- Academic Editor
Background: Dysmenorrhea is the most common pelvic pain phenomenon during menstruation in women of reproductive age, and is often characterized by social, educational, and economic impact. The objective of the study is to update the epidemiological and clinical characteristics of dysmenorrhea in a university setting, in a low- and middle-income country (LMIC). Methods: A prospective longitudinal descriptive study, over 6 months, conducted in three university residences in Cocody, Abidjan, the capital of Côte d’Ivoire. It involved female students of all levels of study, present at the time of the survey, volunteers and suffering from menstrual pain for more than 12 months, with an intensity higher than 3 on the visual analog scale (VAS). Pain intensity was divided into mild (1–3), moderate (4–5), and severe (7–10) on the VAS. Students with unstable psychological status or with a disability were not included. After obtaining administrative approval from the university, the questionnaire was administered. The parameters studied were general data and specific characteristics of dysmenorrhea. Statistical analysis was performed using EPI INFO 3.5.4 software (Center for disease control and prevention (CDC), Atlanta, GA, USA). Results: The incidence of dysmenorrhea was 79.7%, with an average age of 23.40 years and a median age of 23 years. These students were aged between 20 and 35 (75%), and participated in undergraduate courses (55.8%). The main form of dysmenorrhea was primary (74.2%), the pain location was pelvic (42.3%) or diffuse (53.1%), protomenial (51.2%), severe pain (56.9%), and torsional pain (44.2%), which affects school activities, with an average duration of 3.49 days. Conclusions: Dysmenorrhea is a common disease among women of childbearing age, and due to social and cultural considerations, it may be underdiagnosed in low resources countries. Due to its diverse symptoms, it has a negative impact on the quality of life, leading to a decrease in enrollment rates.
Dysmenorrhea refers to pelvic pain during menstruation, and is one of the most common gynecological diseases among adolescent women of childbearing age [1, 2, 3, 4, 5]. Generally speaking, two types of dysmenorrhea are described. Primary dysmenorrhea involves many young girls, occurring several months or years after the onset of menstruation, without gynecological anatomical support. Secondary dysmenorrhea on the other hand, was observed in women in their 30s and 40s, and is associated with organic pelvic pathology [2, 3, 4, 5, 6].
Reports of school and work absenteeism due to unmet menstrual needs have rapidly increased attention to menstruation in policy and practice [2, 3, 4, 5]. The impact on family and social life, friendships, school and work performance has significant social and economic dimensions [4, 5, 6]. The estimated prevalence of diseases in developed countries is very high [1, 2], and underestimated in low-and middle-income countries (LMICs) [6, 7, 8, 9, 10]. In fact, few girls or teenagers in these countries are aware of this, and their views or attitudes toward pain are not well expressed [1, 2]. However, in African countries, especially Cote d’Ivoire, there seems to be few quantitative studies reported in the published literature related to this disease [6, 7, 8, 9, 10].
The pathogenesis of dysmenorrhea is based on the excessive production of prostaglandin, accompanied by excessive muscular atrophy, local ischemia and hypoxia [11, 12, 13], or organ pathology of menstrual blood flow obstruction [14, 15, 16]. In addition, menstrual pain, irritability, insomnia, discomfort, headache, nausea, vomiting, diarrhea, and fatigue are often considered important reasons for school absenteeism.
The management of primary dysmenorrhea is mainly related to two types of therapeutic drugs: anti-inflammatory drugs and estrogen and progestogen pills used alone or in combination, with good results [12].
Some studies have shown that transcutaneous electrical nerve stimulation [11, 16], acupuncture, and moxibustion [1, 11, 16, 17] have moderate efficacy, which is not available in our country. Due to social and cultural beliefs, some women do not take medication for a painful crisis [6, 7, 8, 9, 10, 11]. The purpose of this study is to update the epidemiological and clinical characteristics of dysmenorrhea in the environment of LMIC’s University, in sub–Saharan Africa.
This is a prospective descriptive cross-sectional study, conducted over six
months, on female students who suffer from menstrual pain, in three university
residences in the city of Cocody, Cote d’Ivoire. We included all volunteers and
present students, who reported more than 12 months menstrual pain, with an
intensity greater than 4 on the Visual Analogue Scale (VAS). This intensity was
chosen because it corresponds to the theoretical threshold of clinical pain
tolerance. VAS pain intensity is divided into mild (1 to 3), moderate (4 to 5),
and severe (7 to 10) pain. Students with fragile psychological states and people
with disabilities (blind, deaf, mute) are not included. For the clinical judgment
of dysmenorrhea, we also used a “clinical score” which takes into account the
following symptoms: pelvic pain, low back pain, vomiting, nausea, diarrhea,
intestinal disorders, irritability, fatigue, myalgia, lipothymia, and
absenteeism. Their scores range from 0 to 3, allowing for the definition of mild
(1 to 10), moderate (11 to 20), and severe (21 to 30) pain. The anonymous
questionnaire was randomly administered in the different university residences by
the chief investigator. For the research sampling method, we randomly selected
the number of buildings in various university dormitories in Abidjan. The sample
size (N) was determined using Fischer’s method: N = [£
We interviewed 326 female students, of which 260 experienced painful periods, with a prevalence rate of 79.7%. The average age was 23.40 years with a standard deviation of 5.13 years. Most people were between the ages of 20 and 35 (75%) and graduated with a bachelor’s degree (55.8%). Table 1 present student’s general data and Table 2 summarizes the clinical characteristics of dysmenorrhea.
Variables | Numbers | (%) | |
University residence | N = 260 | ||
Campus | 137 | 52.7 | |
City Mermoz | 77 | 29.6 | |
Red city | 46 | 19.7 | |
Age range (years) | |||
55 | 21.2 | ||
20–25 | 132 | 50.8 | |
26–35 | 63 | 24.2 | |
10 | 3.8 | ||
Education level | |||
Bachelor’s | 145 | 55.8 | |
Masters | 92 | 35.4 | |
PhD | 23 | 8.8 | |
Ivorian ethnic groups | 217 | 83.5 | |
Southeast | 119 | 45.8 | |
North | 38 | 14.6 | |
Southwest | 60 | 23 | |
Ivorian ethnic groups students | 43 | 17.7 |
Variables | Students (n = 260) | (%) | |
Types of dysmenorrhea | |||
Primary | 193 | 74.2 | |
Secondary | 67 | 25.8 | |
Painful location | |||
Pelvic | 111 | 42.3 | |
Lumbar region | 11 | 4.2 | |
Abdominal diffuse | 138 | 53.1 | |
Pain duration (day) | |||
1–2 | 101 | 38.8 | |
3–5 | 123 | 47.3 | |
5–10 | 32 | 12.3 | |
4 | 1.5 | ||
Pain occurrence time | |||
Premenstrual | 125 | 48.1 | |
Protomenial dysmenorrhea | 133 | 51.1 | |
Telemenial dysmenorrhea | 2 | 0.8 | |
Pain intensity (VAS) | |||
4 to 5 (minor) | 13 | 5.0 | |
6 to 7 (moderate) | 99 | 38.1 | |
8 to 10 (severe) | 148 | 56.9 | |
Types of painful crisis | |||
Torsion-like pain | 115 | 44.3 | |
Tingling pain | 57 | 21.9 | |
Spasmodic pain | 88 | 33.8 |
VAS, visual analog scale.
Dysmenorrhea was primary (74.2%), with pelvic pain (42.3%), or diffuse
abdominal pain location (53.1%) (Table 2). The average duration is 3.49 days,
with a minimum of 1 day and a maximum of 11 days. The pain occurrence is
protomenial (51.1%), with an intensity of 8 to 10 (56.9%) and involves torsion
(44.2%), which has an impact on school activities (Table 2). In Table 3, we saw
that the dysmenorrhea had a definite impact on academic activity in more than
half of the (64.2%). The main symptoms described are, weakness (49.2%), nausea
associated with vomiting (37.3%), occurrence of diarrhea (36.5%) and emotional
irritability (32.7%). This symptomatology was at the origin of a cessation of
schooling (35.0%) or even a bed rest (27.3%). Symptoms such as irritability
(p
Data | Students (n = 260) | % | |
Impact on academic activity | |||
Yes | 167 | 64.2 | |
No | 93 | 35.8 | |
Supporting signs | |||
Weakness | 128 | 49.2 | |
Nausea and vomiting | 97 | 37.3 | |
Diarrhea | 95 | 36.5 | |
Irritability | 85 | 32.7 | |
Headaches | 73 | 28.1 | |
Sadness | 70 | 26.9 | |
Vertigo | 62 | 23.8 | |
Insomnia | 56 | 21.5 | |
Joint pain | 52 | 20.0 | |
Palpitation | 15 | 5.8 | |
Types of impact on academic activities | 167 | 64.2 | |
Stop activity | 91 | 35.0 | |
Bedtime | 71 | 27.3 | |
Hospitalization treatment | 5 | 1.9 |
Data | Interruption of academic activity (n = 91) | None impact on academic activity (n = 93) | Odds ratio (95% CI) | p value | |
Supporting signs | |||||
Irritability | 54 | 31 | 2.91 (1.60–5.32) | p | |
Insomnia | 38 | 18 | 2.98 (1.54–5.79) | p | |
Joint pain | 19 | 33 | 0.47 (0.24–0.92) | p | |
Kind of pain | |||||
Torsion | 81 | 34 | 14.05 (6.43–30.68) | p | |
Pain intensity (VAS) | |||||
4 to 5 (minor) | 2 | 11 | 0.16 (0.03–0.77) | p | |
6 to 7 (moderate) | 39 | 60 | 0.41 (0.22–0.74) | p | |
8 to 10 (severe) | 80 | 67 | 2.88 (1.29–6.13) | p | |
Location of pain | |||||
Pelvic | 45 | 66 | 0.51 (0.27–0.95) | p | |
Abdominal diffuse | 88 | 50 | 25.22 (7.44–85.51) | p | |
Pain duration (day) | |||||
1–2 | 11 | 90 | 0.0046 (0.0012–0.017) | p | |
3–5 | 33 | 90 | 0.019 (0.0056–0.06) | p | |
5–10 | 28 | 4 | 9.88 (3.30–29.59) | p |
CI, confidence interval.
Data | Bed rest (n = 71) | No Bed rest (n = 96) | Odds ratio (95% CI) | p value | |
Symptoms related to pain | |||||
Weakness | 37 | 91 | 0.059 (0.02–0.16) | p | |
Nausea and vomiting | 25 | 72 | 0.12 (0.065–0.24) | p | |
Diarrhea | 65 | 30 | 8.66 (4.32–17.41) | p | |
Sadness | 8 | 37 | 0.20 (0.08–0.47) | p | |
Vertigo | 18 | 44 | 0.25 (0.13–0.49) | p | |
Insomnia | 18 | 38 | 0.31 (0.16–0.61) | p | |
Types of pain | |||||
Torsion | 68 | 47 | 24.63 (6.95–80.33) | p | |
Spasmodic | 19 | 59 | 0.22 (0.11–0.44) | p | |
Pain intensity (VAS) | |||||
8 to 10 (severe) | 67 | 81 | 3.10 (0.98–9.79) | p | |
Location of pain | |||||
Pelvic | 55 | 56 | 2.45 (1.23–4.88) | p | |
Diffuse abdominal pain | 68 | 70 | 8.41 (2.43–29.11) | p | |
Pain duration (day) | |||||
1–2 | 11 | 90 | 0.01 (0.22–0.14) | p | |
3–5 | 33 | 90 | 0.05 (0.0056–0.06) | p | |
5–10 | 28 | 4 | 14.97 (4.94–45.37) | p |
VAS, visual analog scale.
Dysmenorrhea is one of the most common and significant health problems, especially among adolescent girls. It results in some negative effects on their daily activities. As described in the West Africa literature, our findings support the claim that menses is the root cause of work and school absenteeism [8, 9, 10]. It is reported that absenteeism presents such high rate, that should rise our vigilance. Therefore, we should pay more attention to this missing part in the life of women’s lives of childbearing age.
We reported a study that was located in university dormitories in a sub-Saharan country Capital, revealing a significant incidence of dysmenorrhea. However, this prevalence rate only reflects a small portion of the general population, and does not allow predictions of national prevalence rates. In literature, similar discoveries have been made by African [3, 8, 9, 10, 17, 18, 19, 20, 21, 22] and Western authors [1, 2, 6, 14, 15, 16, 19, 20]. Dysmenorrhea was reported by majority of respondents aged between 20 and 25, as widely described in Western literature [1, 2, 6, 12, 13, 14, 15, 16, 19], Asia or Africa [3, 5, 6, 7, 8, 9, 10]. In fact, dysmenorrhea is widely observed in girls aged 12 to 17 years [1, 2, 3, 12, 19, 20, 21, 22, 23]. The main gynecological complaint of adolescents is dysmenorrhea. In some adolescent series, girls are quite young, with an average age of 14.37 years [1, 3, 8, 11, 19]. However, in this study, this age group was also affected, with a relatively small proportion (21.2%). Primary dysmenorrhea is defined as pain during the menstrual cycle in the absence of an identifiable cause. This form dominated in this study as widely reported in literature [2, 3, 4, 8, 9, 10, 20, 21], where it was considered one of the most common causes of pelvic pain in women. The prevalence of dysmenorrhea is difficult to determine as it is usually considered a normal condition [1, 2], although in this study, more than half of the students experienced severe pain on VAS (56.92%). Dysmenorrhea was moderate, and pain severity stayed relatively constant with age [12, 13, 14, 15, 16, 19]. Noncyclical pelvic pain at least once a month was reported by more than a half of participants [16, 19]. Other studies have confirmed this, indicating that the assessment of pain severity and intensity may be subjective due to sociocultural considerations or dysmenorrhea age [1, 5, 8, 9, 10, 19].
The report on menstrual abnormalities leading to absenteeism quickly increased
attention to menstruation in policy and practice. However, there seem to be few
quantitative studies reported in the published literature that capture the
prevalence of this hypothetical absenteeism level caused by menstruation [4, 14, 17]. In most LMICs, the high cost of medical services and insufficient medical
insurance limit the use of healthcare (appointment and treatment). This tends to
reinforce negative perceptions of health problems, including minimizing the
extent of dysmenorrhea-related disorders [3, 5, 6, 7, 8, 9, 10, 21, 22, 23]. However, when these
pains are associated with disabling symptoms such as weakness, diarrhea, and
irritability, medical consultation should be systematic [4, 13, 14]. Women
described the negative effects of these symptoms on social, occupational, and
relational activities [4, 6, 13, 14, 15], as this type of dysmenorrhea is a cause of
diseases such as absenteeism, intellectual decline, and decreased school
performance [4, 6, 13, 14, 15]. Studies assessed the socio-professional, and economic
impacts of dysmenorrhea management, including significant money losses [13, 14, 15, 16, 17, 18].
The low financial losses observed in African countries are believed to be related
to the low attendance rates of health facilities. In this study, due to limited
income, few female students consulted doctors (19.23%). In addition, menstrual
torsion like painful crisis (p
Dysmenorrhea is a common disease among women of childbearing age, especially young girls. Due to social, cultural, and financial considerations, even in a university environment, poor countries may have insufficient diagnosis or poor treatment. The negative impact on quality of life, work and school attendance, physical and psychological emotions is undeniable. Effective management is mainly based on pain relief, through pharmacological means or the use of alternative procedures.
Data supporting the results of this study are available from the corresponding author, but restrictions apply to their availability. The data were used under license for the current study, and are therefore not publicly available. However, the data are available from the authors upon reasonable request and with permission from Dehi Boston Mian.
PN’G, DBM, VA, KN’G and SB made substantial contributions to conception, acquisition, or interpretation of data. PN’G, DBM, VA, KN’G, SB, have been involved in drafting the manuscript or reviewing it critically for important intellectual content. PN’G, DBM, VA, KN’G, SB, given final approval of the manuscript to be published, have participated in the work to take public responsibility for appropriate portions of the content, and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
We have obtained the approval of the National Committee of Ethics of Health and Life (N 322666-CI/2020) of the Felix Houphouet Boigny University for the publication of this manuscript. All subjects gave their informed consent for inclusion before they participated in the study.
The authors would like to thank the students in the university residences and the administrative authorities of the university residences.
This research received no external funding.
The authors declare no conflict of interest.
Publisher’s Note: IMR Press stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.