European Journal of Cardiovascular Medicine

The World Health Organization (WHO) defines adolescents as individuals aged 10–19 years. There are about 360 million adolescents, comprising nearly 20% of the population in the countries of the South-East Asia Region (SEAR)1. Adolescents’ health and well-being are important as they account for 45% of potential skeletal growth, 15–25% of adult height gain, and 37% of total bone mass accumulation.²˒³

Menarche is defined as the first menstrual period and is considered the most notable event during female puberty.⁴ Menstruation is the monthly shedding of the endometrium, resulting in the discharge of blood from the uterus and occurring approximately every 28 ± 7 days.⁵˒⁶ The average duration of menstrual bleeding is about 5 days, amounting to approximately 67 months of menstruation during a woman’s reproductive life.⁷

Although menstruation is a normal physiological process in the female reproductive cycle, variations in menstrual patterns are frequently observed among adolescents.⁸ Dysmenorrhea is defined as pelvic pain occurring during menstruation and is often associated with symptoms such as headache, back pain, nausea, vomiting, and diarrhea.⁹ It is a major menstrual problem that affects females’ daily activities, including school attendance. Adolescent girls commonly visit physicians with complaints of delayed, irregular, painful, and heavy menstrual bleeding.¹⁰

Menarche usually occurs between 11 and 15 years of age, with a mean age of 13 years. Menstrual hygiene practices during menstruation are very important, as poor practices increase susceptibility to reproductive tract infections (RTIs).¹¹ Poor menstrual hygiene practices may lead to infertility, miscarriages, cancer, toxic shock syndrome, reproductive tract infections, and urinary tract infections.¹² Hence, the present study was designed to assess and compare the menstrual problems among adolescent girls and reproductive health morbidities among school-going adolescent girls and boys in rural and urban areas.

A school-based cross-sectional study was carried out from March 2023 to March 2025. The study population consisted of adolescent girls and boys aged 10–19 years residing in the urban and rural field practice areas of Kurnool Medical College, Kurnool, South India.

Out of 305 schools in Kurnool district, four government schools providing education from 6th to 10th standard were located in the field practice areas of Kurnool Medical College. In the present study, students from 7th to 10th standard studying in these schools were included. Data were collected from two government high schools in the rural field practice area and two government high schools in the urban field practice area of Kurnool Medical College. From each school, students aged 10–19 years were selected using a simple random sampling method.

The sample size was calculated based on the prevalence of premenstrual syndrome (41.6%) reported in a previous study by Divya Dwivedi¹³, with a non-response rate of 5%, resulting in an estimated sample size of 416. As this was a comparative cross-sectional study, 208 participants were selected from the rural field practice area and 208 participants from the urban field practice area under the Department of Community Medicine, Kurnool Medical College.

Adolescent girls and boys aged 10–19 years studying in 7th to 10th standards in the selected schools, whose parents/teachers consented to participation, were included in the study.

Adolescents who were absent during the study period and could not be contacted after three consecutive visits, adolescent girls who had not attained menarche, seriously ill adolescents, and those unwilling to provide consent/assent for participation were excluded from the study. Ethical approval for the study was obtained from the Institutional Ethics Committee (IEC No. 209/2023).

 After obtaining permission from the school authorities, dates were fixed for interviewing the students. Participants were randomly selected from each field practice area to achieve the desired sample size of 208. Equal numbers of male and female adolescents were included from each school to maintain uniformity.

A total of 416 students were finally selected for the study. Students from each class were randomly selected using roll numbers from the class registers.

The objectives and benefits of the study were explained to the participants, and written informed assent was obtained from adolescents aged above 12 years. A semi-structured questionnaire was used for data collection.

Participants were interviewed using a pretested, semi-structured questionnaire to collect socio-demographic information and details regarding menstrual and reproductive health. Menstrual health was assessed using menstrual characteristics such as age at menarche, cycle length, duration of menstrual flow, amount of menstrual blood loss, dysmenorrhea, regularity of periods, and common menstrual symptoms experienced by adolescent girls.

Reproductive health was assessed based on symptoms such as itching and discharge from the genitalia, pustules/swelling over the genitalia, and pain during micturition.

Statistical analysis was performed using IBM SPSS Version 21. Descriptive data were presented as frequencies and proportions. Categorical variables were analyzed using the chi-square test. A p-value of less than 0.05 was considered statistically significant.

In the present study, among the 208 urban and 208 rural participants, the majority in both areas belonged to the 10–15 years age group (urban: 76.92%; rural: 79.32%). With regard to religion, most participants were Hindus in both urban (79.80%) and rural (74.51%) areas.

Regarding fathers’ education, the highest proportion of fathers in urban areas had completed intermediate/diploma education (22.11%), whereas in rural areas, the majority had studied up to high school (24.51%). For mothers’ education, middle school education was most common in urban areas (22.59%), while in rural areas, primary school and middle school education were equally predominant (24.51% each).

 In both urban and rural areas, the majority of fathers were skilled workers (urban: 32.21%; rural: 38.46%). Among mothers, the majority in urban (42.30%) as well as rural areas (40.38%) were unskilled workers.

Regarding family type, nuclear families constituted the majority in both urban (76.44%) and rural areas (71.63%). According to the Modified B.G. Prasad classification, most families in the urban area belonged to Class V (31.73%), whereas in the rural area, the majority belonged to Class IV (43.75%).

MENSTRUAL HEALTH OF GIRLS:

Table 1: Menstrual characteristics of adolescent girls according to place of residence (N=208)

Table 1 shows that the majority of adolescent girls attained menarche between 13–14 years in the urban area (50%), whereas the majority of adolescent girls in the rural area attained menarche between 10–12 years (64.42%). A menstrual cycle duration of 21–30 days was reported by 74.03% of adolescent girls in the urban area and 71.15% in the rural area.

Regarding the duration of menstrual flow, 75% of adolescent girls in the urban area and 81.73% in the rural area reported a duration of 3–5 days. Dysmenorrhea was reported by 17.30% of adolescent girls in the urban area and 16.34% in the rural area. Regular menstrual cycles were reported by 87.50% of adolescent girls in the urban area and 85.57% in the rural area.

Table 2: Factors associated with menstrual regularity in adolescent girls (N=208)

Table 2 shows the factors associated with menstrual regularity among adolescent girls in both urban and rural areas. Regular menstruation was more common during early adolescence in both settings. A statistically significant association was observed between age and menstrual regularity in both urban and rural areas.

Regular menstruation was more common among first-born adolescent girls in both urban and rural areas. This association was statistically significant in urban areas but was not statistically significant in rural areas.

Regular menstruation was also more common among adolescent girls with normal body weight in both urban and rural areas, and this association was found to be statistically significant. Furthermore, regular menstruation was more commonly observed among adolescent girls with mild anemia in both urban and rural areas. This association was statistically significant in urban areas but not statistically significant in rural areas.

Table 3: Frequency of menstrual symptoms among adolescent girls according to place of residence (N=208)

 Table 3 presents the frequently occurring symptoms experienced during menstruation among adolescent girls. In the urban area, the most common symptoms reported during menstruation were tiredness (24.03%), abdominal pain (14.42%), lower back pain (14.42%), sleepiness (12.50%), and altered appetite (10.57%). In the rural area, the most commonly reported symptoms during menstruation were tiredness (30.76%), lower back pain (16.34%), altered appetite (15.38%), and sleepiness (10.57%).

REPRODUCTIVE HEALTH:

Table 4: Frequency of distribution of Reproductive Morbidity among adolescent boys and girls according to place of residence (N=416)

Table 4 presents the frequently occurring symptoms of reproductive morbidity among adolescent boys and girls in urban and rural areas. In the urban area, the most commonly reported symptom among adolescents was itching in the genital area, followed by pain during micturition and unusual discharge from the genitalia. In the rural area, the most common symptoms reported among adolescents were itching in the genital area and unusual discharge from the genitalia, followed by pain during micturition.

Menstruation and menstrual health problems are among the major reproductive health concerns experienced by women, beginning in adolescence and continuing throughout their reproductive lives.

The most commonly used measure of sexual maturity is the age at menarche, which is influenced by various factors such as family size, body mass index (BMI), socioeconomic status, educational level, and genetic and environmental factors. Early menarche is associated with obesity, endometrial cancer, breast cancer, and uterine leiomyoma.

In the present study, the prevalence of regular menstruation was 87.50% in urban areas and 85.57% in rural areas. Similar findings were reported by Shabnam Omidvar et al.¹⁴ in a study conducted in urban areas of South India, where regular menstruation was reported by 77.9% of the participants.

In the present study, the majority of adolescent girls (46.15% in urban areas and 64.42% in rural areas) attained menarche between 10–12 years of age, and a menstrual cycle length of 21–30 days was reported by 74.03% of participants from urban areas and 71.15% from rural areas. These findings were contrary to those reported by Shabnam Omidvar et al.¹⁴ in urban areas of South India, where the majority of participants attained menarche between 13–14 years of age and had a cycle duration of 28–35 days.

In the present study, 75% of adolescent girls from urban areas and 81.73% from rural areas reported a menstrual flow duration of 3–5 days.

The prevalence of dysmenorrhea in the present study was 17.30% in urban areas and 16.34% in rural areas. Dysmenorrhea is an important menstrual disorder and is common among young women with ovulatory cycles. Several studies¹⁵ have reported its prevalence to range from 25% to 90% among women and adolescent girls.

A statistically significant association was found between menstrual regularity and age as well as BMI among adolescents in both urban and rural areas. However, this finding was contrary to the study conducted by Sharma S et al.¹⁶ in urban areas of South India, in which cycle length was found to be statistically associated with age groups.

In the present study, the most common symptoms associated with menstruation were tiredness (27.40%), dysmenorrhea (16.82%), and lower back pain (15.38%). These findings were comparable to those reported by Shabnam Omidvar et al.¹⁴ in urban areas of South India, where the majority of participants reported tiredness (50.1%), followed by back pain (27.6%).

Menstrual symptoms encompass a wide range of physical and emotional problems occurring around the menstrual cycle. While some women experience menstruation with little or no discomfort, others experience various physical and emotional symptoms that may be distressing both physically and psychologically.

Reproductive health:

In the present study, the most common symptoms of reproductive tract infection among adolescents in urban areas were itching in the genitalia (4.80%), followed by pain during micturition (3.84%). Among adolescents in rural areas, the most common symptoms were itching in the genitalia (5.28%) and unusual genital discharge (5.28%), followed by pain during micturition (2.40%). Similar findings were reported by Jayashree S. Gothankar et al.¹⁷, in which the majority of adolescent girls reported itching, followed by unusual vaginal discharge.

Sexually transmitted infections (STIs) among adolescents are recognized as a significant public health problem in India. Reproductive tract infections (RTIs), though preventable and curable, may result in adverse outcomes such as pregnancy wastage, ectopic pregnancy, low birth weight, infertility, and other serious complications.

The prevalence of dysmenorrhea was higher in urban areas compared to rural areas. Tiredness was the most commonly reported symptom experienced during menstruation among girls in both urban and rural areas. The most common symptom of reproductive tract problems among adolescents in both settings was itching in the genitalia.

Existing adolescent health programs should be effectively implemented to address these issues. Awareness programs should be conducted by health professionals and teachers through school health programs to improve menstrual and reproductive health awareness among adolescents.

1. World Health Organization. Adolescent health in the South-East Asia Region,2024. https://www.who.int/southeastasia/health-topics/adolescent-health.
2. Empowering adolescent girls and boys in India. Adolescent development and participation [Internet]. UNICEF India; 2022; Available from: Adolescent development and participation | UNICEF India
3. Dobner J, Kaser S. Body mass index and the risk of infection - from underweight to obesity. In Clinical Microbiology and Infection. 2018 Jan;24(1):24-28.
4. Abdulla E, Ibraheem NM. Assessment of the influencing factors on age of menarche among girls in Tikrit city. Tikrit Med J. 2010;16(2):129–33.
5. Stedman’s medical dictionary. Menstruation. 27th ed. Baltimore: Williams & Wilkins; 2000. p. 1092.
6. Berek SJ. Novak’s gynecology. 14th ed. London: Williams and Wilkins publication; 2006. p. 1696.
7. Chiou MH, Wang HH, Yang YH. Effect of systematic menstrual health education on dysmenorrheic female adolescents’ knowledge, attitudes, and self-care behavior. Kaohsiung J Med Sci. 2007;23(4):183–90.
8. Dambhare DG, Wagh SV, Dudhe JY. Age at menarche and menstrual cycle pattern among school adolescent girls in Central India. Glob J Health Sci. 2012;4(1):105–11.
9. Durain D. Primary dysmenorrhea: assessment and management update. J Midwifery Womens Health. 2004;49(6):520–8.
10. Lee LK, Chen PC, Lee KK, Kaur J. Menstruation among adolescent girls in Malaysia: a cross-sectional school survey. Singapore Med J. 2006;47(10):869–74
11. Bekkalale Chikkalingaiah Sowmya, Shashikala Manjunatha, Jayanth Kumar. Menstrual Hygiene Practices among Adolescent Girls: A Cross-Sectional Study. Journal of Evolution of Medical and Dental Sciences 2014;3:7955-7961.
12. Mathiyalagen P, Peramasamy B, Vasudevan K, Basu M, Cherian J, Sundar B. A descriptive cross-sectional study on menstrual hygiene and perceived reproductive morbidity among adolescent girls in a union territory, India. J Family Med Prim Care. 2017 Apr-Jun;6(2):360-365.
13. Dwivedi, D., Singh, N. & Gupta, U. Prevalence of Menstrual Disorder in Women and Its Correlation to Body Mass Index and Physical Activity. J Obstet Gynecol India 74, 80–87 (2024). https://doi.org/10.1007/s13224-023-01914-0.
14. Omidvar S, Amiri FN, Bakhtiari A, Begum K. A study on menstruation of Indian adolescent girls in an urban area of South India. J Family Med Prim Care 2018;7(4):698-702.
15. Daley AJ. Exercise and primary dysmenorrhoea : a comprehensive and critical review of the literature. Sports Med. 2008;38(8):659-70.
16. Sharma, S., Deuja, S., & Saha, C. G. (2016). Menstrual pattern among adolescent girls of Pokhara Valley: a cross sectional study. BMC Women’s Health, 16(1).
17. Gothankar JS, Patil RS, Plkar SH. Knowledge and practices related to reproductive health amongst adolescent girls. In Medical Journal of Dr. D.Y. Patil University 2015;8:719-23.