J Pediatr Adolesc Gynecol (2009) 22:365e371
Original Study
Questionnaire Study on Menstrual Disorders in Adolescent Girls
in Singapore
Anupriya Agarwal, MS, MRCOG and Annapoorna Venkat, DGO, MMed
Abstract. Study Objective: Adolescence, the transitional
phase of physical and mental development between child-
hood and adulthood, is characterized by immense hormonal
changes. Owing to the immaturity of the hypo-thalamo-
pituitary-ovarian axis, menstrual cycles tend to be rather
irregular. This variability poses a dilemma for physicians
treating these girls and may result in a delay in the diagno-
sis and treatment of underlying problems. The purpose of
this study was to collect data on the characteristics of men-
strual cycles in Singapore adolescents to determine the
prevalence of menstrual abnormalities and the pattern of
use of medical treatments for these abnormalities.
Design: Cross-sectional study using a self-administered,
27-point structured questionnaire.
Setting: Sixty-two secondary schools and junior colleges
in Singapore from January to December 2004.
Participants: Data from 5561 girls, 12 to 19 years old,
were included in the analysis.
Results: Of the 5561 participants, 23.1% reported having
irregular cycles. Oligomenorrhea was the most frequently
reported problem (15.3%), and polymenorrhea was much
less prevalent (2.0%). With increasing body mass index
(BMI), there was a significant increase in the prevalence of
oligomenorrhea, whereas polymenorrhea was more prevalent
in the girls with a low BMI. Dysmenorrhea was a significant
problem, with 83.2% respondents reporting it in various
degrees and 24% girls reporting school absenteeism owing
to it. Dysmenorrhea was severe enough to require analgesics
for pain relief in 45.1% of all subjects. In spite of menstrual
problems being common, only 5.9% girls reported seeking
medical advice for them. Traditional Chinese medications
were used most commonly for menstrual cycle problems,
and over-the-counter medications for dysmenorrhea. The
use of oral contraceptives for menstrual problems was
minimal.
Conclusion: Menstrual problems among adolescent
females are common and a significant source of morbidity
in this population. However, adolescent girls are reluctant
This study was permitted by the Ministry of Education (Singapore)
NUS Grant. The Author has nothing to declare.
Address correspondence to: Anupriya Agarwal, Department of
Obst. & Gyn., National University Hospital, 5 Lower Kent Ridge
Road, Singapore 119074; E-mail: dr_anupriya@yahoo.com
Ó 2009 North American Society for Pediatric and Adolescent Gynecology
Published by Elsevier Inc.
to seek medical treatment, leading to delay in diagnosis
and treatment. Appropriate health education measures need
to be put into place to prevent this trend.
Key Words. Adolescence—Menstrual disorders—
Dysmenorrhoea—Oligomenorrhoea—Polymenorrhoea
Introduction
Adolescence is the transitional period during which
a child matures into an adult. Ascribed to the immatu-
rity of the hypothalamo-pituitary-ovarian axis, men-
strual cycle disturbances are quite common during
this phase of life. Menstruation-related problems con-
tribute to school absenteeism and can significantly
add to the problems faced by adolescents and their
families during this sensitive and difficult phase of de-
velopment. Also, menstrual problems can be symp-
toms of certain conditions like polycystic ovarian
syndrome and endometriosis, which if undiagnosed
and untreated may have profound implications in both
the reproductive and general health of women.
It has been shown that a society’s socioeconomic
status can have an influence on the age of menarche
as well as the prevalence of menstrual irregularities
in the population.1-3 Singapore, although rapidly
climbing up the economic ladder, has a paucity of
local data on adolescent menstrual trends. To address
this lack of data, we planned a study to investigate the
prevalence of menstrual abnormalities in its adoles-
cent population and the pattern of use of medical
treatments for these abnormalities.
Methods
This cross-sectional study was conducted in 62 second-
ary schools and junior colleges in Singapore from Janu-
ary to December 2004. Prior approval was obtained from
the Ministry of Education and the National University
Hospital ethical review board. A letter of information
1083-3188/09/$36.00
doi:10.1016/j.jpag.2009.02.005
366 Agarwal et al: Adolescent menstrual disorders

was sent to the principals of the schools explaining the
purpose and nature of the study. Upon receiving their
approval, the 27-point questionnaire was distributed to
the schools willing to participate, and the research coor-
dinator of the study went on-site to answer any queries
regarding the completion of the questionnaire. Confi-
dentiality was ensured and emphasized.
Data collected included age, ethnic group, history
of any medical or surgical problems, the age of
menarche, height, and weight. Details of the men-
strual history that were included in the questionnaire
included cyclicity; cycle length, duration, and amount
of flow; dysmenorrhea and its severity; the require-
ment of medication taken to relieve the pain; and
school/work days missed as a result. Menstrual cycle
patterns were defined as follows:
Primary amenorrhea: absence of menses by the
16th birthday
Regular menstrual cycles: cycle length of 22-35
days
Irregular menstrual cycles: cycle length less than
22 or more than 35 days
Oligomenorrhea: average length of the cycle
between 36 and 180 days
Polymenorrhea: average cycle duration of 20 days
or less
Secondary amenorrhea: absence of menses for
more 6 months
Menorrhagia (heavy menstrual loss): use of 4 or
more fully soaked pads a day for any duration during
the menstrual periods
Hypomenorrhea (light menstrual bleeding): less
than 1 fully soaked pad or use of panty liner being
sufficient for protection
Data were analyzed using the Statistical Package
for Social Sciences (SPSS) version 13.0.1 release date
February 28, 2005 (SPSS, Inc., Chicago, IL). Statisti-
cal significance of differences between groups was
tested using the Pearson’s c2 test, and logistic regres-
sion was used for analysis.
Results
A total of 10, 303 questionnaires were distributed to
schools, 2,573 girls declined participation, and the
remaining 7,730 female students returned the ques-
tionnaire. Three hundred fifty girls were older than
19 years and 1,819 questionnaires were incomplete,
hence these questionnaires were excluded from
further analysis. The mean age of the 5,561 girls
included in the analysis was 15.95 (1.05) years, with
ages ranging from 12 to 19 years.
Ethnicity
The ethnic distribution of the respondents reflected
the ethnic breakdown of the population of Singapore,
with 76.5% Chinese, 14.8% Malay, 6.0% Indian, and
2.7% from other ethnic groups.
Menarche
The age at menarche ranged from 9 to 16 years
(Figure 1). The mean age of menarche ( standard
deviation [SD]) was 12.15 (1.13) years, with 27%
of the girls having attained menarche before their
12th birthday.

2,500

2,000

1,500
n

1,000

500

Mean = 12.1493
Std. Dev. = 1.1317
0 N = 5,238
8.00 10.00 12.00 14.00 16.00 18.00
Age at menarche

Fig. 1. Age at menarche.

 Agarwal et al: Adolescent menstrual disorders 367

Response to menstrual
irregularity
N=5524/5561
(99.3%)

Regular cycles Irregular cycles

N=4268 N=1256
(77.3%) (22.7%)

Oligomenorrhea Polymenorrhea Unclassified

N=972/1256 N=111/1256 N=173/1256
(17.5%) (2.0%) (3.13%)

Cycles 35-90 days Cycles 91-180 days Cycles >180 days Unclassified
N=589 N=216 N=67 N=100
(10.6%) (3.9%) (1.2%) (1.8%)

Fig. 2. Prevalence of menstrual cycle irregularities in the study population.

Menstrual Irregularity Influence of Body Mass Index on the Menstrual

A total of 5,524 of the 5,561 girls included in the anal- Pattern
ysis reported on menstrual cyclicity. Of these, 1256 Body mass index (BMI) could be calculated for 5,296
girls (23.1%) reported having irregular cycles (95.23%) girls. The median ( SD) BMI for this pop-
(Figure 2). Oligomenorrhea was the most frequently ulation was 19.38  3.31 kg/m2. With increasing
reported problem (17.5%), and polymenorrhea was BMI, there was a significant increase in the preva-
much less prevalent (2.0%). Most girls with oligome- lence of oligomenorrhea (P ! .001); on the other
norrhea had a cycle duration of 35-90 days, and only hand, the prevalence of polymenorrhea was more
1.2% reported periods more than 6 months apart. common in girls with lower BMI and progressively
The prevalence of menstrual irregularity decreased decreased as the BMI increased (Table 1).
significantly with chronological age; this prevalence Logistic regression analysis was performed to
was 25.0% between the ages of 12-13 years and estimate the value of individual determinants of the
decreased to 19.3% after the age of 18 years menstrual cycle pattern (Table 2). We studied the
(P 5 .06). The decrease was also seen with increasing effect of gynecological age, BMI, parental income (as
gynecological age (years from menarche); the preva- a surrogate for socioeconomic status), and race, as these
lence was 36.2% in the first gynecological year factors had been shown by other studies as having a sig-
and progressively declined to 19% five years post- nificant effect on menstrual cycle regularity. The anal-
menarche (P ! .001). ysis showed a significant effect of gynecological age
In spite of the high prevalence of menstrual irreg-
ularities, only 5.9% of all respondents reported having Table 1. The effect of Body Mass Index (BMI) on Menstrual
been treated for menstrual cycle disturbances, and Cycle Disturbances
older girls sought medical treatment more frequently
than younger ones. Although none of 12-14 year olds Oligomenorrhea Polymenorrhea
BMI (kg/m2) n (%) (%)* (%)**
reported being treated, 10.2% of those older than 18
years had sought medical advice for menstrual prob- 10.0-14.0 9 (0.17%) 14.3 11.1
14.1-18.0 1439 (27.8%) 17.6 2.3
lems. Traditional Chinese and herbal medications 18.1-23.0 3045 (58.9%) 16.6 1.9
were the most frequently used agents for menstrual 23.1-30.0 591 (11.4%) 21.4 1.0
cycle problems (2.7%), 1.6% used noncontraceptive O 30.1 86 (1.6%) 39.5 1.2
hormonal medications (progestagens), the use of oral Total 5170 (100%)
contraceptive pills was minimal (0.1%), and the *p 5 0.0005.
remaining 1.4% were unsure of the medication taken. **p 50.040.
368 Agarwal et al: Adolescent menstrual disorders

Table 2. Logistic Regression Analysis to Estimate the Value of Determinants of the Menstrual Cycle

Menstrual Irregularity Oligomenorrhea Polymenorrhea

Variable P OR 95% CI P OR 95% CI P OR 95% CI
Gynecological age !0.001 0.850 0.810-0.891 !0.001 1.111 1.058-1.166 .005 1.203 1.506-1.370
BMI .003 1.157 1.052-1.272 !0.001 0.841 0.761-0.923 .017 1.490 1.074-2.067
Parental income .76 0.919 0.837-1.009 .737 1.017 0.923-1.120 .116 1.242 0.948-1.629
Race .882 1.007 0.914-1.110 .902 0.994 0.902-1.096 .687 0.949 0.735-1.225
Abbreviations: BMI, body mass index; CI, confidence interval; OR, odds ratio.

and BMI on the prevalence of oligomenorrhea as well
as polymenorrhea. However, neither ethnicity nor so-
cioeconomic status, as reflected by parental income,
influenced the regularity of menstrual cycles in this
population.
Amount of Menstrual Flow
Of the 5,433 who responded regarding the amount of
menstrual flow, 3.8% of the girls reported a light flow
and 14.5% reported heavy flow, whereas the majority
(81.7%) reported average menstrual blood loss.
Dysmenorrhea
Dysmenorrhea was a significant problem, with 83.2%
of respondents reporting various degrees of dysmen-
orrhea. Among these girls, 38.1% classified their pain
as mild, 50.4% as moderate, and 11.6% as severe.
With increasing chronological (Table 3) as well as
gynecological age (data not shown), the prevalence
of moderate and severe dysmenorrhea increased
significantly (P 5 .017 and !0.001 respectively).
Dysmenorrhea was severe enough to require anal-
gesics for pain relief in 45.1% of respondents. Parace-
tamol, used by 87.2% of the girls with dysmenorrhea,
was the most commonly used analgesic. Another
8.3% of all girls used nonsteroidal anti-inflammatory
drugs (NSAIDs), and the rest did not know the anal-
gesic they were using. Dysmenorrhea was an impor-
tant contributor to school absenteeism, as 25.9% of
girls with mild dysmenorrhea, about half with moder-
ate dysmenorrheal, and 75.5% of those with severe
dysmenorrhea reported taking leave from school for
this problem (Tables 3-5).
Discussion
Singapore is an island nation in Southeast Asia, with
a rapidly increasing population. According to the last
census in year 2000, the population was over 4 mil-
lion, an increase of more than a million since 1990.
The number of adolescent girls had also increased
since the last census; there were 113, 749 adolescent
girls aged 10-14 and 102, 262 aged 15-19 years.
Realizing the special needs of this important segment
of population, the Singapore government has been
providing special school- and clinic-based services
for more than 4 decades. Within the education system,
students in Singapore attend primary school (grades
1-6) followed by secondary school (grades 7-10)
before going to junior college (grades 11 and 12).
Health teams composed of doctors and nurses,
through annual visits to more than 400 educational in-
stitutions, provide school-based screening programs.
In addition to general health issues like obesity, exer-
cise, smoking, alcohol consumption, and drug abuse,
the program also provides education and screening
services for menstrual disorders, sexually transmitted
diseases, teenage pregnancy, and abortion. Because
menstrual problems were common in the adolescent
population, the Pediatric and Adolescent Gynecology
Clinic was started in 2 major hospitals in Singapore in
1984. Trained gynecologists who are assisted by spe-
cially trained nursing staff run these clinics. Students

Table 3. Relationship of Dysmenorrhea to Chronological Age

Dysmenorrhea
Mild Moderate Severe
Age (y) n % n % n %
12.1-13.0 4 36.4 7 43.6 0 0
13.1-14.0 47 52.8 38 42.7 4 4.5
14.1-15.0 50 37.3 72 53.7 12 9.0
15.1-16.0 453 37.6 619 51.4 132 11.0
16.1-17.0 794 38.2 1055 50.7 230 11.1
17.1-18.0 368 39.4 445 47.6 121 13.0
18.1-19.0 123 32.7 196 52.1 57 15.2
Total 1839 38.1 2432 50.4 556 11.6
 Agarwal et al: Adolescent menstrual disorders 369

Table 4. Use of Analgesics and School Absenteeism in Subjects of local data, we are unable to comment on the trends of
Reporting Dysmenorrhea age at menarche. Based on our observation that almost
Analgesics Leave from School because
a third of girls attain menarche before their 12th birth-
Age (y) for Pain Relief* (%) of Dysmenorrhea** (%) day, it is essential for sanitary facilities to be made
12.1-13.0 20.0 0
available for primary school girls. Greater emphasis
13.1-14.0 18.9 13.1 should be placed on providing adequate health infor-
14.1-15.0 36.8 19.3 mation to these young girls using age-appropriate edu-
15.1-16.0 35.3 19.6 cational material. In the future, it would be interesting
16.1-17.0 40.7 20.2 to follow the trends of adolescent obesity as well as its
17.1-18.0 46.2 26.1
18.1-19.0 47.2 34.0
relationship with age at menarche.
All 45.1 24.0
*P ! 0.001. Menstrual Cycle Abnormalities
**P ! 0.001. The prevalence of menstrual irregularities (22.7%)
was similar to that reported by other studies.11-13
who during the screening exercise are found to have However, what is striking is that in spite of a well-
menstrual problems are referred to these clinics for established school health program, only 5.9% of these
specialist consultations. 22.7% girls reported having been treated for men-
Menstrual disorders are known to be common strual cycle disturbances. Menstrual abnormalities
among adolescents. Information regarding the normal are most often the result of an immature hypothala-
menstrual pattern of Singaporean girls as well as the mo-pituitary-ovarian axis, however lack of appropri-
prevalence of menstrual problems is important, as it ate investigation and treatment may mean that
needs to be taken into account while providing health sometimes, the diagnosis of anemia, systemic hemo-
information as well as sanitary facilities for female pu- static disorders, and certain endocrinological abnor-
pils in primary and secondary schools. Menstrual prob- malities may be missed or delayed, making these
lems can also have a significant impact on the quality conditions and their sequelae more difficult to treat
of life and academic performance of adolescent girls. at a later date.
Recognizing the paucity of data on menstrual disorders The reason behind the low numbers of girls seek-
in Singaporean adolescents, we have endeavored to ing treatment needs to be investigated further. It is
quantify them in this cross-sectional study. possible that the girls lack proper information and
tend to assume that their menstrual pattern is normal
Menarche and hence do not report them at the regular school
It is well known that body weight and nutrition play an health check-ups. If this is the main cause found,
important role in pubertal development and that a criti- efforts to improve menstrual health education needs,
cal body fat mass is required for the onset of menarche. to be instituted. It is also possible that the primary
It has been shown that in tandem with improving nutri- care personnel attending to these girls are not trained
tion and increasing obesity in the developed world, the appropriately to enable them to understand when to
age of menarche has gradually fallen. Singapore refer the girl to the adolescent clinic, in which case,
achieved remarkable economic progress in the past 2 involved staff will need to be appropriately trained.
decades, and a sharp increase in obesity followed. Rec- Although studies in Western populations report
ognizing this problem, in 1992, a school-based obesity a substantial (10%-20%) use of oral contraceptive pills
prevention program was launched by the government, in the adolescent population,12-14 their use in our study
and in the last 15 years it has successful in reducing population was minimal, whereas traditional Chinese
the prevalence of adolescent obesity in school children medications were the most frequently used agents. This
from 14% in 1992 to 10% in 2001.4 finding could be attributed to sociocultural differences,
The mean age of menarche in our study (12.14  since Asian populations are traditionally more conser-
1.15 y) is similar to that reported from the region as vative and reluctant to use hormonal pills in adoles-
well as the West,2, 5-10 however because of the paucity cence. However, this result could also be a result of

Table 5. Use of Analgesics and School Absenteeism According to the Severity of Dysmenorrhea

Moderate Severe
Mild (%) % OR 95% CI % OR 95% CI P
Analgesics used 10.4 26.1 3.46 3.05-3.92 59.6 10.55 8.50-13.08 !0.001
School absenteeism 25.9 49.7 3.58 3.02-4.23 75.5 14.99 12.03-18.69 !0.001
Abbreviations: CI, confidence interval; OR, odds ratio.
370 Agarwal et al: Adolescent menstrual disorders
a significantly lower proportion of girls seeking medi-
cal advice for contraception or menstrual problems,
as demonstrated in our study. Given that about 3% of
adolescents report having initiated sexual activity,15
and that teenage abortions account for more than 10%
of all abortions in Singapore,16 the reasons for poor
uptake of oral contraceptives by adolescents should
be further studied.
Within the Singapore context, to increase acceptabil-
ity of this excellent contraceptive and help Singaporean
teenagers benefit from its several noncontraceptive
benefits, enhancing parental education is as important
as educating adolescents themselves. Nonprofit chari-
ties, primary health care workers, and school-based
educational programs for parents may help.
Trends in Dysmenorrhea
Dysmenorrhea, as it is a subjective variable, has var-
ied reported prevalence rates. In our study population,
83.2% respondents reported varying degrees of dys-
menorrhea. Although this finding is similar to that
reported by others,17,18 the prevalence of severe dys-
menorrhea (11.6%) was much lower than that
reported by Banikarim (42%) and Klein(23%).19-21
About half of the study respondents reported using
analgesics for relief from dysmenorrhea, and predom-
inantly over-the-counter medications were used. Only
a small proportion (13%) of those with dysmenorrhea
reported seeing a doctor and using prescribed medica-
tion for dysmenorrhea. It is likely that dysmenorrhea
is considered to be quite ‘‘normal’’ by most adoles-
cents as well as their caregivers and is often ignored,
resulting in a delay in the diagnosis of organic prob-
lems like endometriosis and pelvic inflammatory dis-
ease. Although dysmenorrhea in adolescents and
young adults is usually primary (functional) and is
associated with normal ovulatory cycles, there is
evidence that in approximately 10% of adolescents
and young adults with severe dysmenorrhea, pelvic
abnormalities such as endometriosis or uterine anom-
alies may be found.22 This information needs to be
incorporated in the educational material of school
health personnel as well as the students in an attempt
to improve the diagnosis of these serious problems,
which can impact their physical and reproductive
health in the future.
School absenteeism is a surrogate measure of the
effect of menstrual health problems on the quality
of life of adolescent girls. Excessive school absentee-
ism can interfere with academic performance, and
hence it can negatively influence the academic future
of a student. The school absenteeism rate in our study
was 24%, similar to that reported by others.19-22 Since
dysmenorrhea appears to be a significant problem that
affects school attendance and possibly school perfor-
mance, it is important to provide relevant health
education to adolescent girls as well as their parents,
regarding both the causes and availability of effective
treatments for dysmenorrhea. It has been our experi-
ence that analgesics are perceived as habit-forming
and their use for relief of dysmenorrhea is not
favored. It is important to dispel this myth among
girls and their caregivers, as well as health care
workers. With adequate, simple measures like appro-
priate use of analgesics and oral contraceptives in
refractory cases, it may be possible to reduce the rate
of school absenteeism, and the problem of invaluable
school time loss can be significantly reduced.
Limitations
In spite of the large sample size, there were some limi-
tations to this study. First, because the study was cross-
sectional in nature, causality cannot be determined
from the results. Missing data and incomplete question-
naires were another problem. As it was a questionnaire-
based study, recall bias was an expected problem. All
conclusions were based on self-reported symptoms,
and as financial constraints did not permit the inter-
viewing of participants, the reported findings could
not be validated. Finally, the study was conducted only
in schools and colleges, and school drop-outs were not
included, hence the results may not be generalizeable to
the entire population.
Conclusion
Adolescent menstrual problems are common and
a significant source of morbidity in this population.
In this study we have illustrated that almost 1 girl in
4 reaches menarche while still at primary school. This
finding needs to be taken into account when providing
sanitary facilities and age-appropriate health informa-
tion for female pupils in primary school. Menstrual
cycle disorders and dysmenorrhea are quite common
in the adolescents of Singapore. However, adolescents
seem reluctant to seek medical help for these prob-
lems. Further studies should be performed to deter-
mine the reason for this trend, and newer strategies
need to be employed. In addition to educating adoles-
cents, the education of parents, adolescents, and
medical, paramedical, and nursing staff is essential
to improve the state of health of Singaporean
adolescents.
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