International Journal of Pharma and Bio Sciences A STUDY OF THE PREVALENCE, SEVERITY AND TREATMENT OF DYSMENORRHOEA IN MEDICAL AND NURSING STUDENTS

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1 International Journal of Pharma and Bio Sciences RESEARCH ARTICLE PHARMACOLOGY A STUDY OF THE PREVALENCE, SEVERITY AND TREATMENT OF DYSMENORRHOEA IN MEDICAL AND NURSING STUDENTS KIRAN B* 1, TASNEEM SANDOZI 1, AKILA L 1, ANANYA CHAKRABORTY 2,MEHERBAN 2 AND R JAMUNA RANI 1 1 Department of Pharmacology, SRM Medical College and Research Centre, SRM University,, Tamilnadu, India. 2 Department of Pharmacology, Vydehi Institute of Medical Sciences and Research Centre,, Karnataka, India. Department of Zoology, University of Allahabad, Allahabad, , India KIRAN B Department of Pharmacology, SRM Medical College and Research Centre, SRM University,, Tamilnadu, India. *Corresponding author ABSTRACT To study the prevalence, severity and treatment of dysmenorrhoea in medical and nursing students. A total of 401 and 97 students from SRM University, and Vydehi Institute of Medical Sciences and Research Center, respectively were enrolled in this study. In 306 students gave a history of dysmenorrhoea giving a prevalence of 76.30%. 57.1% had severe and 19.20% had mild dysmenorrhoea. All the students enrolled in presented with a history of dysmenorrhoea, 73.19% with severe and 26.80% mild dysmenorrhoea. Allopathic treatment was taken by 33 and 37.11%, home made remedies by 6.20 and 2.06% and ayurvedic medicines by 0.98 and 1.03% by and students respectively. Homeopathic treatment was taken by 2.28%students in only. It is important to spread awareness about the causes and treatment of dysmenorrhoea to avoid undue sufferings causing absenteeism from work and studies. P - 161

2 KEYWORDS Dysmenorrhoea, non-steroidal anti-inflammatory drugs (NSAIDs), prostaglandins. INTRODUCTION The term dysmenorrhoea is derived from the greek words dys (difficult, painful or abnormal), meno (month) and rrhea (flow). It refers to severe, painful cramping sensation in the lower abdomen often accompanied by other biological symptoms including sweating, tachycardia, headache, nausea, vomiting, diarrhea and tremulousness occurring just before or during the menses. It is a common gynaecological problem among adolescent ladies which is severe enough to keep them from functioning at home, college or work place for a day or two every month. Dysmenorrhoea is of two types- primary and secondary. Primary refers to pain with no obvious pathologic pelvic disease which occurs in women younger than 20 years of age. Secondary is painful menses resulting from pelvic pathology like endometriosis, pelvic inflammatory disease, adenomyosis, fibroids and polyps. It is mostly seen in women older than 20 years of age. (1) Dysmenorrhoea is caused by the release of prostaglandins in the menstrual fluid, which cause uterine contractions responsible for the pain. MATERIALS AND METHODS A prospective cross sectional study was done between March and July The study was done in medical and nursing colleges of two different states of South India. Ethical approval was obtained from the respective ethical committees at both places. A written informed consent was obtained from all the students. The students were asked to complete a self assessment questionnaire related to menstruation. Questionnaire elucidated variations in menstrual patterns viz age of attaining menarche, type of menstrual cycle, family history of dysmenorrhoea, symptoms experienced, number of days of menstrual bleeding, college absenteeism during menstruation, type of medications and associated gynaecological problems. RESULTS The prevalence of dysmenorrhoea was and 100% in medical and nursing students of and respectively. The students experienced various symptoms like severe abdominal cramps, mild leg cramps, nausea, vomiting, headache, giddiness and so on. (Table-2)(Figure. 2). Table 2 Symptoms experienced by the students during menstruation Physical symptoms n=306 Head ache 61(19.93 %) 21(21.64 % ) Giddiness 41 (13.39 %) 15(15.46 %) Syncope 7(2.28% ) 2(2.06 % ) Breast engorgement 30 (9.80 %) 8(8.24%) Nausea, vomiting 44(14.37 % ) 13(13.40 %) P - 162

3 Anorexia 23(7.51 %) 15(15.46 %) Diarrhoea 31(10.13%) 13(13.40%) Sweating 39(12.74 %) 18(18.55%) Chills 20(6.53 %) 4(4.12% ) Abdominal cramps 229(74.83%) 55(56.70 %) and pain Cramps of lower limbs (41.23%) (36.60% ) Psychological symptoms Mood swings 88(28.75 %) 56(57.73%) Figure 2 Severity of symptoms Severe abdominal cramps were considered as severe dysmenorrhoea in this study. 57.1and 73.19% of students had severe dysmenorrhoea in and respectively.(table.1) Table 1 Severity of dysmenorrhoea(%) n=401 Severe dysmenorrhoea 229( 57.10%) 71(73.19%) Mild dysmenorrhoea 77 (19.20%) 26 (26.80%) Nearly 50 and 36% of the students from and respectively presented a family history of dysmenorrhoea.(figure.1)(table.3) Table 3 Positive Family history of dysmenorrhoea Family history n=306 Mother 106(34.64%) 26(26.80%) Sister 53(17.32%) 9 (9.27%) P - 163

4 Figure. 1 Positive family history of dysmenorrhoea The mean age of attaining menarche was years in and years in with a range of 9-16 years. (Table.4) Table 4 Age of attaining menarche Age of attaining menarche n= (0.5% ) 1(1.03%) 10 2(0.5%) 1(1.03 %) 11 16(3.99%) 2(2.06 %) 12 69(17.2 % ) 24(24.74%) (41.64%) 40(41.23 %) 14 93(23.19% ) 21(21.64 %) 15 47(11.72 %) 6(6.19%) 16 5(1.25%) 1(1.03% ) and 78.35% had regular and and 21.64% had irregular cycles both in and students respectively.(table.5) Table 5 Type of menstrual cycle Type of cycle n=401 Regular 330(82.29 %) 76(78.35 %) Irregular 71(17.70 %) 21(21.64%) The average duration of menstrual flow was 2.5 and 3.5 days in and students respectively. (Table.6) P - 164

5 Table 6 Average duration of bleeding No. of days n= (3.49%) Nil 2 109(27.18 %) Nil 3 144(35.91 %) 6(7.65%) 4 or more 98(24.43%) 70(89.34%) Not mentioned 36(8.97% ) 21(21.64%) and 39.18% students took treatment and and 60.82% did not take any treatment in and respectively.(table.8) Table 8 Allopathic treatment taken for dysmenorrhoea Drug name n=84 n=36 Ibuprofen 34(33.36%) 2.77% (1) Mefenamic acid + dicyclomine 23(22.77 %) Nil Mefenamic acid 1(0.99%) 36.11% (13) Paracetamol 2(1.98 %) 5.55% (2) Diclofenac sodium 2(1.98 %) 5.55% (2) Ketorolac 1(0.99 %) Nil Nimesulide 1(0.99 % ) 5.55% (2) Sodium metamizol ( Baralgan) 1(0.99%) Nil Dicyclomine 5(4.95 %) 41.66% (15) Hyoscine 2(1.98 %) Nil Drotaverine 3(2.97% ) Nil Metoclopramide 3(2.97%) Nil Ondansetron 1(0.99%) Nil Loperamide 2(1.98 %) Nil Domperidone + Pantoprazole 1(0.99 %) Nil Medroxy progesterone 1(0.99 %) 2.77% (1) Zn + Vitamins 1(0.99 %) Nil Not mentioned the drug name 17(16.83%) P - 165

6 The treatment taken included allopathic (33 and 37.11%), home made remedies (6.20 and 2.06%) and ayurvedic medicines (0.98 and1.03%) by and students respectively. Only 2.28% of students had taken homeopathic treatment.(table.7)(figure. 3) Table 7 Type of medication n=306 Allopathy 101(33%) 36(37.11% ) Ayurveda 3(0.98%) 1(1.03%) Homeopathy 7(2.28%) NIL Home made medicine 19(6.20%) 2(2.06%) No treatment 177(57.84%) 59(60.82%) Figure 3 Type of medication Figure 4 Students on NSAIDs P - 166

7 The students on allopathic treatment had mainly taken non-steroidal anti-inflammatory drugs (NSAIDs) alone or in combination with anti-cholinergic drugs.(table.9) Table 9 Groups of drugs taken by students n=84 n=36 Analgesics 42(50%) 13(36.11%) Analgesic+ anti muscarinic 23(27.38%) Nil Anti muscarinic antispasmodic 7(8.33%) 14(38.88%) Non anti-muscarinic anti spasmodic 3(3.57 %) Nil Anti emetics 5(5.95%) Nil Antidiarheals 2(2.38 %) Nil Oral contraceptive pills 1(1.19 %) 1(2.77%) Nutritional supplements 1(1.19%) Nil Oral contraceptive pills were taken by only one student in both and and 27.77% students from and respectively students took physician prescribed treatment. 42 and 55.55% students self medicated in and respectively.(table.11) The duration of treatment was 1 to 2 days in nearly 50% of treated cases in both places and 5.15% of students consulted a gynaecologist for their dysmenorrhea in and respectively.(table.13) Table 10 No. of students on different NSAIDs NSAID n=42 n=20 Ibuprofen 34(80.95% ) 1(5% ) Mefenamic acid 1(2.38%) 13(65%) Paracetamol 2(4.76%) 2(10%) Diclofenac sodium 2(4.76%) 2(10%) Ketorolac 1(2.38 % ) Nil Nimesulide 1(2.38 % ) 2(10%) Sodium metamizol (Baralgan) 1(2.38%) Nil P - 167

8 Table 11 Type of medication Doctor prescribed Self medication n=84 n =36 41(48.80%) 10 (27.77%) 42(50%) 20 (55.55%) Table 12 Duration of drug intake No. of days n=130 n = (48.46%) 18(46.15%) 2 14(10.76 %) 5(12.82%) 3 6(4.61% ) 6(15.38%) Not mentioned 47(36.15%) 9(23.07%) Table 13 No. of students on Gynaecologist consultation Gynaecologist Consultation n=306 n =97 Yes 35(11.43%) 5(5.15%) 3.59 and 1.03% of students had associated polycystic ovarian disease in and respectively.(table.14) Table 14 Probable secondary causes of dysmenorrhoea Pathology n=306 n =97 PCOD 11(3.59 %) 1(1.03%) Ovarian cyst 1(0.32 % ) Nil Endometriosis 1(0.32% ) Nil Ovarian cyst and endometriosis was detected in 0.32% of cases each in. Dysmenorrhoea resulted in half to one day absence from college attendance in and 11.11% of students in and 4.12 to 6.18% students in. (Table.15) (Figure.5) P - 168

9 Table 15 No.of days of college absenteeism No. of days n=306 n =97 Half 33(10.78%) 4(4.12%) One 34(11.11 %) 6(6.18%) Two 5(1.63 % ) 1(1.03% ) Three 2(0.65 %) 1(1.03%) Figure 5 Number of days of college absenteeism DISCUSSION Dysmennorrhoea presents as crampy pelvic pain occurring at the onset of menstruation lasting for 1-3 days. Primary dysmenorrhoea is attributable to increased endometrial synthesis of prostaglandins PGE 2 and PGF 2α during menstruation. About 2-4 days before the onset of menstruation prostaglandins proceed into the uterine muscle and cause uterine contractions that help in the expulsion of the endometrium. (2) Non steroidal anti inflammatory drugs (NSAIDs) are the best established initial therapy for dysmenorrhoea as they have direct analgesic effect through inhibition of prostaglandin synthesis and they also decrease the volume of menstrual flow. (3) In this study, allopathic treatment was taken only by and 33% of students from and respectively despite and 57.10% of them suffering from severe dysmenorrhea and 41.58% of and students respectively had taken NSAIDs during menstrual pain. Among NSAIDs, Ibuprofen was taken by and 5% students in and respectively. Mefenamic acid was taken by 65% students from.oral contraceptive pills (OCPs) have also shown to be useful in the treatment of dysmenorrhoea.they are more effective than placebo in primary dysmenorrhoea in reducing menstrual fluid P - 169

10 volume and prostaglandins to within, or even below normal range with concomittant clinical relief during menstrual cycle. They also lower the elevated plasma vasopressin levels found in dysmenorrheic women and lead to attenuation of the excessive uterine activity. (4) In our study, OCPs were taken by only one student in both and. A combination of mefenamic acid and dicyclomine was taken by 22.77% students in only and 57.84% students from and respectively had not taken any treatment. The percentages in these results point to us a very important fact that there is no knowledge of dysmennorrhea even in students pursuing medical and nursing courses in two metropolitan cities of South India. It also calls for inclusion of such topics in the curriculum at the level of high school itself so that adolescent girls have complete knowledge and information of the most common gynaecological problem faced by women. This would help in starting proper treatment with precise drugs on time to avoid absenteeism from college or work which has been seen in this study to an extent of and 12.37% in and students respectively. The media can also help in spreading medical knowledge to homemakers and professional women. Public health campaigns by medical personnel can also help in serving this message. Educational campaigns can improve awareness of safety and effectiveness of allopathic treatment and also remove myths related to dysmennorhoea. Self medication with inadequate medical knowledge should be strongly discouraged as one student had taken sodium metamizol (baralgan) which is a banned drug due to the risk of agranulocytosis, hypersensitivity and shock. CONCLUSION It is very important to spread awareness about the causes and treatment of dysmenorrhoea via the education system and the media so that proper treatment with the precise drug is taken to avoid undue sufferings causing absenteeism from work and studies. ACKNOWLEDGEMENTS We thankfully acknowledge Dr.James Pandian,Dean,SRM Medical College Hospital & Research centre who permitted us to conduct this study. REFERENCES 1. Gretchen M.Lentz.Primary and secondary dysmenorrhoea, premenstrual syndrome, and premenstrual dysphoric disorder.in: Katz,Lentz,Lobo,Gershenson(eds.),Compr ehensive Gynecology,Mosby Elsevier,2007,pp Alaettin Unsal,Unal Ayranci,Mustafa Tozun, Gul Arslan, Elif Calik.,Prevalence of dysmenorrhoea and its effect on quality of life among a group of female university students.upsala Journal of Medical Sciences,115: ,(2010) 3. Linda French.,Dysmenorrhoea. American Family Physician,71(2): ,(2005) 4. M.Yusoff Dawood.,Primary Dysmenorrhoea: Advances in Pathogenesis and Management.Obstetrics and Gynecology,108(2): (2006) P - 170