International Journal of Gynecology and Obstetrics 108 (2010) 139–142

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International Journal of Gynecology and Obstetrics

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o

CLINICAL ARTICLE

Dysmenorrhea in a multiethnic population of adolescent Asian girls

Li Ping Wong a,⁎, Ee Ming Khoo b
a
Medical Education and Research Development Unit, University of Malaya, Kuala Lumpur, Malaysia
b
Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To determine the prevalence of dysmenorrhea, its impact, and the treatment-seeking behavior of
Received 28 July 2009 adolescent Asian girls. Method: A cross-sectional study with 1092 girls from 15 public secondary schools and
Received in revised form 2 September 2009 3 ethnic groups in the Federal Territory of Kuala Lumpur, Malaysia. Results: Overall, 74.5% of the girls who
Accepted 14 October 2009 had reached menarche had dysmenorrhea; 51.7% of these girls reported that it affected their concentration
in class; 50.2% that it restricted their social activities; 21.5% that it caused them to miss school; and 12.0%
Keywords:
that it caused poor school performance. Ethnicity and form at school were significantly associated with the
Adolescent girls
Dysmenorrhea
poor concentration, absenteeism, and restriction of social and recreational activities attributed to
Impact dysmenorrhea. Only 12.0% had consulted a physician, and 53.3% did nothing about their conditions. There
Prevalence were ethnic differences in the prevalence, impact, and management of dysmenorrhea. Conclusion: There is a
Urban need for culture-specific education regarding menstruation-related conditions in the school curriculum.
Seeking treatment © 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Dysmenorrhea is one of the most common gynecologic complaints
in adolescent girls seen in primary care [1]. Across the United States,
the prevalence of dysmenorrhea varies widely, ranging from more
than half to more than 90% of menstruating adolescents [1–3].
Somewhat lower rates (84.2%) have been reported for Asia, with
84.2% for Southeast Asia (Thailand) [4], 68.7% for Eastern Asia [5],
74.8% for the Middle East [6], and 54.0% for Southern Asia [7]. The
prevalence reported for Malaysia is 69.4% [8].
Dysmenorrhea is the primary cause of short-term absences from
school [3,4,9–11] and has led to high rates of nonparticipation in social
activities [3,4,9,11]. In addition, dysmenorrhea hinders the girls’
ability to concentrate on their studies, affects their academic
performance, and has significant consequences for both the individual
and society [11]. Despite its high prevalence and associated negative
effects, many women do not seek medical care for this condition [12].
Reported reasons for not seeking medical care are the perception that
painful periods are part of a woman's experience, not knowing that
menstrual pain can be relieved [13], and a lack of family support [5].
The aim of the present study was to explore the attitudes and
problems related to menstruation, premenstrual syndrome, and dys-
menorrhea among adolescent girls in Malaysia attending public
secondary schools. The article presents our findings on dysmenorrhea,
⁎ Corresponding author. Medical Education and Research Development Unit, Faculty of
Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia. Tel.: +60 3 79675738;
fax: +60 3 79675769.
E-mail address: wonglp@ummc.edu.my (L.P. Wong).
its personal and social impact, and the treatment-seeking behavior of
these adolescents.
2. Participants and methods
The school principals of the 94 public secondary schools in the
Federal Territory of Kuala Lumpur were sent information about the
study, along with a copy of the approval letter from the Ministry of
Education of Malaysia, to seek their permission to allow girls in forms 1
through 6 to participate. One class per form was randomly selected from
each participating school. The girls and their parents or caregivers were
then asked for consent. The participating girls were asked to answer a
semistructured questionnaire about menstruation, premenstrual syn-
drome, and dysmenorrhea. The questions concerning dysmenorrhea
assessed each participant's attitudes toward this condition, its impact on
her performance at school and her social activities, and whether she has
sought information and treatment. The questions were adapted from
previous studies [4–6,10,12] and face-validated by a panel of experts.
The questionnaire was available in 2 languages, Malay (the national
language of Malaysia) and English, and the suitability of the Malay
version was verified by back translation at the Malaysia Institute of
Language and Literature. The study was approved by the Ministry of
Education Malaysia and the Medical Ethics Committee of University
Malaya Medical Center, Kuala Lumpur, Malaysia.
Data were analysed using the SPSS package for Windows, version
17.0 (SPSS, Chicago, IL, USA). P b 0.05 was considered significant. Data
analysis consisted in calculating descriptive statistics for the demo-
graphic variables as well as the frequency of concordant answers to each
question. We performed multivariate logistic regression to identify
predictors of the personal and social impact of dysmenorrhea (such as

0020-7292/$ – see front matter © 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijgo.2009.09.018
140 L.P. Wong, E.M. Khoo / International Journal of Gynecology and Obstetrics 108 (2010) 139–142

poor concentration, absenteeism, restriction of activities, and low dysmenorrhea, were drinking cold water or taking a cold bath during
grades). Goodness of fit was assessed by the Hosmer-Lemeshow test. menstruation.
There were 801 girls who reported having dysmenorrhea, for a
3. Results prevalence of 74.5%. Table 2 shows the characteristics of the girls with
and without dysmenorrhea. Compared with girls from other ethnic
Only 15 of the 94 public secondary schools agreed to participate. groups, significantly fewer Chinese girls reported having experienced
Two were girls-only schools, 13 were coeducational, and all were dysmenorrhea. The condition was significantly more prevalent among
multiethnic and multireligious. A total of 1092 girls answered the upper secondary school girls.
questionnaire. Their mean ± SD age was 15.19 ± 1.39 years (range, Of the girls reporting dysmemorrhea, 51.7% indicated that it
13–19 years). Most (56.3%) were Chinese, followed by Malays affected their concentration in the classroom, and approximately half
(31.7%), and Indians (11.2%). Their sociodemographic characteristics (50.2%) indicated that it restricted their social and recreational
are shown in Table 1. activities. While 21.5% considered dysmenorrhea to be a leading
More students (59%) from the lower secondary levels partici- reason for them to miss school, 16.4% thought that it affected their
pated, as the school principals thought the upper secondary students school performance and caused them to receive lower grades.
(those in forms 5 and 6) needed to concentrate on preparing for the Multivariate analysis showed that the Malays and those in the
Sijil Pelajaran Malaysia examination (the Malaysian Certificate of upper secondary levels had significantly higher odds of experiencing
Education) or the Sijil Tinggi Persekolahan Malaysia examination (the poor concentration, missing school, and abstaining from social and
Malaysian Higher School Certificate of Education, which allows recreational activities because of dysmenorrhea. Being in the upper
students to enter the university). Only 2% of the responses were secondary level and from a household with a low income were
from sixth-form students, as most of the participating schools did not predictive of poor school performance or low school grades (Table 3).
have this form. The participants lived in households with a mean and The results of the Hosmer-Lemeshow goodness-of-fit test did not
median income of 3242 and 2000 Malaysian ringgits (MYR), reach significance, which indicates very good fit for the model.
respectively (1 US Dollar = 3.6 MYR). All but 16 girls reported to The treatment-seeking behavior of the girls with dysmenorrhea is
have reached menarche (a response to this question was missing for shown in Table 4. Only 12.0% of these girls had consulted a physician,
1 girl). The mean age at menarche was 12.18 ± 1.07 years. and more than half (53.3%) had done nothing about their condition.
Of the 1075 who had reached menarche, and were included in the The reported management of dysmenorrhea was mainly self-care,
analysis, 67.8% believed that dysmenorrhea was a normal part of the which included massage with an ointment, the use of an over-the-
menstrual cycle; 11.3% that dysmenorrhea was an illness with no counter pain killer (paracetamol), herbal or traditional remedies, and
cure; 9.4% that dysmenorrhea caused infertility; and 8.8%, most of using a hot pad. About 46.0% of the girls who reported taking over-
whom were Chinese, that washing one's hair on the first day of the-counter pain killer for dysmenorrhea were Malays (χ2 = 42.4;
menstruation caused dysmenorrhea. Other reported causes for df = 3; P b 0.001), while the Chinese girls (72.3%) preferred herbal or
traditional remedies (χ2 = 43.0; df = 3; P b 0.001). The Chinese girls
(42.7%) were also more likely to see a physician and take the
Table 1 physician's prescribed medication than were the Malay (39.6%) and
Demographic characteristics of the 1092 original respondents.a the Indian (15.6%) girls (χ2 = 5.3; df = 3; P b 0.02).
Only 67.5% of the total number of participants had acquired
Characteristic No. (%)
information regarding dysmenorrhea. Most (53.3%) had acquired
Ethnicity b information from their mothers, followed by school friends (36.4%),
Malay 346 (31.7)
Chinese 615 (56.3)
Indian 122 (11.2)
Other 9 (0.8) Table 2
Religion Characteristics of 1075 menstruating girls with and without dysmenorrhea.a
Islam 352 (32.2)
Buddhist 539 (49.4) Characteristic Dysmenorrhea χ2 (df) P value
Hindu 108 (9.9)
Yes (n = 801) No
Christian 90 (8.2)
Other 3 (0.3) Ethnicity
Levels of education Malay 275 (79.7) 70 (20.3) 45.9 (3) b 0.001
Lower secondary Chinese 420 (69.8) 182 (30.2)
Form 1 159 (14.6) Indian 98 (82.4) 21 (17.6)
Form 2 227 (20.8) Other 8 (100.0) 0
Form 3 258 (23.6) Levels of education
Upper secondary Lower secondary 442 (70.2) 188 (29.8) 19.3 (1) b 0.001
Form 4 256 (23.4) Upper secondary 359 (80.9) 85 (19.1)
Form 5 170 (15.6) Mean household income, MYRb,c
Form 6 22 (2.0) N4000 186 (75.3) 61 (24.7) 2.2 (2) 0.70
Mean household income, MYRb,c 2000–4000 171 (77.4) 50 (22.6)
N4000 251 (24.1) b2000 411 (73.1) 147 (26.3)
2000–4000 221 (22.3) The parents areb
b2000 569 (54.7) Married 710 (74.6) 242 (25.4) 3.0 (2) 0.75
The parents are b Divorced/separated 47 (68.7) 21 (31.3)
Married 968 (88.8) One or both deceased 41 (80.4) 10 (19.6)
Divorced/separated 69 (6.3) Smoking statusb
One or both deceased 53(4.9) Yes 21 (91.3) 2 (8.7) 4.3 (1) 0.37
Menarcheb No 776 (74.1) 271 (25.9)
Yes 1075 (98.5) Frequent exerciseb
No 16 (1.5) Yes 464 (75.7) 149 (24.3) 5.0 (1) 0.29
a No 334 (73.2) 122 (26.8)
The values are based on the participants’ answers; they do not add up to 100%
a
because they were rounded. Values are given as number (percentage) unless otherwise indicated.
b b
The number of responses was lower than the number of respondents. The number of responses was lower than the number of respondents.
c c
1 US Dollar = 3.6 Malaysian ringgits (MYR). 1 US Dollar = 3.6 Malaysian ringgits (MYR).
 L.P. Wong, E.M. Khoo / International Journal of Gynecology and Obstetrics 108 (2010) 139–142 141

Table 3
Results of logistic regression analyses predicting impact of dysmenorrhea (n = 801).
a
Characteristic No. Logistic regression OR (95% C.I.)

Poor concentration Absence from school Restrict social activities Cause low grades

OR CI P OR CI P OR CI P OR CI P

Ethnicity
Malay 275 1.82 1.38–2.40 0.000*** 2.13 1.55–2.92 0.000*** 1.60 1.22–2.11 0.001** 1.13 0.79–1.63 0.494
Non-Malay 526 1.00 – – 1.00 – – – – – 1.00 – –
Levels of education
Lower secondary 442 0.45 0.35–0.59 0.000*** 0.50 0.37–0.68 0.000*** 0.45 0.35–0.58 0.000*** 0.71 0.51–0.99 0.045*
Upper secondary 359 1.00 – – 1.00 – – 1.00 – – 1.00 – –
Average household income, (MYR) b
N4000 186 1.00 – – 1.00 – – 1.00 – – 1.00 – –
2000–4000 171 1.25 0.85–1.82 0.256 1.47 0.93–2.32 0.100 1.46 0.99–2.13 0.051 1.92 1.10–3.34 0.022
b2000 411 1.10 0.80–1.51 0.572 1.38 0.93–2.04 0.114 1.12 0.82–1.55 0.470 2.38 1.47–3.85 0.000***
Family type b
Parents are married 710 1.19 0.64–2.21 0.590 0.87 0.43–1.75 0.687 1.38 0.74–2.57 0.317 1.93 0.74–5.01 0.18
Parents divorced/separated 47 0.75 0.34–1.66 0.478 0.83 0.33–2.07 0.684 0.92 0.41–2.04 0.832 1.95 0.62–6.13 0.25
One or both parent deceased 41 1.00 – – 1.00 – – 1.00 – – 1.00 – –
Smoking b
No 776 0.60 0.24–1.52 0.28 0.56 0.23–1.36 0.200 0.67 0.28–1.64 0.384 0.49 0.19–1.23 0.130
Yes 21 1.00 – – 1.00 – 1.00 – – 1.00 – –
b
Exercise
No 334 0.99 0.77–1.29 0.964 1.01 0.74–1.38) 0.941 0.99 0.76–1.28 0.930 0.97 0.69–1.36 0.847
Yes 464 1.00 – – 1.00 – – 1.00 – – 1.00 – –
a
Odds ratio (95% confidence interval).
b
Number of respondents does not sum up to 801 due to non-responses.
*** P b 0.001; ** P b 0.01; * P b 0.05.
Model 1 Poor concentration; Hosmer and Lemeshow test, χ2 (8) = 6.201, p = 0.625; Cox and Snell R2 = 0.054; Nagelkerke R2 = 0.072.
Model 2 Absence from school; Hosmer and Lemeshow test, χ2 (8) = 4.016, p = 0.856; Cox and Snell R2 = 0.041; Nagelkerke R2 = 0.063.
Model 3 Restrict social activities; Hosmer and Lemeshow test, χ2 (8) = 3.076, p = 0.929; Cox and Snell R2 = 0.052; Nagelkerke R2 = 0.069.
Model 4 Cause low grades; Hosmer and Lemeshow test, χ2 (8) = 2.257, p = 0.972; Cox and Snell R2 = 0.021; Nagelkerke R2 = 0.035.

printed media such as magazines and newspapers (24.7%), and
teachers (20.2%). Other sources of information were radio and
television (6.5%), and the Internet (5.1%). Many participants (64.3%)
desired to know about the prevention and treatment of dysmenorrhea
as well as the reasons for dysmenorrhea (58.5%).
4. Discussion
The mean age at menarche in this study was consistent with the
age in a local study [8] and in studies from other regions [3,5,12], and
the 74.5% prevalence of dysmenorrhea was also consistent with the
prevalence reported in studies involving similar age groups [5,6,8,11].
Differences in menstrual bleeding among ethnic groups have been
reported in Western communities [14]. In a local study, a higher
prevalence of abnormal duration of menstrual flow was reported
among Malay girls [8]. There were differences in the prevalence of
dysmenorrhea among the 3 ethnic groups represented in this study,
and the Malay and Indian girls had the higher rates. It has been
suggested that the differences in symptoms of dysmenorrhea among
different ethnic groups are in part due to different cultural attitudes
toward menstruation [15]. It remains unclear if the high prevalence of
dysmenorrhea among the Malay girls in our study was related to
biological or cultural factors, and further studies are needed to explore
these issues.
Table 4
Treatments used for dysmenorrhea.a
Treatment used
Massage with ointment
Painkiller
Herbal/traditional remedies
Hot pad
Medication prescribed by a physician
Nothing
a
Values are given as number (percentage); multiple responses were allowed.
In this study, many girls accepted dysmenorrhea as a normal part
of menstruation and believed that it could not be alleviated. It has
been reported that such misperceptions were due to a lack of
information on the causes of dysmenorrhea, a lack of medical advice,
and poor lifestyle habits [4,5,9]. Improving the girls’ knowledge could
therefore influence their healthcare-seeking behavior.
Dysmenorrhea was more likely to affect the Malay girls in terms of
concentration in the classroom, absenteeism from school, and
restriction of social activities. The upper secondary students were
also more likely to be affected by dysmenorrhea, and this could be
attributed to higher academic challenges and expectations, greater
academic stress, and achievement anxiety. Although no epidemiolog-
ical study has reported a relationship between academic stress and
dysmenorrhea, an association between psychological and occupation-
al stress and dysmenorrhea has been shown in many studies [16,17].
The prevalence of dysmenorrhea in this study was 91.3% among
smokers and 73.3% and among nonsmokers. Although studies have
reported an association between severity of dysmenorrhea and ciga-
rette smoking [18], as well as a positive relationship between the
numbers of cigarettes smoked and dysmenorrhea [19], we found no
association between severity of dysmenorrhea and cigarette smoking.
This finding could be attributed to the small number of participants
who reported smoking.
Most girls with dysmenorrhea used a variety of self-care strategies
and complementary treatments in our study. Despite the considerable
impact of dysmenorrhea, both academically and socially, only 12% of
the girls sought medical care. This rate was higher in our study than
the 7% reported in Thailand [4], but lower than the 18% reported in
No. (%) Australia [11] for the same age groups. We also found that more than
(N = 801)
half (53%) of our participants did nothing to alleviate dysmenorrhea.
481 (60.0) Likewise, a study in Hong Kong reported that about half of the
298 (37.2)
adolescents girls studied did not seek treatment for menstrual pain
155 (19.4)
125 (15.6) [20]. This may suggest that there is substantial ignorance or
96 (12.0) misinformation among adolescent girls regarding treatment for
427 (53.3) dysmenorrhea [21]. Our study did not explore barriers to seeking
medical attention for menstrual problems. Nevertheless, the
142 L.P. Wong, E.M. Khoo / International Journal of Gynecology and Obstetrics 108 (2010) 139–142
participants’ responses indicated that they perceived dysmenorrhea
as being untreatable, and a normal aspect of menstrual cycle. These
were likely the reasons for their not seeking medical treatment.
This study revealed ethnic differences in the management of
dysmenorrhea. Further studies are warranted to investigate the
factors contributing to these differences, but the parents may have
the most important influence on an adolescent's healthcare-seeking
behavior. In this study, the Chinese girls were more likely to take
traditional or herbal remedies for their menstrual problems. A range
of traditional Chinese remedies have been used for centuries to treat
dysmenorrhea, they have been reported to be effective, with minimal
adverse effects [22], and are worth exploring.
Consistent with another local report [8], most adolescent girls in
this study considered their mother as their most important source of
information about dysmenorrhea. However, mothers could perpetu-
ate cultural myths, misperceptions, and negative attitudes toward
dysmenorrhea. The fact that few adolescents seek medical care for
dysmenorrhea may be due to a lack of knowledge. Reproductive health
is hardly approached in the formal school setting, and yet school may
be the only place, or the more appropriate place, for students to receive
accurate information about reproductive health [23,24]. Measures
should be taken to address this matter. It has been suggested that
education about menstruation should start before menarche, so that
the girls are prepared psychologically and physically [5].
We found that many girls would like to have information as to why
and how dysmenorrhea occurs. This suggests that reproductive health
classes should emphasize the physiology of dysmenorrhea and its
underlying causes. Adolescents also need to be informed about the
importance of seeking treatment and about treatment options.
Lifestyle and dietary modifications need to be emphasized. Emotional
and other psychological factors associated with dysmenorrhea may
also need to be attended. Peer-to-peer education may be helpful, as
adolescents spend a large portion of their time interacting with their
peers. Developing peer influence and peer support groups has been
shown to positively influence reproductive health behaviors among
adolescents [24].
The results of this study should be interpreted with caution owing
to the small number of schools that agreed to participate. Further-
more, the survey was conducted in an urban setting, with no
representatives from rural areas. The number of Chinese girls did
not match the ethnic distribution of Malaysia, and this group was
overrepresented. Although our sample may not have been represen-
tative of the nation, the mean household income per month, which
was MYR 3242, was close to the mean for Malaysia, which is MYR
3686 [25]. Additionally, we did not differentiate between primary and
secondary dysmenorrhea. Finally, all measures were based on self-
reporting, which is subject to error. Despite these limitations, this
study can serve as a guide to other multiethnic and multireligious
Asian communities or countries where reproductive health education
is not part of the school curriculum.
In conclusion, we found the prevalence of dysmenorrhea to be
high in the study population, especially among the Malay girls and the
upper secondary students, and the functional impairment caused by
dysmenorrhea was evident. The differences with which the 3 ethnic
groups handled dysmenorrhea highlighted a lack of knowledge about
dysmenorrhea on the part of Kuala Lumpur school girls, as well as
Chinese traditional practices that may be interesting to explore.
Reproductive health education should be incorporated early enough
in the school curriculum to prepare girls for menstruation and the
options available to them should they experience dysmenorrhea.
5. Conflict of interest
The authors declare that they have no conflict of interest.
Acknowledgment
This study was supported by Science Fund 14-02-03-4015 from
the Ministry of Science, Technology and Innovation Malaysia (MOSTI).
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