Introduction

Women with primary dysmenorrhea tend to have elevated prostaglandin levels, triggering more severe than normal uterine contractions. There is no known cause for the elevated prostaglandin levels. To ensure that their menstrual discomfort is not caused by such reproductive conditions such as endometriosis or fibroids, women with dysmenorrhea require a comprehensive medical review. Owing to various meanings of the disease, the prevalence of dysmenorrhea (painful menstrual cramps of uterine origin) is difficult to determine; prevalence rates range from 45 percent to 95 percent. However, irrespective of age and ethnicity, dysmenorrhea continues to be the most common gynecological disorder in women. The word dysmenorrhea comes from Greek, dys, which means difficult, pain, abnormal, meno, which means month, and rrhea, which means flow. Dysmenorrhea can be defined as a difficult menstrual flow or painful menstruation every month [1–3]. Dysmenorrhea is also called menstrual pain [4], which is a health problem that is complained of by most young women [5,6]. Dysmenorrhea can affect all ages and races and one of the causes of problems with the reproductive organs in the pelvic circumference [7].

Dysmenorrhea is grouped into two categories, namely primary dysmenorrhea and secondary dysmenorrhea. There are no pathological abnormalities in the female genitalia [8] in primary dysmenorrhea, while in secondary dysmenorrhea, gynecological abnormalities are found and can also occur during anovulatory menstrual cycles [9]. Primary dysmenorrhea can be treated with counseling, pain relief, and hormone therapy [10,11], generally occurs in young nulliparous women with normal pelvic reproductive organs examination [12,13]. Secondary dysmenorrhea is more common in women over 20 years of age. Common causes of secondary dysmenorrhea include endometriosis, inflammatory disease of the reproductive organs, use of intrauterine contraceptives (IUD), adenomyosis, fibroids (myoma), and endometrial polyps [5,14], ovarian cysts, intrauterine adhesions or cervical stenosis [14]; [15]. According to the level of pain, dysmenorrhea is divided into mild, moderate, and severe pain. Based on the Visual Analogy Scale (VAS), pain intensity is described as no pain, mild pain, moderate pain, and severe pain. Based on the Visual Analogue Scale (VAS) measuring instrument, it has been recommended that there is no pain (0 - 4 mm), mild pain (5-44 mm), moderate pain (45-74 mm), and severe pain (75-100 mm). (11). There is no normative value for VAS [16].

The prevalence of dysmenorrhea varies between countries, ranging from as low as 34% in Egypt to 94% in Oman [17]. Globally, more than 50% of puberty adolescents experience dysmenorrhea, with 10-20% experiencing severity [18]. The prevalence of dysmenorrhea in Indonesia is not certain. The incidence of dysmenorrhea in Indonesia is 64.25%, consisting of 54.89% primary dysmenorrhea and 9.36% secondary dysmenorrhea. About 75% of women experience mild or moderate pain intensity, and 25% of women experience severe pain that makes the patient helpless [19–21]. In West Java, around 8-10% of women of childbearing age experience dysmenorrhea [22]. In Jakarta, dysmenorrhea's prevalence is 87.5%, with mild pain at 20.48%, moderate pain at 64.76%, and severe pain at 14.76% [23]. The prevalence of dysmenorrhea in Surakarta is unknown and there are no studies on the prevalence of dysmenorrhea in Surakarta.

Symptoms of dysmenorrhea can interfere with health and activity. The main symptom is pain, especially around the genital area and/or the middle and lower abdomen. This is caused by an imbalance between the hormone’s estrogen and progesterone. Other symptoms of dysmenorrhea are emesis or vomiting [6,24–26], diarrhea [24], stomach cramps, back pain, fatigue, weakness [6,23,26], discomfort, headaches [6,23], breast pain [23], joint pain, sleep disorders, and acne [6].

Dysmenorrhea has various effects on young women. The impact of dysmenorrhea includes barriers to social interaction and academic performance [27], long-standing tolerance disorders, ability to attend school or work, activities in class [28]. Dysmenorrhea can affect concentration in class, sports activities, class participation, socialization, homework, test-taking skills, and a decrease in test scores [24]. In Indonesia, studies on the impact of primary dysmenorrhea have been carried out and it was found that dysmenorrhea causes absence from school [23,29,30]; disturbed activities, for example, outdoor activities, household chores, concentration, school/work, and sports [23]; and loss of productivity [30]. Various studies have been conducted, but no research has addressed the relationship between the level of dysmenorrhea pain and activity barriers.  Therefore, this study aimed at the relationship between the level of dysmenorrhea pain and impacted activity among young women in Surakarta.

The study was done on the Pandemic of COVID-19, so the researchers adjusted it to health protocols related to the pandemic. This study observed health protocols during the COVID-19 pandemic. The researchers coordinated with youth organizations to help collect the required data. The first step was to send a permit/approval letter to the village head in each village. The purpose of this study was to determine the relationship between the level of dysmenorrhea pain and impacted activity among young women in Surakarta.

Material and methods

This study was conducted in Surakarta, Central Java, Indonesia. Surakarta was chosen because it is a small city with a high population of various ethnic groups. Surakarta has grown rapidly since the last decade as an education city. The young women are not only from the Javanese ethnic group but also from all over Indonesia and from abroad. The study design of this study was a quantitative cross-sectional study.

Surakarta has been chosen as the study location because it is the 5th ranked education city in Indonesia and is known as a city connected with culture and education. In this city, there are ten universities. As an education city, Surakarta has many young people and represents many ethnic groups, from Javanese to Papuans, some of whom come from abroad. The cross-sectional study was conducted in September 2020. This study obtained ethical eligibility permission from the medical faculty of the Malaysian nationality university no: UKM/PPI/111/8/JEP-2020-179 dated 15 June 2020 and from Dr. Moewardi Surakarta Hospital with number 561/II/HPEC/2020 on 10 March 2020. The study population consisted of young women in the city of Surakarta. Surakarta is a city with an area of ​​46.01 km2 and a population of 499,337. There are 63,164 young women aged 15-24 in Surakarta (https://dispendukcapil.surakarta.go.id/, 2020). The population was selected using inclusion and exclusion criteria. The inclusion criteria were as follows: a) unmarried women aged 15-24 years and no sexual relationship; b) no history of reproductive disorders. The exclusion criteria were respondents whose menstrual cycles were irregular. Samples were selected based on a formula by [31].

s = X²NP(1-P) + d²(N-1) + X²P(1-P)                         (1)

s = sample size

X² = chi-square table value for 1 degree of freedom at the desired confidence level (3.841, from 1.96 x 1.96)

N = population size is 63,164, based on https: //dispendukcapil.surakarta.go.id

P = proportion of population (unknown, so considered 0.50 as this will give the maximum sample size)

d = level of accuracy expressed as a proportion (0.05) [31]

n  =  3.841 x 63,164 x 0.5 x (1 – 0.5)

0.05² (63,164 - 1) + 3.841 x 0.5 (1 – 0.5)

= 381.784

The number of the sample shows respondents.

In this study, we used a researcher-made questionnaire. The questionnaire consists of demographic characteristics and their impacts. The data were collected through manual forms and google forms. The second step was to go to the village to collect data. The researcher explained the study objectives, the study process, and assured the confidentiality of the data. Then, prospective respondents were approved to express their desire to participate. Furthermore, respondents were asked to fill out a questionnaire form. The questionnaire could be collected directly on that day or taken Home by the respondent and handed the following day. The next step was to collect the questionnaires, edit, code, test data quality, describe the data, and test the hypotheses. Data analysis was carried out using the SPSS software. The univariate analysis only characterized respondents, distribution of pain levels. The bivariate analysis explained the relationship between the level of dysmenorrhea pain and affected activity in young women in Surakarta.

Result and Dissection

385 respondents participated in the study. The respondents' characteristics are given below based on age, height and weight, age of menarche, and activity barriers.

Table 1: Respondent Characteristics

Based on Table 1, the highest number of age was 15-19 years. For the heaviest pain, between moderate pain and severe pain, the percentage is almost the same. Meanwhile, for the lightest pain, the largest percentage was mild pain. As for body mass index, most of the respondents were 18.5 - 24.99, which was categorized as normal. Regarding impact on daily activities, 79.2% experienced disturbances in daily activities due to dysmenorrhea. Most of the respondents have a menarche age of 12-14 years. Menstrual cycle, 76.6 ^ normal, as well as menstrual duration, by 89.9% is also normal. Meanwhile, the most pain duration is 1-3 days.

To test the normality of the data, we used the one-sample Kolmogorov-Smirnov test.

Table 2: The normality test of Kolmogorov Smirnov

The normality test in Table 2, p > ​​0.05, indicates that the data were normally distributed. The test for the relationship between the level of pain and impacted activity was chi-square test.

Table 3: The Chi Square test for level of pain and dysmenorrhea’s impact