Relationship between primary dysmenorrhea, presenteeism, and genital self-image in university women: a cross-sectional studyABSTRACT
This study aimed to assess the relationship between primary dysmenorrhea (PD) and presenteeism and genital self-image in university women. This cross-sectional observational study was carried out in Northern Brazil from January to May 2023. Female students aged ≥18 years with PD were included in this research. PD-related pain intensity, presenteeism, and genital self-image were assessed by a numerical pain scale, the Stanford Presenteeism Scale-6 (SPS-6), and the Female Genital Self-Image Scale (FGSIS), respectively. Statistical analysis used the Spearman correlation coefficient test at a 5% significance to evaluate the relationships between PD pain intensity and the SPS-6 and FGSIS. This study included 181 university students (22.54±4.15 years old) with an average PD pain intensity in the last three months of 6.58±1.97 points, classified as moderate. The average SPS-6 score totaled 14.85±4.16 points, showing presenteeism. A significant moderate negative correlation occurred between the total SPS-6 score and PD pain intensity =−0.310 (p<0.0001), that is, the greater the pain, the lower the SPS-6 value, indicating more impact on presenteeism. Regarding genital self-image, a weak significant negative correlation was obtained between the FGSIS and PD pain intensity =−0.232 (p=0.0017). Thus, the greater the pain intensity, the worse the perception of genital self-image. PD had a significant relationship with presenteeism and an impact on genital self-image.
Keywords:
Dysmenorrhea; Presenteeism; Female Genitalia; Menstruation; Self Concept
RESUMO
Este estudo objetivou verificar a relação da dismenorreia primária (DP) com o presenteísmo e com a autoimagem genital de mulheres universitárias. Trata-se de um estudo transversal do tipo observacional, realizado no Norte do Brasil, no período de janeiro a maio de 2023. Foram incluídas mulheres estudantes de ≥18 anos com DP. A intensidade da dor relacionada à DP foi mensurada pela escala numérica de dor, o presenteísmo foi avaliado pelo Stanford Presenteeism Scale-6 (SPS-6), e a autoimagem genital pelo Female Genital Self-Image Scale (FGSIS). Para a análise estatística, realizou-se o teste de Coeficiente de Correlação de Spearman com 5% de significância para verificar as relações entre a intensidade da dor da DP e os instrumentos SPS-6 e FGSIS. Participaram do estudo 181 universitárias (22,54±4,15 anos), com 6,58±1,97 pontos de média da intensidade da dor nos últimos três meses, classificada como moderada. A média do escore total do SPS-6 foi de 14,85±4,16 pontos, apresentando presenteísmo. Houve correlação negativa moderada significativa entre o escore total do SPS-6 e a intensidade da dor da DP =-0,310 (p<0,0001), ou seja, quanto maior a dor, menor o valor do SPS-6, indicando mais impacto para o presenteísmo. Em relação à autoimagem genital, obteve-se correlação negativa fraca significativa entre o FGSIS e a intensidade da dor da DP =-0,232 (p=0,0017); assim, quanto maior a intensidade da dor, pior é a percepção da autoimagem genital. Conclui-se que a DP teve relação significativa com o presenteísmo, além de haver um impacto na autoimagem genital.
Descritores:
Dismenorreia; Presenteísmo; Genitália Feminina; Menstruação; Autoimagem
RESUMEN
Este estudio tuvo como objetivo verificar la relación de la dismenorrea primaria (DP) con el presentismo y la autoimagen genital de las mujeres universitarias. Se trata de un estudio transversal, de tipo observacional, realizado en el Norte de Brasil en el periodo de enero a mayo de 2023. Se incluyeron a mujeres universitarias de ≥18 años con DP. La intensidad del dolor relacionado con DP se midió mediante la escala numérica de dolor, el presentismo se evaluó mediante la Stanford Presenteeism Scale-6 (SPS-6) y la autoimagen genital mediante la Female Genital Self-Image Scale (FGSIS). Para el análisis estadístico, se realizó la prueba del coeficiente de correlación de Spearman con un 5% de significación para verificar las relaciones entre la intensidad del dolor de DP y los instrumentos SPS-6 y FGSIS. Este estudio incluyó a 181 estudiantes universitarias (22,54±4,15 años), con 6,58±1,97 puntos de intensidad media del dolor en los últimos tres meses, clasificada como moderada. La puntuación media total de SPS-6 fue de 14,85±4,16 puntos presentando presentismo. Hubo una correlación negativa significativamente moderada entre la puntuación total del SPS-6 y la intensidad del dolor de DP = -0,310 (p<0,0001), es decir, cuanto mayor es el dolor, menor es el valor de SPS-6, lo cual indica un mayor impacto en el presentismo. Con respecto a la autoimagen genital, se obtuvo una correlación negativa significativamente débil entre FGSIS y la intensidad de dolor de DP =-0,232 (p=0,0017); por lo tanto, cuanto mayor es la intensidad del dolor, peor es la percepción de la autoimagen genital. Se concluye que la DP tuvo una relación significativa con el presentismo, además de haber un impacto en la autoimagen genital.
Palabras clave:
Dismenorrea; Presentismo; Genitales Femeninos; Menstruación; Autoimagen
INTRODUCTION
Dysmenorrhea consists of uterine pain due to menstrual cramps1. It affects about 67-74% of women2, negatively impacting health and society3. Although a common problem, dysmenorrhea has been belittled, underdiagnosed, and undertreated4),(5. Since a large part of the population considers menstrual pain to be normal, no demand exists for specialized treatment2. Moreover, dysmenorrhea has two types: primary (PD) and secondary (SD)6.
PD consists of menstrual cramps with no pelvic disease4) and a clear physiological etiology6. It occurs during the menstrual cycle as painful uterine cramps in the lower abdomen before or during menstruation accompanied or not by other symptoms, such as dizziness, nausea, general discomfort, and even fainting7. On the other hand, SD consists of menstrual cramps that are associated with a pelvic pathology, such as endometriosis, fibroids, adenomyosis, pelvic adhesions, endometrial polyps, pelvic inflammatory disease, or with intrauterine devices1),(6.
Menstrual pain can affect academic performance, negatively affecting students8, who endure reduced concentration and performance in the classroom3, causing losses of productivity and presenteeism9. Overall, researchers have investigated presenteeism due to the decrease in the quality and productivity of working or academic personnel, damaging companies or education10. Thus, presenteeism consists of individuals’ permanence in their work environment despite the limiting physical or psychological symptoms that can reduce their ability to work11, i.e., even suffering from severe menstrual pain, women remain in their work, school, or university12.
The relationship between dysmenorrhea and genital self-image has received scarce attention. Genital self-image consists of individuals’ perception of their genitals13, a subfield of body image research that captures subjective feelings about one’s own genitalia14),(15. Several studies have investigated genital self-image in several contexts, such as premenopause16, dyspareunia16),(17, vitiligo18, and older age19),(20. However, few studies have investigated the genital self-image of women with dysmenorrhea. Allyn et al.21) have found a lack of knowledge about how women regard their menstrual pain and the ways in which it can affect perceptions and views of themselves and their self-image. Thus, investigating the relationship between dysmenorrhea and genital self-image is important and necessary. Women also increasingly express insecurity and dissatisfaction with the appearance of their genitals, which can negatively influence their physical and psychological health and often trigger sexual dysfunction22),(23.
Academia has great demands and long hours of study and concentration. It is important to investigate whether dysmenorrhea interferes with university students’ academic life. Thus, this study aimed to assess the relationship between PD and presenteeism and genital self-image in university women.
METHODOLOGY
Study design and population
This cross-sectional observational study was carried out in Macapá (Amapá State) with a population of university students living with PD. A 5% (p<0.05) significance level (alpha) and a 0.90 prevalence were considered for sample size based on Bernardino (2020)23, generating a sample size of at least 138 participants24.
Selection criteria and location
Data were remotely collected via Google Forms from January to May 2023. University students older than 18 years with PD (who answered affirmatively the question “Do you have menstrual cramps?”), no pelvic diseases, and previous menstrual cycles in the three months prior who were literate and had access to the internet were included in this study. Women who had no PD, were amenorrheic, pregnant, in postpartum up to 12 months, who breastfed, who were postmenopausal, or used intrauterine devices were excluded from this research.
Data collection instruments
To characterize the sample, an anamnesis form prepared by the authors and adapted according to primary dysmenorrhea guideline25) criteria was used. It contained 36 questions about participants’ sociodemographic, gynecological, and menstrual traits and about the characteristics of their dysmenorrhea. Dysmenorrhea27 intensity was measured by a numerical pain rating scale26 that quantified pain intensity in 10 points under the following classification: 0 = no pain; 1-3 = mild; 4-7 = moderate; and 7-10 = intense28, with 10 being equivalent to the greatest pain imaginable. The guiding questions to investigate this variable were: “How would you rate the intensity of your menstrual cramps over the past three months?” (Pain intensity in the last three months) and “Regarding your menstrual cramps in the last month, what was your pain?” (Pain intensity in the last month).
The Stanford Presenteeism Scale-6 (SPS-6), is a questionnaire that has been translated, adapted, and validated for Portuguese29 to assess presenteeism and individuals’ ability to avoid distraction and complete tasks to achieve work productivity was used to investigate presenteeism. This instrument has a field in each question that must be filled out with the health problem to be evaluated. Thus, in this research, such space was filled with the term “Menstrual cramps.” The SPS-6 has six questions on a five-point Likert scale ranging from one to five (from “I totally disagree” to “I totally agree”). The total score is calculated by the sum of each question, which can range from six to 30 points; the higher the score, the better the labor productivity, and the lower the score, the greater the presenteeism, indicated by total scores from six to 18 points30),(31. Moreover, the SPS-6 has two domains: the score of the “Ability to concentrate” domain stems from the sum of questions 1, 3, and 4 (evaluating individuals’ perception of their ability to focus on their work); in this domain, the score is reversed: 1=5, 2=4, 3=3, 4=2, and 5=132. The other domain is “Performing and completing tasks,” with a score obtained by the sum of questions 2, 5, and 6, which evaluates the result of the work32.
The Female Genital Self-Image Scale (FGSIS), which has been validated for Brazilian women by Arruda et al.33, was used to assess genital self-image. It analyzes genital self-image in seven items, assessing women’s feelings and beliefs about their genitals using a four-point response scale ranging from “Strongly agree” to “Strongly disagree.” Its score is obtained by summing the seven items. It can range from 7 to 28, in which higher scores indicate a more positive genital self-image33),(34.
Statistical analysis
The data were tabulated on Excel. The statistical analysis was performed on R (version 4.2.1). To analyze volunteers’ sociodemographic, gynecological, and menstrual profile and the characteristics of their dysmenorrhea, the qualitative variables are described by frequency distribution and their percentages. Means and standard deviations were used for quantitative variables. The correlations between the FGSIS and SPS-6 and pain intensity were evaluated by Spearman’s correlation coefficient according to the following classification: weak (−0.29≤≤−0.10), moderate (−0.49≤≤−0.30) or strong (−1.00≤≤−0.50)35. Data normality was assessed by the Shapiro-Wilk test. A 5% significance level was used in all tests.
RESULTS
A total of 181 female students from various undergraduate courses who reported PD participated in this research, 105 (58.01%) from Biological and Health Sciences courses, 55 (30.39%) from Social and Human sciences courses, and 21 (11.60%) from Exact and Technological Sciences courses. The classification of pain intensity was, on average, moderate. Table 1 characterizes the sample.
Regarding presenteeism, assessed by the total score of the SPS-6, the sample had a mean of 14.85±4.16 points, meaning that dysmenorrhea affects academic productivity since the lower the score, the greater individuals’ presenteeism. Regarding the “Concentration capacity” domain of the SPS-6, the sample obtained a mean of 4.94±2.18. In the “Performing and completing tasks” domain, the average totaled 9.91±2.86. Table 2 shows the analysis of the correlation between pain intensity and SPS-6 scores.
Regarding genital self-image, assessed by the FGSIS total score, the sample had a mean of 20.12±4.50 points, indicating that the participants have a positive genital self-image. Moreover, the analysis of the correlation between the total FGSIS score and dysmenorrhea intensity in the past three months and in the last month obtained a weak and significant negative correlation =−0.154 (p=0.0387) and =−0.232 (p=0.0017), respectively. In other words, the greater the intensity of the pain, the worse the perception of genital self-image.
DISCUSSION
This study found a moderate significant correlation in its analyses between the total SPS-6 score and pain intensity in the last three months, and significant but weak correlations in “Ability to concentrate” and “Performing and completing tasks.” Regarding genital self-image, weak and significant negative correlations were found in the correlation analysis between pain intensity and FGSIS.
In this study, students showed presenteeism, indicated by values from six to 18, since the mean total score of the SPS-6 equaled 14.86 points30, showing a drop in the performance of academic activities. Moreover, presenteeism had a significant moderate-negative relationship with PD, i.e., the greater the pain of dysmenorrhea, the worse the results for presenteeism. A cohort study36 in the Netherlands with 32,748 women aged 15 to 45 years pointed out that 80.7% (n=26,438) of interviewees reported presenteeism and decreased productivity at school or work. A similar result occurred in a cross-sectional study by Cook and Hoek12) with 668 women with dysmenorrhea, which With the support of German and Dutch associations, the authors carried out an online survey and identified that the intensity of menstrual pain was associated with presenteeism β=0.27 (p<0.01), which confirms that people with dysmenorrhea often engage in presenteeism, corroborating our study.
In the analysis by SPS-6 domain, the students showed significant weak negative correlation values, i.e., the higher the pain intensity, the worse their “Ability to Concentrate.” Similarly, Abreu-Sánchez et al.37, which aimed to find the degree of interference of dysmenorrhea in daily life and the impact on academic performance among Spanish nursing students (n=261), reported that 47.8% of participants with PD had a lack of concentration in class or work due to this problem. The systematic review with meta-analysis by Armour et al.2 investigated the impact of dysmenorrhea on academic performance and school activities, pointing out that 40.9% of the samples were negatively affected (n=5,126; 95% CI: 28.3-54.9) in performance or ability to concentrate in the classroom.
The SPS-6 domain “Performing and completing tasks” showed a significant weak negative relationship with pain in the last three months, showing that the greater the pain, the worse the score for this domain. Thus, pain affects the performance and completion of tasks. The cross-sectional online research in European, Asian, and African countries by Schoep et al.9 with 42,819 women aged 15 to 45 years reported that, during the menstrual period, 38.4% (n=16,481) of them reported performing fewer regular daily activities or being unable to do any activity during menstruation. The authors concluded that one in three women abandons their daily activities due to menstrual symptoms9. Moreover, Godoy38 considered the level of complexity of the task since such impact may be related to focus and concentration. Therefore, performing tasks that require less concentration under symptoms of dysmenorrhea can configure a way to reduce productivity loss38.
Regarding genital self-image and dysmenorrhea, this study found an average positive self-image according to the FGSIS. However, correlating pain intensity with FGSIS showed that the greater the pain, the worse the perception of genital self-image. According to Komon et al.39 cultural, biological, and psychological factors can affect female genital self-image. Thus, perceived pain can alter genital self-image, according to our findings. Although Somavilla et al.40, who investigated genital self-image, sexual function, and pelvic floor discomfort in young female university students during the COVID-19 pandemic did not included dysmenorrhea as a variable in their study, the authors pointed out that improved genital self-image was associated with fewer pelvic symptoms (colorectal disorders, urinary disorders, and pelvic floor discomfort)40.
As a strength of this research, this is the first study to add information on genital self-image in women with PD. Moreover, the studied population lived in Northern Brazil, whereas most studies have been conducted in other regions of the country. The limitation of the study refers to its exclusive inclusion of women with internet access as this was an online study. Another limitation is that PD status was based on participants’ self-report rather than on confirmatory medical diagnosis. Moreover, it included no analysis on SD. Therefore, further studies are suggested to investigate and compare SD with PD.
Understanding the relationships between PD, presenteeism, and genital self-image becomes important in physical therapy since clinical physical therapists must assist patients in their entirety, paying attention to the management of PD in its multiple facets.
FINAL CONSIDERATIONS
In the sample studied, PD showed a moderately significant relationship with presenteeism, evaluated by the SPS-6. Moreover, the domains “Ability to concentrate” and “Performing and completing tasks” also suffered the impact of PD, and the higher the intensity of pain, the worse the performances. Our findings provide additional knowledge about female genital self-image and PD, indicating that the greater the intensity of pain, the worse the perception of genital self-image.
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Funding source:
nothing to declare
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Study carried out at the Federal University of Amapá (UNIFAP) - Macapá (AP), Brazil
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Approved by the Research Ethics Committee of the Federal University of Amapá (UNIFAP) under CAAE No. 65165022.6.0000.0003.
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Data Availability:
The data underlying this study are available in the published article .
Edited by
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Responsible editor:
Sônia LP Pacheco de Toledo
