Original Article

From the *Department of Obstetrics

and Gynecology Nursing, Marmara

University Faculty of Health Sciences,

Istanbul; †Abant _Izzet Baysal

University Bolu Health School Golkoy

Campus Bolu, Turkey.

Address correspondence to Dilek

Coskuner Potur, PhD, RN, Marmara

University Faculty of Health Sciences,

Division of Nursing, Department of

Obstetrics and Gynecology Nursing,

Tıbbiye Cad No: 40 Haydarpasa_Istanbul, Turkey. E-mail: dilekcp@

yahoo.com

Received August 21, 2012;

Revised July 30, 2013;

Accepted July 31, 2013.

1524-9042/$36.00

� 2013 by the American Society for

Pain Management Nursing

http://dx.doi.org/10.1016/

j.pmn.2013.07.012

Prevalenceof Dysmenorrheain University Studentsin Turkey: Effect on DailyActivities and Evaluationof Different PainManagement Methods

--- Dilek Coskuner Potur, PhD, RN,*

Nevin Citak Bilgin, PhD, RN,†

and Nuran Komurcu, PhD, RN*

- ABSTRACT:This study was conducted to determine the following among a group

of female university students: the prevalence of dysmenorrhea; pain

severity ratings; methods used to manage dysmenorrhea; and the ef-

fect of dysmenorrhea on daily activities, school attendance, and ability

to communicate with friends. This cross-sectional study was con-

ducted between December 2009 and February 2010 at a public uni-

versity located in Istanbul, in the northwest area of Turkey. The study

group included 1515 female students. Data were collected from the

female students in the study group using a self-report questionnaire;

the severity of dysmenorrhea was determined with the visual analog

scale. The data were examined with mean, percentages, chi-square

analysis, and logistic regression. The prevalence of dysmenorrhea in

the study group was 85.7%. Of this group of subjects with dysmenor-

rhea, 30.4% described their menstrual pain as severe, 49.8% as mod-

erate, and 19.8% as mild. The mean severity of pain among the

students was 6.33 ± 2.32 on the VAS. The majority of participants who

experienced moderate or severe pain regularly used analgesics for

painmanagement, and participantswho experienced severe pain used

analgesics before the beginning of menstruation. Participants who

experienced moderate pain used herbal tea, massage, heat applica-

tion, rest, and distraction for pain management. Participants who

experienced severe pain consulted a physician and that a significant

difference existed between the dysmenorrhea rating groups in this

regard (p < .001). Severe pain was significantly associated with

school absenteeism and limitations in social activities/functioning

Pain Management Nursing, Vol -, No - (--), 2013: pp 1-10

2 Potur, Bilgin, and Komurcu

(p < .001). Dysmenorrhea is highly prevalent

among university students and is related to

school absenteeism, ability to participate in

and enjoy daily activities, and limitations in

social activities/functioning.

� 2013 by the American Society for Pain

Management Nursing

Dysmenorrhea is one of the most common gynecologic

disorders among adolescent girls and women of repro-

ductive age (Cakır, Mungan, Karakas, Girisken, &€Okten, 2007; Lefebvre et al., 2005; Mohamed, 2012).

With dysmenorrhea, the monthly menstrual cycle is

accompanied by a level of pain that requires medication

and that may limit daily activities. Dysmenorrhea is

thought to be caused by the release of prostaglandinsinto the uterine tissue, causing contractions and pain

(Balbi et al., 2002; Ortiz, Rangel-Flores, Carrillo-Alarcon,

& Veras-Gody 2009; Potur & Komurcu, 2013). It is

classified into two categories: primary (when pelvic

examination and ovulatory function are normal) and

secondary (when identifiable gynecological pathology

is present) (Chang & Chuang, 2012; Durain, 2004;

Goldstein-Ferber & Granot, 2006; Irono et al., 2008;Johnson, 2006; Osuga et al., 2005; Sharp, Taylor,

Thomas, Killen & Dawood, 2002; Zhu et al., 2008).

Domestic and international research conducted

during the last decade has shown that the prevalence

of dysmenorrhea varies greatly (between 45.3% and

90%). This variance is dependent on the method of

data collection, the study definition of dysmenorrhea,

and the study population (Balbi et al., 2002; Burnettet al., 2005; Cakır, Mungan, Karakas, Girisken, &€Okten 2007; El-Gilany, Badawi, & El-Fedawy, 2005;

Eryilmaz & Ozdemir, 2009; Ortiz, 2010; Osuga, et al.,

2005; Ozerdo�gan, Sayiner, Ayrancı, Unsal, & Giray,

2009; Polat et al., 2009; Tangchai, Titapant, &

Boriboonhirunsarn, 2004; Zhu et al., 2008).

One third to one half of women report moderate

or severe dysmenorrhea symptoms. These symptomsare frequently associated with being unable to attend

work or school and other activities (Chang & Chuang,

2012; Lefebvre et al., 2005). Despite the frequency

and severity of dysmenorrhea, most women do not

seek medical treatment (Doty & Attaran, 2006). Dys-

menorrhea not only causes physiological discomfort

but also affects overall quality of life and the ability to

take part in daily activities (Doty & Attaran, 2006;Durain 2004; Unsal, Ayranci, Tozun, Arslan, & Calik,

2010).

Studies on the prevalence of menstrual pain have

shown that various factors are related to this disorder.

These factors include early menarche, younger age,

low body mass index (BMI), smoking, long and heavy

menstrual flow, perimenstrual somatic complaints, pel-

vic infections, and a history of dysmenorrhea and obe-

sity (Lefebvre et al., 2005; Unsal, Ayranci, Tozun,

Arslan, & Calik, 2010).

Adolescents and young females consider dysmen-

orrhea to be a condition they can handle and thereforedo not consult health care professionals, often even in

cases where they are using medications. The Campbell

and McGrath (1997) study determined that in a sample

of 268 female high school students, 70% with dysmen-

orrhea had used over-the-counter (OTC) medications

to manage dysmenorrhea, but 57% of these students

took medication less often than the maximum daily fre-

quency. O’Connell, et al. (2006) reported that thehealthy adolescent girl with dysmenorrhea in their

study used numerous non-pharmacologic remedies as

well as medications for pain but infrequently accessed

formal medical care. The doses used of the medicines

in this study were often less than the recommended

doses.

To sum up this introduction, dysmenorrhea is an

important reproductive health problem that concernspublic health, occupational health, and family practice;

it affects both the quality of life and the national

economy due to short-term school absenteeism and

loss of labor. Unfortunately, both the prevalence of dys-

menorrhea and the manner in which females attempt

to solve this problem are unknown in most developing

countries.

PURPOSE OF STUDY

This cross-sectional study was conducted to determine

the prevalence of dysmenorrhea, pain severity ratings,

methods to manage dysmenorrhea, and the effect of

dysmenorrhea on daily activities, school attendance,

and social activity/functioning among female univer-

sity students.

METHODS

This cross-sectional study was conducted between

December 2009 and February 2010 at a public univer-

sity located in Istanbul, in the northwest of Turkey. A

total of 5,984 female students were enrolled in 4

schools during the study period. The required sample

size was estimated to be 1,293 since the prevalence

of primary dysmenorrhea is assumed to be 55.5%, theconfidence level was 95%, and the margin of error

was 5% (Ozerdo�gan, Sayiner, Ayrancı, Unsal, & Giray,

2009). Female students were selected from the 4

schools: 749 from Education (n¼ 3,277), 94 from Phar-

macy (321), 462 from Arts and Sciences (n ¼ 1,845),

3Prevalence of Dysmenorrhea and Management Methods

and 210 from Health Sciences (n ¼ 541). The number

of female students in each class and in each faculty was

assigned by simple randomization in order to represent

all of the classes in the schools. Data were collected

from the female students in the study group using

a self-report questionnaire.

MEASUREMENTS

A questionnaire including 46 items and investigating

the sociodemographic features of the study popula-

tion, the subjects’ description of their dysmenorrhea

and its effects on daily life, and subjects’ methods for

managing dysmenorrhea was developed by the re-

searchers. The questionnaire helped describe the char-

acteristics of the study participants. Additionally, theseverity of the subjects’ painwas assessed using a visual

analog scale (VAS).

The questionnaire was completed in 15 to 20 min-

utes by the students with the researcher present in the

classroom. Male students were taken into separate

rooms to allow female students privacy and to help

them feel more comfortable. Data obtained through

the questionnaire included sociodemographic features(age, marital status, height, weight, BMI, smoking, and

so forth); menstrual features (menarche age, menstrual

regularity, frequency, and duration of menstrual flow);

methods of managing dysmenorrhea (pharmacologic

and non-pharmacologic); and impact of dysmenorrhea

on daily activity, school attendance, and social activity/

functioning.

The VAS used consists of a 0 cm to 10 cm verticalscale with the descriptors ‘‘no pain’’ at the bottom of

the scale and ‘‘worst possible pain’’ on the top. Scores

from the VAS were categorized on a scale of 1 to 10

(1-3.9 mild, 4-7.9 moderate; 8-10 severe). It has been

reported that the VAS is a more sensitive and reliable

pain assessment instrument compared to other one-

dimensional scales (Aslan-Eti, 2002).

ETHICAL CONSIDERATIONS

In all stages of the study, ethical principles were care-

fully taken into consideration. In addition, students

were told that they could quit the study at any time

during the data collection period. Permission to con-

duct the study and access to the female students

were obtained from the dean of the schools of educa-tion, pharmacy, health science, and arts and sciences.

DATA ANALYSIS

Data analyses were carried out using the Statistical Soft-

ware Package for the Social Sciences (SPSS), version

15.0. Data were examined with mean, percentage,

chi-square analysis, and logistic regression (backward

step-wise). The accepted confidence interval was

95%; the significance level for all analyses was p < .05.

RESULTS

Sociodemographic Characteristics of Femalesin Study GroupA total of 1,515 female students completed question-

naires. None of the students was pregnant, and all par-

ticipants were of the same ethnic and regional origin.

The mean age of the participants was 20.74 � 2.11

years (range 17-34 years), and the mean menarche age

was 13.23� 1.17 years (range 9-17 years). The bivariate

analysis showed that the occurrence of dysmenorrheadiffered significantly according to whether a subject

had regular menstrual cycles (p < .05) or had a family

history of dysmenorrhea (p < .001) (Table 1).

Prevalence of DysmenorrheaThe prevalence of dysmenorrhea in the study group

was 85.7% (1,298 out of 1,515 female students). Of

these students, 30.4% described their menstrual painas severe, 49.8% moderate, and 19.8% as mild. The

mean severity of pain was 6.33 � 2.32 on the VAS

(Table 2).

Logistic Regression Analysis of SignificantVariables Related to DysmenorrheaResults of the backward step-wise logistic regression

analysis using the significant bivariate variables aregiven in Table 3. The risk of dysmenorrhea in students

who had a regular menstrual cycle was 1.27 times

higher than in those with an irregular menstrual cycle

(OR 1.27; 95% CI, 1.02-1.58). The risk of dysmenorrhea

in participants who had a family history of dysmenor-

rhea was approximately 2.1 times higher than in par-

ticipants with no prior history (OR 2.08; 95% CI

1.78-2.43). Other risk factors (such as BMI, smoking,and duration of menstrual flow) were not statistically

significant predictors in the multivariate model and

therefore were removed from the model.

Comparison of Pain Management MethodsAccording to Dysmenorrhea RatingsThe pain management methods used by the partici-

pants in different dysmenorrhea rating groups have

been compared. The majority of participants who ex-perienced moderate or severe pain regularly used anal-

gesics (paracetamol or nonsteroidal anti-inflammatory

drugs [NSAIDs]) for pain management, and participants

who experienced severe pain used analgesics before

the beginning of menstruation. There was a significant

TABLE 1.

Sociodemographic Characteristics of Female in Study Group (n ¼ 1,515)*

Characteristics

Dysmenorrhea

p (c2)

Yes (n ¼ 1,298) No (n ¼ 217) Total (n ¼ 1,515)

n % n % n %

FacultiesPharmacy 79 84.0 15 16.0 94 6.20 .05 (9.93)Health Sciences 186 88.6 24 11.4 210 13.9Arts and Sciences 622 83.0 127 17.0 749 49.4Education 411 89.0 51 11.0 462 30.5

Year in schoolFreshman 281 83.4 56 16.6 337 22.2 .05 (14.94)Sophomore 360 88.5 47 11.5 407 26.9Junior 327 89.6 38 10.4 365 24.1Senior 330 81.3 76 18.7 406 26.8

Age, y<20 635 85.8 105 14.2 740 48.8 .05 (6.50)21-24 639 86.2 102 13.8 741 48.9>25 24 70.6 10 29.4 34 2.3

Marital statusMarried 19 73.1 7 26.9 26 1,7 .84 (3.42)Single 1279 85.9 210 14.1 1489 98.3

Body mass index†

Underweight <18.5 242 87.7 34 12.3 276 18.2 .43 (1.66)Normal 18.5 <24.9 980 85.4 167 14.6 1147 75.7Overweight/obese >25 76 82.6 16 17.4 92 6.1

Cigarette smokingYes 143 85.1 25 14.9 168 11.1 .81 (.45)No 1155 85.7 192 14.3 1347 88.9

Menstrual regularityRegular 1179 86.3 187 13.7 1366 90.2 .05 (45.47)Irregular 119 79.9 30 20.1 149 9.8

Duration of menstrual flow, d<7 967 86.0 158 14.0 1125 74.3 .61 (.277)>7 331 84.9 59 15.1 390 25.7

Age of menarche, y<12 335 87.7 47 12.3 382 25.2 .77 (5.12)13-14 803 85.9 132 141 935 61.7>15 160 80.8 38 19.2 198 13.1

Frequency of menstrual cycle, d<21 98 81.0 23 19.0 121 7.9 .74 (5.21)22-34 1179 86.3 187 13.7 1366 90.2>35 21 75.0 7 25.0 28 1.9

Family historyYes 901 69.4 75 34.6 976 64.4 .001 (98.52)No 397 30.6 142 65.4 539 35.6

*Values are given as number (percantage) unless otherwise indicated; percanteges calculated using row totals.†Calculated as weight in kilograms divided by height in meters squared.

4 Potur, Bilgin, and Komurcu

difference between the dysmenorrhea rating groups

(Table 4, p < .001). Approximately half of participants

reported that they used NSAIDs (45.6% [n ¼ 695]).When the authors investigated the use of non-

pharmacological methods for pain management, they

found that participants who experienced moderate

pain used non-pharmacological methods and that a sig-

nificant difference existed between the dysmenorrhea

rating groups. Participants who experienced moderate

pain used herbal tea, massage, heat application, rest,

and distraction for pain management. Another remark-able result was that participants who experienced se-

vere pain consulted a physician and that a significant

difference existed between the dysmenorrhea rating

groups in this regard (Table 4, p < .001). The most

common non-pharmacological methods were found

TABLE 2.

Dysmenorrhea Severity and Ratings (n ¼ 1,298)

Characteristics Mean ± SD n %

Dysmenorrhea severity 6.33 � 2.32Mild (1-3.9) 257 19.8Moderate (4-7.9) 646 49.8Severe (8-10) 395 30.4

5Prevalence of Dysmenorrhea and Management Methods

to be heat application (23.9% [n ¼ 362]) and rest

(11.4% [n ¼ 172]).

Comparison of the Effects of Dysmenorrhea onthe Daily Activities According to SeverityRatingsWhen the authors investigated the effects of dysmenor-

rhea on daily activities according to severity ratings,

they found that the daily activities of participants

who experienced moderate or severe pain were af-

fected and that participants who experienced severe

pain were unable to attend school or experienced lim-

itations in their social lives. The differences betweenthe dysmenorrheal groups were significant in this re-

gard (Table 5; p < .001).

DISCUSSION

Dysmenorrhea is an important health problem that

has a negative impact on the lives of women during

their menstrual periods. Many local and internationalstudies have investigated dysmenorrhea and its preva-

lence. Our study is different from other studies in

that it was conducted in Istanbul in a large study

TABLE 3.

Logistic Regression Analysis of Significant Variables

Characteristics Beta Sta

Age, y<20 Reference21-24 0.45>25 �0.63

Age of menarche, y 0.10Menstrual regularity

Irregular ReferenceRegular 0.24

Family history of dysmenorrheaNo ReferenceYes 0.73

Frequency of menstrual cycle, d<21 Reference22-34 0.46>35 �0.55

population. In addition, other studies have not investi-

gated pain management methods according to pain se-

verity ratings. We consider these two facets of our

study to be strong points.

The high prevalence of dysmenorrhea (85.7%)was

a major finding in this study. Previous studies have re-

ported that the prevalence of dysmenorrhea may varyfrom 45.3% to 90%. Similarly, previous studies conduct-

ed in Turkey indicated that the prevalence of dysmenor-

rhea in females of the same age as those studied ranged

between 45.3% and 89.5% (Cakır, Mungan, Karakas,

Girisken, & €Okten 2007; Cıtak & Terzioglu, 2002;

Eryilmaz & Ozdemir, 2009; Oskay, Can, Tas, & Sezgin

2004; Polat et al., 2009; Ozerdo�gan, Sayiner, Ayrancı,Unsal, & Giray, 2009; Unsal, Ayranci, Tozun, Arslan, &Calik, 2010). The variations in the prevalence rates

may be explained by the fact that these studies have

selected different sample groups. In addition, the

inconsistency of results may have resulted from the

absence of a universally accepted method of defining

dysmenorrhea and dysmenorrheal pain.

In the authors’ study, approximately 80% of the

students who had dysmenorrhea reported that theyexperienced moderate or severe pain. Similarly,

Banikarim, et al. (2000) and Mohamed (2012) have

found that approximately three quarters of their partic-

ipants experienced moderate or severe pain. The au-

thors’ results parallel these findings.

In the authors’ study, the mean severity of pain

among the students was 6.33 � 2.32 according to

the VAS. Various Turkish (Polat et al., 2009;Ozerdo�gan, Sayiner, Ayrancı, Unsal, & Giray, 2009)

and international studies (Chen & Chen, 2004) yielded

similar results. In studies conducted in Italy by Irono

et al. (2008) and in Iran by Goldstein-Ferber and

Related to Dysmenorrhea

ndard Error p Odds Ratio (% 95 CL)

0.17 .10 1.57 (1.11-2.21)0.27 .20 0.52 (0.31-0.90)0.06 .09 0.91 (0.79-1.01)

0.11 .02 1.27 (1.02-1.58)

0.07 .001 2.08 (1.78-2.43)

0.18 .12 1.59 (1.11-2.30)0.32 .87 0.57 (0.30-1.08)

TABLE 4.

Comparison of Pain Management Methods According to Dysmenorrhea Ratings (n ¼ 1,298)*

Characteristics

Dysmenorrhea Rating

p (c2)

Mild Moderate Severe

n % n % n %

PharmacologicAnalgesicsYes 123 13.4 447 48.7 348 37.9 .001 (123.22)No 134 35.3 199 52.4 47 12.4

RegularityYes 53 10.7 230 46.4 213 42.9 .001 (76.83)

AnalgesicsNo 204 25.4 416 51.9 182 22.7

Before pain startsYes 6 5.3 40 35.4 67 59.3 .001 (52.14)No 251 21.2 606 51.1 328 27.7

Nonpharmacologic therapies*Yes 142 15.3 467 50.4 317 34.2 .001 (48.16)No 115 30.9 179 48.1 78 21.0

WalkingYes 26 14.1 92 50.0 66 35.9 .62 (5.56)No 231 20.7 554 49.7 329 29.5

ExerciseYes 7 10.9 34 53.1 23 35.9 .174 (3.49)No 250 20.3 612 49.6 372 30.1

Heat bathYes 73 17.8 201 48.9 137 33.3 .22 (3.01)No 184 20.7 445 50.2 258 291

Herbal teaYes 55 13.3 205 49.8 152 36.9 .001 (20.96)No 202 22.8 441 49.8 243 27.4

MassageYes 45 13.2 159 46.6 137 40.2 .001 (25.53)No 212 22.2 487 50.9 258 27.0

Relaxation methodsYes 12 13.5 44 49.4 33 37.1 .19 (3.31)No 245 20.3 602 49.8 362 29.9

Heat applicationYes 88 13.7 317 49.4 237 36.9 .001 (41.39)No 169 25.8 328 50.1 158 24.1

RestYes 103 13.3 390 50.5 280 36.2 .001 (61.70)No 154 29.3 256 48.8 115 21.9

Call off the attentionYes 25 10.2 126 51.2 95 38.6 .001 (21.05)No 232 22.1 520 49.4 300 28.5

Consulting a doctorYes 26 8.4 125 40.2 160 51.4 .001 (93.92)No 231 23.4 521 52.8 235 23.8

*Numbers do not total 1,298 as multiple answer were reported.

6 Potur, Bilgin, and Komurcu

Granot (2006), pain severity ratings were found to be

higher than those in our study (8.5 and 8.59 on the

0-10 cm VAS respectively). This inconsistency may be

explained by the fact that cultural differences influ-

ence individuals’ perceptions of pain.

According to the bivariate and logistic regression

analysis, women with a family history of dysmenorrhea

had a higher prevalence of dysmenorrhea. These results

indicate that a family history of dysmenorrhea is an im-

portant risk factor for women with dysmenorrhea.

TABLE 5.

Comparison of the Effects of Dysmenorrhea on the Daily Activities According to Severity Ratings(n ¼ 1,298)

Characteristics

Dysmenorrhea Rating

p (c2)

Mild Moderate Severe

n % n % n %

Limitations Daily activityYes 95 10.8 436 49.7 346 39.5 .001 (182.12)No 162 38.5 210 49.9 49 11.6

Absenteeism from schoolYes 9 3.9 75 32.9 144 63.2 .001 (148.27)No 248 23.2 571 53.4 251 23.5

Limitations social activity/functioningYes 27 7.3 158 42.8 184 49.9 .001 (109.55)No 230 24.8 488 52.5 211 22.7

7Prevalence of Dysmenorrhea and Management Methods

Some researchers have suggested that the daughters of

mothers who have menstrual complaints also experi-

ence menstrual discomfort, and the reason for this

could be related to behavior learned through the rela-

tionship with their mothers (Cıtak & Terzioglu, 2002;Ozerdo�gan, Sayiner, Ayrancı, Unsal, & Giray, 2009;

Unsal, Ayranci, Tozun, Arslan, & Calik, 2010). In

addition, these cases may be explained through

similar reactions to the prostaglandins that are related

to the formation of dysmenorrhea because of genetic

similarity.

Primary dysmenorrhea characteristically begins

when adolescents attain their ovulatory cycles, gener-ally within the first year after menarche. It is believed

that the cause of the pain is the excess production of

prostaglandins in the endometrium during the ovula-

tory cycle (Cakır, Mungan, Karakas, Girisken, & €Okten

2007; Durain 2004; Potur 2009). In the authors’ study,

regular menstrual cycles were found to be a risk factor

for dysmenorrhea. Women who have regular cycles

are considered to ovulate during their cycles. Theprostaglandin released with ovulation is thought to

cause dysmenorrhea considering the tendency of

women with a regular menstrual cycle to regularly

ovulate. Our results thus support the literature

(Karaniso�glu &Dinc, 2012). In a study conducted in Tai-

wan, it was determined that the majority of university

students who had dysmenorrhea (56.4%) also had regu-

lar menstrual cycles (Chang & Chuang, 2012).When the pain management methods of the au-

thors’ participants were investigated according to

pain severity groups, 80% of the participants who ex-

perienced moderate or severe pain were found to

use analgesics for pain management.

In various studies, it has been found that between

42% and 71.7% of women in Turkey managed men-

strual pain with analgesic drugs. This variation is

thought to be related to the possibility of over-the-

counter medicines being sold in Turkey (Cakır,Mungan, Karakas, Girisken, & €Okten, 2007; Cıtak &

Terzioglu, 2002; Oskay, Can, Tas, & Sezgin, 2004;

Polat, et al., 2009; Potur 2009) The authors’ results

are similar to those of Campbell and McGratth (1997)

and Cıtak and Terzioglu (2002). In other studies, the

analgesic use rates were reported to be lower. This

may be related to the fact that some women perceive

dysmenorrhea as normal.Study results pertaining to analgesic usage for man-

aging dysmenorrhea in which subjects used the same

analgesic regularly are inconsistent. This may be related

to cultural differences regarding individuals’ reactions

to pain and pain severity and management methods

(Dorn et al., 2009; Hillen, Grbavac, Johnston, Straton,

& Keogh, 1999; Potur, 2009; Tseng, Chen, & Yang,

2005).A significant difference existed in analgesic usage

before the beginning of menstruation between the par-

ticipants who experienced moderate or severe pain

and those who experienced mild pain. This difference

may be explained by the desire to relieve menstrual

discomfort.

Non-pharmacological methods in the management

of dysmenorrhea are very popular nowadays (Potur &Komurcu, 2013). In Turkey, Cakır et al. (2007) deter-

mined thatmost of the participants preferred heat appli-

cation as the most prevalent pain management method

whereas Oskay et al. (2008) found taking a hot shower

to be themost prevalentmethod and Cıtak (2002) found

8 Potur, Bilgin, and Komurcu

that restingwas preferred. International studies indicate

that resting is the most common method (Banikarim,

Choacko, & Kelder, 2000; El-Gilany, Badawi, & El-

Fedawy, 2005; O’Connell, Davis, & Westhoff, 2006;

Tangchai, Titapant, & Boriboonhirunsarn, 2004).

Similarly, in the authors’ study, the majority of

participants who used non-pharmacological methodsreported that heat application (23.9% [n ¼ 362]) and

resting (11.4% [n ¼ 172]) were the most effective.

When the non-pharmacological methods for man-

aging dysmenorrhea were investigated, it was de-

termined that the majority of participants who

experienced moderate pain benefited from these

methods and that a significant difference existed be-

tween this group and other groups. This may be dueto the fact that participants who have mild pain do

not use any pain management methods, whereas

participants who have severe pain use analgesics. In

addition, the participants who have moderate pain

were able to tolerate the pain until the non-

pharmacological methods they used started to show

their effects.

The majority of participants who experience se-vere pain consulted a doctor. There was a significant

difference in pain severity between this group and

other groups. The results in this group are similar to

those of Cakır et al. (2007).

Dysmenorrheal pain affects the daily activities and

social lives of women. Brunett et al. (2005) found that

24% of the women who had severe menstrual pain

were unable to attend to school. El-Gilany et al.(2005) determined that 98.6% of women with severe

menstrual pain were unable to attend to social activi-

ties. In addition, Banikarim et al. (2000) reported that

44% of the students missed days of school and 53%

had problems communicating with their friends.

Previous studies showed that 18.6% to 80.6% of

school absence occurred in female university students

(Eryilmaz & Ozdemir, 2009; Tangchai, Titapant, &Boriboonhirunsarn, 2004). Similar to the authors’

study, Cakır et al. (2007) and Houston, Abraham,

Huang, & D’Angelo (2006) found that a significant

difference in school attendance existed between the

severe pain group and the mild or moderate pain

severity group (Table 5, p < .001).

It has been concluded that dysmenorrhea affects

daily activities, school attendance, and limitations insocial activity/functioning. Previous studies have

found this effect to be smaller compared to the pres-

ent study. This inconsistency may be related to cul-

tural differences regarding reactions to pain and

pain severity.

LimitationsThe authors are well aware of the limitations of the

present study. Firstly, their results cannot be general-

ized since their sample group is limited to only one re-

gion. This study was planned as a cross-sectional study.

In order to obtain more accurate data (pain severity,

methods for pain management, the effects of dysmen-

orrhea on daily activities), a prospective cohort could

be planned; however, because of the possibility of re-duced data return, this method was not used. Another

limitation of the present study is a lack of universal de-

fining criteria for dysmenorrhea.

CONCLUSION

This study showed a high prevalence of dysmenorrhea

among Turkey female university students. The authors

observed that despite the use of pharmacological and

non-pharmacological pain management methods, the

students were unable to manage their pain at a satisfac-

tory level. As a result, dysmenorrhea has a negative im-

pact on the daily lives, school attendance, and the

social activity/functioning of the students. In orderto help female students manage this problem, nurses

who work in the field of school health, public health,

and women’s health should investigate the pain sever-

ity, pain incidence, duration of pain, pain management

methods, and the effect of dysmenorrhea on school

and social life in women who experience dysmenor-

rhea. Nurses should provide training programs about

when and how to use evidence-based pharmacologi-cal and/or non-pharmacological pain management

methods in the case of dysmenorrhea, and they

also should evaluate the outcome of such training

programs.

Acknowledgments

The authors wish to thank all females who so willingly partic-

ipated in this study. They also wish to acknowledge their sta-

tistics expert, Assistant Professor, Dr. €Omer Uysal. The

authors declare that there are no competing interests and

also that there were no funding organizations for this study.

REFERENCES

Aslan–Eti, F. (2002). The assessment methods of pain.

[in Turkish]. Cumhuriyet Universitesi Hemsirelik

Y€uksekokulu Dergisi, 6(1), 9–16.

Balbi, C., Musone, R., Menditto, A., Di Prisco, L.,Cassese, E., D’Ajello, M., Ambrosio, D., & Cardonel, A.(2002). Influence of menstrual factors and dietary habits on

9Prevalence of Dysmenorrhea and Management Methods

menstural pain in adolescence age. European Journal of

Obstetrics & Gynecology and Reproductive Biology, 91(2),143–148.

Banikarim, C., Chacko, M. R., & Kelder, S. H. (2000).Prevalence and impact of dysmenorrhea on hispanic femaleadolescents. Archives of Pediatrics & Adolescent Medicine,

154(12), 1226–1229.Burnett, M. A., Antao, V., Black, A., Feldman, K.,

Grenville, A., Lea, R., Lefebvre, G., Pinsonneault, O., &Robert, M. (2005). Prevalence of primary dysmenorrhea inCanada. Journal of Obstetrics and Gynaecology Canada,

27(8), 765–770.Campbell, M. A., & McGratth, P. J. (1997). Use of medica-

tion by adolescent for the management of menstrual dis-comfort. Archives of Pediatrics & Adolescent Medicine,

151(9), 905–913.Chang, S. F., & Chuang, M. H. (2012). Factors that affect

self care behavior of female high school students with dys-menorrhea: A cluster sampling study. International Journalof Nursing Practice, 18(2), 117–124.

Chen, H.-M., & Chen, C.-H. (2004). Effects of acupressureat the sanyinjiao point on primary dysmenorrhoea. Journalof Advanced Nursing, 48(4), 380–387.

Collins Sharp, B. A., Taylor, D. L., Thomas, K. K.,Killeen, M. B., & Dawood, M. Y. (2002). Cyclic perimenstrualpain and discomfort: The scientific basis for practice. Jour-nal of Obstetric, Gynecologic, & Neonatal Nursing, 31(6),637–649.

Cakır, M., Mungan, _I., Karakas, T., Girisken, _I., & €Okten, A.(2007). Menstrual pattern and common menstrual disordersamong university students in Turkey. Pediatrics Interna-tional, 49(6), 938–942.

Cıtak, N., & Terziolu, F. (2002). Determination of femalestudents’ knowledge and their applications regarding dys-menorrhea at Abant _Izzet Baysal University. [in Turkish].Health and Society, 12(3), 69–80.

Dorn, L. D., Negriff, S., Huang, B., Pabst, S., Hillman, J.,Braverman, P., & Susman, E. J. (2009). Menstrual symptomsin adolescent girls: Association with smoking, depressivesymptoms and anxiety. Journal of Adolescent Health, 44(3),237–243.

Doty, E., & Attaran, M. (2006). Managing primary dys-menorrhea. Journal of Pediatric and Adolescent Gynecol-

ogy, 19(5), 341–344.Durain, D. (2004). Primary dysmenorrhea: Assessment

and management update. Journal of Midwifery & Women’s

Health, 49(6), 520–528.El-Gilany, A. H., Badawi, K., & El-Fedawy, S. (2005). Epi-

demiology of dysmenorrhoea among adolescent inMansouraEgypt. Eastern Mediterranean Health Journal, 11(1-2),155–163.

Eryilmaz, G., &Ozdemir, F. (2009). Evaluation ofmenstrualpain management approaches by Northeastern AnatolianAdolescents. Pain Management Nursing, 10(1), 40–47.

Goldstein-Ferber, S., & Granot, M. (2006). The associationbetween somatization and perceived ability: Roles in dys-menorrhea among Israeli Arab adolescents. Psychosomatic

Medicine, 68(1), 136–142.Hillen, T. I., Grbavac, S. L., Johnston, P. J., Straton, J. A., &

Keogh, J. M. (1999). Primary dysmenorrhea in youngwestern Australian women: Prevalence, impact, andknowledge of treatment. The Journal of Adolescent Health,25(1), 40–45.

Houston, M. A., Abraham, A., Huang, Z., & D’Angelo, L. J.(2006). Knowledge, attitudes, and consequences of men-strual health in urban adolescent females. Journal of Pedi-atric and Adolescent Gynecology, 19(4), 271–275.Iorno, V., Burani, R., Bianchini, B., Minelli, E., Martinelli, F.,

& Ciatto, S. (2008). Acupuncture treatment of dysmenorrhearesistant to conventional medical treatment. Evidence-basedComplementary and Alternative Medicine, 5(2), 227–230.Johnson, N. (2006). Management of dysmenorrhea.

Reviews in Gynaecological and Perinatal Practise, 6(1-2),57–62.Karaniso�glu, H., & Dinc, H. (2012). Reproductive tract

structural and functional Disorders. In A. Coskun (Ed.),Woman Health and Disease Nursing Handbook, (1st ed.)(pp. 435) Istanbul: Koc University Publisher (In Turkish).Lefebvre, G., Pinsonneault, O., Antao, V., Black, A.,

Burnett, M., Feldman, K., Lea, R., & Robert, M. (2005). Pri-mary dysmenorrhea consensus guideline. Journal of Ob-stetrics and Gynaecology Canada, 27(12), 1117–1146.Mohamed, E. M. (2012). Epidemiology of dysmenorrhea

among adolescent students in Assiut City, Egypt. Life ScienceJournal, 9(1), 348–352.O’Connell, K., Davis, A. R., & Westhoff, C. (2006). Self

treatment patterns among adolescent girls with dysmenor-rhea. Journal of Pediatric Adolescent Gynecology, 19(4),285–289.Ortiz, M. I. (2010). Primary dysmenorrhea amongMexican

university students: Prevalence impact and treatment. Eu-ropean Journal of Obstetrics & Gynecology and Repro-

ductive Biology, 152, 73–77.Ortiz, M. I., Rangel-Flores, E., Carrillo-Alarcon, L. C., &

Veras-Gody, H. A. (2009). Prevalence and impact of primarydysmenorrhea among Mexican high school students.International Journal of Gynecology & Obstetrics, 107(3),240–243.Oskay, €U., Can, G., Tas, D., & Sezgin, €O. (2008). Peri-

menstrual complaints of the nursing students [in Turkish].Journal of Istanbul University Nursing Faculty, 63(16),157–164.Osuga, Y., Hayashi, K., Kobayashi, Y., Toyokawa, S.,

Momoeda, M., Koga, K., Yoshino, O., Tsutsumi, O.,Hoshiai, H., Terakawa, N., & Taketani, Y. (2005). Dysmenor-rhea in Japanese women. International Journal of Gyne-cology & Obstetrics, 88(1), 82–83.Ozerdo�gan, N., Sayiner, D., Ayrancı, U., Unsal, A., &

Giray, S. (2009). Prevalence and predictors of dysmenorrheaamong students at a university in Turkey. InternationalJournal of Gynecolgy & Obstetrics, 107(1), 39–43.Polat, A., Celik, H., Gurates, B., Kaya, D., Nalbant, M.,

Kavak, E., & Hanay, F. (2009). Prevalence of primary dys-menorrhea in young adult female university students. Ar-chives of Gynecology and Obstetrics, 279(4), 527–532.Potur, D. C. (2009). Lokal d€us€uk doz ısı uygulamasının

dismenore €uzerine etkileri [The effects of local low-doseheat application on dysmenorrheal]. Marmara €Universitesi

Sa�glık Bilimleri Enstit€us€u Doktora Tezi. Istanbul, Turkey

Potur, D. C., & Komurcu, N. (2013). Complementarytherapies for dysmenorrhea management. [in Turkish].Hemsirelikte E�gitim ve Arastırma Dergisi, 10(1), 8–13.Tangchai, K., Titapant, V., & Boriboonhirunsarn, D.

(2004). Dysmenorrhea Thai adolescent: Prevalence, impactand knowledge of treatment. Journal of the Medical Asso-

citaion Thailand, 87(3), 69–73.

10 Potur, Bilgin, and Komurcu

Tseng, Y. F., Chen, C. H., & Yang, Y. (2005). Rose tea forrelief of primary dysmenorrhoea in adolescent: A random-ized controlled trial in Taiwan. Journal of Midwifery &

Women’s Health, 50(5), 51–57.Unsal, A., Ayrancı, U., Tozun, M., Arslan, G., & Calik, E.

(2010). Prevalence of dysmenorrhea and its effect on quality

of life among a group of female university students. UpsalaJournal of Medical Sciences, 115(2), 138–145.Zhu, X., Bensoussan, A., Zhu, L., Qian, J., Xu, M., Zhou, C.,

Chao, P., & Lo, S. (2008). Primary dysmenorrhoea: A com-parative study on Australian and Chinese women. Comple-

mentary Therapies in Medicine, 17(3), 155–160.