Abstract
The initial physiological change in adolescent girls is the onset of menstruation. The most prevalent challenge they face regarding menstruation is primary dysmenorrhea, characterized by persistent or intermittent pelvic pain in the lower abdomen. The aim of this study was to investigate the influences of stress levels and physical activities on primary dysmenorrhea. A cross-sectional was conducted in Cirebon, Indonesia, in 2023 included young women who had never given birth (nullipara), aged 17–25 years old, had menstruated, and had no history of smoking and alcohol. The data were collected using a set of questionnaires consisting of the Numeric Rating Scale (NRS) to determine primary dysmenorrhea pain, the Depression Anxiety Stress Scales 42 (DASS 42) to determine the level of stress and the International Physical Activity Questionnaire (IPAQ) to determine physical activity. Pearson’s correlation test was used to assess the correlation between the variables (stress levels, physical activity, and dysmenorrhea). A total of 150 young women were included in the study. Moderate stress levels (23.3%) and high physical activity (90.7%) were the most prevalent category observed among studied participants. Approximately 42% of them experienced mild dysmenorrhea pain. Our analysis indicated that stress levels and physical activities had strong positive and negative correlations with dysmenorrhea pain levels, with r=0.782 and r=-0.748, respectively, with both had p<0.001. This highlights that controlling stress could be beneficial in preventing dysmenorrhea pain among young women.
Keywords: Primary dysmenorrhea, menstrual pain, stress level, physical activity, young women
Introduction
Menstruation is the primary physiological change that occurs in adolescent girls characterized by cyclic bleeding that occurs from the uterine corpus, usually beginning at the age of 9–12 years [1,2]. The most frequently encountered problem related to menstruation is primary dysmenorrhea, referring to pelvic pain that occurs continuously or recurrent in the lower abdomen due to uterus’ muscle contractions [3,4]. Dysmenorrhea manifests on the first day of menstruation and lasts for approximately 8−72 hours [5,6]. Primary dysmenorrhea is associated with the ovulatory cycle and involves pain mechanisms mediated by the activity of prostaglandin (PGF2α) [7-11]. The pain level is determined by the increased level of PGF2α in the endometrial fluid [12].
Nearly 90% of adolescent girls experience primary dysmenorrhea [13]. Globally, the prevalence of primary dysmenorrhea in adolescent girls is very high, with an average of more than 50% [14]. Dysmenorrhea in adolescent girls can result in decreased health and productivity in school or work. Studies showed that primary dysmenorrhea was associated with 21.5% of the students to be absent from schools [15], 51.7% experienced problems concentrating in class; 50.2% had limited their social activities; and 12% had a decrease in academic achievement [16]. In general, dysmenorrhea causes a decrease in the quality of life of adolescent girls [5,7-11]. Factors that cause dysmenorrhea are nutritional status, physical activity and the age of menarche [17]. Nutritional status has the potential to influence prostaglandin levels in the body, thereby potentially causing dysmenorrhea [17]. A study found that a higher prevalence of dysmenorrhea in non-athletes (61.6%) compared to athletes (38.4%) [18]. Dysmenorrhea is associated with a higher risk in women who experience menarche at an earlier age [10,15,19]. The aim of this study was to investigate the influences of stress levels and physical activities on primary dysmenorrhea.
Methods
Study design and respondents
A cross-sectional study was conducted at the College of Health Sciences (STIKes) Muhammadiyah Cirebon, Cirebon, Indonesia, in 2023. A total sampling method was employed based on inclusion and exclusion criteria. This study included young women who had never given birth (nullipara), aged 17–25 years old, had menstruated, and had no history of smoking and alcohol. Respondents with a history of reproductive disease or chronic disease, primary dysmenorrhea with severe uncontrolled pain, asthma, and cancer were excluded from the study.
Study variables and data collection
Primary data was collected using a set of questionnaires. Primary dysmenorrhea pain was assessed using the Numeric Rating Scale (NRS) and was categorized into no pain (0), mild pain (1−3), moderate pain (4−6), and severe pain (7−1o) [20-22]. Stress levels were measured by employing the Depression Anxiety Stress Scales 42 (DASS 42) and were classified into normal (0−14), mild (15−18), moderate (19−25), severe (26−33), and extremely severe (>34) [20-23]. The International Physical Activity Questionnaire (IPAQ) was utilized to determine physical activity and its interpretations were divided into moderate activities (600−<1500 metabolic equivalents (MET)-minutes/week) and high activities (1500−3000 MET-minutes/week or more) [24,25].
Data collection was carried out for three days among the respondents. The data collection was assisted by two enumerators who had previously been trained. Respondents were approached and requested to answer the questionnaire directly, accompanied by the study team, facilitating the completion of the questionnaire for respondents who encountered statements they found hard to understand. The questionnaires that had been answered by respondents were examined to ensure that all statements had been filled in completely for data processing.
Statistical analysis
Descriptive data were reported as means and standard deviations (SD) or frequencies and percentages. Pearson’s correlation test was used to assess the correlation between the variables (stress levels, physical activity, and dysmenorrhea). The data was analyzed using SPSS software version 20 (SPSS Inc, Chicago, USA).
Results
Characteristics of respondents
A total of 150 young women were included in the study, as presented in Table 1. Approximately 45% of the respondents were 19 years and those who aged 20 and 18 years old accounted 28% and 21.3%, respectively. More than 75% of experienced menarche at age between 11 and 14 years old of which more than a quarter (25.3%) experienced menarche at the age of 12 (Table 1).
Table 1.
Characteristics of the young women included in the study
| Characteristics | Frequency | Percentage (%) |
|---|---|---|
| Age (year) | ||
| 17 | 2 | 1.3 |
| 18 | 32 | 21.3 |
| 19 | 67 | 44.7 |
| 20 | 42 | 28.0 |
| 21 | 4 | 2.7 |
| 22 | 1 | 0.7 |
| 23 | 1 | 0.7 |
| 25 | 1 | 0.7 |
| Age of menarche (year) | ||
| 9 | 3 | 0.2 |
| 10 | 7 | 4.2 |
| 11 | 23 | 15.3 |
| 12 | 38 | 25.3 |
| 13 | 33 | 22.0 |
| 14 | 24 | 16.0 |
| 15 | 16 | 10.7 |
| 16 | 5 | 3.3 |
| 17 | 1 | 0.7 |
Stress, physical activity and dysmenorrhea pain levels
More than half (52.7%) of the respondents had no stress, while 23.3% and 20% of the respondents had moderate and mild stress (Table 2). Among all of them, 136 young women (90.7%) engaged in high-level physical activity. In terms of dysmenorrhea, 42.7% experienced mild pain while moderate pain affecting 40% of young women (Table 2).
Table 2.
Stress levels, physical activity and pain levels in young women
| Variables | Categories | Frequency | Percentage |
|---|---|---|---|
| Stress levels | Normal | 79 | 52.7 |
| Mild | 30 | 20.0 | |
| Moderate | 39 | 23.3 | |
| Severe | 3 | 2.0 | |
| Extremely severe | 3 | 2.0 | |
| Physical activity | Moderate | 14 | 9.3 |
| High | 136 | 90.7 | |
| Dysmenorrhea pain levels | No pain | 4 | 2.7 |
| Mild pain | 64 | 42.7 | |
| Moderate pain | 60 | 40.0 | |
| Severe pain | 22 | 14.6 |
Distributions of stress levels, physical activity based on dysmenorrhea pain levels
Out of 79 who had no stress, 48.1%, 36.7 and 12.6% had mild, moderate and severe dysmenorrhea pain, respectively (Table 3). Out of the total who had mild stress levels, 40%, 36.6% and 16.% had mild, moderate and severe dysmenorrhea pain, respectively. Those who had severe dysmenorrhea pain was higher among those who had severe level of stress (Table 3). Based on physical activities, among young women who engaged in moderate physical activity, 57.1%, 28.5% and 14.2% had mild, moderate and severe dysmenorrhea pain, respectively (Table 3). In contrast, those who engaged in high physical activity, 41.1%, 41.1%, and 14.7%, had mild, moderate and severe dysmenorrhea pain, respectively (Table 3).
Table 3.
Distribution of stress levels, physical activity and dysmenorrhea pain levels among young women
| Variables | Total | Dysmenorrhea pain level | |||||||
|---|---|---|---|---|---|---|---|---|---|
| No pain | Mild pain | Moderate pain | Severe pain | ||||||
| n | % | n | % | n | % | n | % | ||
| Stress levels | |||||||||
| Normal | 79 | 2 | 2.5 | 38 | 48.1 | 29 | 36.7 | 10 | 12.6 |
| Mild | 30 | 2 | 0.6 | 12 | 40.0 | 11 | 36.6 | 5 | 16.6 |
| Moderate | 39 | 0 | 0.0 | 11 | 28.2 | 18 | 46.1 | 6 | 15.3 |
| Severe | 3 | 0 | 0.0 | 2 | 66.7 | 0 | 0.0 | 1 | 33.3 |
| Extremely severe | 3 | 0 | 0.0 | 1 | 33.4 | 2 | 66.7 | 0 | 0.0 |
| Physical activity | |||||||||
| Moderate | 14 | 0 | 0.0 | 8 | 57.1 | 4 | 28.5 | 2 | 14.2 |
| High | 136 | 4 | 2.9 | 56 | 41.1 | 56 | 41.1 | 20 | 14.7 |
Correlation of stress levels, physical activity and dysmenorrhea pain levels
The study revealed that stress levels and physical activities significantly influenced dysmenorrhea pain levels (p<0.001). A strong positive and negative correlation between stress levels and physical activities with dysmenorrhea pain levels was observed, with r=0.782 and r=0.748, respectively (Table 4).
Table 4.
Correlation between stress levels and physical activities with dysmenorrhea pain levels
| Variables | Pearson correlation (r) | p-value |
|---|---|---|
| Pain levels | ||
| Stress levels | 0.782 | <0.001* |
| Physical activities | -0.748 | <0.001* |
Statistically significant at the 0.001
Discussion
This study found that the incidence of primary dysmenorrhea was observed higher at age 19. The incidence and severity of primary dysmenorrhea tend to decrease with increasing age. The condition often starts within the first 6−12 months after menarche and the pain typically decreases in severity over time as women get older. The reduction in primary dysmenorrhea with age is not due to deterioration of the uterine nerves but rather is thought to be related to changes in the levels of prostaglandins and other inflammatory mediators that contribute to painful uterine contractions. As women age, the production of these pain-inducing substances tends to decrease [27,28].
The stress experienced by a woman can impact the function of the endocrine system, which can ultimately lead to irregular menstruation or dysmenorrhea [29]. This study found that the level of stress was correlated to dysmenorrhea pain levels of which adolescent girls with higher levels of stress have higher pain levels of dysmenorrhea. This aligns with a previous study that reported stress levels in women results were related to the likelihood of dysmenorrhea [30]. Under stressful conditions, the human body produces excessive estrogen and prostaglandin hormones which causes excessive contractions in the uterus, resulting in menstrual pain [31]. Stress triggers a neuroendocrine response, leading to the release of corticotrophin-releasing hormone (CRH), which stimulates the secretion of adrenocorticotrophic hormone (ACTH), resulting in increased adrenal cortisol secretion [32]. These hormones cause the reduced secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), as a result, the release of progesterone is disrupted. Decreased levels of progesterone induce the synthesis of prostaglandin, especially PGF2α [32]. In addition to prostaglandin, the body also produces excess adrenal hormones and estrogen. Elevated estrogen levels lead to excessive uterine contractions [33,34]. Additionally, an increase in adrenaline hormone levels stimulates tension in uterine muscles, leading to constriction of blood vessels by these muscles, thereby reducing oxygen supply and causing ischemia, ultimately resulting in pain. Furthermore, the likelihood of experiencing pain doubles under stress due to the surge activity of sympathetic nerves [33,34].
We also found that there was a correlation between the level of physical activity and dysmenorrhea pain levels, and most young women who experienced mild levels of pain had high levels of physical activity. Intensive physical activity triggers hypothalamic dysfunction, causing disturbances in the secretion of gonadotrophin-releasing hormone (GnRH) [39]. A study has shown that the physical activity significantly reduces pain intensity [5]. This is due to the body producing endorphins when performing physical activities. Endorphins act as a natural sedative, creating a sense of comfort. These hormones are produced by the brain and interact with its receptors to lessen pain perception and induce a positive, euphoric sensation [40,41].
Conclusion
This study showed that the level of stress and physical activity had a significant positive correlation with dysmenorrhea pain levels, with a strong positive correlation. Therefore, incorporating stress-reduction techniques and maintaining an active lifestyle could potentially contribute to reducing the severity of dysmenorrhea symptoms.
Acknowledgments
The authors would like to thank STIKes Muhammadiyah Cirebon, especially the Midwifery and Pharmacy Study Programs, which have supported this study.
Ethics approval
All respondents in this study have provided the informed consent. Ethical permission has been obtained from the Ethics Commission of the Faculty of Public Health, Universitas Diponegoro, Semarang, Indonesia, with number: 237/EA/KEPK-FKM/2020.
Competing interests
All the authors declare that there are no conflicts of interest.
Funding
This study received no external funding.
Underlying data
Derived data supporting the findings of this study are available from the corresponding author on request.
How to cite
Triwahyuningsih RY, Rahfiludin MZ, Sulistiyani S, Widjanarko B. Role of stress and physical activity on primary dysmenorrhea: A cross-sectional study. Narra J 2024; 4 (1): e685 - http://doi.org/10.52225/narra.v4i1.685.
References
- 1.Singh A, Kiran D, Singh H, et al. Prevalence and severity of dysmenorrhea: A problem related to menstruation, among first and second year female medical students. Indian J Physiol Pharmacol 2008;52(4):389–397. [PubMed] [Google Scholar]
- 2.Critchley HOD, Babayev E, Bulun SE, et al. Menstruation: Science and society. Am J Obstet Gynecol 2020;223(5):624–664. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Proctor M, Farquhar C.. Diagnosis and management of dysmenorrhoea. BMJ 2006;332(7550):1134–1138. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Musuka TD, Wilton SB, Traboulsi M, et al. Diagnosis and management of acute ischemic stroke: Speed is critical. Can Med Assoc J 2015;187(12):887–893. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Mahvash N, Eidy A, Mehdi K, et al. The effect of physical activity on primary dysmenorrhea of female university students. World Appl Sci J 2012;17(1):1246–1252. [Google Scholar]
- 6.Guimarães I, Póvoa AM. Primary dysmenorrhea: Assessment and treatment. Rev Bras Ginecol Obstet 2020;42(8):501–507. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Jenabi E, Asltoghiri M, Hajiloomohajeran M, et al. Effect of Stachys lavandulifolia on fatigue, nausea and vomiting associated with primary dysmenorrheal. Procedia Soc Behav Sci 2012;31:124–128. [Google Scholar]
- 8.Larasati T, Alatas F.. Dismenore primer dan faktor risiko dismenore primer pada remaja. Majority 2016;5(3):79–84. [Google Scholar]
- 9.Purba WTR, Azhar MB, Roflin E.. Association of dysmenorrhea and quality of life in female students at Xaverius I Senior High School Palembang academic year 2018-2019. Majalah Kedokteran Sriwijaya 2019;51(1). [Google Scholar]
- 10.Stoelting-Gettelfinger W. A case study and comprehensive differential diagnosis and care plan for the three Ds of women’s health: Primary dysmenorrhea, secondary dysmenorrhea, and dyspareunia. J Am Acad Nurse Pract 2010;22(10):513–522. [DOI] [PubMed] [Google Scholar]
- 11.Abidah SN, Hadisaputro S, Runjati R, et al. Effect of Carica papaya L on menstrual pain and prostaglandin level in adolescent with primary dysmenorrhea: A true experiment. Belitung Nurs J 2017;3(3):198–204. [Google Scholar]
- 12.Fajrin I, Alam G, Usman AN. Prostaglandin level of primary dysmenorrhea pain sufferers. Enferm Clin 2020;30:5–9. [Google Scholar]
- 13.Wong CL. Health-related quality of life among Chinese adolescent girls with Dysmenorrhoea. Reprod Health 2018;15(1):80. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Karout S, Soubra L, Rahme D, et al. Prevalence, risk factors, and management practices of primary dysmenorrhea among young females. BMC Womens Health 2021;21(1):392. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Proctor M, Farquhar C.. Diagnosis and management of dysmenorrhoea. BMJ 2006;332(7550):1134–1138. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Wildemeersch D, Jandi S, Pett A, et al. Management of primary dysmenorrhea in young women with frameless LNG-IUS. Open Access J Contracept 2014;5:23–28. [Google Scholar]
- 17.Novita R. Hubungan status gizi dengan gangguan menstruasi pada remaja putri di SMA Al-Azhar Surabaya. Amerta Nutrition 2018;2(2):172. [Google Scholar]
- 18.Momma R, Nakata Y, Sawai A, et al. Comparisons of the prevalence, severity, and risk factors of dysmenorrhea between Japanese female athletes and non-athletes in universities. Int J Environ Res Public Health 2021;19(1):52. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Ju H, Jones M, Mishra G.. The prevalence and risk factors of dysmenorrhea. Epidemiol Rev 2014;36(1):104–113. [DOI] [PubMed] [Google Scholar]
- 20.Hartrick CT, Kovan JP, Shapiro S.. The numeric rating scale for clinical pain measurement: A ratio measure?. Pain Practice 2003;3(4):310–316. [DOI] [PubMed] [Google Scholar]
- 21.Payne LA, Seidman LC, Sim MS, et al. Experimental evaluation of central pain processes in young women with primary dysmenorrhea. Pain 2019;160(6):1421–1430. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Rodrigues JC, Avila MA, dos Reis FJJ, et al. ‘Painting my pain’: The use of pain drawings to assess multisite pain in women with primary dysmenorrhea. BMC Womens Health 2022;22(1):370. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Al-Gelban KS, Al-Amri HS, Mostafa OA. Prevalence of depression, anxiety and stress as measured by the depression, anxiety, and stress scale (DASS-42) among secondary school girls in Abha, Saudi Arabia. Sultan Qaboos Univ Med J 2009;9(2):140–147. [PMC free article] [PubMed] [Google Scholar]
- 24.Bilgel N, Bayram N.. Depresyon anksiyete stres ölçeğinin (DASS-42) Türkçeye uyarlanmış şeklinin psikometrik özellikleri. Noro Psikiyatr Ars 2011;48(3):1–1. [Google Scholar]
- 25.Hekimoglu L, Altun ZO, Kaya EZ, et al. Psychometric properties of the Turkish Version of the 42 Item Depression Anxiety Stress Scale (Dass-42) in a clinical sample. The International Journal of Psychiatry in Medicine 2012;44(3):183–198. [DOI] [PubMed] [Google Scholar]
- 26.Makara-Studzińska M, Tyburski E, Załuski M, et al. Confirmatory factor analysis of three versions of the depression anxiety stress scale (DASS-42, DASS-21, and DASS-12) in Polish Adults. Front Psychiatry 2022;12:770532. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.MacGregor B, Allaire C, Bedaiwy MA, et al. Disease burden of dysmenorrhea: Impact on life course potential. Int J Womens Health 2023;15:499509. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Martire FG, Piccione E, Exacoustos C, et al. Endometriosis and adolescence: The impact of dysmenorrhea. J Clin Med 2023;12(17):5624. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Sriwati AR. Hubungan antara tingkat stres dengan dismenore primer pada mahasiswi tahun pertama program studi kedokteran angkatan 2018 fakultas kedokteran. Jurnal Ilmu Kesehatan Indonesia 2020;1(2). [Google Scholar]
- 30.Mona Angelia L, Januar Sitorus R, Etrawati F.. Model prediksi kejadian dismenore primer pada siswi SMA Negeri di Palembang. Jurnal Ilmu Kesehatan Masyarakat 2018;8(1). [Google Scholar]
- 31.Rejeki S. Hubungan tingkat stres dan karakteristik remaja putri dengan kejadian dismenore primer. J Kebidanan 2019;8(1):50. [Google Scholar]
- 32.Rohmawati W, Wulandari DA. Faktor yang berhubungan dengan nyeri dismenore primer pada siswi di SMA Negeri 15 Semarang. J Bidan Cerdas 2020;1(3):129–136. [Google Scholar]
- 33.Nuraini S, Sa’diah YS, Fitriany E.. Hubungan usia menarche, status gizi, stres dan kadar hemoglobin terhadap kejadian dismenorea primer pada mahasiswi fakultas kedokteran, Universitas Mulawarman. J Sains Kesehatan 2021;3(3):443–450. [Google Scholar]
- 34.Prafitri LD, Ersila W.. Pengaruh Fc-Bio sanitary pad terhadap penurunan intensitas dismenore. The 4th Univesity Research Coloquium 2016.
- 35.Resmiati R. Aktivitas fisik, magnesium, status gizi, dan riwayat alergi sebagai faktor determinan dismenore. Jurnal Endurance 2020;5(1):79. [Google Scholar]
- 36.Biro FM, Pinney SM, Huang B, et al. Hormone changes in peripubertal girls. J Clin Endocrinol Metab 2014;99(10):38293835. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Azima S, Bakhshayesh HR, Kaviani M, et al. Comparison of the effect of massage therapy and isometric exercises on primary dysmenorrhea: A randomized controlled clinical trial. J Pediatr Adolesc Gynecol 2015;28(6):486–491. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Derived data supporting the findings of this study are available from the corresponding author on request.