J. Obstet. Gynaecol. Res. Vol. 36, No.

2: 377383, April 2010

doi:10.1111/j.1447-0756.2009.01159.x

Inuence of dietary intake of dairy products

on dysmenorrhea
jog_1159

377..383

Khalid K. Abdul-Razzak1, Nehad M. Ayoub1, Ahmed A. Abu-Taleb2 and

Bayan A. Obeidat3
1
Department of Clinical Pharmacy, Faculty of Pharmacy, 2Department of Mathematics and Statistics, Faculty of Arts and
Science, 3Department of Nutrition and Food Technology, Faculty of Agriculture, Jordan University of Science and Technology,
Irbid, Jordan

Abstract
Aim: To determine the frequency of dysmenorrhea and its associated symptoms amongst a number of
adolescent female students and to investigate the possible association between daily dairy product intake and
dysmenorrhea.
Methods: A self-assessment questionnaire was completed by 127 female university students aged between 19
and 24 years. Participants gave information that included demographics, the nature, type, and severity of pain
associated with menstruation if any, management used to relieve dysmenorrhea, associated symptoms, and a
general assessment of dietary intake of dairy products.
Results: The prevalence of primary dysmenorrhea in the population studied was 87.4% with the majority of
the participants pain symptoms beginning a few days before and continuing through the rst two days of
menstruation. Forty-six percent of students were found to have severe dysmenorrhea. Abdominal bloating was
the most frequently expressed symptom associated with dysmenorrhea amongst the population studied.
Dysmenorrhea and associated symptoms were found in signicantly fewer female students who consumed
three or four servings of dairy products per day as compared to participants who consumed no dairy products.
Conclusion: Primary dysmenorrhea is common in young women. This study helps us to better understand the
relationship between low dietary intake of dairy products and the risk of dysmenorrhea.
Key words: calcium, dairy products, dysmenorrhea, pain, symptoms.

Introduction
Dysmenorrhea (painful menstrual cramps of uterine
origin) is the most common gynecological complaint
among female adolescents and young women.1,2 Dysmenorrhea occurs in up to 50% of menstruating girls
and women3 and some degree of dysmenorrhea may be
present in as many as 90%.4 Primary dysmenorrhea,
which is dened as painful menses in women with
normal pelvic anatomy, usually begins during adolescence. The typical age range for occurrence of primary
dysmenorrhea is 1722 years while secondary dysmen-

orrhea becomes more common as a woman ages, which

may be secondary to pelvic organ pathology.5 Dysmenorrhea is characterized by lower abdominal pain that
occurs during menstruation, but may start two or more
days before menstruation.6 Sometimes, pain is associated with headache, nausea, vomiting, backache,
general weakness, gastrointestinal symptoms, and
others.6 Besides the obvious physical concerns about
underlying pelvic pathology, dysmenorrhea can disrupt
daily activities causing signicant social disabilities.7
Pain may inconvenience a woman during holidays,
social activities, or sometimes when high performance

Received: July 17 2008.

Accepted: May 20 2009.
Reprint request to: Professor Khalid K. Abdul-Razzak, Department of Clinical Pharmacy, Jordan University of Science and
Technology, Faculty of Pharmacy, PO Box 3030, Irbid-22110, Jordan. Email: kkalani@just.edu.jo

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Journal compilation 2010 Japan Society of Obstetrics and Gynecology

377

K. K. Abdul-Razzak et al.

is required. Chronic recurrent pain of dysmenorrhea

causes absence from school or work and signicant
costs to the health-care system.7 The pathogenesis of
primary dysmenorrhea is not always understood. Prostaglandins seem to be intimately involved, causing
uterine contractions and pain.8 Abnormalities in plasma
steroid levels could also account for the disturbance,
especially signicantly elevated plasma levels of estradiol in the luteal phase.9
Generally, dysmenorrhea is under-treated because
physicians are not fully aware of its high prevalence
and morbidity.10 Most adolescents self-medicate with
over-the-counter medicines, and few consult a physician about dysmenorrhea.11 Currently, non-steroidal
anti-inammatory drugs (NSAIDs) are the best established initial therapy for dysmenorrhea.12 These drugs
have a direct analgesic effect through inhibition of
prostaglandins synthesis and decreasing the volume
of menstrual ow.12 Furthermore, treatment of dysmenorrhea is a well-accepted off-label use for oral contraceptives (OC).13 However, despite the considerable
efcacy of conventional treatments, for many women,
current medical therapies offer inadequate treatment
with a failure rate of 2025%.14 Besides, some women
prefer not to use NSAIDs or OC because of side-effects
or for cultural reasons.
Many sufferers are now seeking alternatives to conventional medicine, such as herbal and dietary therapies.14,15 A Japanese herbal combination,16,17 thiamine,18
vitamin E,19 sh oil supplements,20 and a low-fat vegetarian diet21 have been proven as having a benecial
effect in the published reports.
Knowledge of benecial food-related practices can
enable better management for this population of girls
and women. Hence, this research was undertaken to
elucidate the possible relationship between daily dairy
product intake and dysmenorrhea and other associated
symptoms as there is a very limited number of studies
that have examined the effect of dairy product intake
on the management of dysmenorrhea.

Methods
Sample
A total of 127 healthy adolescent college students aged
between 19 and 24 were enrolled in this study at Jordan
University of Science and Technology (JUST). Students
who admitted to taking dietary supplements (multivitamins or minerals and calcium supplements) on a
regular basis, or who were vegetarians were excluded
from this investigation.

378

Study design
Adolescent female students who agreed to participate
in the study were instructed to complete a selfassessment questionnaire including their demographics, information regarding menstruation, and an
assessment of their dietary intake of dairy products.
Demographic evaluation included information regarding the students age, height, and weight. Participants
were also asked to answer questions regarding menstruation. Other questions included the age at rst
onset of menses, regularity of menstrual cycles, the
duration of menstruation (<5 or 5 days), the type of
menstruation (slight, normal, or heavy), and the severity of menstrual cramps or pain if present. Pain severity
was graded as the following:
Mild: pain that resolved without the need for
medication.
Severe: pain that is resolved with simple analgesics
(NSAIDs, paracetamol).
Very severe: pain that is not relieved with simple analgesics and may interfere with usual daily activities.
In addition, participants were asked for possible
symptoms associated with dysmenorrhea (e.g. nausea
and vomiting, sweating, abdominal bloating, and
others). Students were also investigated regarding any
medication or alternative therapies administered to
relieve pain associated with menstruation, if any
(NSAIDs, paracetamol, antispasmodics, herbal remedies, and others). Frequency and type of diary
product intake (milk, yogurt, cheese, and labanah,
which is a soft cream cheese made by removal of whey
from yogurt through cheese cloths) were recorded.
Intake of dairy products was determined on a daily
basis as none, single, two, three, or up to four dairy
servings per day.
A dairy serving is dened as: 1 cup of milk or yogurt,
2 full table spoons (2 oz) of labanah, and a 1-ounce
piece of cheese (about the size of a domino or two
ngers).

Statistics
The data were analyzed using statistical software
Minitab 14.
To study the effect of the total number of dairy servings per day on dysmenorrheal pain, the proportion of
female students who experience dysmenorrheal pain
was compared to the proportion of female students
who experience no dysmenorrheal pain for a given
number of servings using the Z-test. The c2 procedure

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Journal compilation 2010 Japan Society of Obstetrics and Gynecology

Dysmenorrhea and dairy products

A total of 127 university students at JUST were enrolled

in this investigation. Their ages ranged between 19 and
24, with a mean age value of 21 1.5 years. The
average body mass index was 21.8 3.3, and the
average age for the onset of menstruation in the sample
was 13 1.4 years.
Among the 127 participants included in this study,
111 participants (87.4%) were dysmenorrheic. The
highest proportion of students (36.6%) had their dysmenorrheal pain onset within one to two days before
menstruation, which continued through the rst two
days of menses. In comparison, 28.6% of participants
acknowledged the occurrence of dysmenorrheal pain a
few days before menstruation, while 34.8% expressed
pain only during the rst and/or second days of their
menstrual cycle. Thirty-eight and a half percent of participants described the duration of their menstruation
as <5 days while 61.5% of participants described the
duration of their menstruation as 5 days. Approximately half of the sample studied graded their dysmenorrheal pain as severe and only a small percentage
of the participants reported very severe menstrual pain
(Fig. 1). It was noticed that in the majority of students
(92.9%), the pain was more frequently in the abdominal
area and 79.5% of participants had their dysmenorrheal
pain radiating to the lower back and/or thighs. The
majority of participants (60.4%) reported that dysmenorrhea affected their daily activity for several days each
month. Besides pain, participants reported a variety of
symptoms associated with dysmenorrhea. Abdominal
bloating was the most frequently presented symptom
in the sample studied and this was followed by loose

9%

78.74
80

Percentage

Results

stools, dizziness, sweating, and nausea and vomiting in

a descending order (Fig. 2).
With respect to treatment options for dysmenorrheal
pain, 65% of participants were found to use medication.
Simple analgesics were the most utilized therapies by
participants as a self-managed guide to pain-relief.
NSAIDs were most popular, followed by paracetamol,
and herbal remedies, while antispasmodics were used
the least (Fig. 3).
In regard to the association between the daily intake
of dairy products and frequency of dysmenorrhea, our
results revealed a signicant difference between high
and low intakes of dairy products. Those women

60
40.16

35.43

29.13

40

20.47

20.47

20
0
N and V

AB

LS

DZ

Others

Symptom
Figure 2 The most common symptoms associated with
dysmenorrhea among the sample studied were nausea
and vomiting (N and V), sweating (S), abdominal bloating (AB), loose stools (LS) and dizziness (DZ). Other
symptoms were various and distributed between
headache, cold sensation, anxiety, generalized weakness, and sleepiness.

37.1

Percentage

was used to measure the association between variables

of interest. P-values < 0.05 were considered statistically
signicant.

40

29.92

30

21.26

20
6.3

10

0.79

em

ce

s
er

er
ba

lr

ra
Pa

O
th

s
ed

m
ta

od
sm
pa
is

An
t

ie

s
ic

ID
s
SA
N

44%

ol

Therapy
47%

Figure 1 Grading pain severity in population studied. ,

mild; , severe; , very severe.

Figure 3 Most commonly used self-therapies for dysmenorrhea in the population studied. Other therapies
involved the use of heat therapy and exercise. NSAIDs,
non-steroidal anti-inammatory drugs.

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Journal compilation 2010 Japan Society of Obstetrics and Gynecology

379

K. K. Abdul-Razzak et al.

reporting an increased intake of dairy of three to four

servings a day reported a marked reduction in dysmenorrhea compared to women reporting no daily
dairy intake (P = 0.000). There was no signicant difference in the prevalence of dysmenorrhea between those
participants taking one compared two dairy servings
daily or even in those consuming three compared to
four dairy servings daily (Table 1).
A similar pattern was found regarding severity of
dysmenorrheal pain with the number of dairy servings. A signicantly lower number of female students
noted mild, severe or very severe dysmenorrheal pain
when their intake of dairy products were three or four
servings per day as compared to participants who con-

sumed none. No female student claimed to have very

severe pain as their dairy intake was increased to four
servings per day (Fig. 4).
Furthermore, the benecial effect of dairy products
on most of the dysmenorrhea-associated symptoms
was observed as symptom frequency was analyzed
against the number of daily servings of different dairy
products. Dysmenorrhea-associated symptoms like
sweating, abdominal bloating, loose stools, and dizziness were signicantly inuenced by a greater intake of
dairy products (three or four servings daily). On the
other hand, nausea and vomiting were not found to be
signicantly inuenced by increasing dietary intake of
dairy products (Table 2).

Table 1 Dysmenorrhea in relation to daily intake of dairy products

Parameter
Number(%) of female students who experienced
dysmenorrheic pain (total number = 111)
Number of female students who experienced no
dysmenorrheic pain (total number = 16)
Total number

Total number of dairy servings/day

2
3

36 (32.4)

26 (23.4)

26 (23.4)

11 (9.9)*

1 (6.3)

3 (18.7)

7 (43.8)

4 (25)

37

29

33

15

4
12 (10.8)**
1 (6.3)
13

There was signicant reduction in dysmenorrheic pain in participants who consumed three daily servings (*P-value = 0.000) or four daily
servings (**P-value = 0.000) of dairy products compared to participants who consumed none.

Figure 4 The relationship between

daily intake of dairy servings
and pain severity. P = 0.028.
P = 0.002. , mild; , severe; ,
very severe.

380

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Journal compilation 2010 Japan Society of Obstetrics and Gynecology

Dysmenorrhea and dairy products

Table 2 The association between intake of daily dairy servings and dysmenorrhea-associated symptoms
Symptom

Nausea and vomiting

Sweating
Abdominal bloating
Loose stools
Dizziness
Others

0
n (%)

1
n (%)

7
13
32
17
17
7

5
10
24
16
9
5

(26.92)
(35.14)
(32.32)
(34.00)
(37.78)
(26.92)

(19.23)
(27.03)
(24.24)
(32.00)
(20.00)
(19.23)

Total number of daily servings

2
3
n (%)
n (%)
8
8
23
12
11
7

(30.77)
(21.62)
(23.23)
(24.00)
(24.44)
(26.92)

3
4
10
4
3
2

(11.54)
(10.81)*
(10.10)**
(8.00)***
(6.67)****
(7.69)

4
n (%)
3
2
10
1
5
5

(11.54)
(5.41)
(10.10)
(2.00)
(11.11)
(19.23)

*P-value = 0.009; **P-value = 0.000; ***P-value = 0.001; ****P-value = 0.000. A signicant reduction in dysmenorrhea-associated symptoms was
found in participants who consumed three daily servings of dairy products compared with participants who consumed no daily servings of
dairy products. n, number of students experiencing the symptom.

Discussion
The prevalence of dysmenorrhea is difcult to determine because of different denitions of the condition.
However, dysmenorrhea seems to be the most common
gynecological condition in women regardless of age
and nationality. It is estimated that the prevalence of
dysmenorrhea varies from 45% to 95%.2225 The results of
this study conrm that dysmenorrhea is common in
young women as 87.4% of our sample experienced
dysmenorrhea. Besides pain, abdominal bloating, loose
stools, dizziness, sweating, nausea, and vomiting were
common symptoms associated with dysmenorrhea in
the sample investigated. These ndings are in agreement with other studies from different parts of the
world.2426 In agreement with our results, a study of 664
female students in secondary schools in urban and rural
areas in Egypt showed that 75% of the students experienced dysmenorrhea, and that fatigue, headache, backache, and dizziness were the commonest associated
symptoms.25
Current understanding of the pathogenesis in
primary dysmenorrhea implicates excessive imbalanced amounts of prostanoids and possibly eicosanoids
released from the endometrium.27 The uterus is induced
to contract frequently and dysrhythmically, with
increased basal tone and increased active pressure.3
Eventually, uterine hypercontractility, reduced uterine
blood ow, and increased peripheral nerve hypersensitivity induce pain.27 Thus, the level of prostaglandins
can be reduced to below normal with NSAIDs, which
are considered an effective treatment. Unfortunately,
little attention is usually given to a womans dietary
history with respect to her gynecological complaints.
Interestingly, our study appears to elucidate the relationship between dietary intake of dairy products and
the risk of dysmenorrhea. Participating female students

who consumed three or four diary servings per day

showed a signicantly lower risk of dysmenorrhea.
The preliminary ndings of this research suggest a
possible positive role for calcium in the management of
primary dysmenorrhea, as more than 70% of dietary
calcium comes from dairy products28 and participating
female students who had consumed no dairy products
had dysmenorrhea more frequently than those who
consumed one or three servings of dairy products daily.
This nding supports the previous suggestions of
Penland and Johnson29 that dietary calcium intake provides a protective effect against menstrual pain. In contrast Di Cintio et al.30 reported little positive association
between cheese and egg intake and dysmenorrhea.
With respect to the association between dysmenorrheic pain and associated symptoms and daily intake
of dairy products, our results revealed no signicant
difference in the prevalence of dysmenorrheal pain
between participants taking one or two and three or four
dairy servings per day. Such a nding is expected and
attributed to a difference of calcium content in similar
dairy products. In view of that, sheeps milk is richer in
calcium than cows milk (473 and 276mg/cup, respectively).31 On the contrary, pasteurized white cheese
made from sheeps milk supplies a smaller amount
of calcium than that made from cows milk (140 and
162 mg/oz, respectively) because sheeps milk yields
1825% cheese while cows milk yields 910% cheese as
a result of different solid content among different
milks.32 Labanah supplies the lowest amount of calcium
per serving, 101mg/oz (company nutritional fact).
Dairy products made from sheeps milk as well as cows
milk are widely consumed in the Middle East.
The mechanism by which calcium reduces the risk of
dysmenorrhea is unknown. Nevertheless we believe
that calcium could play a role in reducing dysmenorrheic pain through controlling neuromuscular activity.

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381

K. K. Abdul-Razzak et al.

Conversely, a reduction in calcium concentration

may increase neuromuscular excitability, resulting in
increased spasms and muscular contractions.29 In addition, adequate calcium intake leads to considerable
health benets including reduction of the risk of
osteoporosis, as most of the worlds population does
not satisfy their calcium needs28 and in adults >19 years
of age, three dairy servings per day are recommended.33
Recently, evidence has demonstrated the efcacy of
calcium in the treatment of premenstrual syndrome
(PMS). Clinical trials showed that calcium supplementation can alleviate mood and somatic symptoms associated with PMS.34 In addition, a casecontrol study
conducted by Bertone-Johson and colleagues demonstrated that a high intake of calcium and vitamin D may
reduce the risk of PMS.35 An interesting nding in our
study is that 36.6% of participants experienced symptoms of dysmenorrhea 12 days prior to the onset of
menses. Such a nding may suggest that those students may suffer from PMS also, which is expected to
be signicantly alleviated by calcium therapy.

Conclusion
The results of this study suggest that dietary calcium
may have a functional role in future management of
dysmenorrheal pain and may be considered a promising nutritional therapy for the relief of pain and symptoms associated with dysmenorrhea. However, large,
prospective, and controlled studies will be necessary to
establish the ndings of this study.

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