In this study, we determined the dysmenorrhoea prevalence and predictors of dysmenorrhoeal pain severity among adolescent student-females. The results showed that the dysmenorrhoea prevalence was 87.2%. These findings are similar to the published values from developing and developed countries. Studies revealed variable rates of dysmenorrhoea varying from 34% in Egypt, 80% in Australia, 85% among Hispanic adolescent females, and 94% in Oman. (42–44) Moreover, the prevalence of severe dysmenorrhoeal pain ranges from 0.9% reported in Korea to 59.8% reported in Bangladesh. (42) Furthermore, a Japanese study on high school girls mentioned that the pain was mild/no pain in 35.5% of the sample, moderate in 46.8 % and severe in 17.7 %, (18) and a similar study on university students in Turkey concluded that mild pain was present in 19.8%, moderate pain in 49.8% and severe pain in 30.4% of their sample. (17) Our results showed that the prevalence of severe dysmenorrhoeal pain was 23.7%. It is challenging to interpret the differences in dysmenorrhoea prevalence. However, the use of various criteria to define dysmenorrhoea in different studies, culture, lifestyle, genetics, and degree of social and personal stress are all potential causes for variations in dysmenorrhoea prevalence. (45–47)
There are many studies in Arab Middle Eastern countries published on the dysmenorrhoea prevalence among female students. A cross-sectional study carried out at Dammam University (Saudi Arabia) reported that 35% of females had severe dysmenorrhoea. (48) Another study from Saudi Arabia reported that the dysmenorrhoea prevalence is 60.9% among female medical students. (49) An Egyptian study revealed a high prevalence of 94% among nursing students. (50) A study from Lebanon revealed the dysmenorrhoea prevalence is 74.3%. (51) Collectively, these studies prove the variable characteristics of the dysmenorrhoea prevalence among different female students in various Arab countries and even within the same country.
In addition to that, a study carried out in Nigeria, showed that adolescents have limited knowledge concerning menstruation and dysmenorrhoea. (52) Fifty-eight percent of their participants reported a present pain and the majority had applied inappropriate ways to control primary dysmenorrhoea. (52) A descriptive cross-sectional study conducted in Iran showed that dysmenorrhoea is associated with symptoms, such as nausea, vomiting, diarrhoea, headache, weakness, and/or fainting, and they are the most common reasons to consult a doctor. (53) Lee et al. reported that 88.9% of schoolgirls had not sought medical advice for problems relating to menstruation. (54) Of the 11.1% who consult a medical doctor, 29.4% opted for alternative or complementary medicine. (54)
Attitudes towards dysmenorrhoea are influenced by several factors, including cultural, ethnic, and religious backgrounds. Mothers, teachers, friends, relatives, television, and books are the main sources of knowledge on menstruation for adolescent girls. (54,55) Girls from rural Malaysia were more conservative compared to city girls and they usually suffered in silence. (56) Contradictory conclusions were made by Weissman et al., who noted that girls in urban areas do not only suffer more but also miss classes and are unable to work. (57) The quality of life during dysmenorrhoea is relatively lower among girls in urban areas, and affected physical motility, work, relationships, social lives, and leisure activities. (58)
In our study, only 47.3% of participants before the awareness campaign knew that menstruation blood comes from the uterus and 54.7% knew that menstrual pain occurs only hours before and during the first two days of the menstrual cycle, but that improved after the campaign with 85.7% and 69.1% respectively.
Most participants did not consult a doctor regarding menstrual pain (91.6%). They thought it is necessary to consult a medical doctor in case of heavy bleeding with clots during menstrual cycles (68.3%), dysmenorrhoea non-responsive to painkillers (67.7%), worsening pain (59%), lower abdominal pain during and even outside the times of menstruation (50%), and pain-induced nausea and vomiting (49.5%) and the percentage of correct answers after the awareness campaign increased to 74%, 71%, 68%, 69%, and 53% respectively. However, a small percentage also thought incorrectly that bearable chronic dysmenorrhoea requires medical attention (20%) and that did not improve after the campaign (23.9%) may be due to the misperception of the question.
As for the normal symptoms that would appear before menstruation, there was a general improvement in choosing the correct answer by a percentage ranging between [0.4 - 18] %. However, two points “bleeding” and “non-white vaginal discharge” had an increased choosing rate for the wrong answer by 3.5% and 3.9% respectively.
Kamonasak et al. noticed that only a small percentage was conscious that mefenamic acid and ibuprofen were useful for dysmenorrhoea, and methods used involved rest (92%), heating pads (34%), analgesics (32%), herbal medicines (12.7%), physician consultation (7.1%), exercise (6.8%), and meditation (4.5%). According to their study, “paracetamol was the drug known to 98.8% of participants with dysmenorrhoea that helped to relieve their pain” (59). In our study, only a small percentage was conscious before the awareness campaign that during menstruation it is permissible to take painkillers (28.5%), eat lemon, cinnamon or ginger (28.4%) and drink cold water (21.7%). However, more than half believed it is permissible to exercise or effort (54.8%). The percentage of correct post-awareness answers mildly increased with 30.9%, 33.6%, 27.4%, and 56.4% respectively. The improvement ranged between [2 - 6]% only. It is worth mentioning that the profit from physical activity is controversial as mentioned earlier in the background section, however, for this paper we considered it positive.
Not to forget, dysmenorrhoea is thought to be a natural characteristic of the menstrual cycle that will resolve with time or after marriage. (60) This is in line with social knowledge, where home cures are often applied for the relief of pain (60). The participants revealed that medication will make them habitual, decrease menstrual blood flow, and affect fertility. (60) Bathing, use of sanitary towels, and exercise are avoided during menstruation. (60) In our study, a high percentage was conscious before the awareness campaign that during menstruation mild pain is a normal thing (81.5%) and it is permissible to shower (67%) and pluck or cut hair (56%); nevertheless, only a small percentage was aware that mild lower abdominal pain outside the times of menstruation is abnormal (36.5%). The percentage of correct post awareness answers changed to 93.1%, 35.5%, 40.5%, and 27% respectively. These results were surprising and totally unexpected. In the fourth section, not only did the percentage of some correct answers plummet, all the questions except for one witnessed an increase in selecting the wrong answer ranging between 10% and 38% increase in the post-awareness results.
A study conducted in Egypt showed that some participants were following general methods for painful periods, like resting and taking painkillers. (61) They were using non-steroidal anti-inflammatory drugs (NSAIDs), vitamin E supplements, and oral contraceptive pills for the relief of premenstrual tension and pain. (61)
Moreover, several women do not report menstrual pain to their family physician. (59) The consequences of untreated dysmenorrhoea involve decreased attention at work and school, leading to less productivity and family and personal disruptions. (59) Similar opinions have been revealed by Banikarim et al. who showed that dysmenorrhoea influences family and social and national economies. (44) Students’ knowledge of physiological changes is poor (54). Kindi & Bulushi revealed that girls did not discuss their menstrual difficulties with their family physician, and they were self-prescribing over-the-counter drugs. (62) It is necessary that consultation is given by family physicians and school staff and handled appropriately to avoid school absenteeism. (62) Proper knowledge about menstruation and its associated difficulties are essential for both adolescent girls and their mothers in order to prevent the delay of medical care. (63) In our study and before the awareness campaign, heavy bleeding was the most thought to be risk-factor with 46.11%, followed by a decreasing tendency by irregular cycles, early menarche, gynaecological infections, structural genitals abnormalities, prolonged periods, post-pregnancy and delivery period, lack of exercise, lack of calcium and vitamin D, presence of a family history of menstrual cycle-related pain, smoking, nulliparity, regular cycles, and obesity. However, post-pregnancy and delivery, lack of exercise and regular cycles are not risk factors. After the awareness campaign, the overall percentage of correct answers increased between [4 - 18.8] %. Unfortunately, the choosing of “lack of vitamin D and calcium” remained the same without changing, and these two points “post-pregnancy and delivery, exercise and effort” had a deterioration after the awareness and the wrong answer’s ratio increased between 5.2% and 8.3% respectively.
To summarize the results we acquired, we calculated the p-value for the answers of the students in relation to the initial assessment and the latter one. Unfortunately, we had a nonsignificant p-value (p = 0.687). And from the already-presented results, it was clear that there was an overall improvement in the answers with some deterioration in a few questions. The general improvement was not as high as predicted. We have a few plausible explanations:
- The relayed information needed further simplification; as the awareness crew comprised medical students might have led to the use of specialized vocabulary, and maybe this kind of students-based campaigns should have had more interactive material to deliver the information properly.
- It could be that some information required the opposite to be mentioned in order to be understood.
- The lecture time was only 15 minutes for each topic, and only color-printed visual aids (slides) were used due to logistical limitations, which prevented the benefit of more useful scientifically-proven media.
- There is a key difference between the classes regarding behavior, which negatively affected the delivery of information. The limited lecture time did not allow for a rapport to be established.
- Furthermore, the students belonged to widely varied backgrounds and the schools themselves varied in means of teaching powers.
- There was also a difference between the lecturing team-members and their abilities to draw the attention of the students.
- Some questions were presented in the negative formulation (e.g. “It is not allowed to drink cold water”), which could have led to misunderstanding, which answer to choose (Yes or No)!
- A final possibility is that such information is not interesting enough for such a target group, and the shyness and preservation of these young girls to discuss such sensitive matters.