Association between Eating Disorders, Academic Stress with Menstrual Dysfunction among College Female Students: A Cross-Sectional Study

Abstract

Background

Academic stress and disordered eating behaviors are emerging as significant health concerns among female students in health-related fields, potentially leading to menstrual dysfunction. Physiotherapy students may be particularly vulnerable owing to the combination of academic, physical, and clinical demands. However, data on this triad in the context of Indian physiotherapy students remain limited.

Methods

A cross-sectional survey was conducted among 216 full-time female physiotherapy students (aged 18-28 years) at NIMS University, Rajasthan. A self-administered questionnaire comprising demographic information, the Eating Attitudes Test-26, a menstrual dysfunction checklist, and the Perceived Stress Scale was completed by the participants. Statistical analysis was conducted using IBM SPSS Statistics version 22 (IBM Co.), and the chi-square test was used to examine associations between variables.

Results

Of the participants, 68.83% showed symptoms of eating disorders, 96.74% experienced moderate academic stress, and 35.81% reported irregular menstrual cycles. The findings indicated a significant association between academic stress and menstrual dysfunction (χ² = 11.59, p < 0.005) and between eating disorders and menstrual dysfunction (χ² = 106.47, p < 0.005). However, the study found no significant difference between undergraduate and postgraduate students, possibly due to the small sample size of postgraduate students (n = 8).

Conclusion

The findings highlight a strong interrelationship between academic stress, disordered eating, and menstrual irregularities among female physiotherapy students. Early identification, stress management, and the implementation of integrated wellness programs within academic institutions can help safeguard the physical and mental well-being of future healthcare professionals.

INTRODUCTION

Eating disorders are serious psychological conditions involving abnormal eating behaviors that often emerge during adolescence or early adulthood. These disorders can have wide-ranging impacts on physical health, mental well-being, and social functioning [1,2]. In Western countries, the prevalence ranges from 0.1% to 7.3% [3], with global rates among youth reaching as high as 14%-22% [4]. Common types include anorexia nervosa (AN), characterized by extreme food restriction and fear of weight gain, and bulimia nervosa (BN), marked by binge eating followed by purging [5]. Students in health-related fields, especially females, are particularly vulnerable due to academic stress and heightened body image concerns, with studies indicating disordered eating in up to 15% of female medical students in the United States [6,7].

Menstrual health, another critical concern for young female, is closely linked to both psychological and physical stress. A typical menstrual cycle ranges from 21 to 45 days, lasts up to 7 days, and involves blood loss of 20-80 mL [8-11]. Although irregular menstruation affects only 2%-5% of women globally, this figure rises significantly with chronic stress [10]. Stress, weight fluctuations, and excessive exercise can interfere with the hypothalamic–pituitary–uterine axis, leading to issues such as premenstrual syndrome (PMS), amenorrhea, oligomenorrhea, and dysmenorrhea, which negatively affect quality of life [12-15].

University students, particularly those in physiotherapy programs, face multiple stressors—academic, social, and environmental. First-year students often struggle with transitioning into university life, while postgraduates (PG) bear heavier academic and clinical burdens [16-19]. Academic pressure stands out as a major stressor, linked to mental health concerns, emotional exhaustion, and decreased academic output [20-22]. In one study involving medical students, high expectations, exam load, and fear of underperformance were among the top reported stressors [23-28]. Among Indian physiotherapy students, nearly 40% reported experiencing PMS, which had a negative impact on their academic performance [29].

Despite growing literature on disordered eating and menstrual dysfunction among Western populations and medical students, research examining these interrelated issues among Indian female physiotherapy students is scarce. Physiotherapy students face a unique combination of physical, academic, and clinical demands, making them particularly vulnerable to stress-related health concerns. While a study conducted in Karnataka found that 39.3% of female physiotherapy students experienced PMS, impacting their academic performance and emotional well-being, few studies have explored the triad of academic stress, disordered eating, and menstrual dysfunction in this specific population in India [30].

Furthermore, existing literature rarely distinguishes between undergraduate (UG) and PG physiotherapy students, limiting insights into how stress exposure may vary across academic levels. This study attempts to address these gaps by examining the interrelationship between academic stress, eating disorders, and menstrual dysfunction among Indian female physiotherapy students.

This study aimed to explore the interrelationships between academic stress, disordered eating, and menstrual dysfunction among Indian female physiotherapy students.

MATERIALS AND METHODS

An application called Google Form was used to administer the instruments. Researchers personally visited potential participants to inform them of the study’s goal and provide an invitation to take part. This was a cross-sectional survey of 216 full-time female graduates and PG selected from the physiotherapy department, at NIMS University Rajasthan, Jaipur’s. The study comprised volunteer participants who were young female students in the physiotherapy courses, ages 18 to 28. The study’s Exclusion criteria included being an alcoholic, smoking, being pregnant, having a recent history of an abortion or miscarriage, having a bad eating habit, ceasing to participate, and using medications like contraceptives. The participants were required to self-administer a questionnaire that included anonymous answers to questions on demographic data, menstrual problems, eating disorders, and perceived stress after receiving ethical approval from the NIMS University (Code: NIMS/PT/OT/June/2024/87, dated 10.6.2024.).

Among the many problems persisting college-going female students, a few are academic stress, eating disorders, with menstrual dysfunction. So, the study insight seeing the relationship between academic stress, and eating disorders with menstrual dysfunction using demographic information, Eating Attitudes Test (EAT)-26, semi structure menstrual dysfunction, and Perceived Stress Scale (PSS).

1. Demographic information

A questionnaire assessed name, age, address, college/department, education, etc.

2. Eating disorder questionnaire

The EAT-26, a screening instrument intended to identify eating disorders, was utilized. A standardized exam for identifying eating disorder symptoms is the EAT-26 [31]. Screening populations at risk for obesity, bulimia, and anorexia is done with it [32]. The EAT-26 is a 26-item version of a scale designed in 1982 by D. Garner and P. Garfinkel to assess eating behaviors and attitudes. It is employed in screening tests and in examining individuals who have been given a clinical diagnosis. Włodarczyk-Bisaga and Dolan [33] are the creator of the Polish tool standardization. There are from 0 and 78 potential points to be earned. If a person receives 20 or more points, they may have an eating issue and should see a professional for evaluation [34,35]. Apart from the overall outcome, three EAT-26 domains may be examined, which include: (1) dieting; (2) bulimia and food obsession; and (3) oral control.

3. Menstrual dysfunction

Participants were asked if their menstrual cycle was regular or irregular. Regular menstrual cycle: A normal menstrual cycle lasts around seven days and usually starts throughout adolescence between the ages of eleven and fourteen. average cycle duration of 21 to 45 days and average blood loss of 20 to 80 milliliters. Irregular menstrual cycle: When the length of your period varies or your period arrives early, late, or not at all, it is considered irregular.

4. Perceived stress scale

This study used the PSS, created by “Kamarck and Mermelstein” in 1983. Since its validity and reliability have been demonstrated, PSS is a commonly used scale for assessing stress levels. The degree that is measured by the scale is evaluated by the challenging conditions. There were ten items total, and the respondents had to select one response option between 0 and 4 (0 for never, 1 for almost never, 2 for sometimes, 3 for fairly often, and 4 for very often). The scoring process is inverted for items nos. 4, 5, 7, and 8. The range of scores is as follows: 0-13 represents mild stress, 14-27 represents medium stress, and 28-40 represents extreme stress [36].

5. Statistical analysis

The percentages (%) and frequencies (n) are used to characterize the categorical data. The relationship between academic stress and eating disorder, with menstrual dysfunction categorical variable was determined using the Chi-square test. Software called IBM SPSS Statistics version 22 (IBM Co.) was used for all statistical analysis.

RESULTS

A total of 216 students willingly participated in this study consequently; we analyzed the data of 216 college students aged 18-28 years. Table 1 shows the demographic characteristics of the 216 participants.

Table 1.

Demographic features of the participants

Variable	Frequency (n)	Percentage (%)
Age (yr)
18-21	136	62.96
22-25	59	27.31
26-28	21	9.72
Marital status
Single	213	98.61
Married	3	1.33
Qualification
Graduate	207	95.83
Postgraduate	9	4.16

Table 2 demonstrates that there was a significant association between the presence of academic stress and menstrual dysfunction. The chi-square value (11.59) is greater than the critical value at p = 0.005 (10.59), indicating a statistically significant relationship between academic stress and menstrual dysfunction. This suggests that higher levels of academic stress are associated with a higher incidence of irregular menstrual cycles.

Table 2.

Relation between academic stress and menstrual dysfunction

Category	Regular	Irregular	Chi-square test	Chi-square value at p = 0.005
Mild	1	0	11.59	10.59
Moderate	137	71	11.59	10.59
Severe	0	6	11.59	10.59

Table 3 demonstrates that the chi-square value (106.47) is significantly greater than the critical value at p = 0.005 (7.879), indicating a highly statistically significant relationship between eating disorders and menstrual dysfunction. This suggests that the presence of an eating disorder is strongly associated with irregular menstrual cycles.

Table 3.

Relation between eating disorder and menstrual dysfunction

Category	Regular	Irregular	Chi-square test	Chi-square value at p = 0.005
Yes	128	20	106.47	7.879
No	10	57	106.47	7.879

1. The prevalence of eating disorder

The findings indicate that 148 participants (68.83%) reported having symptoms of an eating disorder, while 67 participants (31.16%) did not exhibit any signs of an eating disorder.

2. The prevalence of menstrual dysfunction

Results show that 77 participants (35.81%) were having menstrual dysfunction (menstrual cycle irregular), while the others 138 (64.18%) were not having menstrual dysfunction (menstrual cycle regular).

3. The prevalence of academic stress

The results show that participants were having academic stress 1 (0.46%) mild stress, 208 (96.74) moderate stress, and 6 (2.79%) severe stress, in our study.

DISCUSSION

This study explored the interplay between academic stress, disordered eating behaviors, and menstrual disturbances in female physiotherapy students. The results revealed significant statistical links between elevated academic stress and irregular menstrual cycles, as well as between disordered eating patterns and menstrual dysfunction. These findings underscore the pressing need for integrated health strategies within educational institutions.

Chronic academic stress activates the hypothalamic–pituitary–adrenal (HPA) axis, which increases secretion of cortisol and corticotropin-releasing hormone (CRH). Elevated CRH suppresses the hypothalamic release of gonadotropin-releasing hormone (GnRH)—the key hormone responsible for regulating the menstrual cycle [37].

Reduced GnRH secretion leads to downstream suppression of luteinizing hormone and follicle-stimulating hormone (FSH)—both critical for ovarian follicle development and ovulation. This hormonal disruption often results in menstrual irregularities such as:

• Amenorrhea (absence of menstruation),

• Oligomenorrhea (infrequent periods),

• or other cycle disturbances [38,39].

Our study found that most participants reported moderate to severe academic stress, and more than one-third experienced irregular menstruation. These outcomes align with previous studies that highlight the vulnerability of female students—especially in demanding fields like physiotherapy—to stress-related health problems, including menstrual disruption and chronic fatigue [13,40,41]. The demanding nature of physiotherapy education, with its blend of intensive coursework and clinical duties, may play a substantial role in elevating stress levels [42].

Disordered eating patterns—such as severe calorie restriction, bingeing, or purging—result in low energy availability, which disrupts several metabolic and reproductive hormones. Specifically:

• Leptin, produced by adipose tissue, plays a critical role in signaling adequate energy reserves to the hypothalamus. Low leptin levels (due to weight loss or starvation) signal an “energy-deficient state,” leading to suppression of GnRH pulsatility [43].

• Insulin, another key metabolic hormone, also influences ovarian function. Disrupted insulin levels due to poor dietary intake affect the production of androgens and estrogen, further disturbing the menstrual cycle [44].

In conditions like AN or BN, these hormonal imbalances often result in hypothalamic amenorrhea, where menstruation ceases due to central (brain-level) hormonal suppression [45].

Contrary to earlier assumptions that PG students might be more affected by academic stress due to higher clinical demands, our findings did not reveal any significant difference in stress levels or menstrual health outcomes between UG and PG participants. This suggests that stress-related health concerns are prevalent across all academic levels in physiotherapy education.

Comparable patterns have been documented in various academic contexts. For example, a study conducted in Karnataka found a 39.3% prevalence of PMS among physiotherapy students, indicating a substantial impact on both academic engagement and emotional health [29]. These observations reinforce the growing body of evidence that links academic pressure and lifestyle disruptions to menstrual health issues among young adult women in academic settings [46].

To mitigate these challenges, academic institutions must adopt a holistic and preventative approach. Establishing student wellness centers equipped to offer psychological counseling, nutritional education, menstrual health awareness, and stress-reduction strategies is crucial. Initiatives such as yoga, mindfulness training, time management sessions, and early screening for disordered eating or hormonal irregularities can help address these interlinked issues [47].

In conclusion, the hormonal mechanisms—particularly involving the hypothalamic–pituitary–adrenal and hypothalamic–pituitary–gonadal axes—provide biological insight into the menstrual dysfunction observed in students under chronic academic stress. The study highlights the critical need for early identification and multi-faceted interventions to promote both academic success and reproductive well-being among female physiotherapy students.

Contrary to expectations, this study did not reveal a significant difference in academic stress levels or menstrual health outcomes between UG and PG physiotherapy students. However, this result should be interpreted with caution due to the markedly small PG sample (n = 8), which comprised only 3.7% of the total participants. Such a small subgroup size is likely underpowered to detect statistically meaningful differences, even if they exist. Hence, the apparent lack of variation between UG and PG groups may reflect sampling limitations rather than an actual absence of difference. This limitation underscores the need for future studies to recruit a more balanced and representative sample of both UG and PG students to enable more reliable subgroup comparisons.

1. Limitations and future direction

Several limitations must be considered when interpreting the findings of this study. Firstly, due to its cross-sectional nature, the study cannot establish causal relationships between academic stress, disordered eating patterns, and menstrual irregularities. Secondly, the reliance on self-reported data may have introduced recall bias or inaccuracies in participant responses. Thirdly, the use of screening instruments rather than clinical evaluations may have impacted the accuracy of disordered eating prevalence rates.

A particularly important limitation is the underrepresentation of PG students in the sample (n = 8, comprising just 3.7% of the total participants). This small subgroup size restricts the reliability of comparisons made between UG and PG cohorts. As such, any conclusions regarding academic level differences should be interpreted cautiously. Future research should aim to include a more proportionate sample from both academic levels to enable more reliable subgroup analyses.

Future research should aim to include a larger and more proportionate sample of PG students to enable statistically valid comparisons between academic levels and better understand how educational demands affect health outcomes across different stages of physiotherapy training.

2. Clinical implications

The findings of this study underline the urgent need for educational institutions, particularly those offering physiotherapy and other health sciences programs, to proactively address the interconnected challenges of academic stress, disordered eating, and menstrual dysfunction among female students.

1) Institutional wellness programs

Establishing on-campus wellness centers that offer integrated care—including nutrition education, gynecological consultations, and stress management resources—can help identify and address these issues early.

2) Mental health counseling

Given the significant impact of academic stress, institutions should provide access to professional psychological counseling, with targeted support during examination periods or clinical internships.

3) Early screening & health monitoring

Routine screening for menstrual irregularities, stress levels, and eating behaviors during student health check-ups can facilitate early intervention. Simple tools like the Numerical Pain Rating Sclae, PSS, or EAT-26 may be adapted for annual use.

4) Yoga and lifestyle management

Introducing yoga, mindfulness meditation, and lifestyle workshops as part of the academic curriculum or extracurricular offerings can reduce stress levels and improve overall well-being. These interventions are low-cost, scalable, and culturally accepted in the Indian context.

5) Faculty sensitization

Educators should be trained to recognize signs of burnout, disordered eating, and menstrual dysfunction in students, and refer them appropriately. Faculty attitudes toward academic pressure may also need adjustment to create a healthier academic environment.

6) Peer support programs

Institutions may consider peer-led programs where trained senior students offer support or mentoring to junior students facing adjustment difficulties or health challenges.

CONCLUSION

This study highlights a high prevalence of academic stress, disordered eating symptoms, and menstrual irregularities among female physiotherapy students. Significant associations were found between academic stress and menstrual dysfunction, as well as between eating disorders and menstrual irregularities. Contrary to expectations, no notable differences emerged between UG and PG students, though this may be due to the small PG sample size.

These findings underscore the need for early identification, health education, and integrated support systems within academic institutions. Future studies should involve larger and more diverse student populations, using longitudinal and interventional designs to inform effective preventive strategies.

Funding Statement

Funding: None.