Influence of menstrual pain intensity, menstrual symptoms, and catastrophization on cognitive function in young women with primary dysmenorrhea

Abstract

Background

Cognitive function is negatively affected in different chronic painful conditions. This study aimed to examine the relationship between pain intensity, menstrual symptoms, catastrophization, and cognitive functions in young women with primary dysmenorrhea.

Methods

This cross-sectional study comprised 132 nulliparous young women with primary dysmenorrhea. Sociodemographic characteristics and detailed medical, obstetric, and urogynecological history were recorded. Menstrual pain intensity was evaluated with the Visual Analogue Scale, symptoms experienced during the menstrual cycle with the Menstruation Symptom Questionnaire (MSQ), pain-related emotions with the Pain Catastrophizing Scale (PCS), and cognitive functions with the Montreal Cognitive Assessment (MoCA) and Stroop test. All evaluations were performed in the periovulatory phase.

Results

The mean MoCA total score was 24.31 ± 4.86 in young women with primary dysmenorrhea. The MoCA visuospatial/executive subscale showed negative correlations with menstrual pain intensity, pain duration, complaint duration, MSQ coping strategies, PCS rumination, PCS helplessness, and PCS total scores (r = −0.191 to −0.291, P < 0.05). In addition, Stroop 4-time showed a weak positive correlation with complaint duration (r = 0.236, P = 0.016) and PCS rumination scores (r = 0.222, P = 0.024).

Conclusions

Young women with primary dysmenorrhea had low MoCA scores. In primary dysmenorrhea, visuospatial/executive cognitive function and selective attention were impaired, especially in relation to the severity of menstrual pain, pain duration, some menstrual symptoms, and pain catastrophization. Cognitive training, especially to improve visuospatial/executive cognitive function and selective attention, should be included in pain management programs applied to women with primary dysmenorrhea.

INTRODUCTION

Dysmenorrhea, which is commonly seen in young women, is defined as painful menstrual cramps felt in the suprapubic region just before and during menstruation [1,2]. Dysmenorrhea classifies it into two groups as primary and secondary dysmenorrhea [3]. Primary dysmenorrhea can be considered an umbrella term, including any individual who feels disruptive menstrual pain but does not have visible pelvic lesions. It usually begins to appear within 6–12 months after menarche and continues in all ovulatory cycles [4,5]. In primary dysmenorrhea, menstrual pain begins one day before menstruation, immediately after the onset of menstruation, or a few hours later, and its duration is approximately 48–72 hours [6]. This pain is characterized by an increase in the intensity of contraction in the uterine muscles due to an increase in the amount of prostaglandin [7]. In secondary dysmenorrhea, painful menstrual bleeding may be associated with specific problems such as endometriosis [8]. Due to dysmenorrhea, symptoms such as headache, fatigue, diarrhea, lower back pain, nausea, vomiting and dizziness may also be observed in women [9]. In addition, women with menstrual pain often experience psychological disorders such as anxiety, irritability and depression as well as menstrual symptoms, and therefore menstrual pain negatively affects the individual’s attitude, family and friend relationships, social interactions, sports activities, as well as academic performance, school attendance, and concentration level [10–12].

Chronic pain is any persistent or recurring pain that lasts longer than 3 to 6 months and can cause reorganization of the central nervous system [13]. Primary dysmenorrhea provides a good clinical model for chronic pain due to its nature, which includes painful and pain-free periods [14]. Women with primary dysmenorrhea complain of prolonged and recurring menstrual pain that lasts for a long time (48–72) during each menstrual cycle for years [13]. It is emphasized in the literature that primary dysmenorrhea is a unique feature that includes visceral acute pain experiences during menstrual cramps and recurrent pain experiences during each menstrual cycle throughout the reproductive age [13,14]. This type of prolonged menstrual pain shapes the brain and changes the way it perceives, modulates and responds to pain, leading to decreased quality of life, pain catastrophizing, and a variety of mental and health problems such as depression, anxiety, sleep disorders, and high comorbidity associated with functional pain disorders later in life [14].

Cognitive functions are defined as the ability to know, including awareness, perception, logical thinking, language, memory, and reasoning [15]. The relationship between chronic pain and cognitive function is quite complex [15–17]. In the literature, cognitive function has been investigated in chronic painful conditions such as chronic low back pain and knee pain [18,19]. It has been reported that 66.9% of individuals with chronic low back pain have abnormal cognitive function [18]. It has also been stated that age, education level, and pain intensity negatively affect cognitive function [18]. In individuals with chronic knee pain, it has been found that pain due to knee arthritis causes cognitive dysfunction in the long term [19]. In a study conducted on healthy women [20], menstrual symptoms—particularly somatic complaints and negative emotional effects—were found to negatively affect motor imagery skills, including both kinesthetic and visual components. This suggests that even in the absence of diagnosed pathology, the physiological and psychological fluctuations associated with the menstrual cycle, can impair cognitive-motor representations [20]. To the best of the authors’ knowledge, there is no research on the relationship between cyclical menstrual pain and cognitive function in women. Thus, the aim was to examine the relationship between pain intensity, menstrual symptoms, catastrophization, and cognitive functions in menstrual pain, which is one of the chronic pain conditions, and continues cyclically every month for a long time in young women with primary dysmenorrhea. This study will reveal the changes caused by menstrual pain in young women’s cognitive function according to pain severity.

MATERIALS AND METHODS

This prospective, cross-sectional study was conducted from June 20, 2023 to April 20, 2024. Ethics committee permission was obtained from the University of Health Sciences’ Scientific Research Ethics Committee (approval number: 2023-180). The STROBE guideline was used for this study. Individuals who met the inclusion criteria were invited to the physiotherapy unit after being informed about the study and signed a consent form according to the principles stated in the Declaration of Helsinki. The inclusion criteria were being age 18–40, not having given birth, being right-handed, being literate, and meeting the following diagnostic criteria of the American College of Obstetricians and Gynecologists (ACOG) [21]: lower abdominal pain during menstruation that interfered with daily activities, but without any underlying pathological abnormality within or outside of the uterus, a regular menstrual cycle between 27 and 32 days, and pain level of ≥ 4 on the Visual Analogue Scale (VAS) in the past 6 months (0 = no pain and 10 = the worst possible pain). Participants were referred to the university’s department of obstetrics and gynecology to evaluate whether they had primary or secondary dysmenorrhea. Pelvic ultrasonography was performed in order to identify any organic pathology related to secondary dysmenorrhea. Exclusion criteria were as follows: not volunteering to participate in the study, being pregnant, having an orthopedic, surgical, psychiatric, mental or systemic chronic disease, having another accompanying chronic pain such as irritable bowel syndrome, painful bladder, fibromyalgia, any pain or illness during the evaluation, using oral contraceptives, hormonal supplements, opioid-derived systems, or having an organic pelvic pathology. To account for potential confounding variables affecting pain perception and cognitive function, participants were asked to self-report factors such as recent sleep quality, stress levels, and hormonal symptoms. Individuals with notable deviations in sleep or mood were excluded based on self-reporting. This approach aligns with previous studies in dysmenorrhea research where preliminary screening via self-report was used to ensure the homogeneity of the sample population [22,23]. Participants who verbally reported a sleep quality score of 5 or higher and a stress level score of 3 or lower on the respective numerical rating scales were included in the study. Additionally, to minimize the confounding effect of stimulants on cognitive performance, participants were instructed to refrain from consuming caffeine-containing products (e.g., coffee, tea, energy drinks, chocolate) for at least 12 hours prior to the assessment sessions. This precaution was communicated both verbally and in written form during participant briefing and appointment confirmation. The aim was to reduce potential variability in attention and reaction time associated with acute caffeine intake, which has been shown to influence cognitive test outcomes [24].

1. Outcome measures

Sociodemographic characteristics (age, height, weight, body mass index [BMI], marital status, occupation, education level) and detailed medical (smoking and alcohol habits, medications used, surgical operations, presence of chronic disease like rheumatological, orthopedic, neurological, etc.) obstetric and urogynecological history were recorded. Menstrual pain intensity was evaluated with the VAS, symptoms experienced during the menstrual cycle with the Menstruation Symptom Questionnaire (MSQ), pain-related emotions with the Pain Catastrophizing Scale (PCS), and cognitive functions with the Montreal Cognitive Assessment (MoCA) and Stroop test. Evaluations were performed on days 10–14 of the menstrual cycle (pain-free and periovulatory phase). The evaluation day was determined individually according to each person’s menstrual cycle [25].

2. Menstrual pain intensity

Menstrual pain intensity was assessed with a 100 mm VAS. Individuals were asked to mark the place that best expressed themselves on a 100 mm line (“0 mm”: I have no pain, “100 mm”: I have a lot of pain). The distance of the marked point to the starting point was measured with a ruler and recorded in “centimeters (cm)” [26].

3. Menstrual symptoms

The “MSQ,” whose Turkish validity and reliability were validated by Güvenç et al. [27], was used to assess people’s menstrual pain and symptoms. The MSQ is a questionnaire developed in English by Chesney and Tasto [28] to evaluate menstrual pain and symptoms and is widely used in many countries. It has 24 items on a 5-point Likert scale. Participants were asked to rate the symptoms they experienced regarding menstruation between 1 (never) and 5 (always). MSQ score was calculated by taking the total score average of the scale items. An increase in the average score indicates an increase in the severity of menstrual symptoms. The Turkish adaptation of the scale consists of 3 subscales: negative effects/somatic complaints (13 items), pain symptoms (6 items), and coping strategies (3 items) for a total of 22 items [27].

4. Pain catastrophizing

The PCS is a 13-item self-administered questionnaire created to assess the patient’s feelings, thoughts, and emotions related to pain and catastrophizing. It consists of three subscales: helplessness, magnification, and rumination. Each item is scored on a 5-point scale, with higher values representing greater catastrophizing. Subscale scores are given by the sum of the corresponding items, and the total score is calculated by the sum of all items. PCS scores range from 0 to 52 points.

5. Cognitive functions

To evaluate cognitive functions, the MoCA and Stroop test were administered and scored by second author, an experienced physiotherapist who has a certificate, in a quiet and isolated environment. MoCA was developed as a rapid screening test for mild cognitive impairment. This test evaluates 8 different cognitive functions: attention and concentration, executive functions, memory, language, visual structuring skills, abstract thinking, calculation and orientation. The application of MoCA takes approximately 10 minutes. The highest total score that can be obtained from the test is 30. Accordingly, a score of 26 points or above is considered normal [18,29].

The Stroop test is a neuropsychological test that reflects frontal region activity. The Stroop test reflects three basic processes: selective attention, reading, and color recognition. The Stroop test is considered the gold standard of attention measurements [30]. It is applied by keeping time with four stimulus cards consisting of blue, green, red and yellow colors. The first card has color names printed in black on a white background. The second card has color names printed in different colors. However, the color used in printing each word is different from the color the word represents. Other cards and sections were included in the test for control purposes. The third card contains circles with a diameter of 0.4 cm, printed in different colors. On the 4th card, there are neutral words (“up to, weak, if, moderate”) printed in different colors.

6. Data analysis

G*Power package software program (G*Power, version 3.1) was used to determine the required sample size for this study. Based on the previous study [18,31], the sample size was estimated as 114 to obtain 90% power at an alpha level of 0.05, concerning the correlation coefficient between pain intensity and cognitive status. Due to the estimated dropout rate of 20%, the aim was to recruit 137 participants.

Statistical analyses were performed using Statistical Package for the Social Sciences software, version 25 (IBM SPSS Statistics; IBM Co.). The normality of data distribution was checked using visual (histogram and probability plots) and analytical methods (the Kolmogorov–Smirnov test). Descriptive statistics were presented using mean ± standard deviation for normally distributed variables, median and interquartile range, and percent (%) for non-normally distributed variables. Between MoCA and Stroop test domains and variables correlations, as parameters were non-normally distributed, the correlation coefficients and their significance were calculated using the Spearman test. The following cut-off points were used for the interpretation of correlation coefficients: 0.00–0.19 very weak, 0.20–0.39 weak, 0.40–0.69 moderate, 0.70–0.89 high, and 0.90–1.00 very high. Statistical significance was accepted as P < 0.05 [32].

RESULTS

A total of 172 participants were screened for eligibility between June 2023 and April 2024. Forty participants did not meet the inclusion criteria (chronic diseases [n = 5], identified organic pathology related to dysmenorrhea [n = 7], being left-handed [n = 8], having another accompanying chronic pain [n = 13], and unwillingness to participate in study [n = 7]). Consequently, 132 nulliparous, young women with primary dysmenorrhea were included in this study. All included participants filled out the questionnaires and cognitive tests.

The mean age of participants was 22.1 ± 2.9 years and the BMI of participants was 21.3 ± 2.9 kg/m². In terms the education level, all participants had ≥ bachelor’s degree. Detailed information on sociodemographic, clinical and medical characteristics is presented in Table 1.

Table 1.

Sociodemographic, clinical, and medical characteristics of participants

Variable (n = 132)	Min–Max	Value
Age (yr)	19–36	22.1 ± 2.9
Weight (kg)	42–100	58.3 ± 8.6
Height (cm)	154–180	165.6 ± 5.0
Body mass index (kg/m2)	15–34	21.3 ± 2.9
Frequency of menstrual cycle (day)	28–32	29.00 ± 1.00
Menarche age (yr)	10–16	12.94 ± 1.11
Daily sleep duration (hr)	5–10	6.71 ± 1.18
Sleep duration during menstruation (hr)	5–14	7.41 ± 1.56
Education level
Bachelor’s degree	104	78.78
≥ Bachelor’s degree	28	21.21
Family history
Yes	54	47.36
No	60	52.64
Smoking
Yes	22	19.29
No	92	80.71
Alcohol consumption
Yes	35	30.70
No	79	69.30
Regular exercise
Yes	24	21.82
No	86	78.18
Pharmacological agent
No	57	50.00
Analgesics	50	43.85
Oral contraceptive	7	6.15

Values are presented as number only, mean ± standard deviation, or percent (%). Missing data were observed for family history (n = 18), smoking (n = 18), alcohol consumption (n = 18), regular exercise (n = 22), and pharmacological agent (n = 18).

Menstrual characteristics are presented in Table 2. The mean of menstrual pain intensity, pain duration, and complaint duration were 5.18 ± 2.38 cm (according to the VAS), 1.26 ± 0.61 days, and 3.73 ± 4.08 years. In addition, the mean MoCA total scores of the individuals who participated in this study were 24.31 ± 4.86 and 56.4 percent of individuals were less than 26 points. The mean MoCA total, subscale scores, and Stroop test scores are given in Table 2.

Table 2.

Menstrual pain characteristics, MoCA, and Stroop test results

Variable (n = 132)	Min–Max	Value
Menstrual pain intensity (VAS, cm)	4–10	5.18 ± 2.38
Pain duration (day)	1–3	1.26 ± 0.61
Complaint duration (yr)	1–17	3.73 ± 4.08
MSQ
Total	25–112	69.37 ± 17.49
Negative effects/somatic complaints	16–68	40.88 ± 10.36
Pain symptoms	6–32	20.71 ± 5.98
Coping strategies	3–15	8.06 ± 3.49
PCS
Total	0–44	18.80 ± 12.59
Helplessness	0–24	8.22 ± 6.22
Magnification	0–12	3.85 ± 3.06
Rumination	0–21	6.91 ± 4.77
MoCA
Total score	0–30	24.31 ± 4.86
≤ 25 (n/%)		75/56.4
≥ 26 (n/%)		59/43.6
MoCA subscale score
Visuospatial/executive	2–5	4.27 ± 7.21
Naming	1–3	2.78 ± 0.45
Attention	1–6	5.18 ± 1.25
Language	0–3	2.67 ± 0.61
Abstraction	0–2	1.49 ± 0.68
Delayed recall	0–5	2.64 ± 1.63
Orientation	5–6	5.97 ± 0.16
Stroop (second)
1	6.40–18.16	9.39 ± 1.71
2	5.55–23.90	9.61 ± 2.76
3	8.06–19.19	11.47 ± 1.80
4	9.33–20.57	13.54 ± 1.97
5	11.12–33.93	19.94 ± 4.17

Values are presented as number only or mean ± standard deviation.

MoCA: Montreal Cognitive Assessment, VAS: Visual Analogue Scale, MSQ: Menstruation Symptom Questionnaire, PCS: Pain Catastrophizing Scale.

1. Correlation between menstrual pain characteristics and MoCA

There were negative, weak, significant correlations between the menstrual pain intensity (rho = –0.291, P = 0.002), pain duration (rho = –0.200, P = 0.040), complaint duration (rho = –0.275, P = 0.004), and the visuospatial/executive subscale of MoCA, respectively. In addition, a weak negative correlation was determined between the MoCA-visuospatial/executive subscale and PCS-rumination, PCS-helplessness, and PCS-total (r = –0.252, P = 0.009; r = –0.219, P = 0.024; r = –0.208, P = 0.033, respectively). There were very weak, negative correlation between the MoCA-visuospatial/executive subscale and MSQ-coping strategies (r = –0.194, P = 0.046) and between MoCA-total and PCS-rumination subscale scores (r = –0.191, P = 0.046). However, no correlation was found between other menstrual pain characteristics and the MoCA-total and subscales (Table 3).

Table 3.

Correlations among mentrual pain characteristics, MoCA total, domains, and Stroop sub-tests

MoCA		Menstrual pain intensity	Pain duration	Complaint duration	MSQ (total)	MSQ (negative effects/somatic complaints)	MSQ (pain symptoms)	MSQ (coping strategies)	PCS (total)	PCS (helplessness)	PCS (magnification)	PCS (rumination)
Total	rho	0.056	–0.106	–0.014	–0.009	–0.071	0.094	–0.026	–0.118	–0.063	–0.098	–0.191
	p	0.566	0.271	0.889	0.925	0.456	0.330	0.789	0.220	0.515	0.311	0.046*
Visuospatial/executive	rho	–0.291	–0.200	–0.275	–0.107	–0.003	–0.164	–0.194	–0.208	–0.219	–0.049	–0.252
	p	0.002*	0.040*	0.004*	0.276	0.976	0.094	0.046*	0.033*	0.024*	0.618	0.009*
Naming	rho	0.125	–0.003	–0.001	0.040	–0.007	0.097	0.074	–0.034	–0.056	–0.052	0.010
	p	0.203	0.979	0.990	0.684	0.942	0.322	0.449	0.728	0.571	0.596	0.920
Attention	rho	–0.060	–0.045	–0.007	–0.047	–0.121	0.055	–0.055	0.078	0.053	0.123	0.040
	p	0.540	0.647	0.940	0.632	0.215	0.577	0.577	0.429	0.592	0.209	0.681
Language	rho	0.021	–0.021	0.032	0.113	–0.155	0.038	0.113	0.045	0.078	0.017	–0.013
	p	0.832	0.834	0.744	0.247	0.113	0.699	0.249	0.648	0.424	0.862	0.891
Abstraction	rho	0.033	0.151	0.063	–0.028	–0.088	0.029	0.021	–0.036	–0.008	–0.116	–0.018
	p	0.735	0.123	0.522	0.778	0.368	0.772	0.832	0.717	0.932	0.236	0.857
Delayed record	rho	0.176	0.024	0.028	0.043	0.012	0.071	0.039	–0.091	–0.012	–0.125	–0.158
	p	0.072	0.805	0.779	0.661	0.907	0.468	0.694	0.353	0.904	0.202	0.106
Orientation	rho	–0.015	0.074	0.053	0.113	0.070	0.130	0.084	0.143	0.122	0.120	0.153
	p	0.880	0.453	0.587	0.247	0.477	0.183	0.392	0.143	0.213	0.221	0.118
Stroop 1-time	rho	–0.068	0.023	–0.129	0.022	0.025	0.001	0.050	–0.004	0.020	0.050	–0.075
	p	0.487	0.816	0.189	0.824	0.796	0.992	0.613	0.966	0.843	0.611	0.446
Stroop 2-time	rho	–0.035	–0.010	–0.131	0.113	0.103	0.089	0.365	–0.032	–0.010	–0.024	–0.076
	p	0.726	0.919	0.184	0.251	0.294	0.365	0.613	0.920	0.921	0.804	0.441
Stroop 3-time	rho	0.020	–0.024	–0.031	0.134	0.173	0.050	–0.042	–0.077	–0.046	–0.066	–0.134
	p	0.842	0.804	0.754	0.171	0.076	0.612	0.670	0.430	0.643	0.500	0.170
Stroop 4-time	rho	0.015	–0.033	0.236	–0.023	0.033	–0.087	–0.085	–0.128	–0.054	–0.125	0.222
	p	0.878	0.736	0.016*	0.818	0.740	0.380	0.390	0.196	0.583	0.205	0.024*
Stroop 5-time	rho	–0.034	0.058	–0.099	–0.008	0.068	–0.091	–0.061	0.011	0.063	–0.047	-0.036
	p	0.712	0.558	0.314	0.931	0.494	0.354	0.537	0.908	0.525	0.633	0.712

MoCA: Montreal Cognitive Assessment, MSQ: Menstruation Symptom Questionnaire, PCS: Pain Catastrophizing Scale.

*P < 0.05.

2. Correlations between menstrual pain characteristics and the Stroop test

Stroop 4-time showed a weak positive correlation with the complaint duration (r = 0.236, P = 0.016) and PCS rumination scores (r = 0.222, P = 0.024) However, no correlation was found between other menstrual pain characteristics and other subscales of the Stroop test (Table 3).

DISCUSSION

The findings of the current study suggest that the majority of young women with primary dysmenorrhea may exhibit impaired cognitive function (below 26 on the MoCA). The authors found evidence to support that menstrual pain intensity, menstrual pain duration, complaint duration, menstrual symptoms related to coping strategies, and pain catastrophization mostly negatively affect visuospatial/executive cognitive functions. Also, this study focused on the relationship between different parameters and the Stroop test, which is used to measure selective attention. It was found that as the duration of complaints and pain catastrophization related to rumination increased, the fourth part of the Stroop test took longer to complete in primary dysmenorrhea.

In the literature, there are few studies evaluating cognitive function with MoCA in individuals with chronic pain such as low back pain, neck pain, knee osteoarthritis, or tension-type headache [18,33–35]. In the Oz et al. [33] study, the mean MoCA score for patients with chronic low back pain was 22.9, and 63.9% of the patients had a score below 26. In individuals with chronic neck pain, the mean MoCA score was 24 and 64.2% had scores below 26 [33]. In addition, these studies stated that age and education level may be determinants of cognitive function determined by MoCA in individuals with chronic low back and neck pain. Given these findings, the low mean MoCA score in the present study may suggest the poor cognitive ability in women with primary dysmenorrhea, despite their high education level and young age.

The relationship between pain and cognitive function is complicated and not fully explained. In the current study, as menstrual pain intensity, pain duration, and complaint duration increased, visuospatial/executive functions determined by MoCA worsened. Visuospatial abilities encompass the capacity to identify the components and overall structure of a percept, recognize its location in space, incorporate a cohesive spatial framework, and carry out mental operations on spatial concepts [36]. To actively influence our environment, we need to rely on these visuospatial skills [37]. In the present study, the fact that visuospatial functions were affected by menstrual pain intensity, pain duration and complaint duration may have reduced the interaction of women with primary dysmenorrhea with the environment. However, menstrual pain intensity, pain duration, and complaint duration were not significantly correlated with the MoCA total score or other cognitive domains. In a few studies evaluating cognitive function with the MoCA, visuospatial/executive functions, attention, abstraction, language, as well as memory and delayed recall were lower in patients with high pain intensity in different parts of their bodies [18,33,38]. In individuals with chronic neck pain, the abstraction domain score was found to be lower as the severity of resting pain increased [33]. Similar to the present study, visuospatial/executive functions deteriorated in individuals with chronic low back pain [18]. The modified trail-making test, cube copying, and the clock drawing test parameters assess visuomotor and visuaospatial skills in the visuospatial/executive domain, according to MoCA [39]. In addition, visual-spatial skills are seen as an important component of general intelligence. The visuospatial function may generally engage bilateral parietal activation. Executive function is primarily associated with frontal cortex [40]. Ihara et al. [41] noted that individuals with chronic neck pain had worse frontal cortex function than healthy individuals and that this was inversely related to pain severity. According to these results, abnormalities occurring in the parietal and frontal cortex in women with primary dysmenorrhea may have caused worsening of visuospatial/executive function with pain intensity.

Some studies have shown that duration of pain is inversely related to cognitive function [42,43], whereas others have shown that it is not associated with cognitive impairment [34,44]. The present study demonstrated that only the visuospatial/executive domain differed related to pain duration and complaint duration in women with primary dysmenorrhea. Similar to the present study, a negative relationship was found between migraine duration, attack frequency, and MoCA-executive function in individuals with migraine [42]. The longer durations and the increased number of days with pain in primary dysmenorrhea were correlated with decreased cognitive performance, especially in the visuospatial/executive domain. Therefore, when evaluating women with primary dysmenorrhea, as in migraine, the duration of exposure to this cyclic pain should be questioned, as well as the severity of pain, and it should be taken into consideration that long exposure may have worsened cognitive functions.

It is known that symptoms associated with premenstrual syndrome negatively affect cognitive performance related to concentration and productivity in women [45]. However, to the authors’ knowledge, there are no studies related to menstrual symptoms and MoCA scores in dysmenorrhea. The current study demonstrated that the visuospatial/executive domain of MoCA differed negatively with menstrual symptoms associated with coping strategies. This may also be a two-way relationship. In primary dysmenorrhea, young women may be less likely to develop strategies to cope with menstrual symptoms, as menstrual pain intensity, duration, and complaint duration negatively affect visiospatial/executive functions.

Pain catastrophizing and cognitive dysfunction are common variables associated with chronic pain. However; there is no clear conclusion as to the relationship between pain catastrophizing and cognition [46]. The present study revealed that MoCA-spatiovisual/executive function worsened as the score obtained from the PCS total, rumination, and helplessness subscales increased. In addition, pain catastrophizing associated with rumination in women with primary dysmenorrhea also worsened total cognitive function determined by MoCA. These findings suggest an inverse relationship between pain catastrophizing and cognitive function, particularly visuospatial/executive function.

The Stroop test, the gold standard of attention measurements, reflects three basic processes: selective attention, reading, and color recognition. In addition, Stroop performance reflects an individual’s degree of cognitive rigidity-flexibility. All these functions are related to the frontal lobe activities of the brain [47]. The results of this study conducted during the pain-free and periovulatory phases in primary dysmenorrhea show that longer duration of complaints and higher rumination-related catastrophization scores may be associated with a longer completion time for the fourth part of the Stroop test. These results may indicate potential impairments in cognitive functions related to selective attention, reading, and color recognition. Grisart and Plaghki [48] stated that a disturbance of selective attention was a function of pain intensity in chronic pain patients. In a study conducted by Gijsen et al. [49], it was stated that recurrent pain experience had a negative effect on selective attention in the healthy population. Furthermore, the results of this study align with previous research indicating a disturbance in selective attention among individuals experiencing chronic pain, regardless of the underlying condition.

Evaluation of cognitive function with Stroop, a gold standard method, as well as MoCA, is one of the strengths of this study. Another strength is that the population of the study was composed of young and highly educated women, eliminating the confounding effects of age and education on cognition. Additionally, evaluating all participants at a similar phase of the menstrual cycle strengthens the validity of our findings, as participants were likely to have comparable hormonal levels. Despite these strengths, the study has some limitations. Firstly, since this study was planned as cross-sectional, causality cannot be determined. Secondly, though the sample size (132 participants) appears to be adequate, a larger sample could enhance the robustness and generalizability of the findings. The relatively small sample size may have contributed to the identification of weaker correlations rather than stronger correlations. Although all participants were assessed during the mid-follicular phase (days 10–14), when they were pain-free, to avoid the acute influence of menstrual pain, ovulatory hormonal fluctuations inherent to this phase might still have influenced cognitive outcomes. Because all participants were evaluated within the same menstrual phase, hormonal status was relatively uniform across the sample, thereby minimizing between-subject variability. Nevertheless, hormonal levels were not directly measured in the present study, and their potential effects cannot be entirely excluded. A more comprehensive approach including hormonal profiling and cognitive assessment across menstrual phases is recommended to clarify the distinct effects of pain and hormonal changes. Patients without any clinical psychiatric diagnosis were included in the study. However, cognitive functions and pain perception might also have been influenced by potential confounding factors such as sleep quality, stress level, and caffeine intake. These variables were assessed through self-reported verbal ratings in the present study. Future research should evaluate these factors using more objective and standardized methods to ensure greater homogeneity of participants in terms of these parameters, and should also include a control group of women without primary dysmenorrhea, assess cognitive function across all menstrual cycle phases, incorporate larger and more diverse samples, adopt a longitudinal design, utilize a broader range of cognitive tests, integrate neuroimaging techniques such as functional magnetic resonance imaging, and explore interventions aimed at mitigating cognitive impairments. Additionally, future research could evaluate women’s mood and hormone levels during the menstrual cycle through objective blood tests, apply more detailed cognitive assessments focusing on specific executive functions (e.g., attention or visuospatial domains), and conduct imaging studies to further investigate the neural mechanisms underlying cognitive dysfunction in primary dysmenorrhea, thereby addressing the current study’s limitations and enhance the understanding of its cognitive effects.

The results of this study suggest that the cognitive function of most young women with primary dysmenorrhea may be below average, even though their education level is high. In primary dysmenorrhea, which causes repetitive and prolonged menstrual pain in the suprapubic region in each menstrual cycle, visuospatial/executive cognitive functions are negatively affected as pain intensity, pain duration, complaint duration, menstrual symptoms and pain catastrophization increase. In addition, the increase in the duration of complaints and pain catastrophizing also worsens cognitive functions related to selective attention. Thus, young women with primary dysmenorrhea should also be evaluated for cognitive functions, especially those related to visuospatial/executive and selective attention, and a personalized treatment program should be planned to improve cognitive status in addition to treatments to reduce pain.