Prevalence and pattern of menstrual disorders among school going adolescents in northern district of Kerala

Background: Adolescents face a range of health challenges, numerous information and guidance regarding adolescent health remaining ignored due to constraints at different levels of health system. One of the main problems among adolescent girls are irregular menstruation, excessive bleeding and dysmenorrhoea. Menstrual irregularities during adolescent period have association with reproductive morbidities in adulthood. Targeting this age group with awareness and early correction of matters and misconceptions related to adolescent sexual reproductive health issues would enable us to yield a healthy society and empowered youth. Objective: To study the prevalence and pattern of menstrual disorders and its associated factors among IX to XII class adolescent girls in Kannur district. Methods: Cross-sectional study among school going adolescent Girls from class IX to XII in Kannur District Results: Among the 1722 study participants, 48.8% had menstrual disorders, in which dysmenorrhoea is the most common menstrual disorder reported 71.5%. The risk factors like rural residence, lower socio-economic status, mixed diet, non-consumption of egg, not physically active both during routine life and also during menstruation, increased BMI showed a significant association with menstrual disorder among the study participants. Conclusion: Use of services by adolescents is limited may be due to lack of adequate privacy and confidentiality and judgemental attitudes of service providers, who often lack counselling skills. Therefore, effective services like assurance of confidentiality, psychological support, counselling is necessary.


Introduction
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 ISSN: 2349-4158

Research Article
Public Health Review: International Journal of Public health Research Available online at: www.publichealthreview.in 110| P a g e 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].
In a cross-sectional study done by Santina  Absenteeism showed the prevalence of dysmenorrhoea was 51% and that of the pre-menstrual syndrome was 67%. Severity of dysmenorrhoea has a strong association with school absenteeism (p = 0.005) [8].
Use of services by adolescents may be limited. Poor knowledge and lack of awareness are the main underlying factors. Service provision for adolescents is influenced by many factors. 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.
Shortcomings in their professional trainings often result in service providers being unable and sometimes unwilling to deal with adolescents in an effective and sensitive manner. It is important to influence the health seeking behaviour of them as their situation will be central in determining India's health, mortality, and morbidity and population growth scenario. Therefore, effective services must be planned accordingly like assurance of confidentiality, psychological support, counselling.
This study aims to figure out the prevalence and pattern of menstrual disorder among adolescents, in a scenario where not much studies regarding the topic has been studied earlier. Targeting this age group with awareness and early correction of matters and misconceptions related to adolescent sexual reproductive health issues would enable these groups to move forward with their lives in confidence and thus help us to yield a healthy society and empowered youth ready to face the challenges of life further on.
Objectives: To study the prevalence and pattern of menstrual disorders and its associated factors among IX to XII class adolescent girls in Kannur district.

Materials and Methodology
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 Public Health Review: International Journal of Public health Research Available online at: www.publichealthreview.in 111| P a g e 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 b). Vigorous-intensity activity means heart rate increases and the person will not be able to say more than a few words without catching a breath [11].
To assess the obesity, body mass index (BMI) is used.

Results
The study included 1722 participants and they belong to age group 13-18 years ( Table 1). The distribution of religion,     (Table 3).

Discussion
In the present study, the mean age of the study population was 15.67 +1.23. The menarche age was found to be 13 Rewa showed a result of 7.47% of menstrual disorder [5].
Dysmenorrhoea was the most prevalent menstrual problem with young women as in the study done by Santina et al in schoolgirls. They found 74.3% of dysmenorrhoea and it was significantly associated with missing school days [7].
In the present study, 41.1% of the study population with menstrual disorder had school absenteeism and the most common cause reported was 'intolerable pain abdomen during menstruation'. In a study done in Morocco, menstrual pain was often cited as the main single cause of school absenteeism among adolescent girls [6].
Several studies have shown that adolescents with primary dysmenorrhoea report that it effects their academic performance, social and sports activities and is a cause for school absenteeism [13].
Majority in the study follows mixed diet and egg consumption. In this study, the reduced egg consumption was significantly associated with menstrual disorder (p=<0.01). Similar to it, Balbi C et al also found that lower consumption of fish, eggs, and fruits are associated with dysmenorrhoea in adolescent girls [14]. reported to be at a reduced risk of breast cancer.
In their study, subjects who engaged in moderate physical activity had significantly shorter menstrual cycles [16].
And in the present study there is a highly significant association between physically active subjects and regular menstrual cycles (p=0.004).