Gynecological Endocrinology

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Numerical rating scale for dysmenorrhea-related

pain: a clinimetric study

Guilherme Tavares de Arruda, Patricia Driusso, Jéssica Cordeiro Rodrigues,

Amanda Garcia de Godoy & Mariana Arias Avila

To cite this article: Guilherme Tavares de Arruda, Patricia Driusso, Jéssica Cordeiro
Rodrigues, Amanda Garcia de Godoy & Mariana Arias Avila (2022) Numerical rating scale for
dysmenorrhea-related pain: a clinimetric study, Gynecological Endocrinology, 38:8, 661-665,
DOI: 10.1080/09513590.2022.2099831

To link to this article: https://doi.org/10.1080/09513590.2022.2099831

Published online: 19 Jul 2022.

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Gynecological Endocrinology
2022, VOL. 38, NO. 8, 661–665
https://doi.org/10.1080/09513590.2022.2099831

RESEARCH ARTICLE
DYSMENORRHEA

Numerical rating scale for dysmenorrhea-related pain: a clinimetric study

Guilherme Tavares de Arrudaa , Patricia Driussoa , Jéssica Cordeiro Rodriguesb , Amanda Garcia
de Godoya and Mariana Arias Avilaa
a
Study Group on Chronic Pain (NEDoC), Physical Therapy Post-Graduate Program and Physical Therapy Department, UFSCar, São Carlos, Brazil;
b
Laboratory of Research on Women’s Health (LAMU), Physical Therapy Post-graduate Program and Physical Therapy Department, UFSCar, São
Carlos, SP, Brazil

ARTICLE HISTORY
ABSTRACT Received 5 April 2022
Revised 19 June 2022
Objective: To evaluate the numerical rating scale (NRS) measurement properties in women with
Accepted 4 July 2022
dysmenorrhea. Methods: This was an online clinimetric study. Brazilian women aged over 18 years old Published online 19 July
with internet access to respond to online instruments were included in the study. We evaluated criterion 2022
validity (comparing women with and without dysmenorrhea), construct validity between the NRS and
the bodily pain domain of the SF-36, test-retest reliability, and measurement errors (in women with KEYWORDS
dysmenorrhea). Results: Two hundred thirty-eight women with and 192 without dysmenorrhea participated Dysmenorrhea; women’s
health; chronic pain;
in the study. For criterion validity, the area under the receiver operating characteristic curve was 0.902 validation study;
(95%CI, 0.873–0.931), and a cutoff point of 3 was considered to have the best sensitivity (83%) and measurement properties
specificity (86%). For construct validity, the NRS showed a moderate negative correlation with the SF-36
bodily pain domain (r=-0.46; p < 0.001). For test-retest reliability and measurement errors, 105 women
whose symptoms did not change between 7 and 10 days of retest, with intraclass correlation coefficient
= 0.90, standard error of measurement = 0.97, and smallest detectable change = 2.76 points. Conclusions:
The NRS can be considered a valid and reliable patient-reported outcome measure for assessing
dysmenorrhea-related pain intensity.

Introduction
Dysmenorrhea is a gynecological condition defined as menstrual
pain of uterine origin that is most common in women of repro-
ductive age [1]. Unlike secondary dysmenorrhea, in which pain
is associated with pelvic conditions such as endometriosis and
fibroids, primary dysmenorrhea (PD) is believed to be caused
by the increased release of prostaglandins during endometrial
shedding, leading to muscle ischemia and uterine hypoxia [2].
The worldwide prevalence of dysmenorrhea ranges from 10% to
91.5% [2,3]. In addition to pain, other associated symptoms of
dysmenorrhea are fatigue, mood swings, insomnia, nausea, and
headaches [2]. Depending on pain intensity, women with dys-
menorrhea may have limited physical and social activities [4],
absenteeism/presenteeism at school/work [2,3], and a decreased
quality of life [5]. Dysmenorrhea is also an economic problem:
treatment costs are considerable – about $4,053.00 with comple-
mentary and alternative medicine interventions per year [6] – and
pain can interfere with a woman’s work productivity [2,6].
Pain is usually the main clinical complaint of women with
dysmenorrhea [7]. The assessment of pain intensity, defined as
‘how much a patient hurts, reflecting the overall magnitude of
the pain experience’ [8], is essential to understand the impact
a disease may cause [9] as well as to observe the effect of a
treatment on pain relief [10]. Patient-reported outcome measures
(PROMs) are recommended in clinical practice and clinical trials
because they reflect the patients’ perception of their symptoms,
functional status, and health-related quality of life [10]. The
most used PROM to assess pain intensity is the numerical rating
scale (NRS) [11].
The NRS is a single-item generic measure that assesses the
intensity of some health condition on a scale from zero to
10. In pain studies, the NRS is relevant to assess pain intensity,
where zero usually represents ‘no pain’ and 10 ‘the worst
imaginable pain’. Because it is an one-dimensional item, the
administration of the NRS is quick, easy to understand [7],
and can be useful for comparing pain intensity with other
multidimensional instruments for different health conditions,
such as low back pain [12], neck pain [13], and knee osteo-
arthritis [14].
Although the relevance of NRS in the assessment of pain
intensity in research and clinical practice has been recognized,
the measurement properties of this PROM have not been eval-
uated in women with dysmenorrhea. This can help researchers
and clinicians to better assess the presence and intensity of
dysmenorrhea using a scale that is quick, simple, valid and
reliable. In addition, the use of high-quality evidence PROMs
for measurement properties should be encouraged for valid and
reliable measurements [15]. Unlike the Visual Analogue Scale
(VAS), the NRS is better understood by the patients because it
is only necessary to mark a visible number from zero to 10
[16], and it can be used on any online platform like Google
Forms as it is only necessary to mark numbers. Therefore, this
study aimed to evaluate the measurement properties of the NRS
in women with dysmenorrhea.

CONTACT Mariana Arias Avila m.avila@ufscar.br Physical Study Group on Chronic Pain (NEDoC) Therapy Post-Graduate Program and Physical Therapy
Department, Universidade Federal de São Carlos, Rodovia Washington Luís, Km 235, São Carlos 13565-905, SP, Brazil.
© 2022 Informa UK Limited, trading as Taylor & Francis Group
662 G. T. DE ARRUDA ET AL.
Materials and methods
Study design and population
This online clinimetric study was conducted in accordance with
the Declaration of Helsinki and was approved by the Institutional
Ethics Committee (CAAE 30232920.3.0000.5504), following the
COnsensus-based Standards for the selection of health Measurement
INstruments (COSMIN) checklist [15]. The study was disclosed
on social media apps (Facebook, Instagram, WhatsApp), and
women willing to take part in the study contacted the researchers
and received a link to an online Google Form.
Women over 18 years old, able to read and write in Brazilian
Portuguese, and with internet access to respond to online instru-
ments were included in the study. Postmenopausal women, preg-
nant women, those within 12 months after postpartum period,
those with pelvic infection, and those who had not menstruated
in the previous 3 months were excluded from the study. The
data were collected between August 2020 and August 2021.
After reading the consent form on Google Forms, women
interested in participating in the study clicked on ‘I declare that
I have read the terms above, understood it, and I agree to
participate in the research’. Women who agreed to participate
were asked to indicate the initial day of their next menstruation
so that researchers could contact them for the first assessment
between days 6 and 9 (we assumed there was less chance that
the woman was experiencing dysmenorrhea-related pain during
this period) of the menstrual cycle. For the second assessment,
researchers contacted all the participants who responded to the
first assessment seven to ten days later, which is a good retest
time according to the COSMIN [15], and there was a very little
chance that women would have menstruated in this time interval.
Along with the NRS, participants also responded the 7-points
Global Rating of Change Scale (GRCS): ‘Regarding your period
pain, how would you describe it now compared to when it
started?’ with answers from ‘a very great deal better’ to ‘a very
great deal worse’ [17]; we considered variations of up to 2 points
to consider that women’s symptoms did not change [18].
Instruments and data collection
Numerical rating scale
The NRS is a single-item 11-point scale used to assess menstrual
pain intensity; zero was considered the absence of pain, while
10, the worst pain imaginable. Participants were instructed to
use a single number that better defined their menstrual pain
during the current menstrual cycle in the test and retest analysis
for the question ‘In relation to your last menstrual period, how
would you rate your pain intensity?’. The NRS has a strong
correlation (r = 0.96) [19] and agreement (97.9%) [11] with the
VAS score in women with dysmenorrhea.
Medical Outcomes Short-Form Health Survey – bodily pain
domain
The Medical Outcomes Short-Form Health Survey (SF-36) is a
multidimensional questionnaire that evaluates 8 different
domains: physical functioning, role limitations due to physical
health, emotional problems, energy/fatigue, emotional well-being,
social functioning, bodily pain and general health. For the pres-
ent study, we used the bodily pain domain to assess the impact
of bodily pain on health-related quality of life, with scores from
0 to 100, with 0 indicating the worst impact of pain on quality
of life and 100 indicating no impact of pain on quality of life.
The Brazilian version of the SF-36, specifically the bodily pain
domain, has shown satisfactory intra-rater (r = 0.542) and
inter-rater (r = 0.554) reliabilities [20].
Statistical analysis
Women with and without dysmenorrhea were included in the
criterion validity analysis, and comparisons between groups were
performed using the Mann-Whitney U test and the chi-square
or Fisher’s exact test. For criterion validity, the degree to which
a PROM score is an adequate reflection of a ‘gold standard’
[15], the receiver operating characteristic (ROC) curve was cal-
culated between the presence of dysmenorrhea by self-report
(yes/no) and the NRS. The area under the ROC curve ≥0.8 was
considered to indicate excellent accuracy [21].
Test-retest reliability, measurement errors, and hypothesis testing
for construct validity were performed only in women with dys-
menorrhea. Construct validity is defined as the degree to which
the scores of a PROM are consistent with hypotheses, based on
the assumption that the PROM validly measures the construct to
be measured [15]. This measurement property was assessed using
Pearson’s correlation, with r ≥ 0.5 indicating strong correlation;
r = 0.3-0.49, moderate correlation; and r ≤ 0.29, weak correlation
[22]. We hypothesized that the NRS has a moderate negative
correlation (r > 0.3) with SF-36 – bodily pain, because higher scores
on the NRS indicate worse pain and higher scores on the SF-36
– bodily pain indicate less or no impact of pain on quality of life.
Test-retest reliability is defined as the degree to which the
scores for patients who have not changed are the same for
repeated measurements over time [15]. It was assessed using the
intraclass correlation coefficient (ICC) with a two-way mixed-effect
model with interaction for absolute agreement between mean
measures. ICC > 0.75 was considered acceptable reliability.
Standard error of the measurement (SEM) and smallest detectable
change (SDC) at the individual level were calculated while Bland
and Altman graphs were created for the measurement errors,
defined as the systematic and random error of a patient’s score
that is not attributed to real changes in the construct to be mea-
sured [15]. SEM was calculated with the formula [diferenceSD/√2],
with diferenceSD indicating the standard deviation (SD) of the dif-
ference between the test and retest scores of the NRS. The SDC
was calculated using [SEM*1.96*√2] [23]. The limits of agreement
(LoA) were calculated using the Bland and Altman graph with
[d- ± (1.96*diferenceSD)], where d is the average of the differences
between the test and retest of the NRS. All analyses were per-
formed using SPSS 22.0 (IBM, Armonk, NY, USA).
The calculation of sample power was based on the correlation
between NRS and the bodily pain domain in the G*Power 3.1.9.7
software. A two-tailed correlation was used (α = 0.05, rH0 = 0.3
is the expected correlation for the initial hypothesis, sample size
of 238 women with dysmenorrhea, and rH1 = 0.455 is the cor-
relation observed in this study). Thus, the sample power is
(1-β)=0.795 for construct validity.
Results
Figure 1 shows the study flowchart. Data from 430 women were
analyzed: 238 (55.4%) with and 192 (44.7%) without dysmen-
orrhea. The characteristics of the participants included in the
study are shown in Table 1. The mean age for women with and
without dysmenorrhea were 25.5 ± 5.6 and 26.0 ± 5.8 years, respec-
tively. Among women with dysmenorrhea, 223 (93.7%) had PD
 Gynecological Endocrinology 663

Figure 1. Flowchart of the study.

Table 1. Characteristics of the study participants.

Dysmenorrhea No dysmenorrhea
Characteristics (n = 238) (n = 192) p value
Age (years), mean ± SD 25.5 ± 5.6 26 ± 5.8 0.412
Education, n (%) 0.074
Graduate school/ 208 (87.4) 179 (93.2)
University
High School 27 (11.3) 13 (6.8)
 Elementary School 3 (1.3) 0
Marital status, n (%) 0.145
Single 168 (70.6) 146 (76)
Married 27 (11.3) 20 (10.4)
 Divorced 3 (1.3) 6 (3.1)
 Other 40 (16.8) 20 (10.4)
Number of pregnancies 0.3 ± 0.7 0.3 ± 0.7 0.697
Menarche (years), 11.8 ± 1.4 12.2 ± 1.4 0.146
mean ± SD
Hormonal contraceptive 0.042
use, n (%)
 Yes 139 (58.4) 93 (48.4)
 No 99 (41.6) 99 (51.6)
SD: Standard deviation. Statistically significant differences are in bold.

and 15 (6.3%) had secondary dysmenorrhea. The number of

women with dysmenorrhea using oral contraceptives (58.4%) is
significantly higher than women without dysmenorrhea (51.6%).
Criterion validity was assessed with the area under the ROC
curve, which was 0.90 (95%CI 0.87 − 0.93). A cutoff point of 3
Figure 2. ROC curve for NRS criterion validity with dysmenorrhea self-report.
was considered to have the best sensitivity (83%) and specificity
(86%). Thus, NRS score ≥ 3 best screens for dysmenorrhea
(Figure 2). For construct validity, NRS showed a significant, were 0.97 points and 2.76 points, respectively. The 95% CI for
moderate negative correlation with the SF-36 bodily pain domain the mean difference included 0 (-0.070 to 0.172), indicating
(r=-0.46; p < 0.001). that there was no significant systematic bias between the NRS
For test-retest reliability and measurement errors, 152 (61.5%) test-retest measures. The lower (-3) and upper (2.68) LoA are
women with dysmenorrhea answered the instruments between shown in the Bland and Altman graph illustrated in Figure 3.
7 and 10 days of retest. However, 105 (69.1%) were stable
according to the GRCS in this period. The mean intensities of
menstrual pain in the test and retest were 5.1 ± 2.5 points and Discussion
5.2 ± 2.4 points, respectively. For test-retest reliability, the ICC
was excellent (ICC = 0.903; 95%CI 0.858 − 0.934). For measure- This is the first study to assess the measurement properties of
ment errors, the mean difference (d-) between test and retest NRS for women with dysmenorrhea. The present results provide
was −0.16 points. The SEM and the SDC at the individual level evidence of the validity and reliability of NRS for the assessment
664 G. T. DE ARRUDA ET AL.
Figure 3. Bland and Altman graph of dysmenorrhea pain intensity between test
and retest.
of pain intensity due to dysmenorrhea in women. For criterion
validity, there is still no gold-standard method for the assessment
of dysmenorrhea, with patients’ self-reported data on dysmen-
orrhea symptoms still the most common method to diagnose
dysmenorrhea [24]. In the present study, we used dysmenorrhea
self-report data in the analysis of the ROC curve and found
excellent accuracy, high sensitivity, and specificity of the NRS
to discriminate women with and without dysmenorrhea. These
results suggest that NRS is an appropriate tool for differentiating
women with and without dysmenorrhea.
Regarding construct validity, our initial hypothesis between
the NRS and SF-36 – bodily pain was confirmed: NRS showed
a moderate negative correlation with the SF-36 – bodily pain
in women with dysmenorrhea, indicating strong construct, thus
suggesting that the NRS a good way to assess dysmenorrhea-related
pain. The correlation between NRS and SF-36 – bodily pain
was moderate because both measures assess similar constructs,
not identical ones. The SF-36 – bodily pain questionnaire mea-
sures the impact of bodily pain on quality of life. Although we
did not find any studies that compared NRS with SF-36 – bodily
pain for dysmenorrhea, there was one study that correlated the
NRS with the VAS. The results of that study showed a signif-
icant, strong positive correlation (r = 0.957 and rho = 0.995) of
NRS with VAS in the assessment of menstrual pain in 1,387
women [19]. The author suggests the use of NRS in epidemi-
ological studies because VAS is more difficult to understand [19].
Although other studies have evaluated the test-retest reliability
and measurement errors of the NRS for other health conditions
such as low back pain [12,25], neck pain [13], and osteoarthritis
knee pain [14], our study is the first to evaluate these measure-
ment properties for dysmenorrhea. The test-retest reliability of
the NRS for dysmenorrhea pain intensity was 0.903, indicating
that the measure has excellent reliability over time. The SEM for
women with dysmenorrhea was 0.97 points, which means that it
is possible that there is 68% confidence that the true NRS score
ranges from −0.97 to +0.97 points of the observed NRS value,
and 95% confidence that this true score lies is between −1.94 and
+1.94 (± 2 SEM) points of the observed score. The individual
SDC of the NRS was 2.76 points, indicating that a change of at
least 2.76 points in the NRS can be considered a true change in
pain intensity. Along with VAS, NRS is the single-item PROM
most frequently used to assess real-time pain intensity in various
health conditions. Thus, these PROMs do not have a memory
bias, and the response time is fast [26]. No significant systematic
errors were found in NRS measurements. These results are also
presented with the use of NRS in other health conditions such
as chronic pain [25,27] and endometriosis [26].
The present study shows that a PROM very used to assess
pain in other pain conditions [12–14] can also be used for
women with dysmenorrhea. In addition, this was the first study
to evaluate the NRS measurement properties for dysmenorrhea
in a large sample of women and we strictly followed the
COSMIN checklist to improve the quality of measurement prop-
erties. However, there are some limitations. First, although there
are no studies verifying the equivalence of the paper versus
electronic NRS administration methods for dysmenorrhea, in
low back pain, the electronic version of the NRS for pain showed
poor reliability with the paper NRS version, and both versions
should not be considered interchangeable in clinical practice
[28]. Second, the sample comprised women with internet access,
thus including only those with higher education/socioeconomic
levels. This can be considered a sample selection error as it does
not consider the sample of women with lower educational qual-
ifications. Therefore, we suggest that future studies should eval-
uate the reliability of paper versus electronic NRS administrations
for dysmenorrhea in samples with different characteristics.
The NRS can be considered a valid and reliable PROM for the
assessment of dysmenorrhea pain intensity. In the absence of val-
idated gold standards, the excellent values for validity and reliability
of the NRS obtained in this study indicate that this PROM may
be more useful for monitoring the intensity of dysmenorrhea pain,
facilitating better communication between patients and clinicians
regarding treatment response, and contributing to comparing the
outcomes of future studies on the pain of dysmenorrhea.
Acknowledgements
We thank the participants for their contribution to the study.
Conflicts of interest and source of funding
The authors declare no conflict of interest.
Data availability
Data from the present study will be made available at reasonable request.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This study was partially financed by Coordination for Improvement of Higher
Education Personnel (CAPES), Brazil, Finance Code 001 and by São Paulo
Research Foundation (process 2019/14672-7). The funders had no role in
study design, data collection and analysis, decision to publish, or preparation
of the manuscript.
ORCID
Guilherme Tavares de Arruda https://orcid.org/0000-0001-5994-3247
Patricia Driusso http://orcid.org/0000-0001-8067-9786

Jéssica Cordeiro Rodrigues https://orcid.org/0000-0003-4080-9771
Amanda Garcia de Godoy https://orcid.org/0000-0002-4422-9179
Mariana Arias Avila https://orcid.org/0000-0002-5081-5326
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