Health Care for Women Intemationai, 27:418-427, 2006

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ISSN: 0739-9332 print / 1096-4665 online



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DOI: 10.1080/07399330600629583

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The Self-Care Strategies of Girls with Primary
Dysmenorrhea: A Focus Group Study in Taiwan
College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan

Department of Nursing, Kaohsiung Medical University Chung-Ho Memorial Hospital, Taiwan

School of Nursing, University of Washington, Seattle, Washington, USA

Department of Obstetrics and Gynecology, Kaohsiung Municipal United Hospital, Taiwan

Dysmenorrhea is tbe most common gynaecological complaint and
tbe leading cause of recurrent sbort-term school absenteeism among
adolescent girls. To explore adolescent girls' self-care strategies for
dysmenorrhea, we conducted four focus groups in Kaohsiung,
Taiwan, with 23 female adolescents with primary dysmenorrhea.
Thematic content analysis was used to explore and organize
the data. The self-care strategies for dysmenorrhea reported by
participants included reducing physical activity, modifying diet
using herbal remedies or medication, applying complementary
therapies, paying attention to symptom clusters of discomforts, and
expressing emotions. This is the first study to describe the self-care
strategies adopted by adolescent girls with dysmenorrhea in Asia.
Data were analyzed in cultural contexts. Knowledge of beneficial
food-related or herbal bealtb practices can enable professionals to
counsel tbis population more effectively.
Dysmenorrhea is the most common gynaecological complaint among
American female adolescents, with a prevalence of 85% (Banikarim, Chacko,
Received 16 March 2005; accepted 21 September 2005.
This work was supported by a grant from the National Science Council (NSC 91-2314-B037-298), Taipei, Taiwan.
Address correspondence to Dr. Chung-Hey Chen, College of Nursing, Kaohsiung
Medical University, No.lOO Shih-Chuan 1st Road, Kaohsiung 807, Taiwan. E-mail: Chunghey® tw

topical heat patches (Akin et al. 2004). and diarrhoea (Golomb. headaches. 1997. The OTC medications use rates were 55% for aspirin. back pain. Schmid. & Bergman. Klein and Litt (1981) found that only 14. Solidum.. & Duckett. 1998. a study of 706 Hispanic female adolescents found that self-treatments of dysmenorrhea included rest (58%). dizziness. Royburt. In contrast to that study. and exercise (Golomb et al. Primary dysmenorrhea is the leading cause of recurrent short-term school absenteeism among American (Klein & Litt. 2004) and Taiwanese (Chen. acupuncture (Helms.. 1998). McEvoy.. In a study of a Canadian adolescent population (Campbell & McGrath. 1997). 1981. Lurie. and herbs (7%.Self Care Strategies of Primary Dysmenorrhea 419 & Kelder. Primary dysmenorrhea can be defined as the experience of painful menstrual cramps of uterine origin despite normal pelvic anatomy and ovulation. Rabinerson. 1994). medications (52%). 1997). 1998). only 18% had used prescription medication to manage the discomfort.. while 30% did not. 1998). 1982) adolescent girls.5% American adolescents had ever consulted their physicians for help with their cramps. 2001). Lethaby. Lewers. Chen & Chen. associated at times with vomiting. study of undergraduate nursing students found that treatment for dysmenorrhea was predominantly self or "lay.K. Banikarim et al. Varner. exercise (15%).. Wolf & Schumann. Augood. 1999). 1998. 2000). less than one third of dysmenorrhoeic subjects consulted their general physician for treatment. and two thirds of those who did were dissatisfied with the treatment offered (Hewison & Akker. leading to periods of pain (Maciocia & Kaptchuk. and Shaver (1995) found that the most commonly reported strategy for cramping pain was the use of medication among American women with dysmenorrhea between 21 and 44 years of age. and 95% for acetaminophen.1992). tea (20%). & Coupey. which increases the amplitude and frequency of uterine contractions and causes vasospasm of the uterine arterioles. resulting in ischaemia and cyclical lower abdominal cramping pain (Golomb et al. 70% of the girls with dysmenorrhea reported using over-the-counter (OTC) medications to manage the discomfort. Granot et al. Current treatments for dysmenorrhea include analgesic medication (Campbell & McGrath. Peled. oral contraceptives (Milsom.. & Neri. Jarrett. fatigue. 2000) to 93% (Camphell & McGrath. Chang. herbal medicine (Kotani et al. Within the Chinese paradigm. 1987). & Brennan. 2003. transcutaneous electrical nerve stimulation (TENS) (Kaplan. 42% for ibuprofen. Jackson." for which a high rate of satisfaction was observed. Although the prevalence of primary dysmenorrhea in adolescent girls is high. 1999). 1997. In an early study. Another U. These nonsteroidal anti-inflammatory drugs (NSAIDs) work by inhibiting prostaglandin production (Campbell & McGrath. the literature addressing related health maintenance behaviours is . spinal manipulation (Kokjohn. 1997). 2001). & Mannheimer. 1996). 1997). heating pad (26%). Triano. liver-qi stagnation causes women's blood to stagnate in the uterus. Heitkemper. Clelland. & Warren. acupressure (Chang &Jun. Hedner. It arises from the excessive release of prostaglandins.

and were willing to share self-care experiences in a group format. with a range of 16-19 years in age. Small groups are more likely to share their experiences in ways that normalize and validate feelings.8 12.-H. Chinese and Western medical theories on primary dysmenorrhea. 2002). Focus groups are used as a qualitative research technique to promote discussion within small groups. Table 1 Demographic Profile of Participants Focus group Number of participants Average age Average age of menarche 1 2 3 4 5 17 13 5 18 12. Thomas. The average age was 17. Chen et ai..3 . Taylor. limited. Twenty-three girls participated in four focus group discussions. Our purpose in this qualitative study was to use focus groups to develop a description of Taiwanese adolescent girls' self-care strategies for dysmenorrhea. Due to the cultural differences between.4 6 18. The study's procedures were approved by the researchers' universitys' Research Ethics Committee. Each girl participated in only one group. In addition. a city in southern Taiwan. METHODS Focus groups were conducted to explore the self-care strategies of female adolescents with dysmenorrhea. hearing others' treatment strategies may be helpful for girls as a clinical strategy in developing or refining their own symptom management methods (Sharp. during October 2003 to May 2004. The group members were selected prior to the first session and did not change thereafter. To our knowledge there have been no studies that have addressed this issue in Asia. and the size of each group ranged from 5 to 7 individuals. for example.7 11. All participants completed a consent form. Taiwanese girls' self-care strategies may represent culturally specific behaviours not encountered in studies done in other regions of the world.6 years. All the girls were Taiwanese and lived in Kaohsiung. Girls were invited to participate through billboard postings at a medical university and at a teaching hospital or by word-of-mouth through peers. The groups met for three weekly sessions. 2004). The characteristics of the participants are shown in Table 1. were 20 years old or younger. Killeen.8 7 16. & Dawood.5 to 2 hours in length. This method is best suited for studies that seek to understand beliefs and experiences.420 C. Those who responded to the invitation were eligible for the study if they had experienced primary dysmenorrhea. and the strong oral culture generally found within adolescent communities facilitates this approach (Herrel et al. each 1.

I also suffer from stomach aches. avoiding swimming. and verbatim statements were used to illustrate them. so I cannot take any painkillers (NSAIDs) or apply any heat locally which I feel even worse. I cannot do any intense exercise. whose expertise was obstetric-gynaecologic nursing. huddled. Refreshments were offered to the participants at every meeting. and staying in a curled. In addition to menstrual cramps. hurts. H. in particular. and during the first 3 days of my period my belly. lying in a comfortable position. The topic guide presented to each focus group addressed the following broad areas: (a) body experiences during dysmenorrhea. sleeping. I cannot stand up for too long. bent. Thematic content analysis was used to interpret the data. I sometimes have headaches associated with my menstrual cycle. Reducing physical activity A broad variety of ways in which they reduced their physical activity were identified by all the participants. (b) selfcare strategies for dysmenorrhea. Also. It helps to pull up my knees to my chest during menstruation. 2. including bed rest. not moving. Similarities. Lin. the minute I start running. taking leave of absence from school. When I wake up. paying attention to symptom clusters of discomforts. led each focus group. or squatting position. These themes include reducing physical activity. . All group sessions were audiotaped and then transcribed and later translated from Chinese to English. modifying diet. I usually have something to eat and then go back to sleep again. Typically. applying complementary therapies. and expressing emotional. Modifying diet The female adolescents' lifestyle changes during menstruation were mainly directed toward dietary modification to cope with dysmenorrhea. using herbal remedies or medication. I don't feel like standing up and will therefore try to remain in a sitting position most of the time.Self-Care Strategies of Primary Dysmenorrhea All Y. when I am having my period. I usually try to go to sleep in such situations. as my waist and back will hurt. avoiding intense exercise. I even sleep the entire day. and (c) evaluations of self-care strategies. differences. 1. RESULTS Seven themes emerged from the data transcribed from focus groups on the adolescent girls' experience of self-care strategies for dysmenorrhea. and connections among the themes were identified. my uterus starts contracting fiercely and this tends to hurt a lot.

I feel dizzy and suffer from blurred vision. Zhongjiang herbal soup. menstruation won't hurt as much then. Chen et al. At such a time. and the more blood I lose. as I believe that this will make me lose even more blood. who would stew it for them. drinking hot drinks. I don't dare to drink water. I believe that this herbal soup will help adjust my body for the next time I undergo menstruation. sesame oil chicken. it especially helps to drink hot brown sugar water. and then it won't hurt as much during my next period! One can also take Baifeng pills directly or use them to make a decoction. herbal chicken soup.-H. my next period tends to arrive sooner. and increasing or decreasing fluids had all been tried and made sense to them: My belly feels warmer when I drink hot red bean soup. . and then it won't hurt as much as previously. The most commonly used herbs were a Siwu (a traditional herbal medicine composed of four ingredients) soup or pills. People say that taking Siwu pills or drinking Chinese wolfberry ginseng soup regulates the uterus. the more it hurts. dried longan stir-fried in sesame oil. and Baifeng pills: I drink Zhongjiang herbal soup at the end of my period. This is also the mechanism my mother uses to explain why I feel pain during my period and why I should take blood-building food (which in Mandarin means food with energy supplements) at that time. Their mothers. which is why it hurts so much when I have my period. When I am having my period. I have also found that when I eat a lot of Chinese cabbage (a kind of "cold" food in Chinese folk culture). After my period I get used to drinking Siwu soup that mother makes for me. as I believe that this will cleanse my body and make my next period hurt less.422 C. Herbal remedies The participants talked about their use of several kinds of traditional Chinese herbal preparations immediately following a menstrual period. Eating sweets and highly nutritious food. in an attempt to regulate the yin-deficient body and prevent the occurrence of menstrual pain in the future. abstaining from eating so-called "cold-type" foods. It seems that with a balanced diet menstruation passes somewhat more smoothly and it tends to hurt less. often suggested herbal soup to the adolescent girls. I'm therefore relatively weak. Xiaoyao powder. I feel like having sweet drinks. According to Chinese medicine. in effect. During my menstruation. Chinese wolfberry ginseng soup. 3. I have a so-called "cold" body constitution.

so if one takes blood supplements. Paying attention to symptom clusters of discomforts Symptom clusters of related discomforts were a distinct part of their pain experience and influenced their self-care strategies. Of course. 5. massage. or when you have menstrual pain. because my mother says that one may become addicted to painkillers if one consumes them too frequently. Rubbing some mint philtrum here. Some girls took nutritional supplements to fulfill their underlying aetiological beliefs regarding dysmenorrhea and to manage the discomfort: I took a painkiller once. include . I have never taken a drug again. getting fresh hot water to apply whenever the water I am using gets cold. I have heard the side effects and addiction problems with analgesics. I try not to take any Panadol. 6. Strategies for complementary therapies included acupressure. I drink only hot water. also feels good. Only when it hurts a lot during menstruation do I take Panadol. and heat therapy: Normally. Since that experience. so it is not the choice for me. and when it hurts a lot I apply heat to my belly for from 10 to 20 minutes. aromatherapy. My mother says that the uterine contractions experienced during menstruation are caused by anemia. apart from severe pain. I suspect that there is an acupoint related to the menstrual cycle at that location. Inhaling essential (natural) oil fumes during my menstruation really seems to elicit some positive effect for me. between nose and upper lip. but the pain was still there. when it doesn't hurt. sometimes one and sometimes two tablets at a time. Applying complementary therapies Complementary therapies can be described as those applications that are currently not part of the dominant medical system in Taiwan. you can press at the third sacral segment (S3) behind the pelvis so it won't hurt that much. Using medication Participants used drugs prescribed by physicians or OTC medications to relieve severe pain.Self-Care Strategies of Primary Dysmenorrhea 423 4. People have told me to go swimming regularly or to visit a watertreatment centre or spa. Symptoms that co-occur in w o m e n with dysmenorrhea. menstruation won't hurt that much. When I suffer menstrual cramps. and that menstrual cramps are the result of a severe contraction of the uterus.

Whenever I get my period. Chen et al. I will wonder why I have to be a woman and put up with this pain each month. upper-leg. the more it seems to hurt. During menstruation." Sometimes my waist and back hurt. my nipples become painfully swollen and the muscles in my legs tend to hurt. and. My waist and back hurt and I suffer severe headaches. e. I will often cry. especially if that person is a good friend of mine. and I tend to get gas easily. I particularly feel like sleeping. 7. I am less alert and typically suffer a poor appetite. The use of localized heat is supported by Akin and colleagues (2001) in an American adolescent population. I think I become a bit depressed during my period—depressed and relatively unhappy! When I see someone saying something. Heat therapy for dysmenorrhea initiates smooth muscle relaxation and increases blood circulation in the uterus. Expressing emotional The girls in our study also described emotional components. fatigue. When I get my period I become emotionally unstable. emotional fluctuations. . and I really feel "suffocated.g. Sometimes I will keep very quiet.424 C. typically. lower-back. and seeking attention from family or friends. lack of appetite. Sometimes I will cry. other times I will laugh. when they felt helpless. crying. Family members and intimate friends were often the secure objects for emotional outlet. often. and dizziness: When I am having my period. I feel dizzy and have blurred vision. my face grows a lot of pimples. hoping that someone will comfort me. resulting in relieving ischaemia and decrease pain perception. so my emotions go up and down. diarrhoea and constipation. and nipple pain. it feels as if my body is all swollen up. and when I stand up my eyes seem to blacken. DISCUSSION Among the self-care strategies of primary dysmenorrhea described by our participants. hot drinks and local heat application are popular treatments in Taiwan. edema. The more blood I lose. or sometimes I will feel troubled and want to stare angrily at those who speak to me. so quiet that my expression turns bad. I feel like a balloon.. I easily oversleep and am then. I feel like quarrelling with that person. I cry because it hurts so much. late for class.-H.

In Chinese traditional medicine.Self-Care Strategies of Primary Dysmenorrhea 425 Adolescent girls frequently suffer from menstrual discomfort and commonly use OTC medications to manage that discomfort. Suggested exercise activities include regular aerobic exercise. which would be worthy of rigorous scientific testing to determine their effects. and staying in a huddled position to reduce cramps. and stress reduction (Golomb et al. Possible explanations for the effectiveness of acupressure in relieving pain include a spinal gate control mechanism and activation of the endogenous opioid system. exercise modification across the menstrual cycle. however. 1999). health is defined as a state of balance or harmony within an individual. while exercise relieves the stress that may intensify dysmenorrhea. 2004). Our participants notably selected reduced physical activity such as bed rest. it may intervene through increased blood flow. We found that they had adopted acupressure. 1997. some participants described being yin deficient or "cold" of body. not moving. sleeping. it may aggravate menstrual symptoms (Metheny & Smith. and recognized the importance of exercise during the off-menstruation period. stimulation of beta-endorphins. Nevertheless. this modality appeared to be unpopular. Without comprehending the mechanisms.. & Lynn. and tai chi (Sharp et al. no one in our study sample had undergone those treatments. the effectiveness of acupressure is attributed to the invigoration of blood circulation and vital energy. our participants widely used other strategies recommended by mothers and grandmothers in Taiwan. Likewise. a noninvasive technique of traditional Chinese medicine derived from acupuncture. yoga stretching and relaxation. In our study. In the context of ancient Chinese culture. improved metabolism. Contrary to the accounts Western of girls (Campbell & McGrath. 1987) and spinal manipulation treatment (Kokjohn et al.. Jarrett et al. or if the girls wanted to handle their menstrual pain without medication. 1989). and between heaven. 1992) are effective in managing the pain of primary dysmenorrhea. including dietary modification and herbal remedies. but they may not be using OTC medications effectively. Exercise is commonly promoted as a therapy for menstrual cramps. 2002). 1998).. An important aspect of this balance is expressed in the relationship of yin and yang (Beal. Treatment requires use of special foods that are "yang" in nature (Ludman. Despite evidence that acupuncture (Helms. In addition to acupressure. which relieves cramping pain in the uterus (Chen & Chen. earth. one study has shown that. and man. making them susceptible to menstrual pain. as a self-care strategy. complementary therapies to relieve . Newman. although acupuncture-like TENS advantages in the treatment of period pain have been demonstrated in previous studies. nonaerobic exercise.. the girls in our study wanted to stop taking a medication if it was no longer effective or if it had unacceptable side effects. 1995). 1989) and herbal remedies to regulate the body into balance.

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