European Journal of Cardiovascular Medicine

Dysmenorrhea refers to painful cramps in the lower abdomen or pelvis occurring before or during menstruation. The term originates from the Greek words dys (difficult, painful, abnormal), meno (month), and rrhea (flow)^[1]. It is among the most common gynecological complaints in adolescents and young adult women, with global prevalence estimates ranging from 20% to over 90%^[2–4]. Variations arise from differences in study populations, ethnic backgrounds, definitions used, and data collection methods.

In India, reported prevalence rates also vary widely. Agarwal and Agarwal^[5] found a prevalence of 79.67% among adolescent girls, while Singh et al.^[6] reported similar figures among female medical students. Despite its frequency, dysmenorrhea is often normalized, leading to underreporting and delayed healthcare-seeking behavior^[7]. The condition is not only a source of physical discomfort but also impacts educational performance and social participation, contributing to a considerable public health burden^[8].

Primary dysmenorrhea, the most common form in young women, is attributed mainly to excessive production of prostaglandin F₂α in the secretory endometrium, causing strong myometrial contractions and uterine ischemia^[9,10]. The role of leukotrienes in enhancing uterine pain sensitivity has also been proposed, particularly in cases resistant to prostaglandin inhibitors^[11,12]. Secondary dysmenorrhea, associated with pelvic pathology, is less common in this age group but can present with similar symptoms.

Multiple factors influence the occurrence and severity of dysmenorrhea, including early age at menarche, longer menstrual cycles, extended bleeding duration, family history, lifestyle habits, and psychosocial stressors^[6,13,14]. However, most existing studies in India have been conducted in metropolitan or medical college settings, with limited data from smaller urban centers such as Jhalawar, Rajasthan. Understanding prevalence patterns and associated risk factors in such contexts is important for developing locally relevant menstrual health education and intervention programs.

The present study was therefore conducted to estimate the prevalence of dysmenorrhea among college-going female students in Jhalawar city, Rajasthan, and to identify demographic, menstrual, lifestyle, and familial factors associated with its occurrence.

Study Design and Setting

A cross-sectional study was conducted among female students from two colleges in Jhalawar city, Rajasthan to estimate the prevalence of dysmenorrhea and identify associated demographic, menstrual, lifestyle, and familial factors.

Sample Size and Sampling Method

The sample size was calculated using the formula for estimating a proportion in a population:

Where ​ = 1.96² (95% confidence level), expected prevalence P = 70%, and absolute precision d = 6%. The calculation yielded a minimum sample size of 223 participants. Convenience sampling was used to recruit students meeting eligibility criteria.

Inclusion and Exclusion Criteria

Inclusion criteria were unmarried, nulliparous female students aged 17–25 years who provided written informed consent. Students with a history of amenorrhea, pelvic surgery, or any abdominal surgery were excluded.

Ethical Considerations

The Institutional Review Board waived ethical approval as the study involved a minimal-risk, anonymous, questionnaire-based survey without collection of any personally identifiable information or biological samples, and participation was entirely voluntary with informed consent obtained from all respondents. Written informed consent was obtained from all participants prior to inclusion.

Data Collection Tool

A structured, self-administered questionnaire was used. It consisted of two sections:

1. General Profile: demographic details, dietary habits, physical exercise, and socioeconomic status.
2. Menstrual Profile: menstrual history, cycle characteristics, bleeding volume, history and severity of dysmenorrhea, premenstrual symptoms, and absenteeism from academic or social activities.

The menstrual history section was adapted in part from previously published studies on dysmenorrhea among young women in India and internationally^[5–7,14]. Pain severity was graded using the Verbal Multidimensional Scoring System (VMSS), a pre-validated tool widely used for dysmenorrhea assessment^[2].

Pilot Testing

The questionnaire was pilot-tested on 30 students to assess clarity, comprehension, and completion time. Minor wording modifications were made based on feedback. The pilot study results were excluded from the main analysis.

Definitions

• Body Mass Index (BMI): calculated as weight (kg) / height² (m²) and classified according to WHO criteria: underweight (<18.5 kg/m²), normal (18.5–24.99 kg/m²), overweight (≥25 kg/m²).
• Menstrual Irregularity: cycle length <21 or >35 days.
• Heavy Menstrual Bleeding: estimated blood loss >100 ml per cycle/ ≥ 5 fully soaked sanitary pads on heaviest menstrual bleeding day.
• Premenstrual Symptoms (PMS): mood changes, breast tenderness, bloating, or headache resolving with menstruation (Rijal & Shrestha).
• Dysmenorrhea: lower abdominal or pelvic pain before or during menstruation, graded according to VMSS: Grade 0 – no pain; Grade 1 – mild pain without limitation of activity; Grade 2 – moderate pain with some limitation; Grade 3 – severe pain with marked limitation and systemic symptoms^[2].

Data Collection Procedure

The study purpose was explained to all participants. Guidance was provided while filling the questionnaire to minimize misunderstanding and reduce response bias.

Statistical Analysis

Data were entered in Microsoft Excel and analyzed using IBM SPSS Statistics version 23. Categorical variables were expressed as frequencies and percentages; continuous variables were presented as mean ± standard deviation (SD). Associations between categorical variables were assessed using the Chi-square test, with p < 0.05 considered statistically significant.

A total of 223 unmarried, nulliparous female college students participated in the study. The age distribution revealed that 46.9% (n = 104) of participants were aged 17–19 years, 43.1% (n = 96) were aged 20–22 years, and 10% (n = 23) were above 23 years. The overall mean age was 19.81 ± 1.74 years (95% CI: 19.54–20.08). The mean age at menarche was 12.47 ± 1.42 years, with a range of 10–15 years.

Menstrual cycle characteristics showed a mean cycle length of 27.48 ± 3.43 days (95% CI: 26.94–28.02), indicating predominantly regular cycles within the normal physiological range. The mean duration of menstrual bleeding was 4.83 ± 1.24 days, with 34.9% (n = 78) reporting prolonged bleeding of ≥7 days. These baseline characteristics are detailed in Table 1.

Table 1. Demographic and menstrual characteristics of study participants

The overall prevalence of dysmenorrhea in this cohort was 84.2% (n = 188; 95% CI: 79.1–88.2%), indicating that more than four out of every five students experienced menstrual pain. Only 15.8% (n = 35) reported no menstrual pain in the last six months.

Among those with dysmenorrhea, pain was experienced every month by 47.6% (n = 89), most months by 18.4% (n = 35), occasionally by 25.9% (n = 49), and rarely by 8.2% (n = 15). In terms of severity, based on the Verbal Multidimensional Scoring System (VMSS), 34.7% (n = 77) reported mild pain (Grade 1), 26.6% (n = 59) had moderate pain (Grade 2), and 23% (n = 52) experienced severe pain (Grade 3) associated with marked activity limitation and systemic symptoms.

The distribution of prevalence, frequency, and severity is presented in Table 2, while Figures 1 and 2 visually depict overall prevalence and severity distribution, respectively.

Table 2. Prevalence, frequency, and severity of dysmenorrhea

Figure 1. Prevalence of dysmenorrhea among study participants.

Figure 2. Severity distribution of dysmenorrhea as per VMSS grades.

Lifestyle variables, including BMI, fast food consumption, and physical activity, were examined for their association with dysmenorrhea. The majority of participants (77.2%) had a BMI within the normal range (18.5–24.99 kg/m²), 8.9% were underweight, and 13.9% were overweight or obese. Dysmenorrhea prevalence was slightly higher in the normal BMI group (81.4%) compared to underweight (75.0%) and overweight (80.6%) groups, but these differences were not statistically significant (p = 0.147).

Fast food consumption was common, with 81.0% (n = 181) consuming commercially prepared foods regularly. Dysmenorrhea prevalence among fast food consumers was 86.7%, compared to 73.8% in non-consumers (p = 0.287).

In terms of physical activity, 75.3% (n = 168) reported less than 30 minutes of outdoor exercise daily, and these students had a slightly higher prevalence of dysmenorrhea (86.9%) than those exercising ≥30 minutes/day (76.4%). However, this difference was not statistically significant (p = 0.062). These results are summarized in Table 3.

Table 3. Dysmenorrhea and lifestyle factors

Several menstrual characteristics were significantly associated with dysmenorrhea (Table 4).

• Early menarche (≤12 years): Prevalence was 88.6%, significantly higher than in those with menarche at 13–14 years (75.0%) or ≥15 years (72.0%) (p = 0.022).
• Prolonged menstrual cycle (≥35 days): Associated prevalence was 77.3%, compared to 88.9% in those with a cycle length of 21–34 days (p = 0.020).
• Prolonged bleeding (≥7 days): Prevalence was 76.9% versus 88.3% in those with shorter bleeding duration (p = 0.027).
• Positive family history: The strongest association was observed here — prevalence reached 94.9% among students with a mother or sister with dysmenorrhea, compared to 58.5% among those without such history (p < 0.001).

These findings highlight the importance of genetic and menstrual pattern-related risk factors in the occurrence of dysmenorrhea.

Table 4. Association between menstrual characteristics and dysmenorrhea

Figure 3. Significant menstrual factors associated with dysmenorrhea.

Dysmenorrhea had a notable impact on daily and academic activities (Table 5). Among affected students, 52.7% reported reduced participation in social activities during menstruation, and 74.4% limited sports or other physical activities. Most strikingly, 79.8% of students with dysmenorrhea reported missing classes due to menstrual pain, a statistically significant finding (p < 0.001).

Table 5. Impact of dysmenorrhea on daily life

Premenstrual symptoms were reported by 67.7% (n = 151) of the total participants. Dysmenorrhea prevalence was slightly lower among those with PMS (78.3%) compared to those without PMS (86.1%), but this difference was not statistically significant (p = 0.218).

Similarly, 32.7% (n = 73) reported experiencing stress in the month preceding the survey, with no significant difference in dysmenorrhea prevalence between stressed (80.8%) and non-stressed (86.0%) students (p = 0.644).

When analyzed by age group, dysmenorrhea was significantly more prevalent among younger students. The highest prevalence was in the 20–22 years group (92.7%), followed by the 17–19 years group (82.7%), while the lowest was observed in students above 23 years (69.6%) (p = 0.010) (Table 6).

Table 6. PMS, stress, and age group associations with dysmenorrhea

Key Findings

This study identified a markedly high prevalence of dysmenorrhea (84.18%) among college-going female students in Jhalawar, Rajasthan. The majority of affected participants experienced recurrent monthly pain, with almost half reporting moderate to severe symptoms. Menstrual characteristics significantly associated with dysmenorrhea included early menarche (≤12 years), prolonged cycles (≥35 days), and extended bleeding duration (≥7 days). A strong association was also observed with a positive family history. In contrast, lifestyle-related factors such as physical inactivity, fast-food consumption, premenstrual symptoms (PMS), and perceived stress did not show statistically significant relationships.

Comparison with Existing Literature

Prevalence and Severity

The prevalence observed in our cohort is at the upper range of global estimates, which vary from 45% to over 90% depending on study design, population, and diagnostic criteria^[3]. Comparable high prevalence has been reported in multi-country meta-analyses of young women in academic settings^[13]. In contrast, earlier Indian studies, such as those by Sharma et al. (33%) and Singh et al. (40.7%), reported lower prevalence rates^[7,15]. Such variation may reflect differences in definitions used, recall periods, and the sensitivity of data collection tools.

Severity distribution in our study—26.58% moderate and 23% severe—aligns with reports from Turkey (36.4% moderate/severe) and Australia (up to 25% severe)^[13,16]. These figures underline the considerable functional impairment associated with dysmenorrhea, particularly when severe pain is accompanied by systemic symptoms.

Menstrual Characteristics

Early menarche emerged as a significant risk factor, consistent with longitudinal studies demonstrating that girls with earlier onset menstruation have higher lifetime risk and longer cumulative exposure to dysmenorrhea^[17]. The biological basis may relate to prolonged exposure to prostaglandin-mediated uterine activity and heightened nociceptive sensitivity during adolescence^[10].

Similarly, prolonged cycles and extended bleeding duration were associated with higher dysmenorrhea prevalence. This finding is supported by work linking anovulatory or hormonally irregular cycles with increased prostaglandin release and ischemic uterine contractions^[9]. However, as in Klein and Litt’s work^[18], menstrual irregularity per se did not correlate with dysmenorrhea severity, suggesting that cycle length and bleeding duration may be more influential than regularity.

Familial Predisposition

One of the strongest associations was with family history, echoing findings from Ju et al. and Dawood, who suggested that genetic predisposition, shared environmental factors, and learned pain perception may all contribute^[13,19]. Familial clustering of dysmenorrhea has been linked to inherited variations in prostaglandin synthesis and pain modulation pathways^[20].

Lifestyle and Psychosocial Factors

While most participants reported fast-food consumption and low physical activity, these were not statistically significant predictors in our cohort. This contrasts with studies in Saudi Arabia and Mexico linking unhealthy diets and sedentary lifestyles to greater dysmenorrhea severity^[14,21]. Possible explanations include the homogeneity of lifestyle patterns in our sample, underreporting, or unmeasured confounders.

PMS and perceived stress were common but not significantly related to dysmenorrhea in this study, diverging from findings by Avasarala and Panchangam, who reported a strong link between psychological stress and menstrual pain^[22]. Cultural perceptions, coping strategies, and differences in stress measurement tools may partly account for this discrepancy.

Age Distribution

We observed a decline in dysmenorrhea prevalence after age 23 years. Similar trends have been documented in Scandinavian and Turkish cohorts, attributed to hormonal stabilization, reduced prostaglandin synthesis, and increased pain tolerance with age^[16,23].

Possible Mechanisms

The pathophysiology of primary dysmenorrhea is well established, centring on excessive endometrial prostaglandin F₂α production during menstruation, leading to increased myometrial tone, high-frequency contractions, and ischemic pain^[19]. Leukotrienes, vasopressin, and central sensitization may exacerbate symptoms in severe or refractory cases^[12]. Our associations with early menarche, prolonged cycles, and extended bleeding are biologically plausible in this context, as these factors can intensify prostaglandin-mediated uterine activity.

Public Health and Clinical Implications

The high prevalence, coupled with the observed rate of class absenteeism, highlights dysmenorrhea as both a medical and educational concern. Colleges should consider integrating menstrual health screening, counselling, and evidence-based management strategies—including NSAID use, hormonal therapy where indicated, and lifestyle interventions—into student health services. Educational initiatives could reduce symptom normalization and promote early help-seeking.

Strengths and Limitations

Strengths of this study include a well-defined cohort and the use of a structured, pre-tested questionnaire. Limitations include reliance on self-reported data, potential recall bias, and absence of objective hormonal or imaging studies to exclude secondary dysmenorrhea. The cross-sectional design precludes causal inference. Future longitudinal research incorporating hormonal assays, detailed dietary and activity logs, and validated stress assessment tools could clarify modifiable risk factors.

Future Directions

Given the high burden and functional impact, future work should focus on evaluating cost-effective, culturally appropriate interventions in college populations. Randomized trials comparing pharmacological, behavioural, and educational approaches could inform integrated management strategies.

Dysmenorrhea was found to be highly prevalent among college-going female students in Jhalawar, Rajasthan, with over four-fifths of participants reporting symptoms, and a substantial proportion experiencing moderate to severe pain. Significant associations were observed with early menarche, prolonged menstrual cycles, extended bleeding duration, and a positive family history, suggesting both biological and hereditary influences.

Although lifestyle factors such as physical inactivity and dietary habits were not statistically significant in this cohort, the high functional impact—particularly class absenteeism—underscores dysmenorrhea as a relevant academic and public health concern. Early identification of at-risk students, combined with accessible menstrual health education, effective symptom management, and targeted counselling, may help reduce the burden of this condition.

Future research should employ longitudinal designs and objective assessments to clarify causal relationships and evaluate culturally appropriate interventions that can be integrated into college health programs.

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