ii ABSTRAK
HUBUNGAN ANTARA OBESITAS DENGAN PREVALENSI DISMENOREA PRIMER PADA MAHASISWI FAKULTAS
KEDOKTERAN UNIVERSITAS UDAYANA
Dismenorea adalah gangguan menstruasi yang dapat mengganggu kualitas hidup, produktivitas, dan penggunaan fasilitas kesehatan selama umur reproduktif wanita, terutama terjadi pada usia remaja. Di seluruh dunia, prevalensinya 90% remaja dan lebih dari 50% wanita menstruasi, sedangkan di Indonesia, prevalensinya 54.89%. Dysmenorrhea terbukti berhubungan dengan IMT (Index Massa Tubuh) yang lebih besar, karena adanya jaringan adiposa berlebih yang menyebabkan hiperplasia pembuluh darah pada organ reproduksi wanita. Hal tersebut menimbulkan gangguan pada aliran darah menstruasi dan muncullah dismenorea primer. Hasil-hasil penelitian sebelumnya menunjukkan bahwa hubungan IMT dan dismenorea tidak konsisten. Tujuan penelitian ini adalah untuk mendapatkan angka kejadian dismenorea berdasarkan IMT dan untuk mendapat informasi tentang hubungan antara obesitas dan dismenorea.
Penelitian ini menggunakan studi case control analytical dan dilakukan di Universitas Udayana, Denpasar, Bali, Indonesia, mulai Agustus hingga Desember 2014. Dengan teknik consecutive sampling, 42 mahasiswi dengan IMT normal dan 42 mahasiswi obesitas dari Fakultas Kedokteran Universitas Udayana angkatan 2013 bersedia menjadi sampel dan mengisi kuesioner.
Hasil penelitian menunjukkan dismenorea primer lebih banyak terjadi pada mahasiswi obesitas (78.6%) dibandingkan pada IMT normal (71.4%). Tetapi, tidak ditemukan adanya hubungan yang signifikan antara IMT dengan dismenorea primer (p>0.05). Peneliti menemukan bahwa hanya faktor keturunan yang memiliki hubungan secara signifikan dengan dismenorea primer (p<0.05).
Dengan adanya penelitian ini, dapat ditarik kesimpulan bahwa IMT tidak mempengaruhi angka kejadian dismenorea primer (p>0.05).
iii ABSTRACT
RELATIONSHIP OF OBESITY WITH THE PREVALENCE OF PRIMARY DYSMENORRHEA IN FEMALE STUDENTS OF MEDICAL
FACULTY UDAYANA UNIVERSITY
Dysmenorrhea is a menstrual disorder which can affect women’s quality of life (QOL), work productivity, and health-care utilization during reproductive age, frequently occurred in adolescence. In worldwide, the prevalence of dysmenorrhea was 90% of adolescent and more than 50% of menstruating women, whereas in Indonesia, its prevalence was 54.89%. Dysmenorrhea is proven to have relation with higher BMI, because there is excess adipose tissue that can cause hyperplasia of the blood vessel in women’s reproduction organ. That causes disturbing the blood menstrual flow and primary dysmenorrhea appears. The evidence of an association between BMI and dysmenorrhea is inconsistent. The aims of this study are to get the prevalence of dysmenorrhea according to BMI and to get information about the relationship between obesity and dysmenorrhea.
By a case control analytical study, this research was done in Udayana University, Denpasar, Bali, Indonesia, started from August until December 2014. Using the consecutive sampling technique, 42 normal BMI and 42 obesity participants from 2013 batch female students of Medical Faculty were taken as samples and agree to fill in the questionnaires.
There was found that dysmenorrhea was occurred more in obesity (78.6%) than in normal BMI participants (71.4%). However, between BMI and having primary dysmenorrhea was not statistically significant (p>0.05) and only family history found having significant relationship to primary dysmenorrhea (p<0.05).
It is concluded that BMI does not influence the prevalence of primary dysmenorrhea in women (p>0.05).
Key Words: BMI, primary dysmenorrhea, female students, family history, prevalence
iv RINGKASAN
Dismenorea adalah suatu gangguan menstruasi yang dapat mengganggu kualitas hidup, produktivitas, dan penggunaan fasilitas kesehatan selama umur reproduktif wanita, terutama terjadi pada usia remaja. Beberapa budaya menganggap menstruasi adalah sesuatu yang tabu dan najis, menimbulkan keengganan untuk mengeluhkan rasa sakit dan kegagalan fasilitas kesehatan. Ada dua jenis dismenorea, yaitu primer dan sekunder. Dismenorea sekunder adalah menstruasi yang disertai dengan rasa sakit karena kelainan patologis pada pelvis, seperti fibroid, adenomyosis, pelvic inflammatory disease (PID), dan lain-lain.
Pada penelitian ini, penulis hanya membahas tentang dismenorea primer, yaitu kram pada perut bagian bawah pada masa menstruasi, tanpa adanya penyakit pada pelvis, yang mungkin disebabkan karena aktivitas PGF2α. Di Indonesia prevalensinya 54.89% dan di dunia prevalensinya 90% remaja dan lebih dari 50% wanita menstruasi. Hal ini dapat disebabkan oleh IMT (Index Massa Tubuh) yang lebih besar, karena adanya jaringan adipose berlebih yang menyebabkan hyperplasia pada pembuluh darah di organ reproduksi wanita. Hal tersebut menimbulkan gangguan pada aliran darah menstruasi dan muncullah dismenorea primer. Hasil-hasil penelitian sebelumnya menunjukkan bahwa hubungan IMT dan dismenorea tidak konsisten. Karena itu, peneliti ingin membuktikannya.
Dengan menggunakan studi case control analytical, penelitian ini dilakukan di Universitas Udayana, Denpasar, Bali, Indonesia, mulai bulan Agustus hingga Desember 2014. Dengan teknik consecutive sampling, 84 responden (42 mahasiswi dengan IMT normal dan 42 mahasiswi obesitas) dari Fakultas Kedokteran Universitas Udayana angkatan 2013 bersedia menjadi sampel dan mengisi kuesioner. Semua responden sehat secara mental dan fisik, tidak pernah merokok, tidak pernah mengunjungi tempat praktik spesialis obgyn karena masalah pada organ reproduksi atau kelainan menstruasi, belum pernah hamil dan melahirkan, serta tidak pernah mengalami operasi pada organ reproduksi.
Hasil penelitian menunjukkan bahwa dismenorea primer lebih banyak terjadi pada obesitas (78.6%) daripada sampel dengan IMT normal (71.4%). Tetapi, tidak ditemukan adanya hubungan yang signifikan antara IMT dengan dismenorea primer dengan uji chi square (p=0.45). Peneliti menemukan bahwa hanya faktor keturunan memiliki hubungan signifikan dengan dismenorea primer (p=0.001). Sedangkan faktor lain seperti umur kronologis, umur menarche, durasi menstruasi, dan siklus menstruasi didapatkan tidak memiliki hubungan secara signifikan dengan dismenorea primer (p=0.455; p=0.885; p=0.774; p=0.377).
Dengan adanya penelitian ini, dapat ditarik kesimpulan bahwa IMT tidak mempengaruhi angka kejadian dismenorea primer (p>0.05).
v SUMMARY
Dysmenorrhea is a menstrual disorder which can affect women’s quality of life (QOL), work productivity, and health-care utilization during reproductive age, frequently occurred in adolescence. Many cultures still perceive menstruation as taboo and impure, resulting in reluctance of pain report and failure of health care. It has 2 types, primary and secondary. Secondary dysmenorrhea is painful menses because of pelvic pathology like fibroid, adenomyosis, pelvic inflammatory disease, etc.
In this research, the writer only discussed about primary dysmenorrhea. It is cramping pain in the lower abdomen at the onset of menstruation, without pelvic diseases, may be caused by the action of PGF2α. In Indonesia, its prevalence was 54.89% and in worldwide, 90% of adolescent and more than 50% of menstruating women. It can be caused by higher BMI, because there is excess adipose tissue that can cause hyperplasia of the blood vessel in women’s reproduction organ. That causes disturbing the blood menstrual flow and primary dysmenorrhea appears. The evidence of an association between BMI and dysmenorrhea is inconsistent. Therefore, the writer wants to prove this theory.
By a case control analytical study, this research was done in Udayana University, Denpasar, Bali, Indonesia, started from August until December 2014. Using the consecutive sampling technique, all of 84 participants (42 normal BMI and 42 obesity participants) from 2013 batch female students of Medical Faculty were taken as samples and agree to fill in the questionnaires. All of them are physically and physiologically healthy, not smoking cigarette, never went to obstetric and gynecology specialist due to any reproductive organs abnormality or menstruation disorder, have not pregnant or delivering any babies, and also never got any reproductive organs surgeries.
There was found that dysmenorrhea was occurred more in obesity (78.6%) than in normal BMI participants (71.4%). However, there was no statistically significant relationship between BMI and having primary dysmenorrhea (p=0.45). Family history was found having statistically significant relationship with primary dysmenorrhea (p=0.001). In the contrary, chronological age, age of menarche, menstrual duration, and menstrual cycle were statistically difference with primary dysmenorrhea (p=0.455; p=0.885; p=0.774; p=0.377).
It is concluded that BMI does not influence the prevalence of primary dysmenorrhea in women (p>0.05).
vi PREFACE
Firstly, the writer wants to give thanks to dr. Desak Made Wihandani, M. Kes, as the supervisor who has given her attention and guidance to the writer in the process of making this study; and also Prof. dr. N. Agus Bagiada, Sp. Biok as the evaluator.
The writer also wants to give thanks to Dr. dr. I. W. P. Sutirta Yasa, M.Si, as the head of Elective Study block and to dr. Putu Ayu Asri Damayanti, M. Kes, as the secretary.
In this study, the writer realizes that there are still a lot of weaknesses because of the limiting ability of the writer. Therefore, the critics and suggestion is really hoped by the writer to make this proposal become better.
Last but not least, the writer hopes that this proposal can give benefits and can serve good informations for others. The writer hopes that the aims of this study can be achieved.
Denpasar, 11th of December 2014
Writer
vii LIST OF CONTENTS ABSTRAK...v ABSTRACT...vi RINGKASAN………...vii SUMMARY ………...viii PREFACE ... ix LIST OF CONTENTS ... x
LIST OF TABLES ... xii
LIST OF FIGURES ... xiii
LIST OF ATTACHMENTS ... xiv
CHAPTER I INTRODUCTION ... 1
1.1 Research Background ... 1
1.2 Research Question ... 3
1.3 Purposes ... 3
1.4 The Benefits of the Research ... 3
1.4.1 Scientific Benefits ... 3
1.4.2 General Benefits ... 3
CHAPTER II LITERATURE REVIEW ... 4
2.1 Primary Dysmenorrhea ... 4
2.2 Pathophysiology of Primary Dysmenorrhea ... 5
2.2.1 Prostanoid ... 5
2.2.2 Vasopressin ... 7
2.2.3 Uterine Contractions ... 7
2.2.4 Uterine Blood Flow ... 8
2.3 BMI and Dysmenorrhea ... 8
CHAPTER III FRAME OF RESEARCH, CONCEPT, AND HYPOTHESIS ... 13
3.1 Frame of Research ... 13
3.2 Research Concept ... 13
3.3 Hypothesis ... 14
CHAPTER IV RESEARCH METHODOLOGY ... 15
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4.1.1 Design ... 15
4.1.2 Time and Place ... 15
4.2 Subjects and Samples ... 15
4.2.1 Variability of Population ... 15
4.2.2 Criteria of Subjects ... 16
4.2.2.1 Inclusion ... 16
4.2.2.2 Exclusion ... 16
4.2.3 Quantity of Samples ... 16
4.2.4 Technique to Determine Samples ... 17
4.3 Variables ... 17
4.3.1 Variable Identification ... 17
4.3.2 Variable Classification... 18
4.3.3 Operational Definition of Variables ... 18
4.4 Materials and Instruments ... 20
4.5 Research Protocol ... 20
4.6 Analysis ... 20
CHAPTER V RESULT AND DISCUSSION ... 21
6.1 Result ... 21
6.2 Discussion ... 27
CHAPTER VI CONCLUSION AND SUGGESTION ... 28
6.1 Conclusion ... 28
6.2 Suggestion ... 29
REFERENCES ... 30 ATTACHMENT
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LIST OF TABLES
Table 5.1 Distribution Table of Participants with and without Primary Dysmenorrhea ... 22 Table 5.2 BMI Classification of Participants with and without Primary Dysmenorrhea ... 23 Table 5.3 Relation of Confounding Factors and Primary Dysmenorrhea ... 24 Table 5.4 Distribution Table of Participants Menstrual Cycles ... 25 Table 5.5 Distribution Table of the Associated Symptoms of Primary Dysmenorrhea ... 26
x
LIST OF FIGURES
Figure 2.1 Pathophysiology of Primary Dysmenorrhea ... 8
Figure 2.2 The pathway of PGF2α synthesis ... 10
Figure 3.1 Research Concept ... 13
Figure 4.1 Research Protocol ... 20
Figure 5.1 Diagram of Participants’ Age ... 21
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LIST OF ATTACHMENTS
Attachment 1. Ethical Clearance Attachment 2. Informed Consent Attachment 3. Kuesioner Penelitian Attachment 4. Research Questionnaire Attachment 5. Data of Participants Attachment 6. SPSS Calculation Attachment 7. Curriculum Vitae
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CHAPTER I
INTRODUCTION
1.1 Research Background
Generally, all women must be experienced menstruation at their life, expect for pregnant and menopause women. Some of them get menstrual pain at their cycles, but some others do not. That pain is called by dysmenorrhea.
Dysmenorrhea is a menstrual disorder which can affect women’s quality of life (QOL), work productivity, and health-care utilization during reproductive age, frequently occurred in adolescence (Ju H. et al, 2014). It is derived from the Greek, ‘‘dys’’ (difficult), ‘‘meno’’ (month), and ‘‘rrhea’’ (flow) (Madhubala and Jyoti, 2012). Many cultures, such as some Mediterranean, Muslim, Hindu, and Chinese, still perceive menstruation as taboo and impure, resulting in reluctance of pain report and failure of health care (IASP, 2007). The risk factors are family history of dysmenorrhea, young age (<30 years), early menarche (<12 years), low or high body mass index (<20 or >30), nulliparity, smoking, longer cycles or duration of bleeding, irregular or heavy menstrual flow, premenstrual symptoms, clinically-suspected pelvic inflammatory disease, history of sexual assault, and psychological symptoms such as depression and anxiety (Berkley, 2013).
Dysmenorrhea has two types, primary and secondary. Primary dysmenorrhea is cramping pain in the lower abdomen at the onset of menstruation, without pelvic diseases, may be caused by the action of
xiii
prostaglandins, PGF2α. Secondary dysmenorrhea is painful menses because of pelvic pathology like fibroid, adenomyosis, pelvic inflammatory disease, etc (Jyoti and Madhubala, 2012).
In this study, the writer only discussed about primary dysmenorrhea. In worldwide, the prevalence is 90% of adolescent and more than 50% of menstruating women, 10–20% of them felt severe and distressing pain (Berkley, 2013), whereas in Indonesia, its prevalence was 54.89% of the menstrual women (Mahmudiono and Nazari, 2011).
BMI (body mass index) is a simple method to classify underweight, overweight and obesity in adults. It equals to weight/height2 (kg/m2) (WHO, 2004). Dysmenorrhea is proven to have relation with higher BMI because there is excess adipose tissue causing hyperplasia of the blood vessel (blood vessels pressed by adipose tissue) in women’s reproduction organ. It disturbs the blood menstrual flow and primary dysmenorrhea appears (Novia and Puspitasari, 2008).
The evidences of an association between BMI and dysmenorrhea are inconsistent. A study done by Lakshmi et al (2011) in SRM Medical College Hospital and Research Centre, SRM University, Kattankulathur, Tamilnadu, India, found that there was no significant relationship between BMI and dysmenorrhea (p= 0.259), whereas by Jyoti and Madhubala (2012) in Rajkiya Balika Uchh Prathmik Vidyalaya, Bedla and at Rajkiya Janjati Kasturba Balika Vidyalaya, Madhuban, Udaipur, India, found that the relationship between dysmenorrhea and BMI was statistically significant (p=0.01) with more prevalence in the low BMI. In Indonesia, the study done by Novia and
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Puspitasari (2006) in Banjar Kemantren Village, Sidoarjo, East Java, found that there was not statistically difference between BMI or nutritional status and dysmenorrhea. Therefore, the writer wants to prove this theory and do a research in Udayana University to compare the result with the former studies that have been done.
1.2 Research Question
According to the background of this research above, the research question can be made is: How is the relationship between dysmenorrhea in obese and normal BMI?
1.3 Purposes
To get the prevalence of primary dysmenorrhea according to BMI and get information about the relationship of normal and obesity BMI with primary dysmenorrhea.
1.4 The Benefits of the Research
1.4.1 Scientific Benefits:
Giving information for other researchers to be used as a comparative study.
1.4.2 General Benefits:
1. Giving a chance to widen people’s knowledge, especially about dysmenorrhea.
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2. The result of this research can be a reason for people to maintain a normal weight.
