Experiences of undergraduates with dysmenorrhea: understanding the limitations of pharmacological management

Introduction

Menstrual disorders according to Parker et al. [1] are highly widespread among adolescent girls, and common characteristics are period pain, fatigue, and mood changes. Dysmenorrhea is a regular gynecological problem comprising painful cramps that come with menstruation, which in the absence of any underlying pathology is known as primary dysmenorrhea. According to Bernardi et al. [2], primary dysmenorrhea is usually frequent in younger women and is consistent with good health outcomes, even though there is an association with reduced quality of life. The secondary forms of dysmenorrhea occur together with endometriosis and adenomyosis and may portray the key symptom of dysmenorrhea as reported by Kaya et al. [3]. Diagnosis is made based on the clinical history and the physical assessment and is confirmed by ultrasonography, which is very effective in ruling out certain secondary causes of dysmenorrhea, such as endometriosis and adenomyosis. To prove the cause, research documents that women with dysmenorrhea have increased levels of prostaglandins, hormones known to bring about cramping abdominal pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are medications that block the production of prostaglandin and inhibit the action of cyclooxygenase, an enzyme accountable for the formation of prostaglandins [4].

Iacovides et al. [5] stated that a literature review of previous studies showed that dysmenorrhea negatively impacts the quality of life of affected females including their interaction with family members and friends, school or work performance in addition to social and recreational pursuits. It is further reported that women with dysmenorrhea are more sensitive to pain in general even at the time when they have no menstrual pain.

Material and methods

This study was carried out among female students of PAMO University of Medical Sciences. The study design is descriptive cross-sectional. In total 208 students were selected from the study population of 358 using the multistage sampling technique. The instrument for data collection was a researcher-structured questionnaire designed to elicit responses in line with the study objectives. The questionnaire had four sections with questions on respondents’ sociodemographics, respondents’ experience of dysmenorrhea, activities that impact respondents’ dysmenorrheal experience and respondents’ management practices during dysmenorrhea. Questions under the management section of the questionnaire included pharmacologic and non-pharmacologic measures used to relieve menstruation pain. Face and content validity of the questionnaire was ensured by assessing the judgmental validity. In addition, validity was ensured by assessing the agreement of the experts on appropriate utilization of a conceptual definition in the research instrument. Data were collected using a questionnaire with a reliability coefficient of 0.84. The completed questionnaires were collected by trained research assistants. The data collection procedure was supervised by the authors. Data were analyzed and descriptive (mean, standard deviation and percentage) data were computed using SPSS version 20.0.

The researcher obtained ethical approval for this research study from the University of Port Harcourt (UNIPORT) Ethics Review Committee, Rivers State, Nigeria after the submission and proper scrutiny of copies of the research instrument, chapter one, two and three of the study used by the research ethical committee of UNIPORT as a working guide.

Results

Discussion

Menstrual periods as reported by Lobo et al. [6] are a cyclic physiological phenomenon, in which several problems can arise including irregular cycles, excessive bleeding, and dysmenorrhea. Dysmenorrhea is commonly described as a severe, painful, cramping sensation in the lower abdomen that is often associated with other symptoms, such as sweating, headaches, nausea, vomiting, and diarrhea. Globally, it is the paramount problem of motherhood, but there is limited evidence on the incidence of dysmenorrhea in the study area as well as in Nigeria.

Reviewing the incidence of dysmenorrhea, obstetric and gynecological related characteristics among respondents revealed that all (100%) participants have commenced menstruation. Among study participants, 112 (57.4%) have a positive history of dysmenorrhea and 175 (89.7%) experience painful menstruation, which is higher than the findings reported by Azagew et al. [7], where about half (50.7%) of the participants complained of lower abdominal pain and recorded varying intensities of pain during menstruation: 83 (29%), 174 (60.8%), and 29 (10.2%) reported having mild, moderate, and severe menstrual pain, respectively. In line with our findings, another study by Kwabena et al. [8] added that dysmenorrhea affects more than 80% of women in the reproductive age. Our data revealed that 76 (43.4%) participants started feeling menstrual pain during menstruation, while the onset of menstrual pain among 57 (32.6%) participants is before menstrual flow. A total of 101 (57.7%) participants experience menstrual pain for 3 to 4 days. One hundred and eighty-three (41.4%) study participants reported a positive family history of dysmenorrhea in the study of Azagew et al. [7], which is quite similar to our findings shown in Table 2. The high incidence of dysmenorrhea among university students could be linked to young age (less than 30 years old) as a risk factor which was observed by Ju et al. [9], but our study revealed daily activities of life that aggravate painful menstruation.

There are recorded activities of daily living that increase and worsen dysmenorrhea. Data from this survey indicate that dysmenorrhea is aggravated by walking among 67 (38.3%) respondents; dysmenorrheal symptoms increased when excess amounts of sweet drinks/snacks (though no specific class of food was indicated) were consumed by 106 (60.6%) participants. This result agrees with the findings of Bajalana et al. [10], who opined that inconsistent results were reported among participants experiencing dysmenorrhea on consumption of some nutritional groups. Another study by Najafi et al. [11] indicated that nutrition can play a key role in the prevalence and severity of dysmenorrhea. It further showed that subjects who ate mixed food items and snacks had a higher likelihood of experiencing moderate to severe dysmenorrhea in comparison with subjects who were lacto-vegetarians. Even though the evidence on the association between dietary factors and dysmenorrhea is not conclusive, Fjerbaek et al. [12] suggest that high consumption of fish, fruits and fiber may reduce the intensity of menstrual pain. However, our data could not prove this, as it contrarily reported that 2 (1.1%) participants’ symptoms are aggravated by ingestion of cold or hot water (cold or warm compress), which should have provided a therapeutic effect but on the contrary aggravated and worsened menstrual pain.

To help respondents attain tranquility, the present study noted the likelihood of respondents to need pain medications during menstrual pain. It also observed that medications used by respondents were prescribed drugs but more often home remedies such as ingestion of herbal mixtures prepared with Bitter and Scent leaf extracts and assuming a comfortable body position were coping mechanisms to ease period pains (Table 4). These are less empirically proven strategies that serve as alternatives to pharmacological pain-relieving drugs (non-steroidal anti-inflammatory drugs) and offer hope for treating menstrual pain when front-line courses of actions fall short, are short of supply or are inaccessible. Oladosu et al. [13] recorded that about 18% of women experiencing dysmenorrhea are unresponsive to NSAIDs, leaving them and their physicians to seek unproved alternatives. Concordant with this are studies suggesting potential mechanisms fundamental to non-steroidal anti-inflammatory drug resistance and further explaining the reasons alternative options may help in stubborn cases. Hence, this review recognizes key areas for further study to advance menstrual pain treatment and suggests investigation of the influence of body positioning, ingestion of herbal preparations and activities of daily living such as exercises on release of prostaglandin and subsequent spasmodic contraction of the uterus during menstruation.

Furthermore, assessment of the effect of medications taken for dysmenorrhea revealed that our respondents are not likely to experience side effects from any drug taken for menstrual pain. Contrary to this observation is the report by Oladosu et al. [13], which highlighted molecular contributors to NSAID-resistant dysmenorrhea, suggesting processes that may cause a decline in the use of NSAIDs for treating menstrual pain. Another report opined that side effects accompanying NSAIDs such as gastrointestinal discomfort limit medication adherence. This informs the reason our respondents are not likely to seek care during menstruation pain as a means of keeping safe while in pain rather than worsening their condition.

One of the well-known processes involved in dysmenorrhea as documented by Harel [14] is the elevated delivery of prostaglandins into the uterine tissue at the onset of menstruation, which increases vasoconstriction and myometrial contractions, leading to uterine ischemia and pain. In order to ease menstrual pain, records prove that NSAIDs and oral contraceptive pills (OCPs) are the most preferred medicines used by women [14], but the respondents in our study have limited access to OCPs as all students live on the campus and the university clinic is short of these supplies because its scope of healthcare provision is within primary prevention and subsequent referrals for expert management. However, the study under review did not assess the use of OCPs provided by other sources such as relatives and staff of the university to the respondents.

Conclusions

The incidence of dysmenorrhea is rising. Onset and duration vary considerably among indigenous people as certain food items worsen the experience of painful menstruation. Non-pharmacological agents such as positioning and herbal mixtures are becoming effective in offering comfort, thereby calling for further empirical support.