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

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

Taiwanese girls' self-care strategies may represent culturally specific behaviours not encountered in studies done in other regions of the world. with a range of 16-19 years in age. The study's procedures were approved by the researchers' universitys' Research Ethics Committee. & Dawood.6 years. Focus groups are used as a qualitative research technique to promote discussion within small groups.8 12.8 7 16. The group members were selected prior to the first session and did not change thereafter. All the girls were Taiwanese and lived in Kaohsiung. Our purpose in this qualitative study was to use focus groups to develop a description of Taiwanese adolescent girls' self-care strategies for dysmenorrhea. Each girl participated in only one group.5 to 2 hours in length. The average age was 17. To our knowledge there have been no studies that have addressed this issue in Asia. Killeen. and the strong oral culture generally found within adolescent communities facilitates this approach (Herrel et al.420 C. during October 2003 to May 2004. Those who responded to the invitation were eligible for the study if they had experienced primary dysmenorrhea. The characteristics of the participants are shown in Table 1.7 11. This method is best suited for studies that seek to understand beliefs and experiences. Chen et ai. Chinese and Western medical theories on primary dysmenorrhea. and the size of each group ranged from 5 to 7 individuals..-H. for example. Twenty-three girls participated in four focus group discussions. In addition. Girls were invited to participate through billboard postings at a medical university and at a teaching hospital or by word-of-mouth through peers. Due to the cultural differences between. 2004). Taylor. a city in southern Taiwan. METHODS Focus groups were conducted to explore the self-care strategies of female adolescents with dysmenorrhea. 2002). Small groups are more likely to share their experiences in ways that normalize and validate feelings. 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. and were willing to share self-care experiences in a group format. each 1. were 20 years old or younger. hearing others' treatment strategies may be helpful for girls as a clinical strategy in developing or refining their own symptom management methods (Sharp.3 . All participants completed a consent form. The groups met for three weekly sessions. Thomas. limited.4 6 18.

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

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

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

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

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

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