Abstract
Background:
Primary dysmenorrhea is a prevalent condition characterized by menstrual pain in the absence of pelvic pathology, which can affect quality of life (QOL).Objectives:
This study aimed to assess the QOL in medical students with dysmenorrhea in Iran.Methods:
This cross-sectional study included 298 female students between December 2021 and August 2022. The EQ-5D-3L questionnaire was used to assess the QOL of subjects. Also, age, weight, height, sleep hours per day, and exercise hours per week were evaluated. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 22. The chi-squared test and Fisher’s exact test were used for data analysis.Results:
The mean age of students was 20.32 ± 3.19 years, and the prevalence of dysmenorrhea was 83.6% (n = 249). There was a significant difference in daily activity (P < 0.05) and exercise hours per week (P < 0.05) between the two groups. Pain and discomfort were remarkably higher in group with dysmenorrhea (P < 0.01). In addition, personal care was significantly reduced among subjects with dysmenorrhea (P < 0.05). Sleep hours per day, body mass index (BMI), age, mobility, and anxiety were similar between the two groups.Conclusions:
According to our results, dysmenorrhea was significantly related to impaired QOL, considering some aspects such as daily activity.Keywords
1. Background
Primary dysmenorrhea is a common gynecological problem among women of reproductive age. It is defined as recurrent menstrual cramps of uterine origin without obvious medical pathology, causing physical, mental, and social changes such as mood swings and socioeconomic changes. It can also cause considerable restrictions on all activities (1, 2). Dysmenorrhea affects between 45 - 95% of women with menstrual periods (3). In severe cases, it can cause absence from school, which happens among 14 - 51% of students (4). Pain is one of the most important influencing factors on lower quality of life (QOL) (5). QOL is defined as an individual’s perception of life from different aspects and is regarded as a daily routine challenge (6, 7). Researchers have shown a decline in health-related QOL in women with dysmenorrhea (8).
2. Objectives
This study aimed to assess QOL in medical students with dysmenorrhea.
3. Methods
The present cross-sectional survey included 298 female medical students in Shohada Tajrish hospital affiliated to Shahid Beheshti University of Medical Sciences, Tehran, Iran between December 2021 and August 2022. Out of 315 participants, 17 students were excluded due to not meeting inclusion criteria, and 298 subjects were enrolled in the study. The inclusion criteria were female medical students aged at least 18 years old. Exclusion criteria were psychological disorders, chronic pain in other organs, irregular menses, cancer, and known cases of endometriosis or amenorrhea.
All participants signed the informed consent documents. The survey was distributed online using the Google platform to fill out the EQ-5D-3L questionnaires. The reliability and validity of the Persian version of this questionnaire were evaluated by Dastourani et al. (9). EQ-5D-3L scale as a useful tool for measuring health-related QOL consists of five dimensions: mobility, self-care, daily activity, pain or discomfort, and anxiety or depression (10). Each item is scored based on a three-point scale (never = 0, sometimes = 1, and always = 2). Data including age, weight, height, sleep hours per day, and exercise hours per week were also evaluated. The study protocol was approved by the ethics committee of the Functional Neurosurgery Research Center (FNRC) at Shohada Tajrish Hospital. The data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 22 (IBM Inc.). P-value < 0.05 was regarded statistically significant.
4. Results
Out of a total of 315 medical students, we included 298 individuals with a mean age of 20.32 ± 3.19 years and BMI of 21.65 ± 3.22 kg/m2. The prevalence of dysmenorrhea among students was 83.6% (n = 249), while only 16.4% of them reported no menstrual pain. The lifestyle variables of groups with/without dysmenorrhea were demonstrated in Table 1. EQ dimensions were presented in Table 2. There was a statistically significant difference between the two groups considering exercise hours per week (P = 0.049) and daily activities (P = 0.001). Students with dysmenorrhea experienced significantly higher pain and discomfort (P = 0.001). Also, personal care was reduced among subjects with dysmenorrhea (P = 0.04). Sleep hours per day, BMI, age, mobility, and anxiety were similar between the two groups. Regarding the self-perception scores of EuroQol, the mean score of the study samples was 75.33 ± 11.20 with a minimum of 18 and a maximum of 100.
Lifestyle Variables of Groups with/without Dysmenorrhea a
| Lifestyle Variables | Dysmenorrhea | No Dysmenorrhea | P-Value |
|---|---|---|---|
| Age | 20.70 ± 2.25 | 20.16 ± 3.20 | 0.281 |
| BMI | 20.23 ± 3.19 | 19.99 ± 3.38 | 0.163 |
| Hours of sleep/day | 8.23 ± 1.05 | 8.17 ± 1.20 | 0.315 |
| Hours of exercise/week | 1.52 ± 1.07 | 3.57 ± 0.60 | 0.049 |
Percentage of Women with/Without Dysmenorrhea Who Presented Problems in One of the EuroQol Dimensions
| EQ dimensions | Dysmenorrhea, % | No Dysmenorrhea, % | P-Value |
|---|---|---|---|
| Mobility | 0.634 | ||
| No problem | 91.5 | 94.2 | |
| Problem | 8.4 | 5.8 | |
| Personal care | 0.042 | ||
| No problem | 89.6 | 98.7 | |
| Problem | 10.4 | 1.3 | |
| Daily activities | 0.001 | ||
| No problem | 74.5 | 94.1 | |
| Problem | 25.5 | 5.9 | |
| Pain/discomfort | 0.001 | ||
| No problem | 61.8 | 92.7 | |
| Problem | 38.2 | 7.3 | |
| Anxiety/depression | 0.297 | ||
| No problem | 91.5 | 90.5 | |
| Problem | 8.5 | 9.5 |
5. Discussion
In the present study, dysmenorrhea was found to be a prevalent gynecological pain amongst medical students with 249 (83%) affected individuals; however, other studies estimated its prevalence in the world at 50 - 90% (11, 12). This result was in line with other studies that reported the prevalence of dysmenorrhea by 75 - 85% (13-15). In a meta-analysis study, Omani Samani et al. reported that prevalence of menstrual disorders in Iran was 73.27% (16). This dispersion in prevalence can be explained by the difference in the age of the participants in the study, the assessment methods of dysmenorrhea, or even a different definition of dysmenorrhea. Some studies showed that with increasing age, disorders related to dysmenorrhea decreased (17-19). This study showed that the hours of physical activity per week in the group without dysmenorrhea was significantly higher than those who experienced dysmenorrhea. In line with our study, Joshi et al. reported that dysmenorrhea had a negative impact on QOL; however, they found no association between exercise and dysmenorrhea (14). A clinical trial by Kannan et al. reported that physical activity significantly reduced pain associated with dysmenorrhea, even though it had no effect on the occurrence of pain (2). A meta-analysis study indicated that exercise and physical activity reduced the intensity of pain and other symptoms related to menstruation (20). Ortiz stated that probably 50 minutes of exercise three times a week could have positive effects in reducing menstrual pain (1, 11). Another study reported that home exercise could lead to a significant improvement in the QOL related to health and pain in patients with dysmenorrhea (21). In general, studies have stated the positive effects of exercise on improving the QOL during menstruation period. The findings of this study indicated that dysmenorrhea can significantly reduce daily activity. In line with this study, Joshi et al. showed that people with dysmenorrhea experience three times more chance of reducing daily activities than people without dysmenorrhea (14). In the study by Sima et al. which was conducted on medical students, people with dysmenorrhea had less energy for their physical activities, and its amount depended on the severity of dysmenorrhea symptoms (15). Another study indicated that moderate and severe dysmenorrhea had a negative impact on school and daily activities (22). In addition, more than 60% of women with dysmenorrhea reported its effects on their daily activities, including attending the classroom (23). In the study by Rostami, dysmenorrhea decreased daily activity and school attendance, and it did not even improve by using painkillers (24). The study by Rakhshaee reported that severe dysmenorrhea led to increased absence from the university and limited the social and daily activities of the individuals (25). The results of numerous studies showed that the severity of dysmenorrhea could affect the QOL of people, such as presence in the society and daily activities. Regarding the indicators of QOL, there was no significant correlation between anxiety and depression and QOL in dysmenorrhea; a similar study also approved this issue (13). Also, a study conducted on 376 medical students found no association between stress and dysmenorrhea (26). In a study conducted on girls aged 12 - 18, the results indicated that dysmenorrhea could increase anxiety and depression, while the degree of depression had no effect on dysmenorrhea (4). In another study, Onur et al. reported that dysmenorrhea increased feelings of pain and stress and also affected communication with family and friends (21). In a systematic review, it was shown that women during menstruation experience a poor mental state compared to the follicular phase (painless period), or people with dysmenorrhea (3, 27, 28). In addition, there was a high correlation between depression and anxiety with menstrual pain (3, 29, 30). The different results in the studies can result from the other factors that affect mental health, including the socioeconomic status of the subjects or the dietary pattern that can affect inflammatory factors and oxidative stress. Pain and discomfort in dysmenorrhea have been stated as one of the influencing factors in the QOL of people during menstruation, which can affect various dimensions of a person's life, including social activity and physical activity (3, 31-33).
The present study showed that people with dysmenorrhea experience significantly higher pain and discomfort. In line with our study, Fernandez-Martinez et al. found that pain and discomfort levels were higher in people with dysmenorrhea (13). In the study by Fernandez et al., the results showed that severe pain was more common in younger women (12). Also, another study showed that moderate to severe pain was significantly higher in people with dysmenorrhea (19). Mohapatra et al. showed that people with a lower BMI experienced higher levels of dysmenorrhea pain (34). In the present survey, BMI was similar among participants. However, a longitudinal study in Australia demonstrated that underweight and obese women were at higher risk for dysmenorrhea (35). This inconsistency is because most of the participants in our survey had a normal BMI. The results indicated that the intensity of pain in dysmenorrhea is different, and it is related to the conditions of people. This study also showed that personal care significantly reduced in people with dysmenorrhea. However, in the study by Bavil et al., that there was no difference between the self-care of people with dysmenorrhea and without dysmenorrhea (36). Also, the study by Fernandez-Martinez et al. did not observe any difference between these two groups (13).
5.1. Conclusions
This study was conducted on medical students. Therefore, due to the cross-sectional study design, the causality between QOL and dysmenorrhea is ambiguous. Since our study sample was limited to medical students, the study population cannot represent the whole society. In addition, we collected data through self-report, which is based on the individual's perception of pain. Also, we did not consider marital status, socioeconomic status, and cigarette or alcohol consumption, which can be confounding factors and influence QOL. Also, we did not calculate the minimum sample size. There is a relatively small sample size in groups without dysmenorrhea. In conclusion, further studies with higher sample sizes are recommended.
References
-
1.
Tsonis O, Gkrozou F, Barmpalia Z, Makopoulou A, Siafaka V. Integrating Lifestyle Focused Approaches into the Management of Primary Dysmenorrhea: Impact on Quality of Life. Int J Womens Health. 2021;13:327-36. [PubMed ID: 33762855]. [PubMed Central ID: PMC7982556]. https://doi.org/10.2147/IJWH.S264023.
-
2.
Kannan P, Chapple CM, Miller D, Claydon-Mueller L, Baxter GD. Effectiveness of a treadmill-based aerobic exercise intervention on pain, daily functioning, and quality of life in women with primary dysmenorrhea: A randomized controlled trial. Contemp Clin Trials. 2019;81:80-6. [PubMed ID: 31071464]. https://doi.org/10.1016/j.cct.2019.05.004.
-
3.
Iacovides S, Avidon I, Baker FC. What we know about primary dysmenorrhea today: a critical review. Hum Reprod Update. 2015;21(6):762-78. [PubMed ID: 26346058]. https://doi.org/10.1093/humupd/dmv039.
-
4.
Sahin N, Kasap B, Kirli U, Yeniceri N, Topal Y. Assessment of anxiety-depression levels and perceptions of quality of life in adolescents with dysmenorrhea. Reprod Health. 2018;15(1):1-7. [PubMed ID: 29373981]. [PubMed Central ID: PMC5787268]. https://doi.org/10.1186/s12978-018-0453-3.
-
5.
Nouri B, Roshandel S. Is Artificial Intelligence a New Diagnostic Approach for Patients with Endometriosis? Inter Pain Med Neuromod. 2022;2(1). https://doi.org/10.5812/ipmn-128720.
-
6.
Sarbazi F, Akbari E, Nouri B. Pain Management in Endometriosis. Inter Pain Med Neuromod. 2022;2(1). https://doi.org/10.5812/ipmn-128043.
-
7.
Alimohammadzadeh K, Akhlaghdoust M, Bahrainian SA, Mirzaei A. Survey on Mental Health of Iranian Medical Students: A Cross- sectional Study in Islamic Azad University. Shiraz E-Med J. 2017;18(7). https://doi.org/10.5812/semj.14929.
-
8.
Kapadi R, Elander J. Pain coping, pain acceptance and analgesic use as predictors of health-related quality of life among women with primary dysmenorrhea. Eur J Obstet Gynecol Reprod Biol. 2020;246:40-4. [PubMed ID: 31931396]. https://doi.org/10.1016/j.ejogrb.2019.12.032.
-
9.
Dastourani A, Mansour Sohani S, Shah Ali S. [Reliability and validity of the Persian version of the european quality of life questionnaire (EQ-5D-3L) in patients with meniscus and knee ligaments injury]. J Paramed Sci Rehabili. 2018;7(4):73-82. Persian.
-
10.
Reenen M, Oppe M. EQ-5D-3L User Guide: Basic information on how to use the EQ-5D-3L instrument (Version 5.1). EuroQol Research Foundation; 2019.
-
11.
Ortiz MI, Cortes-Marquez SK, Romero-Quezada LC, Murguia-Canovas G, Jaramillo-Diaz AP. Effect of a physiotherapy program in women with primary dysmenorrhea. Eur J Obstet Gynecol Reprod Biol. 2015;194:24-9. [PubMed ID: 26319652]. https://doi.org/10.1016/j.ejogrb.2015.08.008.
-
12.
Fernandez H, Barea A, Chanavaz-Lacheray I. Prevalence, intensity, impact on quality of life and insights of dysmenorrhea among French women: A cross-sectional web survey. J Gynecol Obstet Hum Reprod. 2020:101889. [PubMed ID: 32781307]. https://doi.org/10.1016/j.jogoh.2020.101889.
-
13.
Fernandez-Martinez E, Onieva-Zafra MD, Parra-Fernandez ML. The Impact of Dysmenorrhea on Quality of Life Among Spanish Female University Students. Int J Environ Res Public Health. 2019;16(5). [PubMed ID: 30818861]. [PubMed Central ID: PMC6427338]. https://doi.org/10.3390/ijerph16050713.
-
14.
Joshi T, Kural M, Agrawal D, Noor N, Patil A. Primary dysmenorrhea and its effect on quality of life in young girls. Int J Med Sci Public Health. 2015;4(3):381. https://doi.org/10.5455/ijmsph.2015.0711201472.
-
15.
Sima RM, Sulea M, Radosa JC, Findeklee S, Hamoud BH, Popescu M, et al. The Prevalence, Management and Impact of Dysmenorrhea on Medical Students' Lives-A Multicenter Study. Healthcare (Basel). 2022;10(1). [PubMed ID: 35052320]. [PubMed Central ID: PMC8775858]. https://doi.org/10.3390/healthcare10010157.
-
16.
Omani Samani R, Almasi Hashiani A, Razavi M, Vesali S, Rezaeinejad M, Maroufizadeh S, et al. The prevalence of menstrual disorders in Iran: A systematic review and meta-analysis. Int J Reprod Biomed. 2018;16(11):665-78. [PubMed ID: 30775681]. [PubMed Central ID: PMC6350848].
-
17.
Chayachinda C, Rattanachaiyanont M, Phattharayuttawat S, Kooptiwoot S. Premenstrual syndrome in Thai nurses. J Psychosom Obstet Gynaecol. 2008;29(3):203-9. [PubMed ID: 18608818]. https://doi.org/10.1080/01674820801970306.
-
18.
Osman HA, El-Houfey AA. Prevalence of Dysmenorrhea and its Impact on Quality of Life among Nursing Students at Assuit University, Egypt. Int J Nurs Didact. 2016;6(2):23-9. https://doi.org/10.15520/ijnd.2016.vol6.iss2.136.23-29.
-
19.
Emem E, Hassan H. Correlation between quality of life and dysmenorrhea among nursing schools students. Int J Nurs Sci. 2017;7(6):123-32.
-
20.
Abaraogu UO. Effectiveness of exercise therapy on pain and quality of life of patients with primary dysmenorrhea: a systematic review with meta-analysis. Turk Fiz Tıp Rehabil Derg. 2016;62(4):346-54. https://doi.org/10.5606/tftrd.2016.95580.
-
21.
Onur O, Gumus I, Derbent A, Kaygusuz I, Simavli S, Urun E, et al. Impact of home-based exercise on quality of life of women with primary dysmenorrhoea. S Afr J Obstet Gynaecol. 2012;18(1):15-8.
-
22.
Tanmahasamut P, Chawengsettakul S. Dysmenorrhea in Siriraj medical students; prevalence, quality of life, and knowledge of management. J Med Assoc Thai. 2012;95(9):1115-21. [PubMed ID: 23140026].
-
23.
Safari S, Zali A, Akhlaghdoust M, Pezeshgi P. Iran’s Scientific Publications on Neuromodulation. Inter Pain Med Neuromod. 2021;1(1). https://doi.org/10.5812/ipmn.115244.
-
24.
Rostami M. The study of dysmenorrhea in high school girls. Pak J Med Sci. 2007;23(6):928.
-
25.
Rakhshaee Z. A Cross-sectional Study of Primary Dysmenorrhea among Students at a University: Prevalence, Impact and of Associated Symptoms. Ann Res Rev Biol. 2014;4(18):2815-22. https://doi.org/10.9734/arrb/2014/9646.
-
26.
Hashim RT, Alkhalifah SS, Alsalman AA, Alfaris DM, Alhussaini MA, Qasim RS, et al. Prevalence of primary dysmenorrhea and its effect on the quality of life amongst female medical students at King Saud University, Riyadh, Saudi Arabia. A cross-sectional study. Saudi Med J. 2020;41(3):283-9. [PubMed ID: 32114601]. [PubMed Central ID: PMC7841556]. https://doi.org/10.15537/smj.2020.3.24988.
-
27.
Iacovides S, Avidon I, Bentley A, Baker FC. Diclofenac potassium restores objective and subjective measures of sleep quality in women with primary dysmenorrhea. Sleep. 2009;32(8):1019-26. [PubMed ID: 19725253]. [PubMed Central ID: PMC2717192]. https://doi.org/10.1093/sleep/32.8.1019.
-
28.
Iacovides S, Baker FC, Avidon I, Bentley A. Women with dysmenorrhea are hypersensitive to experimental deep muscle pain across the menstrual cycle. J Pain. 2013;14(10):1066-76. [PubMed ID: 23769507]. https://doi.org/10.1016/j.jpain.2013.04.010.
-
29.
Shaterian N, Soltani A, Samieefar N, Akhlaghdoust M. Artificial Intelligence and Migraine: Insights and Applications. Inter Pain Med Neuromod. 2022;2(1). https://doi.org/10.5812/ipmn-127675.
-
30.
Nikfar B, Moazzami B, Chaichian S, Ghalichi L, Ekhlasi-Hundrieser M, Chashmyazdan M, et al. Sleep Quality and its Main Determinants Among Staff in a Persian Private Hospital. Arch Iran Med. 2018;21(11):524-9. [PubMed ID: 30551693].
-
31.
Pitangui AC, Gomes MR, Lima AS, Schwingel PA, Albuquerque AP, de Araujo RC. Menstruation disturbances: prevalence, characteristics, and effects on the activities of daily living among adolescent girls from Brazil. J Pediatr Adolesc Gynecol. 2013;26(3):148-52. [PubMed ID: 23507005]. https://doi.org/10.1016/j.jpag.2012.12.001.
-
32.
Eryilmaz G, Ozdemir F, Pasinlioglu T. Dysmenorrhea prevalence among adolescents in eastern Turkey: its effects on school performance and relationships with family and friends. J Pediatr Adolesc Gynecol. 2010;23(5):267-72. [PubMed ID: 20493741]. https://doi.org/10.1016/j.jpag.2010.02.009.
-
33.
Wong LP, Khoo EM. Dysmenorrhea in a multiethnic population of adolescent Asian girls. Int J Gynaecol Obstet. 2010;108(2):139-42. [PubMed ID: 19944416]. https://doi.org/10.1016/j.ijgo.2009.09.018.
-
34.
Mohapatra D, Mishra T, Behera M, Panda P. A study of relation between body mass index and dysmenorrhea and its impact on daily activities of medical students. Asian J Pharm Clin Res. 2016;9(3):297-9. https://doi.org/10.22159/ajpcr.2016.v9s3.14753.
-
35.
Ju H, Jones M, Mishra GD. A U-Shaped Relationship between Body Mass Index and Dysmenorrhea: A Longitudinal Study. PLoS One. 2015;10(7). e0134187. [PubMed ID: 26218569]. [PubMed Central ID: PMC4517870]. https://doi.org/10.1371/journal.pone.0134187.
-
36.
Bavil DA, Dolatian M, Mahmoodi Z, Baghban AA. Comparison of lifestyles of young women with and without primary dysmenorrhea. Electron Physician. 2016;8(3):2107-14. [PubMed ID: 27123219]. [PubMed Central ID: PMC4844476]. https://doi.org/10.19082/2107.