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
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

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

420 C. Those who responded to the invitation were eligible for the study if they had experienced primary dysmenorrhea. a city in southern Taiwan. The characteristics of the participants are shown in Table 1. To our knowledge there have been no studies that have addressed this issue in Asia. 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.. This method is best suited for studies that seek to understand beliefs and experiences. All the girls were Taiwanese and lived in Kaohsiung. 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. Taiwanese girls' self-care strategies may represent culturally specific behaviours not encountered in studies done in other regions of the world. and were willing to share self-care experiences in a group format. limited. The study's procedures were approved by the researchers' universitys' Research Ethics Committee.6 years. The average age was 17. Twenty-three girls participated in four focus group discussions. were 20 years old or younger. 2002). Each girl participated in only one group. METHODS Focus groups were conducted to explore the self-care strategies of female adolescents with dysmenorrhea. Due to the cultural differences between. Thomas. and the size of each group ranged from 5 to 7 individuals.-H.7 11.8 12.5 to 2 hours in length. The groups met for three weekly sessions. Taylor. for example. each 1. Chen et ai. Our purpose in this qualitative study was to use focus groups to develop a description of Taiwanese adolescent girls' self-care strategies for dysmenorrhea. The group members were selected prior to the first session and did not change thereafter. and the strong oral culture generally found within adolescent communities facilitates this approach (Herrel et al. Chinese and Western medical theories on primary dysmenorrhea. All participants completed a consent form.8 7 16. 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. 2004). Girls were invited to participate through billboard postings at a medical university and at a teaching hospital or by word-of-mouth through peers. & Dawood. Killeen. Focus groups are used as a qualitative research technique to promote discussion within small groups.4 6 18.3 . In addition.

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

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

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

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

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

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