QUESTIONNAIRE BASED STUDY ON MENSTRUAL PATTERNS AMONG FEMALE MEDICAL UNIVERSITY STUDENTS OF RURAL NORTH INDIA.
Women's first menstruation is called menarche. It is an important maturity indicator used to assess the development status of a pubertal female. Menstruation is the natural part of the reproductive cycle.  One of the most common gynaecologic complaints in young women who present to the clinicians is Dysmenorrhoea.  Disorders in cycles or its irregularities are a major gynaecological problem among female adults especially adolescent and a major source of anxiety to them and their family. Premenstrual syndrome (PMS) is another problem that some women experience during the late luteal phase of each menstrual cycle (7-14 days prior to menstruation). Although various aetiologies of premenstrual syndrome such as elevated prolactin levels, hypoglycaemia or vitamin deficiencies have been proposed, none of these theories has been definitely proven. [4,5] Despite being a regular phenomenon the menstruation has been surrounded by secrecy and myths in many societies which affect many aspects of social and cultural life. 
Information on a women's menstrual pattern aids in clinical evaluation of gynaecological problems and will make womanhood easier for adolescent women and adults.
This Self-descriptive cross-sectional study was conducted to determine age at menarche, menstrual cycle length and regularity, duration and amount of flow, type and severity of pain related to menstruation, need for analgesia, and symptoms suggestive of premenstrual syndrome (PMS), impact of menstrual pain on academic and social activities, taboos related to menstruation and need of analgesia and treatment taken. Also, to infer the extent of awareness and source of information regarding menstruation possessed by Indian girls before attaining puberty.
The questionnaire included questions on concerning their age at menarche, menstrual cycle length and regularity, duration and amount of flow, type and severity of pain related to menstruation, need for analgesics, symptoms suggestive of premenstrual syndrome (PMS) and taboos related to menstruation. Respondents were also asked about the impact of menstruation and its disorders on the social life and academic activity. Other variables of interest included; any additional menstrual related symptoms or gynaecologic symptoms not mentioned in the questionnaire, source of information regarding menstrual health knowledge and academic performance were the main sources of information.
Aims & Objectives
To determine the menstrual pattern, menstrual disorders, information regarding menstruation and taboos associated with menstruation among female medical students of university of rural North India.
Self-descriptive cross-sectional study was carried out among female Medical students (MBBS I-V) between the ages 17-24 years. A Total of 235 questionnaires were administered to postmenarcheal Indian female students attending medical college in SGT University, Gurugram, Haryana between August 2017-July 2018. India. The sample size of 235 patients were taken for convenience.
MBBS girl students aged between 17 to 24 years, menstruating, and unmarried; those students who cooperated to provide correct and complete information and fitted into the study criteria were included for the study.
Respondents were selected from each class using stratified random sampling method. Students were briefed on the objective of the study and duly completed questionnaires were collected and analysed.
The data were analysed using SPSS for Windows version 16.0. Descriptive statistics was used to determine mean age of the subjects, age at menarche, frequency of menstrual disorders, prevalence of dysmenorrhea, PMS and activities affected by this condition.
Out of the 235 students, 200 responded to the questionnaire. The mean age of the female medical students was 19.45 [+ or -] 2.5 years. The mean age of menarche was 12.59 [+ or -] 1.25 years exhibiting wide variations, i.e., 10 to 16 years among the participants. Most respondents 184 (92 %) menstruated by the age of 15.
Menstrual characteristics as indicated by the selected subjects are presented in Table 1.
Regular menses occurred in 65.5 % (n = 131/200) of girls; a cycle length ranging from 21 to 35 days (Mean, 27.58 [+ or -] 1.79 days) and the mean duration of menstruation was 4.77 [+ or -]1.06 days with a range of 2-8 days. The pattern of menstrual related morbidities, additional symptoms reported by participants and treatment patterns are shown in Table 1.
166 respondents reported various menstrual disorders, giving a prevalence rate of 83 %. Dysmenorrhea was the most prevalent 140 (70 %) menstrual disorder in our sample, followed by PMS 64 (32 %), and abnormal cycle lengths 54 (27.5%)
Of the 140 (70%) girls who reported dysmenorrhoea 70 (50%) had mild, 48 (34.28%) moderate and 22 (15.72%) had severe dysmenorrhea.
Despite the fact that girls are studying in a medical college still only 36(18%) are consulting a doctor for help.
Overall, menstrual disorders prevented 29% (n=58) of students from participating in social activities and 12.5% (n = 25) from attending college.
Dysmenorrhea was responsible for the highest rate of college absenteeism (61 %) followed by PMS (38 %). The majority of absences (58 %) were for 1 day, with 32 % for up to 2 days and 3 girls reported missing up to 4 days of college each cycle.
169 (83.5%) of participants were aware of menstruation before attaining menarche. Source for information varied from mothers and friends to TV, magazines, and newspaper; nevertheless, the major sources were mothers and friends 148 (74%).
As shown in the table 5 there are many misconceptions about menstruation despite the fact that the students are studying medical education due to lack of awareness and communication. Maximum misconception is regarding that one should not enter temple, touch holy books, do not exercise and should not enter kitchen during menstruation.
235 questionnaires were distributed out of which 200 were retrieved of 85.4% which is a good response rate. A number of factors such as general health, genetic factors, socioeconomic and nutritional factors determine the age of menarche.  It has been reported that regional and racial differences have a lot of bearing on menarchial age. [8,9] Also studies have suggested that menarche tends to appear earlier in life as the sanitary, nutritional and economic conditions of a society improves. [10,11] The mean age for menarche observed in the present study from SGT Hospital was 12.59 [+ or -] 1.25 years which was lower compared to the result of other studies. Similar study from south India Mysore reported 13.36 [+ or -] 1.25 years. . Although small differences are obvious between the reported ages, varying from 13.06 [+ or -] 1.43 years in West Bengal  to 13.4, 13.5, and 13.6 years in Goa, Chennai, and East Delhi, respectively. [14,15,16,17] Recent reports from many countries of the world indicate a decline in the mean age; the current age as per reports from European and North American countries is 12.5 years, while 12.8 [+ or -] 1.3 years is from Turkey.  Our study is showing a decline in the menarcheal age lower than the various above studies.
This is similar to study from south India and as medical students coming to the university are a mix of girls from both urban and rural background.
Dysmenorrhoea 140 (70%) is the most common problem associated with female medical students in this study lower compared to other studies. Studies in Ethiopia and Turkey showed a overall prevalence of dysmenorrhoea among students 85.1% and 89.5% respectively which was higher than our study.  Recently, it has become an important public health problem among the female population; The proportion of mild, moderate and severe dysmenorrhoea in the present study were 67 (54, 9%), 49(37.78%)and 15(12.29%) respectively while study from Ethiopia showed 47.5%, 38.2% and 14.2% respectively which was almost comparable. Prevalence of dysmenorrhea among the selected group was 78.2% and 66.8% in studies on adolescents from south India  andjt was associated to early menarche age; similar observation is reported among Moroccan girls . Probably early onset of menarche leads to earlier ovulatory cycles and an earlier experience of dysmenorrhea. Occurrence of severe pain during menstrual period accounts for 3-20% in most population. Early menarche could be reason for significantly higher incidence of dysmenorrhoea. Various studies have shown that severity of pain decreases with increase in age, and in older women the frequency of severe pain decreases.
53.27% of dysmenorrhoeic women had limitation of their working ability while the south Indian study showed 68.8% of the participants said their working ability was affected to moderate extent, the association between severity of pain and limited work ability was statistically significant (P = 0.000). It is important to know the health problems of the general population so that corrective measures can be incorporated in the health intervention programs; our study has contributed to the current health-related problems of women which curtails their productivity. Although the problem faced by the women is for a short duration, the repetitiveness makes it a serious concern and requires a corrective measure.
The prevalence of PMS in our study was 52% which was almost similar to the Mysore study was 116 (58%). But this was less than the prevalence found among Jima University students of Ethiopia,  teacher training university students of Iran,  university students of Thailand  and university students of Nigeria  which was 99.6%, 98.2%, 85.5% respectively. This difference could be due to the different population studied different study groups, different time of study and different criteria used in different studies.
Other common disorders in present study were abnormal menstrual flow, abnormal duration of flow followed by irregular length of cycle. Our study showed that 34.5% girls had irregular cycles out of which 24% had prolonged cycles and 10.5% had frequent cycles which was significantly higher than the study from Mysore South India where 2.2% and 4.1% of the participants had to encompass short and long menstrual periods, respectively. It could be possible that the increase in the incidence of irregularity is due to changes in lifestyle that is being introduced in different spheres of life and various other factors like pollution, pesticides in food and drinking water in large quantities and radiation.
However, higher percentages (7-24%) of occurrence are reported from Turkey and Nigeria.  In our study 21 (10.5%) girls had shorter cycles <= 20 days and 48 (24%) had cycles >35 days which is significantly more than in other studies.
Similarly, reports have indicated variations in duration of flow, the mean duration being 5.3 [+ or -] 1.32 days and stretched to more than 7 days for Indians. One to four percent of women population is reported to have long duration of flow . We found a mean duration of 4.77 [+ or -] 1.06 days as the normal period of menstrual flow, with 4.1% of participants having more than 7 days Irregularity in the monthly shedding is also indicated in different studies, percent occurrence from Bangladesh,  Lebanon,  and Gambia  varied from 3 to 16%, whereas studies from India presents a figure of 5 to 9%.29
121 (60.5%) were aware of menstruation before menarche as compared to the south study of 101 (50.5%). Awareness regarding menarche is common among young girls and gradually it is increasing in rural area as shown by the figure in our study. The major source of information was mothers, sisters and friends, or the information media, such results were also reported by other works.
Despite the fact that menstrual disorders are so common majority of girls 55(50%) do self-medication, 20 (18.18%) took treatment as advised by parents and 35(31.81%) only consulted the doctor for dysmenorrhoea. The consultation of the doctor only occurred in severe cases.
There are many taboos and superstitions associated with menstruation. only 17.5% girls had no misconception. 70.5% do not attend temple, 54% do not touch holy books, 55% do not exercise, 38% do not drink cold beverages, 33.5% do not touch or take sour food and 38% consider severe pain as normal which is similar to study by Garg S and Anand T. 
Dysmenorrhea, PMS, and menstrual irregularity are more prevalent among young females and gradually increasing with time. These problems affect the social and academic life of the college girls. Despite increasing awareness, self-medication is still the rule which may be damaging in the long run. Timely intervention and consultation with the doctor would help in significantly improving the life of the college girls thereby improving the productivity. Timely programs regarding awareness of the disorders of menstruation would help girls cope better and seek proper medical assistance.
The limitation of the present study is that it consists only of College and University students, and may not represent the frequency of dysmenorrhea and other menstrual disorders among young women in the general population.
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Bindoo Yadav (1), Poonam Taneja (2)
(1) Associate Professor, Department of Obstetrics and Gynaecology, SGT Medical College Hospital and Research Institute, SGT University, Budhera, Gurugram, Haryana, India.
(2) Associate Professor, Department of Obstetrics and Gynaecology, SGT Medical College Hospital and Research Institute, SGT University, Budhera, Gurugram, Haryana, India.
'Financial or Other Competing Interest': None. Submission 18-02-2019, Peer Review 29-03-2019, Acceptance 05-04-2019, Published 15-04-2019.
Poonam Taneja, Department of Obstetrics and Gynaecology, 1180, Sector-4, Gurugram-122001, Haryana, India.
E-mail: taneja-poonam @rediffmail.com
Table 1. Showing Various Menstrual Characteristics Characteristics Frequency (N) (%) Menstrual Cycle Length <20 21 10.5% (days) 20-35 131 65.5% >35 48 24% Duration of Menstrual <2 9 4.5% Flow/No. of Days 2-6 181 90.5% >7 10 5% Regularity of Menstrual Regular Cycle 131 65.5% Cycles Irregular Cycle 69 34.5% Table 2. Showing Various Menstrual Complaints Dysmenorrhea No Dysmenorrhoea 60 30% Mild 70 50% Moderate 48 34.28% Severe 22 15.72% PMS Absent 136 68% Present 64 32% Abnormal Cycle Lengths Absent 146 73% Prolonged Cycle 42 21% Frequent Cycle 12 6% Table 3. Showing Need of Treatment No Need 90 45% Self-Medication 44 22% Treatment Given by Parents 30 15% Treatment Given by A Doctor 36 18% Table 4. Depicting Awareness Before Menarche No Information 31 16.5% Mom/Sister 77 38.5% Friends 71 35.5 % Doctor/Nurse 5 2.5 % Mass Media 16 8 % Table 5. Showing Prevalent Myths and Taboos Related to Menstruation No Misconception 35 17.5% Do not enter temple 141 70.5% Do not sleep on bed 34 17% Do not enter kitchen 56 28% Do not wash head during mensus 46 23% Do not touch holy books 108 54% Women are unhygienic during mensus 51 25.5% Avoid sour food like curd, pickles etc 67 33.5% do not exercise during menses 110 55% Severe Pain during mensus is normal 69 38.5% Don't drink cold beverages 76 38%
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|Title Annotation:||Original Research Article|
|Author:||Yadav, Bindoo; Taneja, Poonam|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Apr 15, 2019|
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