1

Dysmenorrhea among female medical students in

some colleges and universities in Hanoi:
A cross-sectional study

Anh D. Nguyen 1, 2, Dat T. Do 1,2, Duc T. Nguyen 2, Duc A. Tran 2, Thuong T. T. Phan2, Toan K. Nguyen 2,
Giang T. T. Duong 2 , Ha. T. T. Nguyen 2.

Corresponding author: Anh Duy Nguyen

Postal address: Hanoi Obstetrics and Gynecology Hospital - 929 La Thanh, Ba Dinh district, 100000, Hanoi,
Vietnam
Email address: dr.duyanhnguyen@hogh.vn
Telephone: +84989661093 Fax numbers: None.

ABSTRACT:

Aim: Dysmenorrhea is one of the most common health problems among women.

Dysmenorrhea can be an early sign of several gynecological conditions, including

endometriosis. Young women can suffer from menstrual pain for a long time, but without

proper attention, it can have consequences on quality of life, possibly even infertility. We

plan to investigate the prevalence of dysmenorrhea and its impact on young women

(medical/nursing students).

Methods: This is a descriptive cross-sectional study of 922 female students in some

medical colleges and universities in Hanoi, Vietnam, between October 2019 and May

2020. Participants were distributed and answered based on available questionnaires to

collect information.

Results: The prevalence of dysmenorrhea was 86,0%, The average pain level (VAS

scale) was 4.17 ± 1.58. Dysmenorrhea was associated with several factors such as the

familial history of cyclic abdominal pain (OR 2.786; 95% C.I 1.809 – 4.290), age at

menarche < 15 years (OR 2.204; 95% C.I 1.495 – 3.249). Dysmenorrhea significantly
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increases the proportion of absenteeism and the use of pain relievers (p < 0.001).

Conclusions: Therefore, we plan to investigate the situation of dysmenorrhea and its

impact on young women (medical/nursing students) in Hanoi, Vietnam. These results

open up the need for more extensive and in-depth research models to identify a group of

female medical students of girls with dysmenorrhea to receive appropriate advice and

early detection of adverse conditions and management of these populations.

Key words: Dysmenorrhea, early detection, female medical student.

1 Introduction

Dysmenorrhea is one of the most common health problems among women.

Dysmenorrhea is defined as a cramping pain that is located in the lower abdomen,

sometimes accompanied by other symptoms such as headache, back pain, pain

when urinating/ defecating. This condition is prevalent, but this rate can vary from

study to study at about 16.8% - 81%, and the highest rate of 90% has been

recorded (1). Dysmenorrhea in young women includes acyclic pain and cyclic pain

and may present an array of confounding symptoms (2). Adolescents were found

to have endometriosis most commonly present with both cyclic and acyclic pain

(62.6%), as opposed to acyclic pain alone (28.1%), or cyclic pain alone (9.4%) (3).

Many studies have shown that dysmenorrhea limits daily activities and has many

adverse effects on the quality of life and, especially in women with severe pain (4).

As we all know, the academic life of medical students is often more stressful than

students of other disciplines, so only when it is severe, they have to drop out of

school. However, there are still not many studies evaluating the effects of
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dysmenorrhea on the academic ability of medical students, such as absenteeism

(5). Moreover, prolonged menstrual pain affects work and school ability, thus

indirectly affecting the patients they care for. Medical students have a specific

understanding of the symptoms, so they are also ideal research subjects to

identify dysmenorrhea and its impact on quality of life.

Dysmenorrhea can be an early sign of several gynecological conditions, including

endometriosis. This disease is difficult to diagnose because of a lack of reliable

biomarkers and considerable symptom overlap with other gynecological

pathologies. Consequently, this delay may decrease their life quality and

reproductive potential. Moreover, early identification and intervention for

endometriosis may resolve pain, prevent disease progression/organ damage, may

preserve fertility and/or ovarian reserve.

Therefore, we plan to investigate the situation of dysmenorrhea and its

personal/social impact on young women (medical/nursing students) in Hanoi,

Vietnam. These results open up the need for more extensive and in-depth

research models to identify a group of female medical students of girls with

dysmenorrhea to receive appropriate advice and early detection of adverse

conditions and management of these populations.

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2 Methods

Study design

This is a descriptive cross-sectional study conducted from October 2019 to May

2020 at Hanoi Obstetrics and Gynecology Hospital, Vietnam. This study was
approved by the Ethics Committee of Hanoi Obstetrics and Gynecology Hospital.

Study population

Female medical students study Hanoi Medical College, University of Medicine and

Pharmacy – Vietnam National University, and Hanoi Medical College. Exclusion

criteria: Subjects were absent at the time of investigation (leaving school, ...),

refused to participate in the study, unstable mental state, severe psychological

stress, hearing and vision impairments, pronounce.

Study size

Our study has a sample size of 922 study subjects, collected within eight months.

Measurement

Our questionnaire has been built before, including two main parts: Part 1 includes

ten evaluation questions on demographic characteristics (age, academic level,

BMI, family history of dysmenorrhea) and menstrual cycle characteristics of

research subjects (age at menarche, the duration of the period, the difference

between the cycles, the symptoms of vaginal discharge). Part two includes seven

questions to assess the degree of dysmenorrhea of the study subject and its

impact on the subject's life (the accompanying symptoms, the absence from

school because of the pain, the use of pain relievers). To assess pain, we use the

VAS (Visual Analog Scale for pain) pain scale; the pain levels will be divided into
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no pain, mild pain (VAS 1-3), moderate pain (VAS 4-7), and severe pain (VAS 8-

10).

Procedure

First of all, eligible students were informed about the study by investigators and

signed an agreement form to take part in the study. Our investigator gives

students some pre-information to attend OBGY lectures or lectures on

reproductive diseases (lecture time could be 45 minutes as we do here). All

questionnaires should be distributed before the lecture. After the lecture, we will

request only female students to stay in the lecture room and reply to a series of

questions in the supplied questionnaire (fundamentals only). The investigators will

support research subjects that still have misunderstood problems to help them

have a correct view of menstrual pain and its harmful effects. At the end of the

session, we collected onsite after completing them to avoid response bias. After

collecting questionnaires, we will explain to all students that we will inform them if

they are included in the high-risk group and please attend a gynecologist for

further management. We will check all questionnaires by doctors in charge of this

project and summarize the data with proper discussion.

Data analysis

Information on the questionnaire was encrypted and entered, processed, and

analyzed using SPSS 20.0 software, which aids in calculating experimental

parameters: mean and standard deviation. The averages and standard deviation

were determined for the quantitative and qualitative variables by frequency and

percentages. The Chi-square test (χ2) (corrected Fisher's exact test when

appropriate), was used to compare two proportions. The tests and comparisons
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have statistical significance when p < 0.05.

3 Results

The study enrolled 922 female medical students with a proportion of

dysmenorrhea is 86.0% and the average pain level is 4.17 ± 1.58. Most of the

students who suffered from dysmenorrhea (60.9%) suffered from moderate pain

(with 4 – 6 points following the VAS scale). Back pain is the commonest (42.7%)

symptom accompanying dysmenorrhea. (Table 1)

Most of the demographic factors surveyed have not been associated with the

incidence of dysmenorrhea. A significant proportion of study subjects with age

below 20 years old with normal BMI; Both these characteristics and the academic

level of the study subjects were not statistically significant with dysmenorrhea (p >

0.05). Family history of cyclic abdominal pain was associated with dysmenorrhea

(OR 2.786; 95% CI 1.809 – 4.290; p < 0.001); however, family history of acyclic

abdominal pain was none (p > 0.05). (Table 2)

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When analyzing the characteristics of the menstrual cycle, we found that the

earlier age at menarche increases the risk of dysmenorrhea (OR 2.204; 95% CI

1.495 – 3.249; p < 0.001). Other characteristics such as the length of the

menstrual cycle, the difference between the two menstrual cycles, the number of

days of the menstrual cycle, the history of gas, or the degree of discharge did not

affect the menstrual pain of the study subjects (p > 0.05). (Table 3)

When assessing the impact of pain on the life of the study subjects, we divided

them into groups and conducted assessments. We found that the degree of

dysmenorrhea and the rate of absence from school had a statistically significant

relationship (p < 0.001); although pain level seemed to increase the time of

absence from school, it was not statistically significant (p < 0.077). The severity of

pain has increased the proportion of reliever medication use (p < 0.001), but the

effect of pain severity on the need for physician visitation rates was unclear (p =

0.172). (Table 4)

4 Discussion

Many studies worldwide have shown that dysmenorrhea can significantly reduce

the quality of life and limit daily activities, especially in cases of severe pain (4) (6).

The secondary dysmenorrhea is associated with some gynecological diseases,

such as endometriosis (7) (8). That's why dysmenorrhea can be an early

manifestation of some gynecological diseases in the future. If we can help these

young women find the cause of dysmenorrhea early, we can help these women

avoid unfortunate consequences, such as infertility.

The rate of dysmenorrhea in female medical students in our study was 86.0%.

This rate is relatively high compared to other studies, such as Evans Ameade's
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study (83.6%) (9); Nahla Khamis Ibrahim (60.9%) (10) and Alaettin Unsal (72.7%)

(11). These variations may be due to differences between the target populations,

lifestyle, or due absence of a standardized universally accepted method for

defining dysmenorrheal, which was probably as greatly responsible for the dispatỉy

as the methods of collecting information the dysmenorrhea's and pain's definition.

The average severity of dysmenorrhea in our study was about 4.17 ± 1.58

(according to the VAS scale), of which the most attention should be paid to the

group with severe pain (VAS 7-10). Because this may be a group that needs a

doctor's help with immediate goals to reduce pain and improve quality of life,

further investigations may also be required in the future to detect potential medical

conditions. In the cases of dysmenorrhea, other symptoms were also noted, the

most common was back pain (47.4%, VAS score 3.84 ± 1.58), the second was

headache (6.9%) and less often. Some other rare accompanying symptom of

dysmenorrhea is a pain when urinating or defecating. The presence of additional

symptoms may worsen the pain or interfere with daily activities or work.

With the anthropometric characteristics of the study subjects, we found that the

rate of dysmenorrhea had no statistically significant relationship with age group (p

= 0.441), academic level (p = 0.939), BMI (p = 0.118). This result is similar to the

study of Nahla Ibrahim when researching female medical students in King

Abdulaziz University (KAU), Jeddah, Saudi Arabia (10). However, a family history

of cyclical abdominal pain was associated with dysmenorrhea in study subjects. A

similar result was obtained from India (12). Some studies have shown that family

history was a risk factor for dysmenorrhea, which may be related to the risk for

related conditions like endometriosis and genetic factors (11).

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When considering the characteristics of the menstrual cycle, we found that the

early age of menarche (<15 years) was statistically significantly associated with

dysmenorrhea. Our results are similar to the study conducted in India in 2006 (13).

The underlying reason could be that girls who attend menarche early have more

prolonged exposure to uterine prostaglandins, leading to a higher prevalence of

dysmenorrhea. We also did not find a statistically significant association between

menstrual cycle length and dysmenorrhea. This result is similar to the study in

Saudi Arabia (10) but not consistent with some other studies in Egypt (14).

Our study shows that those with severe pain found this to be more of interference

during the previous activities mentioned than those with mild or moderate pain,

precisely the rate of students dropping out of school is a higher and increasing

proportion of the use of pain reliever (p < 0.001). Additionally, dysmenorrhea was

found to have a more significant impact on daily life, the practice of sport, work,

and family relations.

These results align with other studies of women suffering specific pathologies

manifested with dysmenorrhea, such as endometriosis. These conditions often

have similar symptoms and are associated with treatments that, if not done right

and early, can also have significant consequences in many aspects of life, such as

infertility and repeated surgeries in women (15).

Although our study is only a cross-sectional study to investigate the

epidemiological situation and some related aspects of dysmenorrhea among

female students in Hanoi, there are no further steps to diagnostic criteria for the

cause of dysmenorrhea such as transvaginal ultrasound or diagnostic marker

testing and beyond are interventions aimed at reducing pain severity and
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improving quality of life. This is the first step to pave the way for further research,

the need for school education programs, social attention, and planning for

dysmenorrhea intervention in Vietnam.

In conclusion, with a reasonably common prevalence, dysmenorrhea has become

a common health problem and is of increasing concern due to its negative impact

on daily activities, work and study not only on women worldwide, but female

medical students in general. Our research and further studies will raise people's

awareness of social intervention programs, school education, especially early

diagnosis of potential diseases and timely treatment intervention.

Disclosure

Conflict of interest: No conflict was declared.

Disclosure: No disclosure is present.

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Table 1. Prevalence of dysmenorrhea, pain severity and some symptoms

accompanying dysmenorrhea among female medical students

Frequency Percentage VAS scale

Symptoms
(No.) (%) Mean (SD)
Dysmenorrhea (n=922)
Yes 793 86.0
4.17 (1.58)
No 129 14.0
Pain severity (n=793)
Mild pain (VAS 1-3) 287 36.2
Moderate pain (VAS 4-6) 483 60.9
Severe pain (VAS 7-10) 23 2.9
Accompanying pain (n=793)
Back pain 339 42.7 3.84 (1.58)
Pain during urination 16 2.0 2.56 (1.26)
Pain during defecation 22 2.8 2.93 (1.31)
Headache 55 6.9 2.79 (1.53)
Othes (ex. joint pain) 41 5.2 3.68 (1.71)
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Table 2. The relationship between dysmenorrhea and personal, familial

characteristics of female medical students

Dysmenorrhea Yes No
X2 p OR 95% C.I
Variable No. % No. %

Age
≤ 20 734 85.7 122 14.3
0.677 0.411
> 20 59 89.4 7 10.6

BMI

Normal (< 25) 779 86.3 124 13.7

Overweight and obesity (≥ 2.449 0.118
14 73.7 5 26.3
25)
Academic level

College 611 86.1 99 13.9

0.006 0.939
University 182 85.8 30 14.2

Familial history of cyclic abdominal pain

Yes 363 92.4 30 7.6 1.809-

23.008 <0.001 2.786
No 430 81.3 99 18.7 4.290

Familial history of acyclic abdominal pain

Yes 67 87.0 10 13.0

0.070 0.789
No 726 85.9 119 14.1
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Table 3. The relationship between dysmenorrhea and menstrual

characteristíc of female medical students

Dysmenorrhea Yes No
X2 p OR 95% C.I
Variable No. % No. %

Age at menarche
< 15 607 88.7 77 11.3 1.495-
16.459 <0.001 2.204
≥ 15 186 78.2 52 21.8 3.249

Duration between menstrual cycle

< 24 days 53 91.4 5 8.6

24 – 28 days 262 87.6 37 12.4

3.335 0.343
28 – 32 days 354 84.1 67 15.9

> 32 days 124 86.1 20 13.9

Duration of bleeding

< 3 days 21 84.0 4 16.0

3 – 4 days 427 86.1 69 13.9 0.087 0.958

> 4 days 345 86 56 14.0

The difference between two cycles

≤ 2 days 160 86.5 25 13.5

3 – 4 days 396 86.3 63 13.7 0.194 0.907

≥ 5 days 237 85.3 41 14.7

History of vaginal discharge

Yes 533 87.5 76 12.5

3.407 0.068
No 260 83.1 53 16.9

Vaginal discharge frequency

Irregular 300 87.0 45 13.0

0.232 0.629
Regular 233 88.3 31 11.7
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Table 4. The relationship between the severity of dysmenorrhea and its

impact on the quality of life of female medical students

Moderate
Severity of pain Total Mild pain Severe pain
pain

Variable No % No. % No. % No. %

Absent from school (n =

793)

No 641 80.8 261 80.8 368 76.2 12 52.2

Yes 152 19.2 26 19.2 115 23.8 11 47.8

Durration of absent from

school (n = 152)
Half day / late attendance
98 64.5 17 65.4 76 66.1 5 45.5
or early return to home

1 day 49 32.2 6 23.1 37 32.2 6 54.5

≥ 2 days 5 3.3 3 11.5 2 1.7 0 0

Pain reliever (n = 793)

No 681 85.9 273 95.1 391 81.0 17 73.9

Yes 112 14.1 14 4.9 92 19.0 6 26.1

Visit doctor (n = 793)

No 749 94.4 276 96.2 452 93.6 21 91.3

Yes 44 5.6 11 3.8 31 6.4 2 8.7

* : Fisher’s exact test