Pattern of menstruation and its problem among adolescent girls: a school based cross-sectional study

INTRODUCTION

Adolescence (10-19 years) is the period of transition from childhood to adulthood wherein child goes through various physical, emotional and social changes.¹ The period of adolescence is characterized by specific growth spurt that are associated with development of gonads, reproductive organs and secondary sexual characteristics along with development of new thoughts and motivations, including a wide range of social, behavioral, and emotional changes.² Menstruation is an unique phenomenon among adolescents girls that involves periodic vaginal bleeding occurring every 26 to 30 days till she reaches 5^th decade of her life.³

Attaining menarche is one of the significant milestones in a woman’s life as it signifies the initiation of capacity to reproduce along with development of pubertal characteristics.⁴ The time of menarche and the pattern of menstruation vary from woman to woman. Menarche typically occurs within 2-3 years after thelarche, Tanner stage IV usually between 12 and 13 years. Almost 98% of girls have already attained her menarche till she is 15 years.⁵ Menstruation is considered as a matter that needs to be kept secret and women should feel ashamed of it. Nepalese society considers menstruating women impure and they are kept under several social and religious restrictions.⁶ Due to these restrictions adverse health outcomes are to be faced by menstruating woman as they remains unaware of the scientific facts regarding the normal phenomenon and compelled to follow unhygienic practices.⁷

Dysmenorrhea is a medical term that means “difficult or painful periods” which can be classified as “primary” and “secondary”.² The pain or difficulty occurs as result of uterine contractions. Most young women having dysmenorrhea will experience have lower back pain and cramping in the lower area of the abdomen during their period. This pain can be dull to pulsatile ranging from mild to severe in nature. Problems as symptoms of GI upset, bloating in belly area, excessive bleeding might also occur during menstrual episodes.

On a study conducted in India out of 600, 245 (40%) girls remained absent from school during their menstruation.⁸ School absenteeism was significantly associated with the type of absorbent used, lack of privacy at school, restrictions imposed on girls during menstruation, mother's education, and source of information on menstruation. Majority 65% reported that school activity is affected as they had to remain absent from school out of shyness, pain and anxiety about leakage and staining at their school uniform.⁸

Adolescent with age group of 10-19 constitutes more than 1.2 billion of world’s population, 70% of them belonging to developing countries. Adolescents account for nearly a quarter of Nepal's population (approximately 6.4 million). According to Nepal Demographic and Health Survey (NDHS), 2011 average age of menarche is 13.5 years old.⁹ Every day, an estimated 290,000 women and adolescent girls in Nepal menstruate.¹⁰ The NDHS of 2011 revealed that of the top ten sexual and reproductive health issues of concern identified by teenage girls, seven were menstruation-related.

Many of the girls’ concerns relate to why physical changes occur, what is “normal,” and the consequences of puberty. This lack of knowledge is echoed by the fact that almost a quarter of teenage girls had “no idea” what their menarche was prior to its onset, and only 36% reported that menstruation was a monthly cycle where blood flows from the vagina for 4-5 days.⁹

In the context of Nepal menstruation is considered as a matter of shame and dirty. Therefore, many women and girls are excluded from aspects of daily living including education and religious functions and are forced to follow traditional norms and practices, despite physical discomfort and/or lack of resources and remain absent from school.¹¹ Thus the study was conducted to explore the pattern of menstruation and problems associated with it among school going adolescent at Birgunj, Nepal.

METHODS

This quantitative descriptive cross-sectional study was carried out in two purposively selected private schools situated in Birgunj metropolitan city which lie in Parsa district of state no 2 of Nepal. This study was approved by institutional review committee (F-NMC/429/075/076) of National Medical College and Teaching Hospital, Birgunj, Nepal. The study period was September 2019 to January 2020 and the data collection period was 1^st week of December 2019. All the girls who were studying in grade 8, 9 and 10 who had attended menarche and were willing to participate were included in the study whereas the girls who had attended menarche within last 6 months of data collection date were excluded. Sample size was estimated at 95% confidence level and 5% confidence interval based on the prevalence of dysmenorrhea (78.7%) among adolescents in a study conducted in Eastern Nepal.⁷

Total enumerative sampling technique was adopted and obtained sample size was 244. Formal administrative approval from the school authority and informed written assent was obtained from the adolescents. A self-administered semi structured questionnaire in English language was used for data collection. An orientation class was taken by the researcher before administering the tool to ensure that the adolescent truly understands the purpose of the research and the interpretations regarding various characteristics of menstruation. Pain during menstruation was assessed by instructing the adolescent to indicate the severity of pain on a numeric scale from 0-10 (0 means no pain, 1-3=mild pain. 4-7=moderate pain, and 8-10=severe pain) that was attached in the questionnaire. The pattern of menstruation was categorized according to the guideline given by American College of Obstetrics and Gynecology.⁵ Validation of the tool was done by consulting experts in the related field and intense literature review. Pretesting of the tool was done among 10% of the total sample size (n=30). Reliability of the tool was ascertained by computing Crohnbach’s alpha and obtained value was (r=0.81). The collected data were analyzed with statistical package for the social sciences (SPSS) version 23 using descriptive and inferential statistics. Logistic regression analysis was adopted to calculate the odds ratio with 95% confidence interval (CI) and the probability value (p value) of <0.05 was considered statistically significant at 95% CI.

RESULTS

Socio demographic variables

Result revealed that mean age of adolescent was 14.97±1.02 years ranging from 12-17 years. than 1/3^rd (40.59%) was study in grade 8. Regarding type of family majority (68.04%) belonged to joint family. majority (73.36%) followed Hindu religion. More than half (51.63%) adolescents reported their female family members as 1^st source of information about menstruation (Table 1).

Pattern of menstruation

The mean age at menarche was 13.13±0.72 years wherein majority (79.3%) had their menarche at 13-14 years. Regarding regularity (78.27%) adolescents had regular (21-35 days) type of menstruation meanwhile, (69.6%) had their menstrual duration of 4-8 days. Majority (81.15%) used sanitary pad only as absorbent whereas (11.89%) consumed both sanitary pad and cloths. Regarding pain (48.3%) experienced moderate to severe pain during menstruation. As a remedy only (11.06%) use to take pain medicines. Furthermore, (8.6%) adolescents missed their school during menstruation and the main reason for absenteeism was pain and discomfort (76.19%) (Table 2).

Physical and social problems during menstruation

Feeling of tiredness (76.8%) was the most prevailed physical problem among adolescent followed by abdominal bloating (59.3%), changes in appetite (32.8%), excessive blood loss (22.6%), and mood swings (13.5%) respectively. Regarding social problem restriction in religious/family activities (81.65%) was the most prevailed problem followed by restrictions to touch male members in family (27.9%), restriction to cook utensils (22.6%), restriction to sleep in regular bed (9.8%) and restriction to wear regular cloths (4.9%) respectively (Figure 1 and 2).

*Statistically significant at the level of p value<0.05

Association of age of adolescent with regularity of menstruation and dysmenorrhea

A logistic regression analysis was carried out to calculate the odds ratio and to find out the association of age of adolescents with dysmenorrhea and regularity of menstruation. The prevalence of moderate to severe pain among adolescents aged 12-14 was more than 4 times higher than adolescents of age 15-17 (COR 4.03 95% CI: 2.21-7.36) (Table 4).

Meanwhile, the adolescents aged 15-17 were more likely to have their menstruation at regular interval compared to adolescents aged 12-14 (COR 0.93 95% CI: 0.46-0.18) (Table 5). Regularity of menstruation and dysmenorrhea had significant association with age of adolescent at the level of p value <0.05 (Tables 4 and 5).

*Statistically significant at the level of p value<0.05

*Statistically significant at the level of p value<0.05

DISCUSSION

This study sought to identify the typical pattern of menstruation and its disorders among school adolescent. The mean age of adolescents was 14.97±1.02 and mean age at menarche was 13.13±0.72. The mean age of adolescents and mean age at menarche was 14.67±1.7 and 12.49±1.20 respectively on a study done on Egypt.¹² Similarly on a study done on Turkey the mean age at menarche was 12.8±1.3.¹³ The mean age at menarche among adolescents was 12.94±1.01.¹⁴ On a study conducted in Uttar Pradesh and 13.2±1 on a study conducted in Lucknow, India.¹⁵ The mean age of adolescents and mean age at menarche was 14.0±1.3 years and 12.2±0.9 years respectively on a study conducted in Pokhara city of Nepal.¹⁶

There is a variation in the age at menarche among adolescents which may be due to influence of genes, socio-demographic conditions, geographical variations, general health and wellbeing, nutritional status and activities of daily living.⁴ The age at menarche was 16.5 years in the year 1840 but now it has fallen to 13.0 in the industrialized countries.⁴ Whereas in developing countries like Nepal the average age at menarche remains to be around 13.5 years old.⁹ In the present study the regularity in menstruation cycle was observed among 78.27% of adolescents. This finding is in contrast with the finding with study conducted in Egypt (57%) and 65% on a study conducted in India.^12,15

In the present study the regularity of menstruation was significantly associated with age of adolescents. The girls in the age group 15-17 had regular type of menstruation compared to adolescent in the age group 12-14. This finding is supported by similar study conducted in Pokhara, Nepal.¹⁶ In the first 2 years of menarche adolescents experience irregular menstruation.¹⁷

Age is one of those factors which are associated with the pattern of menstruation among women at any phase of reproductive life.¹⁸ Likewise, in present study the age of adolescent had significant association with dysmenorrhea. This finding is supported by a similar study conducted in India which reported that dysmenorrhea prevailed among (62.6%) of total participants and this was significantly associated with age.¹⁹ Report of another similar study supported the finding of present study stating that there is a significant association of onset of dysmenorrhea and post menarche years.²⁰

Pain during menstruation had significant impact on adolescent’s daily activities including missed school days in the present study. The finding is supported by the study Conducted among adolescent girls at Parsa district Nepal by United Nations International Children's Emergency Fund (UNICEF) in 2016.²¹

The findings of present study revealed that 43.45% of adolescent adopted miscellaneous remedies to manage menstrual symptoms whereas 9.43% took rest and fluid more than usual and 23.36% use to do nothing. The findings of another similar study from Far Western Nepal revealed that 44% used to take rest and 19.3% did nothing as remedial measure to manage physical symptoms of menstruation.⁶ Regarding types of absorbent used during menstruation 81.15% adolescents in our study used sanitary pad only whereas 6.96% used cloths only and remaining 11.89% used both. The finding is supported with the findings of study conducted in Kathmandu valley that revealed 84.4% used sanitary pad only, 15.6% used both sanitary pad and cloths.²²

Nevertheless, the finding is in contrast with similar study conducted in far Western Nepal in the year 2016 which revealed that only 44.4% used sanitary pad and 57.8% used cloths.⁶ This might be due to the geographical variation and the variation in the study period. Moreover, the government’s free sanitary pad distribution program implemented from October 2019 has significant impact in the rate of sanitary pad use among adolescent.²³

Regarding the problems faced by adolescent during menstrual days feeling of tiredness and abdominal bloating remains the most prevailed physical problem and restriction in religious and family activities was experienced by majority of the adolescents. This finding is congruent with the finding of another similar studies conducted in Eastern Nepal.^7,24 In addition, literature suggests that pattern and problems of menstruation is determined by socioeconomic, dietary and climatic conditions.²⁵

CONCLUSION

Menarche is attained by adolescents at appropriate age regardless of its pattern. The pattern of menstruation is determined by the age of adolescent. Various physical and social problems are experienced by the adolescent during menstruation. These problems have impact on the lifestyle of the adolescents including missed school days. Social restrictions during menstruation may lead to various psychological impacts on adolescents. Education regarding hygiene, self-care and management of menstrual symptoms, clarifying menstrual taboos among family and community members is required so that the adolescent can experience their feminine feature with health and dignity.

ACKNOWLEDGEMENTS

Author would like to acknowledge the school authority and the class teachers for making necessary adjustment so as to facilitate the data collection procedure. They are also equally grateful towards the girls who actively participated in the study as they are the core of study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Review Committee

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