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Accepted Manuscript

Dysmenorrhea: Prevalence & Impact on Quality of Life among Young Adult JordanianFemales

Moamar Al-Jefout, MD, PhD, Dr Seham Abu-Fraijeh, MD Jameel Hijazeen, MDRanda Al-Qaisi, MD Ola Al-Maaitah, MD Oday Al-Maaitah, MD Georgina Luskomb,PhD

PII: S1083-3188(14)00259-9

DOI: 10.1016/j.jpag.2014.07.005

Reference: PEDADO 1741

To appear in: Journal of Pediatric and Adolescent Gynecology

Received Date: 10 May 2014

Revised Date: 28 June 2014

Accepted Date: 9 July 2014

Please cite this article as: Al-Jefout M, Abu-Fraijeh S, Hijazeen J, Al-Qaisi R, Al-Maaitah O, Al-MaaitahO, Luskomb G, Dysmenorrhea: Prevalence & Impact on Quality of Life among Young Adult JordanianFemales, Journal of Pediatric and Adolescent Gynecology (2014), doi: 10.1016/j.jpag.2014.07.005.

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Title:

Dysmenorrhea: Prevalence & Impact on Quality of Life among Young Adult

Jordanian Females Dr Al-Jefout Moamar1,

, MD, PhD; Abu-Fraijeh Seham1, MD; Hijazeen Jameel1, MD; Al-Qaisi Randa1,

MD; Al-Maaitah Ola1, MD; Al-Maaitah Oday1, MD; Luskomb Georgina2, PhD

1Department of Obstetrics & Gynecology, Mutah Medical Faculty, Mutah University, Karak, Jordan2 Queen Elizabeth II research Institute for Mother and Infants, Department of Obstetrics & Gynecology, Sydney University, Sydney, Australia

Correspondent author:

Mobile: +962-797377790.

Fax: +96-3232351728.

Mailing address: Postal code: 61151- Karak, Al-Thaniya, P.O Box 33. Jordan.

Email: [email protected]

Abstract: Study Objective To establish the prevalence and impact on quality of life of dysmenorrhea among young adult Jordanian females. Design: Cross-sectional study based on quantitative self reported anonymous questionnaire. Setting: University-based study. Participants: A total of 272 female medical students (aged 19-25 years). Intervention: None. Main outcome measures: Self-reports of menstruation-related pain symptoms and methods of dealing with them. Results: Of study subjects 152/272 (55.8%) participants had moderate and severe dysmenorrhea. Of them, 55.8% had a family history of severe dysmenorrhea compared with 33.1% of those without dysmenorrhea (2 = 13.40, df = 1, p < 0.001). There was strong association between severity of dysmenorrhea and poor university attendance (2 = 45.35, df = 2, p < 0.001), poor social activities (2 = 32.06, df = 2, p < 0.001), poor relationships with family (2 = 18.46, df = 2, p < 0.001) and friends (2 = 19.14, df = 2, p < 0.001), and poor sport activities (2 = 12.15, df = 2, p = 0.002). Dysmenorrhea worsens during examination periods in 50% of cases. The most common pain symptom was low back pain (60.2%). Body mass index, family monthly income and early age at menarche had no correlation with the occurrence of dysmenorrhea. Of those with dysmenorrhea, 69.4% were using analgesics. Mothers were the main source of information regarding menstruation. Conclusions: Dysmenorrhea is highly prevalent among young adult Jordanian females and seems to negatively affect quality of life, particularly as related to university attendance and performance and social relationships.

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Keywords: Young Adult Females; Dysmenorrhea; Menstruation; Quality of Life; School absence.

Introduction:

Menarche is the onset of menstruation and it is one of the most important events in a woman's life. The age of menarche in the Arab population was reported to be around 13 years [1-5]. Despite the fact that menstruation is a normal physiological process, it is not often discussed openly in Jordan [6]. Some women consider menstruation to be inconvenient or embarrassing [7-9]. This is partly due to the fact that menstrual issues, including menstrual pain and abnormal menstrual flow, are considered socially taboo subjects [10, 11]. Thus, population studies on the normal and abnormal features of menstruation and its related health problems are scarce in Arab societies. However, knowledge on this issue is necessary for patient education and to guide clinicians and health care providers towards the best possible clinical outcome.

Primary dysmenorrhea (PD) can be defined as a cramp-like pain in the lower abdomen at or around the onset of menstruation without any organic pelvic pathology with a reported prevalence between 50 and 90% [12]. Primary dysmenorrhea usually begins six to 12 months after menarche. It is the most common gynecologic complaint among adolescent and young adult females [13]. Dysmenorrhea is less common in early adolescence, when most of the menstrual cycles are anovulatory. However, it becomes more prevalent during mid and late adolescence, with the establishment of ovulatory menstrual cycles [14]. Other conditions such as abnormal and /or excessive uterine bleeding and premenstrual syndrome are also common menstrual disorders in young adult females. Symptoms such as low back pain, premenstrual irritability, nervousness, depression, headache, nausea, vomiting, bloating, constipation, diarrhea, fatigue, and an urge to urinate frequently may be observed in patients with dysmenorrhea during at least part or for the duration of menstruation [15-17]. Unfortunately, dysmenorrhea is not well studied world-wide due to the fact that females suffering from dysmenorrhea have usually been educated that it is normal to experience these pains, an incorrect assumption encouraged by families and most health care providers [18, 19].

Although primary dysmenorrhea is common among adolescent and young adult females, not all of them will require medication. However, at least 25% of women experience menstrual pain that forces them to use medication and even may cause absenteeism from study and interference with social activities [5, 20-23]. It seems that cultural and social practices regarding menstruation and related pains depend on girls' education, attitude, family environment, culture, and beliefs [4]. Despite the high prevalence of dysmenorrhea, many girls either do not seek medical advice or are under-treated [24] . In one study, a majority (98%) of adolescents used non-pharmacologic approaches to treat dysmenorrhea, with perceived

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effectiveness of 40% or less [25]. In other studies from different populations, 3070% of girls reported at least occasionally self-medicating with over-the-counter (OTC) pain medications [26]. Only half of young girls knew that certain medications could be helpful in relieving menstrual pains[27], and 27% of girls were unable to recognize any of three non-steroidal anti-inflammatory drugs (NSAID) listed as possible treatments for dysmenorrhea [28].

The data on dysmenorrhea and other menstrual problems and their impact on quality of life in Arab young adult females are limited and largely unknown. In this study we aimed to explore the menstrual characteristics, prevalence of pain symptoms, and the impact on quality of life among young adult Jordanian females. The obtained results may be helpful for future studies related to this issue.

Methodology:

Questionnaire The menstrual disorder of teenagers (MDOT) questionnaire was the base for this study [29]. Permission via correspondence was taken by main author to use the MDOT questionnaire. However, some modifications have been made to adjust to the specificity of the Arab population for the purposes of this study. . The language of the study was English as all participants were medical students who had a good command of the English language. The questionnaire took around 25 minutes or less to complete, and was structured with repetitions in themes and questions throughout to ensure the consistency of responses. The questionnaire had several sections which covered subjects around the characteristics of the study subjects in terms of age, geographical background, etc. (for details please refer to Appendix 1). A mixture of question types were used, including single and multiple response, rating scales, true/false statements and, at the end, an open-ended question, without the explicit use of the word dysmenorrhea. The survey also included questions about menstrual pattern, and how and from whom the students asked for information and help in case of painful menstruation. A visual analog scale evaluation was used for students who said that they had painful menstruation. In the concerned scale the students rated the severity of their pain between 1 and 10. The nine life activities listed in the interference section were: attending school; completing school work; social activities; sport and exercise; relationship with family, and relationship with friends. However, questions regarding relationships with partners and sexual activities were not included, as Jordanian community traditions do not promote premarital sexual relationships. Questions around casual paid work were also not included also because the greatest majority of medical students dedicate their entire time to studying.

Procedure and exclusion criteria

For data collection, Mutah Medical Faculty provided permission to approach all female medical students enrolled in the six-year medical program. After male students were dismissed from teaching halls, the

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female members of the research team explained the aims of the study and the procedure. They then asked the study subjects to sign an informed consent form to be collected separately from the questionnaire. The students who agreed to participate in our study then filled out the study questionnaire under the supervision of the research team to address any uncertainty. The exclusion criteria in our study were those refusing to participate in the study or to sign the consent form.

Approvals and data analysis

This study was approved by the Scientific Committee and the Ethics Committee at Mutah University. (Approval No - 2/2012). Data were entered into a Statistical Package for Social Sciences (SPSS) 20.0 database. Categorical data were assessed using chi-square tests; one independent-samples Students t-test and Mann-Whitney U z test were carried out. If results were skewed, we used non-parametric correlations (the Kruskal-Wallis and Spearmans tests). A P-value of $1700 and around 10% were below the poverty line in Jordan (monthly income < $700). More than 70% reported that their mothers were the main source of information about menstruation.

The majority of study subjects reported having a period every month (n=245/272, 90.1%) and just under two-thirds (n=159/272, 58.5%) had never missed a period. A little under half of the sample had problems with their periods (including pain and heavy flow) (n=123/267, 46.1%). However, about one-fifth reported to have had tests because things werent right (n=51/257, 19.8%). Menstruation was found to last 13 days in 4.1% of the students, 46 days in 61.7%, 710 days in 32.6% and 11 days and more in 0.9%.

The menstrual cycle median was 28 days and IQR from 27 to 29 days. Of 267 students reporting number of days of bleeding ranged from 3 to 10 days, mean 5.8 days, SD 1.3. This was significantly skewed: median 6 days, IQR 5 to 7 days. None of the respondents claimed to have bleeding for more than 10 days.

Menstrual pain symptoms prevalence and types:

Of the study subjects, 152 (55.8%) had moderate and severe dysmenorrhea. Symptoms typically accompany the start of menstrual flow or occur within a few hours before or after its onset, and last for the first 2448 hours. The different symptoms of pain associated with menstruation reported by study subjects experiencing menstrual pains were: lower back pains (62%), aching (30%), cramping (50%), stabbing (20%), dysuria (9%), pain when bladder is full (13%), pain with passing wind (9%) and pain during defecation (12%).

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Association between age at menarche and menstrual problems:

The median age of menarche was 13 years (range 9.0 to 18.0 years). However, age at menarche was significantly skewed; 5.3% (n=14/265) of subjects had reached menarche before the age of 12 years and 36.2% (n=96/265) from 14 years and onwards, so we used a non-parametric procedure (the Mann-Whitney U z test) to examine the relationship between age at menarche and menstrual problems. There was not a statistically significant difference in age at menarche between those with and without menstrual problems (z = -1.52, p = 0.128).

Because of the skewness, we used a non-parametric procedure (the Kruskal-Wallis test) to examine the relationship between age at menarche problems with periods and period pain occurrence. There was not a statistically significant difference in age at menarche between those with and without menstrual problems (z = -1.52, p = 0.128). In addition, there was no statistically significant difference in age at menarche between those with no/mild pain, moderate or severe pain (Kruskal-Wallis chi-square = 0.93, df = 2, p = 0.627). Moreover, both age at menarche and length of menstruation were significantly skewed so we used Spearmans non-parametric correlation. There was not a significant correlation between age at menarche and length of menstrual flow (rs = -0.05, p = 0.421, n = 260). In addition, there was no statistically significant difference between those women who did or did not rate at least one day of their period as heavy at age of menarche (Mann-Whitney U z = -1.53, p = 0.127).

Association between family monthly income and menstrual problems:

There was not a statistically significant relationship between monthly family income and menstrual problems (2 = 3.82, df = 2, p = 0.148). There was also not a statistically significant relationship between monthly family income and severity of menstrual pain over the previous six months (2 = 3.35, df = 4, p = 0.501). There was not a statistically significant relationship between monthly family income and having at least one day of heavy bleeding (2 = 1.01, df = 3, p = 0.603).

Association between BMI and menstrual problems:

The average BMI (Body mass index) in our study subjects was 22.2. Less than 1% of our study subjects had a BMI >30, 14.7 % had a BMI between 25 and 30, 72.8 % had normal BMI and 16% had a BMI

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0.080). In contrast, there was a statistically significant association between self-reports of menstrual problems and family history (mother or sister) of severe period pain. Of women with menstrual problems, 55.8% had a family history of severe period pain compared with 33.1% of those without menstrual problems (2 = 13.40, df = 1, p < 0.001).

The distribution of menstrual problems by university year:

The distribution of menstrual problems by university year differed significantly - from a low of 27.3% in year four to a high of 69.4% in year two. (linear by linear association 2 = 4.19, df = 1, p = 0.041). While there does not appear to be an obvious pattern here, the proportion of study subjects with menstrual problems among the first three years (59.6%, n=62/104) is higher than for the latter three years (38.9%, n=61/157). There was not a statistically significant relationship between university year and severity of menstrual pain over the previous six months (linear by linear association (2 = 0.07, df = 1, p = 0.787).

Aspects of the period that cause school absence (Table 1, Figure 1): Severity of pain:

There was a statistically significant association between severity of period pain of the past six months and whether or not periods being too painful caused school absence (2 = 73.97, df = 2, p < 0.001).

Heavy flow: There was a statistically significant association between severity of period pain of the past six months and whether or not periods being too heavy caused school absence (2 = 6.54, df = 2, p = 0.038).

Nausea related to periods: There was a statistically significant association between severity of period pain of the past six months and whether or not nausea related to the period caused school absence (2 = 11.87, df = 2, p = 0.003).

Vomiting related to periods: There was a statistically significant association between severity of period pain of the past six months and whether or not vomiting related to the period caused school absence (2 = 10.33, df = 2, p = 0.006).

Association between severity of menstrual pain over the past six months and life activities

There was a statistically significant association between severity of period pain in the past six months and whether or not periods caused university absence (2 = 59.47, df = 2, p < 0.001). There was a statistically significant association between severity of menstrual pain over the previous six months and degree to which periods interfered with attending university (2 = 45.35, df = 2, p < 0.001), with completing

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university work (2 = 46.21, df = 2, p < 0.001), with social activities (2 = 32.06, df = 2, p < 0.001), with relationships with family (2 = 18.46, df = 2, p < 0.001), with relationships with friends (2 = 19.14, df = 2, p < 0.001) and with sports and exercise (2 = 12.15, df = 2, p = 0.002) (Figure 1, Table 1).

School absence because of periods being painful and other complaints (heavy flow, vomiting and nausea) (Table 2, Figure 2):

Period problems affected school attendance: 4.8 % (n= 13) students claimed missing school in every period, 30.5 % claimed missing school with some periods (n= 83). Of them 27.6% missed one day at school. Fifty percent of females with period pains reported that their periods worsen during examination times.

Of 110 students who had mild pains, 10 (9.1%) missed school of 98 students with moderate pain, 35 (35.7 %) missed school, and of 54 students with severe pains, 41 (75.9%) missed school (p < 0.001). Of those with heavy flow and mild pains 6.4 % (n= 7), moderate pain 8.2% (n= 8) and severe pains 18.5% (n= 10) missed school (p = 0.038). Of those with nausea and mild pains 5.5% (n= 6), moderate pains 13.3% (n= 13), and with severe pain 24.1 % (n= 13) missed school (p = 0.003). Of those with vomiting and mild pains 0.9% (n=1), moderate pains 7.1% (n= 7) and with severe pains 13.0% (n= 7) missed school (p = 0.006).

Use and effectiveness of medication

163 of 235 (69.4%) with period pain (mild, moderate or severe) reported taking medication for relieving pain symptoms. The proportion of study subjects who take medication increases (from approximately half with mild pain, to three-quarters with moderate pain to 85% with severe pain). Of these 160 (missing 3 answers), 137 (85.6%) rated the medication as highly effective (scale 5 to 10). The most used medication among our study subjects was OTC Paracetamol (61.2%).

The usage of herbal medicine for menstrual pain:

In our data, 118 study subjects take traditional Arab herbs. Of 115 who answered the question about the effectiveness of herbs, 45 (39.1%) rated herbs as highly effective (scale 5 to 10). In 75.4% of cases these herbs were suggested by mothers.

Discussion:

We determined the median age at menarche for the subjects in this study as 13.0 years, which was in concordance with reports from other studies conducted in Jordan [2]. There was not a statistically significant difference in age at menarche and menstrual flow between those with no/mild pain, moderate or severe pain (p = 0.627). Our finding contradicts the conclusions of other studies where early menarche was related to an increase of dysmenorrhea prevalence and severity [30, 31] and is in concordance with the report of the Ethiopian authors [32].

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In this study we defined dysmenorrhea as painful menstruation (just before or during periods) in the past six months. In some studies, [33, 34] mild to intermediate menstrual pain has been considered sufficient to define dysmenorrhea. Others have considered dysmenorrhea to be menstrual pain associated with the need for medication and the inability to function normally [35]. These two definitions are quite different and there is a need to have a more specific unifying definition for dysmenorrhea among gynecologists, as the prevalence of dysmenorrhea in different studies may vary depending on how it is defined. This survey-based study is the first of its kind in our country and found the cumulative prevalence of mild to severe primary dysmenorrhea of 55.8%. This high prevalence of dysmenorrhea is higher than data reported by Bata et al [2] study; who reported a prevalence among adolescent girls of 38%. This discordance can be explained by the fact that our study subjects belong to an older age group in which periods are more ovulatory than in the adolescent group. Our data is in concordance with other reports [34, 36]. Interestingly, when exploring the percentage of study subjects with menstrual pain symptoms that caused them to miss days at university; the prevalence of dysmenorrhea dropped to 31.6% (n- 86 students).

Dysmenorrhea, either primary or secondary, is a common and important health problem that has a negative impact on the daily activities of young adult females in the menstrual and premenstrual periods. Pain is an extremely subjective symptom and it has been very difficult to quantify[37]. Researchers have, therefore, found out a way to measure pain by various scoring systems like VAS [38] . Depending on pain score obtained on VAS, pain was divided into mild, moderate and severe, a 3 point scale. In our study, the prevalence of dysmenorrhea depended on self-reported presence or absence of dysmenorrhea in the past 6 months. The most common pain symptoms were lower back pains (62%), aching (30%), cramping (50%), and accompanied by nausea and vomiting. Recent studies have shown that about two-thirds of adolescent girls with dysmenorrhea have laparoscopic evidence of endometriosis and one-third of these females with endometriosis have moderatesevere disease [39]. This means that around 10 students in our study may have undiagnosed endometriosis.

Regarding factors associated with the development of dysmenorrhea, a little under half of the sample had problems with their periods. However, about one-fifth reported to have had tests because things werent right. Our results also showed that of those females with menstrual problems, 42.1% reported a family history (mother or sister) of menstrual problems compared with 31.6% of those either without menstrual problems or did not know if there is family history. This was not a statistically significant association (p = 0.080). In contrast, there was a statistically significant association between self-reports of menstrual problems and family history (mother or sister) of severe period pain. However, of women with menstrual problems, 55.8% had a family history of severe period pain compared with 33.1% of those without menstrual problems (p < 0.001). In addition, neither body mass index nor family monthly income and early age at menarche had any positive correlation with the occurrence of dysmenorrhea.

In our data set, 10% of females with mild pain, 17 % of those with moderate pain and 29 % of those with severe pains missed university. Of them 4.8 % claimed missing classes in every period and 30.5 % claimed missing classes with some periods, with 27.6% of those with pains missing one day at university. Fifty percent of females with period pains reported that their periods worsen during examination times. Severity of pain either with heavy flow, with vomiting or with nausea symptoms was associated with high

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rates of missing school. Our data is in concordance with other reports regarding school absenteeism due to dysmenorrhea [12, 16, 40-43]. Moreover, menstrual pain symptoms caused a major interference with social and family relationships. Our results indicate that the adverse effects of dysmenorrhea on school performance and psychosocial aspects increase with increasing pain intensity. Therefore, females who experienced dysmenorrhea had negative relationships with their families and friends. This also negatively affected their school performance. Our results confirm the conclusions by other reports [36, 44].

In our study, more than 70% reported that their mothers were the main source of information about menstruation. This percentage is higher than the one reported by other similar studies conducted in similar societies [5]. This fact stresses the importance of educating both females and mothers regarding pain and menstrual flow symptoms. There is some evidence that educational intervention can improve the severity of dysmenorrhea and the quality of life [45].

Our results showed that only two-third of our study subjects are taking medication for pain symptoms. These results are the same as reported by another study [34] with Paracetamol as the first choice, which seems to work effectively (in 85%). Our results are in concordance with another report in Omani adolescence [43].The most common pharmacological treatments for dysmenorrhea are NSAIDs. NSAIDs inhibit cyclooxygenase, leading to a reduction in prostaglandin production. Moreover, less than half of our study subjects with dysmenorrhea are using traditional Arab herbs and less than 40% reported herbs as an effective option. Study subjects reported that mothers were the main person who suggested the use of herbs (75% of cases). Interventions such as herbal preparations have been reported to improve dysmenorrhea [46]. The need to explore the utilization of such remedies in dysmenorrhea treatment should be a subject for future research. Conclusions and Recommendations

This study highlights that dysmenorrhea prevalence is high among young adult females in Jordan (55.8%). Dysmenorrhea definition is still lacking and there is a real need for a consensus among gynecologists. Dysmenorrhea and associated pain symptoms were found to adversely affect university performance and social attitudes towards family and friends. It is concluded that increased awareness among our population (especially in families and among health care providers) and the development of educational programs for effective dysmenorrhea identification and management would be beneficial for young adult females and may improve their school performance and social relationships. This study will improve awareness among health care providers and allow them to be more sensitive to issues related to the management of dysmenorrhea as well as improve identification of young adult females with severe pains caused by endometriosis.

Limitations of the study

Small sample size is an important limitation of the study. Because menstruation-related problems are a 'taboo' subject in our population, we thought to start with a relatively small sample. However, we intend to explore this problem in a wider population in future studies. Another major weakness of this study is its failure to examine the possible associations between dysmenorrhea and sexual activity due to cultural sensitivities among the participating students in the area where the study was conducted. We also could

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not discriminate between primary and secondary dysmenorrhea, so pain related to periods was considered as a whole. In addition, the obtained data is based on female participants' responses which are subjective, and some over-reporting and some minor inconsistency in some responses may be an issue.

Acknowledgment The authors thank all the female medical students at Mutah University who participated in this study. We would also thank Mrs Jenine Jaradat for her assistance in editing the writing of this manuscript.

Disclosure

The authors report no conflicts of interest in this work.

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32. Zegeye, D., B. Megabiaw, and A. Mulu, Age at menarche and the menstrual pattern of secondary school adolescents in northwest Ethiopia. BMC women's health, 2009. 9(1): p. 29.

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33. Ortiz, M.I., et al., Prevalence and impact of primary dysmenorrhea among Mexican high school students. International Journal of Gynecology & Obstetrics, 2009. 107(3): p. 240-243.

34. Polat, A., et al., Prevalence of primary dysmenorrhea in young adult female university students. Archives of Gynecology & Obstetrics, 2009. 279(4): p. 527-32.

35. Dawood, M.Y., Dysmenorrhoea and prostaglandins: pharmacological and therapeutic considerations. Drugs, 1981. 22(1): p. 42-56.

36. Burnett, M.A., et al., Prevalence of primary dysmenorrhea in Canada. Journal of obstetrics and gynaecology Canada: JOGC= Journal d'obsttrique et gyncologie du Canada: JOGC, 2005. 27(8): p. 765.

37. McGuire, D.B., Comprehensive and multidimensional assessment and measurement of pain. Journal of pain and symptom management, 1992. 7(5): p. 312-319.

38. Schofield, P., Management of Pain in Older People. 2007, England: M&K Update Ltd. 86.

39. Janssen, E.B., et al., Prevalence of endometriosis diagnosed by laparoscopy in adolescents with dysmenorrhea or chronic pelvic pain: a systematic review. Human reproduction update, 2013.

40. Lee, L.K., et al., Menstruation among adolescent girls in Malaysia: a cross-sectional school survey. Singapore medical journal, 2006. 47(10): p. 869.

41. Cakir, M., et al., Menstrual pattern and common menstrual disorders among university students in Turkey. Pediatrics International, 2007. 49(6): p. 938-942.

42. Unsal, A., et al., Prevalence of dysmenorrhea and its effect on quality of life among a group of female university students. Upsala journal of medical sciences, 2010. 115(2): p. 138-145.

43. Al-Kindi, R. and A. Al-Bulushi, Prevalence and impact of dysmenorrhoea among Omani high school students. Sultan Qaboos University Medical Journal, 2011. 11(4): p. 485.

44. Banikarim, C., M.R. Chacko, and S.H. Kelder, Prevalence and impact of dysmenorrhea on Hispanic female adolescents. Archives of pediatrics & adolescent medicine, 2000. 154(12): p. 1226.

45. Jung, H.-S. and J. Lee, The effectiveness of an educational intervention on proper analgesic use for dysmenorrhea. European Journal of Obstetrics & Gynecology and Reproductive Biology, 2013. 170(2): p. 480-486.

46. Kotani, N., et al., Analgesic effect of a herbal medicine for treatment of primary dysmenorrhea-a double-blind study. The American journal of Chinese medicine, 1997. 25(02): p. 205-212.

Tables and Figures legends

Figure 1: Association between severity of menstrual pain over the previous six months and life activities

Table 1: Interference of menstrual pain with life activities

Table 2: Relationship between school absence due to period problems and severity of pain

Figure 2: Relationship between school absence due to period problems and severity of pain

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Al-Jefout Dysmenorrhea and QoL Questionnaire (Appendix 1)

Variable Values

Value Label

Study subject ID Age Study year at Faculty Marital_status 1 Single

2 Married 99a missing

Religion 1 Muslim 2 Christian 3 Other 99a missing

Geography 1 City 2 Town

3 Village 4 Tent (Bedouin) 5 Other 99a missing

Income 1 1,000 JD 99A

Uni_entrance_year Age_menarche Grade_menarche

Learnt_mother 0 blank (not ticked) 1 ticked

Learnt_brothers 0 blank (not ticked) 1 ticked

Learnt_female_friends 0 blank (not ticked) 1 ticked

Learnt_school 0 blank (not ticked) 1 ticked

Learnt_internet 0 blank (not ticked) 1 ticked

Learnt_med_professional 0 blank (not ticked) 1 ticked

Learnt_father 0 blank (not ticked) 1 ticked

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Learnt_sisters 0 blank (not ticked) 1 ticked

Learnt_books 0 blank (not ticked) 1 ticked

Learnt_media 0 blank (not ticked) 1 ticked

Learnt_cant_remember 0 blank (not ticked) 1 ticked

Learnt_other 0 blank (not ticked) 1 ticked

Whom_discuss_mother 0 blank (not ticked) 1 ticked

Whom_discuss_father 0 blank (not ticked) 1 ticked

Whom_discuss_sisters 0 blank (not ticked) 1 ticked

Whom_discuss_brothers 0 blank (not ticked) 1 ticked

Whom_discuss_female_friends 0 blank (not ticked) 1 ticked

Whom_discuss_med_professional 0 blank (not ticked) 1 ticked

Whom_discuss_no_one 0 blank (not ticked) 1 ticked

Whom_discuss_other 0 blank (not ticked) 1 ticked

Q1_Period_every_month 0 False 1 True

3 Don't know

88 Not applicable (no periods) 99a missing (all of S3 blank)

Q2_Never_missed_period 0 False 1 True

3 Don't know


Q3_Problems_with_period 0 False 1 True

3 Don't know


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Q4_Periods_normal 0 False 1 True

3 Don't know


Q5_Tests_abnormal_period 0 False 1 True

3 Don't know


Q6_Period_problem_name 0 False 1 True

3 Don't know


Q7_OCP 0 False 1 True

3 Don't know


Q8_OCP_regulate 0 False 1 True

3 Don't know


Q9_OCP_contraception 0 False 1 True

3 Don't know


Q10_OCP_period_pain 0 False 1 True

3 Don't know


Q11_No_OCP_hx 0 False 1 True

3 Don't know


Q12_Periods_dont_worry 0 False

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1 True

3 Don't know


Q13_Periods_worry_a_lot 0 False 1 True

3 Don't know


Q14_Periods_mostly_normal 0 False 1 True

3 Don't know


Q15_Sometimes_periods_wrong 0 False 1 True

3 Don't know


Q16_Sure_periods_wrong 0 False 1 True

3 Don't know


Q17_Only_use_pads 0 False 1 True

3 Don't know


Q18_Pimples_face 0 False 1 True

3 Don't know


Q18_Pimples_back 0 False 1 True

3 Don't know


Q18_Pimples_chest 0 False 1 True

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3 Don't know


Q19_Hair 0 False 1 True

3 Don't know


Q20_Blood_test_dysmenn 0 False 1 True

3 Don't know


Q21_Ultrasound 0 False 1 True

3 Don't know


Q22_Operation 0 False 1 True

3 Don't know


Q23_Talk_to_friends 0 False 1 True

3 Don't know


Q24_Talk_to_family 0 False 1 True

3 Don't know


Q25_Talk_to_GP 0 False 1 True

3 Don't know


Q26_Talk_to_specialist_dr 0 False 1 True

3 Don't know

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Q27_Talk_to_naturopath 0 False 1 True

3 Don't know


Q28_Grumpy_b4_during 0 False 1 True

3 Don't know


Q29_Grump_all_the_time 0 False 1 True

3 Don't know


Q30_Teary 0 False 1 True

3 Don't know


Q31_Overwhelmed 0 False 1 True

3 Don't know


Q32_Withdraw 0 False 1 True

3 Don't know


Q33_Moods_not_affected 0 False 1 True

3 Don't know


S4_Q1_have_periods 0 No 1 Yes

99 missing S4_Q2_Period_12m_hx 1 regular

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2 irregular 3 don't know

88 not applicable (don't have periods) S4_Q3_cycle_length 88 not applicable (don't have periods)

99a missing S4_Q3_irreg_dk 1 period irregular

2 don't know cycle length 88 not applicable (don't have periods) 99a missing

D1_heaviness 1 Light 2 Medium 3 Heavy 88 not applicable (don't have periods) 99a missing

D2_heaviness 1 Light 2 Medium

3 Heavy 88 not applicable (don't have periods) 99a missing








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Clots 1 yes 2 no

88 not applicable (don't have periods) 99a missing

Clot_frequency 1 sometimes 2 most of the time

3 all the time

88 not applicable (don't have clots or don't have periods) 99a missing

Spotting 1 Just before a period 2 In between periods 3 Never

88 not appliable (don't have periods) 99a missing

Miss_school 0 No

1 Yes - every period 2 Yes - Just with some periods 88 not applicable (don't have periods) 99a missing

Miss_school_too_painful 1 Too painful circled 88 not applicable (don't have periods or don't miss school) 99a missing

Miss_school_flow_too_heavy 1 Blood flow too heavy circled

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88 not applicable (don't have periods or don't miss school) 99a missing

Miss_school_nausea 1 Nausea circled 88 Not applicable (don't have periods or don't miss school) 99a missing

Miss_school_vomiting 1 Vomiting circled 88 not applicable (don't have periods or don't miss school) 99a missing

Miss_school_other 1 Other reason for missing school circled 88 not applicable (don't have periods or don't miss school) 99a missing

Sx_worsened 0 No 1 Yes

88 not applicable (no periods) 99a missing

Exam_increased_flow 0 No

1 Yes


Exam_irregular 0 No 1 Yes


Exam_pain_worse 0 No 1 Yes


Pain_rating 88 not applicable (no periods or no period pain) 99a missing

Herb_rx 0 No

1 Yes

88 not applicable (no periods or no period pain) 99a missing

Herb_type 88 not applicable (no periods or no period pain) 99a missing

Herb_suggested_by 1 Mother 2 Sister 3 Female friend

4 GP 5 Specialist doctor 6 Herbalist

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7 Doctor


Herb_efficacy 0 Not effective 10 Highly effective 88 not applicable (no periods, no period pain, no herbal rx) 99a missing

Dysmen_med_rx 0 No 1 Yes


Med_type_Panadol 0 No 1 Yes


Med_type_Aspirin 0 No 1 Yes


Med_type_Ponstan 0 No 1 Yes


Med_type_Naproxyn 0 No 1 Yes


Med_type_Nurofen 0 No 1 Yes


Med_type_other 0 No 1 Yes


Med_efficacy 0 Not effective 10 Highly effective 88 not applicable (no periods, no period pain, no pain meds) 99a missing

Nausea 0 No or never

1 Just before a period

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2 At the time of period 3 Any time of the month 4 All the time

5 Sometimes 88 Doesn't apply to me 99a missing

Vomiting 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time


Bloating 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time


Diarrhoea 0 No or never

1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time


Indigestion 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time


Appetite_change 0 No or never 1 Just before a period 2 At the time of period

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3 Any time of the month 4 All the time


Aching_outside_vagina 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time


Aching_down_legs 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time


Pelvic_pain_aching 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time


Pelvic_pain_cramping 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time


Pelvic_pain_stabbing 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month

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4 All the time


Pelvic_pain_other 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time


Lower_back_pain 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time


Pain_micturition 0 No or never



Pain_full_bladder 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time


Pain_passing_wind 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time

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Pain_emptying_bowels 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time


Bowel_urgency 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time


Bleeding_anus 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time


Frequent_micturition 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time


Tired 0 No or never


5 Sometimes

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88 Doesn't apply to me 99a missing

Headaches 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time


Thrush 0 No or never



Dizziness 0 No or never



Depressed 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time


Other_sx 0 No or never 1 Just before a period 2 At the time of period 3 Any time of the month 4 All the time

5 Sometimes 88 Doesn't apply to me

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99a missing Interfere_school_attendance 0 no interference

10 major interference 88 not applicable 99a mssing

Interfere_completing_schoolwork 0 no interference 10 major interference 88 not applicable 99a mssing

Interfere_social 0 no interference


Interfere_family 0 no interference 10 major interference 88 not applicable 99a mssing

Interfere_friends 0 no interference


Interfere_sport_exercise 0 no interference 10 major interference 88 not applicable 99a mssing

Intefere_frequency 1 Some periods 2 Most periods 3 All periods 88 not applicable 99a missing

Interfere_pain 0 no interference 10 major interference 88 not applicable 99a mssing

Interfere_heavy_flow 0 no interference 10 major interference 88 not applicable 99a mssing

Interfere_tiredness 0 no interference 10 major interference 88 not applicable

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99a mssing Interfere_moods 0 no interference


Interfere_generally_unwell 0 no interference 10 major interference 88 not applicable 99a mssing

Interfere_other 0 no interference


Interfere_sx_frequency 1 Some periods 2 Most periods 3 All periods 88 not applicable 99a missing

Heard_of_PCOS 0 No 1 Yes

2 Don't know

99a missing Heard_of_Endometriosis 0 No

1 Yes

2 Don't know

99a missing Heard_of_PID 0 No

1 Yes

2 Don't know

99a missing Dx_PCOS 0 No

1 Yes

2 Don't know

99a missing Dx_Endometriosis 0 No

1 Yes

2 Don't know

99a missing Dx_severe_dysmenorrhea 0 No

1 Yes

2 Don't know

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99a missing Dx_fibroids 0 No

1 Yes

2 Don't know

99a missing Dx_cystitis 0 No

1 Yes

2 Don't know

99a missing Dx_IBS 0 No

1 Yes

2 Don't know

99a missing Fam_hx_period_problems 0 No

1 Yes

2 Don't know

99a missing Fam_hx_severe_period_pain 0 No

1 Yes

2 Don't know

99a missing Fam_hx_PID 0 No

1 Yes

2 Don't know

99a missing Fam_hx_PCOS 0 No

1 Yes

2 Don't know

99a missing Fam_hx_endometriosis 0 No

1 Yes

2 Don't know

99a missing a. Missing value

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Table 1: Interference of menstrual pain with life activities

Type of life activity Level of interference No/mild pain

% (n) Moderate pain

% (n) Severe pain

% (n) P value

School attendance

Low interference 89.6 (95) 83.0 (78) 43.1 (22) p < 0.001.

Major interference 10.4 (11) 17.0 (16) 56.9 (29)

Completing school work Low interference 85.7 (90) 58.9 (56) 32.1 (17)

p < 0.001. Major interference 14.3 (15) 41.1 (39) 67.9 (36)

Social activities Low interference 74.5 (79) 46.9 (45) 30.2 (16)


Relationship with family Low interference 72.9 (78) 54.2 (52) 38.9 (21)


Relationship with friends

Low interference 78.5 (84) 56.8 (54) 46.3 (25) p < 0.001.


Sports and exercise

Low interference 57.7 (60) 39.6 (38) 30.8 (16) p = 0.002.


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Table 1: Relationship between school absence due to period problems and severity of pain

Aspects type School absence

No/mild pain

% (n)

Moderate pain

% (n)

Severe pain

% (n) P value

Severity of pain

No 90.9 (100) 64.3 (63) 24.1 (13) p < 0.001

Yes 9.1 (10) 35.7 (35) 75.9 (41) Heavy flow

No 93.6 (103) 91.8 (90) 81.5 (44) p = 0.038 Yes 6.4 (7) 8.2 (8) 18.5 (10)

Nausea

No 94.5 (104) 86.7 (85) 75.9 (41) p = 0.003 Yes 5.5 (6) 13.3 (13) 24.1 (13)

Vomiting

No 99.1 (109) 92.9 (91) 87.0 (47) p = 0.006 Yes 0.9 (1) 7.1 (7) 13.0 (7)

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Figure 1: Association between severity of menstrual pain over the previous six months and life activities

0

20

40

60

80

No/mild pain Moderate pain Severe pain

%

Attending school Completing school work

Social activities Relationship with family

Relationship with friends Sport and exercise

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Figure 2: Relationship between school absence due to period problems and severity of pain

.

0

10

20

30

40

50

60

70

80

No/mild pain Moderate pain Severe pain

%

School absence Too painful Blood flow too heavy Nausea Vomiting

1-s2.0-s1083318814002599-main

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