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

Copyright © Taylor & Francis Group, LLC
ISSN: 0739-9332 print / 1096-4665 online
•^

|-»
|<

!7V

g % Taylor & Francis Croup

DOI: 10.1080/07399330600629583

». »

'

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

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

MARGARET McLEAN HEITKEMPER
School of Nursing, University of Washington, Seattle, Washington, USA

KUN-MING WU
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®
kmu.edu. tw
418

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

4 6 18. and the size of each group ranged from 5 to 7 individuals. The group members were selected prior to the first session and did not change thereafter. Girls were invited to participate through billboard postings at a medical university and at a teaching hospital or by word-of-mouth through peers. Killeen. Thomas. Twenty-three girls participated in four focus group discussions.5 to 2 hours in length. All the girls were Taiwanese and lived in Kaohsiung.6 years. a city in southern Taiwan. Focus groups are used as a qualitative research technique to promote discussion within small groups. were 20 years old or younger. Chinese and Western medical theories on primary dysmenorrhea. In addition. 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. METHODS Focus groups were conducted to explore the self-care strategies of female adolescents with dysmenorrhea. Chen et ai. The characteristics of the participants are shown in Table 1. 2002). To our knowledge there have been no studies that have addressed this issue in Asia. All participants completed a consent form. Each girl participated in only one group. Taiwanese girls' self-care strategies may represent culturally specific behaviours not encountered in studies done in other regions of the world.7 11. and the strong oral culture generally found within adolescent communities facilitates this approach (Herrel et al. Those who responded to the invitation were eligible for the study if they had experienced primary dysmenorrhea.8 7 16.3 . Our purpose in this qualitative study was to use focus groups to develop a description of Taiwanese adolescent girls' self-care strategies for dysmenorrhea. for example. Small groups are more likely to share their experiences in ways that normalize and validate feelings.-H.8 12. limited. Taylor.. each 1. with a range of 16-19 years in age. during October 2003 to May 2004. The average age was 17. The groups met for three weekly sessions. and were willing to share self-care experiences in a group format.420 C. hearing others' treatment strategies may be helpful for girls as a clinical strategy in developing or refining their own symptom management methods (Sharp. This method is best suited for studies that seek to understand beliefs and experiences. The study's procedures were approved by the researchers' universitys' Research Ethics Committee. & Dawood. 2004). Due to the cultural differences between.

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

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

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

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

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

Research on menstruation discomforts of a five-year vocational school's students.. 44.. M. S. Nursing efforts toward empowering the adolescent to assume responsibility for her body are likely to be more effective than efforts aimed at compliance (McEvoy et al. Yamitsky. (1999). 2000. E. Public Health. M.. R. epinephrine and norepinephrine in the college students.. A. D. & McGrath. 1226-1229. foumal of Advanced Nursing. Helms. dysmenorrhea... S. Hewison & Akker.. Acupuncture for the management of primary dysmenorrhea. 97. P.xc. & Warren. it must be kept in mind that most of the self-care strategies stated in this study are based on oral reports by its participants and warrant scientific evidence. Z. M. Solidum. 33. J. 51-56. D. 1987. L. cortisol. 9. B. T. (2004). Chen et al. REFERENCES Akin. Obstetrics and Gynaecology. Adolescent girls are becoming more mature. A. For example. K. 154. Chen. P. Banikarim. Applications to women's reproductive health C2. (1982). 98.. Chen. Use of medication by adolescents for the management of menstaial discomfort. D. consumer literature often focuses on information about diagnosis or medications.. 1996. 451^62. Klein & Litt. R. 906—909. M. Primary dysmenorrhea and physical activity. P. Pain perception in women with dysmenorrhea. Effects of SP-6 acupressure on dysmenorrhea. A. Campbell. it appears that Taiwanese adolescents may not always use medications effectively and would benefit from additional information on period pain management. C. H. (2001).. H. 48. Y. Chacko. R. and responsible for self-care.-H. 905-913. Acupuncture and acupressure. Helms. Effects of acupressure at the Sanyinjiao point on primary dysmenorrhoea. 151. M. 2004). (2001). 380-387. & Zimmer. & Smith. Peer. E. Golomb. Hinkle. 343-349. Weingand. J. C. Hengehold. (1998).. H. Archives of Paediatrics & Adolescent Medicine. (1987).. (1997). Obstetrics & Gynecology. such as massage and aromatherapy. Medicine and Science in Sports and Exercise. & Kelder. Itskovitz-Eldod. Unfortunately. Taehan Kanho Hakhoe Chi. Continuous low-level topical heat in the treatment of dysmenorrhea. M. J.. Partially consistent with some earlier reports in the West (Banikarim et al. W.. A. M. the effective communication of knowledge about beneficial food-related or herbal health practices could help professionals counsel their clients. 69. 407-411.. 1981). Beal. Granovsky. Y. Goodale. W.. & Jun. E. 1038-1046. M. (2003). Granot. M. Chang. Obstetrics & Gynecology.. gradually have been attracting the attention of female adolescents in Taiwan..426 C. S. independent. (2000). & Chen. B. M. M. 30. Prevalence and impact of dysmenorrhea on Hispanic female adolescents. . The study's results highlight the need for more culturally appropriate health education materials on dysmenorrhea management. 217-230. Archives of Paediatrics & Adolescent Medicine. Joumai of Nurse-Midwifery. Last.

matory drugs for heavy menstrual bleeding (Cochrance Review).. L.. N. E. J. C. L. C. 125-130. UK: Update Software. 15. 16. (1995). M. stress.. J. M. & Neri. Peled. Varner. 345-349.. Triano. Symptoms and self-care strategies in women with and without dysmenorrhea. J. 29. (1998). Olevitch. Oyama. D. 25.. & Brennan. T. . K. 5. L. D... Kokjohn. Maciocia (Eds.. M. (1989). D. Jarrett. Kotani. M. dysmenorrhea. & Matsuki. Clelland. 569-586. 205-212.. (1998).. British foumal of Nursing. menstrual attitude and GP consultation. K. 661-664. F. (1996). J.. Muraoka. J. (1992). Wolf. Sakai.. & Coupey. 279-285. J. & Dawood. Oxford. 68. Cyclic perimenstrual pain and discomfort: The scientific basis for practice. & Said. A. Jackson. A. (1997). (1997). Dysmenorrhoea. Ludman. D... P. D. Y. Common menstrual disorders in adolescence: Nursing interventions. In J. Gynecologic & Obstetric Investigation. (1981). 235-260). (1994). K. 49. Chang. L E. V. Lethaby... Transcutaneous electrical nerve stimulation in the relief of primary dysmenorrhea. & Smith. & Duckett. Issue 1. 1122-1124.. MCN the American foumal of Maternal Child Nursing. Hashimoto. The effect of spinal manipulation on pain and prostaglandin levels in women with primary dysmenorrhea.). 3-9. Killeen. Hewison. American foumal of Obstetrics & Gynecology. and Neonatal Nursing. Schmid. 167-178. M. J.. T. Clinical evaluation of a new model of a transcutaneous electrical nerve stimulation device for the management of primary dysmenorrhea. & Mannheimer. 255-259. N. Thomas. A. J. M. A. N. T. S. (2002). & Bergman.. 12. The Cochrane Library. & Lynn.Self-Care Strategies of Primary Dysmenorrhea 427 Herrel. G. Physical Therapy. 123-129. K. M. M. 31. Rabinerson. & Litt.. Y. 89. M. Painful periods. R.. Kind. L.. (2004). & Kaptchuk. S. (1999). B.. E.. 11. Augood. K. New York: Churchill Livingstone. DuBois. C. P. (1999). L. Lewers. Klein.. M. and primary dysmenorrhea. Terry./owmfl/ of the American Dietetic Association. (2004). Thorp. Obstetrics and Gynaecology in Chinese Medicine ipp. A. A.. Health Care for Women Intemational. Nonsteroidalanti-inflam. Pediatrics. & Schumann. J. Sharp.. Taylor. 41-49. Heitkemper. E.. Kaptchuk & G. L. Comparative study of the effect of high-intensity transcutaneous nerve stimulation and oral naproxen on intrauterine pressure and menstrual pain in patients with primary dysmenorrhea. & Shaver. McEvoy. D.. foumal of Manipulative and Physiological Therapeutics. 637-649. L. H. 44. Metheny. Blood-building foods in contemporary Chinese populations. B. The relationship among exercise. Joumai of Behavioral Medicine. D. (1989). P. 69. foumal of Midwifery & Women's Health. 170. Joumai of the American Academy of Nurse Practitioners. Maciocia. L. Joumai of Obstetric. American foumal of Chinese Medicine. Epidemiology of adolescent dysmenorrhea. Newman.. Milsom. Ogawa.. R.. Hedner. K.. & Akker. 480-484. Gynecologic. Y. Analgesic effect of a herbal medicine for treatment of primary dysmenorrhea—^A double-blind study. Kaplan. W. P.. L. B. R. J. R. A. Somali refugee women speak out about their needs for care during pregnancy and delivery.. Lurie.... A. Royburt.. C.