Menstruation is a natural phenomenon involving the discharge of blood from the uterus through the vagina, occurring at more or less regular monthly intervals during the reproductive life of females.[1] Normal menstruation first occurs in adolescents between 11 and 14 years of age, with a period length of 7 days or less, and a normal cycle length of 21 to 45 days with average blood loss of 20-80ml.[2] There are various types of menstrual disorders, including dysmenorrhea, premenstrual symptoms, menorrhagia, polymenorrhea, abnormal vaginal bleeding, amenorrhea, oligomenorrhea, and irregular menstruation.[3] Studies have shown that a large proportion of the female population of reproductive age suffers from menstruation-related health issues.[4,6] Menstrual problems not only carry an economic burden but are also one of the most common causes of absenteeism and poor academic performance among young females.[7,9] Dysmenorrhea is one of the most prevalent menstrual problems during adolescence[5,7] and can even cause patients to become bed-ridden.[10] A review by Devis et al[11] showed that, 20-90% of adolescent girls reported dysmenorrhea, and almost 15% of those experienced severe dysmenorrhea. Another menstrual problem that can affect Patients’s daily activities is premenstrual syndrome (PMS). In a systematic review, the pooled prevalence of PMS was found to be 47.8%.[12] Menstrual disorders such as menorrhagia, abnormal uterine bleeding, and polymenorrhea contribute to almost 12% of gynecology referrals, and are usually associated with a very high chance of surgical intervention.[13] Coulter et al[14] reported that 60% of patients underwent a hysterectomy within 5-years of a referral for menorrhagia. Menstrual patterns can be affected by a number of factors, including age, ethnicity, family history, smoking, physical activity, and dietary habits.[15] Stress can be a major contributor to, or cause of menstrual irregularities, and an association has been documented between stress and various menstrual irregularities including menorrhagia, oligomenorrhea, dysmenorrhea, and PMS.[16,17] In addition, a high incidence of menstrual problems has been observed in students studying medicine and health sciences.[6] The majority of health science students reported that they are under continuous and chronic academic stress related to their studies and exams, resulting in negative health outcomes, including menstrual problems in females.[18]

A prospective study was conducted in the Department of Obstetrics and Gynaecology, VIMS, Gajraula for 10 months. Inclusion criteria • 100 patients were included in the study. Patients with age ranging from 20-40 yrs, coming to gynaecology OPD with presenting history of menstrual irregularities were included. Exclusion criteria • Patients with normal cycles, pregnancy were excluded. Data regarding age, marital status, parity, symptoms, menstrual history, obstetric history, examination, co morbidities, investigation findings, associated pathology and treatment modality were noted. Majority of patients belong to the age group of 30-40yrs- 70 % and the rest belong to the age group 20-30yrs. In our study majority of our patients were multiparous patients 75% and 25% patients were nulliparous. Lower socio-economic status had 70% in the group. 20% in middle and 10% in upper socio-economic status.

Table 1: Age Distribution Age in years No. % 20-30yrs 30 30 30-40yrs 70 70 Table 2: Body Mass Index Body Mass Index No. % 18.5 (underweight) 10 10 18.5-24.9 (normal weight) 20 20 25- 29.9 (overweight) 66 66 30-39.9 (obesity) 4 4 >40 (morbid obesity) 0 0 Overweight category had the maximum patients of 66, with 20 normal weight patients. 10 patients were under weight. Our study had no patients who were morbidly obese. Table 3: Menstural Disturbances Menstural Disturbances No. % Heavy menstrual bleeding 7 7 Increased frequency of cycles 9 9 Intermenstural bleeding 4 4 Continuous bleeding PV 5 5 Decreased frequency with menorrhagia 4 4 Post-menopausal bleeding 1 1 Amenorrhoea f/b menorrhagia 1 1 Post coital bleeding 1 1 Spotting PV 1 1 Table 4: Pain Pain No. % Congestive dysmenorrhea 4 4 Spasmodic dysmenorrhea 4 4 Continuous pain 6 6 Dyspareunia 5 5 Menstrual disturbances and pain abdomen were the two symptoms as presenting complaints. In menstrual disturbances, increased frequency of cycles was the highest with 9 patients. Next was heavy menstrual bleed with 7 patients. Decreased frequency with menorrhagia, intermenstural bleed and continuous bleed had the same number of patient distribution of 4. Less common symptom was spotting pv, amenorrhoea followed by bleeding, post coital bleed and post-menopausal bleed. Table 5: Pre Menstural-Syndrome Pre-Menstural syndrome No. % Back ache 25 25 Abdominal pain 32 32 Anxiety 4 4 Nervousness 5 5 Depression 3 3 In pain abdomen, continuous pain was the most common with dyspareunia and dysmenorrhea Abdominal pain was observed by 32 patients with back ache also being the most common symptom. Other uncommon symptoms were nervousness, depression and anxiety. Majority of patients had menarche after 12yrs. 30 patients had recent history of onset of symptoms from 3 months. Maximum patients had symptoms from one year. Very few of them had from 2 yrs. Out of 100 cases anaemia was present in 40 patients. 12 patients having severe anaemia who had blood transfused. Mild and moderate anaemia were treated with multiple doses of iron sucrose injection. D & C, Done for 57 patients out of 100 patients. Table 6: Endometrium report Endometrium No. % Secretory 32 32 proliferative 22 22 Hyperplastic 3 3 Normal cervix was found in most of the patients. Cervical fibroid, polyp was seen in few patients. 60 patients had normal uterus whereas 40 patients had fibroid or adenomyosis as the USG finding. Patients with high BMI had high rate of menstrual disturbances. Whereas 30 patients with normal BMI also had menstrual complaints.

Majority of patients belong to the age group of 30-40yrs- 70 % and the rest belong to the age group 20-30yrs. Similar association was seen is G. Warrilow et al. study.[19] Alpana et al. study stated that incidence of menstrual disturbances increases with parity as seen even in the present study showing 75% parous patients having menstrual disturbances.[20] As found in our study, menstrual disturbances are commoner among upper class due to obesity and lower class due to malnutrition. This correlation was found in Hawai et al. study.[21] Increase in BMI is a risk factor for menstrual disturbances due to the excess production of estrogen. Overweight category had the maximum patients of 66, with 20 normal weight patients. 10 patients were under weight. Our study had no patients who were morbidly obese. Similar correlation was observed in Hamdy et al. study.[22] Commonest presenting complaint was polymenorrhagia in our study. This result was also found in Moghal et al. study.[23] There was a positive correlation noted between PMS and High BMI as also seen in Lu Z et al. study.[24] 60 patients had normal uterus whereas 40 patients had fibroid or adenomyosis as the USG finding. Vercillin et al., study also had the same pathology as commonest.[25] D&C is done for patients having acyclical bleeding / if medical therapy fails, hence only 57% had the procedure done. Similar management was observed in Kate D C etal study.

BMI plays a very important role in menstrual cycle regulation. Lifestyle modifications and nutritional counselling could decrease the incidence of menstrual irregularities. Healthy eating habits and maintaining optimal BMI improves menstrual health.

1. In: House S, Mahon T, Cavill S, editors. Menstrual hygiene matters. A resource for improving menstrual hygiene around the world. Module one Menstrual hygiene – the basics. [cited 2012] Available from URL:www.wateraid.org/~/media/ Files/Global/MHM%20files/ Compiled_LR.pdf. 2. Hertweck P, Yoost J. Common problems in pediatric andadolescent gynecology. Expert Review of Obstetrics and Gynecology 2010; 5: 311. 3. In: Malhotra N, Kumar P, Malhotra J, Bora NM, Mittal P,editor. Jeffcoate’s Principles of Gynaecology. New Delhi (IN):Jaypee Brothers Medical Publishers (P) Ltd.; 2014. 4. Deliwala KJ, Shah HH, Shah BS. Evaluation of menstrual problems among urban females of Ahmedabad. Journal ofClinical Research Letters 2013; 4: 49-53. 5. Amu EO, Bamidele JO. Prevalence of menstrual disorders among adolescent girls in Osogbo, Southwestern Nigeria. Int J Adolesc Med Health 2014; 26: 101-106. 6. Karout N, Hawai SM, Altuwaijri S. Prevalence and pattern ofmenstrual disorders among Lebanese nursing students. EastMediterr Health J 2012; 18: 346-352. 7. Anandha Lakshmi S, Saraswathi I, Saravanan A. Ramamchandran C. Prevalence of premenstrual syndromeand dysmenorrhoea among female medical students and itsassociation with college absenteeism. Int J Biol Med Res 2011;2: 1011-1016. 8. Bitzer J, Tschudin S, Stadlmayr W. [Menstruation and its impacton patients’s health]. Zentralbl Gynakol 2005; 127: 282-287. 9. Houston AM, Abraham A, Huang Z. Knowledge, attitudes, and consequences of menstrual health in urban adolescent females. Journal of Pediatric and Adolescent Gynecology 2006;19: 271-275. 10. Hillen TI, Grbavac SL, Johnston PJ, Straton JA, Keogh JM. Primary dysmenorrhea in young Western Australian patients: prevalence, impact, and knowledge of treatment. J Adolesc Health 1999; 25: 40-45. 11. Davis AR, Westhoff CL. Primary dysmenorrhea in adolescentgirls and treatment with oral contraceptives. J Adolesc Health1999; 25: 40-45. 12. Direkvand-Moghadam A, Sayehmiri K, Delpisheh A, Kaikhavandi S. Epidemiology of Premenstrual Syndrome(PMS)-A systematic review and meta-analysis study. J Clin Diagn Res 2014; 8: 106-109. 13. Effective health care. The management of menorrhagia. Effective Health Care Bulletin 1995; 9: 1-14. 14. Coulter A, Bradlow J, Agass M, Martin-Bates C, Tulloch A, etal. Outcomes of referrals to gynaecology outpatient clinics for menstrual problems: an audit of general practice records. Br J Obstet Gynaecol 1991; 98: 789-796. 15. Liu Y, Gold EB, Lasley BL, Johnson WO. Factors affecting menstrual cycle characteristics. American Journal ofEpidemiology 2004; 160: 131-140. 16. Ekpenyong CE, Davis KJ, Akpan UP, Daniel NE. Academicstress and menstrual disorders among female undergraduates inUyo, South Eastern Nigeria - the need for health education. Niger J PhysiolSci 2011; 26: 193-198. 17. Zhou M, Wege N, Gu H, Shang L, Li J, Siegrist J. Work and family stress is associated with menstrual disorders but not with fibrocystic changes: cross-sectional findings in Chinese working patients. J Occup Health 2010; 52: 361-366. 18. Nisar N, Zehra N, Haider G, Munir AA, Sohoo NA. Frequency, intensity and impact of premenstrual syndrome in medicalstudents. J Coll Physicians Surg Pak 2008; 18: 481-484. 19. Warrilow G, Kirkham C et al. Quatification of menstural loss”, the ostetrician and gynaecologist. 2004; 6:88-92. 20. Mohite RV, Mohite VR, Kumbhar SM, Ganganahalli P. Common Menstrual Problems among Slum Adolescent Girls of Western Maharashtra, India. JKIMSU. 2013; 2(1):89-97. 21. Karout N, Hawai SM, Altuwaijri S. Prevalence and pattern of menstrual disorders among Lebanese nursing students. East Mediterr Health J. 2012 Apr;18(4):346-52 22. Moghal N. diagnostic value of endometrial curettage in AUB. The iraqui pg medical Journal, 2007, 295-7. 23. Lu Z. the relationship between menstrual attitudes n menstrual symptoms among taiwanese patients. 2006; 33:621-8. 24. Vercellin P, Parazzini F et al., adenomyosis at hysterectomy: a study on frequency distribution and patient characteristics. 1995; 10:1160-62. 25. Kate DC et al. prevalence of dysmennorrhea with association of menorrhagia. Eur J C Obs N Gynec Repord. 116-201-6.