Middle East Fertility Society Journal 23 (2018) 486–490

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Original Article

Prevalence and patterns of dysmenorrhea and premenstrual syndrome

among Egyptian girls (12–25 years)
A.E. Arafa a, S.A. Senosy a,⇑, H.K. Helmy b, A.A. Mohamed c
a
Department of Public Health and Community Medicine, Faculty of Medicine, Beni-Suef University, Egypt
b
Department of Maternal and Newborn Health, Faculty of Nursing, Beni-Suef University, Egypt
c
Department of Community Health, Faculty of Nursing, Beni-Suef University, Egypt

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: Most girls experience pain and other discomforting symptoms during their menstrual periods.
Received 1 December 2017 The aim of this study is to investigate the prevalence, and patterns of dysmenorrhea and premenstrual
Revised 9 January 2018 syndrome (PMS) amongst girls in Beni-Suef, Egypt.
Accepted 13 January 2018
Study design: Population-based, cross sectional study.
Available online 29 January 2018
Methods: This study was conducted on 4122 girls (12–25 years) representing Beni-Suef City. A structured
questionnaire was used and a team of data collectors interviewed the girls.
Keywords:
Results: High rates of dysmenorrhea (92%) and PMS (86.3%) among girls. A solid association between
Dysmenorrhea
Premenstrual syndrome
dysmenorrhea and PMS was detected. While gynaecological age was the only risk factor for dysmenor-
Girls rhea, gynaecological age, marriage, educational level and sleeping hours were determinants for PMS
Risk factors (p < .05). Backaches, generalized aching and nervousness were the most commonly reported symptoms
63.3%, 62.4% and 43.5%, respectively. More than half of girls who experienced dysmenorrhea reported
drinking herbal fluids and taking analgesics to alleviate their symptoms. Girls resorted mostly to family
members to get information about menstruation.
Conclusion and recommendations: Dysmenorrhea and PMS are highly prevalent among girls in Beni-Suef.
Many risk factors have been suggested to be linked with dysmenorrhea and PMS. Health awareness
programs should be encouraged to improve girls’ knowledge regarding menstrual disorders. Further
research should focus on the adaptive techniques used by girls to avoid the negative consequences of
menstrual disorders.
Ó 2018 Middle East Fertility Society. Production and hosting by Elsevier B.V. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction Many various etiologies have been linked to dysmenorrhea and

PMS such as hormonal abnormalities, vitamin deficiencies, stress,
Menstrual disturbances have negative impacts on the girls’ smoking, certain dietary habits and lack of exercise [5,6].
quality of life [1]. The additional healthcare costs, absenteeism Several national and international studies have investigated the
from work, and restriction from activities add an economic burden epidemiology of dysmenorrhea and PMS amongst young females;
to such disorders [2]. Dysmenorrhea and premenstrual syndrome however the differences in age and socio-demographic characteris-
(PMS) come on the top of menstrual disorders list. While dysmen- tics of target populations resulted in wide variations in the preva-
orrhea is usually defined as painful menstruation [3], PMS is the lence of both disorders [7,8]. Further, most national studies
name given to a group of physical and psychological problems explored menstrual problems among school or university students
females experience one or two weeks prior to menstruation [4]. using convenience sampling techniques and covered limited geo-
Dysmenorrhea may be accompanied by backaches, nervousness, graphic areas [9,10].
headache, fatigue, weight gain, nausea and vomiting, and breast The physical and psychological problems caused by menstrual
tenderness [3]. disorders are opposed by limitation in our knowledge about the
magnitude of the problem among girls and their health-seeking
behaviour, which hinders developing appropriate health services.
Peer review under responsibility of Middle East Fertility Society. Since population-based studies on the epidemiology of dysmenor-
⇑ Corresponding author at: Beni-Suef, 62511 Mukbel, Egypt.
rhea and PMS among the Egyptian girls are scarce, the objective of
E-mail addresses: [email protected], [email protected]
this study is to explore the patterns and correlates of dysmenorrhea
(S.A. Senosy).

https://doi.org/10.1016/j.mefs.2018.01.007
1110-5690/Ó 2018 Middle East Fertility Society. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 A.E. Arafa et al. / Middle East Fertility Society Journal 23 (2018) 486–490 487

and PMS among girls (12–25 years) in Beni-Suef, detect the associ- PMS in the past 12 months, associating symptoms, and relieving
ating symptoms and the commonly used pain relief methods, and methods. Section III had questions about the effect of dysmenor-
figure out the main sources of information girls use to acquire infor- rhea and PMS on attending school, university, work, etc. and if
mation about their menstrual cycles and menstrual disorders. the girl had to visit a physician for her menstrual disturbance. Also,
this section included a question about the main sources of infor-
2. Methods mation about menstruation.
Before commencing the fieldwork, a pilot study on 250 girls was
2.1. Study design and area conducted to test the validity and reliability of the questionnaire.
The Cronbach’s alpha for reliability was 0.72 while content validity
This population-based, cross-sectional survey was conducted in was judged by a professor of public health and a professor of gyne-
Beni-Suef City on 4122 young girls in the period between August cology and obstetrics.
2016 and April 2017. According to 2016 estimates, 2.9 million peo- A total of 6000 young girls were asked to participate in the
ple live in Beni-Suef Governorate (74% in rural areas and 26% in study; of them 4142 were interviewed giving a response rate of
urban areas). Beni-Suef City is the capital of Beni-Suef Governorate, 69%, then 20 questionnaires were excluded because of the
situated 120 km south to Cairo and constituted of an urban incompleteness.
Metropolitan surrounded by 39 villages established on the sides
of the highways linking Beni-Suef to Cairo, El-Minia and El- 2.6. Statistical analysis
Fayoum Governorates. Almost 60–70% of the population in Beni-
Suef City live in municipal areas. Data were analyzed using the software, Statistical Package for
Social Science (SPSS Inc. Released 2009, PASW Statistics for Win-
2.2. Sample size dows, version 18.0: SPSS Inc., Chicago, Illinois, USA). Frequency dis-
tribution as percentage and descriptive statistics in the form of
It was calculated using Epi-Info version 7 Stat Calc, [Center for mean and standard deviation were calculated. Chi-square, t-test
Disease Control (CDC), WHO], based on the following criteria; dys- and correlations were done whenever needed. P values of less than
menorrhea rate/PMS rate of 50%, confidence level of 90%, margin of .05 were considered significant.
error of 5% and non-response rate of 40%.
3. Results
2.3. Sampling
A total of 4122 young girl with a mean age 19.9 ± 3.3 years par-
First, the urban Metropolitan of Beni-Suef City was classified ticipated in the study. The great majority of the participants
into three socioeconomic strata (low, middle, and high). From each (91.2%) were not married, and more than half of them (55.2%) were
stratum, two suburbs were selected randomly, and from each sub- living in rural areas. Most of the participating girls were students;
urb, a hundred households or more were chosen using a random whether school students (27.4%) or university/high institute stu-
start. Then, the rural villages surrounding the Metropolitan were dents (46.3%), and more than half of their parents had post elemen-
stratified according to their location on the map (North, West, tary educational certificates (Table 1).
and South), and two villages were selected randomly from each Only 19.4% of girls reported regular exercise activity, 67.6% sta-
location. The villages were clustered roughly to three or four areas, ted preference of salty diet, while 46.1% reported exposure to pas-
where householders of these areas were invited to take part in the sive smoking at home and/or work. Of the 4122 girls, 2420 (58.7%)
study. were circumcised. The mean age of menarche among the girls
stood at 13.1 ± 1.4 years, and the duration of menstrual cycle was
2.4. Ethical considerations 28.2 ± 6.8 days, with 5.2 ± 1.4 flow days (Table 1).
Our results showed that 92% of the girls experienced dysmenor-
After getting institutional approvals, The Research Ethical rhea, 86.3% had PMS, and 81% had both during the past 12 months.
Committee (REC) of Faculty of Medicine, Beni-Suef University Only 2.7% of the girls had neither dysmenorrhea nor PMS during
has approved the study protocol. Individual verbal consents were the same period (p < .05). Girls who experienced PMS were more
taken. likely to suffer dysmenorrhea (p < .05), and the duration of dys-
In both urban and rural areas, a trained team of medical stu- menorrhea in girls with PMS was considerably longer than their
dents with a supervisor from the Public Health Department, counterparts without PMS (p < .05) (Table 1).
Beni-Suef University visited the selected household. Uninhabited Using univariate analysis, older girls and girls with higher
households or those inhabited by non-Egyptians were considered gynaecological age, girls residing urban areas, girls attending uni-
ineligible. Householders were briefed of the steps and purposes versities and uncircumcised girls were more likely to experience
of the study and their girls (between 12 and 25 years) were invited dysmenorrhea during the past 12 months, however multivariate
to participate. Older or younger girls and the married who were analysis for the possible associations showed that increased gynae-
using hormonal contraceptives were not allowed to participate in cological age was the only potential risk factor for dysmenorrhea in
the study. this study (p < .05) (Table 1).
On the other hand, many determining risk factors were corre-
2.5. Data collection tool lated with PMS amongst young girls; namely increased gynaeco-
logical age, marriage, higher education, higher mother’s
Data were collected using an interview questionnaire. The ques- education, less sleeping hours per day, and shorter menstrual cycle
tionnaire had three sections: section I included socio-demographic (p < .05) (Table 1).
data, gynaecological age (Calender age minus age at menarche), Both dysmenorrhea and PMS were associated with absence
dietary habits, physical activity, sleeping hours, circumcision, in from regular activities such as school, work, etc, since 53% of girls
addition to few questions about the regularity of the menstrual who had dysmenorrhea and 53.3% of those who had PMS missed at
cycle and usage of contraceptives for the married women. Section II least one activity due to their menstrual problems. Also, 22.4% of
questioned about whether the girls experienced dysmenorrhea or girls with dysmenorrhea and 22.6% of girls with PMS visiteda
488 A.E. Arafa et al. / Middle East Fertility Society Journal 23 (2018) 486–490

Table 1
Factors associated with dysmenorrhea and premenstrual syndrome during the past 12 months among the participating young females, Beni-Suef, Egypt, 2017.

Factors Overall n = 4122 (%) Dysmenorrhea n = 3793 (%) Premenstrual syndrome n = 3556 (%)
**
Age (Mean ± Sd) 19.9 ± 3.3 20.0 ± 3.2 20.1 ± 3.2**
Residence Urban 1846 (44.8) 1720 (45.3)* 1626 (45.7)*
Rural 2276 (55.2) 2073 (54.7) 1930 (54.3)
Married 405 (9.8) 373 (9.8) 380 (10.7)** D
Studying or employment status School Student 1130 (27.4) 1016 (26.8) 930 (26.2)
University or High Institute Student 1908 (46.3) 1773 (46.7)* 1669 (46.9)** D
Employed 634 (15.4) 594 (15.7) 584 (16.4)
Not working or studying 450 (10.9) 410 (10.8) 373 (10.5)
Father’s education Illiterate 646 (15.7) 586 (15.4) 546 (15.4)
Elementary 921 (22.3) 833 (22.0) 772 (21.7)
High 2555 (62.0) 2374 (62.6) 2238 (62.9)*
Mother’s education Illiterate 1049 (25.4) 951 (25.1) 857 (24.1)
Elementary 872 (21.2) 796 (21.0) 753 (21.2)
High 2201 (53.4) 2046 (53.9) 1946 (54.7)** D
Sleeping hours/Day (Mean ± Sd) 8.3 ± 1.7 8.3 ± 1.7 8.2 ± 1.7** D
Physical activity 799 (19.4) 740 (19.5) 701 (19.7)
Preference of salty diet 2786 (67.6) 2559 (67.5) 2407 (67.7)
Exposure to passive smoking 1901 (46.1) 1761 (46.4) 1629 (45.8)
Circumcised 2420 (58.7) 2210 (58.3)* 2060 (57.9)*
Menarche age (Mean ± Sd) 13.1 ± 1.4 13.1 ± 1.4 13.0 ± 1.4**
Gynaecological age (Mean ± Sd) 6.9 ± 3.5 7.0 ± 3.4** DD 7.0 ± 3.4** DD
Menstrual cycle (Mean ± Sd) 28.2 ± 6.8 28.2 ± 6.6 28.1 ± 6.5* D
Flow duration (Mean ± Sd) 5.2 ± 1.4 5.2 ± 1.4 5.2 ± 1.4
Premenstrual syndrome 3556 (86.3) 3340 (88.1)*
Dysmenorrhea duration (Mean ± Sd) 2.0 ± 1.2 2.1 ± 1.2**
Absence from School, Work, etc 2065 (50.1) 2010 (53.0)** 1894 (53.3)**
Visiting a Physician for a Gynaecological Complaint 895 (21.7) 848 (22.4)** 804 (22.6)**
*
p value < 0.05 by univariate analysis.
**
p value < 0.001 by univariate analysis.
D
p value < 0.05 by multivariate analysis.
DD
p value < 0.001 by multivariate analysis.

physician, at least for once, because of gynaecological complaints tively (Table 2). For girls who experienced dysmenorrhea, drinking
(Table 1). herbal fluids and having analgesics were the most commonly used
Among the participating girls, 63.3% reported backaches, 62.4% pain relief methods (Table 3).
generalized aches, 43.5% nervousness, and 41.9% had acne or flush- When the girls were asked about their sources of information
ing. Abdominal distension, insomnia and dysuria were the least about menses and menstrual disorders, 71.9% selected family
complaints to be reported by girls 15%, 11.6% and 10.6%, respec- members, 24.2% friends, 18.2% school teachers and school nurses,
13.6% TV and social media, while only 6.2% resorted to doctors
(Table 4).
Table 2
Common clinical presentations associated with men-
struation during the past 12 months among the partic- 4. Discussion
ipating young females, Beni-Suef, Egypt, 2017.

Clinical presentations n = 4122 (%) Dysmenorrhea and PMS are public health problems of great
concern due to their negative effect on health, work and psycho-
Backaches 2611 (63.3)
General aching 2573 (62.4) social status. This population-based study highlights the preva-
Nervousness/irritation 1794 (43.5) lence, patterns and correlates of dysmenorrhea and PMS among
Acne/flushing 1727 (41.9) girls (12–25 years) in Beni-Suef, Egypt. It reported high percentage
Headache 1073 (26.0) of girls suffered from dysmenorrhea (92%) which was considerably
Breast tenderness 873 (21.2)
Anorexia/vomiting 724 (17.6)
higher than rates from studies conducted on adolescent secondary
Abdominal distension 619 (15.0) school girls in Assiut city (76.1%) [7] and Mansoura (75%) [10]. It
Insomnia 477 (11.6) was also higher than rates reported in Arab countries as among
Dysuria 437 (10.6) nursing students in Lebanon (38.1%) [11] and African countries
Others 297 (7.2)
as among students of Bahir Dar University in Ethiopia (85.1%)
[12]. On the other hand, the prevalence of PMS in our study was

Table 3
Relieving methods used by the participating Table 4
young females to alleviate symptoms of Sources of information for the participating young
dysmenorrhea during the past 12 months, females about menstrual disorders, Beni-Suef, Egypt,
Beni-Suef, Egypt, 2017. 2017.

Treatment n = 3793 (%) Source of information n = 4122 (%)

Herbal fluids 2423 (58.8) Family 2965 (71.9)
Drugs 2162 (52.2) Friends 997 (24.2)
Heating pads 438 (10.6) School 752 (18.2)
Exercise 332 (8.1) TV and Internet 561 (13.6)
Rest 279 (6.8) Doctor 254 (6.2)
 A.E. Arafa et al. / Middle East Fertility Society Journal 23 (2018) 486–490 489

86.3%. This rate consisted with the prevalence rates among univer- the most commonly reported symptoms were nervousness, irri-
sity students in El Minia (80.2%) [13], and Ain Shams University tability, backache, and headache [7], El-Gilany et al. reported fati-
medical students (89%) [14], but lower than results from Jima uni- gue, headache, backache and dizziness [10], Karout et al.
versity students in Ethiopia (99.6%) [15]. and university students in reported abdominal pain and backacke [11], while Seedhom et al.
Thailand (98%) [16]. Our relatively higher rates of dysmenorrhea reported nervous tension, headache and mood swings [13].
and PMS could be attributed to the higher mean age of our study Regarding the used pain relief methods, drinking herbal fluids
group. Also, while we questioned the participants in our study and having analgesics were highly prevalent among the participat-
about their menstrual problems throughout the past 12 months, ing girls in our study. Alike, El-Gilany et al. found that rest/relax-
other authors detected shorter or longer time spans to explore ation, herbal/home remedies and/or drugs were mostly used by
these disorders. Further, almost 15% of the participants in our girls for their menstrual disorders [10]. Shrotriya et al. showed that
study were employed and 10% were married by the time of the having medications and application of heat in the form of hot
study. Working and married females have more commitments water bag were the most widely used methods to alleviate men-
and face more social and economic challenges which put them strual pain [8].
under chronic stress and make them more prone to experience In this study, family members was cited as the main source of
menstrual disorders. information about menses and menstrual disorders (71.9%), which
Our results could also consolidate the relationship between come in accordance with previous studies [9,26,27]. Another study
dysmenorrhoea and PMS since 88.1% of girls who experienced dys- from Iran highlighted the role of school nursesas the first source of
menorrhea had history of PMS and 81% of the study group suffered information [28], while Rajni et al. concluded that friends were the
both dysmenorrhea and PMS. This association has been suggested most important source of information [29]. Only 6.2% in girls in our
in previous literatures [12,17]. study resorted to doctors to get information about menses. Our
In the present study, increased gynaecological age was of the results could be explained by the private and sensitive nature of
most potential risk factors for dysmenorrhea and PMS. In agree- menstrual issues in addition to lack of specific programs explaining
ment, El-Gilany et al. and Andersch and Milsom reported higher adolescent physical changes. So, many girls feel reluctant to seek
rates of dysmenorrheal in older girls [10,18] and Mohamed’s study medical advice and prefers their family members and close friends.
showed an association between earlier menarche and dysmenor-
rhea.[7] Karout et al. suggested that girls with menarche age less
than 11 years were more likely to experience menstrual disorders 5. Limitation of this study
[11]. Girls who attend menarche earlier have longer exposure to
uterine prostaglandins, resulting in higher prevalence of menstrual The study population represented only Beni-Suef City, the Cap-
disturbance [8]. ital of Beni-Suef Governorate. In comparison to the rest of cities in
Unlike findings of Seedhom et al. [18], physical inactivity and the Government, Beni-Suef City has significantly different residen-
exposure to passive smoking in our study were not associated with tial distribution, higher educational levels and socio-economic
PMS [13]. Exercise is thought to be associated with lower water standards. The sensitivity of the topic and the conservative nature
retention and autonomic reactions that protect from menstrual of the community have resulted in low response rate (69%), and
disorders [19]. The fact that Nicotine is a vasoconstrictor can those who refused to respond might carry different characteristics.
explain the association between smoking and dysmenorrhea
through reduced endometrial blood flow [20]. Besides, cigarette 6. Conclusion
smoke may have an anti-estrogenic effect [21].
Although the negative gynaecological and psychological conse- Dysmenorrhea and PMS are frequent among girls in Beni-Suef.
quences of female circumcision have been heavily reported Since girls do not tend to express their menstrual problems frankly,
[12,22,23], the circumcised girls in our study showed no difference gynecologists and primary care physicians should screen for those
regarding dysmenorrhea or PMS prevalence. However, some cul- problems. Health awareness programs should be encouraged to
tural aspects in this regards should be considered. In our study, improve girls’ knowledge regarding menstrual disorders. Medical
girls residing rural areas were almost three times more likely to and nursing students can be mobilized to implement such pro-
be circumcised. On the other hand, talking about menstrual disor- grams. The role of school nurses in managing such problems of
ders in conservative rural communities is a very sensitive issue; in public health interest has to be stressed on. Prospective studies
particular amongst the single girls because many of them believe may be beneficial in exploring the etiologies of the menstrual prob-
that exposing their menstrual problems may decrease their lems and the adaptive techniques used by girls to avoid their neg-
chances of getting appropriate marriage. This might lead to a final ative consequences.
conclusion that rural girls who had higher rates of circumcision
were less likely to explicit their dysmenorrhea and PMS. Generally,
stress and painful physical scars due to circumcision were sug- Competing interests
gested to be of the risk factors for dysmenorrhea [12].
Dysmenorrhea and premenstrual symptoms were serious Authors have no conflict of interests.
enough to be associated with absence from regular activities in
53% and 53.3% of the participants, respectively. This was in coher-
Funding
ence with Karout et al. who reported that 60% of the Lebanese
nursing students reported that PMS affected their daily activities
This research did not receive any specific grant from funding
[11]. Also, most high school female students reported that dysmen-
agencies in the public, commercial, or not-for-profit sectors.
orrhea and PMS significantly disturbed their academic attendance
and achievement [24]. Dysmenorrhea has been estimated to be the
main cause of time lost from work and school in the United States Acknowledgments
[25].
Backache, generalized aching and nervousness were the most Medical Students’ Team (Abdelaziz HA, Marwan MM, Magdy M,
prominent clinical presentations associated with menstruation Fathy IO, Safwat HM, Ramadan AK) who help authors in data
among the participating girls in this study. Mohamed showed that collection.
490 A.E. Arafa et al. / Middle East Fertility Society Journal 23 (2018) 486–490

References [15] A. Tenkir, N. Fisseha, B. Ayele, Premenstrual syndrome: prevalence and effect
on academic and social performance of students in Jimma Uniersity, Ethiopia,
Ethiop. J. Health Dev. 17 (3) (2003) 181–188.
[1] P.D. Parker, Premenstrual syndrome, Am. Fam. Physician 50 (1994) 1309–
[16] M. Thu, E.O. Diaz, S. Kapaw, Premenstrual syndrome among female university
1317.
students in Thailand, AU J. Technol. 9 (3) (2006) 158–162.
[2] J. Bitzer, S. Tschudin, W. Stadlmayr, Menstruation and its impact on women’s
[17] D.A. Booton, R.Y. Seideman, Relationship between premenstrual syndrome and
health, Zentralblatt fur Gynakologie 127 (2005) 282–287.
dysmenorrhea, AAOHN J. 37 (8) (1989) 308–315.
[3] L. French, Dysmenorrhea, Am. Fam. Physician 71 (2) (2005) 285–291.
[18] B. Andersch, I. Milsom, An epidemiologic study of young women with
[4] C.W. Henderson, ACOG issues guidelines on diagnosis and treatment of PMS,
dysmenorrhea, Am. J. Obstet. Gynecol. 14 (1982) 655–659.
Women’s Health Weekly 5 (6) (2000) 20–22.
[19] W.G. Johnson, R.E. Carr-Nangle, K.C. Bergeron, Macronutrient intake, eating
[5] A. Cerin, A. Collins, B.M. Landgren, P. Eneroth, Hormonal and biochemical
habits, and exercise as moderatorsof menstrual distress in healthy women,
profiles of premenstrual syndrome, Acta Obstet. Gynecol. Scand. 72 (1993)
Psychosomat. Med. 57 (4) (1995) 324–330.
337–343.
[20] F. Parazzini, L. Tozzi, R. Mezzopane, L. Luchini, M. Marchini, L. Fedele, Cigarette
[6] M.Y. Dawood, Advances in primary dysmenorrhea, Obstet. Gynecol. 108 (2)
smoking, alcohol consumption, and risk of primary dysmenorrhea,
(2006) 428–441.
Epidemiology 5 (1994) 469–472.
[7] E.M. Mohamed, Epidemiology of Dysmenorrhea among adolescent students in
[21] J.A. Baron, C. La Vecchia, F. Levi, The antiestrogenic effect of cigarette smoking
Assiut City, Egypt, Life Sci. J. 9 (1) (2012) 348–353.
in women, Am. J. Obstet. Gynecol. 162 (1990) 502–514.
[8] C. Shrotriya, A. Ray, S. Ray, G.A. Thomas, Menstrual characteristics and
[22] S. Vangen, R. Hoffmann, K. Flo, B. Lorentzen, S. Sand, Female circumcision–
prevalence and effect of dysmenorrhea on quality of life in medical students,
complications and treatment, Tidsskr Nor Laegeforen 9;126(4) (2006):475–
Int. J. Collab. Res. Intern. Med. Publ. Health 4 (2012) 276–294.
477.
[9] N.A. AbdEl-Hameed, M.S. Mohamed, N.H. Ahmed, E.R. Ahmed, Assessment of
[23] A. Elnashar, R. Abdelhady, The impact of female genital cutting on health of
dysmenorrhea and menstrual hygiene practices among adolescent girls in
newly married women, Int. J. Gynaecol. Obstet. 97 (3) (2007) 238–244.
some nursing schools at EL-Minia Governorate, Egypt, Life Sci. J. 7 (1) (2011) 1–
[24] L.M. Dickerson, P.J. Mazyck, M.H. Hunter, Premenstrual syndrome, Am. Fam.
10.
Physician 67 (2003) 1743–1752.
[10] A.H. El-Gilany, K. Badawi, S. El-Fedawy, Epidemiology of dysmenorrhea among
[25] L.J. Waite, US women at work, Population Bull. 36 (1981) 3.
adolescent students in Mansoura, Egypt, East Meditter. Health 11 (1) (2005)
[26] B. Ersog, C. Balkan, T. Gunay, A. Onag, A. Egemen, Effects of different
155–163.
socioeconomic conditions on menarche in Turkish female students, Early
[11] N. Karout, S.M. Hawai, S. Altuwaijri, Prevalence and pattern of menstrual
Hum. Dev. 76 (2004) 115–125.
disorders among Lebanese nursing students, East Meditter. Health 18 (4)
[27] H.O.U. Tiwari, R. Tiwari, Knowledge, attitudes and beliefs about menarche of
(2012) 346–352.
adolescent girls in Anand district, Gujarat, East Mediterr. Health J. 12 (3–4)
[12] M.T. Shiferaw, M. Wubshet, D. Tegabu, Menstrual problems and associated
(2006) 428–433.
factors among students of Bahir Dar University, Amhara National Regional
[28] S.M.T. Ayatollahi, A.E. Dowlat, S.A.R. Ayatollahi, Age at menarche in Iran, Ann.
State, Ethiopia: a cross-sectional survey, Pan. Afr. Med. J. 17 (2014) 246.
Hum. Biol. 29 (4) (2002) 355–362.
[13] A. Seedhom, E. Mohammed, E. Mahfouz, Life style factors associated with
[29] D. Rajni, K. Anil, K. Manpreet, Knowledge and practices related to
premenstrual syndrome among El-Minia University students, Egypt, Hindawi
menstruation among Tribal (Gujjar) adolescent girls, Ethno-Med. 3 (1)
Publishing Corporation ISRN Public Health, 2013; ID 617123, pp. 6.
(2009) 43–48.
[14] I. Bakr, H.S. Ez-Elarab, Prevalence of premenstrual syndrome and the effect of
its severity on the quality of life among medical students, Egypt J. Commun.
Med. 28 (2) (2010) 19–30.