Adolescents face a range of health challenges, including malnutrition and anaemia, lack of knowledge on Sexual and Reproductive Health, substance misuse, communicable and non-communicable diseases, injuries and violence. Numerous information and guidance regarding adolescent health remaining ignored due to constraints at different levels of health system [1].

The main problems faced by the adolescent girls are irregular menstruation, excessive bleeding and dysmenorrhoea. Due to dysmenorrhoea, disruption in social life and the adverse qualities of life such as sickness absenteeism (28-48%), loss of physical activity, academic dissatisfaction, personal relationships, confidence and concentration are seen[2]. Menstrual irregularities during adolescent period have association with reproductive morbidities in adulthood.

A cross sectional study conducted among school adolescent girls of classes five to twelve in the District Wardha, Maharashtra, Central India in 2009 showed a result of 22.1% of the study subjects had a menstrual cycle of length longer than 35 days and 8.38% adolescents had a menstrual cycle length shorter than 21 days. Among them 390 (69.52%) had a cycle length between 21 and 35 days [3].

Another study, a cross-sectional study of 194 unmarried female students studying in various degrees level classes from undergraduate and postgraduate institutions from Mysore city explained the results of 11.9% of the participants had menstrual cycle length irregularity [4].

The study done by Amita Singh et al at Rewa, showed that the prevalence of menstrual disorders like irregularity, prolonged menstrual bleeding, heavy menstrual bleeding and Polycystic Ovarian Diseases were 7.47%, 10.28%, 23.36% and 3.73% respectively [5].

The dysmenorrhoea, at times, the pain is severe enough that a girl has to miss school, college or her work. Dysmenorrhoea is the most common gynaecologic disorder among female adolescents, with a prevalence of 60% to 93%. In the United States, dysmenorrhoea is the leading cause of recurrent short-term school absenteeism [5].

In a study in Morocco, menstrual pain was often cited as the main single cause of school absenteeism among adolescent girls [6].

A School-based Cross-sectional study was conducted among school going adolescent Girls from class IX to XII in Kannur District from 1st July 2013 to 30th June 2014. For the study, Kannur district was divided into two strata: urban and rural. All the Municipalities were considered as urban and all the Panchayat were considered as rural. All the Municipalities and Panchayats were divided into 3 sub-strata. One school from each sub-stratum was randomly selected.

All girls/ mixed schools in Kannur District with IX- XII classes were taken for the study. All the female students from class IX to XII were considered for the study. In Municipalities, there were 17 government schools, 12 aided schools, 9 unaided schools and in Panchayats, there were 66 government schools, 28 aided schools and 39 unaided schools. One school from each sub-stratum were randomly selected using random number table. In total, six schools were selected by this Stratified Random Sampling Method.

Sample size of 1670 participants were achieved according to the prevalence rate of menstrual disorder, in a study done at Thiruvananthapuram was 21.1% [9] and by considering 10% of relative precision and 10% non-response rate. All the study participants, who haveattained menarche and those whose parents given consent,were included in the study. The students who were not present even after 2 visits were excluded from the study.

Height measurement using stadiometers with a minimum reading of 0.5cm and Weight measurement using standardized digital weighing scale of BGS-1219, maximum weight up to 150kg and minimum difference that can be measured is of 100gms.

A pre-tested, self-administered, semi-structured questionnaire which comprises socio-demographic information such as age, parents' employment, and economic status along with dietary habits, physical activities and its frequency, menstrual characteristics such as the cycle regularity, duration of menstrual bleeding in a cycle, the length of menstrual cycle, presence of dysmenorrhoea, menstrual hygiene.

A validated Malayalam questionnaire for students and parents were used. With the forwarding letter of District education officer (Kannur), permission from respective schools was taken for collecting data.

The study included 1722 participants and they belong to age group 13-18 years (Table 1). The distribution of religion, residence, socio-economic status (S-E) is given in Table 1. Mixed diet was followed by 65.3% and 34.7% were on vegetarian diet. Among study subjects, 30.4% were doing physical activity for <3 days in a week and 26.1% of them were doing it daily.

The reasons for school absenteeism during menstruation were uncomfortable 9.0%,discomfort in changing pad/cloth 4.1%, intolerable pain 19.2%, heavy bleeding 4.1%.

Figure-3: Pattern of Menstrual cycle among the study participants

Table-3: Distribution of characteristics among study population with and without menstrual disorders

Menstrual disorder was more among overweight and obese adolescents in this study. Most of the people who consume egg did not have menstrual disorder and people who consume fried food also were not found to have menstrual disorder. School absenteeism due to menstruation was more among adolescents with menstrual disorder in the present study and the major reason which they pointed out was pain abdomen.

Use of services by adolescents are limited may be due to, at the level of health system, lack of adequate privacy and confidentiality and judgemental attitudes of service providers, who often lack counselling skills, are barriers that limit access to services. Therefore, effective services like assurance of confidentiality, psychological support, counselling is necessary. Initiatives like Adolescent Reproductive and Sexual Health Clinics (ARSHC) should be upheld and broaden the services.

The current study has several limitations. First, as this study was based on a self-administered questionnaire. Second, this study was unable to reach the school drop-outs. This study had insufficient data to explain other menstrual disorders like Menorrhagia since the amount of bleeding were not able to assess and Metrorrhagia, since most of the study subjects may confuse it with oligomenorrhoea etc.

Importantly, this study has done to fill the gaps in areas related to menstruation within the literature. Secondly, a good number of samples from schools and the stratified random sampling of Kannur district in the study gave a good representation of the whole Kannur district.

First and foremost I thank God, the almighty for his blessings throughout my research work to complete it successfully. This study could not have been possible without the support and participation of students, their parents and teachers and authorities of the schools where the study was conducted. I find words inadequate to express my gratitude to Dr A. K. Jayasree, Professor and HOD, Department of Community Medicine, Academy of Medical Sciences, Pariyaram for permitting me to do this study and her constant encouragement, unreserved support and guidance throughout the study.