Real-life use of non-pharmacological strategies and their relationship with symptom burden in primary dysmenorrhea: a cross-sectional study

Abstract

Background

Primary dysmenorrhea is a common health problem among women of reproductive age that negatively affects quality of life. Due to the limitations of pharmacological treatments, many women adopt non-pharmacological strategies. However, little is known about how the use of these strategies relates to multidimensional symptom profiles. This study aimed to examine the association between pain intensity, multidimensional menstrual symptom profiles, and the use of non-pharmacological strategies.

Methods

This descriptive cross-sectional study included 199 women aged ≥ 18 years. Data were collected using a Descriptive Information Form, the Menstrual Symptom Questionnaire (MSQ), and the Visual Analog Scale (VAS). Descriptive statistics, independent samples t-test, one-way ANOVA, and Pearson correlation analysis were performed. As this was an exploratory study, only unadjusted bivariate analyses were conducted. Statistical significance was set at p < 0.05.

Results

The mean age of participants was 23.18 ± 4.30 years, and the mean age at menarche was 13.16 ± 1.41 years. A family history of dysmenorrhea was reported by 60.3% of participants, and 44.7% stated that dysmenorrhea substantially affected daily life. Overall, 68.8% reported using non-pharmacological methods. Among CAM users (n = 137), the most commonly reported methods were heat application (80.3%), massage (35.8%), chamomile or fennel tea (35.8%), and consumption of dark chocolate (32.8%). Pain intensity was positively correlated with MSQ total and subscale scores (p < 0.001). Women using heat application, massage, progressive muscle relaxation, and dark chocolate had significantly higher lower abdominal pain scores than non-users (p < 0.05).

Conclusion

Women with primary dysmenorrhea experienced a multidimensional symptom burden extending beyond pain intensity. Greater symptom burden and the use of non-pharmacological methods frequently co-occurred. However, because of the cross-sectional and exploratory design, these findings should not be interpreted as evidence of treatment effectiveness or causal relationships. Routine multidimensional symptom assessment may support patient-centered, evidence-informed counseling on non-pharmacological management options.

Background

Primary dysmenorrhea (PD) is one of the most prevalent gynecological conditions among women of reproductive age and represents a significant source of physical discomfort and functional impairment. It is characterized by recurrent, cramping lower abdominal pain occurring in the absence of identifiable pelvic pathology [1]. This pain is commonly attributed to prostaglandin activity during menstruation and typically emerges within 6 to 24 months following menarche [2–4]. Dysmenorrheic pain generally follows a cyclical pattern, reaching its peak intensity on the first day of menstruation and lasting up to 72 h [4].

Globally, PD affects approximately 16% to 91% of women of reproductive age and may be accompanied by a wide range of symptoms, including nausea, vomiting, diarrhea, lower back, thigh and leg pain, migraine, dizziness, fatigue, insomnia, muscle stiffness, breast tenderness, hyperthermia, as well as psychological symptoms such as anxiety, depression, and irritability [1, 4–7]. These symptoms can adversely affect health-related quality of life, daily functioning, work productivity, and academic performance, and may lead to absenteeism during educational activities [4, 5, 7]. The high prevalence of PD and its detrimental impact on quality of life have accelerated the search for effective treatment options. Pharmacological management of PD primarily involves nonsteroidal anti-inflammatory drugs (NSAIDs), which inhibit prostaglandin synthesis and are generally considered the first-line treatment. Hormonal contraceptives may also be used, particularly when contraception is desired or when symptoms are insufficiently controlled with NSAIDs [1, 4]. Evidence from a network meta-analysis indicates that commonly available analgesics, including ibuprofen, naproxen, diclofenac, and ketoprofen, are more effective than placebo in relieving primary dysmenorrhea-related pain, although their comparative safety profiles vary [8]. Nevertheless, adverse effects, contraindications, incomplete symptom relief, and nonresponse or resistance to NSAIDs may limit pharmacological management in some women [8, 9]. These limitations, together with preferences for accessible and self-administered options, may encourage women to use non-pharmacological or complementary approaches.

Non-pharmacological management of PD includes a wide range of interventions, such as exercise, stretching, relaxation techniques, massage, local heat application, yoga, acupuncture, acupressure, transcutaneous electrical nerve stimulation (TENS), mind–body therapies, physiotherapy-based interventions, herbal products, and selected nutritional supplements [1, 4]. Recent systematic reviews and network meta-analyses indicate that exercise, local heat therapy, acupuncture, acupressure, yoga, TENS, and physiotherapy-based interventions are associated with reductions in menstrual pain and related symptoms, although the strength of evidence differs among interventions [3, 5, 10–12]. Herbal preparations, including ginger, cinnamon, and fennel, as well as vitamin D supplementation, have also shown potential benefits in reducing symptom severity; however, heterogeneity in intervention protocols and study quality warrants cautious interpretation of these findings [13–15].

Although controlled trials and evidence syntheses have mainly evaluated the efficacy of individual interventions, women’s management of menstrual pain in everyday life is often more complex. In a large cross-sectional study of 9,144 women, heat application, tea consumption, and massage were among the most frequently reported non-pharmacological self-management strategies, demonstrating that women commonly use readily accessible methods outside clinical settings [16]. Other observational evidence indicates that women may combine pharmacological and non-pharmacological practices and that their management choices can be shaped by symptom severity, previous experiences, perceived effectiveness, information sources, and access to professional care [7, 16, 17]. Ramos-Pichardo et al. (2020) further reported that many women normalize menstrual pain, rely on informal advice or self-management, and do not seek professional healthcare despite experiencing substantial symptoms [17].

The use of non-pharmacological strategies may vary across sociocultural settings, where health beliefs, lifestyle, and family influences may shape symptom management. In Türkiye, dietary habits, physical activity, menstrual characteristics, and family history have been associated with menstrual pain severity [18]. Although evidence specifically addressing primary dysmenorrhea in southeastern Türkiye is limited, qualitative research from Şanlıurfa suggests that women’s health practices are influenced by traditional beliefs, intergenerational knowledge, and advice from older family members [19]. These contextual characteristics may also influence women’s preferences for home-based and other non-pharmacological approaches to menstrual symptom management. However, evidence describing the real-life use of non-pharmacological strategies for primary dysmenorrhea in women living in southeastern Türkiye remains limited.

Despite growing interest in non-pharmacological management, evidence on how women use these approaches in everyday settings remains limited. Previous research has primarily examined the effectiveness of individual interventions, the prevalence of their use, or pain severity as the main outcome [3, 10, 16]. Most studies have assessed dysmenorrhea using unidimensional measures such as the Visual Analog Scale (VAS) or Numeric Rating Scale (NRS), which focus primarily on pain severity. However, primary dysmenorrhea involves a broader range of physical symptoms and coping responses that are not fully captured by these measures. The Menstrual Symptom Questionnaire (MSQ) offers a multidimensional assessment of menstrual symptoms and enables evaluation of broader symptom profiles [20–22]. Whether women’s choice of non-pharmacological strategies differs according to multidimensional symptom profiles remains largely unexplored, and examining this relationship may provide a more comprehensive understanding of symptom-related treatment preferences in everyday practice.

To our knowledge, few studies have investigated whether multidimensional menstrual symptom profiles, rather than pain intensity alone, are associated with women’s choice of non-pharmacological management strategies in everyday practice. Therefore, this study aimed to identify the non-pharmacological strategies used by women aged 18 years and older with PD and to examine whether their use was associated with both pain intensity and multidimensional menstrual symptom profiles assessed using the MSQ.

Methods

Study design

This study was designed as a descriptive cross-sectional study.

Study participants

The study population consisted of women aged 18 years and older who attended the Gynecology and Obstetrics Outpatient Clinic of a Training and Research Hospital in Şanlıurfa, southeastern Türkiye. Eligible participants were identified through face-to-face interviews conducted by the researchers. Eligibility was determined based on participants’ self-reported symptoms consistent with primary dysmenorrhea and their self-reported medical history. Women with a previous physician diagnosis of conditions associated with secondary dysmenorrhea were not considered eligible for participation.

The sample size was determined a priori using G*Power version 3.1.9.4 before data collection. As the study was designed as a descriptive cross-sectional study involving a single sample, the calculation was performed using the t tests test family and the “Means: Difference from constant (one sample case)” statistical test. Based on Cohen’s conventional benchmarks, a small standardized effect size (Cohen’s d = 0.20) [23], a two-tailed significance level of 0.05, and a statistical power of 80% (1 − β = 0.80) were specified. Based on these parameters, the minimum required sample size was 199 participants. Comparisons between users and non-users of individual non-pharmacological strategies were conducted as secondary exploratory analyses and did not form the basis of the original sample size calculation.

Inclusion, exclusion, and withdrawal criteria

The World Health Organization (WHO) defines adolescence as the period between 10 and 19 years of age [24]. Accordingly, only women aged 18 years and older were eligible for inclusion in the present study. This criterion excluded younger adolescents while including individuals aged 18–19 years, who are classified as late adolescents according to the WHO definition.

Women aged 18 years or older who reported symptoms consistent with primary dysmenorrhea and voluntarily agreed to participate were included in the study.

Women reporting a previous physician diagnosis of endometriosis, adenomyosis, uterine leiomyomas, pelvic inflammatory disease, ovarian cysts, congenital uterine anomalies, or other clinically diagnosed pelvic pathologies associated with secondary dysmenorrhea were excluded. Participants with diagnosed psychiatric disorders, communication difficulties, or incomplete questionnaire data were also excluded.

Participants who withdrew from the study before completing the data collection process or submitted incomplete questionnaires were excluded from the final analysis.

Data collection tools

For data collection, a semi-structured descriptive information form developed based on a literature review [2, 7, 13, 25], the Menstrual Symptom Questionnaire (MSQ), and the Visual Analog Scale (VAS) were used.

Descriptive information form for women

The form included information on participants’ sociodemographic characteristics (such as age, marital status, smoking/alcohol use, etc.), menstrual characteristics (such as age at menarche, regularity of menstruation, family history of dysmenorrhea, presence of menstrual pain, coping with pain, and its impact on daily life), as well as non-pharmacological methods used for menstrual pain. For each non-pharmacological method, participants were asked whether they had used the method to manage menstrual pain (yes/no). Information regarding the frequency, duration, timing, or perceived effectiveness of each method was not collected.

Visual analog scale (VAS)

The validity and reliability of this scale, which was developed by Price et al. (1994) to assess pain intensity, were tested in Turkish by Eti Aslan (2004) through evaluating the presence of pain in postoperative patients. The scale is rated from 0 to 10, where 0 = “no pain” and 10 = “unbearable pain” [26, 27]. In addition to MSQ-based multidimensional assessment, VAS was used to provide a direct and region-specific evaluation of pain severity, including lower abdominal, low back, and leg pain.

Menstrual symptom questionnaire (MSQ)

Chesney and Tasto developed the Menstrual Symptom Questionnaire (MSQ) in 1975 to evaluate the pain and symptoms experienced by women during menstruation [20]. The factor structure and usability of the scale were re-evaluated and updated by Negriff et al. in 2009 [21]. The scale, which has been widely used in many countries, was adapted into Turkish and its validity and reliability were tested by Güvenç et al. in 2014 [22]. The scale consists of 22 items and has a five-point Likert type response format: “never (1),” “rarely (2),” “sometimes (3),” “often (4),” and “always (5).” The MSQ comprises three subdimensions: “negative effects/somatic complaints,” “menstrual pain symptoms,” and “coping methods.” Scores for each subdimension are calculated by summing the item scores within the subdimension or by computing the mean score. Higher scores or mean values for a subdimension indicate increased severity of menstrual symptoms related to that subdimension. The Cronbach’s alpha value for the Turkish adaptation of the MSQ was reported as 0.92 [22]. In the present study, the Cronbach’s alpha value was determined as 0.91.

Data collection

After obtaining ethics committee approval, data were collected between June and August 2025 by the researchers. Prior to data collection, participants were informed about the purpose, scope, and confidentiality principles of the study, and written informed consent was obtained. Data were collected through face-to-face interviews conducted by trained researchers, each lasting approximately 20 min. To minimize potential bias, all interviews were conducted using standardized data collection procedures and the same study instruments. Participants were interviewed individually in a private setting, and no third parties were present during data collection.

All assessments were performed during the first 72 h of menstruation, when primary dysmenorrhea symptoms are typically most pronounced, to ensure standardized symptom assessment. The three Visual Analog Scale (VAS) assessments (lower abdominal pain, low back pain, and leg pain) were completed simultaneously during a single assessment session within this 72-hour period.

Data analysis

The research data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 27.0. Continuous variables were presented as mean (M) and standard deviation (SD), while categorical variables were expressed as frequency (n) and percentage (%). The normality of data distribution was assessed using skewness and kurtosis values, which ranged between − 2 and + 2, indicating approximate normal distribution.

Based on the assumption of normality, the independent samples t-test was used to compare two groups, and one-way analysis of variance (ANOVA) was used for comparisons among three or more groups. Pearson correlation analysis was performed to examine the direction and strength of the relationships between pain intensity and menstrual symptom levels.

Because the study was designed as an exploratory descriptive investigation, only unadjusted bivariate analyses were performed to examine associations between variables. No multivariable analyses were conducted to adjust for potential confounding variables. Therefore, the reported associations should not be interpreted as independent effects or causal relationships. In addition, no adjustment for multiple comparisons was applied; accordingly, the reported associations should be considered exploratory and interpreted with appropriate caution.

The primary outcome of the study was the total score of the Menstrual Symptom Questionnaire (MSQ). Secondary outcomes included the three MSQ subdimension scores (negative effects/somatic complaints, pain symptoms, and coping methods), pain intensity measured using the Visual Analog Scale (VAS), and the use and preferences of non-pharmacological strategies for menstrual pain.

A two-tailed p value of < 0.05 was considered statistically significant.

Ethical considerations

For the conduct of the study, ethical approval was obtained from the Hasan Kalyoncu University Health Sciences Non-Interventional Research Ethics Committee (dated 28.05.2025, decision no: 2025/071), as well as written permission from the Şanlıurfa Governorship Provincial Directorate of Health where the research was conducted (E-52941166-799-289732202). Electronic written permission was obtained from the owner of the scales to be used in data collection. After providing explanations regarding the study, participants who agreed to take part and met the inclusion criteria signed the “Informed Consent Form” before implementation. The study was conducted in accordance with the principles of the Helsinki Declaration on Human Rights.

Results

Table 1 presents the sociodemographic and menstrual characteristics of the participants. The mean age was 23.18 ± 4.30 years, and the mean age at menarche was 13.16 ± 1.41 years. Most participants were aged 18–20 years (35.6%), single (68.3%), and reported no substance use (68.8%). Regarding menstrual characteristics, 36.6% had menarche at age 14 years or older, and 87.4% reported having a regular menstrual cycle. The majority of participants had a menstrual cycle length of 21–35 days (73.4%) and a menstruation duration of 5–7 days (65.8%). Additionally, 11.6% reported using more than five pads per day during menstruation (Table 1).

Table 1.

Sociodemographic and menstrual characteristics of the participants (n = 199)

Categorical Variables	Mean ± SD	Min – Max
Age (years)	23.18 ± 4.30	18–35
Age at menarche (years)	13.16 ± 1.41	10–17
Categorical Variables	n	%
Age Groups
18–20 years	71	35.6
21–23 years	64	32.2
≥ 24 years	64	32.2
Marital Status
Single	136	68.3
Married	63	31.7
Substance Use Status
Yes*	62	31.2
No	137	68.8
Age at menarche (years)
10–12 years	62	31.2
13 years	64	32.2
≥ 14 years	73	36.6
Regular Menstrual Cycle
Yes	174	87.4
No	25	12.6
Menstrual Cycle Length
< 21 days	33	16.6
21–35 days	146	73.4
> 35 days	20	10.0
Duration of Menstruation
< 5 days	36	18.1
5–7 days	131	65.8
> 7 days	32	16.1
Daily Amount of Menstrual Bleeding
< 3 pads	83	41.7
3–5 pads	93	46.7
> 5 pads	23	11.6
Total	199	100.0

SD Standard Deviation, Min. Minimum value, Max. Maximum value

*Substance use refers to smoking and/or alcohol consumption

Table 2 presents participants’ pain-related characteristics and their use of complementary and alternative medicine (CAM). More than half of the participants had a family history of dysmenorrhea (60.3%) and indicated that they coped with menstrual pain (59.3%). Menstrual pain substantially affected daily life in 44.7% of participants, while 56.3% had consulted a physician because of menstrual pain. Overall, 68.8% reported using CAM methods for dysmenorrhea. Among CAM users, 87.6% perceived these methods as beneficial. Confidence in CAM methods was moderate, with 40.2% of participants assigning scores between 7 and 10 and a mean confidence score of 5.31 ± 2.94.

Table 2.

Distribution of participants’ pain conditions during menstrual periods and the complementary and alternative medicine methods they used (n = 199)

Categorical Distribution	N	%
Family history of dysmenorrhoea*
Yes	120	60.3
No	79	39.7
Coping with pain during menstruation
Yes	118	59.3
No	81	40.7
Impact of menstrual pain on daily life
Affects very little	24	12.1
Affects moderately	86	43.2
Affects severely	89	44.7
Consulting a doctor for menstrual pain
Yes	112	56.3
No	87	43.7
Use of CAM for dysmenorrhea
Yes	137	68.8
No	62	31.2
Perceived benefit from CAM use**
Yes	120	87.6
No	17	12.4
Confidence in CAM methods (1–10 points)
1–3 points	66	33.2
4–6 points	53	26.6
7–10 points	80	40.2

	Mean ± SD	Min. – Max.
Confidence in CAM use	5.31 ± 2.94	1–10

Confidence in CAM use was assessed in the entire study sample (n = 199)

CAM Complementary and Alternative Medicine, SD Standard deviation, Min. Minimum, Max. Maximum.

*Mother, aunt, or sister

**Percentages for perceived benefit from CAM use were calculated only among participants who reported using CAM (n = 137)

Table 3 presents the reasons for preferring CAM and the CAM methods used among participants who reported CAM use (n = 137). The most frequently reported reasons for preferring CAM were its perceived naturalness (57.7%), ease of access (42.3%), and perceived effectiveness (38.0%). Heat application to the abdomen was the most commonly reported CAM method (80.3%), followed by massage and chamomile or fennel tea (35.8% each), consumption of dark chocolate (32.8%), walking (28.5%), and thyme tea (27.7%).

Table 3.

Reasons for preferring complementary and alternative medicine (CAM) and types of CAM methods used among participants (n = 137)

Variables	N	%
Reasons for preferring CAM*
Natural	79	57.7
Effective	52	38.0
Easy to Access	58	42.3
Low cost	19	13.9
Few side effects	36	26.3
Recommended by others	33	24.1
CAM methods used*
Heat application to abdomen	110	80.3
Massage	49	35.8
Chamomile or fennel tea	49	35.8
Consumption of dark chocolate	45	32.8
Walking	39	28.5
Thyme tea	38	27.7
Listening to music	31	22.6
Cinnamon or ginger tea	31	22.6
Onion juice	21	15.3
Yarrow infusion	35	25.5
Progressive muscle relaxation	22	16.1
Breathing exercises	17	12.4
Meditation	17	12.4
Yoga	9	6.6

*Multiple responses were permitted; therefore, percentages do not sum to 100%. Percentages were calculated among participants who reported CAM use (n = 137).

Table 4 presents the mean MSQ total and subscale scores. The mean total MSQ score was 79.46 ± 17.55. Among the subscales, the highest mean score was observed in the negative effects/somatic complaints dimension (46.91 ± 10.70). Mean VAS pain scores were 6.95 ± 2.25 for lower abdominal pain, 6.57 ± 2.33 for low back pain, and 6.09 ± 2.64 for leg pain. All VAS measurements reflect pain intensity within the first 72 h of menstruation.

Table 4.

Distributions of the participants’ MSQ total and subscale mean scores and some pain severity mean scores on the VAS

Scales and Subdimensions	Item Number	Expected Min-Max	Observed Min-Max	Mean ± SD	Median (Q1-Q3)
MSQ	22	22–110	25–108	79.46 ± 17.55	83 (65–92)
Negative Effects/Somatic Complaints	13	13–65	14–65	46.91 ± 10.70	49 (39–55)
Pain Symptoms	6	6–30	7–30	23.38 ± 5.40	25 (20–27)
Coping Methods	3	3–15	3–15	9.16 ± 3.85	9 (6–12)
VAS-Lower Abdominal Pain	-	0–10	0–10	6.95 ± 2.25	7 (5–9)
VAS-Low Back Pain	-	0–10	0–10	6.57 ± 2.33	6 (5–8)
VAS-Leg Pain	-	0–10	0–10	6.09 ± 2.64	6 (4–8)

VAS scores represent pain intensity measured within the first 72 h of menstruation

SD Standard Deviation, Min. Minimum value, Max.: Maximum value, Q3 75th Percentile, Q1 25th Percentile, MSQ Menstrual Symptom Questionnaire, VAS Visual Analog Scale

Table 5 presents the comparison of MSQ total and subscale scores according to selected variables. MSQ total and subscale scores did not differ significantly according to the perceived impact of menstrual pain on daily life or consultation with a physician (p > 0.05). Participants who reported using heat application had significantly higher negative effects/somatic complaints, coping methods, and total MSQ scores than those who did not use this method (p < 0.05). Participants who reported using progressive muscle relaxation had significantly higher MSQ total and all subscale scores than non-users (p < 0.05). Similarly, participants who reported massage or onion juice use had significantly higher coping methods scores, whereas those who reported consuming chamomile or fennel tea had significantly higher pain symptoms, coping methods, and total MSQ scores. Participants who reported thyme tea use had significantly higher negative effects/somatic complaints and total MSQ scores (p < 0.05). No significant differences were observed for other methods, including dark chocolate, cinnamon or ginger tea, breathing exercises, yoga, meditation, walking, listening to music, and yarrow infusion (p > 0.05).

Table 5.

Comparison of participants’ descriptive characteristics and applied complementary and alternative medicine (CAM) methods with the mean scores of the MSQ and Its subdimensions

					Negative Effects/ Somatic Complaints	Pain Symptoms	Coping Methods	MSQ
					Mean ± SD	Mean ± SD	Mean ± SD	Mean ± SD
Impact of menstrual pain on daily life
Affects very little (n=24)					46.79 ± 12.79	23.38 ± 5.82	9.38 ± 3.55	79.54 ± 19.99
Affects moderately (n=86)					45.91 ± 11.07	22.70 ± 5.69	8.76 ± 3.67	77.36 ± 17.95
Affects very much (n=89)					47.92 ± 9.72	24.04 ± 4.95	9.50 ± 4.08	81.46 ± 16.41
				p*	0.462	0.257	0.430	0.305
Consultation with a physician for menstrual pain
Yes (n=112)					46.89 ± 10.11	23.21 ± 5.33	9.07 ± 4.07	79.17 ± 17.21
No (n=87)					46.94 ± 11.48	23.61 ± 5.51	9.28 ± 3.56	79.83 ± 18.08
			p*		0.974	0.602	0.711	0.794
Application of heat to the abdomen
Yes (n=110)					48.86 ± 10.32	23.71 ± 4.81	10.05 ± 3.40	82.62 ± 16.34
No (n=89)					44.51 ± 10.73	22.98 ± 6.05	8.07 ± 4.10	75.55 ± 18.29
		p*			0.004	0.355	< 0.001	0.005
Consumption of dark chocolate
Yes (n=45)					47.93 ± 10.51	23.76 ± 4.65	9.40 ± 3.68	81.09 ± 16.53
No (n=154)					46.62 ± 10.77	23.27 ± 5.61	9.09 ± 3.90	78.98 ± 17.87
		p*			0.469	0.599	0.637	0.480
Cinnamon or ginger tea
Yes (n=31)					48.16 ± 10.90	23.55 ± 5.51	9.71 ± 3.96	81.42 ± 18.46
No (n=168)					46.68 ± 10.68	23.35 ± 5.39	9.06 ± 3.83	79.10 ± 17.42
		p*			0.482	0.852	0.389	0.500
Progressive muscle relaxation
Yes (n=22)					54.14 ± 8.93	25.23 ± 3.16	10.73 ± 2.99	90.09 ± 12.65
No (n=177)					46.02 ± 10.66	23.15 ± 5.58	8.97 ± 3.90	78.14 ± 17.66
		p*			< 0.001	0.013	0.018	< 0.001
Massage
Yes (n=49)					48.12 ± 10.85	24.29 ± 5.04	10.27 ± 3.30	82.67 ± 16.53
No (n=150)					46.52 ± 10.58	23.09 ± 5.49	8.80 ± 3.95	78.41 ± 17.80
		p*			0.364	0.178	0.012	0.140
Breathing exercises
Yes (n=17)					44.12 ± 12.45	22.06 ± 6.21	10.24 ± 3.40	76.41 ± 20.12
No (n=182)					47.18 ± 10.52	23.51 ± 5.32	9.06 ± 3.88	79.74 ± 17.33
		p*			0.261	0.292	0.229	0.456
Yoga
Yes (n=9)					48.56 ± 9.82	24.11 ± 5.46	10.33 ± 3.54	83.00 ± 16.25
No (n=190)					46.84 ± 10.76	23.35 ± 5.41	9.11 ± 3.86	79.29 ± 17.64
		p*			0.639	0.679	0.351	0.537
Meditation
Yes (n=17)					47.53 ± 7.64	24.29 ± 5.16	9.76 ± 3.82	81.59 ± 13.92
No (n=182)					46.86 ± 10.96	23.30 ± 5.43	9.10 ± 3.86	79.26 ± 17.88
		p*			0.743	0.468	0.500	0.602
Walking
Yes (n = 39)					46.95 ± 9.58	23.23 ± 5.16	9.82 ± 3.52	80.00 ± 16.31
No (n = 160)					46.91 ± 10.99	23.42 ± 5.47	9.00 ± 3.92	79.33 ± 17.89
		p*			0.982	0.846	0.233	0.830
Listening to music
Yes (n = 31)					48.97 ± 8.69	24.23 ± 4.99	10.06 ± 3.86	83.26 ± 15.08
No (n = 168)					46.54 ± 11.01	23.23 ± 5.47	8.99 ± 3.83	78.76 ± 17.93
		p*			0.177	0.345	0.155	0.190
Chamomile or fennel tea
Yes (n = 49)					49.25 ± 9.10	25.57 ± 4.18	10.47 ± 3.05	85.29 ± 14.10
No (n = 150)					46.15 ± 11.10	22.67 ± 5.57	8.73 ± 3.99	77.55 ± 18.18
		p*			0.054	< 0.001	0.002	0.003
Thyme tea
Yes (n = 38)					50.79 ± 11.40	24.66 ± 4.71	10.00 ± 3.17	85.45 ± 16.75
No (n = 161)					46.00 ± 10.36	23.08 ± 5.52	8.96 ± 3.97	78.04 ± 17.49
		p*			0.013	0.105	0.090	0.019
Onion juice
Yes (n = 21)					49.00 ± 9.42	25.24 ± 4.38	10.71 ± 2.63	84.95 ± 14.23
No (n = 178)					46.67 ± 10.84	23.16 ± 5.48	8.98 ± 3.93	78.81 ± 17.83
		p*			0.346	0.056	0.011	0.080
Yarrow infusion
Yes (n = 35)					47.66 ± 11.06	23.49 ± 5.35	9.57 ± 3.43	80.71 ± 17.58
No (n = 164)					46.76 ± 10.65	23.36 ± 5.42	9.07 ± 3.93	79.19 ± 17.59
		p*			0.652	0.901	0.488	0.642

MSQ Menstrual Symptom Questionnaire

*Independent samples t-test was used for two-group comparisons and One-way ANOVA for multiple-group comparisons

Table 6 presents the comparison of VAS-based pain intensity scores according to non-pharmacological methods. Pain intensity measured by VAS did not differ significantly across most non-pharmacological methods (p > 0.05). However, participants who used heat application, dark chocolate, progressive muscle relaxation, and massage reported significantly higher lower abdominal pain scores (p < 0.05), while no significant differences were observed in low back or leg pain. No statistically significant differences were found in VAS scores across other non-pharmacological methods (p > 0.05).

Table 6.

Comparison of some pain intensity mean scores on the VAS according to the CAM methods used by the participants

			VAS-Lower Abdominal	VAS-Low Back	VAS-Leg
			M ± SD	M ± SD	M ± SD
Application of heat to the abdomen
Yes (n=110)			7.26 ± 1.92	6.65 ± 2.28	6.31 ± 2.66
No (n=89)			6.57 ± 2.56	6.47 ± 2.40	5.81 ± 2.60
		p*	0.036	0.603	0.185
Consumption of dark chocolate
Yes (n=45)			7.60 ± 2.07	6.87 ± 2.44	6.29 ± 2.81
No (n=154)			6.77 ± 2.72	6.48 ± 2.30	6.03 ± 2.59
		p*	0.028	0.329	0.558
Cinnamon or ginger tea
Yes (n=31)			6.90 ± 2.27	6.19 ± 2.33	5.42 ± 2.38
No (n=168)			6.96 ± 2.25	6.64 ± 2.33	6.21 ± 2.67
		p*	0.890	0.332	0.127
Progressive muscle relaxation
Yes (n=22)			8.00 ± 1.48	6.86 ± 2.19	6.68 ± 2.12
No (n=177)			6.82 ± 2.30	6.53 ± 2.35	6.01 ± 2.68
		p*	0.002	0.529	0.262
Massage
Yes (n=49)			7.61 ± 1.78	6.47 ± 2.31	6.35 ± 2.79
No (n=150)			6.74 ± 2.35	6.60 ± 2.34	6.00 ± 2.59
		p*	0.007	0.734	0.426
Breathing exercises
Yes (n=17)			7.18 ± 1.55	6.29 ± 1.99	5.29 ± 2.66
No (n=182)			6.93 ± 2.31	6.59 ± 2.36	6.16 ± 2.63
		p*	0.672	0.614	0.197
Yoga
Yes (n=9)			6.33 ± 2.00	7.33 ± 2.50	6.78 ± 2.28
No (n=190)			6.98 ± 2.62	6.53 ± 2.32	6.05 ± 2.66
		p*	0.398	0.314	0.422
Meditation
Yes (n=17)			6.00 ± 1.87	6.76 ± 2.25	5.35 ± 2.50
No (n=182)			7.04 ± 2.27	6.55 ± 2.34	6.15 ± 2.65
		p*	0.067	0.717	0.232
Walking
Yes (n=39)			6.59 ± 1.74	6.31 ± 2.45	5.90 ± 2.73
No (n=160)			7.04 ± 2.35	6.63 ± 2.30	6.13 ± 2.62
		p*	0.180	0.438	0.621
Listening to music
Yes (n=31)			6.55 ± 2.00	6.45 ± 2.23	5.65 ± 2.17
No (n=168)			7.03 ± 2.29	6.59 ± 2.35	6.17 ± 2.72
		p*	0.275	0.763	0.313
Chamomile or fennel tea
Yes (n=49)			7.14 ± 1.70	6.86 ± 2.06	6.31 ± 2.35
No (n=150)			6.89 ± 2.41	6.47 ± 2.41	6.01 ± 2.73
		p*	0.425	0.281	0.502
Thyme tea
Yes (n=38)			7.32 ± 2.02	6.89 ± 2.29	5.97 ± 2.54
No (n=161)			6.87 ± 2.30	6.49 ± 2.34	6.11 ± 2.67
		p*	0.273	0.338	0.773
Onion juice
Yes (n=21)			7.62 ± 1.66	6.81 ± 2.50	6.14 ± 2.20
No (n=178)			6.88 ± 2.30	6.54 ± 2.32	6.08 ± 2.69
		p*	0.153	0.616	0.916
Yarrow infusion
Yes (n=35)			7.09 ± 1.70	6.40 ± 2.16	5.74 ± 2.02
No (164)			6.93 ± 2.35	6.60 ± 2.37	6.16 ± 2.75
		p*	0.643	0.640	0.307

VAS Visual Analog Scale

* Independent samples t-test was used for two-group comparisons

Table 7 presents the correlations between MSQ scores and pain intensity. MSQ total scores were positively correlated with lower abdominal (r = 0.613, p < 0.001), low back (r = 0.463, p < 0.001), and leg pain intensity (r = 0.431, p < 0.001). Similarly, all MSQ subscale scores were positively correlated with pain intensity across all three anatomical regions (all p < 0.001).

Table 7.

Correlation between menstrual symptom questionnaire (MSQ) scores, its subdimensions, and pain intensity measured by the visual analog scale (VAS)

	MSQ	Negative Effects / Somatic Complaints	Pain Symptoms	Coping Methods
MSQ	r 1p	0.956*< 0.001	0.841*< 0.001	0.722*< 0.001
Lower abdominal pain	r 0.613* p <0.001	0.561* < 0.001	0.499* <0.001	0.533* < 0.001
Low back pain	r 0.463* p <0.001	0.415* < 0.001	0.485* < 0.001	0.280* < 0.001
Leg pain	r 0.431* p <0.001	0.389* < 0.001	0.349* < 0.001	0.397* < 0.001

VAS Visual Analog Scale, MSQ Menstrual Symptom Questionnaire

* Pearson’s correlation analysis was used. p<0.01

Discussion

In this cross-sectional study (n = 199), the evaluation of dysmenorrhea extended beyond pain intensity to include somatic, psychosocial, and coping-related dimensions, revealing a considerable symptom burden among young women (MSQ = 79.46 ± 17.55; lower abdominal/low back/leg pain ≈ 7/6.6/6.1). In addition, the use of certain non-pharmacological methods was associated with differences in both VAS-based pain intensity scores and MSQ scores, and significant associations were observed between pain intensity and multidimensional menstrual symptom scores, consistent with the study objectives. Importantly, these findings indicate an observational association between the use of non-pharmacological methods and symptom burden. Given the cross-sectional and exploratory nature of the study, these associations should not be interpreted as evidence that symptom burden drives the use of these methods or that the methods themselves are therapeutically effective. These findings highlight the multidimensional associations observed between symptom burden and the use of non-pharmacological strategies.

Participants with primary dysmenorrhea experienced a broad multidimensional symptom burden. In addition, 60.3% reported a family history of dysmenorrhea, and 59.3% reported attempting to cope with menstrual pain. The mean total MSQ score (79.46 ± 17.55) further indicated a broad menstrual symptom burden in this sample. Previous studies have similarly identified family history of dysmenorrhea as a factor associated with primary dysmenorrhea [6, 7, 28]. Dysmenorrhea has also been shown to adversely affect daily functioning, academic performance, and health-related quality of life [4, 7, 29]. In the meta-analysis by Wang et al. (2022), the pooled prevalence of primary dysmenorrhea among students was 66.1%, and family history of dysmenorrhea was among the factors significantly associated with the condition [28]. Taken together, these findings are consistent with evidence that primary dysmenorrhea is associated with multiple menstrual, lifestyle-related, and familial factors [4, 6, 7, 28].

Pain intensity was positively and significantly correlated with the total MSQ score and all MSQ subscale scores (p < 0.001). Correlations between total MSQ scores and pain intensity across the three pain regions ranged from r = 0.431 to r = 0.613, indicating positive associations of varying magnitude. These findings suggest that greater pain intensity was accompanied by a broader multidimensional symptom burden within this study population. Previous studies have likewise shown that dysmenorrhea can interfere with daily activities and academic functioning [4, 7, 29].

The finding that 56.3% of participants consulted a physician suggests that health-seeking behavior was relatively common in this sample. However, previous research indicates that many young women tend to normalize dysmenorrhea and refrain from seeking medical help [17]. This apparent inconsistency may reflect contextual or sociocultural differences influencing health-seeking patterns. In particular, in sociocultural contexts where menstrual pain is often perceived as a normal and unavoidable condition, such perceptions may directly influence help-seeking behavior.

A substantial proportion of participants (68.8%) reported using complementary and alternative medicine (CAM) methods to cope with dysmenorrhea. Among CAM users (n = 137), the most commonly reported methods were heat application to the abdomen (80.3%), massage (35.8%), chamomile or fennel tea (35.8%), and consumption of dark chocolate (32.8%). In addition, 87.6% of CAM users reported perceiving CAM methods as beneficial. However, this finding reflects participants’ subjective perceptions rather than objective evidence of treatment effectiveness. Consistent with our findings, Rodrigues et al. reported frequent use of heat therapy, tea, and massage for the self-management of primary dysmenorrhea-related pain [16]. Furthermore, a systematic review and meta-analysis of randomized controlled trials found that fennel may reduce menstrual pain, although methodological limitations and substantial heterogeneity warrant cautious interpretation [30].

Given the cross-sectional design, it is equally plausible that women experiencing greater symptom burden were more likely to adopt non-pharmacological strategies than that the use of these strategies influenced symptom severity. Therefore, the observed associations should not be interpreted as evidence of treatment effectiveness or ineffectiveness. Longitudinal and intervention studies are required to clarify the temporal relationship between symptom burden and the selection of non-pharmacological management strategies.

Although these findings are exploratory, they suggest that multidimensional assessment of symptom burden may help clinicians better understand women’s self-management behaviors. Evidence from systematic reviews and meta-analyses of intervention studies suggests potential benefits of several non-pharmacological approaches; therefore, clinical decisions regarding specific strategies should be informed by intervention evidence rather than by the present observational associations alone [3, 10–12, 15].

Furthermore, because only unadjusted bivariate analyses were performed, the reported associations should be interpreted as preliminary exploratory findings rather than independent relationships. The absence of multivariable adjustment and correction for multiple comparisons increases the possibility that some observed associations may have been influenced by residual confounding or chance findings. In addition, information regarding the frequency, duration, timing, and perceived effectiveness of individual non-pharmacological strategies was not collected. Future longitudinal and intervention studies incorporating detailed assessments of non-pharmacological strategy use, together with appropriate adjustment for potential confounding factors, are needed to better understand these observed associations.

Strengths and limitations of the study

This study provides a multidimensional evaluation of primary dysmenorrhea by assessing not only pain intensity but also somatic symptoms, psychosocial effects, and coping-related dimensions. The combined use of the Visual Analog Scale (VAS) and the Menstrual Symptom Questionnaire (MSQ) enabled a comprehensive assessment of symptom burden. In addition, examining women’s real-life use of non-pharmacological methods together with their perceived benefit provides valuable insight into symptom management practices in everyday settings.

However, several limitations should be considered. First, primary dysmenorrhea was identified based on participants’ self-reported symptoms and medical history rather than clinical examination or diagnostic confirmation, which may have resulted in misclassification. Second, the cross-sectional design precludes causal inference, and because the study was exploratory, only unadjusted bivariate analyses were performed without multivariable adjustment or correction for multiple comparisons. In addition, the small and unequal subgroup sizes for some non-pharmacological strategies limited the statistical power of these comparisons, particularly for detecting small effects. Therefore, the reported associations should be interpreted as preliminary exploratory findings, and non-significant findings should be interpreted cautiously. Third, the use of self-reported data may have introduced recall and social desirability bias. Fourth, recruitment from a single hospital-based outpatient clinic may have introduced selection and non-response bias, thereby limiting the generalizability of the findings. Fifth, non-pharmacological strategies were assessed only as binary variables (used/not used); information regarding their frequency, duration, timing, and perceived effectiveness was not collected, limiting a more detailed evaluation of their relationship with symptom burden. Finally, physiotherapy-specific interventions commonly used in the management of primary dysmenorrhea, such as transcutaneous electrical nerve stimulation (TENS), manual therapy, and supervised therapeutic exercise, were not specifically evaluated, which may have limited the comprehensiveness of the assessment.

Conclusion and recommendations

This study highlights the multidimensional symptom burden experienced by women with primary dysmenorrhea, extending beyond pain intensity to include somatic and coping-related dimensions. The observed associations indicate that greater symptom burden and the use of non-pharmacological methods frequently co-occur. However, because of the cross-sectional and exploratory nature of the study, these findings should not be interpreted as evidence that symptom burden drives the use of these methods or that the methods themselves are therapeutically effective.

From a clinical perspective, healthcare professionals may consider routinely assessing women’s multidimensional symptom profiles and providing evidence-informed guidance on the appropriate use of accessible, non-invasive non-pharmacological strategies, such as heat application, herbal remedies, and relaxation techniques. Nevertheless, the effectiveness of specific non-pharmacological approaches cannot be inferred from the present findings and should be confirmed in well-designed prospective and intervention studies.

Future research should prioritize longitudinal and interventional designs to clarify the temporal relationship between symptom burden and the use of non-pharmacological methods, determine whether these methods contribute to symptom reduction, or whether they are more frequently adopted by women experiencing greater symptom burden.

Authors’ contributions

Conceptualization: SK, ÜS, SA Investigation: SK Validation: SK, SA Formal Analysis: SK, SA Data Curation: SK, SA Resources: SK, SA Project Administration: SK, ÜS Visualization: SK, SA, ÜS Supervision: ÜS Writing – Original Draft: SK, SA Writing – Review & Editing: SK, ÜS, SA.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Non-Interventional Research Ethics Committee (dated 28.05.2025, decision no: 2025/071) and from the Provincial Directorate of Health (E-52941166-799-289732202). Written informed consent was obtained from all participants. The study was conducted in accordance with the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.