Ansong et al.

BMC Women's Health (2019) 19:35

https://doi.org/10.1186/s12905-019-0730-5

RESEARCH ARTICLE Open Access

Menstrual characteristics, disorders and

associated risk factors among female
international students in Zhejiang Province,
China: a cross-sectional survey
Emmanuel Ansong1, Samuel Kofi Arhin2, Yaoyao Cai1, Xinxin Xu1 and Xueqing Wu1*

Abstract
Background: Until now, no previous study has addressed the menstrual patterns among female international
students in China. In this present study, our objectives are to ascertain the menstrual characteristics and address the
menstrual problems together with their associated risk factors among international students in China.
Methods: A cross-sectional survey was carried out with 500 previously piloted self-structured questionnaires which
were administered to female international students enrolled in 15 universities in Zhejiang Province, China from May
2–August 31, 2016. Participants were required to provide answers to a semi-structured questionnaire which asked
questions about their socio-demographics and their menstrual characteristics while in their home countries.
Relevant changes in their menstrual pattern in terms of amount of flow and duration, regularity, length and
suggestive symptoms for premenstrual syndrome in the months after coming to reside in China were also inquired.
Respondents indicated changes in eating habits and selected stressors relevant to them from a given list. Their
stress levels were assessed and further categorized with the help of the Perceived Stress Scale (PSS). Measurements
for the main outcomes included the characteristics of menstrual patterns after arrival in China, stress levels, stressors
and new lifestyle patterns.
Results: Four hundred and nine (81.8%) out of the 500 questionnaires met the criteria and constituted the
population for this study. The respondents’ mean age was 21.405 years. Almost half of our respondents (49.1%)
reported varying changes in their menstrual pattern after arrival to China. Although, menstrual regularity, normal
menstrual length (21-35 days) and duration of flow (3–7 days) remained fairly normal among most of the
respondents, disorders like premenstrual symptoms (PMS) (33.82%); abnormal amount (17.97%) and dysmenorrhea
(16.38%) were prevalent. There was a significant association between high stress (PSS > 20) and menstrual change
0R = 1.636, 95% CI 1.051–2.547, p = 0.029) and dysmenorhea (p = 0.037). Common stressors included language
barrier 81(25.88%), food 64(20.45%), and loneliness 56(17.89%).
Conclusion: Menstrual disorders are high among international students in China. We established premenstrual
symptoms as the most common menstrual disorder. High levels of stress (PSS > 20) emanating from factors
including the language barrier, diet and loneliness was significantly related to the disruptions in their menstruation.
Keywords: Menstruation, Menarche, Premenstrual symptoms, Dysmenorrhea, International students

* Correspondence: [email protected]
1
Department of Obstetrics and Gynaecology, The First Affiliated Hospital of
Wenzhou Medical University, Nanbaixiang, Street, Ouhai District, Wenzhou,
Zhejiang Province 325000, People’s Republic of China
Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Ansong et al. BMC Women's Health (2019) 19:35 Page 2 of 10

Background The paucity of information regarding menstrual pat-

China has become one of the popular study hubs for inter- terns and the risk factors for menstrual irregularities
national students as a result of the recent call for the among female international students in China make this
internationalization and globalization of our world [1]. In current study extremely necessary. The main focus of
2015 alone, China’s Ministry of Education reported a total the authors of this study was to identify the common
of 397,635 overseas students enrolled in various institu- menstrual disorders and the factors in their new envir-
tions. This quotation was almost 6% higher than that of onment that predispose them to menstrual disturbances.
2014, which recorded a total of 377,054 students. The top We hypothesized that menstrual changes among inter-
three famous study destinations for these inbound stu- national students could be associated with the stress of
dents were Beijing, Shanghai and Zhejiang [2]. Although having to cope or survive in their completely new
the statistics do not specifically detail the number of fe- environment.
male students, we believe they constitute a larger portion
of this international community. Methods
Menstruation is a normal physiological phenomenon This cross-sectional survey was done from May to Au-
among women of reproductive age. Disorders that are gust, 2016 among female international students selected
usually linked with menstruation affect women from all from 15 universities located in major cities like
parts of the world and it’s increasingly becoming one of Hangzhou, Ningbo and Wenzhou, all of which are in
the major reasons for gynecological visits. Menstrual ir- Zhejiang Province, China. Permission to carry on with
regularity is associated with prolonged menstrual bleed- this study was granted after careful evaluation by the
ing and usually occurs right after the age of menarche as Ethics Committee of The First Affiliated Hospital of
a result of annovulatory cycles. Instability in the endo- Wenzhou Medical University in April 2016 (No.w-
metrial lining that arises as a result of the uncontrolled yyy2016–011). Female students included in this study
production of unopposed estrogen causes the breakdown were enrolled in these selected universities, and had
in vasoconstriction and myocardial contractility [3]. Dur- been living in China for a year. They had no prior his-
ing the ovulatory cycle, the production of the prostaglan- tory of primary amenorrhea, bleeding disorders, or any
dins in excess is thought to be the cause of the pain in history of abdominal or pelvic surgery. Also, they were
dysmenorrhea. The presence of the prostaglandins at the time of the study not on any medication that
causes the contraction of the myometrium and vasocon- could influence their menstrual patterns. Data collection
striction locally. Elevated levels of serum vasopressin, ni- was done using a pretested, structured and validated
tric oxide and interleukin-6 have also been reported to self-administered English questionnaire (SAQ) consisting
be implicated in dysmenorrhea [4–6]. of rating scales and close ended questions. We clarified
Among the student population, disturbances arising the aims of the study and students were assured that
from menstruation could contribute to absenteeism, ex- their participation in the study was absolutely voluntary.
emption from physical exercises and social and emo- Prior to the dissemination of the questionnaires, eligible
tional distress. Among adolescents however, delayed, participants were offered instructions sheets on how to
irregular, painful and heavy menstruation are extremely answer the questionnaires and had to finally offer an oral
common and remain the chief reasons for physician acknowledgement whether or not reading and under-
visits [7]. Premenstrual syndrome greatly affects the stu- standing English language was problematic to them. Our
dent population and causes a considerable amount of research assistants obtained verbal consent from all par-
anxiety [8]. Dysmenorrhea and menstrual irregularity are ticipants before they proceeded to complete the ques-
also reportedly prevalent among the student population tionnaires. Instructions were given to complete the
and these also affect these young women’s social life and questionnaires without inputting their names and were
class attendance [5, 9, 10]. On the whole, students who given confidentiality assurance. The questionnaires in-
are victims of menstrual disturbances also experience a quired facts about their socio-demographics, menstrual
tremendous impact on their social and physical health pattern characteristics and living conditions. We asked
[11]. Apart from the pathological factors that disrupt them to characterize their menstrual patterns before
women’s cycles, certain environmental factors and diet- they arrived to China and also indicate any observable
ary or lifestyle trends have also been reported to influ- changes in terms of regularity of menstrual cycle, dur-
ence the menstrual pattern like depression, cigarette ation and length, amount of menstrual flow and nature
smoking, changes in body weight and stress [12–15]. of associated menstrual symptoms after their arrival to
International students are reported to be exposed to a China. This was to provide us with the opportunity to
wide range of factors in their new environment and are properly classify the section of participants with changes
likely to develop new lifestyle habits to help them cope in their menstrual pattern and to look for potential risk
and adapt to their new environment [16–18]. factors. The criteria that defined menstrual cycle were as
Ansong et al. BMC Women's Health (2019) 19:35 Page 3 of 10

follows; irregular menstrual cycles: varying cycle length the months after arrival to China and was referred to
less than 21 or more than 35 days, regular menstrual cy- as the “No change group”.
cles: cycle length of 21–35 days, hypomenorrhea (men-
strual flow less than 2 days), prolonged menstrual flow General characteristics and demographics of participants
(menstrual flow of more than 7 days), and amount of The population had a median (± SD) of 27.89 ± 2.77 kg/
blood loss as reflected by the number of sanitary towels m2 for BMI and a mean age of 21.405 years for a range of
or pads changed per day during menstruation catego- 17–35 years. Health Science 238 (58.19%) was the most
rized as little, moderate and heavy for 4 pads, 5–7 pads popular program among the respondents. Only 49
and a maximum of 8 pads per day respectively. Included (11.98%) of the respondents read Business related courses
in the questionnaire were list of symptoms indicative of with only 32 (7.82%) studying engineering courses. The
premenstrual symptoms (PMS) and respondents were to larger portion of the respondents 203(49.63%) were
select ones applicable to them. nationals from Africa, with the least 20(4.89%) from
They were also asked to provide answers to questions Europe (Table 1).
regarding their living conditions which included specifics
like dietary habits, stress and common stressors. We in- Menstrual characteristics for the change group
tegrated the Perceived Stress Scale (PSS) in the question Two hundred and one 201(49.14%) respondents re-
to enable us evaluate their stress levels. To evaluate their ported varying changes in their menstruation (Change
stress levels, we incorporated the Perceived Stress Scale group). With a range of 9 to 16 years, majority 173
(PSS), which examined their thoughts and feelings dur- (86.07%) of the respondents had menstruated by age 13
ing the previous month. The scale is made up of 5-point with the mean onset of menarche as 11.830 years. Char-
Likert response format (0–4). The sum of the responses acteristic menstruation comprised: regular menses in
indicates the total score. Overall scores on the PSS-10 75.62% (152), 43.78% (88) for cycle length with a range
can range from zero to forty (0–40). Respondents with of 21 to 35 days, 46.26% (68) for duration of flow with a
PSS value of ≤20 and > 20 were categorized as low stress range of 3–7 days and moderate flow as reflected by the
and high stress respectively. In addition, variables such use of 5-7pads/day was 32.34% (n = 65). Menstrual ir-
as language barrier, academic pressure, money, loneli- regularity was recorded in 49(24.38%) of the respon-
ness, homesickness and food were provided for, which dents. PMS was the most prevalent 256 (33.82%)
respondents could selectively indicate as stressors. New menstrual disorder among our respondents. Most phys-
social habits including smoking, drinking, late sleeping, ical premenstrual symptoms were headaches 66(22.07%),
lack of exercise and lack of socialization were used to in- bloating 23(7.69%), breast tenderness 13(4.35%) and
vestigate new lifestyle patterns. back pain 12(4.01%) with irritability 16(5.35%) scoring
Where appropriate, data were expressed as numbers in the most reported psycho-behavioral premenstrual symp
the form of percentages or as mean ± SD. Data were tom. Other reported abnormalities included; abnormal
taken through revision, coded and tabulated using the amount 136(17.97%), dysmenorrhea 124(16.38%), abnor-
frequency and percentage to analyze and interpret the mal length 113(14.93%) and abnormal duration
results. Logistic regression and odds ratio were done to 79(10.45%) (Table 2).
identify risk factors for menstrual change and to test the
significance of the variables, p < 0.05. All calculations Analysis of statistical significance between factors and
were statistically carried out with the help of Statistical menstrual changes
Package for the Social Science (SPSS); SPSS Inc., Chi- Among our overall population, 248(60.64%) and
cago, IL, USA) version 20.0 for Microsoft Windows. 161(39.36%) were classified as high stress (PSS > 20) and
low stress (PSS ≤ 20) respectively according to the PSS
Results scale. High stress (PSS > 20) was the significant factor
We circulated five hundred (500) questionnaires in among the population that showed a strong association
total but 40 of them were not returned. Out of the between the two groups [p = 0.029, OR = 1.636,CI
460 that were returned, 51 were rejected due to lack 1.021–2.547]. Alcohol consumption, lack of exercise and
of information giving a response rate of 81.8%. The lack of socialization showed increased risks for men-
remaining four hundred and nine (409) questionnaires strual change with (OR 1.993,CI 0.671–5.921), (OR
met the criteria and were used for the analysis. Two 1.389 CI 0.891–2.167) and (OR 1.306 CI 0.562–3.038)
hundred and one (n = 201, 49.14%) respondents re- respectively. Lack of exercise was credited as the preva-
ported noticeable menstrual changes after arrival to lent 203 (49.63%) of new social habits developed after ar-
China and were categorized as the “Change group”. rival in China. Late sleeping and lack of socialization
Among two hundred and eight (n = 208, 50.86%) par- were the next common habits among the respondents
ticipants, menstrual patterns remained unchanged in scoring 180(44.01%) and 29(7.09%) respectively. Only18
Ansong et al. BMC Women's Health (2019) 19:35 Page 4 of 10

Table 1 General Characteristics and Demographics of Participants. (n = 409)

DEMOGRAPHICS STUDENTS POPULATION
CHANGE NO CHANGE P value
Number Percentage (%) Number Percentage (%)
Age 17–20 87 43.28 80 38.46
21–25 100 49.75 120 57.69 0.239
26–30 6 2.99 2 0.96
31–35 8 3.98 6 2.89
BMI Underweight(< 18.5) 1 0.50 1 0.48
Normal weight (18.5–24.9) 72 35.82 93 44.71 0.142
Overweight (25–29.9) 77 38.31 78 37.50
Obese(> 30) 51 25.37 36 17.31
Program Health Science 118 58.7 120 57.70
Engineering 10 5.0 22 10.60 0.145
Business 28 13.9 21 10.10
Others 45 22.4 45 21.60
Country Africa 110 54.72 93 44.71
Asia 60 29.85 87 41.83 0.024
Europe 9 4.48 11 5.29
Arab 13 6.47 15 7.21
Others 9 4.48 2 0.96

(4.4%) of the respondents had developed the habit of al- students are exposed to factors in varying degrees that can
cohol consumption (Table 3). potentially cause disruptions in their menstrual patterns.
These irregularities can have significant effects on these
Main stressors among the general population women’s life, health and work [15]. In close to 80% women
The commonest stressor among the study population with normal ovulation, the estimated blood loss on aver-
was the language barrier 81 (25.88%) followed by food age is about 33.2 ml (10-84 ml), cycle length of 26–35
64(20.45%), loneliness 56(17.89%) and homesickness days, bleeding follows a 3–6 day period with a range of 2–
40(12.78%). Finance was considered as a stressor among 12 days with the maximum flow on the second day [11].
35(11.18%) with only 32(10.22%) rating their respective The onset of menstruation is marked by menarche which
academic programs as a form of stressor (Fig.1). is a very important indicator of sexual maturity in females.
The mean age for the onset of menarche is reported dif-
Relationship between high stress level and menstrual ferently worldwide and Africans are reported to have the
disorders earliest age of menarche probably attributed to their high
We attempted to establish the relationship of the various body mass index [19, 20]. The age of menarche is also cru-
factors with menstrual irregularities and found out high cial since women who experience menarche much later
stress was also significantly associated the risk of dys- have a higher risk for menstrual irregularities [21].
menorrhea (p = 0.037). Although other factors like age, Unusually infrequent (oligomenorhea), unusually light
age of menarche, program of study, alcohol consump- (hypomenorrhea), heavy flow (menorrhagia), metrorrha-
tion, lack of exercise, lack of socialization and BMI did gia, unusually painful (dysmenorrhea), premenstrual syn-
not show strong significant associations they increased drome (PMS), absent or delayed menstruation (amenorr
the respondents’ risk of developing menstrual irregular- hea) and unusually frequent (polymenorrhea) are among
ities (Table 4). the types of menstrual disorders women suffer and the
number one reason for gynecologic visits [22, 23]. The
Discussion reasons for irregularities in menstruation vary as women
This is the maiden study done to throw more light on the age and can occur due to a plethora of conditions ran-
menstrual characteristics, disorders and associated risk ging from hormonal imbalances, pregnancy, malignan-
factors among female international students in Zhejiang cies, infections, diseases, trauma to the use of certain
Province, China. This study revealed that international medications [24–29]. Environmental factors and new
Ansong et al. BMC Women's Health (2019) 19:35 Page 5 of 10

Table 2 Menstrual Characteristics for the Change Group (n = 201).

Menstrual Characteristics Parameters Number Percentage (%)
Age of menarche 9–10 years 33 16.42
11–13 years 140 69.65
14–16 years 28 13.93
Total: 201 100.00
Menstrual regularity Regular 152 75.62
Irregular 49 24.38
Total: 201 100.00
Menstrual Length < 21 days 52 25.87
21–35 days 88 43.78
> 35 days 61 30.35
Total: 201 100.00
Duration of flow < 3 days 36 24.49
3–7 days 68 46.26
> 8 days 43 29.25
Total: 147 100.00
Amount of flow Little (4pads/day) 60 29.85
Moderate (5–7 pads/day) 65 32.34
Heavy (max 8pads/days) 76 37.81
Total: 201 100.00
Dysmenorrhea (Abdominal cramps) 124 100.00
Premenstrual Symptoms(PMS) Bloating 23 7.69
Back Pain 12 4.01
Headache 66 22.07
Nausea & Vomiting 2 0.67
Breast tenderness 13 4.35
Constipation 0 0
Irritability 16 5.35
Fever 0 0
Diarrhea 0 0
Others 1 0.33
None 39 13.04
Total: 295 100.00

lifestyle trends like caffeine consumption, physical ac- interactions [8]. Unlike in our study, which indicated
tivity, stress, smoking, age, weight gain and diet have headaches as the commonest premenstrual symptom, lit-
also been closely correlated with menstrual disorders erature reports irritability and anger as the commonest
[30–35]. and severe forms of PMS with an onset than earlier to
Premenstrual menstrual symptoms (PMS) was as- other symptoms [36].
cribed the main menstrual disorder (33.82%) among the Abnormal amount 136 (17.97%) was reported as the
group with change in their menstrual pattern. PMS is second menstrual disorder among our respondents
characterized by a multifarious pattern change in mood, with menstrual changes. Personalized estimation of
behavior and physical symptoms invariably experienced menstrual flow volume and hygiene coupled with dif-
during the premenstrual phase and resolve quickly be- ferent sanitary products on the market make the esti-
fore the onset of menstruation. It is reported that ap- mation of the accurate menstrual blood flow extre
proximately 5% of women experience severe forms of mely difficult. Various quantification methods for
PMS that distorts both their personal and social menstrual blood loss estimation have been reported
Ansong et al. BMC Women's Health (2019) 19:35 Page 6 of 10

Table 3 Analysis of statistical significance between factors and menstrual changes(n = 409)
Indicator Menstrual Pattern
No Change Change P-Value Odds Ratio OR95%CI
Number % Number % LOWER UPPER
Age
17–20 80 47.90 87 52.10 0.8676 1.1040 0.344752 3.535526
21–25 120 54.55 100 45.45 0.8548 0.8970 0.280026 2.873634
26–30 2 25.00 6 75.00 0.3408 2.6660 0.354385 20.05635
31–35 6 42.86 8 57.14 – – – –
AOM
9–10 years 27 45.00 33 55.00 – – – –
11-13 years 155 52.54 140 47.46 0.8452 0.9406 0.508649 1.739472
14-16 years 26 48.15 28 51.85 0.4028 1.4368 0.614638 3.358937
BMI
Normal 94 56.97 71 43.03 0.9886 4.2651E-9 0.0E0 .
Overweight 78 50.32 77 49.68 0.9999 10.4435 0.0E0 .
Obese 36 41.38 51 58.62 0.9996 7.7275E-9 0.0E0 .
Country
Africa 93 45.81 110 54.19 0.1248 0.27794 0.054173 1.426003
Arab 15 53.57 13 46.43 0.1708 0.28153 0.045896 1.726932
Asia 87 59.18 60 40.82 0.0386 0.17774 0.034559 0.914166
Europe 11 55.00 9 45.00 0.0470 0.15242 0.023799 0.976166
Others 2 18.18 9 81.82 – – – –
Program
Health 120 50.42 118 49.58 0.4653 0.773 0.387 1.543
Business 30 42.86 40 57.14 0.898 1.053 0.478 2.317
Engineering 32 64.00 18 36.00 0.028 0.367 0.150 0.895
Others 26 50.98 25 49.02 – – – –
Stress
≤ 20 96 59.63 65 40.37 – – – –
> 20 112 45.16 136 54.84 0.029 1.636 1.051 2.547
Food
Chinese 37 48.68 39 51.32 0.693 0.897 0.523 1.539
Western 154 50.00 154 50.00 – – – –
CAW 17 68.00 8 32.00 0.158 0.523 0.213 1.284
Social
Drinking 7 38.89 11 61.11 0.215 1.993 0.671 5.921
Habits
LS 101 56.11 79 43.89 0.254 0.766 0.485 1.211
LOE 94 46.77 109 53.23 0.147 1.389 0.891 2.167
LOS 13 44.83 16 55.17 0.535 1.306 0.562 3.038

to provide unreliable and conflicting outcomes [37]. been reported to correlate with the correct amount of
In our study, we employed the use of the traditional menstrual blood loss [38]. Nevertheless, future studies
method, whereby women self-estimated their men- could preferably make use of a more reliable ap-
strual loss by counting the number of sanitary prod- proach to quantify menstrual blood loss since the
ucts used per day. This method is convenient and has amount of menstrual blood loss is a useful tool in the
Ansong et al. BMC Women's Health (2019) 19:35 Page 7 of 10

Other(s) 5

Language Barrier
Academics 32
Food

Loneliness
Finances 35
Homesick
Stressors

Finances
Homesick 40
Academics

56 Other(s)
Loneliness

Food 64

Language Barrier 81

0 10 20 30 40 50 60 70 80 90
Number

Fig. 1 Main stressors among the general population

assessment of an individual’s productivity, general pain threshold, cultural differences in the perception of
well-being and iron status [39, 40]. pain and the absence of a standardized universal method
Dysmenorrhea was the third predominant menstrual to assess and grade dysmenorrhea [43].
disorder (16.38%) among our respondents. Although it is One of the widely used instruments employed in the as-
a common gynecological complaint among women in sessment of psychological stress among individuals with
developing countries, it’s characterized by varied preva- respect to varying situations over the past months is the
lence rate in literature. In one large study conducted perceived stress scale (PSS) [44]. With the help of the PSS,
among Australian teenagers for example, the prevalence our general population was categorized as low stress
was 93% and in another study among 664 Egyptian teen- (PSS ≤ 20) and high stress (PSS > 20) and we discovered
agers, the prevalence was reported as 80% [41, 42]. This more than half (60.64%) of the study population were high
difference has been linked to individual differences in stress. This buttresses the point that international students

Table 4 Relationship between high stress level and menstrual disorders (n = 201)
Menstrual Grade P-Value Odds OR95%CI
Disorders Ratio
High stress Low stress
Number % Number % LOWER UPPER
Irregular 30 100.0 19 100.0 .892 .946 .425 2.105
Menstrual Length
<21 days 35 44.30 17 50 .605 1.276 .506 3.218
>35 days 44 55.70 17 50 .453 .713 .295 1.724
Duration of flow
<3 days 26 48.15 10 40 .118 .440 .157 1.233
>8 days 28 51.85 15 60 .871 .931 .390 2.220
Amount of flow
Little 38 40.43 22 52.38 .156 1.976 .770 5.070
Heavy 56 59.57 20 47.62 .986 .992 .411 2.393
Dysmenorrhea 90 100.0 37 100.0 .037 .172 .033 .896
PMS 136 100.0 65 100.0 .069 .940 .880 1.005
Ansong et al. BMC Women's Health (2019) 19:35 Page 8 of 10

experience a great deal of stress that emanates from diffi- adjusting to new environment and dormitory settings
culties with adjustment, support, perceived discrimination, [52]. The few reports of lack of socialization as a new so-
homesickness, insecurity, anxiety, depression, language cial habit among our students could be attributed to the
and academics [16–18]. issue of language barrier which limits the scope of
The female reproductive system is very sensitive to socialization and interpersonal interactions.
physical and physiological stress. Although small doses Our present study is limited in some areas that we will
of stress can motivate individuals to respond to changes, like to address. Firstly, the present study involved stu-
face challenges and complete tasks, high stress can have dents who were enrolled in universities studying very de-
detrimental physical and psychological health effects. manding courses, which could obviously be viewed as
When the corticotrophin-releasing hormone system is potential stressors. Further comparative studies with for-
activated as a physiological response to stress, menstrual eigners who are not students or domestic students from
function can be consequently disrupted [45]. The correl- other provinces are needed to generalize the results.
ation of menstrual irregularities and high stress in our Causality inference of the factors identified as being cor-
study is in line with the various publications that have related with menstrual change is highly limited by virtue
registered menstrual changes in universities students of our choice of study design. Prospective follow up
studying demanding courses or individuals with com- studies are therefore needed to look for causality. An-
petitive life style including severe exercises [35, 46, 47]. other limitation of our study lies in the type of instru-
High stress (PSS > 20) was also found to be significantly ments we utilized. Although, the application of the 20 or
correlated with dysmenorrhea (p = 0.037) in our study. higher cut-off point to categorize women with high
Stress impairs the development of the follicle by inhibit- stress was recommended by Cohen et al. [44], recall bias
ing the release of follicle-stimulating hormone and and differences in individualized interpretation could be
luteinizing hormone. This may in turn alter progester- a possible limitation since stress levels were assessed by
one synthesis and release which may affect the action of questions from the previous months. The reader should
prostaglandin. Other stress related hormones like adren- also remember that participants estimated their men-
aline and cortisol also can influence prostaglandin syn- strual amount and duration by calculating the quantities
thesis and/or binding in the myometrium and may of sanitary pads used or by the number of days of men-
explain the role of stress in dysmenorrhea. A positive as- struation and blood loss. This approach is likely to also
sociation has also been reported between perceived suffer varying degrees of individual variations. Future
stress and the risk of dysmenorrhea in both longitudinal studies could employ the use of a more objective quanti-
and cross-sectional studies [23, 48–50]. The most preva- fication like the menstrual pictogram [53].
lent stressor among our respondents was language bar-
rier 81(25.88%) which may be attributed to the study of Conclusion
Chinese language as part of their academic curriculum Menstrual disorders are prevalent among the inter-
or their limited scope of socialization due to having very national student community as a result of a wide range
few English speaking colleagues around them. The issue of factors that contribute to the irregularity of menstrual
of language barrier goes beyond just being a stressor, as patterns. In the present study, the most common dis-
it can hinder physician consultation, hamper doctor–pa- order these students experienced was premenstrual
tients communication or result in poorer compliance symptoms, followed by abnormal amount and dysmen-
and less patient satisfaction [16]. Other common orrhea. The most predominant premenstrual symptom
stressors among our study population included food 64 was headaches, followed by bloating and irritability. The
(20.45%), loneliness 56 (17.89%), homesickness 40 top three main forms of stressors among the general stu-
(12.78%) and academic issues 32(10.22%). dent population were language barrier, food and loneli-
In our attempt to investigate our respondents’ new ness. These stressors accounted for a high level of stress
lifestyle trends, lack of exercise was found to be the (PSS > 20) among more than half of the students who
prevalent new social habit developed months after living have witnessed changes in their menstrual pattern and
in China. A significant association between lack of exer- this high stress was significantly correlated with dysmen-
cise and premenstrual symptoms has been reported in orrhea. Although, the formation of new social habits did
several studies. In one publication, aerobic exercises was not show strong association with menstrual disorders
evidenced as one of the options to help alleviate the among the students body, it was striking to note that
symptoms of premenstrual symptoms [51]. Late sleeping majority of these international students do not engage in
was the second reported habit after arrival to China. exercises and sleep rather late. With the large scale
This finding is not surprising, since the issue of sleep movement of international students into Chinese Uni-
problems is significantly escalated during university, and versities and Colleges, we believe additional studies with
among international students, due to problems with larger population size across major universities in China
Ansong et al. BMC Women's Health (2019) 19:35 Page 9 of 10

are needed to broadly assess this problem to help illu- Publisher’s Note
minate its prevalence. It is important that prospective Springer Nature remains neutral with regard to jurisdictional claims in
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studies which are done can include factors that can in-
fluence stress, such as cultural and religious background, Author details
1
social support and personality type, so that respective Department of Obstetrics and Gynaecology, The First Affiliated Hospital of
Wenzhou Medical University, Nanbaixiang, Street, Ouhai District, Wenzhou,
universities can develop and strategize appropriate inter- Zhejiang Province 325000, People’s Republic of China. 2Department of
ventions to help eradicate or minimize the effect of these Reproductive Medicine, The Second Affiliated Hospital of Wenzhou Medical
potential factors that predispose these individuals to University, Xueyuan Western Road, Lucheng District, Wenzhou, Zhejiang
Province 325027, People’s Republic of China.
menstrual irregularities.
Received: 27 June 2017 Accepted: 30 January 2019
Abbreviations
BMI: Body mass index; CAW: Chinese and Western; LOE: Lack of exercise;
LOS: Lack of socialization; LS: Late sleeping; PMS: Premenstrual symptoms;
PSS: Perceived Stress Scale References
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