A school based cross-sectional study was carried out in secondary school girls of Pondicherry who attained menarche, belonging to 13 – 19 years age, after taking consent from the school authorities and approval from hospital ethical committee. Four secondary schools (2 urban and 2 rural) in Pondicherry were chosen based on stratified random sampling method. Students and the school authorities were explained about the purpose of the study and given information on the questionnaire. All students who attained menarche and who were willing to participate in the study were included in the study. They were invited to answer the questionnaire, which dealt with anthropometric data, socio-economic data, menstrual history, and diet and exercise pattern. The questionnaire was self administered, semi-structured and prepared in local and English languages. Students who did not attain menarche, who are suffering from any chronic health condition and are using any medicines for long duration (more than a month) were excluded from the study.

Anthropometric data included weight and height. Body mass index was calculated as the subject’s weight in kilograms divided by square of the height in meters (kg/m²). Details on menstrual history included age of menarche, average length of menstrual cycle, duration of menstrual flow, any passage of clots during periods, occurrence of dysmenorrhoea and if present, is it severe enough to skip classes or any need to take medications like analgesics or antispasmodics and any perception of premenstrual symptoms.

For purpose of this study, authors decided upon the following definitions of menstrual abnormalities. The duration of menstrual cycle is defined as the period between the first day of menstrual flow and the day immediately prior to the next menstrual flow. Irregular menstrual cycles are defined as past history of irregular cycles experienced by the students within 6 months prior to the study. Abnormal duration of flow is defined as menstrual bleeding which lasted for less than 2 days or more than 7 days. Dysmenorrhea is defined as acute spasmodic pain experienced in the lower abdomen which appeared on the first day of menses and rarely lasted for more than 2 days.

Premenstrual symptoms (PMS) are defined as a constellation of physical, emotional, and behavioral symptoms which occurred premenstrually and remitted after the onset of bleeding. Physical symptoms include abdominal pain, headache, nausea, skin disorders, abdominal bloating, breast tenderness, and swelling of extremities. Emotional symptoms include irritability, anger, depression, and tension. Behavioural symptoms include increased or decreased food intake, hypersomnia, lethargy, and marked lack of energy. All these symptoms were enlisted in the questionnaire and students were asked whether they experienced any discomfort before menses which remits after the onset of menses and if so, they were asked to indicate which kind of discomfort they experienced.

Physical activity in terms of number of days of regular physical exercise per week (activities for >20 minutes that make them sweat) was categorised as follows: one day of physical exercise per week (category a); 2–3 days of physical exercise per week (category b); 4–7 days of physical exercise per week (category c) and no regular physical exercise (Category d). Similarly, junk food consumption was studied by assigning categories-eating junk food 1day/ week (category a); eating junk food 2-3 days/ week (category b); eating junk food 4-7 days/ week (category c) and eating junk foods regularly (category d). Fussy behavior at eating food and eating less food in order to lose weight (dieting) were also explored.

Prevalence of each menstrual abnormality was calculated and expressed as proportions. Chi-square test and Fisher’s exact test was used to compare the dietary and exercise patterns among students having menstrual abnormalities and those who do not have menstrual abnormalities. Statistical analysis was done using SPSS V13 Software and p value <0.05 was considered as statistically significant.

A total of 861 students participated in the study with 100% response rate. Eight students were excluded from the study as seven of them were on Eltroxine for hypothyroidism and one student was taking anti tuberculosis treatment for pulmonary tuberculosis. [Table/Fig-1] shows the baseline demographic and lifestyle characters of the students studied (n=853). 711 (83.4%) students were from urban schools and 142 were from rural schools. [Table/Fig-2] shows the menstrual problems experienced by the study population. Dysmenorrhea (72.8%) and premenstrual symptoms (51.2%) were the most frequent problems encountered.

[Table/Fig-2]:

Prevalence of menstrual disorders among the study subjects (n=853)

[Table/Fig-3] shows the association between the menstrual problems and lifestyle factors. Premenstrual symptoms were significantly more common among girls who were overweight, in girls who were eating junk food regularly, who are eating less food (dieting) in order to lose weight and in those who were not doing regular physical activity. Though not statistically significant, dysmenorrhea was more commonly experienced by girls in the underweight and overweight groups. Dysmenorrhea was significantly more common in the girls who were dieting to lose weight (p=0.022). Passage of clots was also significantly high in the girls who were dieting (p=0.011).

Lot of studies have been done in the past on the prevalence of menstrual problems in adolescent girls, yet much research was not done on their relation with lifestyle factors. In this study we attempted to find a relation between various lifestyle factors like eating junk food, dieting behavior, lack of physical activity with the menstrual problems experienced by the adolescent girls as these are the risk factors which are modifiable and intervention at this stage might result in healthier adults This study is first of its kind in India.

Nutritional deficiency is considered one of the important factors that induce hypothalamic-pituitary-ovarian dysfunction. Recently, adolescents have tended to lose body weight by dietary restriction for cosmetic purpose. Dieting behavior was observed in almost 30% of the girls in our study. We found that girls who were dieting had significantly heavy bleeding, dysmenorrhea and premenstrual symptoms. Dysmenorrhea was also high in the girls who were under weight. Montero et al., studied 1147 urban Spanish adolescents, and found that nearly 40% of the adolescents tried to lose weight. Attempting to lose weight is significantly associated with an increase in irregular menstruation and dysmenorrhea, without a significant relation with body mass index in their study [5]. In a study done by Fujiwara et al., in 18-20 year-old Japanese girls, the intensity of dysmenorrhea was high in those with a history of dieting in adolescence, suggesting that diet in adolescence has long-lasting adverse effects on reproductive function in young women [6]. Balbi C et al., found that lower consumption of fish, eggs, and fruits is associated with dysmenorrhea in adolescent girls [7]. These findings warn us of the possibility that diet limitation in adolescence can become a trigger for the subsequent development of organic gynecologic diseases. Inadequate dietary habits may influence women’s quality of life not only in the present but also in the future.

Goel et al., performed a study in adolescent girls in Haryana and found that more than two-third (66.25%) adolescent girls skipped at least one meal a day and the most frequently missed meal was breakfast (41.25%) [3]. The most common effect of skipping meal among adolescent girls was consumption of junk food (60.37%). This results in consuming excess of energy, protein and fat but inadequate micronutrients like iron and beta–carotene. In our study, premenstrual symptoms were significantly high in girls who were regularly eating junk food, similar to the findings of Anandha Lakshmi et al., [8]. Fujiwara et al., found an association between fast food consumption and dysmenorrhea [9]. But in our study, we did not find any significant association between junk food and dysmenorrhea. Junk foods being rich in saturated fatty acids might interfere with the metabolism of progesterone in the luteal phase of menstrual cycle and result in premenstrual symptoms. Junk foods being deficient in micronutrients like vitamin B₆, calcium, magnesium and potassium, might also be responsible for triggering premenstrual symptoms.

Premenstrual symptoms were also significantly high in girls who did not do regular physical activity in our study. Teixeira AL et al., [10] and Amany Edward Seedhom et al., [11] also found similar association between premenstrual symptoms and physical activity. But, in the study done by Lee et al., no association was found between physical activity and menstrual problems [1]. Lee et al., concentrated on whether the subjects exercised in the seven days prior to the study. But we concentrated on how regular the subject was doing physical exercise. This might be the reason for the association of physical exercise with premenstrual symptoms in our study. Physical activity releases endorphins into the body, which can improve premenstrual symptoms like getting rid of feelings of depression or anxiety.

The drawback in this study was that data was collected in schools, and school-age female adolescents who had left school or dropped out of school at various ages could not be reached. So, the results cannot be generalised to all female adolescents nationwide. In addition, this being a cross-sectional study, we can suggest associations, but not prove causality.

To conclude, life style modifications like regular physical activity, decreasing the intake of junk food, and promoting healthy eating habits should be emphasised in school health education programs to improve menstrual health. Improvement of menstrual health will not only help in improving the academic performance of the students and their self esteem, but also prevents future problems like Polycystic Ovarian Disease, hyperlipidemia, obesity and infertility.