Menstrual Disorder February 2020 Vol

Al-Qazaz & Al-Dabbagh (2020): Menstrual disorder February 2020 Vol. 23 Issue 4

Menstrual disorder: Cross-sectional study on prevalence and self-care practice among adolescents in Iraq

Harith Kh. Al-Qazaz1*, Raghad O. Al-Dabbagh, 1

1 Department of Clinical Pharmacy, College of Pharmacy, University of Mosul, 81011, Ninevah, Iraq.

*Corresponding Author: Dr. HarithKh. Al-Qazaz, PhD ([email protected])

Abstract Menstrual disorders are common among females, especially in their teen’s age. Little is known about the prevalence and management practice of menstrual disorder in Iraq. Finding prevalence and pattern of menstruation disorder as well as the self-care activities among adolescent girls in Mosul city, Iraq. A descriptive cross-sectional study was carried out among 385 single females in secondary schools in Mosul city with an age range of 14-18 years from October to December 2018. Ten randomly selected schools were invited via an official letter from the research group and only those agreed to be included were visited. A semi-structured questionnaire was prepared by the researchers and the questionnaire was systematically translated and validated to produce the Arabic version. The mean age was 16.11 years ± 0.787. The age of menarche of 77.9% of the participants was between 13–15 years. The prevalence of dysmenorrhea was 93.6% and the prevalence of premenstrual symptoms was 84.9% among the study sample. Mothers’ level of education, family size, the experience of PMS and regularity of the cycle were significantly associated with the history of having dysmenorrhea. In conclusion, the prevalence of menstrual disorders, including dysmenorrhea and PMS, among Iraqi adolescents was high and affect the social and academic performance and even low-grade scoring of the students. The study highlights the need for the menstrual educational systems in the schools, in addition to screening activities performed by health care providers from school health sectors in the directorates of health.

Key words: Adolescents, Dysmenorrhea, Premenstrual symptom, Prevalence

How to cite this article: Al-Qazaz HK, Al-Dabbagh RO(2020): Menstrual disorder: Cross-sectional study on prevalence and self-care practice among adolescents in Iraq, Ann Trop Med & Public Health; 23 (4): S500. DOI: http://doi.org/10.36295/ASRO.2020.23416

Introduction

Menstrual disorders are very common amongst females, in which pain and mood changes are the mostly occurred symptom during the periods. Approximately, 75% of all women affected by primary dysmenorrhea throughout their life especially in their teen’s age [1]. Primary dysmenorrhea is defined as “menstrual pain in the absence of any organic cause with the pain commonly starting within three years of menarche[2].Although the secondary form can occur at any time in a woman’s life between menarche and menopause, it most often happens after 25 years of age subsequent to a gynecological pathology such as endometriosis and ovarian cysts[3].Dysmenorrhea’s symptom range fromcrampy to colicky spasms of the lower abdomen, taking place within 8–72hr of menstruation.[3].Moreover, women may experience other symptoms likegastrointestinal (nausea, vomiting, diarrhea), headache or back pain.

The physiological increase in prostaglandins during the period plays a significant role in primary dysmenorrhea [4]. Prostaglandins, act by stimulating the contraction of uterine muscles to reduce the blood flow which is responsible for uterine hypoxia that induces painful cramping [4-5]. Other contributing factors for primary dysmenorrhea are the increased synthesis and secretion of vasopressin and oxytocin which lead to an increase in the production of PG and activate the type C pain fiber [4, 6]. Menstrual disorders are significantly associated with decreased quality of life [7-9] school non-attendance [5] reduction in sport and social actions, and sleeping problems [10].

Primary dysmenorrhea is guilty of a decrease in quality of life, [7-9] absence from work or school, decrease participation in sport and social activities [5] altered pain perception and sleeping problems [10]. In 2007, the International Association for the Study of Pain estimated that at each menstrual period, around 10% to 15% of ©Annals of Tropical Medicine & Public Health S500

dysmenorrheic women were unable to work for 24–27 days [8]. In the United States, dysmenorrhea causes an annual loss of nearly 140 million working hours [9]. In Japan, it was estimated that economic losses due to dysmenorrhea totaled $4.2 billion dollars annually [11]. In Iraq, little is known about the prevalence of menstrual disorders among this age group as well as how the adolescents practice during menstruation.

The main aim of the study is to find the prevalence and pattern of menstruation disorder as well as the self-care activity among adolescent girls in Mosul city, Iraq. The secondary aim is to explore the factors associated with the occurrence of premenstrual symptoms.

Materials and Method

Design, Participants and setting A descriptive cross-sectional study was carried out among single females in secondary schools in Mosul city with an age range of 14-18 years from October to December 2018. A non-probability convenient sampling method in each school was conducted. Ten randomly selected schools were invited via an official letter from the research group and only those agreed to be included were visited (3 privets and 2 governmental). The required sample size was 385as calculated by using an online Raosoft sample size calculator with a 95% confidence interval and a 5% marginal error (http://www.raosoft.com/samplesize.html). Inclusion criteria were females who had menstruation for at least two consecutive months between the ages of 14 – 18 years. Age below 14 years, married females, those who have a history of chronic diseases and those with irregular cycles were excluded.

The study was conducted after obtaining initial approval from the Scientific Committee of the Department of Clinical Pharmacy, College of the Pharmacy / University of Mosul. The approval from the Central Ethical Committee at the Mosul Directorate of Health was obtained to get the authorization of the study protocol. In addition to that, permission from Mosul directorate of Education / Department of Arrangements and Training /Division of Research and Educational Studies was obtained. Participation in the study was totally voluntary and consent form (written) was signed by all participants after the verbal explanation of the aim of the study.

A semi-structured questionnaire was prepared by the researchers after an extensive literature review. The questionnaire used in this study was amended from earlier studies in Australia and Erbil [12-13]. The final data collection form included socio-demographic data, menstrual data, clinical manifestation and self-management approaches to minimize the dysmenorrheal symptoms. Pain intensity was measured using a numerical rating scale (NRS) and categorized into three levels [14-15]. The questionnaire was prepared first in the English language. Translated version with cultural adaptation was used to prepare the final Arabic version according to international guidelines [16]. For validation assurance, repeatability, exploring the problems within the questionnaire, the data collection form was piloted among 30 females within the same age group from other settings using the snowball sampling method and the calculated Cronbach’s alpha value was 0.83. Those 30 participants were not included in the final analysis of data. During the data entry, 28 participants were excluded because of incomplete data collection forms. A sample of 357 participants was included in the final analysis of data.

The distribution of the participants among the schools was as follows; Al-Ferdaus Private Secondary School = 17, Al-Awael Private Secondary School = 96, Dar Al- Uloom Private Secondary School = 55, Mutamyz at Governmental Secondary School = 103 and Balqees Governmental Secondary School = 86. Data were properly coded by the researchers before entry to the statistical software.

All analyses wereconducted using SPSS software (version 19). Descriptive statistics were used to explore the basic socio-demographic and menstrual symptoms data. A Chi-square test was used to evaluate the association between menstrual symptom data and different factors evaluated by the study. A p-value of < 0.05 was considered significant.

Results

Only 357 participants’ data were included in the data analysis and the mean age was 16.11 (SD=0.787), and the BMI mean was 21.35 (SD=3.36). Table 1 shows the basic socio-demographic information of the study sample. Among the study participants, about half of the participant’s mothers had a university-level education (184, 51.5%) and 206 ©Annals of Tropical Medicine & Public Health S500

(57.7%) of participants has a family size between 6 – 8 members. More than three-quarters of the participants (278, 77.9%) started menstruation at the age of 13 – 15 years followed by the age of fewer than 13 years (53, 14.8%). The usual duration of the cycle of the participants was between 21 to 35 days including the bleeding days (249, 69.7%) and the bleeding duration was 5 – 7 days among 228 (63.9%). More than half of the participants (212, 59.4%) indicated that their menstruation cycle was regular. Out of the study participants, 334 (93.6%) suffered from dysmenorrheal pain during the days of menstruation and 303 (84.9%) indicated that they suffered from premenstrual symptoms.

Table 1: Demographic and gynecological characteristics of study participants

Variable N (%) Educational level for mother Non formal education 6 (1.7) Primary 51 (14.3) Secondary 116 (32.5) university 184 (51.5) Educational level for father Non formal education 1 (0.3) Primary 13 (3.6) Secondary 70 (19.6) University 273 (76.5) Monthly income Low 7 (2.0) Medium 266 (74.5) High 84 (23.5) Family size 3 – 5 140 (39.2) 6 – 8 206 (57.7) 9 and above 11 (3.1) Age of menarche 10- 12 53 (14.8) 13-15 278 (77.9) 16-18 26 (7.3) Menstrual cycle length (whole

days) 60 (16.8)

≤ 20 249 (69.7) 21-35 48 (13.4) > 35 Duration of menstrual bleeding 1-4 101 (28.3) 5-7 228 (63.9) >7 28 (7.8) Regularity of menstruation Yes 212 (59.4) No 145 (40.6) Did you suffer from

dysmenorrhoric pain 334 (93.6) Yes 23 (6.4) No Occurrence of premenstrual

symptoms 303 (84.9) Yes 54 (15.1) No

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With regards to dysmenorrheal pain and premenstrual symptoms, table 2 shows the distribution of participants’ responses in relation to their menstruation. Using the numerical rating scale to measure pain intensity, the mean ± SD of pain intensity was 5.36 ± 2.77 and there were 109 participants (30.5%) who indicated that the pain intensity was severe. Lower abdominal pain 156 (46.7%) and pain of all the body 99 (29.6%) were the most indicated pain locations by the study participants. More than half of the participants 184 (55.1%) indicated that their dysmenorrheal pain and PMS occurred frequently on every consecutive period and the first day of the period was mostly indicated as the peak of pain occurrence (145, 43.3%). The most commonly describedPMS were tiredness by 331 (99.1%), back pain 313 (93.7%), acne 285 (85.3%), and generalized aches 276 (82.6%). In addition to that, the most common described psychological symptoms were sleep disturbances by 302 (90.4%) and difficulty in performing homework and concentratingby 276 (82.6%) as shown in table 2.

Table 2: Characteristics of premenstrual and dysmenorrheal symptom (n=334)

Variable N (%) Pian intensity by NRS n=334 (mena ± SD = 5.36 ± 2.77) Mild (0 – 4) 78 (21.8) Moderate (5 – 6) 147 (41.2) Severe (7 – 10) 109 (30.5) Pain Location Lower abdomen 156 (46.7) Low back 55 (16.5) Sides of abdomen 24 (7.2) Pain at different locations 99 (29.6) Pain description Twisting 33 (9.9) Sharp 31 (9.3) Stinging 123 (36.8) Mix 147 (44.0) Frequency of occurrence pain More frequently (every periods) 184 (55.1) Less frequently (Once between two or more periods) 124 (37.1) Rarely(Once in 6 months) 26 (7.8) Initiation of dysmenorrheal pain Previous day 115 (34.3) First day 145 (43.3) Second day 18 (5.4) Later 10 (3.0) No fixed pattern 47 (14.0) Pain duration One day 191 (57.2) Two days 101 (30.2) Three days 29 (8.7) Entire of period 13 (3.9) Associated symptoms Physical Acne 285 (85.3) Headache 199 (59.5) Breast tenderness 118 (35.3) Dysuria 33 (9.8) Weight gain 197 (58.9) Weight loss 8 (2.3) Tiredness 210 (62.9) Increased vaginal discharge 6 (1.7) Back pain 313 (93.7)

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Vulvar itching 287 (85.9) Generalized aches 143 (42.8) Psychological Sleep disturbances 302 (90.4) Mood swings (Anger) 112 (33.5) Difficulty in performing homework and concentrate 276 (82.6) Eating more than usual 61 (18.2) Depressed mood 169 (50.5) Craving for sweat foods and appetite change 73 (21.8) Difficulty concentrating 211 (63.1)

Concerning the participants’ practices before and through the period, table 3 shows that 91 participants (25.4%) increased in their consumption of tea and coffee during the period pain and 97 participants (27.1%) performed exercises to reduce PMS. The application of warm or hot compresses was used by 101 (30.2%). The PMS and dysmenorrheal pain affected the school attendance for 155 (43.4%) of the study participants and negatively affected their academic performance. Parents were mostly indicated as prescribers for medications used to treat the PMS and dysmenorrheal pain in 210 participants (62.3%) (table3).

Table 3: Practice of study participants around the menstruationdays

Increase coffee or tea consumption before & during period pain? Yes 91 (25.4) No 266 (74.6) Performing any type of exercise to reduce PMS Yes 97 (27.1) No 260 (72.9) Practices to manage the PMS and period pain Usemedications 150 (42.0) Use herbal preparation 60 (18.0) Worm yourself by blanket 25 (7.5) Put worm water compresses on your abdomen 101 (30.2) Increase water intake 9 (2.7) Decrease spicy & salty food 30 (9.0) Take more than one action in a time 94 (28.1) School attendance Affected 155 (43.4) No affected 202 (56.6) Use of drugs for menstrual disorders? Self-medication 81 (24.0) Treatment given by parents 210 (62.3) Treatment given by a doctor 46 (13.6)

Table 4 shows the Chi-square test for the factors associated with the experience of dysmenorrhea. Mothers’ level of education and family size were significantly associated with the history of dysmenorrhea. The test revealed that participants who are suffering from PMS were significantly more likely to have a dysmenorrheal symptom. In addition to that, participants with a regular period were less likely to have dysmenorrhea.

Table 4: Factors associated with experience of dysmenorrhea

PMS occurrence variable X2 P - value Mother’s level of education 12.610 0.021 Family size 13.492 0.033 ©Annals of Tropical Medicine & Public Health S500

Performing sports 1.532 0.216 Increasing coffee and tea consumption 0.419 0.516 Experience of PMS 32.814 < 0.001 Dysmenorrheal pain duration 6.702 0.152 Age of Menarche 0.174 0.917 Period duration (free of bleeding) 12.074 0.014 Regularity of period 7.218 0.007

Discussion

This study was carried out among 357 teenage participants whose demographic characteristics were comparable to previous studies. However, the prevalence of PMS (84.9%) was higher than the others and a higher prevalence of dysmenorrhea was also found (93.6%). This difference might be due to the participants’ age; all participants in this study were secondary school female students, not university students like other studies [17-18]. Also, the overestimation of the participants might be reason Moreover, this prevalence was lower than a study conducted in Egypt among the same age group of participants [19]. The subjective results in our locality in this field of female privacy might be affected by the cultural concept that menstruation period should be kept a secret as it is considered a ‘dirty’ physiological period and it is better to avoid discussing its related issues unless it becomes out of control. However, this belief issue is not unique to the Arabic nations, where a negative impression about menstruation is found in other cultures [20-22]. The duty of encouraging the girls to feel more comfortable with their physiological periods and rejecting the shameful view with menstruation relies primarily on mothers. Moreover, health care providers can play an important role to explain that menstruation is just a physiological monthly event rather than a hygienic crisis.

The study was sought to provide information about the pattern of girls’ behavior during menstruation in Iraq. With regard to the participants’ age of menarche, it was found to be comparable with other studies from other nations like American, Ethiopian, and Egyptians [19, 23, 24]. The exact data collected was not enough to evaluate and comment on the age of menarche-related issues. Around 70% of the participants were within the normal full-cycle duration [25] and the abnormal length was consistent with some studies [26, 27]. Dysmenorrheal pain in adolescent girls is usually primary, without underlying pathology. Menstruation symptom including PMS and dysmenorrhea are widely common among adolescents and cause significant disruption in daily activities of their life [28].

In this study, a very high ratio of participants suffering from dysmenorrhea was found (93.6%) and a high rate of PMS was also reported in this study sample (84.9%). These results were consistent with other studies in the region [17, 19, 29]. The intensity of the pain was severe among only 30.5% of the participants which is almost consistent with some studies [12, 30-31]. Differences in pain severity might be due to the tools used for the evaluation as well as cultural perception regarding pain. More than half of the girls in this study had pain duration of one day (57.2. However, school non-attendance is the main consequence of dysmenorrhea and PMS in addition to disturbances in social and academic performance. Appropriate self-care practice and education could resolve the symptoms to avoid the performance issues and discomfort of the girls. The use of pharmacological and non-pharmacological treatments is usually safe and simple to reduce the impact of the symptoms. The school attendance was affected by a lower percentage of the study participants (43.4%). The medication use by the study participants was not high, in addition to a low rate of using a hot pad, drinking hot fluids to relieve symptoms. Exercising was also noticed in some participants (27.1%). However, most of the managements used should be properly taught by the mother, teachers and health care providers [32].

Additional symptoms rather than PMS and dysmenorrhea were also reported in different percentages ranging from 85.3% for acne to 2.3% for weight gain for the physical symptoms and from 90.4% for sleep disturbances to 18.2% for eating more than usual for psychological symptoms. These symptoms were found in the literature in different proportions [19-20, 33] and the cultural differences in perception might be the cause of these differences. Additional contributory factors include the differences in methodology, variations in study populations, eating disorder, accepting PMS as a normal aspect of menstruation and polycystic ovaries syndrome.

The inferential analysis found that mothers’ level of education, family size and dysmenorrheal pain during the period and cycle duration are the factors associated with the PMS occurrence in this study. Mothers’ level of education could affect the proper practice to manage the PMS as well as dysmenorrhea[17]. Little communication between mothers and their daughters due to lack of knowledge, cultural taboos and crowded home in large families might be the reason. In addition, irregularity of the period each month was significantly associated with the presence of PMS. Providing knowledge about the symptoms and methods to cope with them in addition to information about when to consult the doctor are important factors to avoid bad consequences both academically and socially.

Limitation: This study was limited to the secondary schools of girls from the city of Mosul and those who are not in the school or are from rural areas might change the picture of the results. Because of the sensitivity of the subjectin theIraqi culture, real personal issues regarding menstruation might not be explored. Although the sample size was sufficient for the analysis,further works with including the rural area might provide deeper information to understand the cultural and genetic variation of the Iraqi population.

In conclusion, the prevalence of menstrual disorders, including dysmenorrhea and PMS, among Iraqi adolescents were common and can affect the social and academic performance and even result in low-grade scoring of the students. This study is one of the largest cross-sectional studies among schoolgirls in the north of Iraq to evaluate the prevalence of menstruation disorders. It is reported a prevalence that was higher than expected. The study highlights the need for the menstrual educational systems in the schools in addition to screening activities performed by health care providers from school health sectors in the directorates of health. Knowledge improvement by health professionals via social media could positively affect the practice to cope with the symptoms.

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