An observational population based study on dysmenorrhea and its risk factors
An observational population based study on dysmenorrhea and its risk factors
TANG. 2015. Aug, 5(3): 18-18
Copyright © 2015, Association of Humanitas Medicine
This is an open access article under the CC BY-NC license. (
  • Received : January 17, 2015
  • Accepted : August 06, 2015
  • Published : August 31, 2015
Export by style
Cited by
About the Authors
Tabassum Kotagasti
Reader, Dept. of Ilmul Qabalat wa Amraze Niswan (OBG), National Institute of Unani Medicine, Bangalore
Nishad Rias
P.G Scholar, Dept. of OBG, NIUM, Bangalore, India

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.
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
- Method of collection of data
By history.
- Inclusion criteria
All married women complaining of pain abdomen during menstruation.
- Exclusion criteria
Menopausal women.
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 )
Age wise distribution of patients.
PPT Slide
Lager Image
n = 230
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.
Age of Menarche.
PPT Slide
Lager Image
n = 230
- 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 ).
Duration of menstrual cycle.
PPT Slide
Lager Image
n = 230
Duration of menstrual flow.
PPT Slide
Lager Image
n = 230
Amount of flow.
PPT Slide
Lager Image
n = 230
- 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 ).
Dysmenorrhea and parity.
PPT Slide
Lager Image
n = 230
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.
CONFLICT OF INTEREST There is no conflict of interest.
The author thankful to the hospital staff of NIUM for their support in data collection.
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 395 595 - 600
Andersch B , Milsom I 1982 An epidemiologic study of young women with dysmenorrhea Am J Obstet Gynecol 144 655 - 660
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 91 143 - 148    DOI : 10.1016/S0301-2115(99)00277-8
Banikarim C , Chacko MR , Kelder SH 2000 Prevalence and impact of dysmenorrhea on hispanic female adolescents Arch Pediatr Adolesc Med 154 1226 - 1229    DOI : 10.1001/archpedi.154.12.1226
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 16 349 - 352    DOI : 10.1163/1568569041798353
Derman O , Kanbur NÖ , Baltaci G , Akbayrak T , Tokur T 2004 The pain intensity level in adolescence with primary dysmenorrhea The Pain Clinic 16 349 - 352    DOI : 10.1163/1568569041798353
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 103 1134 - 1142    DOI : 10.1111/j.1471-0528.1996.tb09597.x
Ju H , Jones M , Mishra G 2014 The prevalence and risk factors of dysmenorrhea Epidemiol Rev 36 104 - 113    DOI : 10.1093/epirev/mxt009
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 69 484 - 488    DOI : 10.1016/S1726-4901(09)70313-2
Kaprio J , Rimpelä A , Winter T , Viken RJ , Rimpelä M , Rose RJ 1995 Common genetic influences on BMI and age at menarche Hum Biol 67 739 - 753
Kennedy S 1997 Primary dysmenorrhoea Lancet 349 1116 -    DOI : 10.1016/S0140-6736(05)63018-8
Klein JR , Litt IF 1981 Epidemiology of adolescent dysmenorrhea Pediatrics 68 661 - 664
Latthe P , Mignini L , Gray R , Hills R , Khan K 2006 Factors predisposing women to chronic pelvic pain: systematic review BMJ 332 749 - 755    DOI : 10.1136/bmj.38748.697465.55
Locke RJ , Warren MP 1999 Curbside consult: What is the effect of exercise on primary dysmenorrhea? West J Med 171 264 - 265
Loto OM , Adewumi TA , Adewuya AO 2008 Prevalence and correlates of dysmenorrhea among Nigerian college women Aust N Z J Obstet Gynaecol 48 442 - 444    DOI : 10.1111/j.1479-828X.2008.00869.x
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 26 243 - 249    DOI : 10.1080/030144699282741
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 21 323 - 327
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) 1 20 - 26
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 113 453 - 463    DOI : 10.1111/j.1471-0528.2006.00874.x
Pawlowski B 2004 Prevalence of menstrual pain relation to the reproductive life history of women from the Mayan Rural community Ann Hum Biol 31 1 - 8    DOI : 10.1080/03014460310001602072
Rosenwaks Z , Seegar-Jones G 1980 Menstrual pain: its origin and pathogenesis J Reprod Med 25 207 - 212
Skierska E , Leszczyńska-Bystrzanowska J , Gajewski AK 1996 Risk analysis of menstrual disorders in young women from urban population Przegl Epidemiol 50 467 - 474
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 87 2013 - 2017
Sterasam BI 1997 The Biology of Menstruation in Homo Sapiens: Total Lifetime Menses, Fecundity, and Nonsynchrony in a Natural-Fertility Population Current anthropology 38 123 - 129    DOI : 10.1086/204592
Sundell G , Milsom I , Andersch B 1990 Factors influencing the prevalence and severity of dysmenorhoea in youg women BJ of OBG 97 123 - 129
Tangchai K , Titapant V , Boriboonhirunsarn D 2004 Dysmenorrhea in Thai adolescents: prevalence, impact and knowledge of treatment J Med Assoc Thai 87 S69 - S73
Vink CW , Labots-Vogelesang SM , Lagro-Janssen AL 2006 Menstruation disorders more frequent in women with a history of sexual abuse Ned Tijdschr Geneeskd 150 1886 - 1890
Walraven G , Ekpo G , Coleman R , Scherf C , Morison L , Harlow SD 2002 Menstrual disorders in rural Gambia Stud Fam Plann 33 261 - 268    DOI : 10.1111/j.1728-4465.2002.00261.x
Weissman AM , Hartz AJ , Hansen MD , Johnson SR 2004 The natural history of primary dysmenorrhoea: a longitudinal study BJOG 111 345 - 352    DOI : 10.1111/j.1471-0528.2004.00090.x
Wong CL , Farquhar C , Roberts H , Proctor M 2009 Oral contraceptive pill for primary dysmenorrhoea Cochrane Database Syst Rev CD002120 7
Zukri SM , Naing L , Hamzah TNT , Hussain NHN 2009 Primary dysmenorrhea among medical and dental university students in Kelantan: prevalence and associated factors IMJ 16 93 - 99