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Pediatrics International (2007) 49, 938–942

Original Article

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

Menstrual pattern and common menstrual disorders among university students in Turkey

MURAT CAKIR , 1 ILKE MUNGAN , 1 TANER KARAKAS , 1 LKNUR GIRISKEN 1 AND AYSENUR OKTEN 2

Departments of 1 Pediatrics and 2 Pediatric 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 9 – 17 years. The duration between two periods and the menstrual fl 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 fi 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 insuffi cient information about menstrual problems. Hence, an education program is needed at the end of primary school about menarche and menstrual problems.

Key words

dysmenorrhea , menarche age , menstrual pattern .

Menarche is a milestone in female puberty that signifi es 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 fi rst year of menarche due to anovulatory cycles. Height, weight and body fat content continue to increase for 1 – 2 years following menarche and the cycles become regular within 2 – 3 years. Typically a menstrual fl ow lasts 2 – 7 days in 70 – 80% of cases, and changing three to six pads per day suggests normal fl ow. The duration between two menstrual cycles ranges from 21 to 45 days in the 1 – 2 years after menarche. When ovulatory cycles begin, 60 – 80% of the cycles are 21 – 34 days long, which

Correspondence: Murat Cakir, MD, Kazı m Dirik Mah., Süvari 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.

© 2007 Japan Pediatric Society

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 defi ned as pelvic pain directly related to menstruation, and is associated with symp- toms ranging from headache and back pain to nausea, vomiting and diarrhea. It is classifi ed into two categories: primary when pelvic examination and ovulatory function are normal; and secondary when there is an identifi able gynecological pathology. Primary dysmenorrhea characteristically begins when adoles- cents attain their ovulatory cycles; generally within the fi 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 con- traction and local vasoconstriction that cause the menstrual effl uent to be expelled from the uterine cavity. It was shown

that women with dysmenorrhea have higher levels of PG in their plasma and menstrual effl uent than women without dysmenorrhea. 5 Additionally, elevated serum vasopressin,

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 condi- tion 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; men- strual 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.

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 2004 – 2005 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 question- naire 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 dysmen- orrhea 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 fi 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 10 – 16 years, and we divided the reported menarche age into three groups: early normal menarche age was con- sidered 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 defi ned as any type of pain or discom- fort associated with menstrual period. The severity of the dys- menorrhea was measured on multidimensional scoring system.

Menstrual problems among adolescents

939

On the multidimensional scoring system the severity of dysmenorrhea was defi ned as mild, moderate and severe based on the pain, limitation of activities and medication taken. Severe dysmenorrhea was defi ned as clearly inhibition of the daily activities associated with systemic symptoms and poor improvement with analgesics. 8 In deciding whether the men- strual pattern of the subjects was regular we were cognizant of the normal variation in the menstrual cycle of 21 – 45 days, and that it is variable within this range on a month-to-month basis. Prolonged menstrual fl ow (PMF) was defi ned 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 acti- vities affected by this condition. The categorical data were analyzed using 2 or Fisher’s exact test. The continuous data were analyzed using unpaired t -test. P < 0.05 was considered to be statistically signifi cant.

Results

The questionnaires were distributed to 480 subjects and 391 subjects (81.4%) completed it. The mean age ± SD of the par- ticipants was 20.745 ± 1.823 years (decimal age), with a range of 16.731 – 26.902 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 9 – 17 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

problems

Menarche age, menstrual pattern and major menstrual

Parameters

Mean ± SD

Age (years) Menarche age Early menarche, n (%) Medium menarche, n (%) Delayed menarche, n (%) Duration between two periods (days) Duration of menstrual fl ow (days) Menstrual irregularity, n (%) Prolonged menstrual fl ow (>10 days), n (%) Dysmenorrhea, n (%)

20.745 ± 1.823 12.8 ± 1.3 (9 – 17) 87 (22.2) 273 (69.8) 31 (7.9) 27.7 ± 2.5 (12 – 60) 5.8 ± 1.4 (2 – 15) 122 (31.2) 21 (5.3) 350 (89.5)

© 2007 Japan Pediatric Society

  • 940 M Cakir et al.

periods and the menstrual fl 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 irregu- lar menstrual pattern, and 21 of the subjects had PMF. Subjects with irregular menstrual pattern were signifi cantly younger than the subjects with regular menstrual pattern (20.503 ± 1.882 years vs 20.855 ± 1.788 years, P < 0.05). However, no signifi - cant 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 coagu- lopathy. These subjects had menstrual fl ow >2 weeks and were changing approximately 10 pads per day; fi 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 ).

Dysmenorrhea

The prevalence of dysmenorrhea among the subjects was 89.5%, and approximately 10% of them had severe dysmenor- rhea. No signifi cant differences were noted between the sub- jects with and without dysmenorrhea in terms of age, menarche age, and duration of menstrual fl 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-

940 M Cakir et al. periods and the menstrual fl ow were 27.7 ± 2.5 days

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

940 M Cakir et al. periods and the menstrual fl ow were 27.7 ± 2.5 days

© 2007 Japan Pediatric Society

Table 2

Associated symptoms in dysmenorrheic subjects

Symptoms

Girls with dysmenorrhea (n = 350) N (%)

Abdominal pain

270 (77.1)

Backache

230 (65.7)

Nervousness

203 (58)

Depression

147 (42)

Fatigue

138 (39.4)

Chills

125 (35.7)

Polyuria

96 (27.4)

Increased appetite

89 (25.4)

Diarrhea

65 (18.5)

Loss of appetite

57 (16.2)

Headache

53 (15.1)

Vomiting

40 (11.4)

Other

12 (3.4)

More than one symptom/girl.

 

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 confi ned 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 signifi cantly

Table 3

Comparison of factors according to dysmenorrhea status

 

Severe dysmenorrhea ( n = 37) Mean ± SD

Mild – moderate dysmenorrhea ( n = 313) Mean ± SD

P

Age (years)

20.750 ± 1.702

20.762 ± 1.873

0.96

Menarche age (years)

13.3

± 1.2

12.8 ± 1.3

0.01

Menstrual irregularity, n (%)

12

(32.4)

94 (30)

0.91

Menstrual cycle

27.4

± 2.2

27.7 ± 2.6

0.53

(days) Menstrual fl ow (days)

6.2 ± 1.1

5.8 ± 1.4

0.11

Limited social activities, n (%)

12

(32.4)

58 (18.5)

0.07

School absenteeism,

16

(43.2)

5 (1.5)

<0.0001

n (%) Admitted to a physician, n (%)

17

(45.9)

37 (11.8)

<0.0001

high ( P = 0.014), and school absenteeism and need to consult a physician were more common in subjects with severe dysmen- orrhea (P < 0.0001). The management strategies for pain are given in Table 4 . One hundred and seventy-fi ve subjects (50%) used medica- tion for the management of their pain. Naproxen sodium and ibuprofen were the most commonly used non-steroidal anti-infl ammatory agents among the dysmenorrheic girls. One hundred and fi 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 fi 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 men- struation and menarche in secondary school.

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 ado- lescents and their parents. The age of menarche is determined by general health, genetic factors, socioeconomic and nutritional status. It is typ- ically 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

N (%)

Heating pads

151 ( 43.1)

Medications

175 ( 50)

Analgesics

165 (47.1)

Naproxen sodium

33 (9.4)

Ibuprofen

39 (11.1)

Paracetamol

32 (9.1)

Mefenamic acid

4 (1.1)

Aspirin

3 (0.8)

Diclofenac

2 (0.5)

Non-specifi c

42 (12)

Others

10 (2.8)

Vitamins

10 (2.8)

Sleeping

14 (4)

Exercise

6 (1.7)

Menstrual problems among adolescents

941

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 improve- ment of nutritional and socioeconomic status of the adoles- cents 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 ano- vulatory 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 dys- menorrhea. Although approximately 90 % of cases with PMF associated with anovulatory cycles during adolescence, systemic bleeding disorders such as factor defi ciencies and thrombocy- topenia must be excluded for the defi nite diagnosis. 2 Dysmenorrhea is an important menstrual disorder in adoles- cence. 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 dysmenor- rhea 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 associ- ated with dysmenorrhea such as smoking, nulliparity, weight loss, depression and anxiety. 16 The association between dys- menorrhea and early menarche age has been defi ned by Montero et al. in Moroccan girls. 17 In the present study we did not fi nd any relationship between dysmenorrhea and menarche age, but the menarche age of subjects with severe dysmenor- rhea was signifi cantly higher than subjects with mild – moderate 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 vari- ety 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

© 2007 Japan Pediatric Society

  • 942 M Cakir et al.

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 12 – 17 years missed school because of menstrual cramps and it was more common in subjects with severe dysmenor- rhea. 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 import- antly, 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 know- ledge mostly depends on their mother’s 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 fre- quency 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 pre- sented to a physician, and have inappropriate and insuffi cient 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.

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© 2007 Japan Pediatric Society