Middle East Fertility Society Journal (2015) 20, 198–203

Middle East Fertility Society

Middle East Fertility Society Journal

www.mefsjournal.org
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ORIGINAL ARTICLE

Menstrual disorders among Zagazig University

Students, Zagazig, Egypt
Ahmed M. Nooh *

Obstetrics & Gynaecology Department, Zagazig University Students’ Hospital, Zagazig, Egypt

Received 27 May 2014; revised 15 August 2014; accepted 21 August 2014

Available online 25 October 2014

KEYWORDS Abstract Objective: To determine the nature and prevalence of menstrual disorders among the
Menarche; young female students at Zagazig University, Zagazig, Egypt.
Menstruation; Study design: A questionnaire covering items on adolescents’ demographic data and menstrua-
Adolescent; tion characteristics was used for information collection.
Amenorrhoea; Results: A total of 283 questionnaires were analysed. The mean age at menarche was
Dysmenorrhoea 12.1 ± 1.6 years with a range of 11–16 years. Oligomenorrhoea was reported by 17 girls (6.0%)
while 6 others (2.1%) mentioned having polymenorrhoea. Hypomenorrhoea was noted in 20 stu-
dents (7.1%), while hypermenorrhoea was reported by 15 (5.3%). Irregular periods were mentioned
by 22 girls (7.8%). Dysmenorrhoea was reported in 185 students (65.4%). Out of these, 79 (27.9%)
graded their pain as mild, 66 (23.3%) as moderate and 40 (14.1%) as severe. PMS was mentioned by
158 students (55.8%). Consulting somebody regarding their menstrual problems was reported by 32
students (11.3%).
Conclusion: The results of this study are comparable to those in other parts of the world. Ado-
lescents should be encouraged to chart their menstrual periods from menarche onwards in order to
focus their attention on when and how to seek medical advice. Health education on menstrual dis-
orders targeting adolescents and including education on reproductive health in the school/university
curriculum may assist in early detection of these disorders.
Ó 2014 Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society.

1. Introduction

Menstrual disorders are not uncommon among adolescents

* Address: 4 Maes Watford, Caerphilly CF83 1LP, South Wales, UK.
Tel.: +44 (0) 2920 026568.
E-mail address: ahmednoohuk@yahoo.co.uk.
Peer review under responsibility of Middle East Fertility Society.
Production and hosting by Elsevier
http://dx.doi.org/10.1016/j.mefs.2014.08.002
1110-5690 Ó 2014 Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society.
and young adult women (1–3). These disorders can adversely
affect the quality of the adolescents’ lives and, therefore, are
often the source of anxiety for them and their families (4,5).
In addition to the recognised health problems, there can also
be consequences such as limitations on attendance at work
and academic performance which hinder practical achieve-
ments and employment prospects. Early diagnosis and manage-
ment of these disorders will not only improve a young woman’s
Menstrual disorders among Zagazig University Students
current health, sense of well-being and overall quality of life but
may also lower her risks for future disease and ill-health (6,7).
Erroneously, menstrual disorders and the private nature of
the data related to menstruation are generally perceived as
only minor health concerns and thus irrelevant to the public
health agenda, particularly for women in developing countries
who may face life-threatening conditions (8,9). It is suggested
that menstrual disorders may be as common in developing
countries as they are in developed countries, and that when
services are available, this will prompt women in developing
countries to seek care for them (10).
There is a lack of information about the knowledge and
attitude of adolescents regarding menstruation. Many girls
have little or no information about normal and abnormal men-
struation (11). Houston et al. reported that twice as many Afri-
can–American adolescents felt unprepared and did not receive
information about menarche when compared with Caucasian
teens (7). Most of what girls know about menstruation is often
information obtained from their mothers and their peers. Girls
are interested in knowing more about normal and abnormal
menstruation. Equipped with this sort of information, they
could make correct decisions on when to seek medical advice.
Population-specific reference data are useful to establish
what is normal and acceptable, and what is not. Few popula-
tion studies have been conducted in Egypt on normal and dys-
functional menstruation. Knowledge of their variability is
needed for patient education purposes and also to guide clini-
cians’ management of these disorders (5).
The purpose of this study was to determine the nature and
prevalence of menstrual disorders among young female stu-
dents at Zagazig University, Zagazig, Egypt.
2. Materials and methods
This was an observational study of a sample of newly-enrolled
female students at Zagazig University, Zagazig, Egypt for the
academic year 2013–2014.
2.1. Sample size
For the academic year 2013–2014, a total of 17,167 new stu-
dents were enrolled at Zagazig University. Of these, 9986 were
females. Using Epi-info, version 6 and based on a prevalence
of menstrual disorders of 25% and with 95% confidence inter-
val (95% CI) and 5% error, the minimum sample size was esti-
mated as 280. However, allowing for non-respondents and
exclusions for various reasons, the aim was to recruit 308.
2.2. Statistical analysis
Data were analysed using SPSS, version 20 (SPSS Inc, Chi-
cago). Frequencies and percentages were presented as
mean ± standard deviation (±SD). The chi-squared (v2) test,
F-test (analysis of variance – ANOVA), odds ratio (OR) and
95% CI were used where appropriate. P < 0.05 was consid-
ered to show a statistical significance.
2.3. Data collection
A random sample of female students attending the university
pre-enrolment medical examination at Zagazig University
199
Students’ Hospital, Zagazig, Egypt agreed to participate in
the study. A purpose-designed questionnaire was filled anony-
mously. Ethical approval was obtained from the local institu-
tional ethical committee, and students gave their verbal consent.
The objectives of the study were explained to the partici-
pants. It was emphasized that all data collected would be
strictly confidential. For every participant, the questionnaire
was distributed and collected on the same day to ensure confi-
dentiality and prevent information contamination.
The questionnaire covered information about the following
demographic and clinical data: age, age at menarche, body
mass index (BMI), marital status, place of residence, presence
of pregnancy and breastfeeding (to rule out the cause of
amenorrhoea, if present) and physical exercise.
The participants were then asked about the characteristics of
their menstruation: the cycle length (<21, 21–35, >35 days or
irregular), duration of menses (<3, 3–7 or >7 days), amount of
blood loss as reflected by the number of vulval pads/sanitary
towels changed per day during menstruation (61, 2–4 or P5).
Pain during menstruation (dysmenorrhoea) was assessed by
the verbal multidimensional scoring system (12). This system
grades pain as none, mild, moderate or severe. It also takes into
account the effect on daily activity, symptoms perception and
the need for analgesia. The respondents were then questioned
about symptoms of pre-menstrual syndrome (PMS), and
whether they consulted any physician, pharmacist, nurse, rela-
tive or friend regarding their menstrual problems.
For the purpose of this study, menstrual disorders are
defined as follows: secondary amenorrhoea: no period for
P3 months, oligomenorrhoea: cycle repeated once every
>35 days but <3 months, polymenorrhoea: cycle repeated
once every <21 days, hypomenorrhoea: duration of menses
<3 days with slight blood loss (using 61 pad/day), hyperm-
enorrhoea/menorrhagia: duration of period >7 days and/or
blood loss P80 ml (using P5 pads/day). PMS is defined as
one or more of the following symptoms starting 10 days before
menstruation and disappearing at the start of period: rapid
mood changes, depression, painful or tender breasts and bloat-
ing or swelling of the abdomen.
3. Results
The questionnaires were distributed and collected over the per-
iod from 1st September to 13th October 2013. Out of 308 ques-
tionnaires distributed, 297 (96.4%) were returned. However,
14 questionnaires were excluded as they were either incom-
pletely or inappropriately filled. The remaining 283 question-
naires were thus analysed for the purpose of this study.
The participants generally belonged to middle class fami-
lies. Tables 1a and 1b show the demographic and clinical char-
acteristics for the sample as a whole. All the respondents were
single.
In this study, 207 participants (73.1%) had regular menses
since menarche, 54 (19.1%) reported having irregular periods
only during the first 6–12 months after menarche while only
22 (7.8%) continued to have irregular periods beyond the first
year after menarche.
Table 2 shows the relation between certain biological fac-
tors (age at menarche, duration of menses and menstrual cycle
length) and severity of dysmenorrhoea, Table 3 shows the rela-
tion between BMI and both of dysmenorrhoea and PMS and
200 A.M. Nooh

seldom inhibited their normal activity and analgesics were

Table 1a Demographic and clinical data.
seldom required, 66 cases (23.3%) felt the pain as moderate,
Mean Range daily activity was affected, analgesics were required which gave
Age (years) 17.8 ± 0.7 17–19 relief so that absence from classes was unusual, while the
Age @ menarche (years) 12.1 ± 1.6 11–16 remaining 40 cases (14.1%) reported severe pain, activity
BMI (kg/m2) 23.4 ± 1.2 15.6–38.5 was clearly inhibited, poor effect of analgesics and systemic
BMI: Body mass index. symptoms, e.g., tiredness, headache, nausea, vomiting and
diarrhoea were present.
Table 4 shows the relation between physical activity and both
of dysmenorrhoea and PMS. 4. Discussion
Those who suffered dysmenorrhoea reported having lower
abdominal pain during menses that extended to the thighs. Timing of the onset of menstruation (menarche) is individual-
Dysmenorrhoea was reported in 185 students (65.4%). Of specific, within a broad range of normality (13). The mean age
these, 79 cases (27.9%) described their pain as mild which at menarche varies from population to population and is

Table 1b Demographic and clinical data.

No %
Residency
With family 258 91.2
@ University campus 25 8.8
Physical activity
Athlete 18 6.4
Active 236 83.4
Sedentary 29 10.2
Menstrual cycle length (days)
<21 6 2.1
21–35 237 83.7
>35 to <90 17 6.0
Irregular menstrual pattern 22 7.8
Duration of menses (days)
<3 20 7.1
3–7 248 87.6
>7 15 5.3
Number of vulval pads changed per day
61 27 9.5
2–4 245 86.6
P5 11 3.9
Dysmenorrhoea
Grade 0 (absent) 98 34.6
Grade 1 (mild) 79 27.9
Grade 2 (moderate) 66 23.3
Grade 3 (severe) 40 14.1
PMS
Absent 125 44.2
Present Not interfering with activity and not using medicines 96 33.9
Interfering with activity and/or using medicines 62 21.9
Advice-seeking 32 11.3

Table 2 Relation between certain biological factors and severity of dysmenorrhoea.

Dysmenorrhoea F test P value
Grade 0 Grade 1 Grade 2 Grade 3
No Mean ± SD No Mean ± SD No Mean ± SD No Mean ± SD
Age at menarche 98 13.1 ± 1.4 79 12.9 ± 1.3 66 12.8 ± 1.1 40 12.3 ± 1.2 3.78 <0.05
Duration of menses 98 4.9 ± 1.3 79 5.1 ± 1.2 66 5.6 ± 0.9 40 5.7 ± 1.5 6.67 <0.01
Menstrual cycle length 98 27.9 + 4.3 79 28.5 + 1.3 66 28.9 + 1.5 40 28.3 + 2.3 1.73 0.16
F-test is used in analysis of variance (ANOVA).
Menstrual disorders among Zagazig University Students
Table 3 Relation between BMI and both of dysmenorrhoea and PMS [Data are expressed as numbers (%)].
Obese Over weight
(BMI P 30) (BMI 25–29,99)
(n = 17) (n = 104)
Dysmenorrhoea (n = 185) 10 (58.8%) 67 (64.4%)
PMS (n = 158) 12 (70.6%) 69 (66.3%)
BMI: Body mass index.
PMS: Pre-menstrual syndrome.
v2: The chi-squared test.
Table 4 Relation between physical activity and both of dysmenorrhoea and PMS [Data are expressed as numbers (%)].
Athletes and Physically active (n = 254)
Dysmenorrhoea (n = 185) 164 (64.6%)
PMS (n = 158) 148 (58.3)
PMS: Pre-menstrual syndrome; CI: Confidence interval; OR: Odds ratio.
known to be a sensitive indicator of various characteristics
including nutritional status, geographical location, environ-
mental conditions and magnitude of socioeconomic inequali-
ties in a society (13–15). Menarche tends to appear earlier in
life as the living standards of a society improve, e.g. adequate
nutrition and improved health care (3,14,16).
In this study, the mean age at menarche was
12.1 ± 1.6 years with a range of 11–16 years. Age at menarche
in our study was reported as completed years and, therefore,
data might have not been very precise.
In Western European countries, the average age at menar-
che appears to have dropped over the past 150 years from over
16 to under 14 years. In the UK, girls enter puberty around the
age of 10 years with a median age at menarche of 12.9 years
(17). In Italy, the mean age at menarche was estimated at
12.4 ± 1.3 years (16,18).
North American adolescents also show trends towards
early menarche with mean age in black American girls ranging
from 12.06 to 12.16 years and that of white American girls
ranging from 12.55 to 12.88 years with 90% of adolescent girls
having attained their menarche by 13.75 years (15).
However, Zegeye et al. in a study from northwest Ethiopia
reported a delayed age at menarche by both probit analysis
(14.8 years) and recall method (15.8 years), and Padez, report-
ing from Mozambique, noted the figure of 13.9 ± 1.29 years
(19,20).
Early menarche with risky sexual behaviour in early adoles-
cent years may lead to transmission of sexually transmitted
diseases, unwanted pregnancy and its illegal hazardous termi-
nation as well as adolescent motherhood; all of which adversely
affect the reproductive health of adolescent females (21).
In this study, the menstrual cycle length ranged between 21
and 35 days in 237 students (83.7%) and menses lasted for 3–
7 days in 248 participants (87.6%).
Gumanga and Kwame-Aryee, reported that the menstrual
cycle length for 86.1% of the girls ranged from 21 to 35 days
and the mean length of the menstrual cycle was
27.9 ± 0.9 days with the median and mode being 28 days
(21). Similar results were reported by Zegeye et al. (19).
In a study where 368 menstrual periods were analysed,
Dewhurst et al. reported that menses lasted between 3 and
201
Normal weight Under weight v2 value P value
(BMI 18–24,99) (BMI < 18)
(n = 127) (n = 35)
88 (69.3%) 20 (57.1%) 2.27 0.51
70 (55.1%) 7 (20.0%) 24.41 <0.001
Sedentary (n = 29) OR (95% CI of the difference) P value
21 (72.4%) 1.44 (0.58–3.7) 0.40
10 (34.5%) 2.65 (1.12–6.41) 0.01
7 days in 88% of the cycles, with an average duration of 5 days
(22). Similar results were reported by Gumanga and Kwame-
Aryee, and Zegeye et al. (19,21).
This study showed that 207 participants (73.1%) had regu-
lar menses since menarche, 54 (19.1%) reported having irregu-
lar periods only during the first 6–12 months after menarche
while only 22 (7.8%) continued to have irregular periods
beyond the first year after menarche.
With the exception of Karout et al., who reported the prev-
alence of irregular menstruation in 59.4% of their participants,
the average incidence of irregular menses was noted to be 5–
24% beyond the first 6–12 months after menarche
(9,16,21,23,24).
Irregular menstruation is a factor that increases the rate of
emotional and psychological stresses (25). It has also been
associated with increases in the rate of coronary heart disease
and type II diabetes mellitus (26).
In this study, 11 girls (3.9%) reported that they used to
change P5 vulval pads/sanitary towels per day during their
periods and sometimes they passed clots.
Attempts to measure the amount of menstrual blood loss
on the basis of number of vulval pads used per day or fre-
quency of changing them are not accurate because of varia-
tions in quality of sanitation product used, individual
fastidiousness and individual estimation of volume of men-
strual flow (19).
During a normal menstrual cycle the amount of blood loss
ranges between 30 and <80 ml with the first 2 days being the
heaviest (23). Heavy menstrual flow was found in 1% and 4%
of the students as reported by Esimai and Esan, and Walraven
et al., respectively (8,24).
Menorrhagia may put women at risk of anaemia (6,27). It
also can result in poor menstrual hygiene and increased risk
of infection since many young girls may not be able to afford
costly sanitary pads to take care of the extra days especially
when they are on campus. They may resort to the use of toilet
paper, cotton and old clothes or rugs (21).
It is important to remember that prolonged cycles and
heavy menstruation warrant attention when these conditions
are associated with anovulation, hirsutism or moderate/severe
acne (28,29). Coagulopathies in up to 20% of cases have been
202
reported in female teenagers with menorrhagia; the most com-
mon being von Willebrand disease, which occurs in as many as
15% of women (30).
In this study, 185 students (65.4%) reported suffering from
dysmenorrhoea. Out of these, 79 girls (27.9%) graded their
pain as mild, 66 (23.3%) as moderate and 40 (14.1%) as severe.
The prevalence of dysmenorrhoea varies widely between
different populations and between different age groups within
the same population. Such variation may be due to different
aetiologies, cultural differences in pain perception and vari-
ability in pain threshold (23). Prevalence rates between 51%
and 78% have been reported (3,16,19,21,23,29,31).
Banikarim et al. reported that dysmenorrhoea was the lead-
ing cause of short-term school absenteeism in 48.8% of the suf-
fering adolescents who reported to be absent from school
merely due to pain (32). This figure matches well with the fig-
ure of 34–50% reported by other researchers (4,31,33).
This study showed a statistically significant association
between the age at menarche and dysmenorrhoea (p < 0.05),
and a highly significant statistical association between duration
of menses and dysmenorrhoea (p < 0.01). Early menarche was
related to an increase in the severity of dysmenorrhoea. Also,
the severity of dysmenorrhoea increased with increasing dura-
tion of menstruation. However, this study failed to show a sta-
tistically significant association between menstrual cycle length
and dysmenorrhoea (p = 0.16). This is in agreement with
Andersch and Milsom (12).
No statistically significant association was shown in this
study between BMI and dysmenorrhoea (p = 0.51). This is
in agreement with Andersch and Milsom, and Anandha
Lakshmi et al. (12,31). Also, no statistically significant associ-
ation was shown between physical activity and dysmenorrhoea
(p = 0.40). This is in agreement with Anandha Lakshmi et al.
(31).
Despite the fact that dysmenorrhoea in adolescents is usu-
ally primary, there is evidence that in approximately 10% of
subjects with severe dysmenorrhoea, pelvic or uterine anoma-
lies may be found (16). Dysmenorrhoea may present as dyspa-
reunia or pain of bladder or bowel origin suggesting the
presence of endometriosis (3,23,34).
This study showed that 158 students (55.8%) reported suf-
fering from one or more of the manifestations of PMS.
The incidence of PMS varies among different populations
and figures between 54.0% and 99.6% have been reported
(19,23,31).
The increase in BMI was shown in this study to have a
highly significant association with PMS (p < 0.001). This
study also showed a highly significant association between
physical activity and PMS (p = 0.01). This is in agreement
with Anandha Lakshmi et al. (31).
Karout et al. stated that there was a significant association
between being resident in a dormitory away from the family
and the development of PMS (23). However, our study failed
to show this relation as the participating students who lived
on the university campus have done so only for a few days
prior to the start of this study.
Various socio-biological and psychological causes for PMS
have been proposed including altered endorphin modulation
of gonadotrophin secretion, abnormal serotonin function,
altered trans-capillary fluid balance, a diet rich in beef or caf-
feine-containing beverages, exercise habits, smoking and alco-
hol consumption (35).
A.M. Nooh
In this study, 17 girls (6.0%) reported having oligomenor-
rhoea. However, figures of 3.4% and 25.2% have been
reported by Rigon et al., and Karout et al., respectively
(16,23).
Six students (2.1%) in this study reported having polym-
enorrhoea. This matches very well with the figure of 3.0%
reported by Rigon et al. (16). In contrast, Karout et al.,
reported an incidence of polymenorrhoea of 51.4% among
the nursing university students in Lebanon (23),
In this study, 32 students (11.3%) mentioned that they con-
sulted a physician, pharmacist, mother, sister or a friend
regarding their menstrual problems.
Mothers were found as potential sources of information
regarding the adolescents’ menstrual problems in urban
females whereas school teachers played that role for rural girls
(19,36).
Some limitations of this study need to be addressed. It was
cross-sectional in design and the self-reported information
about the participants’ menstruation could not be validated.
However, the relatively large size of the study sample was
probably enough to enable a robust analysis of the menstrual
disorders identified. Another limitation lies in that no informa-
tion was obtained on treatment of any menstrual disorder.
5. Conclusion
To the best of the author’s knowledge, this is one of the
largest studies on menstrual patterns and disorders among
the Egyptian university students. The results of this study
are comparable to those in other parts of the world.
Teenagers whose menstrual cycles are consistently outside
the normal range should be assessed for pathological
conditions. Adolescents should be encouraged to chart their
menstrual periods from menarche onwards in order to focus
their attention on when and how to seek medical advice.
Health education on menstrual disorders targeting adoles-
cents and including education on reproductive health in
the school/university curriculum may assist in early detection
of these disorders.
Contribution to authorship
AMN alone was involved in concept and design of the study,
recruitment of the participants, supervising and participating
in the conduct of the study as well as writing and revising
the manuscript.
Conflict of interest
The author declares that he has no conflict of interest.
Funding
None declared.
Acknowledgement
The author would like to thank the nursing staff at the Zagazig
University Students’ Hospital, Zagazig, Egypt for their
contribution to collection of the data of this study.
Menstrual disorders among Zagazig University Students
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