This was a cross-sectional study conducted by the Department of Obstetrics and Gynecology and Social and Preventive medicine at U.P.U.M.S. Saifai, Etawah, between July-August 2019, in 150 female medical students selected by random sampling. Sample size was 150 students, keeping in mind the limited resources because a maximum of 150 female medical students were found at the study center that included all the consenting semester students.

Informed consent was obtained from students after discussing the purpose and methodology of the study. Ethical clearance for the study was taken from the Institute’s Ethics Committee (letter no. 34/2019-20).

Inclusion criteria: All the female medical students who had given the consent for study were included. After explaining the terminologies used in questionnaire they were asked to fill the preformed, pretested questionnaire based on Menstrual symptom questionnaire and menstrual bleeding questionnaire [10,11] and questionnaires were modified according to need and only those questions were removed which was not relevant to the study and further content validity was checked by two experts of Obstetrics and Gynaecology. Questionnaire was first given to pilot group and the queries were rectified; like definitions of dysmenorrhea and PMS were added, irregularity and regular exercise term were defined before giving the questionnaire to students for main study.

Exclusion criteria: The students who did not given the consent for study were not included in the study. If consenting students had any difficulty in filling the questionnaire, they were helped out by investigators at the same time.

Some terminologies used in this study are described below:

Regular menstrual cycle: Occurs every 24-38 days±2-3 days in which the menstrual flow lasts for 4-8 days with an average loss of 5-80 mL of blood per cycle [12].

Irregular menstrual cycle: Defined as when there is variation of >20 days in between 2 cycles (if distance between 2 last menstrual period more than 48 days, if the previous cycles were of 28 days) [12].

Heavy blood loss: For >80 mL blood loss in one cycle. It is assessed in our study by number of completely soaked pads. If the number of completely soaked regular sized pads were more than five in a day it was assessed as excessive blood loss [5].

According to body mass index students were classified in three categories: Underweight (BMI <18.5 kg/m²), normal (BMI=18.5 to 24.9 kg/m²) and overweight and obese (>=25.0 kg/m²) students [1].

Regular exercise: If the students were doing brisk walking, jogging, aerobic exercise, dancing, swimming for minimum 30 minutes for ≥5 days in a week or equivalent exercise for 150 minutes per week. (moderate exercise for 150 min per week is minimum required for fitness of adults as per American heart association) [13].

Dysmenorrhea: Lower abdominal pain radiating to back and thighs, perceived before or during menstruation and this pain may be of varying severity [14,15].

Pre-menstrual syndrome: Includes a wide variety of cyclic, recurrent, physical, emotional and behavioural symptoms which occur during late luteal phase of menstrual cycle and subside with the beginning of menses. These symptoms include some physical and neurological symptoms like weight gain, headache, fatigue, nervousness, irritability and mood swings [14].

Statistical analysis of data was done by using Statistical Package for the Social Sciences (SPSS) software version 21.0 Chicago and data was analysed by Pearson chi-square test. The p-value of <0.05 was considered significant.

Data of 150 students were analysed. Mean age of students were 21.9 years. Maximum number of students was in the age group of 21-23 years age group (52%). Most of the students (68%) were in normal BMI category; 76% were vegetarian [Table/Fig-1].

Out of 150 students, 80% students were in the habit of eating junk foods but most of them took junk foods occasionally (60.7%); 17.3% girls were addicted to tea, coffee and chocolates; only 28% girls were on regular exercise [Table/Fig-2].

In all the girls, age at menarche was between 10-15 years except one student for whom it was <10 years. Mean age at menarche was 13.4 years. In most of the students (82%), the cycle was regular and cycle length was of 28-35 day in all girls that had regular cycles and duration of flow was 2-7 days in all 150 girls. Total 18% (27) girls had irregular cycles out of which only five girls had taken treatment for this.

Increased blood loss in menses was present in 4.7% students out of which two students had taken treatment. Dysmenorrhea was present in 56% students whereas PMS is present in 73.3% students. 17.8% (15) students were using medication for dysmenorrhea. Total 7.1% students remained absent from class for one or two days during menses due to dysmenorrhea [Table/Fig-3,4].

In this study, the underweight students having irregularity in cycle were more as compared to the normal BMI students (33.3% and 16.7%, respectively) but the difference was not significant whereas the amount of blood flow was more in 8.3% of overweight and obese students as compared to 4.9% in normal BMI girls. Amount of blood flow was found to be increased in 5.8% girls that consumed junk foods. In the girls that were addicted to tea, coffee and chocolates 26.9% girls had irregular cycles as compared to 16.2% who were nonaddict whereas flow of menstrual blood was increased in only 3.9% girls (less than nonaddicts).

No statistical correlation was found between regularity of cycle and frequency of exercise. Amount of blood loss was normal in 95% girls that were on regular exercise as compared to 91.6% of girls who were not doing exercise, but difference in regularity and amount of flow were not statistically significant [Table/Fig-5].

Dysmenorrhea was more common (66.6%) in underweight girls whereas PMS was more common in overweight and obese girls (79.1%) but difference is statistically insignificant. There was significant association between Dysmenorrhea and regular consumption of junk foods (p=0.01) but PMS was insignificantly less in the girls that consumed junk foods. About 57.6% girls addicted to tea coffee and chocolate had dysmenorrhea which is insignificantly more than in nonaddicts (55.6%) whereas 57.6% had PMS compared to 76.6% in nonaddicts (p=0.04). Dysmenorrhea and PMS was less in the girls that were dieting for weight reduction (46.1% and 61.5%, respectively). Dysmenorrhea and PMS was also less in the girls who were doing exercise regularly (45.2% and 69%, respectively) but the difference was insignificant [Table/Fig-6].

In this study, three students had history of treated tuberculosis and four students were hypothyroid and were taking treatment for the same and none of them were having any menstrual abnormality. The students who had any form of menstrual abnormality and were not investigated and did not take any treatment, counselling was done and relevant investigations were advised after compilation of results of study.

There are many studies on menstrual irregularities in medical students done in India and outside India. Summary of the previous studies are tabulated in [Table/Fig-7] [5,16-18]. In this study, the mean age of menarche was 13.4 years which was almost similar to that found in other studies from India and outside [16-18]. In this study irregular cycle was found in 18% of students which was less than reported in other studies done in India and outside. It may be because in this study, number of students with normal BMI were more than reported in other studies [16-18].

Prevalence of dysmenorrhea was 56% in this study whereas in other studies prevalence was higher [16,18]. In this study, no statistically significant correlation was present in BMI and irregularity of cycle, amount of blood lost in menstrual cycle, dysmenorrhea and PMS whereas in the study conducted by Lakkawar NJ et al., Karki PK and Gupta R showed that irregular cycles were significantly associated with being overweight. It may be because of the larger sample size and more number of overweight patients in their study [5,16].

In this study, no significant association was found between irregular cycle or amount of blood lost in menstrual period and junk food consumption in contrast to it the study conducted by Lakkawar NJ et al., which showed large number of students (86%) consumed junk food on regular basis and there was significant association between irregular cycles, abnormal flow and consumption of junk food [5]. This may be because of small sample size in the index study. In the index study number of students consuming junk food on >3 days in a week was only 16.7%.

Significant association was found in regular consumption of junk food and dysmenorrhea in contrast to Sujatha V et al., that reported no relation in dysmenorrhea and junk food consumption but significant correlation was reported in regular consumption of junk food and PMS in their study [17]. But the reason for this contradiction could not be made out. No statistically significant association was found in BMI, physical exercise, dieting and menstrual abnormalities in this study which may be because of small sample size in the study.

This study has limitations because it was based on the answers given by students by filling the given proforma, no examination or investigation was done in this study. Sample size was small and an external validation is recommended.

In this study, the most common menstrual abnormality that was found was dysmenorrhea and PMS. Dysmenorrhea was most common abnormality for which students were taking medication. Also, most of the parameters did not show a significant association, so a larger study or multicentric study is required to find the association between menstrual abnormalities, BMI and other variables.