a. cakir. menstrual pattern

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Pediatrics International(2007) 49, 938942 doi: 10.1111/j.1442-200X.2007.02489.x

2007 Japan Pediatric Society

Menarche is a milestone in female puberty that signifies the

maturation of reproductive potential and physiological growth.

It generally occurs approximately 2.3 years after the initiation

of puberty, between the ages of 11 and 14 years in 95% of girls

depending on race, ethnicity, socioeconomic and nutritional

status.1 Menstrual cycles are irregular during the first year of

menarche due to anovulatory cycles. Height, weight and body

fat content continue to increase for 12 years following

menarche and the cycles become regular within 23 years.

Typically a menstrual flow lasts 27 days in 7080% of cases,

and changing three to six pads per day suggests normal flow.The duration between two menstrual cycles ranges from 21 to

45 days in the 12 years after menarche. When ovulatory

cycles begin, 6080% of the cycles are 2134 days long, which

is a similar pattern to that in adults.2 Some variety of menstrual

dysfunction occurs in approximately 75% of adolescent girls,

and may affect the life of adolescent and young adult women.3,4

Dysmenorrhea is one of the most common gynecologic

disorders among adolescent girls. It is defined as pelvic pain

directly related to menstruation, and is associated with symp-

toms ranging from headache and back pain to nausea, vomiting

and diarrhea. It is classified into two categories: primary when

pelvic examination and ovulatory function are normal; and

secondary when there is an identifiable gynecological pathology.

Primary dysmenorrhea characteristically begins when adoles-cents attain their ovulatory cycles; generally within the first

year after menarche.5 It is believed that the cause of the pain is

excess production of prostaglandins (PG) in the endometrium

during the ovulatory cycle. PG stimulate the myometrial con-

traction and local vasoconstriction that cause the menstrual

effluent to be expelled from the uterine cavity. It was shown

that women with dysmenorrhea have higher levels of PG in

their plasma and menstrual effluent than women without

dysmenorrhea.5 Additionally, elevated serum vasopressin,

Original Article

Menstrual pattern and common menstrual disorders among

university students in Turkey

MURAT CAKIR,1 ILKE MUNGAN,1 TANER KARAKAS,1 LKNUR GIRISKEN1

AND AYSENUR OKTEN2

Departments of1Pediatrics and2Pediatric Endocrinology, Faculty of Medicine,

Karadeniz Technical University, Trabzon, Turkey

Abstract Background: Menstrual disorders may affect the life of adolescents and young adult women, and may sometimes

cause serious problems. The patterns of menstrual cycles were analyzed for association with age of menarche,

prevalence of menstrual irregularity, dysmenorrhea, prolonged menstrual bleeding, and effect of menstrual

disorders, especially dysmenorrhea, on social activities and school attendance among the female students.

Methods: A total of 480 students were randomly selected and asked to complete an the anonymous questionnaire

of 25 items.

Results: The mean age of the subjects at menarche was 12.8 1.3 years with a range of 917 years. The durationbetween two periods and the menstrual flow were 27.7 2.5 days and 5.8 1.4 days, respectively. The prevalence

of menstrual irregularity, prolonged menstrual bleeding and dysmenorrhea were 31.2%, 5.3% and 89.5%,

respectively. Approximately 10% of dysmenorrheic subjects had severe dysmenorrhea; and school absenteeism

and need to consult a physician were more common in those subjects. The first source of their knowledge about

menarche and menstruation was their mothers in 211 subjects (54%); only 18 subjects (4.6%) were given a

lecture about menstruation and menarche at school.

Conclusion: The prevalence of dysmenorrhea and menstrual irregularity was high, and most adolescents have

inappropriate and insufficient information about menstrual problems. Hence, an education program is needed at

the end of primary school about menarche and menstrual problems.

Key words dysmenorrhea, menarche age, menstrual pattern.

Correspondence: Murat Cakir, MD, Kazm Dirik Mah., Svari Cad.No: 55, Mutluba lar Apt, Daire: 9, Bornova, Izmir, Turkiye.Email: [email protected]

Received 10 January 2006; revised 20 March 2006; accepted26 October 2006; published online 31 October 2007.


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Menstrual problems among adolescents 939


nitric oxide and interleukin-6 levels have been reported in

women with primary dysmenorrhea.6,7

Dysmenorrhea is the major cause of activity restriction

and school absence in adolescent girls. However, this condi-

tion is often considered as physiological pain and ignored

by adolescents; and only few adolescents need to consult a

physician for menstrual pain and most of them self-medicatewith over-the-counter medicines.

This cross-sectional study was conducted to determine:

(i) the patterns of menstrual cycles associated with the age of

menarche; (ii) the prevalence of menstrual disorders; men-

strual irregularity, dysmenorrheal and prolonged menstrual

bleeding; (iii) source of knowledge and management strategy

of menstrual disorders, especially dysmenorrhea; and (iv) the

effect of menstrual disorders on social activities and school

attendance among female university students.

Methods

The subjects were student girls from two faculties (Faculty of

Medicine and Midwife School) of Karadeniz Technical

University, Trabzon. In total there were 506 female students in

two faculties during the 20042005 academic years. We aimed

to include at least 75% of the female students in the study.

A total of 480 students, who were present at the school at time of

the study; were asked to complete the anonymous question-

naire of 25 items distributed by the researchers. The aim of the

study and the contents of the questionnaire were explained to

each subject, and voluntary participation was requested.

Subjects who had primary amenorrhea and had a history of

abdominal or pelvic surgery were not eligible for the study. Allparticipants gave written informed consent before enrollment,

and ethics approval was obtained from the ethics committee.

The questionnaire included data regarding demographic

features, menarche age, menstrual pattern, severity of dysmen-

orrhea and associated symptoms, impact of menstrual disorder

on social, sport activities and school attendance, management

strategy of the pain, the source of their knowledge about

menarche and whether they required medical help (from a

doctor, nurse or midwife) for menstrual disorder or not.

Students were asked to identify the year of their first period.

Questions such as Do you remember which grade you were

in when you started having period? were used to help thesubjects remember the date. The normal range of menarche

age is 1016 years, and we divided the reported menarche

age into three groups: early normal menarche age was con-

sidered between 10 and 12 years; mid-normal menarche

age was between 13 and 14 years; and late normal menarche

age was between 15 and 10 days.

The data were analyzed using SPSS for Windows version 9

(SPSS, Chicago, IL, USA). Descriptive statistics were used to

determine mean age of the subjects, age at menarche, frequency

of menstrual disorders, treatment of dysmenorrhea and acti-

vities affected by this condition. The categorical data were

analyzed using 2 or Fishers exact test. The continuous data

were analyzed using unpaired t-test. P < 0.05 was considered

to be statistically significant.

Results

The questionnaires were distributed to 480 subjects and 391

subjects (81.4%) completed it. The mean age SD of the par-

ticipants was 20.745 1.823 years (decimal age), with a range

of 16.73126.902 years. Menarche age, menstrual pattern and

common menstrual problems are listed in Table 1.

Menarche age and menstrual pattern

The mean age of the subjects at menarche was 12.8 1.3 years

with a range of 917 years. Eighty-seven subjects (22.2%) had

an early menarche age and four subjects were younger than

10 years of age; 273 subjects (69.8%) had a medium menarche

and 31 subjects (7.9%) had a delayed menarche and two of

them were older than 16 years. The duration between two

Table 1 Menarche age, menstrual pattern and major menstrualproblems

Parameters Mean SD

Age (years) 20.745 1.823Menarche age 12.8 1.3 (917)

Early menarche, n (%) 87 (22.2)Medium menarche, n (%) 273 (69.8)Delayed menarche, n (%) 31 (7.9)

Duration between two periods (days) 27.7 2.5 (1260)Duration of menstrual flow (days) 5.8 1.4 (215)Menstrual irregularity, n (%) 122 (31.2)Prolonged menstrual flow (>10 days), n (%) 21 (5.3)Dysmenorrhea, n (%) 350 (89.5)


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940 M Cakir et al.


periods and the menstrual flow were 27.7 2.5 days and

5.8 1.4 days, respectively. Two hundred and sixty-nine girls

(68.8%) had a regular menstrual pattern.

One hundred and twenty-two subjects (31.2%) had irregu-

lar menstrual pattern, and 21 of the subjects had PMF. Subjects

with irregular menstrual pattern were significantly younger

than the subjects with regular menstrual pattern (20.503 1.882years vs 20.855 1.788 years, P< 0.05). However, no signifi-

cant difference was found in menarche age. PMF was more

common in subjects with delayed menarche (5.7%, 3.6% and

19.3%, P< 0.0001) and 10 of the subjects with prolonged

menstrual bleeding were hospitalized and evaluated for coagu-

lopathy. These subjects had menstrual flow >2 weeks and

were changing approximately 10 pads per day; five of them

had delayed menarche. Two of them were given erythrocyte

suspension and iron therapy due to severe anemia, and one of

them had immune thrombocytopenic purpura (Fig. 1).

Dysmenorrhea

The prevalence of dysmenorrhea among the subjects was

89.5%, and approximately 10% of them had severe dysmenor-

rhea. No significant differences were noted between the sub-

jects with and without dysmenorrhea in terms of age, menarche

age, and duration of menstrual flow, menstrual irregularity and

duration between the two periods. Nevertheless, only two of

21 subjects with PMF had dysmenorrhea (P< 0.0001). Table 2

shows reported symptoms associated with dysmenorrhea. The

most common associated symptoms among the dysmenorrheic

subjects were abdominal pain (77.1%), backache (65.7%) and

nervousness (58%). Daily activities were limited by dysmen-

orrhea in 104 girls (29.7%), 83 of them reported that theirsocial and sport activities were limited, while 21 subjects

missed school because of menstrual pain, for 2 days in 10 of

them. More than 50% of the dysmenorrheic girls reported that

their class concentration was affected, and approximately 15%

of the subjects missed exams or scored a lower grade at least

once due to menstrual cramps. Seven subjects (2%) were unable

to participate in normal activities and were confined to bed due

to menstrual pain. Table 3 shows the comparison of the various

factors between the subjects with severe dysmenorrhea and

mild to moderate dysmenorrhea. Menarche age was significantly

Table 2 Associated symptoms in dysmenorrheic subjects

Symptoms Girls with dysmenorrhea (n= 350)

N (%)

Abdominal pain 270 (77.1)Backache 230 (65.7)

Nervousness 203 (58)Depression 147 (42)Fatigue 138 (39.4)Chills 125 (35.7)Polyuria 96 (27.4)Increased appetite 89 (25.4)Diarrhea 65 (18.5)Loss of appetite 57 (16.2)Headache 53 (15.1)Vomiting 40 (11.4)Other 12 (3.4)

More than one symptom/girl.

Table 3 Comparison of factors according to dysmenorrhea status

Severedysmenorrhea

(n= 37)Mean SD

Mildmoderatedysmenorrhea

(n= 313)Mean SD

P

Age (years) 20.750 1.702 20.762 1.873 0.96Menarche age

(years)13.3 1.2 12.8 1.3 0.01

Menstrualirregularity,n (%)

12 (32.4) 94 (30) 0.91

Menstrual cycle

(days)

27.4 2.2 27.7 2.6 0.53

Menstrual flow(days)

6.2 1.1 5.8 1.4 0.11

Limited socialactivities,n (%)

12 (32.4) 58 (18.5) 0.07

Schoolabsenteeism,

n (%)

16 (43.2) 5 (1.5)


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Menstrual problems among adolescents 941


high (P= 0.014), and school absenteeism and need to consult a

physician were more common in subjects with severe dysmen-

orrhea (P< 0.0001).

The management strategies for pain are given in Table 4.

One hundred and seventy-five subjects (50%) used medica-

tion for the management of their pain. Naproxen sodium

and ibuprofen were the most commonly used non-steroidalanti-inflammatory agents among the dysmenorrheic girls.

One hundred and fifty-one subjects (43.1%) used heating

pads or locally applied heat packs to manage their pain.

Sleeping or exercise was used less commonly among the

subjects.

The first source of their knowledge about menarche and

menstruation was their mothers in 211 subjects (54%). Friends,

magazines, newspaper and television were the other sources,

and only 18 subjects (4.6%) were given a lecture about men-

struation and menarche in secondary school.

Discussion

Adolescence is a time of enormous physical and hormonal

change for a young girl. Although organic gynecological

pathologies are rare in this period, menstrual disorders may be

seen commonly, and may cause further problems for the ado-

lescents and their parents.

The age of menarche is determined by general health,

genetic factors, socioeconomic and nutritional status. It is typ-

ically between 12 and 13 years; but with the improvements in

the nutritional status and general health it has declined in many

populations during the last decades.9,10 In the present study we

found that the mean age of menarche was 12.8 1.3 years;similar to the other studies that have been done in recent

years.11 However, the present results differed to those from

another study that was done 10 years ago in Ankara. The mean

menarche age was 13 years and 2 months, which was 4 months

later than the present one.12 This may be related to improve-

ment of nutritional and socioeconomic status of the adoles-

cents in recent decades.

Problems with menstrual pattern may affect 75% of girls, and

are the major cause of recurrent short-term school absenteeismin female adolescents.3,4 Menstrual irregularity and prolonged

menstrual bleeding are the most common menstrual disorders

in early adolescents. Prolonged menstrual bleeding usually

occurs early after menarche due to anovulatory cycles. In ano-

vulatory cycles, estrogen unopposed by progesterone produces

an unstable endometrial lining that eventually breaks down,

and vasoconstriction and myocardial contractility do not

occur.13 In the present study PMF was common in subjects

with delayed menarche and less common in subjects with dys-

menorrhea. Although approximately 90% of cases with PMF

associated with anovulatory cycles during adolescence, systemic

bleeding disorders such as factor deficiencies and thrombocy-

topenia must be excluded for the definite diagnosis.2

Dysmenorrhea is an important menstrual disorder in adoles-

cence. Contrary to prolonged menstrual bleeding and menstrual

irregularity, it is common in young women with ovulatory

cycles. The prevalence increases through the adolescent years

and decreases with increasing age. In the present study we

found that the prevalence of dysmenorrhea among university

students was 89.5% and approximately 10% of them described

their dysmenorrhea as severe. High prevalence of dysmenor-

rhea was also reported by Campbell and McGrath (93%)14 and

Banikarim et al. (85%).15 Klein and Litt studied 2699

menarcheal adolescents and found that 59.7% had menstrual

cramps, and socioeconomic status was positively correlatedwith dysmenorrhea.3 Other risk factors have been found associ-

ated with dysmenorrhea such as smoking, nulliparity, weight

loss, depression and anxiety.16 The association between dys-

menorrhea and early menarche age has been defined by

Montero et al. in Moroccan girls.17 In the present study we did

not find any relationship between dysmenorrhea and menarche

age, but the menarche age of subjects with severe dysmenor-

rhea was significantly higher than subjects with mildmoderate

dysmenorrhea (13.3 1.2 years vs 12.8 1.3 years, P = 0.014).

In general, early onset of menarche leads to earlier ovulatory

cycles and to earlier experience of dysmenorrheal symptoms.

It remains to be determined in future studies whether girls whoexperiencing dysmenorrhea symptoms at a later age may suffer

from more severe dysmenorrhea symptoms.

The syndrome of dysmenorrhea is associated with a vari-

ety of physical symptoms. The most common associated

symptoms were abdominal pain, backache and nervousness,

respectively. Not only the pain but also these associated

symptoms cause daily activity restriction and school absence

in adolescent girls. In the present study 29% of subjects

reported that the pain caused restriction on their social

Table 4 Management strategy for dysmenorrhea (n= 350)

Management strategy N(%)

Heating pads 151 (43.1)Medications 175 (50)

Analgesics 165 (47.1)

Naproxen sodium 33 (9.4)Ibuprofen 39 (11.1)Paracetamol 32 (9.1)Mefenamic acid 4 (1.1)Aspirin 3 (0.8)Diclofenac 2 (0.5)Non-specific 42 (12)Others 10 (2.8)Vitamins 10 (2.8)

Sleeping 14 (4)Exercise 6 (1.7)


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942 M Cakir et al.


activities and 6% reported school absence. School absence

was more common in subjects with severe dysmenorrhea

(43.2% vs 1.5%, P < 0.0001). It should be noted that academic

activities were limited in >60% of the dysmenorrheic girls.

Results of a US study indicated that 14% of adolescents

aged 1217 years missed school because of menstrual cramps

and it was more common in subjects with severe dysmenor-rhea.3 It is accepted that dysmenorrhea is the leading cause of

absenteeism in young girls with regard to school, social

activities and work.

Despite its high prevalence and negative effects, young

adolescents choose to resist their pain and believe that painful

periods are normal. They rarely discuss their pain with their

physician; and in the present study only 18% of all girls with

dysmenorrhea had consulted a doctor due to pain. More import-

antly, half of the girls with severe dysmenorrhea had never

seen a doctor. Mothers were found to be the most important

source of knowledge about menarche and menstrual problems.

In traditional culture there is a restriction in discussing

menstrual problems for young girls with friends or physicians,

especially in rural areas. Mothers are responsible for giving

information about menarche and related issues. Their know-

ledge mostly depends on their mothers knowledge. Only 4.6%

of the subjects were given a lecture about menstruation and

menarche at school.

The limitation of the present study is that it consists only of

university students, and therefore may not represent the fre-

quency of menstrual disorders among young women in the

overall population.

As a result the present study indicates that prevalence of

dysmenorrhea and menstrual irregularity among university

students is high and that most adolescents have never pre-sented to a physician, and have inappropriate and insufficient

information about their menstrual problems. It is important for

clinicians to inquire about any menstrual problems when

young women visit the clinics. Moreover, a comprehensive

school education program on menarche, menstrual problems

and gynecological health given by teachers and medical staff

specialized in adolescent gynecology, is needed at the end of

primary school including for the mothers.

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