Prevalence of dysmenorrhea among University students in Northern Ghana; its impact and management strategies

The onset of puberty in the life of a young girl sets into motion hormonal, psychological, cognitive and physical changes which transforms the girl from a child to a sexually matured woman [1]. Menstruation, which is controlled by the hormones of the hypothalamopituitary axis and is one of the milestones of puberty in girls, involves the cyclical shedding of the inner lining of the uterus [2]. Onset of menstruation is celebrated in some cultures as it shows the girl is becoming a woman [3]. It however, also heralds a period of inhumane treatment of some post pubescent girl since some cultures and religions consider the menstruating woman as impure leading to forced seclusion, reduced mobility, as well as dietary and social restrictions [2‐5]. Some women, before or during menstruation also had to contend with dysmenorrhea which is a painful cramping sensation in the lower abdomen and sometimes accompanied by headache, dizziness, diarrhea, bloated feeling, nausea and vomiting, backache and leg pains [6‐9]. This menstruation associated pain occurs as a result of excessive production of prostaglandins in the endometrium during the ovulatory cycle which then causes contraction of myometrium, vasoconstriction as well as sensitization of nerve ending [10, 11]. Dysmenorrhea is classified as primary when there is no evidence of pelvic or hormonal pathology but is secondary when the pain is due to identifiable pathological conditions including endometriosis, ovarian cysts, pelvic inflammatory disease, myomas or intrauterine devices [9, 12]. Whereas the management of secondary dysmenorrhea requires the treatment of the primary cause, non-pharmacological methods which include fatty diet restriction, exercise, rest, heat application, spinal manipulation, acupuncture, have been reported in several studies to ease the pains of primary dysmenorrhea [1, 12‐14]. Medications which provide relief for primary and secondary dysmenorrhea include non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen sodium, diclofenac, and mefenamic acid. Other allopathic drugs such as combined oral contraceptives, medications that reduce uterine contraction, dietary supplements and narcotics analgesics had found some role in the management of dysmenorrhea [6, 7]. Prevalence of dysmenorrhea varies widely across the world ranging from 15 to 94% [8, 9, 12, 15]. Dysmenorrhea, which can be so debilitating to disrupt the daily activities, work and schooling of post pubescent females is therefore of public health concern. Several studies have reported various risk factors associated with dysmenorrhea which include age less than 20 years, nulliparity, higher socioeconomic status, heavy menses, depression, smoking, anxiety, and lack of physical activity [9, 12, 16]. The socio-economic impact of dysmenorrhea is rather underestimated and not appreciated by the general populace. Previous studies conducted in Ghana on dysmenorrhea were among pre-tertiary students and a limited number of university students all in southern Ghana. This study is therefore aimed at estimating the prevalence of dysmenorrhea, its impact and management among female students of the Tamale campus of the University for Development Studies in Tamale, northern Ghana.

Menstruation is considered a private issue in many cultures hence its associated complaints are borne silently by most post-pubescent females. For some women, they experience a monthly ritual of lower abdominal pain during menstruation known as dysmenorrhea. This study found a high prevalence of dysmenorrhea (83.6%) which is comparable to 85.0% recorded in United States of America (USA) [17] and 84.1% in Italy [9]. An earlier study among secondary school students in Accra, Ghana recorded a lower prevalence rate of 74.4% [18]. Studies in some other countries recorded lower rates between 38.1 and 76.0% [1, 6, 12, 19, 20] but higher prevalence rates of 92.5 and 94% were respectively reported in Taiwan and Oman [8, 21]. The varying prevalence rates of dysmenorrhea across the world could be attributed to the use of different categories of subjects as well as the lack of a universally accepted definition of dysmenorrhea. Majority of respondents in this study described their menstrual pain as moderate similar to studies in Italy and Oman [8, 9] but in some studies, majority classified their pain as mild [6, 11]. Pain perception and expression of pain is influenced by genetics, psychological, developmental, familial, social and cultural factors [22‐24]. Therefore, the aforementioned factors as well as variability of pain threshold of the different categories of respondents who participated in all these studies could account for the differences in the description of their pains. Dysmenorrhea in this study affected the daily life activities of two-thirds of the female students including school attendance as reported similarly in several studies across the world [1, 6, 8, 9, 12, 13]. Attending lectures was the most disrupted daily life activity for respondents in this study and even if they make it to the lectures, their concentration was greatly disturbed due to the dysmenorrhea. Just as reported in several studies on dysmenorrhea, two-third of subjects in this study experience menstruation associated symptoms such as diarrhea, headaches, lethargy, loss of appetite, nausea, joint and body pains, vomiting but the most common symptom was changes in the breast such as tenderness, heaviness, engorgement, as well as tingling and painful nipples which occurred in 39.1% of respondents [1, 12, 21]. This study did not find any significant association between incidence of dysmenorrhea and socio-demographic characteristics such religious affiliation, socio-economic status at menarche and locality of residence. This study however found a significant association between a respondent experiencing dysmenorrhea and the chronological as well as gynecological ages which was also reported in other studies which showed that incidence of dysmenorrhea decreases with increasing chronological age or gynecological age [16, 25]. Type of menstrual cycle, nature of the menstrual flow, number of days of menstrual flow and exercise did not predict the presence or absence of dysmenorrhea in this study. It would have been expected that the undesirable effects of dysmenorrhea and menstruation associated symptoms on the activities of respondents, would cause them to be eager to visit the hospital but only 16.3% ever did so. Similar hospital attendance rates between 12.1 and 18.0% were reported in Iran, Malaysia, Nigeria, Turkey and the USA [2, 10, 14, 17, 26]. A mere 3% was even recorded in Oman [8]. Self-treatment of menstrual pain using mostly non-steroidal anti-inflammatory drugs and antispasmodic drugs seem to be the most common practice in many countries [2, 6, 8, 10, 12, 14, 26, 27]. The self-treatment of dysmenorrhea by many women rather than visit a hospital is because many consider the pain as normal thus not worth taking to a hospital where they may join long queues to consult a physician. Again, many who self-medicate get relieve from the use of these medications as shown in this study. In this study, up to four-fifth of users of non-prescribed medications stated that they always get relieved of their pains after using these medications although the dosage regimen followed by three-fifth of the users were not appropriate. The suggestion by 86.2% of the females that they get relieved even with the high level of incorrect dosage regimen could be due to a challenge of recall of the correct dosage regimen or the healing could be due to the placebo effect [28]. Contrary to other studies, this study did not find any significant relationship between pain intensities suffered by respondents and their biological age, age at menarche, gynecological age, nature and duration of menstrual flow [1, 6, 25, 29]. There was rather an association between the menstrual pattern and severity of dysmenorrhea as recorded in other studies in which persons with irregular menstrual pattern suffered a more severe form of menstrual pain (χ² = 10.54; df = 2; p = 0.005) [6]. This study also found that females with severe dysmenorrhea exhibited a significantly greater tendency to seek treatment at the hospital (χ² = 65.61; df = 2; p < 0.0001) or self-medicate (χ² = 32.77; df = 2; p < 0.0001). The classes of drugs used for the dysmenorrhea did not significantly differ. Paracetamol (Acetaminophen) or its combination preparation was the most patronized analgesic notwithstanding the severity of the menstrual pain. The use of paracetamol for the management of dysmenorrhea was also reported in some earlier studies [8, 10, 26, 27]. Paracetamol, although exhibits a weaker analgesic effect than NSAIDs, it is better tolerated and has better safety profile [30] and could be appropriate for managing dysmenorrhea in females who are at risk of peptic ulcer or asthma; conditions for which NSAIDs are contraindicated.

Dysmenorrhea is a major menstruation related complaint among the female university students in northern Ghana. A significant association exists between the chronological and gynecological ages of respondents with younger students experiencing dysmenorrhea a lot more. Irregular menstruation is significantly associated with the severest form of dysmenorrhea but the chronological age, age at menarche or socio-economic disposition of the respondent do not. Dysmenorrhea and the menstruation associated symptoms adversely affect the daily lives of the females with some missing school. Although bed rest was the most applied modality, allopathic medication especially paracetamol preparations were used especially by those with moderate form of dysmenorrhea.