SLEEPJ, 2019, 1–8

doi: 10.1093/sleep/zsz061
Advance Access Publication Date: 7 March, 2019
Original Article

Original Article
Age at menarche, menstrual problems, and daytime

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sleepiness in Chinese adolescent girls
Ze-Ying Wang1, Zhen-Zhen Liu1, Cun-Xian Jia1,*, and Xianchen Liu1,2,3,*,
School of Public Health, Shandong University, Jinan, China, 2School of Psychology, South China Normal University,
1

Guangzhou, China and 3University of Tennessee Health Science Center, Memphis, TN

*Corresponding authors. Cun-Xian Jia, School of Public Health, Shandong University, No. 44, Wenhuaxi Road, Lixia District, Jinan 250012, China. Email: jiacunxian@
sdu.edu.cn; Xianchen Liu, School of Public Health, Shandong University, No. 44, Wenhuaxi Road, Lixia District, Jinan 250012, China. Email: xliu69@uthsc.edu.

Abstract
Study Objectives:  Menstrual problems and daytime sleepiness are prevalent in adolescent girls. Little is known about the associations
between age at menarche, menstrual problems, and daytime sleepiness. This study aimed to examine the associations of age at menarche
and menstrual problems with daytime sleepiness among Chinese adolescent girls.

Methods:  Of 11,831 adolescents who participated in the baseline survey of Shandong Adolescent Behavior & Health Cohort (SABHC), 5,813
were girls and included for the analysis. A structured self-administered questionnaire was used to collect information about menstrual
problems, sleep, mental health, and demographics. Daytime sleepiness was measured by the Chinese Adolescent Daytime Sleepiness Scale
(CADSS).

Results:  The mean age of the girls was 15.02 (SD = 1.44) years. The prevalence rates of mild, moderate, and severe daytime sleepiness were
20.5%, 16.7%, and 5.5%, respectively. After adjusting for adolescent and family covariates (age, body mass index, physical health, physical
exercise, sleep duration, sleep problems, anxious/depressive symptoms, and family social economic status), sometimes irregular (odds ratio
[OR] = 1.24, 95% confidence interval [CI] = 1.01 to 1.52), often irregular menstruation (OR = 1.58, 95% CI = 1.17 to 2.12), moderate (OR=1.39, 95%
CI = 1.12 to 1.72), and severe (OR = 1.46, 95% CI = 1.04 to 2.04) menstrual pain were significantly associated with increased risk of daytime
sleepiness.

Conclusions:  Our findings suggest that menstrual irregularity and menstrual pain are associated with increased risk of daytime
sleepiness. These findings emphasize the importance of evaluating and intervening menstrual problems for preventing daytime sleepiness
in adolescent girls.

Statement of Significance
Adolescents are prone to experiencing sleep problems such as sleep insufficiency, sleep disturbance, and daytime sleepiness. Menstrual
problems like menstrual pain are also prevalent in adolescent girls. This is the first study to examine the associations between age at
menarche, menstrual problems, and daytime sleepiness in a sample of Chinese adolescent girls. Our study demonstrated that menstrual
irregularity and menstrual pain are associated with increased risk of daytime sleepiness. The associations remained to be significant after
adjusting for adolescent and family covariates. Further research is warranted to examine the psychological and biological mechanisms
between menstrual problems and daytime sleepiness in adolescent girls.

Key words:  menstruation; dysmenorrhea; daytime sleepiness; adolescence

Submitted: 9 October, 2018; Revised: 10 February, 2019

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 2 | SLEEPJ, 2019, Vol. 42, No. 6
Introduction
Adolescence is the period of pubertal transition to adulthood
accompanied by a series of physiological and psychological
changes [1]. Menarche, the first menstrual cycle, is a remarkable
milestone for female adolescents [2]. The median age at
menarche is 12–13  years in most developed countries [3].
Menstrual problems are common in female adolescents,
including dysmenorrhea (menstrual pain or period pain),
menorrhagia, hypomenorrhea, irregularity cycle, and other
related symptoms [1, 4–6]. For example, the prevalence of
dysmenorrhea is 16%–93%, with severe pain being 2%–19% [7].
A  study of Turkey adolescents reported that the prevalence
rates of mild, moderate, and severe menstrual pain were 28%,
43%, and 29%, respectively, and the prevalence of menstruation
irregularity was 34% [8]. Menstrual problems are associated with
school absenteeism, poor concentration, academic performance,
mental health problems, and self-harm or suicidal behaviors [2,
5, 9–11].
Adolescence is also at risk for sleep problems, such as
sleep insufficiency, insomnia, and daytime sleepiness [12–14].
The prevalence of sleep problems in most epidemiological
studies of adolescents is 20%–40% [14–16]. Our previous studies
have demonstrated that early menarche was significantly
associated with insomnia symptoms in 12 to 14-year-old girls,
and menstrual problems were associated with sleep problems
including poor sleep quality and insomnia symptoms [17].
While menstruation and sleepiness are both related to many
neuroendocrine and physiological systems, the hypothalamic–
pituitary–adrenal (HPA) axis may be a possible pathway between
menstruation and sleepiness [18, 19]. However, no studies
have been specifically conducted to examine the associations
between age at menarche, menstrual problems, and daytime
sleepiness in adolescent girls.
The current study of a large sample of adolescent girls
in China was conducted to examine if age at menarche and
menstrual problems are associated with daytime sleepiness
in female adolescents and if the associations are independent
from age, body mass index (BMI), physical exercise, anxiety/
depression, and sleep variables and family demographics [2, 9,
17, 18, 20].
Methods
Study design and participants
The baseline survey of Shandong Adolescent Behavior and
Health Cohort (SABHC) was conducted in November to
December 2015, in three counties (Lijin, Yanggu, and Zoucheng)
Shandong, China. Detailed methods can be found in our previous
publications [21, 22]. Briefly, 12,301 students were sampled from
five middle schools and three high schools in three counties.
The three counties and eight schools were selected, with the
consideration of the social demographics, representativeness of
students in the region, convenience, and budget to conduct the
survey.
After obtaining the consent from the principals and class
teachers of the eight target schools, trained master-level public
health workers administered a self-administered adolescent
health questionnaire (AHQ) [23, 24] to students in the
classrooms during regular school hours. It took about 50 min to
complete the questionnaire. Before filling out the questionnaire,
the students were required to read the instructions carefully
and were informed that the survey was anonymous, and
their participation was voluntary without any penalties for
nonparticipation.
We obtained permission to conduct the study from the
principals in the target schools and informed consent from
participants in the target classes before the survey. Participants
were asked to get permission from their parents to participate
in the survey. The study was approved by the research ethics
committee of Shandong University School of Public Health and
target schools.
Measures
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Age at menarche and menstrual problems
Three questions were used to obtain information about
menarche and menstrual problems for girls. First question
asked about menarche by “Have you begun to menstruate?” If
the answer was yes, age at menarche was asked by “How old
were you when you had your first period?” If the girls have had
menarche, they were then asked to answer the question about
menstrual regularity and menstrual pain. Menstrual regularity
was asked by “How regular is your menstrual period?” with an
answer selection of “regular,” “sometimes irregular,” or “often
irregular” Menstrual pain was asked by “Do you have painful
periods or menstrual cramps?” with a response option of “no,”
“mild,” “moderate,” or “severe.”
Daytime sleepiness
Daytime sleepiness was assessed by Chinese Adolescent
Daytime Sleepiness Scale (CADSS) [21], a self-administered
questionnaire. The CADSS comprises seven questions that
inquire about adolescents’ common feelings of drowsiness and
dozing off at different circumstances during the daytime in the
past month. Instance items are “During the past month, how
often would you say you feel sleepy during the day?” “During
the past month, how often would you say you have dozed off
easily anytime during the day?” “During the past month, how
often would you say you have dozed off while reading, studying,
or doing homework during the day?” All the seven items are
rated on a 5-point scale from 1 = never, 2 = rarely (<1 time/week),
3 = sometimes (1–2 times/week), 4 = often (3–5 times/week), to
5 = almost every day (6–7 times/week). Summing the scores of
the seven items yields a total CADSS score, ranging from 7 to 35.
A higher CADSS score indicates a greater propensity of daytime
sleepiness during the past month. The internal consistency
reliability coefficient with the current sample was 0.89. On the
basis of the total CADSS score, participants were divided into
four groups: “normal (≤16),” “mild daytime sleepiness (17–22),”
“moderate daytime sleepiness (23–30),” and “severe daytime
sleepiness (≥31)” [21].
Sleep duration and sleep problems
Nocturnal sleep duration, insomnia, snoring, and sleep quality
during the past month were assessed by the following questions
[23, 25, 26]. Insomnia symptoms were inquired about difficulty
falling sleep (DIS), difficulty maintaining sleep (DMS), and early
morning awakening (EMA). Insomnia was defined as any of
DIS, DMS, and EMA with an answer of “often or almost every

day.” Nocturnal sleep duration was asked by “During the past
month, on a typical school day, how many hours of actual sleep
did you get at night?” Snoring was asked by “How often did you
have snoring?” The participants responded the question about
insomnia and snoring with an answer from 1 = never, 2 = rarely
(<1 time/week), 3 = sometimes (1–2 times/week), 4 = often (3–5
times/week), to 5  =  almost every day (6–7 times/week). Sleep
quality was asked by “During the past month, in general how
would you estimate the quality of your sleep?” with the response
option of “excellent,” “good,” “fair,” “poor,” or “very poor.”
Anxious/depressive symptoms
The Chinese Youth Self-Report (YSR) of Achenbach’s Child
Behavior Checklist was used to measure anxious/depressive
symptoms [27]. The YSR anxious/depressed subscale consists
of 16 items that are rated on a 3-point scale: “0”  =  not true,
“1” = somewhat or sometimes true, and “2” = very true or often
true. Summing the scores of the 16 items yields a total anxiety/
depression score, ranging from 0 to 32. The higher the scores, the
greater the likelihood of anxiety/depression. The scale score was
used for statistical analysis in the study. The Cronbach alpha
with the present sample was 0.86 for the subscale.
Adolescent and family demographics
Adolescent age, body weight, and height, self-report physical
health, parents’ education, and self-reported family economic
situation in comparison with other families (excellent/good,
fair, poor/very poor) and physical exercise were also asked in
the AHQ. BMI was calculated by the formula that body weight
divided by the square of body height (kg/m2) [17]. Physical
exercise was asked by “How many times per week do you do
physical exercise or bodybuilding during the past month?”
with the response options of “<1  day/week,” “1–2  days/week,”
“3–4 days/week,” or “5–7 days/week.”
Statistical analysis
The frequency for categorical variables and means for continuous
variables were computed for descriptive analysis. Analysis of
variance (ANOVA) was used to examine the mean CADSS score
differences between ages at menarche and between adolescents
with various menstrual problems. Univariate logistic regression
analyses were performed to examine the associations between
age at menarche, menstrual problems, and daytime sleepiness,
followed by multivariate logistic regression to adjust for
adolescent and family covariates, including age, BMI, physical
health, sleep duration, sleep problems, anxiety/depression
scores, parental education, family economic status, physical
exercise, and the school that participants were attending. Odds
ratios (ORs) and 95% confidence intervals (CIs) were computed in
logistic regression models. Interaction effects of sleep variables
(sleep duration, insomnia, snoring, and sleep quality) and
menstrual variables (age at menarche, menstrual irregularity,
and menstrual pain) on daytime sleepiness were then
performed. Furthermore, mediation analyses were performed
using PROCESS [28] to examine the mediating effects of sleep
quality, insomnia, and anxiety/depression on the associations
between menstrual problems and daytime sleepiness. PROCESS
estimated the indirect effect and bias-corrected CIs based on
5,000 bootstrapping samples. An indirect effect was considered
Wang et al.  |  3
significant when the CIs did not include zero. The effect size was
estimated by the ratio of the indirect effect to the total effect
[29]. p  <  0.05 was set as the level of statistical significance. All
statistical analyses were performed by IBM SPSS 24.0 (IBM Crop;
Armonk, NY).
Results
Sample characteristics
Of 12,301 students sampled, 11,836 (96.2%) returned their
questionnaires, and 5,813 were girls and were included for the
statistical analysis. Mean age of the girls was 15.02 (SD  =  1.44)
years. Detailed sample characteristics are presented in Table 1.
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Prevalence of daytime sleepiness
The overall prevalence of daytime sleepiness was 42.7% in the
current sample. The rates of mild, moderate, and severe daytime
sleepiness were 20.5%, 16.7%, and 5.5%, respectively. Figure 1
displays the prevalence of daytime sleepiness by age. Daytime
sleepiness tended to increase from the ages of 12–16 and then
showed a moderating trend.
Demographics and sleep problems associated with
daytime sleepiness
As shown in Table 1, age, BMI, physical health, physical exercise,
anxious/depressive symptoms, sleep duration, sleep problems
including insomnia, snoring and sleep quality over the past
month, father and mother education and family economic
status were all significantly associated with daytime sleepiness
(p ≤ 0. 001).
Mean CADSS scale scores across menstrual problem
variables
Table 2 presents mean CADSS scores across menstrual variables.
Mean CADSS scores were significantly elevated along with the
increasing levels of menstrual irregularity and menstrual pain.
Associations between menstrual problems and
daytime sleepiness
As presented in Table 3, menstrual problems were significantly
associated with daytime sleepiness in univariate logistic
regression models. After adjusting for adolescent and family
covariates, sometimes irregular (OR  =  1.24, 95% CI  =  1.01 to
1.52), often irregular menstruation (OR  =  1.58, 95% CI  =  1.17 to
2.12), and moderate (OR = 1.39, 95% CI = 1.12 to 1.72) and severe
menstrual pain (OR  =  1.46, 95% CI  =  1.04 to 2.04) remained to
be significant. With further adjustment of other menstrual
variables, menstrual irregularity, and menstrual pain were still
significantly associated with daytime sleepiness in multivariate
regressions. Age at menarche had no significant association
with daytime sleepiness.
No interactions were observed between sleep variables
(sleep duration, insomnia, snoring, and sleep quality) and
menstrual variables (age at menarche, menstrual irregularity,
and menstrual pain) for daytime sleepiness (all p > 0.05).
 4 | SLEEPJ, 2019, Vol. 42, No. 6

Table 1.  Demographic and sleep variables in relation to daytime sleepiness in female adolescents

Daytime sleepiness

Characteristics Overall N (%)* N (%)* OR (95% CI) P

Age (year) 5,813 <0.001

 ≤12 247 (4.2) 36 (15.3) 1.00
 13–15 2,998 (51.6) 968 (34.0) 2.85 (1.98 to 4.10)
 ≥16 2,568 (44.2) 1368 (55.5) 6.89 (4.79 to 9.91)
BMI, M ± SD 5,770 (19.77 ± 2.82) 2,360 (20.09 ± 2.77) 1.07 (1.05 to 1.09) <0.001
Anxiety/depression, M ± SD 5,548 (6.07 ± 5.34) 2,372 (8.16 ± 5.87) 1.15 (1.14 to 1.17) <0.001
Physical health 5,759 <0.001
  Poor/very poor 192 (3.3) 107 (60.1) 2.95 (2.13 to 4.08)
 Fair 4,389 (76.2) 1,873 (44.6) 1.57 (1.37 to 1.81)
 Excellent/good 1,178 (20.5) 379 (33.8) 1.00
Insomnia 5,596 <0.001

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 No 4,803 (85.8) 1,866 (39.7) 1.00
 Yes 793 (14.2) 490 (63.6) 2.66 (2.27 to 3.11)
Sleep duration 5,639 <0.001
 ≤5 902 (16.0) 548 (62.7) 4.80 (3.80 to 6.06)
 6 2,031 (36.0) 1,036 (52.4) 3.14 (2.55 to 3.87)
 7 1,310 (23.2) 432 (34.7) 1.52 (1.22 to 1.90)
 8 802 (14.2) 156 (20.3) 0.73 (0.56 to 0.94)
 ≥9 594 (10.6) 145 (25.9) 1.00
Snoring 5,601 <0.001
 Never 4,874 (87.0) 1,996 (41.8) 1.00
  <1 time/week 503 (9.0) 225 (45.5) 1.16 (0.96 to 1.40)
  1–2 times/week 149 (2.7) 80 (55.9) 1.77 (1.26 to 2.47)
  3–5 times/week 31 (0.5) 22 (73.3) 3.83 (1.70 to 8.61)
  Almost everyday 44 (0.8) 34 (79.1) 5.26 (2.52 to 10.99)
Sleep quality 5714 <0.001
 Excellent/good 2,199 (38.5) 548 (26.0) 1.00
 Fair 2,210 (38.7) 880 (41.4) 2.01 (1.77 to 2.29)
  Poor/very poor 1,305 (22.8) 919 (72.9) 7.65 (6.54 to 8.96)
Physical exercise 5324 <0.001
 <1 day/week 1,098 (20.6) 540 (51.0) 1.00
 1–2 days/week 1,656 (31.1) 551 (34.6) 0.51 (0.43 to 0.59)
 3–4 days/week 1,334 (25.1) 496 (38.4) 0.60 (0.51 to 0.71)
 5–7 days/week 1,236 (23.2) 639 (53.1) 1.09 (0.92 to 1.28)
Father education 5,720 0.001
  Primary school 790 (13.8) 324 (42.9) 0.75 (0.62 to 0.92)
  Middle school 3,071 (53.7) 1,192 (40.2) 0.68 (0.58 to 0.79)
  High school 1,043 (18.2) 440 (44.3) 0.80 (0.66 to 0.96)
  College or above 816 (14.3) 392 (49.9) 1.00
Mother education 5,705 <0.001
  Primary school 1,690 (29.6) 697 (43.0) 0.81 (0.67 to 0.97)
  Middle school 2,690 (47.2) 1,103 (42.5) 0.79 (0.66 to 0.94)
  High school 689 (12.1) 245 (37.4) 0.64 (0.51 to 0.80)
  College or above 636 (11.1) 295 (48.4) 1.00
Family economic status 5,741 <0.001
 Excellent/good 1,007 (17.5) 327 (33.9) 1.00
 Fair 4,089 (71.3) 1,700 (43.2) 1.48 (1.28 to 1.72)
  Poor/very poor 645 (11.2) 332 (53.9) 2.28 (1.85 to 2.80)

BMI = body mass index; M = mean; SD = standard deviation.

*Ns differ due to missing values.

Mediation analyses sleepiness were significant (both p  <  0.05). Table 4 illustrates
significant indirect effects and effect sizes of menstrual
Multiple-mediation analyses based on 5,000 bootstrapping
irregularity and menstrual pain on daytime sleepiness through
samples were conducted to estimate the indirect effects
anxious/depressive symptoms, poor sleep quality, and insomnia.
of menstrual pain and irregular menstruation on daytime
sleepiness via anxious/depressive symptoms, sleep quality,
and insomnia. The total effects of menstrual pain and irregular
menstruation on daytime sleepiness were 0.243 (95% CI = 0.165
Discussion
to 0.321) and 0.404 (95% CI = 0.274 to 0.533), respectively. Direct To our knowledge, this is the first study to examine the
effects of menstrual pain (0.134, 95% CI  =  0.049 to 0.218) and associations between age at menarche, menstrual problems, and
irregular menstruation (0.220, 95% CI = 0.081 to 0.360) on daytime daytime sleepiness in a large sample of adolescent girls (N = 5,813).
 Wang et al.  |  5

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Figure 1.  Prevalence of daytime sleepiness in female adolescents by age. Normal: CADSS score ≤ 16, mild: CADSS score 17–22, moderate: CADSS score 23–30, and severe:
CADSS score ≥ 31.

Table 2.  Mean CADSS scale scores across menstrual problem variables in female adolescents

CADSS scores

Variables Overall N* Mean SD F (P)

Age at menarche (year) 5,080 0.896 (0.465)

 ≤11 513 16.70 7.27
 12 1,684 16.83 7.14
 13 1,794 17.00 7.37
 14 867 17.27 7.10
 ≥15 222 17.41 7.24
Menstrual regularity 5,062 42.270 (<0.001)
 Regular 848 15.59 7.14
  Sometimes irregular 3,713 16.95 7.10
  Often irregular 501 19.36 7.70
Menstrual pain 4,981 49.340 (<0.001)
 No 1,390 15.79 6.87
 Mild 2,320 16.72 7.07
 Moderate 970 18.24 7.35
 Severe 301 20.62 7.65

*Ns differ due to missing values.

The major findings of this study are (1) daytime sleepiness was
prevalent in Chinese adolescent girls, with the overall prevalence
of mild, moderate, and severe daytime sleepiness were 20.5%,
16.7%, and 5.5%, respectively; (2) menstruation irregularity and
menstrual pain were significantly associated with increased risk
of daytime sleepiness after adjusting for adolescent and family
covariates; (3) anxious/depressive symptoms, poor sleep quality,
and insomnia were significant mediators of the associations
between menstrual irregularity, menstrual pain, and daytime
sleepiness; and (4) age at menarche was not significantly
associated with daytime sleepiness.
Daytime sleepiness is prevalent in adolescents [30], in the
current study, we found that the overall prevalence of mild,
moderate, and severe daytime sleepiness were 20.5%, 16.7%, and
5.5% in Chinese adolescent girls. The prevalence rates were higher
in Chinese adolescent girls than that reported in other countries.
For example, the overall prevalence of excessive daytime
sleepiness were 18.2% and 9.7% in Korea and Turkey adolescent
girls, respectively [13, 31]. Ohayon and Roberts showed that 5.9% of
European adolescents reported experiencing daytime sleepiness
[32]. The difference between our results and other studies may
be due to different measures and criteria used to assess daytime
 6 | SLEEPJ, 2019, Vol. 42, No. 6

Table 3.  Prevalence rates (%) and odds ratios (OR) of daytime sleepiness in association with menstrual problems in female adolescents

Daytime sleepiness

Variables Overall N (%)* N (%)* Crude (95% CI) Adjusted† (95% CI) Adjusted‡ (95% CI)

Age at menarche (year) 5,080 2,216

 ≤11 513 (10.1) 211 (43.2) 0.77 (0.56 to 1.06) 1.08 (0.71 to 1.65) 1.03 (0.68 to 1.55)
 12 1,684 (33.1) 723 (44.1) 0.80 (0.60 to 1.06) 1.06 (0.74 to 1.53) 1.04 (0.73 to 1.49)
 13 1,794 (35.3) 783 (45.1) 0.83 (0.62 to 1.11) 1.13 (0.79 to 1.62) 1.09 (0.76 to 1.55)
 14 867 (17.1) 395 (46.9) 0.89 (0.66 to 1.21) 1.07 (0.73 to 1.56) 1.00 (0.69 to 1.45)
 ≥15 222 (4.4) 104 (49.8) 1.00 1.00 1.00
Menstrual regularity§ 5,062 2,205
 Regular 848 (16.7) 307 (37.8) 1.00 1.00 1.00
  Sometimes irregular 3,713 (73.4) 1,610 (44.8) 1.34 (1.14 to 1.56) 1.24 (1.01 to 1.52) 1.25 (1.03 to 1.52)
  Often irregular 501 (9.9) 288 (58.9) 2.36 (1.87 to 2.96) 1.58 (1.17 to 2.12) 1.56 (1.17 to 2.08)
Menstrual pain§ 4,981 2,180

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 No 1,390 (27.9) 523 (39.1) 1.00 1.00 1.00
 Mild 2,320 (46.6) 967 (43.1) 1.18 (1.03 to 1.35) 1.10 (0.93 to 1.31) 1.13 (0.95 to 1.34)
 Moderate 970 (19.5) 499 (52.7) 1.74 (1.47 to 2.05) 1.39 (1.12 to 1.72) 1.39 (1.13 to 1.71)
 Severe 301 (6.0) 191 (64.5) 2.84 (2.18 to 3.68) 1.46 (1.04 to 2.04) 1.48 (1.07 to 2.07)

*Ns differ due to missing values.

†
Adjusted for age, BMI, physical health, sleep problems including insomnia, sleep time, loud snoring and sleep quality over the past month, physical exercise,
parental education, family economic status, anxiety/depressive symptoms that were all significantly associated with daytime sleepiness in Table 1 and school.
‡
Additional adjustment of other menstrual variables.
§
Both adjusted† and adjusted‡ p < 0.05.

Table 4.  The indirect effect of menstrual irregularity and menstrual pain on daytime sleepiness through anxious/depressive symptoms, sleep
quality, and insomnia

Path Indirect effect SE 95% CI Effect size

Menstrual irregularity → anxious/depressive symptoms → daytime sleepiness 0.124*** 0.018 0.090 to 0.160 0.307
Menstrual irregularity → sleep quality → daytime sleepiness 0.102*** 0.019 0.067 to 0.141 0.252
Menstrual irregularity → insomnia → daytime sleepiness 0.014*** 0.006 0.004 to 0.029 0.035
Menstrual pain → anxious/depressive symptoms → daytime sleepiness 0.087*** 0.012 0.065 to 0.114 0.358
Menstrual pain → sleep quality → daytime sleepiness 0.053*** 0.011 0.031 to 0.076 0.218
Menstrual pain → insomnia → daytime sleepiness 0.011*** 0.005 0.003 to 0.022 0.045

SE and 95% CI were estimated using bootstrapping with n = 5,000 samples.

Effect size = the ratio of the indirect effect to the total effect.
***p < 0.001.

sleepiness. For instance, we reported daytime sleepiness including
mild, moderate, and severe daytime sleepiness based on a validated
daytime sleepiness scale for Chinese adolescents. Other studies
used different measures and reported the prevalence of overall
excessive daytime sleepiness only. On the other hand, cultural
and school differences may also contribute to the discrepancies,
such as different school start time, homework loads, and priorities
placed on academic achievements in different countries [33–36].
In the middle and high schools included in the study, students
need to attend an early morning class before breakfast and have
heavy homework loads after school. Adolescent students are more
likely to have insufficient sleep and daytime sleepiness as a result
of waking up early and staying up late [37].
Our findings demonstrated that mean daytime sleepiness
score significantly elevated with frequency/severity of menstrual
irregularity and menstrual pain. Logistic regression indicated that
menstrual problems were significantly associated with increased
risk of daytime sleepiness after adjusting for age, physical exercise,
BMI, sleep duration, snoring, insomnia, sleep quality, and anxiety/
depression. Although no specific studies have reported the
associations between menstrual problems and daytime sleepiness,
the significant associations may be interpreted as follows. First,
menstrual problems are associated with increased risk of poor sleep
quality and insomnia symptoms and mental health problems [17,
38–42], all of which can lead to daytime sleepiness. Our mediation
analyses supported the mediating effects of poor sleep quality,
insomnia, and anxiety/depression on the associations between
menstrual problems and daytime sleepiness. Second, sleep and
menstrual cycle are complex entity involving many interactions
of the central nervous and endocrine systems. Abnormal activities
of the HPA axis may be a possible pathway between menstrual
problems and daytime sleepiness [19]. Third, melatonin may
play a role in the link between menstrual problems and daytime
sleepiness [43–45]. There is evidence that irregular melatonin
rhythm, which is associated with irregular sleep patterns and
sleep problems, was associated with menstrual irregularity
and menstrual problems [45]. In addition, regular menstruation
showed a diurnal rhythm with a significantly higher level during
the night than during the day in comparison with irregular menses
[44]. Also, melatonin has been shown to relieve daytime sleepiness
by ameliorating the circadian rhythm [46].
Menstrual irregularity and menstrual pain may have different
pathways to daytime sleepiness as menstrual irregularity may be
very common in early adolescence. However, our study cannot
distinguish their effects on daytime sleepiness. Our multivariate
analyses demonstrated that both menstrual irregularity and

menstrual pain were significantly associated with daytime
sleepiness after adjusting for age, sleep variables, and anxiety/
depression. The mediation analyses showed that anxiety/
depression, poor sleep quality, and insomnia could mediate
the effects of both menstrual irregularity and menstrual pain
on daytime sleepiness. We did not find significant interactions
of either menstrual irregularity or menstrual pain with age
on daytime sleepiness. Furthermore, menstrual irregularity
and menstrual pain were significantly associated or comorbid
(χ2 = 73.89, p < .001). Based on these analyses, we hypothesized
that menstrual irregularity and menstrual pain may have
similar pathways to daytime sleepiness. However, this is a cross-
sectional questionnaire survey, further longitudinal studies
and biological studies are needed to examine the potential
psychological and biological mechanisms of daytime sleepiness
associated with menstrual irregularity and menstrual pain.
It should be noted that menstrual pain is only experienced for a
few days around menses, but having menstrual pain is associated
with increased daytime sleepiness assessed over the past month.
Our mediation analysis demonstrated that menstrual pain may
exert effect on daytime sleepiness through insomnia, poor sleep
quality, and anxiety/depression. That is, although menstrual pain
lasts only several days, its psychological and biological effects on
mental health and sleep may not be limited to the days when
individual experience pain. However, this is a cross-sectional
survey. Further research is warranted to investigate if women
with dysmenorrhea have increased daytime sleepiness across the
month or only in association with their pain.
This study examined the associations between age at
menarche, menstrual problems, and daytime sleepiness
in a large sample of adolescent girls. Multiple potential
characteristics were statistically controlled for, including
age, BMI, physical exercise, physical health, sleep duration,
sleep problems, anxious/depressive symptoms, and family
demographics. However, the following limitations should be
considered when interpreting the findings. First, we could not
establish the causal relationships between menstrual problems
and daytime sleepiness based on the cross-sectional study. This
may be particularly true for the mediation analyses because
cross-sectional approaches to longitudinal mediation might
generate biased estimates of longitudinal mediation parameters
[47]. Further mediation analyses with multiple waves of data are
warranted to clarify the mediating effects of sleep problems
and anxiety/depression on the associations between menstrual
problems and daytime sleepiness. Second, menstrual problems
and daytime sleepiness were all self-reported, which might
lead shared response bias. Nevertheless, since menstrual
problems may occur in female adolescents every month, they
are less likely to be influenced by recall bias. Third, although
the mediation effects were all statistically significant, these
effects only accounted for a small ratio to the total effect (0.035–
0.358) (Table 4) [29]. The extent to which the indirect effects are
clinically meaningful needs to be further investigated. Fourth,
although the sample size was large, it is unknown whether
the findings from the sampled schools could be generalized
to adolescents in other regions. Furthermore, other variables
such as caffeine use, irregular sleep patterns, and premenstrual
symptoms, which may be associated with menstrual irregularity
and menstrual pain and sleep problems, were not included in
the study. These variables should be included in future studies.
Further longitudinal studies with objective measures of sleep
and clinical assessment of menstrual problems are needed.
Wang et al.  |  7
In summary, our study reported the prevalence of daytime
sleepiness and demonstrated that menstruation irregularity
and menstrual pain were associated with increased risk of
daytime sleepiness among a large sample of adolescent girls.
These findings emphasize the importance of assessing and
intervening menstrual problems for preventing daytime
sleepiness in adolescent girls. From public health perspectives,
primary health care workers should recognize the importance
of menstruation hygiene education and implement health
education on puberty, menstruation, and sleep hygiene in the
clinical practice setting and at school [11, 48–50]. Adolescent
girls should learn to seek medical treatment when experiencing
menstrual problems [6]. Family support, especially from
parents, is important to alleviate the symptoms associated with
menstruation. Adjusting school schedule and reducing heavy
Downloaded from https://academic.oup.com/sleep/article/42/6/zsz061/5373063 by guest on 29 October 2020
homework loads may also be important to reduce menstruation
related stress and daytime sleepiness [51, 52]. Further research
is warranted to examine the causal relationship and potential
psychological and biological mechanisms between menstrual
problems and daytime sleepiness.
Acknowledgments
The authors would like to thank staffs of Lijin, Yanggu, and
Zoucheng County Center for Disease Control and Education
Bureau for help with data collection. The authors would also
like to thank all participating school teachers for their help with
data collection and all students for their voluntary participation
in the study. The authors would also like to thank Bao-Peng
Liu and Peng-Peng Yu at Shandong University School of Public
Health for their assistance with statistical analysis.
Funding
This research was supported by the National Natural Science
Foundation of China (grant number  81573233) and Shandong
University School of Public Health Third Level Discipline
Infrastructure Project Fund (grant number 2017-08).
Conflict of interest statement. All authors have no financial and
nonfinancial conflict of interests to declare.
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