Incidence of Primary Menstrual Pain in International Islamic High School and International Islamic Boarding School Students
Kejadian Nyeri Haid Primer Pada Siswi International Islamic High School dan International Islamic Boarding School
Andon Hestiantoro, Juliand Hidayat Department of Obstetrics and Gynecology Faculty of Medicine Universitas Indonesia Dr. Cipto Mangunkusumo General Hospital
Jakarta
Abstract
Objective: To determine description of primary dysmenorrhea in International Islamic High-School and International Islamic Boarding-School Students Methods: This was an observational analytic study with cross sectional method performed in International Islamic High School and International Islamic Boarding School. All female students who experienced menstrual pain were included in this study. Physical activity data collection was carried out using the IPAQ (International Physical Activity Questionnaire) questionnaire which was filled in 7 consecutive days before menstruation, while data on the degree of pain in primary dysmenorrhea used the NRS (Numeric Rating Scale) which was filled in when experiencing pain before receiving therapy or pain relievers. Data were analyzed using computational calculations using the SPSS program with a bivariate test using the X2 test or the chi-square test with a significance degree of 0.05.
Results: There were 114 samples who were recruited to the study. In a comparison of physical activity and the degree of primary menstrual pain, it was found that 75 female students (35.5%) who did light physical activity complained more about moderate to severe menstrual pain compared to female students who did moderately severe activities. 16 female students (7.6%). Based on the results of bivariate analysis using the chi-square test, the value of p = 0.002 (P> 0.05) showed that there was a significant relationship between physical activity and the degree of primary dysmenorrhea.
Conclusions: Low physical activity is 5.95 times the risk of experiencing moderate to severe primary dysmenorrhea than severe physical activity
Keywords: primary dysmenorrhea, physical activity
Abstrak
Tujuan: Untuk mengetahui gambaran dismenore primer pada siswi International Islamic High School dan International Islamic Boarding School.
Metode: Penelitian observasional analitik dengan metode potong lintang yang dilakukan di International Islamic High School dan International Islamic Boarding School. Seluruh mahasiswi yang mengalami nyeri haid diikutsertakan dalam penelitian ini. Pengumpulan data aktivitas fisik dilakukan dengan menggunakan kuesioner IPAQ (International Physical Activity Questionnaire) yang diisi 7 hari berturut-turut sebelum menstruasi, sedangkan data derajat nyeri pada dismenore primer menggunakan NRS (Numeric Rating Scale) yang diisi pada saat mengalami nyeri sebelum mendapat terapi atau obat pereda nyeri. Data dianalisis menggunakan perhitungan komputasi menggunakan program SPSS dengan uji bivariat menggunakan uji X2 atau uji chi- square dengan derajat kemaknaan 0,05.
Hasil: Terdapat 114 sampel yang diikutsertakan untuk penelitian. Pada perbandingan aktivitas fisik dan derajat nyeri haid primer didapatkan 75 siswi (35,5%) yang melakukan aktivitas fisik ringan lebih banyak mengeluhkan nyeri haid sedang sampai berat dibandingkan dengan siswi yang melakukan aktivitas sedang berat. 16 siswa perempuan (7,6%).
Berdasarkan hasil analisis bivariat dengan menggunakan uji chi-square diperoleh nilai p = 0,002 (P>0,05) menunjukkan bahwa ada hubungan yang signifikan antara aktivitas fisik dengan derajat dismenore primer.
Kesimpulan: Aktivitas fisik rendah berisiko 5,95 kali mengalami dismenore primer sedang hingga berat dibandingkan aktivitas fisik berat
Kata kunci: dismenore primer, aktivitas fisik
INTRODUCTION
Adolescence is a period of transition from puberty to adulthood, namely at the age of 11-20 years. During this transitional period the individual matures physiologically, psychologically and socially. Adolescence is marked by the emergence of primary sex characteristics, this is influenced by the start of the reproductive system. Events that appear at puberty are rapid body growth, the emergence of secondary sex characteristics, menarche, and physical changes. In women, puberty is marked by the onset of menstruation or menstruation. Menstruation is the process of releasing blood from the uterus through the vagina every month during the childbearing age.1,2
The first menstruation experienced by a woman is called menarche, generally occurs at the age of 14 years. Menarche is a sign of the end of puberty, a period of transition from childhood to adulthood.3 Menstruation experienced by teenage women can cause problems, one of which is dysmenorrhea or menstrual pain.
Dysmenorrhea is a gynecological problem that is generally experienced by women, both teenagers and adults.4
Menstrual pain (dysmenorrhea) is pain during menstruation caused by uterine muscle spasms. During menstruation, the
prostaglandin hormone is released in the uterus which causes vasoconstriction of blood vessels, thereby inhibiting blood flow to the uterus. Excessive production of prostaglandins results in uterine contractions, causing pain or dysmenorrhea.5
According to the World Health Organization (WHO), the prevalence of dysmenorrhea ranged from 1.7% -97% in 106 studies with 125,249 female respondents. A cross-sectional study of 256 female students conducted in Asia in 2013 at the University of Hong Kong reported a prevalence of dysmenorrhea around 80%. Research conducted in 2013 in India stated that 51% of women experienced dysmenorrhea and even 22.1% of respondents experienced limitations in carrying out daily activities.6
The prevalence of dysmenorrhea in Indonesia is 64.2%, consisting of 54.89%
experiencing primary dysmenorrhea and
9.36% experiencing secondary
dysmenorrhea.7
Dysmenorrhea is divided into two, namely primary and secondary dysmenorrhea. Primary dysmenorrhea is the occurrence of menstruation at the beginning of menstruation (menarche) which is accompanied by pain, but there is no specific disease that is the cause. Meanwhile, secondary dysmenorrhea is pain caused by a
collection of symptoms of gynecological diseases, such as endometriosis or fibroid.8
Primary dysmenorrhea is defined as menstrual pain that is not based on a pathological condition. It is characterized by excess production of prostaglandins by the endometrium which causes uterine hypercontractility resulting in uterine muscle ischemia, hypoxia. Primary dysmenorrhea is the most common gynecological disease in women. However, it is underdiagnosed, undertreated, and even underestimated by women themselves, who accept it as a normal part of the menstrual cycle.9
Dysmenorrhea is often classified as mild, moderate, or severe based on the relative intensity of pain. The pain can impact the ability to perform daily activities. Pain intensity according to the Multidimensional Scoring of Andersch and Milsom classifies dysmenorrhea pain as follows.
a) Mild dysmenorrhea is defined as menstrual pain without activity restrictions, no need for analgesia and no systemic complaints.
b) Moderate dysmenorrhea is defined as menstrual pain that affects daily activities, with the need for analgesics for pain relief and there are several systemic complaints.
c) Severe dysmenorrhea is defined as menstrual pain with limitations in daily activities, minimal analgesic response to
relieve pain, and the presence of systemic complaints such as vomiting, and fainting.10
To deal with menstrual pain, non- steroidal anti-inflammatory drugs can be used to reduce the symptoms caused.
Treatment of dysmenorrhea can be done in two ways, namely by pharmacological therapy and non-pharmacological therapy.
Basic pharmacological therapy can be given non-steroidal anti-inflammatory drugs (NSAIDs). Whereas for non-pharmacological therapy there are several ways, namely by compressing warm water, exercise, and getting enough sleep.11
Various risk factors for primary dysmenorrhea have been identified in the literature with varying prevalence results.
These risk factors are associated with an increased incidence of primary dysmenorrhea. These risk factors include 1) early menarche, 2) family history of complaints of dysmenorrhea, 3) abnormal body mass index, 4) duration of bleeding during menstruation, 5) exposure to cigarette smoke, 6) consumption of coffee.
The impact of dysmenorrhea if it occurs continuously, what needs to be watched out for is that young women often limit their daily activities, especially learning activities at school become disrupted, concentration decreases, so that the material
obtained cannot be digested properly and can result in repeated absences at school and even frequent truancy, laziness, weakness and lose enthusiasm.12
Based on the description above, researchers are interested in conducting research on menstrual pain in young women considering the problem of menstrual pain in adolescents which can interfere with daily activities, the researchers want to know more about "Incidence of Primary Menstrual Pain in International Islamic High School and International Islamic Boarding School Students”. It is hoped that with these data, more intervention plans can be made for preventive action in tackling the problem of primary dysmenorrhea.
METHODS
This was an observational analytic study with cross sectional method performed in International Islamic High School and International Islamic Boarding School, during the period of April 2023. All female students who experienced menstrual pain were included in this study.
The dependent variable is the degree of primary dysmenorrhea, while the independent variables are body mass index, age at menarche, duration of menstruation, menstrual cycles and physical activity.
Physical activity data collection was carried out using the IPAQ (International Physical Activity Questionnaire) questionnaire which was filled in 7 consecutive days before menstruation. Respondents' physical activity was categorized as severe physical activity (severe activity >3 days plus >1500 METs minutes/week or >7 days walking combined with moderate/severe activity and total METs
>3000 METs minutes/week), moderate (>3 days doing activities severe >20 minutes/day or >5 days of moderate activity/walking >30 minutes/day or >5 days of a combination of moderate intensity walking, minimum severe activity >600 METs minutes/week), and light (excluding severe and moderate physical activity or no moderate to severe physical activity <10 minutes/day or 600 METs minutes/week).13 While data on the degree of pain in primary dysmenorrhea uses the NRS (Numeric Rating Scale) which was filled in when experiencing pain before receiving therapy or pain relievers.14
The data analysis used was univariate and bivariate analysis. Univariate analysis yielded the frequency distribution and total percentage of each variable. Bivariate analysis aims to examine the relationship between each independent variable and the dependent variable. This study had been approved by the Research Ethics Committee
of Faculty of Medicine, Universitas Indonesia. Collected data were then analyzed using SPSS for Macintosh ver. 24 with a bivariate test using the X2 test or the chi- square test with a significance degree of 0.05.
RESULTS 1. Analysis Univariate
Based on the questionnaire obtained, the number of female students included in the inclusion criteria was 211 people. Table 1 shows that most of the respondents are included in the BMI with normal weight, namely 74 people (56.5%). The rest fall into the underweight and overweight categories.
Table 1. Distribution Case Primary Dysmenorrhea Based on BMI
IMT n (%)
Underweigh 27 (12,8)
Normal Weight 166 (78,7)
Overweight 18 (8,5)
Total 211 (100)
Table 2 shows that case partial primary dysmenorrhea big happened to respondents who experienced menarche at age between < 13 years that is as many as 100 people (47.4%). this result state that part big respondent own age deep menarche normal range.
Table 2. Distribution Case Primary Dysmenorrhea Based Age Menarche
Age Menarche n(%)
< 13 years 100 (47.4) 13 - 15 years 98 (46.4)
> 15 years 13 (6,2)
Total 211 (100)
Table 3 shows that case partial primary dysmenorrhea big occurred in respondents whose menstrual period was 5-7 days that is as many as 160 people (75.8%)
Table 3. Distribution Case dysmenorrhea Primer Based on Duration of Menstrual Duration Mestrual n(%)
< 5 days 25 (11.8) 5 - 7 days 160 (75.8) 7 - 14 days 23 (10,9)
> 14 days 3 (1.5)
Total 211 (100)
Table 4 shows that case partial primary dysmenorrhea big occurs in respondents who cycle her period every 21 - 35 days that is as many as 134 people (63.5%)
Table 4. Distribution Cycle Period
Cycle Period n(%)
< 21 days 64 (30.3) 21 - 35 days 134 (63.5)
> 35 days 13 (6,2)
Total 211 (100)
Based on Table 5 it can be seen that the onset of primary dysmenorrhea in most respondents (127 people) was at the beginning of menstruation and only 3 respondents experienced primary dysmenorrhea at the end of menstruation.
Table 5. Distribution Onset dysmenorrhea Onset of onset
dysmenorrhea n(%)
Before period 55 (26.1) At the beginning period 127 (60.2)
In the middle period 8 (3,8) At the end period 3 (1,4) During period 18 (8.5)
Total 211 (100)
Based on the degree of pain, 120 people (56.9%) complained of mild pain and 91 people (43.1%) complained of moderate to severe pain as shown in Table 6.
Table 6. Distribution Case Primary Dysmenorrhea Based Degrees dysmenorrhea
Degrees dysmenorrhea
n(%)
Mild pain 120 (56.9)
Moderate severe pain 91 (43.1)
Total 211 (100)
Respondents in this study had various symptoms and from some of these symptoms,
almost all respondents experienced mood changes.Only a small proportion experienced depression when experiencing menstrual pain (Table 7).
Table 7. Distribution Case Primary Dysmenorrhea Based Symptom Participant
Symptom Participant
n(%)
Constipation 7 (3,3)
Diarrhea 15 (7,1)
Vomit 6 (2,8)
Nauseous 30 (14,2)
Breast tight 51 (24.2)
Headache 68 (32,2)
Depression 5 (2,4)
Bloating stomach 39 (18.5) Feel tired 115 (54.5)
Mood swings 165 (78.2)
Acne 125 (59.2)
Based on Table 8, it can be seen that most of the respondents felt the impact of primary dysmenorrhea on learning activities.
The impact that was experienced the most was in the form of being present at the lesson, but not focusing on the lesson is 108 people (51.2%). While the least impact is not attending school.
Table 8. Distribution of Primary Dysmenorrhea Cases Based on the Impact
The resulting impact n(%) No present school 12 (5,7) Present, lying in the SMR 16 (7 ,6) Present, no focus lesson 108 (51.2)
Present, no participate 56 (26.5) No feel disturbed 19 (9.0)
Total 211 (100)
Table 9 shows that case dysmenorrhea pioneer in research This more Lots experienced by respondents who have habit exercising ≤3 days that is as many as 119 people (41.7 % ).
Table 9. Distribution Case Primary Dysmenorrhea Based Habit Sport
Habit sport n(%)
No Once 83 (40.3)
≤3 days 119 (41.7)
> 3 days 9 (18.0)
Total 211 (100)
Based on activity physical , respondents who do activity light that is as many as 93 people (44.1%) and did activity currently heavy as many as 118 people (55.9%) like shown in Table 10 .
Activity Physique n(%)
Activity light 93 (44.1) Activity currently
heavy
118 (55.9)
Total 211 (100)
Various efforts will usually be made by respondents to reduce the dysmenorrhea they experience. Table 11 shows that the most effort made by respondents to reduce dysmenorrhea was rest and the least effort made was drinking herbal medicine for 4 people (1.9%).
Table 11. Distribution Primary Dysmenorrhea Based on Business for
Reduce dysmenorrhea Effort For
Reducing Pain n(%)
Rest 171 (81.0)
Pain medication 51 (24.2) Heating pads 47 (22.3)
Drink jamu 4 (1,9)
Examination to a doctor or other health facility is one of the efforts made to treat dysmenorrhea and Table 12 shows that most of the respondents in this study never came to a doctor or other health facility to have their dysmenorrhea checked. The reason most respondents did not go for a check-up was because they could still endure the pain they were experiencing.
Table 12. Distribution Respondents who did Inspection to Doctor or Other Health
Facilities
Check to Doctor /
Facility health n(%)
Never 196 (92.9)
Ever 15 (7,1)
Total 211 (100)
Table 13. Distribution of Respondents Who Examine Doctors or Other Health Facilities
Reason No Check n(%) Is matter reasonable 82 (25.1)
can bear the pain 120 (56.9) Afraid check 9 (18.0)
Total 211 (100)
2. Analysis Bivariate 1) Body Mass Index
Table 14. Relationship between body mass index and degree primary dysmenorrhea
Body Mass Index
Primary Menstrual Pain
Degree Total OR
(95% CI) p- valu Low Moderate es
Severe
n % n % f %
Under 5 2.4 22 10.4 27 12.8
2.51 (1.89 -
3.33)
Normal 112 53.1 54 25.6 166 78.7 Compare 10.37 (2.88 - 17.35)
Over 3 1.4 15 7.1 18 8.5
Total 120 56.9 91 43.1 211 100
0.00 0*
The table above shows the results of the analysis of the relationship between body mass index and the degree of primary dysmenorrhea, there were 27 respondents with less body mass index (<18.5), 22 people with moderate to severe primary dysmenorrhea (10.4%) and 10.4% who experienced mild dysmenorrhea. 5 people with a percentage (2.4%). There were 166 respondents with a normal body mass index (18.5-25.0), 112 people had mild dysmenorrhea with a percentage (53.1%) and 54 people had moderate severe dysmenorrhea with a percentage (25.6%). There were 18 respondents who had a body mass index of more than bb (> 25.0) who experienced moderate to severe primary dysmenorrhea as many as 15 people with a percentage (7.1%) and who experienced mild dysmenorrhea as many as 3 people with a percentage (1.4%).
Statistical test results showed a relationship between body mass index and the degree of primary dysmenorrhea and from the results of the statistical test (chi- square test) the result was (p=0.000) which means that there is a significant relationship between physical activity and the degree of
primary dysmenorrhea because the p-value
<0 ,05. Then, from the results of the analysis between the low body mass index (<18.5) and the normal body mass index (18.5-25.0), OR
= 2.51 means that girls with a thin body mass index (<18.5 ) has a 2.51 times risk of experiencing moderate to severe primary dysmenorrhea compared to female students with a normal body mass index (18.5-25.0).
A fat body mass index (> 25.0) with a normal body mass index (18.5-25.0) is obtained OR
= 10.37 meaning that girls with a fat body mass index (> 25.0) have a risk of 10.37 times experiencing moderate to severe dysmenorrhea compared to female students with a normal body mass index (18.5-25.0).
2) Age of Menarche
Table 15. Relationship between age of menarche with degree primary
dysmenorrhea
Age of Menarche
Primary Menstrual Pain Degree
Total p-
values
Low Moderate
Severe
n % n % f %
< 13 years 17 8.1 85 40.3 102 48.3
13 - 15 years 93 44.1 4 1.9 97 46
> 15 years 10 4.7 2 0.9 12 5.7
Total 120 56.9 91 43.1 211 100 0.000*
The table above shows the results of the analysis of the relationship between the age of menarche and the degree of primary dysmenorrhea, there were 102 respondents with menarche age <13 years who experienced moderate to severe primary dysmenorrhea as many as 85 people with a percentage (48.3%) and who experienced mild dysmenorrhea as many as 17 people with a percentage (8.1%) ). There were 97 respondents with menarche age of 13-15 years as many as 93 people had mild dysmenorrhea with a percentage (44.1%) and 4 people had moderate severe dysmenorrhea with a percentage (1.9%). There were 12 respondents with menarche > 15 years of age who experienced moderate to severe primary dysmenorrhea as many as 2 people with a percentage (0.9%) and who experienced mild dysmenorrhea as many as 10 people with a percentage (4.7%).
Statistical test results showed a relationship between body mass index and the degree of primary dysmenorrhea and from the results of the statistical test (chi- square test) the result was (p=0.000) which means that there is a significant relationship between physical activity and the degree of primary dysmenorrhea because the p-value
<0,05.
3) Physical Activity
Table 16. Relationship between activity physique with degree primary dysmenorrhea
Activity Physique
Primary Menstrual Pain Degree
Total
OR (95%
CI)
p- values
Light Medium
Heavy
n % n % f %
Light 18 8.5 75 35.5 93 44.1
Medium
Heavy 102 48.4 16 7.6 118 55.9 5.95
(3.73 - 9.49)
Total 120 56.9 91 43.1 211 100 0.002*
The table above shows the results of the analysis of the relationship between physical activity and the degree of primary dysmenorrhea, there were 93 respondents who did light physical activity who experienced moderate to severe primary dysmenorrhea with a proportion (35.5%) and who experienced mild dysmenorrhea as many as 18 people with a proportion (8.5%) . There were 118 respondents who carried out moderately strenuous activities, 102 people experienced mild dysmenorrhea with a proportion (48.4%) and 16 people
experienced moderate severe dysmenorrhea with a proportion (7.6%).
The table above shows the relationship between physical activity and the degree of primary dysmenorrhea and from the results of the statistical test (chi-square test) the result is (p=0.000) which means that there is a significant relationship between physical activity and the degree of primary dysmenorrhea because the p-value <0. 05 . Then, from the results of the analysis between light activity and moderate activity, the OR = 5.95 means that students who do light physical activity have a 5.95 times the risk of experiencing moderate to severe primary dysmenorrhea compared to students who do moderate physical activity.
DISCUSSION
1. Relationship between Body Mass Index and the Degree of Primary Dysmenorrhea Based on the analysis results obtained, students with BMI BB have less risk of experiencing moderate to severe menstrual pain 2.51 times compared to students with normal BMI and students with BMI BB have more risk of 10.37 times experiencing moderate to severe dysmenorrhea compared to students with BMI normal .
This study is in accordance with the theory that women who have a thin and fat
BMI are a risk factor for primary dysmenorrhea. One of the studies conducted Rafique et al and Khalid et al found that underweight and obese BMI tend to be at risk of experiencing primary dysmenorrhea than normal BMI.15,16 The more fat the more prostaglandins are formed, while the increase in prostaglandin levels in the blood circulation is suspected as the cause of dysmenorrhea.17 Being overweight can cause primary dysmenorrhea, because in the body of a person who is overweight there is excessive fatty tissue which can increase blood vessel hyperplasia (suffocation of blood vessels by fatty tissue) in the female reproductive organs so that blood that should flow during menstruation disturbed and primary dysmenorrhea occurs.18
This research is in line with research conducted by Madhubala and Jyoti (2018) which stated that there is a relationship between BMI and dysmenorrhea (p-value = 0.01).19 Likewise, a study conducted by Hong Ju et al (2023) stated that there was a significant relationship between BMI and dysmenorrhea (p-value = 0.001) and the results of the analysis obtained that underweight BMI had a risk of 1.34 times to experience primary dysmenorrhea. than normal BMI. BMI fat (obese) 1.22 times the risk of experiencing dysmenorrhea.20
2. Relationship between Menarche Age and Degree of Primary Dysmenorrhea
Based on the results of statistical tests, it showed that there was a significant relationship between the age of menarche and the degree of primary dysmenorrhea (p-value
= 0.000). This research is in line with research conducted by Azagew (2020) on female students which found that there is a relationship between the age of menarche and the incidence of primary dysmenorrhea with a value (p-value = 0.031) and people who are at the age of early menarche are at risk of 1.6 times experiencing dysmenorrhea. primary versus ideal menarche age.21 A study conducted by Muluneh (2018) at secondary and preparatory school students in Debremarkos town, North-West Ethiopia stated that menarche aged >14 years had a lower risk of experiencing dysmenorrhea with an OR of 0.7 (for menarche over 14 years compared to menarche under or equal to 13 years.22
A study conducted by Acheampong (2019) DKK states that a fast menarche age is at risk of experiencing primary dysmenorrhea rather than the ideal age of menarche. The female reproductive organs must function properly. However, if menarche occurs at an earlier age than normal, where the
reproductive organs are not ready to undergo changes and there is still narrowing of the cervix, pain will occur during menstruation.23 3. The Relationship between Physical Activity and the Degree of Primary Dysmenorrhea
Based on the results of statistical tests, it showed that there was a significant relationship between physical activity and the degree of primary dysmenorrhea (p-value = 0.002). The results of this analysis show that light physical activity is 5.95 times the risk of experiencing moderate to severe primary dysmenorrhea compared to moderate physical activity. These results are in line with research conducted by Golomb et al (2019) that women who do not exercise are 3.5 times more at risk of experiencing primary dysmenorrhea than those who exercise.24 Research by Abaraogu et al (2018) analyzed exercise through a semi- experimental study in one group, with results showing a relationship between fitness and dysmenorrhea.25
Lack of exercise habits can cause reduced blood flow to the uterine muscles so that it can cause dysmenorrhea. Exercise that is done before and during menstruation is highly recommended because it can improve blood flow so that it can overcome
dysmenorrhea that is experienced. In addition, exercise can also stimulate the formation of endorphins.26 This hormone is a hormone produced by the brain and spinal cord which can function as a natural sedative that will make a person feel comfortable and relaxed. Conditions like this will make the body stop all hormone production which can cause dysmenorrhea and also stop the hormones produced during stress.27
CONCLUSION
From the results of research conducted on students at the International Islamic High School and the International Islamic Boarding School, it was concluded; 44.1%
are classified as doing light physical activity, 55.9% are classified as having moderate physical activity.
The proportion of mild primary dysmenorrhea was 56.9% and moderate to severe dysmenorrhea was 43.1%. There is a relationship between primary dysmenorrhea and physical activity and there is a relationship between primary dysmenorrhea and body mass index.
DECLARATIONS
The data used in this study can be requested from corresponding author upon reasonable request.
CONFLICT OF INTEREST
Authors declare that there is no conflict of interest in this study.
FUNDING STATEMENT
All of the funding for this research was financed by authors.
ACKNOWLEDGEMENTS
Authors would also like to express sincere gratitude to all International Islamic High School and International Islamic Boarding School students for their invaluable contributions to this research.
REFERENCES
1. Mohammed H, Hassen N, Musa A. Dysmenorrhea and associated factors among secondary school students in East Hararghe Zone, Eastern Ethiopia. East Afr J Health Biomed Sci. 2019;3(1):39–48.
2. Osayande AS, Mehulic S. Diagnosis and Initial Management of Dysmenorrhea. American Family Physician. 2018;89(5):341-346.
3. Ju H, Jones M, Mishra G. The prevalence and risk of dysmenorrhea.
Oxford University Press 2018.
[accessed April 26, 2023]; 36(1):104- 13. http://epirev.oxfordjournals.org/
4. Latthe P, Latthe M, Say L, Gülmezoglu M. WHO Systematic Review of Prevalence of Chronic Pelvic Pain: a Neglected Reproductive Health Morbidity.
2018;7:1–7.
5. Hong J, Mark J, Gita M. The Prevalence and Risk Factor of Dysmenorrhea. Am J Epidemiol.
2019;36(1):104–13.
6. Proctor M, Farquhar C. Diagnosis and managementofdysmenorrhoea. BMJ.
2018 May 13;332(7550):1134-8.
7. Beckmann C, Ling F, Herbert W, et al. Obstetrics and Gynecology.
Williams & Wilkins; 2017.
8. Madhubala C, Jyoti K. Relation between dismenorrhea and body index in adolescents with rural versus urban variation. The Journal of Obstetrics and Gynecology of India.
2019; 62(4):442-5.
9. Tu F. Dysmenorrhea: contemporary perspectives. International Association fot the Study of Pain.
2020; 15(8):1-4.
10. Kural M, Noor NN, Pandit D, Joshi T, Patil A. Menstrual Characteristics and Prevalence of Dysmenorrhea in College Going Girls. J Fam Med Prim Care. 2018;4(3):426-431.
11. IPAQ. (2005). Guidelines For Data Processing and Analysis of The International Physical Activity Questionnaire (IPAQ) Short and Long Forms.
12.Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain. 2018;27:117–126.
13.Rafique N, Al‐Sheikh
MH. Prevalence of primary dysmenorrhea and its relationship with body mass index. J Obstet Gynaecol Res. 2018;44:1773‐1778.
14.Khalid M, Jamali T, Ghani U, Shahid T, Ahmed T, Nasir T. Severity and relation of primary dysmenorrhea and body mass index in undergraduate students of Karachi: a cross sectional survey. J Pak Med Assoc.
2020;70:1299‐1304
15.Rad M, Sabzevari MT, Rastaghi S, Dehnavi ZM. The relationship between anthropometric index and primary dysmenorehea in female high
school students. J Educ Health Promot. 2018;7:34.
16.Abarca‐Gómez L, Abdeen ZA, Hamid ZA, et al. Worldwide trends in body‐mass index, underweight, overweight, and obesity.
2017;390:2627‐2642.
17. Madhubala, C. & Jyoti, K., 2018.
Relation Between Dismenorhea And Body Mass Index In Adolescents With Rural Versus Urban Variation.
The journal of obstetrics and gynecology of india, 62(4):442-5.
18. Hong Ju, Mark Jones, Gita Mishra.
The Prevalence and Risk Factors of Dysmenorrhea. Epidemiologic Review [internet]. 2018 [cited 2023 April 19]: 36(1):104-113. Dapat diakses di: Oxford Journals
19.Azagew AW, Kassie DG, Walle TA. Prevalence of primary dysmenorrhea, its intensity, impact and associated factors among female students’ at Gondar town preparatory school, Northwest Ethiopia. BMC Womens Health. 2020;20:5.
20. Muluneh AA, Nigussie T, Gebreslasie KZ, Anteneh KT, Kassa ZY. Prevalence and associated factors of dysmenorrhea among secondary and preparatory school
students in Debremarkos town, North-West Ethiopia. BMC Womens Health. 2018;18:57.
21.Acheampong K, Baffour-Awuah D, Ganu D, et al. Prevalence and predictors of dysmenorrhea, its effect, and coping mechanisms among adolescents in Shai Osudoku District, Ghana. Obstet Gynecol Int.
2019;2019:5834157
22. Golomb L.M., Solidum A.A. Warren M.P. Primary dysmenorrhea and physical activity. Med Sci Sports Exerc. 1998; 30: 906-90
23. Abaraogu U.O. Tabansi-Ochiogu C.S. Igwe E.S. Effectiveness of exercise therapy on pain and quality of life of patients with primary dysmenorrhea: a systematic review with meta-analysis.Turk J Phys Med Rehab. 2018; 62: 346-354
24.Bonen, A. and H. A. Keizer. Athletic menstrual cycle irregularity:
endocrine response to exercise and training. PhysicianSportsmed. 12:78- 93, 2019.
25. American College of Obstetrics and Gynecology. Dysmenorrhea: painful periods.Availableat: https://www.aco g.org/Patients/FAQs/Dysmenorrhea-
Painful-Periods. Accessed April.
22, 2023.
26.Madhubala C, Jyoti, K. Relation between dysmenorrhea and body mass index in adolescents with rural versus urban variation. The Journal of Obstetrics and Gynecolog of India.
2022; 62(4): 442-5.