Menstruation is a physiological event which represents a woman’s fertility . Women experience a variance of physical and psychological symptoms during menstruation, including pain, headache, and lethargy .
Dysmenorrhea is a common symptom in adolescent women which can affect between 45-95% of menstruating ones . However, prevalence estimates vary widely due to methodological and cultural differences that may limit the generalizability of international estimation. Dysmenorrhea was classified as primary, with no underlying pathology, is more common in adolescents and usually occurs 6 to 12 months after menstruation. Moreover, the secondary dysmenorrhea that is associated with organic causes may occur years after menstruation [4-6].
The actual cause of primary dysmenorrhea is unclear; the most well-known etiology is the overproductions of intrauterine prostaglandins, particularly PGF2a and PGF2, which lead to uterine contractions and menstrual pain .
Dysmenorrhea affects individual social life, the educational and works performance, social relationships, and daily activities. The impacts of painful periods include absenteeism, anxiety, depression, poor work performance, and social withdrawal contributing to poor quality of life  [8-10].
Coronavirus disease 2019 (COVID-19) is a global public health emergency which causes a global pandemic [10-11]. The intense anxiety and fear associated with the Covid-19 pandemic and the disruption of daily life have created a global emotional health crisis. Women, in particular, have a higher prevalence of anxiety, depression, and stress-related disorders, owing to the physical and social health determinants. Furthermore, the negative impacts of the pandemic on women’s emotional health can cause further unintended adverse health consequences . Additionally, the pandemic may affect women’s ability to control their menstrual cycle and health . Therefore, the study aims to investigate the menstrual pattern, prevalence, and impact of dysmenorrhea among Iraqi university students during the COVID-19 pandemic.
Materials and Methods
This study is cross-sectional conducted from March to May 2021 at various universities (Medical, pharmacy, and Dentistry College) in Baghdad, Iraq. Data was collected through a self-administered questionnaire from 1,312 Iraqi university students. Ethical approval was obtained for this study from the College Council at the College of Medicine at Al-Iraqia University. All participants were informed of the study and informed written consent which had obtained. An online research tool had designed to collect information related to demographics, menstrual characteristics, menstrual pain, educational activities, and self-management practices during the pandemic. The Pearson correlation coefficient was used to measure the instrument’s test-retest reliability. Descriptive statistics had used to present the study findings using SPSS version 22. For qualitative data, we used the chi-square test and the independent sample t-test. A P-value of 0.05 or less is considered statistically significant.
Results and Dissections
The average age of participants was (23.9±4.4) years old, the average age of menarche (12.1±0.8) years old and (69.8%) were single. The majority of students (78.7%) have regular menstrual cycles. The average BMI was (24.1±4.1) kg/m2. Over half of the participants (56.9%) had suffered, or at least one of their relatives had Covid-19 infection (Table1).
It is also found that over half of the participants (51.5%) were experiencing varying degrees of dysmenorrhea during the Covid-19 pandemic. The highest frequency of participints (32.1%) were rated dysmenorrhea as mild, (13.3%) moderate and (6.1%) as severe menstrual pain (Table1). Moreover, the most frequent treatment used by female students (62.0%) for relieving their menstrual pain was analgesics (NSAID) (Table 3).
Furthermore, the impact of dysmenorrhea on educational activities was significant among Iraqi university students during the COVID-19 pandemic. The predominant impaired educational activities were lack of concentrations (50.1%) and difficulty in working (42.7%) (Table 4).
During the pandemic, approximately (18.1%) of participants reported worsening of their menstrual pain, while (8.2%) were reported improvement of menstrual pain. (21.3%) reported irregular menstruation, (8.8%) had reported increases in menstrual irregularity. (32.5%) reported an increase in their BMI. Moreover, (35.5%) of students have reported increases in learning difficulties, whereas (12.3%) reported improvement in educational activities. Furthermore, (13.4%) of students reported an increase in the medication used for relieving dysmenorrhea during the pandemic (Table 3).
The current study indicated a significant relationship between dysmenorrhea and the age of students, menstrual irregularity, medication use, and Covid-19 infection of students (P<0.005). Furthermore, a highly significantly relationship had found between dysmenorrhea and the learning difficulties and interpersonal relationships of students (p-value<0.001) (Tables 3 and 4).
Dysmenorrhea is one of the most common gynecological disorders in adolescent females. Menstrual pain harms the personal, family, and academic life of female students.  A WHO systematic review of dysmenorrhea reported that the incidence of dysmenorrhea was 16–81% . Recent studies determined the prevalence of dysmenorrhea from 45–95% of menstruating women .
According to the results, the current study demonstrates that (51.5%) of the students experienced dysmenorrhea. The distribution of pain intensity indicated that (32.1%) of the participants had mild dysmenorrhea, (13.3%) moderate, and (6.1%) had severe menstrual pain. The prevalence of dysmenorrhea in our study is consistent with other studies results from Turkey (53.6%), Ethiopia (51.5%), and Georgia (52%) (16-18). However, it was lower than the prevalence of dysmenorrhea in Egypt (93%), Iran (73.27%) and Saudi Arabia (61%) [19-20]. Furthermore, the prevalence of dysmenorrhea in our study was more than that rated in developing countries (25-50%) of adult women .
Differences in the prevalence and severity of dysmenorrhea can be due to geographical and cultural differences in pain perception and variations in pain threshold. The wide prevalence variation may also be due to the focus on selected subject groups rather than a representative sample of the female population in the community .
The present study reported that the average age of participants was (23.9±4.4) years old and the average age of menarche (12.1±0.8) years old. Most previous studies have included that dysmenorrhea peaks in late adolescence then declines with age . Previous systematic reviews also revealed that the prevalence of dysmenorrhea decreases with age [19-22]. The findings of our study confirmed those of prior studies.
The current study indicated a significant relationship between dysmenorrhea and the age of students, menstrual irregularities, use of treatments, and the students or their relatives who had the Covid-19 virus infection (p < 0.005). These results were consistent with those of the previous studies among women of childbearing age . Furthermore, recent studies have reported an increase in menstrual pain and a deterioration in a menstrual pattern during the pandemic [25-26]. In addition, a study from Palestine indicated that students with irregular menstrual cycles were almost twice as likely to have dysmenorrhea .
Finally, the study found an association between dysmenorrhea and academic performance. Further, there were a highly statistically significant relationships between dysmenorrhea and learning difficulties as well as the interpersonal relationships among students (p<0.001). Our findings was consistent with findings of previous systematic reviews and meta-analyses in low and middle-income countries that concluded that dysmenorrhea has a statistically significant negative effect on academic performance both in school and during higher education [23-28].
In conclusion, the present study revealed significant relationships between dysmenorrhea and student’s age, menstrual irregularities, medications use, and COVID-19 infection. Moreover, the study demonstrated highly statistically significant relationships between dysmenorrhea, learning difficulties, and poor interpersonal relationships among Iraqi university students during the COVID-19 pandemic. Future studies need to focus on improving pain and symptoms management strategies to reduce the effects of dysmenorrhea so that young women can optimize their educational and future life opportunities.
The author extends thanks to all university students who participated in the study.
This research did not receive any specific grant from fundig agencies in the public, commercial, or not-for-profit sectors.
All authors contributed toward data analysis, drafting and revising the paper and agreed to responsible for all the aspects of this work.
Conflict of Interest
We have no conflicts of interest to disclose.
Ekhlas Ali Hussein
HOW TO CITE THIS ARTICLE
Ekhlas Ali Hussein, Israa Talib Hassan, Hala Saadi Issa, Mahasen M. Abd Al-Majeed. Dysmenorrhea among Female University Students during the COVID-19 Pandemic, J. Med. Chem. Sci., 2022, 5(5) 787-792