JOURNAL OF WOMEN’S HEALTH

Volume 00, Number 00, 2019

ª Mary Ann Liebert, Inc.
DOI: 10.1089/jwh.2018.7615

The Prevalence and Academic Impact

of Dysmenorrhea in 21,573 Young Women:
A Systematic Review and Meta-Analysis

Mike Armour, PhD,1,2 Kelly Parry, BSc,1 Narendar Manohar, MPH,3 Kathryn Holmes, PhD,4 Tania Ferfolja, PhD,4
Christina Curry, PhD,4 Freya MacMillan, PhD,2,3 and Caroline A. Smith, PhD1,2

Abstract
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Introduction: Dysmenorrhea (period pain) and associated symptoms are very common in young women <25
years. This time corresponds with a significant stage in adolescents and young women’s academic lives at both
school and in higher education. Dysmenorrhea may cause absenteeism from class or result in reduced classroom
concentration and performance. Owing to cultural and economic differences, any impact may vary by country.
This systematic review and meta-analysis examines the prevalence of dysmenorrhea in young women and
explores any impact it has on their academic performance and other school-related activities.
Materials and Methods: A search in Medline, PsychINFO, EMBASE, and Cumulative Index to Nursing and
Allied Health Literature was carried out in June 2018.
Results: Thirty-eight studies including 21,573 young women were eligible and included in the meta-analysis.
Twenty-three studies were from low-, lower middle-, or upper middle-income countries, and 15 studies were
from high-income countries. The prevalence of dysmenorrhea was high 71.1% (N = 37, n = 20,813, 95% con-
fidence interval [CI] 66.6–75.2) irrespective of the economic status of the country. Rates of dysmenorrhea were
similar between students at school (N = 24, 72.5%, 95% CI 67.5–77.0) and at university (N = 7, 74.9%, 95% CI
62.9–84.0). Academic impact was significant, with 20.1% reporting absence from school or university due to
dysmenorrhea (N = 19, n = 11,226, 95% CI 14.9–26.7) and 40.9% reporting classroom performance or con-
centration being negatively affected (N = 10, n = 5126, 95% CI 28.3–54.9).
Conclusions: The prevalence of dysmenorrhea was high, irrespective of country, with dysmenorrhea having a
significant negative impact on academic performance both at school and during higher education.

Keywords: dysmenorrhea, adolescent, academic, education

Introduction young women <25 years of age.3 Secondary dysmenorrhea is

menstrual pain associated with an identifiable cause.6 The

M enstrual disorders are highly prevalent among

adolescent girls, and commonly feature period pain,
fatigue, and mood changes.1,2 Dysmenorrhea (period pain)
affects around three quarters of all women during their re-
productive life, and is especially common in young women in
their teens and early adult life.3
Primary dysmenorrhea is defined as menstrual pain in the
absence of underlying pathology, with the pain commonly
starting within 3 years of menarche (the first menstrual pe-
riod)4,5 and is the most common cause of dysmenorrhea in
most common identifiable cause of secondary dysmenorrhea
is endometriosis.7
A previous systematic review describing the prevalence of
dysmenorrhea in women during their reproductive lifespan
reported rates ranging from 16.8% to 81%.8 In 2010, a review
of younger women <20 years of age found higher prevalence
rates of 43%–91%.9
Since the publication of earlier reviews,8,9 there has been a
significant number of observational surveys published. The
majority of this literature is from low- and middle-income

1
NICM Health Research Institute, Western Sydney University, Penrith, Australia.
2
Translational Health Research Institute, Western Sydney University, Penrith, Australia.
3
School of Science and Health, Western Sydney University, Penrith, Australia.
4
Centre for Educational Research, Western Sydney University, Penrith, Australia.

1
 2 ARMOUR ET AL.
countries, where menstrual rates and the subsequent impact
may be significantly different due to cultural taboos around
menstruation and lack of support structures at school. This
lack of support includes not being able to access facilities to
change sanitary products without humiliation or embarass-
ment.10 Cultural and social factors are also likely to influence
the prevalence and reporting of dysmenorrhea.11 For in-
stance, there is variance in the prevalence of dysmenorrhea
reported in surveys between different cultural groups, even
when geographical locations are similar.12,13 It is currently
unclear whether the differences in prevalence rates are due to
biological or cultural factors; however, it is possible that the
difference may be due, at least in part, to the presence of a
public ‘‘culture of silence’’ around menstrual issues in some
traditional cultures, demonstrated by women under-reporting
primary dysmenorrhea in surveys, but showing similar rates
across cultures in physicians’ consultations.11
The availability of new data from these countries may give
more insight into the impact of menstruation worldwide. Pre-
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vious studies have reported that among school-age adolescents
and young women across a wide spectrum of social and cultural
groups, dysmenorrhea causes educational absences,13–18 as well
as reducing young women’s capacities to concentrate, partici-
pate, and apply test-taking skills, thereby adversely impacting
on overall grades.16 It is often suggested that the severity of
dysmenorrhea reduces with age,19 so women at university may
experience less negative impact than those at school; however,
data on this comparison are currently lacking.
Owing to the potential impact that dysmenorrhea and the
associated symptoms have on young women’s academic per-
formance at a critical stage in their academic lives,17 an ac-
curate understanding of the prevalence worldwide and how this
affects young women in different countries are vital to identify
the potential impact on young women’s future prospects.
The aim of this systematic review and meta-analysis was to
determine the overall rate of dysmenorrhea in young women
globally and to explore the impact of dysmenorrhea on at-
tendance and classroom performance at school, university, or
other higher educational institutes. Furthermore, any differ-
ences in the prevalence and/or impact between countries with
different economic status were explored.
Methods
Preferred Reporting Items for Systematic Reviews and Meta-
Analyses guidelines were adhered to throughout this review.20
Search strategy and selection criteria
A literature search was performed on Cumulative Index to
Nursing and Allied Health Literature, Medline, Embase, and
PsycINFO databases. All databases were searched from 1980
till June 1, 2018 using the following main keywords: ‘‘im-
pact,’’ ‘‘symptoms,’’ ‘‘dysmennorhoea,’’ ‘‘adolescen*.’’ The
search and selection process are outlined in Figure 1. The
detailed search strategy is enclosed in Supplementary Data.
Only English language articles published in peer-reviewed
journals were included.
Observational studies (including cohort, cross-sectional,
and case–control) were included. Studies that specified that
the participants were either at school or university or if the
mean age of the young women in the sample was <18 years
were included. Eligible studies were those that included ei-
ther the outcome of prevalence of dysmenorrhea or academic
absenteeism. Studies that reported on secondary dysmenor-
rhea only were excluded as these would not represent the true
prevalence rate or impact of dysmenorrhea. Studies that only
reported qualitative data were not eligible for inclusion.
Data extraction
Two authors (N.M. and M.A.) assessed eligibility, whereas
three authors (M.A., N.M., and K.P.) and a research assistant
(T.J.) extracted the data independently, and any disagree-
ments were resolved by discussion. Where data were missing
or unclear, the study authors were contacted via e-mail to
request the data. Authors were contacted twice for a 6-week
period, and if no response was received within that period, the
data were marked as missing. A systematic tool for data ex-
traction was developed to extract all relevant data from eli-
gible studies. The tool is given in Supplementary Table S1.
Data were extracted on all of the following outcomes
(if reported):
(a) Prevalence of dysmenorrhea.
(b) Severity of dysmenorrhea via numeric rating scale
(NRS) or visual analogue scale (VAS).
(c) Symptoms of dysmenorrhea (bloating, emotional
changes, fatigue, and breast tenderness).
(d) Absenteeism from school.
(e) Reduced classroom performance.
(f) Reduction in other school activities.
(g) Reduction in other social activities.
Study characteristics (location and demographics) were
also extracted.
Quality assessment
Quality assessment of the included studies was performed
independently and in duplicate by C.A.S., C.C., M.A., N.M., and
K.P., with any disagreements resolved by a third party. Quality
was assessed using a condensed version of the Strengthening
the Reporting of Observational Studies in Epidemiology
guidelines that have been used in previous reviews.21,22
Data synthesis and meta-analysis
A random effects meta-analyses were conducted using
Comprehensive Meta-Analysis software (Version 3). Data
were pooled for each outcome where there were data from at
least three independent studies.
A random effects model was used to account for expected
heterogeneity between studies. Statistical heterogeneity be-
tween studies was quantified using Cochran’s Q and I2 sta-
tistic, both of which provide estimates of the degree of
heterogeneity resulting from between-study variance, rather
than by chance. Cochrane’s Q with p-value of <0.05 was
classified as significant heterogeneity, and I2 of >75% was
considered to indicate high-level heterogeneity, I2 of 50%–
75% as indicative of substantial heterogeneity, and an I2 of
<40% as low heterogeneity.
A priori mean age at the time of the survey was used in a
meta-regression to explore any difference in dysmenorrhea
rates with age. Preplanned subgroup analyses were conducted
to examine whether there was a difference in prevalence or
impact in high-income versus low-income, lower middle-
 IMPACT OF DYSMENORRHEA ON YOUNG WOMEN
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income, and upper middle-income economies (as classified
by the World Bank23) due to differences in access to suitable
medical and/or social support. A postori a subgroup analysis
exploring prevalence and impact in students at school or
university was undertaken.
Results
Thirty-eight studies with 21,573 young women were in-
cluded in the meta-analysis. Figure 1 outlines the search and
selection process. Nine studies were undertaken in Nigeria,24–32
four in Australia,1,17,33,34 three in India,35–37 two each in
Ethiopia,38,39 Iran,40,41Taiwan,42,43 and the United States,16,44
and one each from Belgium,45 Brazil,46 Egypt,47 Finland,48
Ghana,49 Hong Kong,50 Italy,51 Japan,52 Malaysia,53 Mexico,13
Palestine,54 Poland,55 Sri Lanka,56 and Turkey.57 Study publi-
cation dates ranged from 1985 to 2018. Eighteen studies had
publication dates in the past 5 years (from 2013 onward). The
mean age of participants ranged from 1345 to 23 years,49 with a
median age of 17.15 years old at the time of the survey.
There were 23 studies from low-, lower middle, or upper
middle-income countries (termed LMIC in the analysis) and
15 studies from high-income countries (termed HIC).
Twenty-three studies reported on young women at school,
nine reported on young women at university or higher edu-
cation, one recruited from both school and university, and
five recruited from a community population. Table 1 sum-
marizes the included studies.
Quality assessment
The results of the quality assessment for the 38 studies are
summarized in Supplementary Table S2. Seventeen studies
3
FIG. 1. PRISMA flow diagram.
PRISMA, Preferred Reporting
Items for Systematic Reviews and
Meta-Analyses.
clearly reported their eligibility criteria. Eighteen studies used a
form of random sampling. Response rates ranged from 15.7%
to 100%. Eight studies did not report response rates. Thirteen
studies reported no conflict of interest, with one study reporting
a potential conflict that was disclosed. Only six studies reported
on the reliability and validity of their measures, with one ad-
ditional study reporting that the questionnaire was validated
but did not provide any details. Most studies used composite
scoring methods, where a VAS or NRS was embedded as part
of a larger questionnaire that had been developed by the au-
thors, so although the VAR or NRS was valid and reliable, the
rest of the questionnaire was generally not validated. All
studies were susceptible to self-reporting bias.
Prevalence of dysmenorrhea
Across 37 studies with a total of 20,813 women, the overall
prevalence of dysmenorrhea was 71.1% (N = 37, n = 20,813,
95% confidence interval [CI] 66.6–75.2, Q = 2344, p < 0.001,
I2 = 98.5). Figure 2 shows the forest plot for the complete data
set. Subgroup analysis found there was no difference ( p = 0.881)
in the prevalence of dysmenorrhea between LMIC (N = 24,
70.6%, 95% CI 65.6–75.2) and HIC (N = 13, 73.2%, 95% CI
62.2–82.0), or between students at school (N = 24, 72.5%, 95%
CI 67.5–77.0) and university (N = 7, 74.9%, 95% CI 62.9–84.0).
There was no effect of age at the time of the survey on the
prevalence of dysmenorrhea (b = 0.0874, Z = 1.45, p = 0.1245).
Severity and symptoms of dysmenorrhea
Complete data on dysmenorrhea severity measured via an
NRS or VAS were only reported in three studies and were,
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Table 1. Characteristics of Included Studies

Study ID (author Mean Sample Sample
and year) Study design Country age (years) size population Reports on
Abidoye and Agbabiaka Questionnaire-based Nigeria NR 180 School and Presence of dysmenorrhea, emotional symptoms, physical
(1994)24 study: cross-sectional university symptoms
Abraham et al. (1985)34 Questionnaire-based Australia NR 1377 Community Presence of dysmenorrhea, physical symptoms
study: cross-sectional
Abu Helwa et al. Questionnaire-based Palestine 19.73 956 University Presence of dysmenorrhea, physical symptoms, absenteeism
(2018)54 study: cross-sectional (academic), severity of dysmenorrhea
Adetokunbo et al. Questionnaire Nigeria NR 300 School Presence of dysmenorrhea
(2009)25
Adinma and Adinma Questionnaire-based Nigeria NR 550 School Presence of dysmenorrhea, emotional symptoms, physical
(2008)26 study: cross-sectional symptoms
Adinma and Adinma Questionnaire-based Nigeria NR 550 School Presence of dysmenorrhea, emotional symptoms, physical
(2009)27 study: cross-sectional symptoms, absenteeism (academic), absence—school
(days)
Akinnubi (2016)28 Questionnaire-based Nigeria NR 150 School Presence of dysmenorrhea, physical symptoms, absenteeism
study and interviews: (academic), impact on classroom performance
cross-sectional
Ameade et al. (2018)49 Questionnaire-based Ghana 23 293 University Presence of dysmenorrhea, emotional symptoms,
study: cross-sectional absenteeism (academic), impact on classroom
performance

4
Banikarim et al. Questionnaire-based United States NR 740 School Presence of dysmenorrhea, physical symptoms, absenteeism
(2000)16 study: cross-sectional (academic), impact on classroom performance, impact on
other school activities, impact on social activities
Chang and Chuang Questionnaire-based Taiwan NR 603 School Presence of dysmenorrhea, severity of dysmenorrhea
(2012)43 study: cross-sectional
Chia et al. (2013)50 Questionnaire-based Hong Kong 20.1 240 University Presence of dysmenorrhea, absenteeism (academic), impact
study: cross-sectional on classroom performance, impact on other school
activities
Chiou and Wang42 Questionnaire-based Taiwan 16.7 760 University Emotional symptoms, absenteeism (academic), impact on
study: cross-sectional classroom performance, impact on social activities
Devi (2014)35 Questionnaire-based India NR 100 School Presence of dysmenorrhea, physical symptoms
study: cross-sectional
Fawole et al. (2009)29 Questionnaire-based Nigeria NR 1673 School Presence of dysmenorrhea
study: cross-sectional
Hillen et al. (1999)17 Questionnaire-based Australia NR 388 School Presence of dysmenorrhea, physical symptoms, impact on
study: cross-sectional other school activities, impact on social activities
Hoppenbrouwers et al. Questionnaire-based Belgium 13 769 Community Presence of dysmenorrhea, absenteeism (academic), impact
(2016)45 study (quantitative) on other school activities, impact on social activities
Houston et al. (2006)44 Questionnaire-based United States 15.6 184 Community Presence of dysmenorrhea, emotional symptoms, physical
study: cross-sectional symptoms, absenteeism (academic), impact on social
activities
Kamel et al. (2017)47 Questionnaire-based Egypt 20.4 269 University Presence of dysmenorrhea, physical symptoms, impact on
study classroom performance, duration of dysmenorrhea
(continued)
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Table 1. (Continued)
Study ID (author Mean Sample Sample
and year) Study design Country age (years) size population Reports on
Karthiga et al. (2011)36 Questionnaire-based India NR 371 School Presence of dysmenorrhea
study: cross-sectional
Kazama et al. (2015)52 Cross-sectional Japan 14.3 1018 School Presence of dysmenorrhea, severity of dysmenorrhea
Moronkola and Questionnaire-based Nigeria NR 120 University Presence of dysmenorrhea, emotional symptoms, impact on
Uzuegbu (2006)30 study classroom performance, impact on other school activities
Muluneh et al. (2018)38 Questionnaire-based Ethiopia 17.55 539 School Presence of dysmenorrhea
study: cross-sectional
13
Ortiz et al. (2009) Questionnaire-based Mexico NR 1152 School Presence of dysmenorrhea, absenteeism (academic), impact
study: cross-sectional on social activities
1
Parker et al. (2010) Questionnaire,-based Australia 16 1051 School Presence of dysmenorrhea, emotional symptoms, physical
study (quantitative) symptoms, absenteeism (academic), impact on classroom
performance, impact on other school activities, impact on
social activities
Pitangui et al. (2013)46 Questionnaire-based Brazil 13.65 218 School Presence of dysmenorrhea, physical symptoms, absenteeism
study: cross-sectional (academic), impact on social activities
Poureslami and Osati- Questionnaire-based Iran NR 250 School Presence of dysmenorrhea, impact on social activities
Ashtiani (2002)40 study: cross-sectional
Rostami (2007)41 Questionnaire Iran NR 660 School Presence of dysmenorrhea, absenteeism (academic), impact
on social activities
Subasinghe et al. Questionnaire Australia NR 247 Community Presence of dysmenorrhea, absenteeism (academic)

5
(2016)33
Sule and Ukwenya Questionnaire Nigeria NR 400 School Presence of dysmenorrhea, emotional symptoms, physical
(2007)31 symptoms, absenteeism (academic)
Suvitie et al. (2016)48 Questionnaire-based Finland 16.8 1103 School Presence of dysmenorrhea, absenteeism (academic)
study: cross-sectional
Titilayo et al. (2009)32 Questionnaire Nigeria 22 415 University Presence of dysmenorrhea
(qualitative/
quantitative)
Unsal et al. (2012)57 Questionnaire-based Turkey NR 390 School Presence of dysmenorrhea
study: cross-sectional
Vani et al. (2013)37 Questionnaire-based India NR 861 School Presence of dysmenorrhea
study: cross-sectional
Wijesiri and Suresh Questionnaire-based Sri Lanka NR 200 School Presence of dysmenorrhea, impact on social activities
(2013)56 study: cross-sectional
Wong (2011)53 Questionnaire-based Malaysia 15.28 1295 School Presence of dysmenorrhea, absenteeism (academic), impact
study: cross-sectional on classroom performance, impact on social activities
Yesuf et al. (2018)39 Questionnaire-based Ethiopia 20.5 535 University Presence of dysmenorrhea, absenteeism (academic), impact
study: cross-sectional on classroom performance
Zannoni et al. (2014)51 Questionnaire-based Italy 17.7 250 Community Presence of dysmenorrhea, absenteeism (academic), impact
study: cross-sectional on other school activities, impact on social activities
Zurawiecka and Questionnaire-based Poland NR 700 University Presence of dysmenorrhea
Wronka (2017)55 study: cross-sectional
NR, not reported.
 6 ARMOUR ET AL.
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FIG. 2. Prevalence of dysmenorrhea.
therefore, not included in the analysis. Secondary symptoms
of dysmenorrhea were very common, with 48.3% of women
reporting one or more of emotional changes, breast tender-
ness, bloating, or fatigue (N = 33, n = 16,178, 95% CI 39.4–
57.3, Q = 3112, I2 = 98.97, p < 0.001). Bloating was the most
commonly reported symptom, with 56.3% of women re-
porting this symptom (N = 6, n = 3381, 95% CI 42.5–69.1,
Q = 251, I2 = 98.0, p < 0.001), 56.0% reported breast tender-
ness (N = 6, n = 2038, 95% CI 25.2–82.8, Q = 616, I2 = 99.2,
p < 0.001), 44.0% reported fatigue (N = 12, n = 6671, 95% CI
42.5–69.1, Q = 1245, I2 = 98.0, p < 0.001), and 34.6% re-
ported emotional changes (N = 8, n = 3381, 95% CI 18.7–
54.9, Q = 932, I2 = 99.1, p < 0.001). Figure 3 shows the forest
plot for all secondary dysmenorrhea symptoms.
Educational impact
Across 19 studies with a total of 11,226 women, 20.1%
were absent from school or university due to dysmenorrhea
(N = 19, n = 11,226, 95% CI 14.9–26.7, Q = 987, I2 = 98.2,
p < 0.001). Subgroup analysis showed there was a trend
( p = 0.061) toward a greater percentage (26%) of young
women taking time off school in LMIC (N = 10, 95% CI
16.8–32.1, Q = 403, I2 = 97.7, p < 0.001) compared with HIC
at only 12.1% (N = 9, 95% CI 6.2–22.2, Q = 574, I2 = 98.6,
p < 0.001). There was no difference ( p = 0.432) in absentee-
ism between young women at school (N = 10, 18.2%, 95% CI
11.6–27.5) and at university (N = 5, 23.5%, 95% CI 14.4–
35.9).
Overall 40.9% of young women reported classroom per-
formance or concentration being negatively affected (N = 10,
n = 5126, 95% CI 28.3–54.9, Q = 743, I2 = 98.8, p < 0.001, 10
studies, 5126 women). There was no difference ( p = 0.789)
between classroom performance being affected in LMIC
(37.6%, 95% CI 24.0–53.4) and HIC (52.4%, 95% CI 25.6–
77.9) or between ( p = 0.878) young women at school (N = 4,
44.8%, 95% CI 22.8–69.0) and at university (N = 6, 42.4%,
95% CI 25.3–61.5). Reduction in other school activities was
 IMPACT OF DYSMENORRHEA ON YOUNG WOMEN
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FIG. 3. Prevalence of secondary symptoms of dysmenorrheal; bloating, breast tenderness, emotional changes, and
fatigue.
reported by 29.6% of young women (95% CI 15.6–48.8,
Q = 561, I2 = 98.9, p < 0.001, 7 studies, 3524 women). There
were not enough studies reporting this outcome to perform
either subgroup analysis.
Other impact
Reduction in ‘‘other activities’’ such as social or sporting
activities was reported by 37% of young women (95% CI
24.2–50.7, Q = 2533, I2 = 99.4, p < 0.001, 15 studies, 13,306
women). There was no difference ( p = 0.593) in reduction in
other activities between LMIC (40.5%, 95% CI 24.1–59.3)
and HIC (34%, 95% CI 20.1–51.1).
Discussion
Prevalence of dysmenorrhea, regardless of the economic
status of the country, was high, with more than two-thirds
(70.8%) of young women reporting the presence of dys-
menorrhea, regardless of geographical location. The LMIC
subgroup included countries such as Sri Lanka, Nigeria, and
7
India, where menstrual taboos are more prevalent58–60 and,
therefore, reporting rates on menstruation and related issues
is expected to be lower due to stigma, shame, or misinfor-
mation. However, despite these expected differences in re-
porting, there was no difference in overall prevalence rates
between HIC and LMIC. This suggests that strategies to as-
sist young women in managing dysmenorrhea are as impor-
tant in HIC as in LMIC.
Most studies did not provide the definition they used for
dysmenorrhea, and this is likely to, at least in part, explain the
varying rates of dysmenorrhea between surveys.14,61 A
common theme regardless of geographic areas or cul-
tures16,62 is that most young women think period pain is a
normal part of becoming a woman.63 Additionally many
young women were unable to identify the symptoms of
dysmenorrhea.28 Therefore, given the normalization of pain
by young women, surveys that did not provide a definition of
what constitutes dysmenorrhea (e.g., pain in the lower ab-
domen just before or during menstrual bleeding) may have
resulted in an underestimate of the prevalence of dysmen-
orrhea in this meta-analysis. This is due to potential
 8 ARMOUR ET AL.
misunderstandings of how much pain is ‘‘normal’’ and,
therefore, not worth reporting.
The severity of menstrual pain was not consistently re-
ported, with only three articles reporting dysmenorrhea
scores via a VAS or NRS, with the remainder using ‘‘mild,
moderate, severe’’ or some variation thereof. This classifi-
cation system is not unusual as clinicians tend to use a scale
of mild, moderate, or severe depending on how daily living
is impacted,64 and there are prespecified scales using this
criterion.65 However, the definition of pain scores that were
classified into these three groups was not consistently ap-
plied and this prevented meaningful comparisons be-
tween studies. Reporting of secondary symptoms was more
consistent, and very common, with almost half (48.3%) of
young women reporting secondary symptoms. Future
studies should endeavor to use a standard self-report scale
such as a VAS or NRS for pain to allow comparison between
populations.
The impact of menstrual symptoms on education was
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significant, with around one in five young women (20%)
being absent and 40% reporting that classroom performance
(such as concentration levels or test-taking abilities) had been
negatively affected. This illustrates that girls and young
women may be significantly disadvantaged in their studies by
the impact of dysmenorrhea. Hillen et al. succinctly sum up
the possible impact of these academic restrictions on young
women, stating that ‘‘School attendance and ability to
concentrate on studies in Grades 11 and 12 are vital, as
achievement in these high school years has significant long-
term consequences for an individual.’’17 Our subgroup
analysis suggests that this negative impact starts at school and
continues relatively unchanged when young women progress
to university/tertiary education. Previous systematic reviews
on dysmenorrhea have suggested that as women age, the
prevalence of dysmenorrhea decreases,15,66 Latthe et al.
found dysmenorrhea prevalence decreased with age, but in
their review the subgroup analysis was age >30 years com-
pared with age <30 years.15 Our findings do not support any
significant reduction in prevalence with increasing age in this
younger population, where the majority of women were <25
years. It is also important to note that the severity of dys-
menorrhea does not appear to reduce significantly over time,
even after age 25 years,67 and a significant proportion of
women with severe dysmenorrhea may go on to develop
more persistent pelvic pain symptoms.68
These findings also have implications for teachers, cur-
riculum, and pedagogy. Teachers, particularly health edu-
cators, need to have knowledge about dysmenorrhea to be
able to educate young women about the condition and pro-
vide appropriate suggestions for material and emotional
support. Although apparent in the syllabus, teachers may or
may not address the topic adequately or, in some instances, at
all. As Duffy et al. found, teachers, particularly in primary
school education, demonstrate little confidence in teaching
about ‘‘sensitive’’ topics, including menstruation.69 Dysme-
norrhea is, therefore, likely to be omitted from classrooms,
disadvantaging the young women who experience the con-
dition and reinforcing its invisibility in learning contexts.
Thus, awareness needs to be raised in teacher education
courses and professional learning provided for current
teachers. Greater explicitness is required within school cur-
riculum documentation to increase awareness and ensure the
topic is adequately addressed. In addition, enhancing teacher
awareness generally may have implications for pedagogy;
that is, teachers need to provide young women who have
missed lessons or who have poorly absorbed information due
to the symptoms of dysmenorrhea, opportunities for addi-
tional pedagogical support. Even simple accommodations
such as allowing more time during tests or extensions on the
submission dates of tasks may be useful and contribute to a
more equitable learning environment.
Other activities either directly school-related (such as
sports) or social activities were also commonly affected in
around a third of young women. Although there was no
significant difference between absenteeism in LMIC and
HIC, the trend toward greater absenteeism in LMIC found in
the data may reflect the possibility that women in LMIC
could be missing school not necessarily due to pain alone, but
rather due to lack of sanitary products needed for menstrual
management.10 Once again, schools could provide support
through on-going and targeted programs to provide sanitary
products and information on effective pain management
options such as ibuprofen or other nonsteroidal anti-
inflammatory drugs (NSAIDs),9,70 and, where appropriate,
NSAIDs could be dispensed in line with school policy and
parental consent. This is especially important for disadvan-
taged young people to ensure that they have the means to
manage their period, and in doing so, continue to attend
school and avoid absenteeism on this basis.
There are a number of strengths in this systematic review
and meta-analysis. We searched for articles across a range of
databases and used dual data extraction via a prespecified
data extraction form to ensure rigorous data collection. De-
cisions on how to determine a country’s status used the four
tier World Bank system23 rather than the more simplified
‘‘developing’’ or ‘‘developed’’ bipartite classification. There
are a number of limitations that must be acknowledged. First,
we did not search in languages other than English, so there
may be a number of non-English language articles that were
not included. Second, studies often did not provide the defi-
nition of dysmenorrhea that they used in the study, so there
may be variations between studies in what is classified as
dysmenorrhea. Third, the majority of studies did not report
the recall period of the survey, if questions were related to
experiencing dysmenorrhea at any time since menarche or if
this was during a defined time period (e.g., in the past 6
months). Therefore, although we can be confident in the
overall prevalence, we cannot be certain how frequently
young women experience those dysmenorrhea symptoms,
and this may over or underestimate the impact depending on
how long the time period was. Fourth, the educational impact
may be underestimated as women with severe pain may have
dropped out of school or tertiary education and not been
included in surveys undertaken in those locations, so al-
though there were a number of community-based surveys that
did ask about academic impact, it is possible that the overall
academic impact may be more severe than reported. Fifth,
secondary symptoms for dysmenorrhea are wide ranging and
only a selection of the more common symptoms was included
in this meta-analysis. This may not represent all the comorbid
symptoms experienced by these girls—for example, men-
strual headache, the stabbing pains consistent with pelvic
muscle dysfunction, or bowel symptoms. Further studies
could include assessment of a wider range of symptoms to
 IMPACT OF DYSMENORRHEA ON YOUNG WOMEN
ensure even better relevance to girls’ needs. Finally, the
quality of the studies tended to be low, with a lack of clear
inclusion criteria and measures that were susceptible to self-
report bias.
Conclusions
The prevalence of dysmenorrhea among young women is
consistently high and unrelated to the economic status of their
country. The consequences are that a significant number of
young women regularly miss school or university or, if
present, have their academic performance impaired. Con-
sidering the timing of this impact, it is crucial that the neg-
ative influence of dysmenorrhea is reduced as much as
possible. Future research should focus on strategies to im-
prove pain and symptom management with the aim of re-
ducing the impact of dysmenorrhea so that young women can
optimize their educational opportunities and future life
chances.
Downloaded by Lund University from www.liebertpub.com at 07/21/19. For personal use only.
Acknowledgments
Thummini Jayasinghe (T.J.) and Zelalem Mengesha are
thanked for helping with the search strategies.
Author Disclosure Statement
M.A., K.P., and C.A.S.: As a medical research institute,
NICM Health Research Institute receives research grants and
donations from foundations, universities, government agen-
cies and industry. Sponsors and donors provide untied and
tied funding for work to advance the vision and mission of the
institute. This study was not specifically supported by donor
or sponsor funding to NICM. All other authors have no
competing financial interests exist.
Supplementary Material
Supplementary Data
Supplementary Table S1
Supplementary Table S2
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Address correspondence to:
Mike Armour, PhD
NICM Health Research Institute
Western Sydney University
Locked Bag 1797
Penrith, NSW 2751
Australia
E-mail: m.armour@westernsydney.edu.au