JOURNAL OF PSYCHOSOMATIC OBSTETRICS & GYNECOLOGY

2019, VOL. 40, NO. 3, 185–194

https://doi.org/10.1080/0167482X.2018.1470619

REVIEW ARTICLE

Mental health and primary dysmenorrhea: a systematic review

Zahra Bajalana, Farnoosh Moafia, Mohammad MoradiBaglooeib and Zainab Alimoradic
a
Midwifery Department, School of Nursing and Midwifery, Qazvin University of Medical Science, Qazvin, Iran; bPsychiatric Nursing
Department, School of Nursing & Midwifery, Qazvin University of Medical Science, Qazvin, Iran; cSocial Determinants of Health
Research Centre, Qazvin University of Medical Science, Qazvin, Iran

ABSTRACT ARTICLE HISTORY

Several factors including demographic, reproductive, lifestyle, psychological and social factors Received 12 January 2018
can affect incidence and severity of primary dysmenorrhea. This study aimed to systematically Revised 4 April 2018
review the psychological risk factors associated with primary dysmenorrhea. Embase, ISI web of Accepted 24 April 2018
knowledge, ProQuest, Science Direct, Scopus and PubMed central were searched using keywords
KEYWORDS
related to risk factors and primary dysmenorrhea. Observational studies, published in English Mental health; depression;
after 2000, focusing solely on psychological factors affecting primary dysmenorrhea were anxiety; stress; primary
included. The search process retrieved 11,928 potential related articles. Thirty three articles met dysmenorrhea; system-
inclusion criteria and were assessed for final synthesis. The STROBE checklist was used to quality atic review
assessment of studies. Results of study showed that few studies had investigated relationship
between dysmenorrhea and most psychological disorders. Most studies have investigated the
relationship between dysmenorrhea and depression, anxiety, stress, alcohol abuse and somatic
disorders. So, further studies are needed to investigate relation between most psychological dis-
orders with primary dysmenorrhea. Significant relationship between some mental health compo-
nents such as depression, anxiety and stress with primary dysmenorrhea shows the importance
of psychological assessment before the choice of therapeutic methods. Also, the feasibility of
designing and evaluating the effectiveness of the use of psychotherapy interventions for the
treatment of primary dysmenorrhea as alternative therapies can be considered.

Introduction not a life-threatening condition, it can lead to disabil-

Primary dysmenorrhea is characterized by painful uter-
ine cramps that are felt just before or during menstru-
ation in the lower part of the abdomen without any
detectable pelvic pathology [1]. The prevalence of pri-
mary dysmenorrhea is different in various studies. The
results of a review study on 15 studies published
between 2002 and 2011 reported that the prevalence
of primary dysmenorrhea in women in the reproduct-
ive age was 16–91%, which was severe in 2–29% of
cases [2]. The initiation of primary dysmenorrhea usu-
ally occurs in adolescence or shortly after menarche
(6–24 months) [3]. French (2005) reported the preva-
lence of dysmenorrhea in adolescent girls, which was
20–90% [4]. Parker also reported the prevalence of
dysmenorrhea as 93% among high school female stu-
dents (n ¼ 1803), and 40% of them had moderate to
severe pain [5].
Dysmenorrhea is one of the main factors that
reduces the quality of life and social activities among
young women [3,6]. While primary dysmenorrhea is
ity and inefficiency. Painful dysmenorrhea might lead
to absence from the school or workplace [6–8].
Dysmenorrhea has always been assessed in terms of
socioeconomic and social factors with increasing costs
of healthcare and reduction of individuals’ effective-
ness [2].
Several factors can affect the severity of primary
dysmenorrhea [2,3,6]. But there is little and contradict-
ory evidence about factors affecting primary dysmen-
orrhea. For instance, age [9–12], marriage history
[13–15], body mass index [7,9,10], low socioeconomic
status [9,11,12,14–16], smoking [12,15–17], family his-
tory of dysmenorrhea [6,18] and alcohol consumption
[12,15] influence primary dysmenorrhea. In addition to
these factors, the relationship between psychological
factors and severity of dysmenorrhea has been
described [19]. There has been evidence of the pres-
ence of psychological disorders such as depression or
anxiety with dysmenorrhea and their association with
chronic pain [8]. Depression, by increasing the impact
of pain on social and occupational functions can

CONTACT Zainab Alimoradi z.alimoradi@qums.ac.ir Assistant Professor of Midwifery, Qazvin University of Medical Science, Bahonar blv.,
Qazvin, Iran
ß 2018 Informa UK Limited, trading as Taylor & Francis Group
186 Z. BAJALAN ET AL.
reduce individuals’ response to drug therapy and even
increase the perception of pain [20]. Therefore, psy-
chological factors can specifically exacerbate pain and
problems caused by primary dysmenorrhea among
young women and girls [8]. Despite various treatments
available for primary dysmenorrhea, some primary
cases are still not controlled [21] which shows the
importance of consideration to other factors besides
physiological factors. Despite the high prevalence of
primary dysmenorrhea and the potential importance
of the association between psychological factors and
primary dysmenorrhea, related risk factors are still not
well defined. Since the provision of good healthcare
and management of dysmenorrhea needs information
about the underlying causes of this problem and
related risk factors, this study was conducted to sys-
tematically review psychological risk factors associated
with primary dysmenorrhea.
Methods
Search method
The matrix method by Garrard was used to perform
this systematic review [22]. This method provides a
structure and process to facilitate a systematic com-
parison of studies on a specific topic in systematic
reviews. Steps taken to conduct this study were as fol-
low: paper trails: systematic literature search, docu-
ments section: organizing documents for the review,
review matrix: abstracting each document and synthe-
sis: writing the review of the literature.
Search strategy
From June to August 2017, the search was carried out
on the databases of Embase, ISI web of knowledge,
ProQuest, Science Direct, Scopus and PubMed central.
The Boolean search method with the following key-
words was used to retrieve related articles: (Risk Factor
OR Contributing Factor OR Impotent Factor) AND
(Dysmenorrhea OR Menstruating Disturbances OR
Menstruating Disorders OR Menstrual Diseases OR
Pelvic pain OR Painful Menstruation OR Painful Period
OR Periodic pain OR Primary Dysmenorrhea).
Selected studies were further explored to increase
the likelihood of retrieving related articles. The results
of this study were one part of a systematic review on
risk factors associated with primary dysmenorrhea.
Due to the wide range of risk factors associated with
primary dysmenorrhea, factors related to mental
health were reported in the present article.
Inclusion criteria
Studies on primary dysmenorrhea with cross-sectional,
case-control, and cohort designs published after 2000
were included in this systematic review. Studies related
to secondary dysmenorrhea, published before year
2000 and non-English articles were excluded from the
study. Also, the findings of clinical trials, case reports,
letters to the editor, review papers were not included.
Study selection
Title and abstract of all articles retrieved by the elec-
tronic or manual search processes were assessed in
terms of inclusion criteria. The full text of related
articles was examined based on the above-mentioned
criteria by two independent reviewers. Disagreements
about the selection of studies were resolved by discus-
sions between the authors.
Data extraction
Data extraction was independently performed by two
reviewers. A pre-designed form was used to extract
data regarding name, year, study methodology, coun-
try of study, number of participants, age of partici-
pants and study findings. Also, risk factors with
correlations and no correlation with the experience of
primary dysmenorrhea, incidence of dysmenorrhea
and its severity were recorded.
Quality assessment
To assess the quality of the studies, the STROBE tool
was used according to the nature of case-control,
cohort and cross-sectional studies. STROBE is an
authoritative tool that proposes 22 items for reporting
or evaluating different sections of observational stud-
ies [23]. In this study, the STROBE checklist was used
to assess the quality of the selected studies. All stages
of quality assessment were conducted independently
by two reviewers. Disagreements were resolved
through discussions.
Data synthesis
After screening, examining inclusion criteria and
assessing the quality of studies, extraction of data was
carried out and they recorded in pre-designed forms.
Due to the heterogeneity of the studies, the final syn-
thesis of findings was performed to synthesize find-
ings. The findings were presented based on the
classification of data extracted from the studies.

Identification
Records identified through
database searching (N=11928)
Records after duplicates removed
(N=11837)
Screening
Records screened
(N=11837)
Eligibility
Full-text assessed for eligibility
(N=103)
Included
Studies included in final synthesis
(N=33)
Figure 1. PRISMA flow diagram.
Findings
Study description
The search process led to 11,928 potential related
articles. Of them, 197 articles appeared to be related to
the study topic. Also, 91 articles were repetitions and
3 articles were published in languages other than
English, which were excluded. Therefore, the full texts of
103 articles were evaluated and lastly 33 articles were
included based on the inclusion criteria. Figure 1 showed
the search process based on the PRISMA flowchart.
Most articles (21 articles) had a cross-sectional design,
five were cohort and the remaining were case-control
studies. A total of 38,689 participants were surveyed in
these articles. The highest number of participants was
11,891 individuals in the Jones’ study [24] in Europe. The
Liu’s study in China with 70 participants had the lowest
sample size [25]. Studies were conducted in various
parts of the world including Europe, the United States,
China, Japan, Australia, Iran, Saudi Arabia, Turkey, India,
South Korea, Switzerland, Ethiopia, Israel and Italy. China
with 5 articles had the most number of studies on this
topic. Table 1 shows the characteristics of the studies.
Quality assessment
Evaluation of the studies based on the STROBE check-
list showed that most studies were modest in
JOURNAL OF PSYCHOSOMATIC OBSTETRICS & GYNECOLOGY 187
Records identified through
other sources (N=0)
Records excluded due to lack
of relevance
(N=11734)
Full text elimination due to
lack of eligibility
(N=70)
methodological terms. The majority of them had weak-
nesses in the potential sources of bias, how to calcu-
late the sample size, the description of quantitative
variables and the expression of limitations. Figure 2
shows the representation of the quality of selected
studies, and Table 2 shows the quality of studies in
terms of the checklist’s items.
Outcome measures
To categorize and present the findings of the selected
studies, the classification of mental disorders based on
the DSM-V was used as follows:
 Neurodevelopmental disorders: Only one study inves-
tigated the relationship between autism disorders
and dysmenorrhea, which reported a positive and
significant association between autism disorders in
general and attention shifting category [26].
 Schizophrenia and other psychotic disorders:
Schizophrenia, along with other psychiatric disor-
ders, was studied only in one study by Jones
et al. [24]. It was found that those who reported
severe dysmenorrhea were more likely to have other
psychiatric disorders including schizophrenia [24].
 Bipolar and related disorders: Bipolar disorders were
other psychiatric disorders that were only studied
188 Z. BAJALAN ET AL.

Table 1. Characteristics of selected primary studies.

No of
No Author, year Study design Country participants Age group (year) Results
1 Hailemeskel, Cross-sectional Ethiopia 440 Mean age Statistically significant association
2016 [27] 20.57 ± 1.36 between primary dysmenorrhea
and history of depression
or anxiety
2 Jones, 2016 [24] Cohort European 11,891 18–45 extreme dysmenorrhea pain were
more likely associated to psychi-
atric disorders
3 Pej
cic, 2016 [47] Case-control Serbian 288 18–29 No significant association between
alcohol consumption and
dysmenorrhea.
4 Faramarzi, Cross-sec- Iran 360 17–25 Significant association of depression,
2014 [28] tional study anxiety and stress with
dysmenorrhea.
5 Gagua, 2012 [8] Cross-sectional Tbilisi, Georgia 431 14–20 No correlation between dysmenor-
rhea with alcohol consumption
6 Liang, 2012 [45] Case-control China 191 18–23 Depression and some personality
traits including neuroticism-
Anxiety and Impulsive Sensation
Seeking had significant associ-
ation with dysmenorrhea.
7 Goldstein-Ferber, Cross-sectional Israel 160 14–16 No difference in the level of soma-
2006 [51] tization according to
dysmenorrhea.
8 Liu, 2016 [25] Case control China 70 22.6 ± 1.1 Cases with dysmenorrhea had sig-
nificantly higher scores of anxiety
and depression scale in.
9 Patel, 2006 [14] Cross-sectional India 2262 18–45 Significant association between dys-
menorrhea with depression and
anxiety, somatoform symptoms;
But no association with alcohol
consumption
10 Ibrahim, 2015 [36] Cross-sectional Saudi Arabia 435 Mean of Statistical significant in dysmenor-
21.40 ± 1.4 years rhea pain according to stress
11 Ju, 2015 [46] Prospective Australia 9,688 18–23 Significant association of dysmenor-
population- rhea with alcohol consumption
based and illicit drug use
cohort
12 Jeon, 2014 [39] Cross-sectional South Korea 572 11–16 years Stress was the most influential factor
for dysmenorrhea
13 Tavallaee, 2011 [18] Cross-sectional Iran 381 16–56 Higher stress and depression was
associated to have more
severe pain.
14 Unsal, 2010 [48] Cross-sectional Turkey 623 17–30 Dysmenorrhea was not significantly
associated with alcohol
consumption.
15 Toy, 2016 [26] Case–control Turkey 140 18–25 Dysmenorrhea was positively corre-
lated with Autism Spectrum
Quotient -Total and its’ Attention
Switching subscale. But no signifi-
cant relation between pain with
depression and anxiety.
16 Bavil, Descriptive– Iran 250 18–26 No statistical differences between
2016 [43] comparative eating behavior, stress and
study dysmenorrhea.
17 Grandi, 2012 [49] Cross-sectional Italy 408 22.90 ± 3.03 No significant relation between alco-
18 hol consumption and
dysmenorrhea.
18 Liu, 2007 [38] Prospective China 1645 20–34 Women with dysmenorrhea tended
reproductive to have more perceived stress.
health study
19 Balık, 2014 [29] Cross sectional Turkey 159 13–19 Anxiety and depression was statistic-
ally associated with
dysmenorrhea.
20 Gagua, 2013 [34] A case-con- Tbilisi, Georgia 276 case, 14–20 Primary dysmenorrhea was signifi-
trol study 148 control cantly associated with depression
and anxiety
21 Ambresin, 2012 [30] Cross-sectional Switzerland 3340 16–20 Sever dysmenorrhea was signifi-
cantly associated with Sexual
abuse, Suicide attempt,
Depressive symptoms,
Disordered eating.
(continued)
 JOURNAL OF PSYCHOSOMATIC OBSTETRICS & GYNECOLOGY 189

Table 1. Continued
No of
No Author, year Study design Country participants Age group (year) Results
22 Rapkin, 2006 [35] Prospective USA 124 8–18 no association between anxiety,
study depression or somatization with
dysmenorrhea.
23 Dorn, 2009 [31] Cross-sequen- USA 154 11–17 More depressive symptoms/anxiety
tial design was related to higher numbers of
menstrual symptoms.
24 Nohara, 2011 [12] Cross-sectional Japan 2,166 Not reported significant relationship between
menstrual pain and stress
25 Wang, 2004 [37] Prospective China 388 20–34 The risk of dysmenorrhea was great-
study/cohort est among women with
high stress
26 Gordley, 2000 [40] Cross sectional USA 170 18–41 No statistically significant association
between work-related stress and
menstrual disorders, whereas life
event stress was significantly
associated with dysmenorrhea.
27 Nagata, 2005 [50] Cross-sec- Japan 276 19–24 No significant association was
tional study detected between alcohol con-
sumption with menstrual pain.
28 Xu, 2016 [63] Case-control China 161 18–23 Inappropriate parental bonding or
chronic traumatic attachment
styles have respective relation-
ships with the functional and
emotional disturbances experi-
enced by the primary dysmenor-
rhea patients.
29 Santina, 2012 [44] Cross-sectional Lebanon 389 13–19 Dysmenorrhea was significantly asso-
ciated with negative menstrual
experience scores
30 Dehkordi, 2017 [42] Cross-sec- Iran 100 19–23 An association was established
tional study between high stress levels and
menstrual irregularity.
31 Beal, 2014 [32] Cross-sec- Cincinnati 262 11–17 higher depressive symptoms and
tional design somatic complaints were associ-
ated with greater dysmenorrhea
32 Kollipaka, 2013 [41] Cross sectional India 164 Mean age: 20 ± 1.3 High stress was significantly associ-
ated with dysmenorrhea
33 Obeidat, 2012 [33] Cross sectional Jordan 177 18–24 Anxiety and depression were the
most prevalent symptoms associ-
ated with dysmenorrhea.

by Jones et al. [24]. It was indicated that partici-
pants with severe dysmenorrheal pain more likely
reported bipolar disorders [24].
 Depressive Disorders: Several studies investigated
the relationship between depression and dysmen-
orrhea. Many of them reported a significant rela-
tionship between depression and dysmenorrhea
and higher scores of depression in the dysmenor-
rhea group than in the healthy group
[8,14,18,25,27–33]. Only in two studies, no statistic-
ally significant relationship was found between
depression and dysmenorrhea [24,26].
 Anxiety Disorder: It was another mental health dis-
order that was studied in a large number of stud-
ies. The majority of studies reported a positive and
significant relationship between anxiety disorders
and dysmenorrhea [14,24,25,27–29,31,33,34] and
only two studies found no relationship between
anxiety and dysmenorrhea [26,35].
 Trauma and stressor related disorder: Stress experi-
ence as one of the factors influencing the incidence
of psychological disorders had a significant relation-
ship with dysmenorrhea in most studies
[12,14,18,36–41]. However, a few studies reported a
lack of significant correlation between stress and
dysmenorrhea [40,42,43]. In three studies, a signifi-
cant correlation was found between dysmenorrhea
and post-traumatic stress disorder [24] and trau-
matic experience due to unpleasant menstru-
ation [44].
 Obsessive–compulsive disorder: Only in the Jones’s
study, individuals with severe dysmenorrhea were
more likely to report having other psychiatric disor-
ders including obsessive–compulsive disorders [24].
 Eating disorder: It was reported in the studies by
Jones [24] and Ambresin [30], that showed a statis-
tically significant relationship with dysmenorrhea.
 The history of rape: It was studied only by Ambresin
[30] and a statistically significant association was
reported between these variables.
 Personality disorders: In two studies, some personal-
ity traits such as neuroticism-anxiety and impulsive
190 Z. BAJALAN ET AL.

Generalizability

interpretaon

Limitaons

Key results

Main results

Outcome data

Descripve data

parcipants

Stascal methods

Quantave variables High risk

Study size Low Risk

Unclear
Bias

Measurement

variables

parcipants

seng

Study design

Objecves

abstract

tle

0 5 10 15 20 25 30 35 40
Figure 2. Quality assessment of selected studies according to STROBE checklist.

sensation seeking had significant relationships with
dysmenorrhea, while aggression-hostility activity
and sociability had no relationships [28,45].
 Substance use and addictive disorder: A significant
relationship between substance abuse and
alcohol use was found only in the Ju’s study [46].
No statistically significant relationship between
alcohol consumption and dysmenorrhea was
reported [14,34,47–50].
 Somatic symptoms: There was a significant associ-
ation between dysmenorrhea and somatic disorders
in two studies [14,32], but in two other studies, no
such a relationship was observed [35,51].
Discussion
Primary dysmenorrhea, health problem all over the
world [52], is caused by different factors including
demographic characteristics, lifestyle behaviors,
reproductive factors, psychological and social factors
[2]. Mental health has always been neglected as one
part of reproductive health. The remarkable accom-
paniment of mental health and reproductive health
has been showed in the global burden of the disease
and disability [53]. Regarding the effect of mental
health on women’s reproductive health, the purpose
of this systematic review was to examine the relation-
ship between the experience of primary dysmenorrhea
with mental health and psychological disorders. A sys-
tematic review of studies in the above-mentioned
databases showed that a few studies were available
on the association between dysmenorrhea and most
of the psychological disorders. Most studies examined
the association between dysmenorrhea and depres-
sion, anxiety, stress, alcohol abuse and som-
atic disorders.
Depression is the most common disorder and one
of the ten leading causes of disability in the world
Table 2. Quality assessment of selected studies according STROBE checklist.
Title
and abstract Introduction Methods Results Discussion
Article Study Study Quantitative Statistical Descriptive Outcome Main Key
No Title Abstract Background Objectives design Setting Participants Variables Measurement Bias size variables methods Participants data data results results Limitations Generalizability
1 þ þ þ þ þ þ þ þ þ    ? þ þ þ þ þ þ þ
2 þ þ þ þ þ  þ ? ?    ? ?  þ þ þ  ?
3 þ þ þ þ þ þ þ þ þ ? þ þ þ þ þ þ þ þ þ þ
4 þ þ þ þ þ þ þ þ þ   þ þ þ þ þ þ þ þ þ
5 þ þ þ þ þ þ þ ? þ  þ ?  þ þ þ þ þ  ?
6  þ þ þ   þ þ þ   þ ?  ? þ ? ? þ ?
7  þ þ þ ? þ þ þ þ   þ ? þ ? þ þ þ þ þ
8  þ þ þ þ þ þ þ þ þ  ? þ þ þ þ ? þ þ ?
9 þ þ þ þ þ þ þ þ þ ? ? ? þ þ þ þ þ þ þ þ
10 þ þ þ þ þ þ þ þ ?  þ þ ? þ þ þ þ þ  þ
11 þ þ þ þ þ þ þ þ þ þ  ? þ þ ? þ þ þ þ þ
12 þ þ þ þ þ þ þ þ þ  þ þ ? þ þ þ ? þ ? þ
13 þ þ þ þ þ þ þ þ ? þ  þ þ þ ? þ þ þ þ ?
14 þ þ þ þ þ þ þ þ þ   þ þ þ ? þ þ þ þ ?
15 þ þ þ þ þ þ þ þ ?   þ þ þ ? þ ? þ þ ?
16 þ þ þ þ ? þ þ þ þ  ? þ ? þ þ þ ? þ  þ
17 þ þ þ þ þ þ þ þ ? ?  þ þ þ þ þ ? þ þ þ
18  þ þ þ þ þ þ þ þ  þ þ þ ? þ þ ? þ þ þ
19  þ þ þ  þ  þ þ    ? þ þ þ þ þ  þ
20 þ þ þ þ þ þ þ þ þ  þ þ þ þ þ þ þ þ ? þ
21 þ þ þ þ þ þ þ þ þ  þ þ ? þ þ þ þ þ þ 
22 þ þ þ þ þ  þ þ þ  þ þ þ   þ þ þ ? 
23  þ þ þ þ þ þ þ þ  þ  ?  þ þ þ þ ? 
24  þ þ þ þ þ þ þ þ  þ þ þ þ þ þ þ þ þ ?
25 þ þ þ þ þ þ þ þ þ þ þ þ þ þ  þ þ þ þ þ
26  þ þ þ  þ þ þ þ  þ þ þ þ þ þ þ þ ? þ
27 þ þ þ þ þ þ þ þ þ  þ ? ? ? ? þ þ þ þ ?
28  þ þ þ  þ þ  þ  ? ? ?   þ þ þ ? ?
29 þ þ þ þ þ þ þ þ þ  þ þ ? þ þ þ þ þ  
30 þ þ þ þ þ   ? þ  ?  ? ?  þ ? þ ? 
31  þ þ þ þ  þ þ þ ? þ þ þ þ þ þ þ þ þ þ
32 þ þ þ þ  þ þ þ þ  þ þ þ þ þ þ þ þ ? þ
33 þ þ þ þ þ  þ þ þ  þ þ þ   þ þ þ ? 
JOURNAL OF PSYCHOSOMATIC OBSTETRICS & GYNECOLOGY
191
192 Z. BAJALAN ET AL.
[53]. Depression and anxiety were psychological dis-
orders that in the majority of the studies had posi-
tive associations with dysmenorrhea. Dysmenorrhea
is one of the conditions that causes chronic pelvic
pain and has significant physical, emotional and eco-
nomic effects on individuals’ health [54]. The higher
prevalence of depression and anxiety in women with
chronic pelvic pain such as dysmenorrhea refers to
replacement mechanisms referred as “brain-gut,” neu-
roendocrine and psychosomatic [55]. Psychological
distress and pain sensitivity are common causes of
idiopathic pain disorders [56]. In a critical review of
dysmenorrhea, Iacovides et al. stated that women
with primary dysmenorrhea had greater sensitivity to
pain compared to healthy individuals [3]. Painful
menstruations that are repeated on a monthly basis
can cause a central sensitization to pain [57]. Central
sensitization is the mechanism of abnormal abdom-
inal pain in the central nervous system, which can
lead to an intensification of the environmental
response to pain [58]. The relationship between
depression, anxiety and stress with dysmenorrhea
has been observed in several studies that can be
due to the association of these factors with the
increased sensitivity to pain in women with dysmen-
orrhea [3]. On the other hand, it can be related to
the emotional experience of menstrual pain, because
pain is not just a sensory experience and can be an
emotional event affecting the development of psy-
chological distress and affective conditions, such as
mood disorders [59]. Research has emphasized the
role of chronic pain as a potential induction factor
of psychological distress [60]. Similar to other types
of chronic pain, menstrual pain acts as a stressor
and exacerbates psychological distress such as the
symptoms of depression and anxiety [61]. Mood dis-
orders such as depression and anxiety are associated
with menstruation that occurs in response to men-
strual pain or in the onset of a subsequent menstru-
ation [62]. Latthe’s meta-analysis also found that
depression and anxiety were risk factors of chronic
pelvic pain [15]. In this systematic review, the rela-
tionship between depression and anxiety with pri-
mary dysmenorrhea in numerous studies confirmed
the interaction between dysmenorrhea and depres-
sion and anxiety.
Another finding of this review study was the posi-
tive correlation between perceived stress (either public
or related to work or life events) and the experience
of dysmenorrhea. While the mechanism of the rela-
tionship between stress and dysmenorrhea was not
well known, the creation of neuroendocrine responses
could be one of the underlying reasons for this
problem [37]. Stress inhibits the release of follicle stim-
ulating hormone and luteinizing hormone, thereby dis-
rupts the follicular development. This change in the
production and release of progesterone can affect the
activity of prostaglandins. Additionally, stress can pro-
duce prostaglandins in myometrium by producing
adrenaline and cortisol hormones [37].
The relationship between somatic disorders and
dysmenorrhea was another finding of this review
study. A significant relationship was reported in two
studies. In a previous meta-analysis, psychosomatic dis-
orders were considered one of the highest risk factors
of chronic pelvic pain [15]. However, studies on the
association between somatic disorders and primary
dysmenorrhea did not reveal such an association. The
reason for this difference in the results of studies can
be differences in the age group of participants. The
mean age of participants in studies that did not show
a correlation between somatic disorders and primary
dysmenorrhea was lower than that of the studies indi-
cating a significant association. Aging can cause som-
atic symptoms due to repeated experience of
dysmenorrhea. Another reason for the difference
between the results of this review and the results of
this meta-analysis can be that in the present study
only primary dysmenorrhea was included, but dysmen-
orrhea was generally classified as chronic (primary and
secondary) pelvic pain.
In the present review, most studies did not show
any association between alcohol consumption and
dysmenorrhea, except one study. This finding is in line
with previous systematic reviews conducted by Latthe
and Ju [2,15].
Conclusion
Findings of this study showed that the relationship
between the majority of psychological disorders
and primary dysmenorrhea was investigated by few
studies, which reflected the need for further studies.
On the other hand, there is a significant relationship
between some mental health components such as
depression, anxiety and stress, and primary dysmenor-
rhea, indicating the importance of psychological
assessment as one part of the evaluation process for
individuals with primary dysmenorrhea before the
selection of treatment. The presence of depression,
anxiety and stress in patients with dysmenorrhea indi-
cates the feasibility of designing and evaluating the
effectiveness of psychotherapy interventions for the
treatment of primary dysmenorrhea as alterna-
tive therapies.

Disclosure statement
No potential conflict of interest was reported by the authors.
ORCID
Zainab Alimoradi http://orcid.org/0000-0001-5327-2411
References
[1] Rapkin AJ, Nathan L. Pelvic pain and dysmenorrhea.
In: Berek JS, editor. Berek and Novak’s Gynecology.
15th ed. USA: Lippincott Williams and Wilkins; 2012.
p. 481.
[2] Ju H, Jones M, Mishra G. The prevalence and risk fac-
tors of dysmenorrhea. Epidemiol Rev. 2014;36:104–113.
[3] Iacovides S, Avidon I, Baker FC. What we know about
primary dysmenorrhea today: a critical review. Hum
Reprod Update. 2015;21:762–778.
[4] French L. Dysmenorrhea. Am Fam Phys. 2005;71:
285–291.
[5] Parker M, Sneddon A, Arbon P. The menstrual dis-
order of teenagers (MDOT) study: determining typical
menstrual patterns and menstrual disturbance in a
large population-based study of Australian teenagers.
BJOG. 2010;117:185–192.
[6] Nazarpour S. Study of factors of influencing on sever-
ity of primary dysmenorrhea in students of faculties
of nursing and midwifery of governmental universities
under the supervision of ministry of Health, treatment
and Medical Education in Tehran. Q J Woman Hyg.
2010;1:109–125.
[7] Haidari F, Akrami A, Sarhadi M, et al. Prevalence and
severity of primary dysmenorrhea and its relation
to anthropometric parameters. Tums-hayat. 2011;17:
70–77.
[8] Gagua T, Tkeshelashvili B, Gagua D. Primary dysmen-
orrhea: prevalence in adolescent population of Tbilisi,
Georgia and risk factors. J Turkish German Gynecol
Assoc. 2012;13:162–168.
[9] Ohde S, Tokuda Y, Takahashi O, et al. Dysmenorrhea
among Japanese women. Int J Gynecol Obstet.
2008;100:13–17.
[10] Pawłowski B. Prevalence of menstrual pain in relation
to the reproductive life history of women from the
Mayan rural community. Ann Hum Biol. 2004;31:1–8.
[11] Santer M, Warner P, Wyke S. A Scottish postal survey
suggested that the prevailing clinical preoccupation
with heavy periods does not reflect the epidemiology
of reported symptoms and problems. J Clin
Epidemiol. 2005;58:1206–1210.
[12] Nohara M, Momoeda M, Kubota T, et al. Menstrual
cycle and menstrual pain problems and related risk
factors among Japanese female workers. Ind Health.
2011;49:228–234.
[13] Pitts MK, Ferris JA, Smith AMA, et al. Prevalence and
correlates of three types of pelvic pain in a nationally
representative sample of Australian women. Med J
Australia. 2008;189:138–142.
[14] Patel V, Tanksale V, Sahasrabhojanee M, et al. The
burden and determinants of dysmenorrhoea: a
JOURNAL OF PSYCHOSOMATIC OBSTETRICS & GYNECOLOGY 193
population-based survey of 2262 women in Goa,
India. BJOG. 2006;113:453–463.
[15] Latthe P, Mignini L, Gray R, et al. Factors predisposing
women to chronic pelvic pain: systematic review. BMJ.
2006;332:1–7.
[16] Burnett MA, Antao V, Black A, et al. Prevalence of pri-
mary dysmenorrhea in Canada. J Obstet Gynaecol
Canada. 2005;27:765–770.
[17] Weissman AM, Hartz AJ, Hansen MD, et al. The natural
history of primary dysmenorrhoea: a longitudinal
study. BJOG. 2004;111:345–352.
[18] Tavallaee M, Joffres MR, Corber SJ, et al. The preva-
lence of menstrual pain and associated risk factors
among Iranian women. J Obstet Gynaecol Res.
2011;37:442–451.
[19] Rodrigues A, Gala S, Neves A, et al. Dysmenorrhea in
adolescents and young adults: prevalence, related fac-
tors and limitations in daily living. Acta Med Port.
2011;24:383–385.
[20] Granot M, Yarnitsky D, Itskovitz-Eldor J, et al. Pain
perception in women with dysmenorrhea. Obstet
Gynecol. 2001;98:407–411.
[21] Sharp BC, Taylor D, Thomas K, et al. Cyclic perimenst-
rual pain and discomfort: the scientific basis for
practice. J Obstet Gynecol Neonatal Nurs. 2002;31:
637–649.
[22] Garrard J. Health sciences literature review made easy:
the Matrix method. 3rd ed. Jones & Bartlett
Publishers; 2011. p. 61–137.
[23] Elm Ev, Altman DG, Egger M, et al. The strengthening
the reporting of observational studies in epidemi-
ology (STROBE) statement: guidelines for reporting
observational studies. PloS Med. 2007;4:1623–1627.
[24] Jones AV, Hockley JR, Hyde C, et al. Genome-wide
association analysis of pain severity in dysmenorrhea
identifies association at chromosome 1p13.2, near the
nerve growth factor locus. Pain. 2016;157:2571–2581.
[25] Liu P, Wang G, Liu Y, et al. White matter microstruc-
ture alterations in primary dysmenorrhea assessed by
diffusion tensor imaging. Sci Rep. 2016;6:25836.
[26] Toy H, Herguner A, Simsek S, et al. Autistic traits in
women with primary dysmenorrhea: a case-control
study. Neuropsychiatr Dis Treat. 2016;12:2319–2325.
[27] Hailemeskel S, Demissie A, Assefa N. Primary dysmen-
orrhea magnitude, associated risk factors, and its
effect on academic performance: evidence from
female university students in Ethiopia. Int J Womens
Health. 2016;8:489–496.
[28] Faramarzi M, Salmalian H. Association of psychologic
and nonpsychologic factors with primary dysmenor-
rhea. Iran Red Crescent Med J. 2014;16:e16307.
[29] € uner I, Kag
Balık G, Ust€ itcı M, et al. Is there a relation-
ship between mood disorders and dysmenorrhea? J
Pediatr Adolesc Gynecol. 2014;27:371–374.
[30] Ambresin AE, Belanger RE, Chamay C, et al. Body dis-
satisfaction on top of depressive mood among ado-
lescents with severe dysmenorrhea. J Pediatr Adolesc
Gynecol. 2012;25:19–22.
[31] Dorn LD, Negriff S, Huang B, et al. Menstrual symp-
toms in adolescent girls: association with smoking,
depressive symptoms and anxiety. J Adolesc Health.
2009;44:237–243.
194 Z. BAJALAN ET AL.
[32] Beal SJ, Dorn LD, Sucharew HJ, et al. Characterizing
the longitudinal relations between depressive and
menstrual symptoms in adolescent girls. Psychosom
Med. 2014;76:547–554.
[33] Obeidat BA, Alchalabi HA, Abdul-Razzak KK, et al.
Premenstrual symptoms in dysmenorrheic college
students: prevalence and relation to vitamin D and
parathyroid hormone levels. Int J Environ Res Public
Health. 2012;9:4210–4222.
[34] Gagua T, Tkeshelashvili B, Gagua D, et al. Assessment
of anxiety and depression in adolescents with primary
dysmenorrhea: a case-control study. J Pediatr Adolesc
Gynecol. 2013;26:350–354.
[35] Rapkin AJ, Tsao JCI, Turk N, et al. Relationships among
self-rated tanner staging, hormones, and psychosocial
factors in healthy female adolescents. J Pediatr
Adolesc Gynecol. 2006;19:181–187.
[36] Ibrahim NK, AlGhamdi MS, Al-Shaibani AN, et al.
Dysmenorrhea among female medical students in
King Abdulaziz University: prevalence, predictors and
outcome. Pak J Med Sci. 2015;31:1312–1317.
[37] Wang L, Wang X, Wang W, et al. Stress and dysmen-
orrhoea: a population based prospective study. Occup
Environ Med. 2004;61:1021.
[38] Liu H, Yang F, Li Z, et al. Passive smoking, Cyp1A1
gene polymorphism and dysmenorrhea. Reproduct
Toxicol (Elmsford, NY). 2007;24:114–119.
[39] Jeon GE, Cha NH, Sok SR. Factors influencing the dys-
menorrhea among Korean adolescents in middle
school. J Phys Ther Sci. 2014;26:1337–1343.
[40] Gordley LB, Lemasters G, Simpson SR, et al. Menstrual
disorders and occupational, stress, and racial factors
among military personnel. J Occup Environ Med.
2000;42:871–881.
[41] Kollipaka R, Arounassalame B, Lakshminarayanan S.
Does psychosocial stress influence menstrual abnor-
malities in medical students? J Obstet Gynaecol.
2013;33:489–493.
[42] Dehkordi ZR. Evaluate the effect of perceived stress
on dysmenorrhea. BMJ Open. 2017;7:bmjopen-2016.
[43] Bavil DA, Dolatian M, Mahmoodi Z, et al. Comparison
of lifestyles of young women with and without
primary dysmenorrhea. Electron Physician. 2016;8:
2107–2114.
[44] Santina T, Wehbe N, Ziade F, Exploring dysmenor-
rhoea and menstrual experiences among Lebanese
female adolescents. East Mediterr Health J.
2012;18:857–863.
[45] Liang W, Zhang Y, Li H, et al. Personality and primary
dysmenorrhea: a study using a five-factor model in
Chinese University Women. Arch Neuropsychiatry.
2012;49:92–93.
[46] Ju H, Jones M, Mishra GD. A U-shaped relationship
between body mass index and dysmenorrhea: a longi-
tudinal study. PLoS One. 2015;10:e0134187.
[47] Pejcic A, Jankovic S. Risk factors for dysmenorrhea
among young adult female university students. Ann
Ist Super Sanita. 2016;52:98–103.
[48] Unsal A, Ayranci U, Tozun M, et al. Prevalence of dys-
menorrhea and its effect on quality of life among a
group of female university students. Ups J Med Sci.
2010;115:138–145.
[49] Grandi G, Ferrari S, Xholli A, et al. Prevalence of men-
strual pain in young women: what is dysmenorrhea?
J Pain Res. 2012;5:169–174.
[50] Nagata C, Hirokawa K, Shimizu N, et al. Associations
of menstrual pain with intakes of soy, fat and dietary
fiber in Japanese women. Eur J Clin Nutr. 2004;59:
88–92.
[51] Goldstein-Ferber S, Granot M. The association
between somatization and perceived ability: roles in
dysmenorrhea among Israeli Arab adolescents.
Psychosom Med. 2006;68:136–142.
[52] Ozerdogan N, Sayiner D, Ayranci U, et al. Prevalence
and predictors of dysmenorrhea among students at a
university in Turkey. Int J Gynaecol Obstet.
2009;107:39–43.
[53] WHO and UNPF, Mental health aspects of women’s
reproductive health: a global review of the literature.
World Health Organization; 2009.
[54] Mathias SD, Kuppermann M, Liberman RF, et al.
Chronic pelvic pain: prevalence, health-related quality
of life, and economic correlates. Obstet Gynecol.
1996;87:321–327.
[55] Westling AM, Tu FF, Griffith JW, et al. The association
of dysmenorrhea with noncyclic pelvic pain account-
ing for psychological factors. Am J Obstet Gynecol.
2013;209:422.e1–422.e10.
[56] Jensen MP, Turk DC. Contributions of psychology to
the understanding and treatment of people with
chronic pain: why it matters to ALL psychologists. Am
Psychol. 2014;69:105.
[57] Yunus MB. Fibromyalgia and overlapping disorders:
the unifying concept of central sensitivity syndromes.
Semin Arthritis Rheum. 2007;36:339–356.
[58] Woolf CJ. Pain: moving from symptom control toward
mechanism-specific pharmacologic management. Ann
Intern Med. 2004;140:441–451.
[59] Bair MJ, Robinson RL, Katon W, et al. Depression and
pain comorbidity: a literature review. Arch Intern Med.
2003;163:2433–2445.
[60] Reynolds N, Mrug S, Hensler M, et al. Spiritual coping
and adjustment in adolescents with chronic illness: a
2-year prospective study. J Pediatr Psychol.
2014;39:542–551.
[61] Terranova P. Dysmenorrhea. In: Reference module in
biomedical sciences. London: Elsevier; 2015.
[62] Fiala C, Chabbert-Buffet N, H€ausler G, et al. Women’s
preferences for menstrual bleeding frequency in 12
European countries: the Inconvenience Due to
Women’s Monthly Bleeding (ISY) survey. Eur J
Contracept Reprod Health Care. 2017;22:268–273.
[63] Xu K, Chen L, Fu L, et al. Stressful parental-bonding
exaggerates the functional and emotional disturban-
ces of primary dysmenorrhea. Int J Behav Med.
2016;23:458–463.
Copyright of Journal of Psychosomatic Obstetrics & Gynecology is the property of Taylor &
Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a
listserv without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.