, n (%) 20.750 1.702 13.3 1.2 12 (32.4) Mildmoderate dysmenorrhea (n = 313) Mean SD 20.762 1.873 12.8 1.3 94 (30) P

0.96 0.01 0.91

27.4 2.2 6.2 1.1 12 (32.4)

27.7 2.6 5.8 1.4 58 (18.5)

0.53 0.11 0.07

Fig. 1 Major menstrual disorders among students according to age. () Early menarche, n = 83; ( ) medium menarche, n = 273; () delayed menarche, n = 31. Prolonged menstrual ow is common in girls with delayed menarche (5.7%, 3.6% and 19.3%, P < 0.0001). 2007 Japan Pediatric Society

16 (43.2)

5 (1.5)

<0.0001

17 (45.9)

37 (11.8)

<0.0001

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high (P = 0.014), and school absenteeism and need to consult a physician were more common in subjects with severe dysmenorrhea (P < 0.0001). The management strategies for pain are given in Table 4. One hundred and seventy-ve subjects (50%) used medication for the management of their pain. Naproxen sodium and ibuprofen were the most commonly used non-steroidal anti-inammatory agents among the dysmenorrheic girls. One hundred and fty-one subjects (43.1%) used heating pads or locally applied heat packs to manage their pain. Sleeping or exercise was used less commonly among the subjects. The rst source of their knowledge about menarche and menstruation was their mothers in 211 subjects (54%). Friends, magazines, newspaper and television were the other sources, and only 18 subjects (4.6%) were given a lecture about menstruation and menarche in secondary school.

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Discussion
Adolescence is a time of enormous physical and hormonal change for a young girl. Although organic gynecological pathologies are rare in this period, menstrual disorders may be seen commonly, and may cause further problems for the adolescents and their parents. The age of menarche is determined by general health, genetic factors, socioeconomic and nutritional status. It is typically between 12 and 13 years; but with the improvements in the nutritional status and general health it has declined in many populations during the last decades.9,10 In the present study we found that the mean age of menarche was 12.8 1.3 years; similar to the other studies that have been done in recent years.11 However, the present results differed to those from

Table 4 Management strategy for dysmenorrhea (n = 350) Management strategy Heating pads Medications Analgesics Naproxen sodium Ibuprofen Paracetamol Mefenamic acid Aspirin Diclofenac Non-specic Others Vitamins Sleeping Exercise N (%) 151 (43.1) 175 (50) 165 (47.1) 33 (9.4) 39 (11.1) 32 (9.1) 4 (1.1) 3 (0.8) 2 (0.5) 42 (12) 10 (2.8) 10 (2.8) 14 (4) 6 (1.7)

another study that was done 10 years ago in Ankara. The mean menarche age was 13 years and 2 months, which was 4 months later than the present one.12 This may be related to improvement of nutritional and socioeconomic status of the adolescents in recent decades. Problems with menstrual pattern may affect 75% of girls, and are the major cause of recurrent short-term school absenteeism in female adolescents.3,4 Menstrual irregularity and prolonged menstrual bleeding are the most common menstrual disorders in early adolescents. Prolonged menstrual bleeding usually occurs early after menarche due to anovulatory cycles. In anovulatory cycles, estrogen unopposed by progesterone produces an unstable endometrial lining that eventually breaks down, and vasoconstriction and myocardial contractility do not occur.13 In the present study PMF was common in subjects with delayed menarche and less common in subjects with dysmenorrhea. Although approximately 90% of cases with PMF associated with anovulatory cycles during adolescence, systemic bleeding disorders such as factor deciencies and thrombocytopenia must be excluded for the denite diagnosis.2 Dysmenorrhea is an important menstrual disorder in adolescence. Contrary to prolonged menstrual bleeding and menstrual irregularity, it is common in young women with ovulatory cycles. The prevalence increases through the adolescent years and decreases with increasing age. In the present study we found that the prevalence of dysmenorrhea among university students was 89.5% and approximately 10% of them described their dysmenorrhea as severe. High prevalence of dysmenorrhea was also reported by Campbell and McGrath (93%)14 and Banikarim et al. (85%).15 Klein and Litt studied 2699 menarcheal adolescents and found that 59.7% had menstrual cramps, and socioeconomic status was positively correlated with dysmenorrhea.3 Other risk factors have been found associated with dysmenorrhea such as smoking, nulliparity, weight loss, depression and anxiety.16 The association between dysmenorrhea and early menarche age has been dened by Montero et al. in Moroccan girls.17 In the present study we did not nd any relationship between dysmenorrhea and menarche age, but the menarche age of subjects with severe dysmenorrhea was signicantly higher than subjects with mildmoderate dysmenorrhea (13.3 1.2 years vs 12.8 1.3 years, P = 0.014). In general, early onset of menarche leads to earlier ovulatory cycles and to earlier experience of dysmenorrheal symptoms. It remains to be determined in future studies whether girls who experiencing dysmenorrhea symptoms at a later age may suffer from more severe dysmenorrhea symptoms. The syndrome of dysmenorrhea is associated with a variety of physical symptoms. The most common associated symptoms were abdominal pain, backache and nervousness, respectively. Not only the pain but also these associated symptoms cause daily activity restriction and school absence in adolescent girls. In the present study 29% of subjects reported that the pain caused restriction on their social
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M Cakir et al. References

1 Tanner JM, Davies PS. Clinical longitudinal standards for height and height velocity for North American children. J. Pediatr. 1985; 107: 31729. 2 Hickey M, Balen A. Menstrual disorders in adolescence: Investigation and management. Hum. Reprod. Update 2003; 9: 493504. 3 Klein JR, Litt IF. Epidemiology of adolescent dysmenorrhea. Pediatrics 1981; 68: 6614. 4 Ziv A, Boulet JR, Slap GB. Utilization of physician ofces by adolescents in the United States. Pediatrics 1999; 104: 3542. 5 Durain D. Primary dysmenorrhea: Assessment and management update. J. Midwifery Womens Health 2004; 49: 52028. 6 Yeh ML, Chen HH, So EC, Liu CF. A study of serum malondialdehyde and interleukin-6 levels in young women with dysmenorrhea in Taiwan. Life Sci. 2004; 75: 66973. 7 Sun MF, Huang HC, Lin SC, Chang LP, Liu CF. Evaluation of nitric oxide and homocysteine levels in primary dysmenorrheal women in Taiwan. Life Sci. 2005; 76: 20059. 8 Andersch B, Milsom I. An epidemiologic study of young women with dysmenorrhea. Am. J. Obstet. Gynecol. 1982; 144: 65560. 9 Bullough VL. Age at menarche: A misunderstanding. Science 1981; 213: 3656. 10 Chowdhury S, Shahabuddin AK, Seal AJ et al. Nutritional status and age at menarche in a rural area of Bangladesh. Ann. Hum. Biol. 2000; 27: 24956. 11 Ersoy B, Balkan C, Gunay T, Onag A, Egemen A. Effects of different socioeconomic conditions on menarche in Turkish female students. Early Hum. Dev. 2004; 76: 11525. 12 Vicdan K, Kukner S, Dabakoglu T, Ergin T, Keles G, Gokmen O. Demographic and epidemiologic features of female adolescents in Turkey. J. Adolesc. Health 1996; 18: 548. 13 Bayer SR, DeCherney AH. Clinical manifestations and treatment of dysfunctional uterine bleeding. JAMA 1993; 269: 18238. 14 Campbell MA, McGrath PJ. Non-pharmacologic strategies used by adolescents for the management of menstrual discomfort. Clin. J. Pain 1999; 15: 31320. 15 Banikarim C, Chacko MR, Kelder SH. Prevalence and impact of dysmenorrhea on Hispanic female adolescents. Arch. Pediatr. Adolesc. Med. 2000; 154: 12269. 16 French L. Dysmenorrhea. Am. Fam. Physician 2005; 71: 28591. 17 Montero P, Bernis C, Loukid M, Hilali K, Baali A. Characteristics of menstrual cycles in Moroccan girls: Prevalence of dysfunctions and associated behaviours. Ann. Hum. Biol. 1999; 26: 2439.

activities and 6% reported school absence. School absence was more common in subjects with severe dysmenorrhea (43.2% vs 1.5%, P < 0.0001). It should be noted that academic activities were limited in >60% of the dysmenorrheic girls. Results of a US study indicated that 14% of adolescents aged 1217 years missed school because of menstrual cramps and it was more common in subjects with severe dysmenorrhea.3 It is accepted that dysmenorrhea is the leading cause of absenteeism in young girls with regard to school, social activities and work. Despite its high prevalence and negative effects, young adolescents choose to resist their pain and believe that painful periods are normal. They rarely discuss their pain with their physician; and in the present study only 18% of all girls with dysmenorrhea had consulted a doctor due to pain. More importantly, half of the girls with severe dysmenorrhea had never seen a doctor. Mothers were found to be the most important source of knowledge about menarche and menstrual problems. In traditional culture there is a restriction in discussing menstrual problems for young girls with friends or physicians, especially in rural areas. Mothers are responsible for giving information about menarche and related issues. Their knowledge mostly depends on their mothers knowledge. Only 4.6% of the subjects were given a lecture about menstruation and menarche at school. The limitation of the present study is that it consists only of university students, and therefore may not represent the frequency of menstrual disorders among young women in the overall population. As a result the present study indicates that prevalence of dysmenorrhea and menstrual irregularity among university students is high and that most adolescents have never presented to a physician, and have inappropriate and insufcient information about their menstrual problems. It is important for clinicians to inquire about any menstrual problems when young women visit the clinics. Moreover, a comprehensive school education program on menarche, menstrual problems and gynecological health given by teachers and medical staff specialized in adolescent gynecology, is needed at the end of primary school including for the mothers.

2007 Japan Pediatric Society