Prevalence of Dysmenorrhea and its Correlates among the Rural Women of Andhra Pradesh, India

Table of contents

1. I. Introduction

ssessing menstrual characteristics is an indicator for women's reproductive biology (Harlow and Ephross 1995). Menstrual disorders include menstrual cycle irregularities (of duration or length), hyper-or hypomenorrhoea, poly or oligomenorrhoea, dysmenorrhoea, amenorrhoea, menorrhagia and premenstrual syndrome (Ray et Dysmenorrhea is considered to be the most common symptom of all menstrual complaints and poses a greater burden of disease than any other gynecological complaint (Patel et al. 2006;Sood et al. 2012). Dysmenorrhea or painful menstruation is defined as a severe, painful, cramping sensation in the lower abdomen that is often accompanied by other symptoms, such as sweating, headache, nausea, vomiting, diarrhea, and tremulousness, all occurring just before or during the menses (Lentz et al. 2012). The reported prevalence of dysmenorrhea of any severity varies between 16% and 91% in women of reproductive age. The lowest prevalence of 16% is reported in a random sample of Japanese women aged 17-51 years (Ohde et al. 2008). The highest prevalence of 91% is reported in a random sample of Iranian women aged 16-56 years (Tavallaee et al. 2011). George and Bhaduri (2002) found dysmenorrhea to be a common problem in India with prevalence of 87.7%. However, the true prevalence of dysmenorrhea among the Indian adult women is not yet established.

Prevalence studies have shown several factors that are associated with dysmenorrhea like age (Messing et al. 1993), smoking (Mishra et al. 2000), higher body mass index (Harlow and Park 1996), earlier age at menarche (Harlow and Park 1996), nulliparity (Sundell et al. 1990), longer and heavier menstrual flow (Harlow and Park 1996), family history of dysmenorrhea (Parveen et al. 2009) and usage of oral contraceptives (Juang et al. 2006) (Gordley et al. 2000). Other common factors, such as education (Chen et al. 2000), employment (Ng et al. 1992), alcohol consumption (Harlow and Park 1996), marital status (Messing et al. 1993), and physical activity (Harlow and Park 1996), show largely negative or inconclusive results. Thus it is important to understand whether, and to what extent the modifiable risk factors explain the variation in the prevalence of dysmenorrhea. Towards this end umpteen studies are available on adolescent sample in Indian populations (Deo and Ghattargi 2007;Agarwal and Agarwal 2008;Karthiga et al. 2011;Kural et al. 2015). Studies pertaining to the prevalence of dysmenorrhea and its risk factors among the Indian adult women are very limited (Khatri and Gupta 1978;Bang et al. 1989;Bhatia et al. 1997). India being multilingual and multiethnic there is a need to have data from each and every population segments to weigh the risk. In the light of this background, the present study has been undertaken to assess the prevalence of dysmenorrhea and its association with life style and socioeconomic conditions of free living rural adult women.

2. II. Materials and Methods

The present research work intends to study the menstrual characteristics and their association with other confounding factors among the rural women aged 20 to 40 years. The design of the study has been cross sectional in nature. A multistage random sampling technique is applied to draw the sample. There are three revenue divisions in Chittoor District. All the revenue divisions are taken into consideration. Each revenue division consists of 22 mandals of which two mandals are randomly selected from each division. In each mandal, 4 villages are randomly selected. In the selected villages 1155 houses have been enlisted. Door to door survey is carried out to recruit the sample. After administering the inclusion and exclusion criteria, 854 women are found fit and finally, 752 women have given consent to participate in the study. The participation rate is 86 percent. Pilot study has been conducted for befriending and for explaining the women participants about the purpose of the study. Data collection is done between Dec 2011 and Jan 2013. The exclusion criteria are women with lactation, women who have undergone surgical menopause and having gross abnormality. The study is approved by the Departmental Ethics Committee of Sri Venkateswara University, Tirupati. Electoral roles have been checked to ascertain the age of the participant to establish the correct age. Each person is interviewed privately at her residence and encouraged to disclose any other health related problems she may have faced in her life.

Standard social survey methods like structured interview schedule, and in-depth interviews have been used to collect the data. A schedule consisting of

3. E

Prevalence of Dysmenorrhea and its Correlates among the Rural Women of Andhra Pradesh, India multidimensional questions on individual's demo-graphics, like age, age at menarche, age at marriage, life styles, fertility, education, occupation and income are procured. Information about women's perception on their own health problems, menstrual hygiene, menstrual problems, regularity of the cycle, use of hormonal contraceptives, bowel habit and prevalence of reproductive tract infections and sexual transmitted diseases (RTI/STDs) have been collected. The prevalence of self reported non-communicable diseases is recorded. Regarding the birth control measures, 83 percent of the women have undergone tubectomy. In the remaining sample, no participant is found practicing temporary birth control measures. Hence, we have dropped the variable for further statistical analysis to see its effect on menstrual problems.

Educational level of the participants and their family income are recorded through their public distribution cards. Physical activity is assessed based on subjects occupational and leisure time activities (Singh et al. 1997). Participants are requested to recall their first experience of menstrual bleeding to ascertain the age at menarche. Information about age at marriage, first and last pregnancies, and number of pregnancies has been gathered. Menstrual cycle length is defined as the gap between first day of one bleeding episode to previous day of next bleeding episode. Duration of menstrual flow is defined as the number of days from first bleeding initiation to last bleeding. Further, different problems related to menstruation are enquired. Since the sample is from rural background, there would be ample possibility that women might have used materials other than sanitary napkin, which may have exerted adverse effect on menstrual health. To test this, women have been enquired regarding the usage of sanitary material during menstruation. Precautionary measures are taken to check the recall bias on self reported information provided by the subject.

Statistical analysis is carried out via SPSS 16.0 and alpha level is set at p < 0.05. Qualitative variables are provided with percentages. Chi square test has been applied to see the strength of association with independent variables. Age adjusted multivariate (binary) logistic regression model with forward conditional entry is employed in predicting the menstrual problems. The independent variables, entered are education, income, physical activity, self reported health, age at menarche (continuous variable), duration of menstrual flow, regularity of the cycle, material used during menstruation, history of RTI/STDs and bowel habits. In each step the variables are entered at 0.05 and removed at 0.10. This model consists of four steps with variables like self rated health, regularity of cycle, duration of menstrual flow, and age at menarche.

4. III. Results

In the present study, mean age of the women was 30.74±4.85 yrs. Data on socioeconomic status, life styles and self reported health status is shown in table I. Illiteracy is noticed to an extent of 16 percent. 11 percent of the women's income is below <24,000 INR and 52 percent of the women's income is in the range of 25,000-44,000 INR. Women with sedentary and heavy physical activity are 24 percent and 27 percent respectively. In the present study 60 percent of the women have opined that their self reported health status is good, while 38 percent have perceived that their self reported health as fair. Around 2 percent of the women have expressed poor health status. Table II depicts the data on demographic and menstrual characteristics. 66 percent of the women got married at below 20 years of age. Age at first conception is 31 percent among the women <20 yrs of age. In the study population, one fourth of the women have attained menarche <11 of age. Oligomenorrhea and hypermenorrhea are noticed to an extent of 12 percent and 9 percent respectively. During menstruation, 32 percent of the women have suffered from different menstrual problems. Primary dysmenorrhea (stomach ache and back ache, head ache, vomiting) is the predominant ailment suffered by 30 % of subjects. Menorrhagia is noticed to an extent of 2.1 percent. 43 percent of the women are said to be using domestic cloth as material during the menstruation, whereas 57 percent of the women have become acclimatized to use commercial pad. Data on RTI/STDs and bowel habits are shown in table III. RTI/STDs have been diagnosed in 19 percent of the women. Irregular bowel habits are noticed to an extent of 15 percent. Percentage frequencies and strength of association between menstrual problems and other confounding factors are shown in tables IV-VI. Subject's physical activity and educational level failed to show significant association with the presence of menstrual problems. The frequency of menstrual problems have found decreased when subject's income increases (P<0.001). Subjects self perception of poor self reported health status elevates the menstrual problems. It is also found that menstrual problems associated significantly with other problems such as hypermenorrhea (? 2 =14.84; P<0.00), oligomenorrhea (? 2 =31.47: P<0.00), RTI/STDs (? 2 =4.55: P<0.03), domestic cloth as material used during menstruation (? 2 =6.32: P<0.01) and irregular bowel habits (? 2 =9.97: P<0.02). Results of the binary logistic regression are presented in table VII. The results show that the chances of having menstrual problems are 2.986 times higher among the women with fair self rated health. The risk of menstrual problems is 4.689 when subjects self perception of health status as poor. The odds of menstrual problems are 3.472 among the women with oligomenorrhea (95%CI: 2.154-5.599). Women with hypermorrhea are thrice at risk towards menstrual problems (95% CI: 1.881-5.728). Women attaining the menarche at 14-15 years show odds of 0.763. In other words attaining early menarche (<11 years) are 1.31 times (1/0.763) higher chances of developing dysmenorrhea.

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8. IV. Discussion

Menstrual disorders represent an important area of unmet need for reproductive health services for women in developing countries. Dysmenorrhea is one of the most common complaints and gynecological problems among worldwide women (George and Bhaduri 2002;Harel 2006;Agarwal and Agarwal 2010). WHO systematic review assessed the geographical distribution of chronic pelvic pain and indicated that the rate of dysmenorrhea was 16 to 81 percent (Latthe et al. 2006). Harlow and Campbell (2004) reviewed the studies in developing countries and indicated that the prevalence of dysmenorrhea is in between 15 to 68 percent among the adult women. On the other hand, studies from the developed countries have reported a range of 60 to 73 percent (Unsal et al. 2010). Studies among the Indian adolescents reveal a high of 67.2 (Sharma et al. 2008) and 84.2 percent respectively (Kural et al. 2015). The results of the present study are in agreement with the above studies that dysmenorrhea is common complaints among the adults which may have negative impact on health related qualify of life. The variation in the prevalence rates across the population groups may be due to ethnic, socio-cultural and life style factors (Al-Kindi and Al-Bulushi 2011).

Prospective studies have observed a significant decrease in the prevalence of dysmenorrhea with increasing age (Aykut et al. 2007). Patel et al (2006) in their study observed a higher prevalence of dysmenorrhea in early adult part of life and decreases with advancement of age. An examination of the results of this study also demonstrates an elevation of primary dysmenorrhea in <29 yrs age group and then the prevalence decreased with advancement of age, however the difference is statistically insignificant. Hence data was not reported and age was adjusted in the regression model to nullify its effects.

Reproductive health of women permeates with social, cultural and lifestyle significance (Marvan et al. 2003). A number of population based studies, investigated variations in menstrual function vis-à-vis menstrual problems and their correlates (Waller et al. 1998). Self-rating of health is the most frequently used tool to assess the health perceptions in epidemiological studies. Feeling fair/poor self rated health of the women in the present study are experiencing greater risk towards dysmenorrhea. Taperi and Rimpela (1989) study concluded that the experience of menstrual pain seems to be related to self rated health as a whole and to life styles rather than to specific disorders and health practices. Our results reiterate the importance of self rated health in assessing the risk towards a condition.

Socioeconomic and behavioral risk factors for dysmenorrhea have long been of interest because of possibility of effective intervention. Associations between dysmenorrhea and being overweight, physical activity, and alcohol consumption have been inconsistent (Klein and Litt 1981). In the present study, though the factors like income, physical activity, sanitary napkin, history of RTI/STD infections and bowel habits have independently shown significant association with dysmenorrhea, yet these effects have been nullified in the presence of other confounding factors. Ciccone et al ( 2010) study has clearly demonstrated that educating the subject on health and management will have greater impact in reducing the burden of risk. The outcome of the work warrants a strong partnership between the care manager and the subject and collaboration between the physician and the care manager in the health management.

Research reports have shown a significant association between early menarche and dysmenorrhea; the underlying reason could be the fact that subjects who attain menarche early have longer exposure to uterine prostaglandins leading to higher prevalence of dysmenorrhea (Shrotriya et al. 2012). A higher proportion of the women in the sample (37% vs 20%) attained menarche <11 of age exhibited 1.31 times risk towards dysmenorrhea when compared to 14-15 years. Our data is in best agreement with other studies where age at menarche is an important factor (Patel et al. 2006).

Oligomenorrhea seems to be one of the potential risk factors for dysmenorrhea in the present study. Different studies have suggested that dysmenorrhea is more prevalent in women with longer cycles (El-Gilany et al. 2005). Two studies proposed that the presence of heavy menses or irregular menses have associated with increased risk for dysmenorrhea, with odds of 1.9 each respectively (Patel et al. 2006; Unsal et al. 2010). The sample under the study exhibited an odds of 3.472 towards dysmenorrhea. No conclusion can be drawn to address this effect because of the limited number of studies. Further menstrual bleeding duration of >7 days is another important risk factor for dysmenorrhea. Subjects who have bleeding duration for more than 7 days have more chance of getting dysmenorrhea with odds of 3.283. This finding is compatible with the result showing that the risk of dysmenorrhea is higher in women with long menstrual flows (Unsal et al. 2010).

The potential limitations of our study are 1) Even though the questionnaire is standardized, certain practical problems like birth control measures and stressful events limit us in gaining the reliable data 2) Lack of data on diet and nutritional anthropometry which are expected to have significant effect on menstrual characteristics. Further, classification of the subjects based on the economic levels in rural settings of India is a laborious exercise, because the window between low and high income groups is narrow. Since the nature of data is self reporting, it may have resulted in under reporting of the conditions in few cases.

The findings of our study could be generalized and applied to all the rural women of India with similar socioeconomic and cultural background. In conclusion, it is inferred that a significant portion of the women in the present study are suffering from dysmenorrheal. The confounding factors for the promotion of the irregularities are self reported health, irregular menstrual cycle, duration of menstrual flow and age at menarche. Hence advocation of preventive strategies in the form of improving healthy life styles can be effective in correcting the menace.

9. V. Acknowledgements

Volume XVI Issue I Version I

Figure 1.
besides depression and stress A
Figure 2.
2011). Menstrual disorders have economic
consequences in terms of health care costs involving
expensive hormonal drugs and laboratory tests
(Rodrigues et al. 2011; Karout et al. 2012; Lentz et al.
2012).
Figure 3. Table I :
I
Variable Females (N=752)
n %
Education
Illiterate 118 15.7
Primary Education 290 38.6
Secondary Education 198 26.3
Higher Education 146 19.4
Family Income in INR
Low income (<24000) 81 10.8
Middle income (25000-44000) 391 52.0
High income (>45000) 280 37.2
Physical activity
Sedentary 179 23.8
Mild 250 33.2
Moderate 122 16.2
Heavy 201 26.7
Self reported health
Good 454 60.4
Fair 285 37.9
Poor 13 1.7
Figure 4. Table II :
II
Variable Females (N=752)
n %
Age at Marriage
< 20 yrs 496 66.0
20-23 yrs 215 28.6
24-27 yrs 28 3.7
>27 yrs 13 1.7
Age at first conception
<20 yrs 232 30.9
20-23yrs 466 62.0
24-26 yrs 18 2.4
>26 yrs 28 3.7
Age at menarche
< 11 yrs 183 24.3
12-13 yrs 438 58.2
14-15 yrs 131 17.4
Menstrual cycle
Normal (28-35 days) 662 88.0
Irregular [Oligomenorrhea (36-50 days)] 90 12.0
Duration of menstrual flow
3 days 21 2.8
4 days 190 25.3
5 days 475 63.2
>7 days (Hypermenorrhea) 66 8.8
Menstrual problems
Yes 240 31.9
No 512 68.1
Type of problem
Primary Dysmenorrhea (Stomach ache and 224 29.9
Back ache & Head ache and Vomitings)
Menorrhagia (heavy bleeding) 16 2.1
Material used during menstruation
Cloth 323 43.0
Pad 429 57.0
Figure 5. Table III :
III
Variable Females (N=752) n %
History of RTI / STD infections
Yes 142 18.9
No 610 81.1
Bowel habits
Regular 643 85.5
Irregular 109 14.5
Figure 6. Table IV :
IV
Variable Menstrual problems
N Yes No ?²-value P-value
n % n %
Education
Illiterate 118 48 40.7 70 59.3
Primary Secondary 290 198 93 58 32.1 29.3 197 140 67.9 70.7 5.78 0.122
Higher 146 41 28.1 105 71.9
Income in INR
Low income (<24000) 81 36 44.4 45 55.6
Middle income (25000-44000) 391 135 34.5 256 65.5 15.76 0.001
High income (>45000) 261 67 25.7 194 74.3
Physical activity
Sedentary 179 69 38.5 110 61.5
Mild Moderate 250 122 81 36 32.4 29.5 169 86 67.6 70.5 6.33 0.096
Heavy 201 54 26.9 147 73.1
Self reported health
Good 454 115 25.3 339 74.7
Fair 285 118 41.4 167 58.6 23.745 0.000
Poor 13 7 53.8 6 41.4
* p<0.05
Figure 7. Table V :
V
Menstrual problems
Variable N Yes No ?²-value P-value
n % n %
Duration of menstrual flow
Normal (< 6days) Hypermenorrhea (>7days) 686 66 205 35 29.9 53.0 481 31 70.1 47.0 14.84 0.000
Menstrual cycle
Regular Irregular 662 90 188 52 28.4 57.8 474 38 71.6 42.2 31.47 0.000
Material used during menstruation
Cloth Pad 323 429 119 121 36.8 28.2 204 308 63.2 71.8 6.32 0.012
* p<0.05
Figure 8. Table VI :
VI
Year 2016
Volume XVI Issue I Version I
D D D D )
(
Menstrual problems
Variable N n Yes % n No % ?²-value P-value
History of RTI/STD Infections
Yes No 142 610 56 184 39.4 30.2 86 426 60.6 69.8 4.55 0.033
Bowel habits
Regular Irregular 643 109 191 49 29.7 45.0 452 60 70.3 55.0 9.97 0.022
* p<0.05.
Note: E
Figure 9. Table VII :
VII
95% CI for OR
Variables ? S.E. Sig OR* Lower Upper
Self rated health
Good Ref.
Fair 0.992 0.175 0.000 2.696 1.914 3.797
Poor 1.545 0.592 0.009 4.689 1.471 14.949
Regularity of cycle 1.245 0.244 .000 3.472 2.154 5.599
Duration of Menstrual flow 1.189 0.284 0.000 3.283 1.881 5.728
Age at menarche -.271 0.079 0.001 0.763 0.653 0.891
Constant 1.868 0.972 0.055 6.478
Variable(s) entered on step 1: Self reported health
Variable(s) entered on step 2: Regularity of cycle
Variable(s) entered on step 3: Duration of Menstrual flow
Variable(s) entered on step 4: Age at menarche
* adjusted for age
OR= Odds ratio
The logistic regression model is Y= 1.868+ 0.992 (fair self reported health) + 1.545 (poor self reported health)
+1.245 (Regularity of cycle) + 1.189 (Duration of Menstrual flow) -.271 (Age at menarche). Where Y=Menstrual
problems.
1

Appendix A

Appendix A.1

The authors greatfully acknowledge the financial assistance provided by University Grants Commission, New Delhi under Centre for Advanced Studies-Phase-1 (F. No. F-6-6/2013(SAP-3). We express our gratitude to all the subjects who volunteered into the study and provided necessary information.

Appendix B

Appendix B.1 Author Contributions

Conceived and designed the study: KKR, TB, PG, KSNR. Data Collection: PG, TB, CP, RBS. Analyzed the data: PG, KKR. Wrote the paper: KKR, KSNR, PG

Appendix B.2 Conflict of Interest

None of the authors has a personal or financial conflict that has an interest in the subject of this Manuscript.

Appendix C

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Notes
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Date: 2016-01-15