Epidemiology

Jerry

of Adolescent

R. Klein,

MD,

and

Iris F. Litt,

Dysmenorrhea

MD

From the Department

of Pediatrics,
Division
of Adolescent
University
School of Medicine,
Stanford,
California

ABSTRACT.
rent

Dysmenorrhea

girls.
logic

and

biologic

menorrhea.

to

variables

Therefore,

lescents,

drawn

17-year-old

in the

data

analytic
graphic

(59.7%)
school

from

a national

girls

(the

because

variation

of dys-

2,699

menarcheal

probability

sample

National

of

cramps.

Health

The

of independent

12-

was not.

However,

school

because

( 12.3%)

even

in this

substantial

of

also suggested
among
blacks.

of

multiple

with

black

dysmenorrhea

students

dysmenorrhea

when

socioeconomic

study

suggest

than

that

is held

biologic

epidemiology,

school

36%

play

the National
to determine
ative

absence.

based

crampy

companied

lower

by

quency

of

cramps
orrhea

nausea,

defecation,

many

abdominal

pain

vomiting,

increased

headaches,

occurring
during
implies
the absence

ity. For

characterized

years

and

has

relative
role of psychologic
and
its pathogenesis.
Dysmenorrhea
leading

Received

for

Presented

Reese

October

PEDIATRICS

American

Dec

to

the

recurrent

5, 1980;

Society

for

surrounded

to (J.R.K.)
29th
(ISSN

Academy

St

and

Department
Ellis

0031 4005).
of Pediatrics.

Aye,

is

in

of dysmenorrhea

has

not

of
been

sample
data
from

survey

consists

III
of

of a represent-

national
probability
noninstitutionalized

sample
adoles-

aged
12 to 17 years.
Data
were
collected
1966 and 1970 by the National
Center
for
Statistics.8

Of the

surveyed,

menarcheal.

our

of age
rate

The

sample

for

approximately

3,203

were

2,699

this

girls

7,000

ado-

and

2,699 were
girls
comprise

menarcheal

analysis.

Michael
1981

by

for

data

available

Health

on tape

Statistics

by questionnaire

tamed

by
San

IL 60616.

raw

Center

from

the

included

from

parent

National

history

and

ob-

daughter,

of a physical
examination
performed
by a
pediatrician
and a nurse,
laboratory
and
psychologic test data,
and interviews
with school
personnel. The sexual
maturity
of each subject
was graded

19, 1981.
Medicine,

of Pediatrics,
Copyright

absence

results

school

Feb

Adolescent

Chicago,

20 years

school

Health
Examination
Survey
cycle
prevalence
and possible
correlates
This

lescents

The
the

variables
nonetheless

short-term

accepted

13 and

overall

in

adolescents

METHODS

1979.

requests
Hospital,

of

publication

in part

Francisco,
Reprint

cause

ac-

fre-

dysmenabnormal-

biologic

the

or
et

muscular

menses.
Primary
of any pelvic

controversy

by

often

school
Golub

incidence
increase

in Finnish

between
an

cross-sectional
on 22 million

Health
recurrent

56%

dysmenorrhea.

of dysmenorrhea.
dysmenorrhea,

is a syndrome

to

epidemiology

cents,
between

Dysmenorrhea

estimated

the possibility
of a higher
Widholm7
described
an

with

The

constant.

variables

An

from
In 1958,

studied
previously
in a large
representative
of American
adolescents.
We analyzed

miss more
students

white

status

girls.

of dysmenorrhea

associated
23.4%.

although

(23.6%)

frequency
from

study
was predicted
by gyneage. Preparation
for menarche,
not predict
either
dysmenorabsence.
Socioeconomic
status

role in the pathogenesis

68:661-664,
1981; menarche,

Pediatrics
adolescent,

proportion

in a stepwise

adolescent

a!6 reported
that
one third
of Philadelphia
public
high
school
girls had frequent
dysmenorrhea,
one
third
had occasional
dysmenorrhea,
and one third
had
no dysmenorrhea.
The
study
by Golub
et al

adoof

Examination

greatest

variables

regression
analysis
in this
cologic
or postmenarcheal
a psychologic
variable,
did
rhea or subsequent
school
was
positively
correlated

Data

pathogenesis

from

among

Stanford

140 million
hours
are lost annually
work
because
of dysmenorrhea.5

were
analyzed
by bivariate
and
multivariate
techniques
for biologic,
psychologic,
and democorrelates
of dysmenorrhea.
Of 1,61 1 adolescents
who
report
dysmenorrhea,
14
frequently
miss

Survey),

race

absenteeism

is the leading
cause
of recurschool
absenteeism
among
adolescent
surrounds
the relative
role of psycho-

short-term
Controversy

Medicine,

the

the

physician

by

using

the

reference

photo-

plates
developed
by Tanner.9
After
determining
the frequency
of dysmenorrhea,
correlations
between
biologic,
psychologic,
and demographic
independent
variables
and
the dependent
variable,
dysmenorrhea,
were determined.
Biologic
variables
graphic

PEDIATRICS

Vol.

68

No.

5 November

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on June 26, 2015

1 981

661

included

tion,

age, stage
of sexual
(postmenarcheal)

chronologic

and

gynecologic

maturaage,
the

number
of years
since
menarche.
A single
psychologic
variable
documented
preparation
for menarche,
Were

determined
you told

when

your

consisted
using

by

response
menstruation

about

periods

began?

of race

and

to

the
before

Demographic

variables

socioeconomic

status

as a proxy
measure
the education
who was head
of the household.
analyzed
as possible
correlates

parent

were

rhea
by bivariate
and multivariate
niques.
In addition,
morbidity
from
was
measured
by school
absence
from

interviews

with

question,
the time

school

(SES),

level of the
All variables
of dysmenoranalytic
techdysmenorrhea
as determined

personnel.
TANNER

STAGE

RESULTS
The
ing.

overall

Of the

fort
or
period.
severe,
The
related

it

of
5
at

subjects,

of dysmenorrhea

1,61 1 (59.7%)

pain
in
Of those

connection
with
pain,

with

chronologic

age

is strik-

reported

with
14%

as mild.
positively
Dysmenorrhea

from

39%

positively

SES

though

the

correlated
difference

with

was

small

n :241

as

n:475

of 12-year-

was
age

573

n:266
I.

c.)

20

n
0-I

-2

2-3

3-4

GYNECOLOGFC

Fig 3.

Prevalence
age.

AGE

of dysmenorrhea

in

80

al-

5-6

6-7

adolescents

by

56%

pc.Ol

from
:737
60

100

I :518

n:1358

40

80

4.1

4-5

(YEARS)

correlate
Increasing

dysmenorrhea
(P < .01);

92

gynecologic

not

n :600

60

cor-

dysmenorrhea
at a gynecologic

of dysmenorrhea
did
preparation
for menarche.

by

P C .001

to 72% of 17-year-old
girls (Fig 1). Similarly,
increased
with
sexual
maturity
rating
from
38%
those
at Tanner
stage
3 to 66% at Tanner
stage
(Fig 2), and from 31% at gynecologic
age 1 to 78%
gynecologic
age 5 (Fig 3). At any chronologic
age

The
problem
with reported

adolescents

4I6

80

girls

or any sexual
maturity
rating,
more
prevalent
in adolescents
of 2 years
or greater.

in

discom-

their
menstrual
described
it

37% as moderate,
and 49%
prevalence
of dysmenorrhea
with
all biologic
variables.

increased

old

prevalence

Fig 2.
Prevalence
of dysmenorrhea
sexual maturity
rating.

:?!

n=436

n49O

20

60
n=536
Cl)

n:429

:-

40

___

n:254

MEDIUM

iiI

SES

Fig 4.
Prevalence
of dysmenorrhea
socioeconomic
status
(SES).

20

a low
,.,

13

4
AGE

Fig 1 . Prevalence
chronologic
age.

662

ADOLESCENT

--

late

(YEARS)

of dysmenorrhea

in adolescents

SES

dysmenorrhea

-ii-.

by

with

in adolescents

and

63% from
a high
SES
experienced
(Fig 4). Further,
race did not correprevalence
of dysmenorrhea.
Gynecologic

age predicted
of all variables

the
in

greatest
proportion
a stepwise
multiple

DYSMENORRHEA

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on June 26, 2015

of variation
regression

by

pc.Ol
n

25

= 166

_:._

Insufficient

Bz

w=

n246

Block
White

14

20

B
B

I5

n:602

ns1355
10

n3O9

n4l4

5.

ALL

LOW

MEDIUM

HIGH

SES

Fig 5.
analysis.
did

Preparation

not

for

contribute

analysis

Prevalence

of school

menarche,

SES,

significantly
in
of dysmenorrhea.

as correlates

the

absence

and

race

regression

associated
with
from school
for

any reason
and
school
absences

of all excessive
as determined

for 25%
in our study

by teachers
reports.
In
girls,
frequently
missed
cramps;
school
mild

50%
because

this
sample,
14%, or 378
school
because
of their

with
severe
dysmenorrhea
of their
cramps,
while
only

cramps

did

so.

Although

black

missed
17% with

preparation

for menarche,

they
their
con-

however,

did

not correlate
with
school
absence.
Although
morbidity
was
great,
only
14.5%
of adolescents
with
dysmenorrhea
had ever sought
help
for this problem from
a physician,
including
only
29% of those
reporting
were
Most

severe
not

aware

adolescents

dysmenorrhea.
of their

Of

daughters

reported

being

struation
prior
to menarche.
whites
having
menarche
at
9.9% of all blacks
were
given
to the event.

parents,

30%

dysmenorrhea.
told

about

dysmenorrhea
morbidity

data

ported

in

Although
shown

upon
a national
to both a high

probability
prevalence

to those

previously

nonrepresentative
except

re-

sample
for

the

of

absence

of

Biologic
variables,
particularly
age, are strongly
correlated
This finding
is compatible
with

implicating
production,
pathogenesis

lack
to be

increased
endometrial
presumably
in ovulatory
of dysmenorrhea.#{176}2

of preparation
for
related
to subsequent

menarche
was
dysmenor-

it is surprising
that
so many
adolescents
aptheir
first period
without
any prior
knowlof menstruation.
More
specific
psychologic
to be studied.

variables

need

include

attitudes

quantitative

about

variables.

These

variables

menstruation

should
as

It is distressing

well

to learn

as

that

so few adolescents
have
ever
consulted
their
physicians
for help with
their
cramps.
In light
of these
findings,
physicians
should
be encouraged
to initiate
or to assist
parents
in initiating
discussions
of menstruation
with
premenarcheal
girls and to question
presence

with
pharmacologic

of dysmenorrhea
the

arche

However,
16.5%
of
or before
age 1 1 and
no information
prior

SES.

comparable

are

a smaller

recent
studies
prostaglandin
cycles,
in the

rhea,
proach
edge

and

adolescents,

in

goal of decreasing
intervention.3

those

postmen-

morbidity

through

by

from

ACKNOWLEDGMENT
This
Robert

findings,
based
draw
attention

by race

racial
differences.6
increasing
gynecologic
with dysmenorrhea.

the
men-

DISCUSSION
These
sample,

These

not

adolescents

reported
no more
dysmenorrhea
than
whites,
were
absent
more
from
school
because
of
cramps
(23.6%
vs 12.3%),
even when
SES held
stant
(Fig 5).
Reported

dysmenorrhea

American

Absence
for cramps
is strongly
missing
an unusual
number
of days
accounted
for girls

for

work
Wood

was

supported

Johnson

in part

a grant

the

Foundation.

REFERENCES
of

in American
adolescents
(59.7%)
and
related
to excessive
school
absence.

1. Gough

HG:

of menstrual
2. Brooks-Gunn

Personality

factors

related

to

distress. J Abnorm
Psycho!
J, Ruble DN: Dysmenorrhea

reported
severity
84:59,
1975
in adolescence.

ARTICLES

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on June 26, 2015

663

No. 8, September
1969
9. Tanner
JM: Growth
at Adolescence.
Scientific
Publications,
Ltd, 1962

Presented
at meeting
of the American
Psychologic
Association,
New York,
September
1979
3. Ruble
DN: Premenstrual
symptoms:
A reinterpretation.
Science
197:291,
1977
4. Starfield
B, Gross
E, Wood
M, et al: Psychosocial
and
psychosomatic
diagnoses
in primary
care of children.
Pediatrics
66:159,
1980
5. Ylikorkala
0, Dawood
Am J Obstet
Gynecol

MY:

New

130:833,

concepts
1978

10.

orrhoeic

survey
of US
Service
Publication

in dysmenorrhea.

SIR WILLIAM
SURGEONS

youths
No.

12-17
1,000,

years
Series

WILDE,
ONE
AND FATHER
CAUSE

Sir
Oscar
ogist

William
Wilde.
and

of the

Wilde
Largely

Like
most
led to visual
He

but

School

OF

also

WJ,
Best
menstrual

subjects.

J Obstet

FA,
fluid

et al: Prostaglandins
in
from
normal
and dysmenGynaecol
Br Commonw
72:185,

din levels
13.

of
1,

in nondysmenorrheic

Prostaglandins
Klein
JR,

Litt

on adolescent

and dysmenorrheic

15:365,
1978
IF, Rosenberg

VISUAL

J Pediatr

IMPAIRMENT

is remembered
is that
he was
the

dominant

of Medicine,

figure

which

of his ophthalmologic
impairment.

not

was

today,
only

if at all, as the
a distinguished

in otology

at its

and

peak

during

he

believed

contemporaries

father
of
archeol-

ophthalmology
his

lifetime.

that

eyestrain

wrote2:

In these
compelled,

days
of forced
both by parents

hours

hours

and

compressed,

and

education
and teachers,

together,
the

legs

with
often

the
dangling

on

the
one hand,
when
to pore over books,
often

head

bent,

in the

the
air,

in

shoulders
crowded,

unhappy
of very
stooped,

badly

children
small
type,
the

are
for

abdomen

ifiuminated,

and

ill-

ventilated
apartments;-when
young
ladies
in the upper
circles,
and those
girls in the
middle
ranks
who are preparing
to be governesses
and teachers,
are obliged
to practice
and read music
for five and six hours
a day;-when
young
gentlemen
are induced,
either
by threats
or emulation,
to read
for eight
and ten hours
a day, and in addition
several
hours of the night,
under
the glare
of a strong
gas light,
in order
to uphold
the character
of a school
or master
at the risk-often
at the expense
of sight
and life-when
on the
other
hand,
unfortunate
tradesmen
are compelled
by low wages,
the
high
price
of
provisions,
and
scarcity
of work,
to support
their
almost
starving
families
by working
in
dark,
damp
cellars
and
garrets
for fourteen
or sixteen
hours
a day;-and
when
poor
seamstresses
and mffliners
are necessitated
by the fashionable
luxuries
of the upper

classes
to this

to work for no less than eighteen

the various
factories
and private

of the
altered

eye to minute
vision
should

objects,
be now

hours
trades

out of the twenty-four;-and

which require
the continuous

we wonder
not
so common
amongst

that
near-sightedness
us.

Noted

when we add
application

and

by T.E.C.,

impaired

Jr,

or

MD

REFERENCES

664

1. Wilson

TG:

Sir William

2. Wilson

TG:

Victorian

ADOLESCENT

Wilde.
Doctor.

Arch
New

Otolaryn
York,
LB

81:626,
Fischer,

1965
1946,

subjects.

A, et al: The
effect
of aspirin
98:987,
1981

dysmenorrhea.

OF IRELANDS
GREATEST
EYE AND EAR
OF OSCAR
WILDE,
ON EYESTRAIN
AS A

(1815-1876)
forgotten

statistician

Dublin

Hall
and

Blackwell

1965
1 1. Lundstrom
V, Green
K: Endogenous
levels
of prostaglandin
F2a and its main
metabolites
in plasma
and endometrium
of
normal
and
dysmenorrheic
women.
Am
J Obstet
Gynecol
130:640,
1978
12. Chan
WY, Hill JC: Determination
of menstrual
prostaglan-

6. Golub LI, Lang WR, Menduke

H: The incidence
of dysmenorrhea
in high school girls. Postgrad
Med
J 23:38, 1958
7. Widholm
0: Dysmenorrhea
during
adolescence.
Acta Obstet
Gynecol
Scand
Suppi
87:61, 1979
8. National
Center
for Health
Statistics:
Plan and operation
of
a health
examination
age. Public
Health

Pickles
VR,
endometnum

London,

p 129

DYSMENORRHEA

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on June 26, 2015

Epidemiology of Adolescent Dysmenorrhea

Jerry R. Klein and Iris F. Litt
Pediatrics 1981;68;661
Updated Information &
Services

including high resolution figures, can be found at:

http://pediatrics.aappublications.org/content/68/5/661

Citations

This article has been cited by 9 HighWire-hosted articles:

http://pediatrics.aappublications.org/content/68/5/661#related-urls

Permissions & Licensing

Information about reproducing this article in parts (figures, tables)

or in its entirety can be found online at:
http://pediatrics.aappublications.org/site/misc/Permissions.xhtml

Reprints

Information about ordering reprints can be found online:

http://pediatrics.aappublications.org/site/misc/reprints.xhtml

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright 1981 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on June 26, 2015

Epidemiology of Adolescent Dysmenorrhea

Jerry R. Klein and Iris F. Litt
Pediatrics 1981;68;661

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/68/5/661

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright 1981 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Indonesia:AAP Sponsored on June 26, 2015