Prevalence of primary dysmenorrhea and associated factors in adult women

SUMMARY

OBJECTIVE:

This study aimed to assess the prevalence and factors associated with primary dysmenorrhea in a sample of adult women.

METHODS:

A cross-sectional study was carried out with women aged between 19 and 49 years from a city of northeastern Brazil. Sociodemographic, gynecological, and obstetric variables were assessed by questionnaires and interviews. Dysmenorrhea was measured by self-report, and the Numerical Pain Rating Scale measured the intensity of pain. Statistical analyses included χ² test, ANOVA, and logistic regression.

RESULTS:

The average age was 33.2±9.1 years and the prevalence of primary dysmenorrhea was 56% for the whole sample. The average duration of symptoms was 2.7±1.8 days and the mean intensity was 6.1±2.6. The previous cesarean section was associated with a higher rate of primary dysmenorrhea (PR=2.33; 95%CI 1.11–4.90) when considering the whole sample. Women who aged 25–39 years and are insufficiently active had higher rates of primary dysmenorrhea (PR=5.24; 95%CI 1.08–27.31).

CONCLUSION:

Primary dysmenorrhea has a high prevalence in young adults, adults, and middle-aged women. Cesarean section and being physically inactive was associated with increased rates of dysmenorrhea among adult women.

KEYWORDS:
Cross-sectional studies; Dysmenorrhea; Epidemiology; Prevalence; Women’s health

INTRODUCTION

Dysmenorrhea is defined as colic pain in the hypogastrium that occurs during menstruation and other symptoms like sweating, headaches, nausea, vomit, diarrhea, and tremors may occur associated¹. Dysmenorrhea is classified into primary (menstrual pain without organic disease) or secondary (menstrual pain associated with another preexistent disease, e.g., endometriosis)¹,².

The prevalence of primary dysmenorrhea (PD) is well studied among teenagers and youngers in different countries and it ranges from 16 to 91%³,⁴. Several risk factors are established in the literature and the casuistic of PD may involve social, demographic, behavioral, gynecological, and reproductive issues¹,⁴,⁵.

As the majority of studies about PD were conducted with students and teenagers, the generalization of these evidence for women of all adult age, including middle-aged women, are limited and needs more clarification⁴. Besides that, it is estimated that the prevalence of PD is even higher since many women associate dysmenorrhea as a normal menstrual cycle pain and do not seek medical assistance for this condition¹.

The perception and coping of pain related to PD vary from the women’s context. Then, issues related to work, social roles, and women’s empowerment can modify these perception among different age groups⁶. This fact reinforces the relevance to know the prevalence of PD and associated factors in the different stages of a woman’s adult life and not just in adolescence.

Moreover, PD represents relevant cause of school and work absence, negatively affects academic performance, productivity, daily life activities, and quality of life of these women⁴,⁷. Then, knowing the prevalence and associated factors in the different ages of woman’s life may allow to intervene and minimize the impacts of dysmenorrhea on the lives of these women⁸. Therefore, this study aimed to assess the prevalence and associated factors to PD in adult women (19–49 years of age).

METHODS

A cross-sectional, community-based study was conducted from December 2015 to November 2016, in the municipality of Santa Cruz, Rio Grande do Norte, Brazil. The Ethical and Research Committee of Federal University of Rio Grande do Norte approved the research protocol under number CAAE 49237315.9.0000.5568. The study followed the Declaration of Helsinki and all the participants signed the informed consent form.

The sample size was determined using the prevalence of 67.5% of dysmenorrhea, power of 90%, and a nonresponse rate of 5%, resulting in a sample of 195 women. This prevalence was obtained in a previous pilot study with 30 women following the same inclusion criteria (data not shown).

Women were proportionally recruited from among the six services of primary healthcare services of the city. Women were approached for convenience while accompanying a relative or waiting for an appointment for themselves. Previously trained interviewers conducted the interviews in a silent, private place of the health care services.

Women, who aged 19–49 years, with the regular menstrual flow in the last 3 months, and who accepted to participate in the study, were included. Exclusion criteria included women who reported a medical diagnosis of endometriosis, adenomyosis, uterine myoma, or pelvic inflammatory disease; in hormone replacement therapy; or had a history of hysterectomy.

Primary dysmenorrhea was assessed by self-reporting of colic-type pain in the lower abdomen associated with menstruation in the last 3 months⁴. The Numeric Pain Rating Scale (NPRS) assesses the intensity of pain (0–10)⁹. The duration of pain was expressed in days.

Independent variables were obtained by conducting interview and include age (grouped into young adults: 19–24 years, adults: 25–39 years, and middle-aged women: 40–49 years); family income (≤1 minimum wage or more); religion; age of menarche (≤11 years old or ≥12); use of any contraceptive method; menstrual cycle length dichotomized into 28–35 days and (<28 or >35 days); and number of children, cesarean section, and vaginal delivery.

Constipation was determined according to ROMA III criteria¹⁰ and the sexual dysfunction was defined as a score <60 points in the Female Sexual Quotient Questionnaire¹¹. The presence and type of urinary incontinence was determined by conducting interview following the recommendations of International Continence Society¹². The short-form of International Physical Activity Questionnaire (IPAQ) evaluated the level of physical activity, and <600 METs-minute/week indicated insufficiently active women¹³.

Data analyzes were conducted by the software SPSS, version 22. The Kolmogorov–Smirnov test confirms the normal distribution of continuous data. We expressed categorical data by absolute and relative frequencies, and continuous data through mean and standard deviations.

Prevalence of dysmenorrhea was calculated for overall and for age groups. ANOVA compared the variance among groups to intensity and duration of pain. Binary logistic regression was performed and the variables with p<0.20 were included in the multivariate logistic regression. Statistical significance was defined as p<0.05.

RESULTS

Initially, we invited 211 women to participate. Of those, 16 were excluded for having a history of hysterectomy (n=7) or being pregnant (n=9), resulting in 195 women included in the study with a mean age of 33.16±9.06 years old. Sociodemographic and clinical profile is shown in Table 1.

Table 1
Social demographic and clinical profile of sample grouped by age (n=195).

Variables		Women
		Young adults (n=40)	Adults (n=96)	Middle-aged women (n=59)
		%
Family income*
	≤1 minimum wage	80.0	79.2	79.7
	>1 minimum wage	20.0	20.8	20.3
	Profess some religion	77.5	85.4	88.1
	Insufficiently physically active	17.5	21.9	13.6
Age of menarche
	≤11 years old	17.5	17.7	22.0
	≥12 years old	82.5	82.3	78.0
	Use any contraceptive method	60.0	49.5	55.2
Menstrual cycle length (n=172)
	28–35 days	68.6	76.2	71.7
	<28 days or >35days	31.4	23.8	28.3
	Constipation	37.5	29.2	44.1
	Urinary incontinence	15	16.7	30.5
	Stress urinary incontinence	7.5	6.3	16.9
	Urgency urinary incontinence	2.5	4.2	6.8
	Mixed urinary incontinence	5.0	6.3	6.8
	Sexual dysfunction	27.5	36.7	40.0
	Have children	75.0	82.3	81.4
	≥1 Cesarean section (n=146)	70.0	66.7	61.0
	≥1 Vaginal delivery (n=146)	67.5	76.0	69.5

• ^*
  In 2016, the value of a minimum wage in Brazil was R$ 880.00.

The prevalence of PD was 55.9% in all samples, and 50% in young adults, 55% in adults, and 61% in middle-aged women. Pain intensity and duration of complaints did not differ among groups (Table 2).

Table 2
Comparative analyses of mean intensity and duration of pain during the menstrual cycle among young adult, adult, and middle-aged women (n=109).

	Intensity of pain (NPRS) Mean±SD	Duration of pain (days) Mean±SD
Total sample	6.14±2.55	2.68±1.83
Young adults	6.70±2.58	2.80±1.61
Adults	5.87±2.55	2.40±1.57
Middle-aged womens	6.22±2.56	3.03±2.22
ANOVA (p-value)	0.454	0.265
Young adults×adults (p-value)*	0.433	0.477
Young adults×middle-aged women (p-value)*	0.782	0.895
Adult×middle-aged women (p-value)*	0.798	0.247

• ^*
  p-value was calculated by the post hoc Tukey test. NPRS: Numeric Pain Rating Scale.

The results of univariate and multivariate logistic regression are shown in Table 3. Having at least one cesarean section was associated with 2.33 times risk of having PD among women aged 19–49 years. Among the adult women, who were insufficiently physically active, it was associated with 5.42 times risk of having PD.

Table 3
Association of independent variables with dysmenorrhea by age groups.

Variables		All sample (n=195)					Young adults (n=40)		Adults (n=96)		Middle-aged women (n=59)
		Crude PR (95%CI)	p	Adjusted PR (95%CI)	p	Adjusted PR (95%CI)	p	Adjusted PR (95%CI)	p	Adjusted PR (95%CI)	p
Profess some religion		0.59 (0.26–0.33) ref.	0.200	0.46 (0.17–1.21) ref.	0.116	–	–	–	–	–	–
	Yes
	No
Family income (R$ 880.00)		–	–	–	–	–	–	–	–	0.13 (0.14–1.31) ref.	0.084
	≤1 minimum wage
	>1 minimum wage
Age at menarche		–	–	–	–	–	–	1.18 (0.32–4.35) ref.	0.802	–	–
	≤11 years old
	≥12 years old
Menstrual cycle length		1.66 (0.81–3.41) ref.	0.168	2.05 (0.90–4.64) ref.	0.086	–	–	3.11 (0.87–10.91) ref.	0.076	–	–
	menstrual cycle >35 or <28 days
	28–35 days
Use of the contraceptive method		–	–	–	–	2.68 (0.58–12.31) ref.	0.206	–	–	–	–
	Yes
	No
Urinary incontinence		0.51 (0.25–1.02) ref.	0.058	0.84 (0.33–2.13) ref.	0.709	–	–	0.52 (0.11–2.54) ref.	0.418	–	–
	Yes
	No
Mixed urinary incontinence		0.24 (0.06–0.92) ref.	0.038	0.33 (0.46–2.35) ref.	0.267	–	–	0.15 (0.01–3.97) ref.	0.256	–	–
	Yes
	No
Insufficiently physically active		–	–	–	–	–	–	5.42 (1.08–27.31) ref.	0.040	–	–
	Yes
	No
Sexual dysfunction		0.57 (0.30–1.06) ref.	0.077	0.61 (0.29–1.24) ref.	0.172	–	–	–	–	0.38 (0.09–1.59) ref.	0.185
	Yes
	No
Have children		0.60 (0.29–1.25) ref.	0.174	1.00 (0.38–2.66) ref.	0.997	0.22 (0.04–1.35) ref.	0.102	–	–	–	–
	Yes
	No
Cesarean section		1.99 (1.09–3.62) ref.	0.025	2.33 (1.11–4.90) ref.	0.026	2.94 (0.60–14.64) ref.	0.185	–	–	1.55 (0.32–7.51) ref.	0.587
	One or more
	None
Vaginal delivery						–	–	1.28 (0.39–4.23) ref.	0.683	0.15 (0.02–1.14) ref.	0.066
	One or more
	None

DISCUSSION

Primary dysmenorrhea is characterized by uterine hypercontractility provoked by the overproduction of prostaglandins in the endometrium, leading to uterine muscle ischemia, hypoxia, and, subsequently, pain¹⁴. Although PD is often a gynecological complaint, it is underdiagnosed, undertreated, and even undervalued by women themselves¹⁴. Our findings show that PS has a high prevalence throughout a woman’s adulthood, contradicting evidence that suggests a decrease in pain after pregnancies³. However, it was observed that risk factors may differ according to the progression of the life cycle and classical factors involved in physiology of PD were not associated with contraceptive methods, menarche age, and having children⁴,¹⁴.

In our study, cesarean section was associated with more cases of PD. It is a warning sign because the cesarean is the most common type of operation performed on women, and women who had undergone multiple cesarean sections can progress with cesarean scar defects¹⁵. The cesarean scar defect when symptomatic is often related to dysmenorrhea and chronic pelvic pain¹⁶,¹⁷. In this context, the nerve section, inadvertent nerve ligation of fibrous scarring, and myofascial syndrome result in menstrual and chronic pelvic pain¹⁷,¹⁸.

Physical inactivity was associated with a higher frequency of PD. The physical activity has positive effects on stress, prostaglandin levels, and blood circulation, resulting in decreased pain and the prevalence of dysmenorrhea¹⁹. Then, women who do not perform exercise do not receive this benefit of endogenous opioids²⁰. Therefore, it is one more motif to encourage women to remain physically active.

Our data are innovative by assessing PD in a sample containing older adults than other studies available in the Brazilian population. Despite this, the generalization of data should be made with caution because our data were collected in a small town, and the prevalence and associated factors to dysmenorrhea in women who live in large cities can be different.

As a limitation of the study, we can mention the use of a convenience sample, the cross-sectional design that prevents the establishment of cause-and-effect relationships, and the collection of data through interviews. For future studies, more robust methodological designs that include clinical assessment are recommended to better establish the relationships found in this study.

CONCLUSION

There was a high prevalence of PD with rates above 50% in adult women of all ages. In this study, only cesarean section and being physically inactive was associated with increased rates of dysmenorrhea among adult women.

• Funding: none.

REFERENCES

• ¹
  Bernardi M, Lazzeri L, Perelli F, Reis FM, Petraglia F. Dysmenorrhea and related disorders. F1000Res. 2017;6:1645. https://doi.org/10.12688/f1000research.11682.1
  » https://doi.org/10.12688/f1000research.11682.1
• ²
  Urbano-Ruiz A, Soares Jr JM, Rossi AGZ, Louback RM, Hummel FV, Baracat EC. Female pelvic pain: a case report of mucocele of the appendix. Eur J Gynaecol Oncol. 2011;32(6):672-3. PMID: 22335033
• ³
  Ju H, Jones M, Mishra G. The prevalence and risk factors of dysmenorrhea. Epidemiol Rev. 2014;36(1):104-13. https://doi.org/10.1093/epirev/mxt009
  » https://doi.org/10.1093/epirev/mxt009
• ⁴
  Burnett M, Lemyre M. No. 345-Primary Dysmenorrhea Consensus Guideline. J Obstet Gynaecol Can. 2017;39(7):585-95. https://doi.org/10.1016/j.jogc.2016.12.023
  » https://doi.org/10.1016/j.jogc.2016.12.023
• ⁵
  Nicolau SM, Soares JM, Schor E, Gonçalves WJ, Freitas V, Baracat EC. Schistosoma mansoni pseudo-cyst as a cause of chronic pelvic pain. J Obstet Gynaecol Res. 2003;29(6):392-4. https://doi.org/10.1111/j.1341-8076.2003.00134.x
  » https://doi.org/10.1111/j.1341-8076.2003.00134.x
• ⁶
  Samulowitz A, Gremyr I, Eriksson E, Hensing G. “Brave men” and “emotional women”: a theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain. Pain Res Manag. 2018;2018:6358624. https://doi.org/10.1155/2018/6358624
  » https://doi.org/10.1155/2018/6358624
• ⁷
  Hashim RT, Alkhalifah SS, Alsalman AA, Alfaris DM, Alhussaini MA, Qasim RS, et al. Prevalence of primary dysmenorrhea and its effect on the quality of life amongst female medical students at King Saud University, Riyadh, Saudi Arabia. Saudi Med J. 2020;41(3):283-9. https://doi.org/10.15537/smj.2020.3.24988
  » https://doi.org/10.15537/smj.2020.3.24988
• ⁸
  Mu J, Wang Q, Dun W, Yang J, Wang K, Zhang M, et al. The effects of long-term menstrual pain on pain empathy in women with primary dysmenorrhea. Pain. 2021;162(7):2051-9. https://doi.org/10.1097/j.pain.0000000000002205
  » https://doi.org/10.1097/j.pain.0000000000002205
• ⁹
  Boonstra AM, Stewart RE, Köke AJ, Oosterwijk RFA, Swaan JL, Schreurs KMG, et al. Cut-off points for mild, moderate, and severe pain on the numeric rating scale for pain in patients with chronic musculoskeletal pain: variability and influence of sex and catastrophizing. Front Psychol. 2016;7(Sep):1466. https://doi.org/10.3389/fpsyg.2016.01466
  » https://doi.org/10.3389/fpsyg.2016.01466
• ¹⁰
  Dantas AAG, Barbosa IR, Castro SS, Ferreira CWS, Camara SMA, Dantas DS. Prevalence and factors associated with constipation in premenopausal women: a community-based study. Arq Gastroenterol. 2020;57(2):188-92. https://doi.org/10.1590/S0004-2803.202000000-36
  » https://doi.org/10.1590/S0004-2803.202000000-36
• ¹¹
  Abdo CHN. Quociente sexual feminino: um questionário brasileiro para avaliar a atividade sexual da mulher. Diagn Trat. 2009;14(2):89-1.
• ¹²
  Milsom I, Altman D, Cartwright R, Lapitan MC, Nelson R, Sillén U, et al. Epidemiology of urinary incontinence (UI) and other lower urinary tract symptoms (LUTS), pelvic organ prolapse (POP) and anal incontinence (AI). In: Abrams P, Cardozo L, Khoury S, Wein AJ, editors. Incontinence: 5th International Consultation on Incontinence. 5th ed. Paris: ICUD-EAU; 2013. p. 15-107. https://www.ics.org/Publications/ICI_5/INCONTINENCE.pdf
  » https://www.ics.org/Publications/ICI_5/INCONTINENCE.pdf
• ¹³
  Ahmad MH, Salleh R, Mohamad Nor NS, Baharuddin A, Rodzlan Hasani WS, Omar A, et al. Comparison between self-reported physical activity (IPAQ-SF) and pedometer among overweight and obese women in the MyBFF@home study. BMC Womens Health. 2018;18(Suppl 1):100. https://doi.org/10.1186/s12905-018-0599-8
  » https://doi.org/10.1186/s12905-018-0599-8
• ¹⁴
  Guimarães I, Póvoa AM. Primary dysmenorrhea: assessment and treatment. Rev Bras Ginecol Obstet. 2020;42(8):501-7. https://doi.org/10.1055/s-0040-1712131
  » https://doi.org/10.1055/s-0040-1712131
• ¹⁵
  Tulandi T, Cohen A. Emerging manifestations of cesarean scar defect in reproductive-aged women. J Minim Invasive Gynecol. 2016;23(6):893-902. https://doi.org/10.1016/j.jmig.2016.06.020
  » https://doi.org/10.1016/j.jmig.2016.06.020
• ¹⁶
  Deng J, Li S, Peng Y, Chen Z, Wang C, Fan Z, et al. Chinese herbal medicine for previous cesarean scar defect: a protocol for systematic review and meta-analysis. Medicine (Baltimore). 2020;99(50):e23630. https://doi.org/10.1097/MD.0000000000023630
  » https://doi.org/10.1097/MD.0000000000023630
• ¹⁷
  Nogueira AA, e Silva JCR, Poli Neto OB. The potential of cesarean section as a causative factor of chronic pelvic pain. Rev Bras Ginecol Obstet. 2016;38(2):53-5. https://doi.org/10.1055/s-0036-1571850
  » https://doi.org/10.1055/s-0036-1571850
• ¹⁸
  Li R, Li B, Kreher DA, Benjamin AR, Gubbels A, Smith SM. Association between dysmenorrhea and chronic pain: a systematic review and meta-analysis of population-based studies. Am J Obstet Gynecol. 2020;223(3):350-71. https://doi.org/10.1016/j.ajog.2020.03.002
  » https://doi.org/10.1016/j.ajog.2020.03.002
• ¹⁹
  Prazeres LMA, Brito RG, Ramos ES. Regular physical exercise, sedentarism and characteristics of dismenorrhea and premenstrual syndrome. Fisioter Mov. 2018;31. https://doi.org/10.1590/1980-5918.031.AO18
  » https://doi.org/10.1590/1980-5918.031.AO18
• ²⁰
  Carroquino-Garcia P, Jiménez-Rejano JJ, Medrano-Sanchez E, Casa-Almeida M, Diaz-Mohedo E, Suarez-Serrano C. Therapeutic exercise in the treatment of primary dysmenorrhea: a systematic review and meta-analysis. Phys Ther. 2019;99(10):1371-80. https://doi.org/10.1093/ptj/pzz101
  » https://doi.org/10.1093/ptj/pzz101

Publication Dates

• Publication in this collection
  23 Feb 2022
• Date of issue
  Jan 2022

History

• Received
  11 Sept 2021
• Accepted
  01 Nov 2021