98

Ann Ist Super Sanità 2016 | Vol. 52, No. 1: 98-103

DOI: 10.4415/ANN_16_01_16

Risk factors for dysmenorrhea among

young adult female university students
articles and reviews

Ana Pejčić and Slobodan Janković

Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia

Abstract Key words

Objectives. The aim of this study was to investigate associated risk factors for dysmenor- •  dysmenorrhea
rhea in a sample of Serbian university students. •  students
O riginal

Methods. A case-control study was conducted among undergraduate students (n = 288) •  risk factors
attending lectures during 2014/2015 academic year at the Faculty of Medical Sciences,
University of Kragujevac.
Results. The only significant associations were between dysmenorrhea and age at men-
arche (OR adjusted = 0.74; 95% CI 0.58-0.95; p = 0.017), family history of dysmenor-
rhea (OR adjusted = 3.39; 95% CI 1.74-6.63; p = 0.000), duration of menstrual flow
(OR adjusted = 1.52; 95% CI 1.16-1.99; p = 0.002) and smoking at least one cigarette
a day (OR adjusted = 5.09; 95% CI 1.83-14.15; p = 0.002). The factors associated with
dysmenorrhea were not interacting with each other.
Conclusion. Our results suggest that earlier age at menarche, longer duration of men-
strual flow, prior family history of dysmenorrhea and smoking at least one cigarette a day
are important risk factors associated with dysmenorrhea. Smoking cessation should be
strongly encouraged.

INTRODUCTION dysmenorrhea in various studies [9]. Most of the stud-

Menstruation is a normal physiological process that ies conducted among university students showed that
occurs approximately once a month in women of repro- earlier age at menarche is a significant risk factor for
ductive age as a result of the breakdown of the endome- dysmenorrhea, probably due to continuing hormonal
trial tissue [1, 2]. This process is triggered by fall in pro- imbalance [3, 4, 12, 13]. Some studies showed that in-
gesterone and estrogen levels in the late secretory phase creased severity of menstrual pain could be associated
of menstrual cycle in the absence of pregnancy [2]. with older age [8], longer length of menstruation [4,
Women may experience certain discomfort and pain 12, 14] and positive family history of dysmenorrhea
in the lower abdomen before or during their menstrua- [14, 15]. The studies which have examined association
tion, but this normally should not affect their ability to of factors such as alcohol consumption, coffee con-
perform everyday activities [3-5]. On the other hand, sumption and smoking with dysmenorrhea show mostly
some women experience pain which is severe enough to conflicting or inconclusive results [9]. For example,
limit normal daily activities and/or require medication, several studies indicated that smokers are more likely
and this kind of pain is called dysmenorrhea [4-8]. Dys- to experience dysmenorrhea [15-17], but other stud-
menorrhea can be categorized as primary or secondary ies did not confirm this association [13, 14, 18]. One
[7]. Primary dysmenorrhea refers to pain in the absence study from Turkey detected that coffee consumption
of obvious pelvic pathology [8, 9]. Secondary dysmen- is an important risk factor for dysmenorrhea [14] and
orrhea is attributed to some underlying pelvic disease or another study from Iran reported that prevalence and
structural abnormality [4]. The reported prevalence of risk of dysmenorrhea was higher among students who
dysmenorrhea among university students considerably had higher intakes of caffeine [19]. But still it is unclear
varies between 51% and 92.5% [10, 11]. Differences how exactly this is related to dysmenorrhea occurrence
in definition of dysmenorrhea are the most important and it was suggested that it might be due to vasocon-
reasons for this variation. Some of the authors of the stricting effect of caffeine [19]. There are also studies
previously conducted studies did not consider severity which did not confirm this association [5, 10, 15]. The
of pain or effects of menstrual pain on daily activities, studies regarding effect of alcohol consumption contain
and used term “dysmenorrhea” to describe pain of any some contradictions. One study showed that consump-
severity associated with menstruation [5, 9]. tion of alcohol more than once per week decreased the
There is a range of factors which were associated with odds of having dysmenorrhea, but in women with exist-

Address for correspondence: Ana Pejčić, Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovica 69, 34000 Kragujevac, Serbia.
E-mail: [email protected].
 99
Risk factors for dysmenorrhea

ing dysmenorrhea it increased the odds of having severe dysmenorrhea, sex life history, abortion, pregnancy and
pain and pain lasting more than two days [17]. Recently menstrual history. Women who reported that they had
conducted studies didn’t find any association of alcohol experienced menstrual pain completed additional ques-
consumption with occurrence of dysmenorrhea [13, 14, tions regarding the characteristics of pain and influence
20, 21]. Also, to our knowledge, there have been no of pain on their ability to perform everyday activities.

articles and reviews

studies conducted in Serbia that examined risk factors Each participant’s body mass index was calculated as
for dysmenorrhea. the subject’s weight in kilograms divided by height in
With these aspects in mind, the aim of this study was squared meters (kg/m2). The other variables that were
to investigate associated risk factors for dysmenorrhea followed were: smoking at least one cigarette a day,
in a sample of Serbian university students, and there- consuming alcohol more than one day per week, con-
fore resolve controversies made by opposing results of suming at least one cup of coffee daily and being physi-
previous studies. cally active more than 30 minutes in addition to routine
daily activities more than one day per week. The period
METHODS between the first day of menstruation and the day im-
Study design and setting mediately prior to the next menstruation was defined as
This study was conducted at the Faculty of Medical the menstrual cycle. Menstrual cycles were considered

O riginal
Sciences, University of Kragujevac, public higher edu- to be regular if ranged between 21 to 35 days. A fam-
cation institution located at the city of Kragujevac in ily history of dysmenorrhea was defined as positive if a
Serbia. The design of our study was of the case-control student’s first degree relative (mother or sister) had a
type, with the primary aim to assess the association be- history of dysmenorrhea.
tween various risk factors and the occurrence of dys-
menorrhea defined by menstrual pain that interferes Statistical analysis
with daily activities and requires medication during The frequency of each risk factor was determined for
each menstrual period. both cases and controls. The results of continuous data
were expressed as mean ± standard deviation (SD). The
Study size differences between cases and controls in the observed
Based on the expected study power of 80%, the prob- characteristics were assessed by the Student t-test or
ability of the statistical error type 1 (α) of 0.05, and sup- Mann-Whitney U test for continuous variables and the
posed difference in average age at menarche between χ2-test for categorical variables. The differences were
the study groups (based on the results from a study considered significant if probability of null hypothesis
conducted in Italy, which showed significant difference was less than 0.05. In order to estimate the association
in mean age at menarche – in a group of students with between potential risk factors and dysmenorrhea, crude
pain 12.45 and in a group of students without pain and adjusted odds ratios (OR) with 95% confidence in-
13.13 years [5]), we calculated a minimal number of tervals (95% CI) were calculated using logistic regres-
59 students per group. We used difference in average sion.
age at menarche between the study groups to calculate
sample size because majority of previously conducted Ethical approval
studies among university students consistently reported The study protocol was approved by the Ethics Com-
that earlier age at menarche is a significant risk factor mittee of the Faculty of Medical Sciences, University of
for dysmenorrhea compared to other tested variables. Kragujevac (No. 01-3098).

Participants: cases and controls RESULTS

The participants were undergraduate students at- This study included 265 pharmacy students and 23
tending lectures during 2014/2015 academic year. A medicine students. Mean age of a total of 288 par-
total of 288 students were enrolled during the study ticipants was 21.5 ± 1.81 years, ranging from 18 to 29
period. The students from the study sample who had years. Menstrual pain was reported by 84.8% (244 out
menstrual pain that interfered with daily activities and of 288) students, with 43.8% (126 out of 288) report-
required medication during each menstrual period in ing that pain occurred during each period in the last
the last year were the cases in this study. The other year, and 41% (118 out of 288) reporting that pain oc-
students from the study sample who did not meet the curred during some periods in the last year. Forty-four
above-mentioned criteria were the controls. students (15.2%) reported that they did not have pain
during menstruation in the last year.
Data collection and variables We classified those having menstrual pain that in-
Data were collected using a self-reported question- terfered with daily activities and required medication
naire which was specially designed for this research. during each menstrual period in the last year as having
The questionnaire was anonymously completed by each dysmenorrhea (cases) and this gives a rate of 29.9% (86
participant who consented to participate in the study. out of 288). Baseline characteristics of the cases and
The students were asked to provide information about controls, and the differences between them, are shown
age, height, weight, smoking, alcohol and coffee con- in Table 1. Significant differences between the cases and
sumption, physical activity, chronic diseases, gyneco- controls were observed in following features: students
logical disorders, use of oral contraceptives, previous with dysmenorrhea (cases) had an earlier menarche (p
gynecological surgical procedures, family history of = 0.015), longer duration of menstrual flow (p = 0.000),
100
Ana Pejčić and Slobodan Janković

Table 1
Baseline characteristics of cases and controls
Variable Cases Controls Test value and Crude odds ratios
(n = 86) (n = 202) significance of null with 95% confidence
hypothesis intervals
articles and reviews

Age (years) 21.84 ± 1.74 21.83 ± 2.13 U = 7603.5; p = 0.089 1.11 (0.97-1.28)
BMI (kg/m ) 2 20.48 ± 2.27 20.65 ± 2.13 T = 1.305; p = 0.193 0.92 (0.82-1.04)
Age at menarche 12.55 ± 1.33 13.0 ± 1.29 U = 7080.0; p=0.015* 0.76 (0.63-0.93)
Duration of menstrual flow (days) 5.87 ± 1.17 5.24 ± 0.9 U = 6401.5; p=0.000* 1.53 (1.22-1.91)
Family history of dysmenorrhea 60/79 (75.9%) 86/181 (47.5%) χ2 = 16.92; p = 0.000* 3.49 (1.93-6.31)
Use of oral contraceptives 2 (2.3%) 12 (5.9%) χ2 = 1.01; p = 0.314 0.38 (0.08-1.72)
Have regular menstrual cycles 77 (89.5%) 189 (93.6%) χ2 = 0.846; p = 0.349 0.59 (0.24-1.43)
Residence (rural vs. urban) Rural: 16 (18.6%) Rural: 35 (17.3%) χ =0.008; p = 0.927
2 1.09 (0.57-2.10)
Urban: 70 (81.4%) Urban: 167 (82.7%)
O riginal

Chronic disease 4 (4.7%) 17 (8.4%) χ2 = 0.769; p = 0.381 0.53 (0.17-1.63)

Had sexual intercourse 59/84 (70.2%) 118/195 (60.5%) χ2= 1.993; p = 0.158 1.54 (0.89-2.67)
Age at first sexual intercourse 18.38 ± 1.82 18.81 ± 1.71 U = 2830.0; p = 0.141 0.86 (0.71-1.04)
Number of sexual partners 1.75 ± 0.75 1.74 ± 1.12 U = 2955.0; p = 0.292 0.99 (0.72-1.36)
Gynecological condition (endometriosis, 10 (11.6%) 17 (8.4%) χ2 = 1.993; p = 0.158 1.43 (0.63-3.27)
polycystic ovaries, etc.)
Had surgical gynecological procedure 4 (4.7%) 5 (2.5%) χ2 = 0.362; p = 0.548 0.52 (0.14-1.99)
Previous pregnancy 0 (0%) 2 (1%) χ = 0.025; p = 0.875
2 0.99 (0.98-1.01)
Smoking at least one cigarette a day 18 (20.9%) 15 (7.4%) χ2 = 9.553; p = 0.002* 3.30 (1.58-6.91)
Consuming at least one cup of coffee daily 63 (73.3%) 119 (58.9%) χ2 = 4.738; p = 0.030* 1.91 (1.09-3.32)
Consuming alcohol more than one day 20 (23.3%) 39 (19.3%) χ2 = 0.360; p = 0.548 1.27 (0.69-2.33)
per week
Being physically active more than 30 41 (47.7%) 124 (61.4%) χ2 = 4.091; p = 0.043* 0.57 (0.34-0.95)
minutes in addition to routine daily
activities more than one day per week
Results are presented as mean ± SD, or n (%); *Significant difference

family history of dysmenorrhea (p = 0.000), were more at least one cup of coffee daily” and “being physically
likely to smoke at least one cigarette a day (p = 0.002), active more than 30 minutes in addition to routine daily
have regular daily coffee intake (p = 0.030) and were activities more than one day per week” (Table 1) were
less likely to be physically active more than 30 minutes significantly different from one, after adjustment con-
in addition to routine daily activities more than one day fidence limits of these odds ratios included the value
per week p = 0.043). None of the participants had his- of one. The interactions between risk factors which are
tory of previous abortions. Also, there were no partici- likely to have an additive risk for dysmenorrhea were
pants who were pregnant at the time of completing the investigated (Table 3). The analysis did not show a clear
questionnaire. synergistic effect for any of the factors that were indi-
The results of the logistic regression analysis (Cox & vidually associated with dysmenorrhea. After adjust-
Snell R square 0.208, Nagelkerke R square 0.294, Hos- ment, the odds ratios dropped down and their confi-
mer-Lemeshow Chi square 7.372, df = 8, p = 0.497) dence intervals included 1, so they were not statistically
with adjustment for potential confounders are shown significant (p > 0.05).
in Table 2. The adjusted model of logistic regression
included 258 participants (79 cases and 179 controls). DISCUSSION
This was due to missing data when multiple variables The obtained results show that significant risk factors
were included in the adjusted model (2 participants did associated with dysmenorrhea were: earlier age at men-
not know how old they were when they experienced arche, family history of dysmenorrhea, longer duration
first menstruation, 28 participants did not know if any of menstrual flow and smoking at least one cigarette a
of their family members had dysmenorrhea and 9 par- day. These factors were not interacting with each other.
ticipants did not provide answers on the question if they In the present study it was observed that students
have ever had sexual intercourse). The only significant who earlier reached menarche were more likely to ex-
associations were between dysmenorrhea and age at perience dysmenorrhea. This finding is consistent with
menarche, family history of dysmenorrhea, duration results of the majority of studies, such as those con-
of menstrual flow, and smoking at least one cigarette ducted among Nigerian, Hong Kong, Bangladesh and
a day. Although the crude odds ratios for “consuming Japanese university students [3, 4, 12, 13]. This may
 101
Risk factors for dysmenorrhea

Table 2
Crude and adjusted odds ratios (OR) of the risk factors for dysmenorrhea
Risk factors Crude OR p Number Adjusted# OR p Number
(95% CI) of women (95% CI) of women
included in included in

articles and reviews

the model: the model:
total (cases/ total (cases/
controls) controls)
Age at menarche 0.76 0.008* 286 (86/200) 0.74 0.017* 258 (79/179)
(0.63-0.93) (0.58-0.95)
Family history of dysmenorrhea 3.49 0.000* 260 (79/181) 3.39 0.000*
(1.93-6.31) (1.74-6.63)
Duration of menstrual flow 1.53 0.000* 288 (86/202) 1.52 0.002*
(1.22-1.91) (1.16-1.99)
Smoking at least one cigarette a day 3.30 0.002* 288 (86/202) 5.09 0.002*
(1.58-6.91) (1.83-14.15)

O riginal
Gynecological condition 1.43 0.394 288 (86/202) 1.47 0.479
(endometriosis, polycystic ovaries, (0.63-3.27) (0.51-4.29)
etc.)
p – Statistical significance
# Adjusted for age, age at menarche, duration of menstrual flow, smoking at least one cigarette a day, consuming alcohol more than one day per week, consuming
at least one cup of coffee daily, being physically active more than 30 minutes in addition to routine daily activities more than one day per week, body mass index,
use of oral contraceptives, family history of dysmenorrhea, regular menstrual periods, place of residence (rural vs. urban), chronic disease, gynecological condition,
previous gynecological surgical procedures
* Statistically significant

be attributed to the similarity of hormonal pattern and Family history of dysmenorrhea was also an impor-
ovulatory efficiency of early maturing girls and adult fe- tant predictor for the dysmenorrhea occurrence. This
males that could lead to a longer exposure to uterine result is in line with studies performed among university
prostaglandins which are responsible for pain [15, 22]. students in Ethiopia, Turkey and Iran [6, 14, 15, 18, 19,
On the other hand, the study conducted among Turk- 23]. Some researchers suggested that this may be due
ish nursing students did not find statistically significant to behavior learned from their mothers and sisters [6,
increased odds for occurrence of dysmenorrhea in stu- 15, 19, 23, 24]. However, some studies suggested that
dents who had earlier menarche [18]. In this study only there is a genetic susceptibility to dysmenorrhea [24,
56 students didn’t have dysmenorrhea opposed to 315 25]. Cytochrome P450 2D6, glutathione S-transferase
who reported dysmenorrhea, and this small number of Mu and Estrogen receptor 1 gene polymorphisms were
controls might be the reason for not reaching statistical associated with increased risk of dysmenorrhea but ex-
significance in logistic regression analysis [18]. Another act biological mechanism by which these gene polymor-
significant risk factor for dysmenorrhea was presence of phisms could contribute to dysmenorrhea occurrence
longer duration of menstrual flow. The majority of pre- has yet to be determined [25, 26]. Also, the results of
vious studies such as those conducted in Hong Kong, the recently conducted meta-analysis observed trend
Iran, Bangladesh, Nigeria and Turkey reported similar towards an increased risk of the variant progesterone
results [3, 4, 12, 14, 19]. receptor gene polymorphism allele and predisposition

Table 3
The interactions between significant risk factors for dysmenorrhea
Risk factors Crude OR Statistical Adjusted# OR Statistical
(95% CI) significance (95% CI) significance
(p) (p)
Family history of dysmenorrhea and smoking at least one cigarette a 5.70 (1.91-16.99) 0.002* 0.42 (0.06-2.78) 0.371
day
Family history of dysmenorrhea and age at menarche 1.08 (1.04-1.13) 0.000* 0.72 (0.42-1.23) 0.228
Family history of dysmenorrhea and duration of menstrual flow 1.30 (1.18-1.44) 0.000* 1.45 (0.82-2.54) 0.195
Smoking at least one cigarette a day and age at menarche 1.10 (1.04-1.17) 0.001* 0.67 (0.30-1.46) 0.314
Smoking at least one cigarette a day and duration of menstrual flow 1.26 (1.11-1.44) 0.001* 0.02 (0.42-2.46) 0.966
Age at menarche and duration of menstrual flow 1.02 (1.01-1.03) 0.028* 0.96 (0.80-1.16) 0.686
#Adjusted for age, age at menarche, duration of menstrual flow, smoking at least one cigarette a day, consuming alcohol more than one day per week, consuming
at least one cup of coffee daily, being physically active more than 30 minutes in addition to routine daily activities more than one day per week, body mass index,
use of oral contraceptives, family history of dysmenorrhea, regular menstrual periods, place of residence (rural vs. urban), chronic disease, gynecological condition,
previous gynecological surgical procedures.
* Statistically significant
102
Ana Pejčić and Slobodan Janković

for the endometriosis which is one of the common risk for dysmenorrhea was highest in women between
causes of secondary dysmenorrhea [27]. 20 and 24 years of age and that both prevalence and
Among the examined lifestyle factors only smoking risk for dysmenorrhea decrease after the age of 25 [23,
at least one cigarette a day was significantly associated 29, 30]. This observation could be attributed to the fact
with dysmenorrhea. Inconsistent results for the associa- that women are more likely to get pregnant and give
articles and reviews

tion between smoking and dysmenorrhea can be found birth as they become older and this protective effect of
in literature. Study conducted among Turkish university pregnancy and delivery may be a result of lower release
students showed that cigarette smokers had 1.6-fold of prostaglandin by endometrium and disappearance of
higher risk compared with nonsmokers [15]. The one- uterine adrenergic nerves [9, 22]. Previously conducted
year prospective study conducted among college wom- studies did not examine interactions of risk factors, but
en in the USA showed that current smokers had a 1.5- our study showed that factors that were associated with
fold increased risk of experiencing pain lasting longer dysmenorrhea acted independently.
than two days [17]. Although it is not entirely clear how Limitation of our study is the fact that data were ob-
smoking might contribute to dysmenorrhea, one of the tained through self-report method, therefore its accura-
possible explanations is the fact that nicotine acts as a cy depends on the truthfulness of the respondents and
vasoconstrictor which leads to reduced blood flow in en- their willingness to share experiences on a sensitive top-
O riginal

dometrium and decreased amount of oxygen available ic like menstruation. Still, it is important to emphasize
to the uterus which result in pain [16]. On the contrary, that self-report method is difficult to avoid since there
two other studies conducted in Turkey and one study is no biomedical marker for dysmenorrhea and the fact
conducted in Japan did not detect significant associa- that pain is subjective phenomenon. Additional limita-
tion of dysmenorrhea with smoking status and authors tion of the study is the fact that we did not collect any
tried to explain this discrepancy by the fact that they data (demographic, clinical, motivation) on students
did not ask what is the dose of cigarettes used and the who refused to participate. Another important limita-
duration of smoking [13, 14, 18]. Nevertheless, smok- tion is that we could not differentiate between primary
ing cessation should be strongly encouraged as it may and secondary dysmenorrhea, since gynecological ex-
have other harmful effects on health. The results of our amination was not performed. Nevertheless, this study
study did not identify association of alcohol and coffee still brings important insights regarding dysmenorrhea
consumption with dysmenorrhea occurrence, which is and associated risk factors for its occurrence in female
in accordance with most of the previously conducted university students.
studies [5, 10, 13-15, 20, 21]. Our results did not de-
tect older age as significant risk factor for dysmenorrhea CONCLUSION
which is in accordance with results of the studies con- Our results suggest that earlier age at menarche, lon-
ducted among Hong Kong and Turkish university stu- ger duration of menstrual flow, prior family history of
dents [12, 18]. On the other hand, studies conducted dysmenorrhea and smoking at least one cigarette a day
in Nigeria and Egypt reported that participants older are important risk factors associated with dysmenor-
than 15 and 17 years, respectively, were more likely to rhea. Smoking cessation should be strongly encouraged.
have dysmenorrhea [8, 28]. Participants in these stud-
ies were younger (10-19 years) than participants in our Conflict of interest statement
study so this might explain discrepancy [8, 28]. The There are no potential conflicts of interest or any fi-
possible reason for more frequent occurrence of dys- nancial or personal relationships with other people or
menorrhea in older age is that the probability of ovu- organizations that could inappropriately bias conduct
lation increases with age, and the fact that menstrual and findings of this study.
pain is more likely to occur during ovulatory cycles [17].
Studies which have included participants of wider age Received on 26 May 2015.
range (18-51 years), showed that the prevalence and Accepted on 26 October 2015.

REFERENCES

1. Maybin JA, Critchley HO. Progesterone: a pivotal hor- women. Aust N Z J Obstet Gynaecol 2008;48(4):442-4.
mone at menstruation. Ann N Y Acad Sci 2011;1221:88- DOI: 10.1111/j.1479-828X.2008.00869.x
97. DOI: 10.1111/j.1749-6632.2011.05953.x 5. Grandi G, Ferrari S, Xholli A, Cannoletta M, Palma F,
2. Berbic M, Ng CH, Fraser IS. Inflammation and endome- Romani C, Volpe A, Cagnacci A. Prevalence of menstrual
trial bleeding. Climacteric 2014;17(Suppl. 2):47-53. DOI: pain in young women: what is dysmenorrhea? J Pain Res
10.3109/13697137.2014.963964 2012;5:169-74. DOI: 10.2147/JPR.S30602
3. Hossain, MG, Sabiruzzaman M, Islam S, Hisyam RZ, 6. Potur DC, Bilgin NC, Komurcu N. Prevalence of dys-
Lestrel PE, Kamarul T. Influence of anthropometric mea- menorrhea in university students in Turkey: effect on dai-
sures and socio-demographic factors on menstrual pain ly activities and evaluation of different pain management
and irregular menstrual cycles among university students methods. Pain Manag Nurs 2014;15(4):768-77. DOI:
in Bangladesh. Anthropological Science 2011;119(3):239- 10.1016/j.pmn.2013.07.012
46. DOI: http://doi.org/10.1537/ase.100903 7. Okoro RN, Malgwi H, Okoro GO. Self-reported knowl-
4. Loto OM, Adewumi TA, Adewuya AO. Prevalence and edge of dysmenorrhoea and its negative academic im-
correlates of dysmenorrhea among Nigerian college pacts among a group of female university students. Novel
 103
Risk factors for dysmenorrhea

Sci Int J Med Sci 2012;1(7):220-5. rhea. Iran Red Crescent Med J. 2014;16(8):e16307. DOI:
8. El Gilany AH, Badawi K, El Fedawy S. Epidemiology of 10.5812/ircmj.16307
dysmenorrhoea among adolescent students in Mansoura, 20. Nohara M, Momoeda M, Kubota T, Nakabayashi M.
Egypt. East Mediterr Health J 2005;11(1-2):155-63. Menstrual cycle and menstrual pain problems and related
9. Ju H, Jones M, Mishra G. The prevalence and risk factors risk factors among Japanese female workers. Ind Health
of dysmenorrhea. Epidemiol Rev 2014;36:104-13. DOI: 2011;49(2):228-34.

articles and reviews

10.1093/epirev/mxt009 21. Unsal A, Tozun M, Aslan G, Ayranci U, Alkan G. Evalu-
10. Cheng HF, Lin YH. Selection and efficacy of self-man- ation of dysmenorrhea among women and its impact on
agement strategies for dysmenorrhea in young Taiwan- quality of life in a region of western Turkey. Pak J Med Sci
ese women. J Clin Nurs 2011;20(7-8):1018-25. DOI: 2010;26(1):142-7.
10.1111/j.1365-2702.2010.03363.x 22. Okoro R, Malgwi H, Okoro G. Evaluation of Factors that
11. Anandha Lakshmi S, Priy M, Saraswathi I, Saravanan Increase the Severity of Dysmenorrhoea among Universi-
A, Ramamchandran C. Prevalence of premenstrual syn- ty Female Students in Maiduguri, North Eastern Nigeria.
drome and dysmenorrhoea among female medical stu- Int J Allied Health Sci Pract 2013;11:1-10.
dents and its association with college absenteeism. Int J 23. Shiferaw MT, Wubshet M, Tegabu D. Menstrual prob-
Biol Med Res 2011;2(4):1011-6. lems and associated factors among students of Bahir Dar
12. Chia CF, Lai JH, Cheung PK, Kwong LT, Lau FP, Leung University, Amhara National Regional State, Ethiopia: A
KH, Leung MT, Wong FC, Ngu SF. Dysmenorrhoea cross-sectional survey. Pan Afr Med J 2014;17:246. DOI:

O riginal
among Hong Kong university students: prevalence, im- 10.11604/pamj.2014.17.246.2230
pact, and management. Hong Kong Med J 2013;19(3):222- 24. Tavallaee M, Joffres MR, Corber SJ, Bayanzadeh M,
8. DOI: 10.12809/hkmj133807 Rad MM. The prevalence of menstrual pain and as-
13. Yamamoto K, Okazaki A, Sakamoto Y, Funatsu M. The sociated risk factors among Iranian women. J Obstet
relationship between premenstrual symptoms, menstrual Gynaecol Res 2011;37(5):442-51. DOI: 10.1111/j.1447-
pain, irregular menstrual cycles, and psychosocial stress 0756.2010.01362.x
among Japanese college students. J Physiol Anthropol 25. Wu D, Wang X, Chen D, Niu T, Ni J, Liu X, Xu X. Meta-
2009;28(3):129-36. bolic gene polymorphisms and risk of dysmenorrhea. Epi-
14. Unsal A, Ayranci U, Tozun M, Arslan G, Calik E. Prev- demiology 2000;11(6):648-53.
alence of dysmenorrhea and its effect on quality of life 26. Woo HY, Kim KH, Lim SW. Estrogen receptor 1, glu-
among a group of female university students. Upsala tathione S-transferase P1, glutathione S-transferase M1,
Journal of Medical Sciences 2010;115(2):138-45. DOI: and glutathione S-transferase T1 genes with dysmenor-
10.3109/03009730903457218 rhea in Korean female adolescents. Korean J Lab Med
15. Ozerdogan N, Sayiner D, Ayranci U, Unsal A, Giray 2010;30(1):76-83. DOI: 10.3343/kjlm.2010.30.1.76
S. Prevalence and predictors of dysmenorrhea among 27. Pabalan N, Salvador A, Jarjanazi H, Christofolini DM,
students at a university in Turkey. Int J Gynaecol Obstet Barbosa CP, Bianco B. Association of the progesterone re-
2009;107(1):39-43. DOI:10.1016/j.ijgo.2009.05.010 ceptor gene polymorphism (PROGINS) with endometrio-
16. Parazzini F, Tozzi L, Mezzopane R, Luchini L, Marchini sis: a meta-analysis. Arch Gynecol Obstet 2014;290(5):1015-
M, Fedele L. Cigarette smoking, alcohol consump- 22. DOI: 10.1007/s00404-014-3308-3
tion, and risk of primary dysmenorrhea. Epidemiology 28. Nwankwo TO, Aniebue UU, Aniebue PN. Menstrual
1994;5(4):469-72. disorders in adolescent school girls in Enugu, Nige-
17. Harlow SD, Park M. A longitudinal study of risk factors ria. J Pediatr Adolesc Gynecol 2010;23(6):358-63. DOI:
for the occurrence, duration and severity of menstrual 10.1016/j.jpag.2010.04.001
cramps in a cohort of college women. Br J Obstet Gynaecol 29. Patel V, Tanksale V, Sahasrabhojanee M, Gupte S,
1996;103(11):1134-42. Nevrekar P. The burden and determinants of dysmenor-
18. Seven M, Güvenç G, Akyüz A, Eski F. Evaluating dys- rhoea: a population-based survey of 2262 women in Goa,
menorrhea in a sample of Turkish nursing students. India. BJOG 2006;113(4):453-63.
Pain Manag Nurs 2014;15(3):664-71. DOI: 10.1016/j. 30. Ohde S, Tokuda Y, Takahashi O, Yanai H, Hinohara S,
pmn.2013.07.006 Fukui T. Dysmenorrhea among Japanese women. Int
19. Faramarzi M, Salmalian H. Association of psychologic J Gynaecol Obstet 2008;100(1):13-7. DOI: 10.11604/
and nonpsychologic factors with primary dysmenor- pamj.2014.17.246.2230