Menstrual cycle is the cyclical shedding of endometrium every 28 ± 7 days in response to hormones. It is a natural phenomenon that occurs throughout the reproductive years of every woman`s life during which blood loss per cycle is not greater than 50 ± 30 ml with or without discomfort [1]. A woman on an average undergoes 400 menstrual cycles prior to menopause and the average menstrual cycle lasts for about 5 days.
Menarche is the onset of menstruation and it is one of the most significant milestones in a woman’s life. The mean age at menarche varies from population to population and is known to be a sensitive indicator of various characteristics of population including nutritional status, geographical location, environmental conditions and magnitude of socio–economic inequalities in a society [1,2].
Knowledge of the length and variation of the menstrual cycle is necessary for patient education and for identifying deviations from normal to guide clinical evaluation [3]. Among the gynaecological problems, menstrual problems are said to be the major ones especially among adolescent females [3,4].
75% of adolescent girls are reported to have menstrual dysfunction and is known to affect the normal daily chores. Delayed, irregular, painful, and heavy menstrual bleeding are common occurrence among younger age and are the leading reasons for physician office visited by adolescents [4]. Dysmenorrhea is yet another major cause of activity restriction and school absenteeism in adolescent girls. However, the condition is often considered as physiological pain and generally ignored [4,5].
Menstrual patterns are influenced by a number of host and environmental factors [5]. Menstruation disorders are also responsible for emotional, physical, behavioural and dietary practice changes. These changes affect their normal functioning and social life. Rigid adherence of traditional norms and practices, ignorance about menstruation, inadequate health care facilities separately for unmarried girls etc also restricted their treatment seeking behaviour also [6].
Knowledge regarding the factors influencing menstrual symptoms is important in order to manage it effectively and help the women to make up the days less troublesome and tolerable. The present study was carried out to find the prevalence of menstrual problems among unmarried girls of Chandigarh, India and to compare their knowledge and beliefs regarding menstruation indifferent sub groups.
Material and Methods
Study Design: A community based cross-sectional study design was adopted in Rural, Urban and Slum strata of UT Chandigarh, India.
Duration of Study: Study was conducted during April 2011 to March 2012 in total duration of 12 months.
Sampling Technique: Stratified Multistage Random Sampling Design with probability proportional to size (PPS) was adopted and respondents were selected with proportional allocation from different selected wards/strata. Whole area of Chandigarh was divided into four geographical strata. Within each stratum, four sectors/colonies/villages were selected at random with proportional allocation to select a total of 16 clusters from the whole population.
Inclusion Criterion for Respondents: Only those unmarried girls who have already attained menarche more than one year back and whose parents were willing to participate in the study were included.
Optimum Sample Size
Optimum sample size was calculated on the basis of a pilot survey using the formula:
N (optimum) = (1.96)2 P (1-P)/L2
Where, P = Prevalence of adolescent girls having some menstrual health problem.
L = Permissible error in estimation.
A sample of an optimum size of 744 respondents was selected by the sampling technique mentioned above. Optimum sample size for the proposed study is calculated on the basis of anticipated population proportion of 75% respondents having at least one menstrual complaint with prior experience, assuming 95% confidence coefficient and 5% permissible error.
Survey Technique: House–to–house surveys were conducted to collect the desired information by personal interview method. Respondents were interviewed individually in privacy using pre-designed, pre–tested, semi-structured interview schedule. Interview schedule was finalized after conducting a qualitative survey to explore relevant questions and to get insight of the problem. A well-trained team of female investigators including co-investigators as well as medical social worker / other female staff of the department were involved in data collection.
Data was analyzed by using SPSS 16. Chi–square value was used for testing statistical significance.
Ethical Consideration
Informed consent following the Ethical Guidelines of World Medical Association Declaration of Helsinki was taken. In case of respondents below 18 years of age, consent from their parents was taken. For respondents aged 18 years and above, informed consent was taken from respondents. Only respondents giving consent were interviewed in privacy ensuring confidentiality. Respondents were not examined for diagnosis of gynecologic morbidity in this community–based study due to some ethical issues involved.
Results
A total of 744 respondents took part in the study. The mean age of the respondents was 16.84±3.05 years. Maximum respondents (40.9%) were educated up to 10th standard/High school. 80.8% were living in the nuclear families [Table/Fig-1].
Respondents by socio-demographic characterstics
| CHARACTERSTIC | NO. | % |
|---|
| Age | | |
| 10-12 | 20 | 2.7 |
| 13-15 | 282 | 37.9 |
| 16-18 | 240 | 32.3 |
| 18-21 | 162 | 21.8 |
| 22-25 | 40 | 5.4 |
| Mean ± SD | 16.84 ± 3.05 | |
| Educational Status |
| Illiterate | 82 | 11.0 |
| Drop-out from school | 60 | 8.1 |
| Primary | 46 | 6.2 |
| Middle | 69 | 9.3 |
| High School/10th standard | 304 | 40.9 |
| 10+2 | 74 | 9.9 |
| Graduation | 8 | 1.1 |
| Post graduation | 7 | 0.9 |
| Professional Courses | 94 | 12.6 |
| Medium if studying presently (n=556) |
| Hindi | 356 | 63.4 |
| English | 122 | 20.4 |
| Panjabi | 78 | 16.1 |
| Type of Family | | |
| Joint | 133 | 17.9 |
| Nuclear | 601 | 80.8 |
| Extended | 10 | 1.3 |
| Educational Status of Father |
| Illiterate/Just literate | 119 | 16.0 |
| Primary | 55 | 7.4 |
| Middle | 96 | 12.9 |
| High School | 169 | 22.7 |
| Intermediate | 116 | 15.6 |
| Graduate | 117 | 15.7 |
| Post Graduate | 58 | 7.8 |
| Professional Degree | 14 | 1.9 |
| Educational Status of Mother |
| Illiterate/Just literate | 187 | 25.1 |
| Primary | 136 | 18.3 |
| Middle | 121 | 16.3 |
| High School | 134 | 18.0 |
| Intermediate | 32 | 4.3 |
| Graduate | 73 | 9.8 |
| Post Graduate | 36 | 4.8 |
| Professional Degree | 25 | 3.4 |
| Occupation of Father | 744 | 100.0 |
| Unemployed | 30 | 4.0 |
| Service | 373 | 50.1 |
| Business | 162 | 21.8 |
| Labourer | 111 | 14.9 |
| Skilled Worker | 53 | 7.1 |
| Others | 15 | 2.0 |
| Occupation of Mother | 744 | 100.0 |
| Housewife | 433 | 58.2 |
| Service | 87 | 11.7 |
| Business | 10 | 1.3 |
| Labourer | 80 | 10.8 |
| Skilled Worker | 106 | 14.2 |
| Others | 28 | 3.8 |
| Socio-economic Status | 744 | 100.0 |
| Low | 219 | 29.4 |
| Middle | 364 | 48.9 |
| High | 161 | 21.6 |
| Total | 744 | 100.0 |
| Family Size |
| Upto 3 | 100 | 13.4 |
| 4-5 | 384 | 51.6 |
| 6-8 | 229 | 30.8 |
| above 8 | 31 | 4.2 |
| BMI |
| Below18.5 | 240 | 32.2 |
| 18.5-25.0 | 476 | 64.0 |
| 25 and above | 28 | 3.8 |
| Overall | 744 | 100.0 |
Among all 744 respondents, 448 (60.2%) were aware of menstruation before starting of menarche [Table/Fig-2].
Respondents by prior knowledge regarding menstruation
| Prior Knowledge | No. | % |
|---|
| No | 296 | 39.8 |
| Yes | 448 | 60.2 |
| Total | 744 | 100.0 |
| Source of Information(n=448) |
| Mother | 210 | 46.8 |
| Elder Sister/ Female Relatives | 116 | 25.9 |
| Friends | 127 | 28.3 |
| Information media | 72 | 16.1 |
| Others | 19 | 4.2 |
Awareness was found to be significantly associated (p= 0.02) with age. Maximum degree of awareness (67.0%) was found among respondents aged 13–15 years.
Respondents of higher age were more likely to have prior knowledge as compared to respondents of lower ages. Awareness was also highly associated with educational status. Among college going girls the proportion of awareness was found to be 74.3% followed by 67.8% among girls studying in schools.
Awareness was found to be very low only 34% among those who were either illiterate or just literate. Among currently studying students Punjabi medium students were having maximum awareness (79.5%) as compared to those of Hindi medium (66.6%). Lowest proportion of girls having prior knowledge of menstruation was found to be 66.3% among Hindi medium students.
However, medium of education was not found to be significantly associated (p= 0.06) with prior knowledge of respondents.
Degree of awareness was found to be maximum among respondents from joint families. Awareness was also found to be significantly associated with occupation of mothers (p= 0.006). Prior knowledge regarding menses was found among 64.4% of the respondents whose mothers were housewives compared to 54.3% among the respondents whose mothers were in any other profession.
Family size was also found to be a significant correlate (p< 0.001) of prior knowledge of menstruation. Maximum awareness was among those respondents who were from families of size 4 to 5. In case of large family size and also in case of single child families awareness was found to be comparatively low which may explain the effect of siblings in the family and probably the problem sharing in case of sister.
Socio–economic status and prior knowledge of respondents was also found to be significantly associated (p< 0.001). Respondents from high socio economic status were having maximum percentage of awareness (68.9%) as compared to only 49.3% in low socio economic status category.
No significant association was found between discussant and prior knowledge it may be due to discussion regarding menstrual problems only after attaining menarche and probably mothers do not discuss menstrual issues with their daughters at pre-menarcheal stage. Religious environment at home and exposure to internet were not playing significant role as far as creating awareness regarding menstruation is concerned [Table/Fig-3].
Prior knowledge of respondents by selected characteristics (n=744)
| Characteristics | Total (n=744) | Prior Knowledge | χ2 (p-value) |
|---|
| No | Yes |
|---|
| Age |
| 10-12 | 20 | 12 (60.0) | 08 (40.0) | χ2= 12.09 (p=0.02) |
| 13-15 | 282 | 93 (33.0) | 189 (67.0) |
| 16-18 | 240 | 100 (41.7) | 140 (58.3) |
| 18-21 | 162 | 71 (43.8) | 91 (56.2) |
| 22-25 | 40 | 20 (50.0) | 20 (50.0) |
| Mean ± SD | 16.84 ± 3.05 | 17.15 ± 3.28 | 16.63 ±2.87 |
| Educational Status |
| Literate / Just Literate | 188 | 124 (66.0) | 64 (34.0) | χ2= 73.4 (p=0.000) |
| School Level | 447 | 144 (32.2) | 303 (67.8) |
| College Level | 109 | 28 (25.7) | 81 (74.3) |
| Medium (n=556) |
| Hindi | 356 | 120 (33.7) | 236 (66.3) | χ2= 5.4 (p=0.06) |
| English | 122 | 36 (29.5) | 86 (70.5) |
| Panjabi | 78 | 16 (20.5) | 62 (79.5) |
| Total | 556 | | | |
| Type of Family |
| Joint | 133 | 50 (37.6) | 83 (62.4) | χ2= 0.73 (p=0.69) |
| Nuclear | 601 | 241 (40.1) | 360 (59.9) |
| Extended | 10 | 05 (50.0) | 05 (50.0) |
| Educational Status of Mother |
| Literate / Just Literate | 323 | 174 (53.9) | 149 (46.1) | χ2= 47.3 (p<0.001) |
| School Level | 287 | 82 (28.6) | 205 (71.4) |
| College Level | 134 | 40 (29.9) | 94 (70.1) |
| Occupation of mother |
| Housewife | 433 | 154 (35.6) | 279 (64.4) | χ2= 7.7 (p=0.006) |
| Others | 311 | 142 (45.7) | 169 (54.3) |
| Family Size |
| Upto 3 | 100 | 59 (59.0) | 41 (41.0) | χ2= 24.2 (p<0.001) |
| 4-5 | 384 | 126 (32.8) | 258 (67.2) |
| 6-8 | 229 | 97 (42.4) | 132 (57.6) |
| above 8 | 31 | 14 (45.2) | 17 (54.8) |
| Mean ± SD | 5.15 ± 1.67 | | | |
| Socio–economic Status |
| Low | 219 | 111 (50.7) | 108 (49.3) | χ2= 17.1 (p<0.001) |
| Middle | 364 | 135 (37.1) | 229 (62.9) |
| High | 161 | 50 (31.1) | 111 (68.9) |
| Discussant |
| Mother | 405 | 159 (39.3) | 246 (60.7) | χ2= 0.11 (p=0.76) |
| Others | 339 | 137 (40.4) | 202 (59.6) |
| Home Environment |
| Religious | 414 | 169 (40.8) | 245 (59.2) | χ2= 0.42 (p=0.55) |
| Non-Religious | 330 | 127 (38.5) | 203 (61.5) |
| Internet Exposure |
| Yes | 75 | 27 (36.0) | 48 (64.0) | χ2= 0.49 (p=0.53) |
| No | 669 | 269 (40.2) | 400 (59.8) |
| Age at Menarche |
| Upto 13 years | 518 | 201 (38.8) | 317 (61.2) | χ2= 0.69 (p=0.41) |
| 14 years & above | 226 | 95 (42.0) | 131 (58.0) |
| Mean ± SD | 13.02± 1.13 | 12.97±1.25 | 13.06±1.13 |
| Overall | 744 | 296 (39.8) | 448 (60.2) | |
In the study 61% (454) of the respondents had a regular flow during menses. Average duration was 3.96 ±1.72 days. Normal flow was reported by 70.2% (522) of the respondents [Table/Fig-4].
Respondents menstrual history
| Menstrual History | No | % |
|---|
| No response | 131 | 17.6 |
| Regular | 454 | 61.0 |
| Irregular | 159 | 21.4 |
| DURATION | | |
| No response | 82 | 11.0 |
| 1 | 16 | 2.2 |
| 2 | 12 | 1.6 |
| 3 | 90 | 12.1 |
| 4 | 149 | 20.0 |
| 5 | 330 | 44.4 |
| 6 | 65 | 8.7 |
| Mean ± SD | 3.96 ± 1.72 | |
| Menstrual Flow | | |
| Scanty | 26 | 3.5 |
| Normal | 522 | 70.2 |
| Excessive | 54 | 7.3 |
| No response | 142 | 19.1 |
| Total | 744 | 100.0 |
Among all respondents, 477 (64.1%) were having at least one problem related to menstruation.Dysmenorrhea was found to be the most common problem suffered by 429 (57.7%) respondents. Feelings of sickness before starting of menstruation were felt by 223 (30.0%) respondents which may indicate high prevalence. Most of respondents (66.7%) reported these complaints one day prior to starting of menstrual cycle with mean number of 1.65 ±1.18 days [Table/Fig-5].
Respondents by menstrual problems/complaints during last one year
| Type of problem faced | No (n=744) | % |
|---|
| Dysmenorrhea | 429 | 57.7 |
| Feeling of sickness | 223 | 30.0 |
| Backache | 143 | 19.2 |
| Nausea / vomiting | 85 | 11.4 |
| General Weakness | 79 | 10.6 |
| Headache | 74 | 9.9 |
| Change in mood | 65 | 8.7 |
| Leg Pains / Cramps | 65 | 8.7 |
| Discomfort | 23 | 3.1 |
| Feeling of anxiety/ Stress | 21 | 2.8 |
| Others | 11 | 1.5 |
| Facing either of the above problem | 477 | 64.1 |
| No problem | 267 | 35.9 |
Discussion
Racial and regional differences have been reported to affect the menarche age [7]. Factors such as heredity, environmental conditions, body stature, socioeconomic status, nutritional and health status, family size, level of education, and psychological well being are known to influence menarche age [7,8].
The mean age for menarche observed in the present study from Chandigarh was 13.02 ± 1.13 years. Small differences have been reported in various studies from across India varying from 13.06 ± 1.43 years in West Bengal [9] to 13.4 years in Goa [10], 13.5 years in Chennai [11], 13.6 years in East Delhi [12] and 13.7 years in Rohtak [13].
Overall prevalence of the menstrual disorders in the present study was found to be 64.1% in the present study. Dysmenorrhea is an important menstrual disorder in adolescence, and common in young women with ovulatory cycles. It is an important public health problem among the female population. Prevalence of dysmenorrhea among the respondents in the present study was 76.9% compared to 61% reported from Chennai and 63.5% from Delhi [11,12].
Socio–economic status and prior knowledge of respondents were also found to be significantly associated (p< 0.001). Respondents from high socio economic status were having maximum percentage of awareness (68.9%) as compared to only 49.3% in low socio–economic status category.
Awareness regarding menarche is common among young girls before encompassing it. In the present study it was 60.2%. The major source for information was mothers, friends, or the information media, such results were also reported by other works [12,14–17]. Mothers and friends/peers generally lack the knowledge regarding menstruation since they have also not been told about this process in life [13,16]. Inaccurate and incomplete information provided to the girls through limited sources can lead to health problems and complications. Parents and print/electronic media can act as better source of knowledge transfer among adolescent girls, since most of girls have access to both. [12,13]. But it is very important that the information is correct. For this parents should be educated first related to adolescent issues. Role of media can also be vital in this area.
Conclusion
Menstrual hygiene is an issue which needs to be addressed at all the levels. A variety of factors are known to affect menstrual behaviours, the most influential ones being economic status. The menstrual disorders among female adolescents are common. The findings of the study suggest that awareness among girls on issues related to sexual and reproductive health through proper population education need to be created and for this, emphasis may be given on various mass media/information, education and communication programmes.