SUMMARY Journal of Rawalpindi Medical College (JRMC); 2017;21(2): 157-160 157 Original Article Prevalence of Menstrual Dysfunction and its Comparative Correlation with Anaemia Rakhshanda Toheed 1, Talha Bin Ayub 2, Hafiza Sidra Ali 3, Faiza Ali 4 1.Department of Gynae/Obs, Avicenna Medical College, Lahore ;2. Department of Medicine, Ittifaq Hospital Lahore;3 Lady Aitchison Hospital Lahore;4. Medical Student, King Edward Medical University, Lahore. Abstract Background: To find out prevalence and pattern of menstrual abnormalities and its contribution to anaemia in teen age students and compare it with other causes of anaemia in them. Methods: In this observational cross sectional study,317 students were included after taking their consent. All girls included in the study; were students ranging from school to medical college, and aged 10-19 years . Details of menarche and menstrual cycle, history of passage of worms in stools, thyroid disease, liver disorder and bleeding clotting disorders were noted . Results: Out of 317 cases 159(50.6%) were anemic. Sixty percent of adolescents belonged to relatively better socio-economic group, 90% were unmarried, 87.4% non-vegetarian, body mass index (BMI) >25 was present in 53/317 cases, <19 in 29/317. All these variables had no significant relationship with anemia statistically (p-value >0.05).Mean age of menarche was 12.95 years in anaemic adolescents and 12.83 in those without anaemia.Out of 317 menstrual cycle was normal in 60.9%, scanty menstruation in 0.3%, irregular normal flow 6.6%, while 15.8 % had irregular heavy menses, 3.5%: heavy regular menses. Heavy menstrual bleeding both regular & irregular was highly associated with anaemia (p-value <0.001).Dysmenorrhea was present in 57.9% anaemic teens (p-value <0.001).Worm infestation was present in 10.1% cases (p-value <0.001) indicating highly significant association with anaemia. p-value for bleeding/clotting disorders was 0.014 showing significant link with anemia. Conclusion:Menstrual dysfunction is the main contributor to anaemia in female adolescents other factors being worm infestation and bleeding/clotting disorders. It needs urgent attention of parents and healthcare providers to correct anaemia according to cause and improve their quality of life and ensure healthy mothers in future. Key Words: Menstrual Dysfunction, Anaemia, Menorrhagia Introduction Adolescence (10-19 years of age) is critical period of life characterized by significant changes like increasingly pulsatile secretion of gonadotrophins, change in body contour and development of brain (prefrontal cortex, improved connectivity of various networks). These changes (adrenarche, thelarche, menarche, growth spurt) are more marked in early phase(10-14 years) and further consolidated in its late part(15-19 years) marking a paradigm shift in the pattern and style of life. 1-3 Normally menarche is expected within 2-3 years of the larches, cycle length varies from 21-45 days, duration of menstrual period 2-7 days, and 3-6 pads/day are consumed. Menstrual cycles become predominantly ovulatory within 8-12 years of menarche. 4 Pattern of menstruation may not be regular, menstrual blood loss may be excessive adding to stress, and causing compromised quality of life. Hesitation to share these issues with parents and health care providers aggravates implications of irregular, heavy and prolonged menstruation. Irregularity of newly initiated menstrual cycle, a common occurrence in adolescents, is largely attributed to immaturity of hypothalamic pituitary ovarian axis. 5 Anovulation is the most frequent physiological cause of heavy and prolonged periods. Other causes are stress, eating disorders, thyroid dysfunction, diabetes mellitus, bleeding disorders etc. 6 Menorrhagia and polymenorrhagia is a risk factor for development of anemia in adolescents in addition to other causes like worm infestation, poor socio-economic status, dietary habits etc. Assessment of Menstruation serves as a benchmark indicator of reproductive health in teen agers. 7 Studies from developing countries show prevalence of excessive menstrual bleeding in <1-18% adolescents.8Anaemia affects 30% women worldwide.9Very high percentage of anaemia was seen in Pakistani adolescent girls in one study. 10Anemia was found highly prevalent in adolescents in rural areas of Maharashtra India.11 Journal of Rawalpindi Medical College (JRMC); 2017;21(2): 157-160 158 Globally largest generation of adolescents is approaching adulthood in human history. 2, 7Pakistan has a great population (9619874 girls in 10-14 years group, and 8211804 girls in 15-19 years group) of adolescent girls approaching adulthood without proper care of their health especially the newly acquired menstrual function. 12 The anemic adolescent girls enter into adulthood with poor general health and little resistance to infections and low threshold to develop serious morbidity as a result of even mildly excessive blood loss in labor.13 In a study on prevalence of anaemia in primigravida, 78% of them were found anaemic indicating that root causes lie in pre-marital period (childhood and adolescence) and this is the motivation for this study.14 Patients and Methods This observational cross sectional study was conducted in King Edward Medical University. Three hundred and seventeen students, aged 10-19 years ,were included after taking their consent. Convenient sampling method was used; duration of study was 6 months from July 2014-Jan. 2015. Details of menarche and menstrual cycle were noted .Menarche was defined as the time of onset of first menstrual period. Normal age range for menarche is 12-15 years. Menorrhagia was defined as heavy and/or prolonged cyclical bleeding.Oligomenorrhoea was defined as scanty bleeding. Infrequent menstruation was bleeding every 3-4 months. Dysmenorrhoea the painful menstruation. Anaemia was defined as hemoglobin level less than 12 grams/deciliter.Severe anaemia: <7gm./dl, moderately severe anaemia: 7-9gm./dl, mild anaemia: >9-11.9 gm./dl.Weight and height were measured to calculate body mass index in Kg/m*2 Results Out of 317 cases 159(50.6%) were anaemic. Sixty percent of adolescents belonged to relatively better socio-economic group, 90% were unmarried, 87.4% non-vegetarian, body mass index(BMI) >25 was present in 53/317 cases, <19 in 29/317. All these variables had no significant relationship with anaemia statistically(p-value >0.05). Mean age of menarche was 12.95 years in anaemic adolescents and 12.83 in those without anaemia (Table 1).No statistically significant association of anaemia with age of menarche was found in this study. Out of 317 adolescents, menstrual cycle was normal in 66.9%, scanty menstruation in 0.3%, irregular normal flow 6.6%, while 15.8 % had irregular heavy menses, 3.5%: heavy regular menses. Heavy menstrual bleeding both regular & irregular was highly associated with anaemia (p-value Table 1:Mean age, BMI and age at menarche in anaemic and non-anaemic cases Anemia No. of cases Mean S.D Minim um Maxim um p- value Age (years) Absent 158 17.39 1.48 13.00 19.00 <0.001 ** Present 159 16.67 1.85 12.00 19.00 Total 317 17.03 1.71 12.00 19.00 BMI Absent 158 22.42 3.03 16.45 32.00 0.947 Present 159 22.39 3.26 13.70 35.60 Total 317 22.41 3.14 13.70 35.60 Mena- rche Absent 158 12.83 0.59 11.00 14.00 0.131 Present 159 12.95 0.81 11.00 16.00 Total 317 12.89 0.71 11.00 16.00 BMI= body mass index, S.D = standard deviation;** Highly significant association Table 2: Menstrual dysfunction and anaemia- Factors responsible No Percentage Income <10000 32 10.1 10000-15000 93 29.3 20000 and above 192 60.6 Total 317 100.0 Menstruation Scanty 2 .6 Normal 212 66.9 Heavy 11 3.5 Irregular heavy 50 15.8 Irregular normal flow 21 6.6 Irregular scanty 21 6.6 Diet Veg 40 12.6 Non-veg 277 87.4 Marital Unmarried 285 89.9 Married 32 10.1 Dysmenorrhea 142 44.8 Heavy bleeding 18 5.7 Hypothyroidism 7 2.2 Liver dysfunction 3 0.9 Bleeding clotting disorder 6 1.9 Worm infestation 73 10.1 <0.001).Dysmenorrhea was present in 57.9% anaemic teens (p-value <0.001). Statistically significant Journal of Rawalpindi Medical College (JRMC); 2017;21(2): 157-160 159 association of anemia with dysmenorrhea associated both with heavy menstrual bleeding as well as those with normal or scanty bleeding was found. Worm infestation: worm infestation was present in 10.1% cases (p-value <0.001) indicating highly significant association with anemia (Table 2).While p-value for bleeding/clotting disorders was 0.014 showing significant link with anaemia (Table 3). Anaemia was seen in 52% of women with dysmenorrheal (Table 4) Table 3.Comparative association of anaemia with different variables Anaemia P-value Absent Present Income <10000 15(9.5%) 17(10.7%) 0.936 10000-15000 47(29.7%) 46(28.9%) 20000 and above 96(60.8%) 96(60.4%) Marital status Married 142(89.9%) 143(89.9%) 0.985 Unmarried 16(10.1%) 16(10.1%) Body mass index <19 14(8.9%) 15(9.4%) 0.595 Normal 121(76.6%) 114(71.7%) >25 23(14.6%) 30(18.9%) Menstruation Scanty 2(0.6%) 0(.0%) <0.001** Normal 122(77.2%) 90(56.6%) Heavy 1(.6%) 10(6.3%) Irregular heavy 7(4.4%) 43(27.0%) Irregular normal flow 10(6.3%) 11(6.9%) Irregular scanty 16(10.1%) 5(3.1%) Diet Veg 18(11.4%) 22(13.8%) 0.512 Non-veg 140(88.6%) 137(86.2%) Dysmenorrhea 50(31.6%) 92(57.9%) <0.001* Hypothyroidism 5(3.2%) 2(1.3%) 0.248 Liver dysfunction 1(0.6%) 2(1.3%) 0.566 Bleeding clotting disorder 0(0%) 6(3.8%) 0.014* Worm 20(12.7%) 53(33.3%) <0.001** ** Highly significant association, *significant association Table 4 :Correlation of dysmenorrhea with anaemia Dysmenorrhoea Anemia p -value Total Absent Present No dysmenorrhoea 108 67 175 Dysmenorrhea present 45 52 .000 97 Dysmenorrhea with menorrhagia 05 40 .000 45 158 159 317 Discussion Prevalence of anaemia in present study was 50.6% having highly significant association with abnormally heavy menstrual bleeding and dysmenorrhea in addition to worm infestation and bleeding from gums and nose. Prevalence of anaemia was 68.8%, 21%, 90% and 52.2%in adolescent girls in different studies. 15-18 Menstrual function is an important landmark measure of normal adolescence. Pattern of menstruation in adolescents of our study revealed normal cycle in 66.9% participants. Regular/ irregular scanty menstruation (7.2%), irregular cycle with normal flow(6.6%), and heavy regular/ irregular heavy cycles were present in(19.3%).Heavy regular and irregular cycles are important contributory factors to adolescence anaemia especially in developing countries with gender bias and low socio-economic status among other contributory factors. In a Singaporean study oligomenorrhoea was present in 15.3% while polymenorrhoea in 2.0% adolescents and dysmenorrhea was reported in 83.2% girls . 5 In a study from Hyderabad 76% adolescents had normal menstrual cycle, 17% had heavy cycles, and 7% had scanty menstruation while 60% girls were anaemic. 19 Prevalence of heavy cycles in this study is comparable to that in our study. 57.9% anaemic adolescents in our study reported dysmenorrhea. Association was significant in those having heavy cycles and those not having heavy menstrual bleeding. Dysmenorrhea was experienced in 75 to 89% adolescents, in different studies. 20-23 It appears that in addition to its association with heavy, prolonged cycles, its impact on attitude and quality of life can not be ruled out. 24 Worm infestation was reported in 10% of adolescents in our study, which is expectable in the context of lack of clean water supplies for a large segment of our population. Worm infestation is highest among school children according to UNICEF, and hence this problem continues in to adolescence if these children are not dewormed in time. 25Other factors like BMI, age of menarche, liver dysfunction, thyroid disorders, vegetarian or non- vegetarian dietary habits, were not found associated with anaemia. In a nutritional survey, prevalence of anaemia in children under 5 years of age was 33.3%.26 In girls, approaching puberty, menstrual dysfunction irrespective of the underlying cause plays leading role in producing or worsening of pre-existing anaemia. 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(2016). “ Prevalence & Predictors of Iron Deficiency Anemia in Children Under five years of Age in Pakistan, A Secondary Analysis of National Nutrition Survey Data 2011- 2012.” PLoS ONE 11(5): e155051.doi: ------------------------------------------------------------- Authorship: 1,2 Conception , synthesis, planning of the research and manuscript writing ; 3,4 Active participation in methodology , interpretation and discussion; 4 Data analysis http://www.pbs.gov.pk/content/pakistan-demographic-survey-2007 http://www.pbs.gov.pk/content/pakistan-demographic-survey-2007