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Prevalence of Pain Symptoms Suggestive of Endometriosis Among Finnish Adolescent Girls (TEENMAPS Study)
Accepted Manuscript Prevalence of Pain Symptoms Suggestive of Endometriosis Among Finnish Adolescent Girls (TEENMAPS study) P.A. Suvitie, MD, M.K. Hallamaa, MD, J.M. Matomäki, MSc, J.I. Mäkinen, Prof., A.H. Perheentupa, MD, PhD PII:
S1083-3188(15)00261-2
DOI:
10.1016/j.jpag.2015.07.001
Reference:
PEDADO 1874
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 6 May 2015 Revised Date:
26 June 2015
Accepted Date: 1 July 2015
Please cite this article as: Suvitie PA, Hallamaa MK, Matomäki JM, Mäkinen JI, Perheentupa AH, Prevalence of Pain Symptoms Suggestive of Endometriosis Among Finnish Adolescent Girls (TEENMAPS study), Journal of Pediatric and Adolescent Gynecology (2015), doi: 10.1016/ j.jpag.2015.07.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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PREVALENCE OF PAIN SYMPTOMS SUGGESTIVE OF ENDOMETRIOSIS
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AMONG FINNISH ADOLESCENT GIRLS (TEENMAPS study)
3 4 P.A. Suvitie MD1,2,4,*, M.K. Hallamaa MD1,2, J.M. Matomäki MSc3, J. I. Mäkinen Prof.1,2,
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and A. H. Perheentupa MD, PhD1,2,4
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Finland
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Department of Obstetrics and Gynecology, Turku University Hospital, FI-20520 Turku,
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Department of Obstetrics and Gynecology, University of Turku, FI-20520 Turku, Finland
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Department of Pediatrics, Turku University Hospital, FI-20520 Turku, Finland
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Department of Physiology, Institute of Biomedicine, University of Turku, FI-20520 Turku,
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Finland
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*Correspondence: Pia Suvitie, MD, Department of Obstetrics and Gynecology, Turku
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University Hospital, Kiinamyllynkatu 4-8, FI-20520 Turku, Finland; Phone: +358 2
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3130917; fax +358 2 3132340; E-mail address: [email protected]
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Study Objective: To evaluate the prevalence of pain symptoms suggestive of endometriosis
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among adolescent girls aged 15-19 years.
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Design: Cross sectional study.
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Setting: University Hospital.
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Participants: Adolescent girls aged 15-19 years attending elementary school, high school or
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vocational institute at three cities in Southwest Finland in 2010-2011.
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Interventions: The school nurses distributed a detailed questionnaire to 2582 girls attending
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school at the time of the study. Answering was voluntary and anonymous.
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Main Outcome Measures: Prevalence and severity of dysmenorrhea, acyclic abdominal
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pain, dyspareunia, dyschezia and dysuria. Severity was evaluated with 11-point numerical
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rating scale (NRS).
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Results: A total of 1103 eligible answers were analyzed. The prevalence of dysmenorrhea
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was 68% with mean NRS of 7.0 (SD 2.0). Acyclic abdominal pain, dyspareunia, dyschezia
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and dysuria were less frequent (19%, 12%, 8% and 5%, respectively). The prevalence of
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severe dysmenorrhea (NRS 8-10) was 33%. Severe dysmenorrhea was associated with
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increased risk of concurrent acyclic abdominal pain (OR 2.7, 95% CI 2.0-3.6), dyschezia
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(OR 2.5, 95% CI 1.6-3.9) and regular absenteeism from school or hobbies (OR 10.0, 95% CI
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4.2-23.6). By using different criteria, 2-10% of all girls could be identified as having
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symptoms suggestive of endometriosis. Five percent of girls (n=53) had severe
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dysmenorrhea, used OC and reported inadequate relief of pain medication.
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Conclusions: One third of 15-19 year old girls have severe menstrual pain and 14% of them
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are regularly absent from school or hobbies. Five percent of all teenage girls are poor
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responders to conventional therapy for primary dysmenorrhea.
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Keywords: adolescent, dysmenorrhea, endometriosis, pain symptoms, epidemiology
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Introduction
44 Endometriosis in adolescence is a poorly recognized and understood disease.1 It is likely to
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appear after puberty, induced by ovarian estrogen synthesis.2 The majority of endometriosis
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patients (66-67%) experience the onset of symptoms before the age of 20.3 Laparoscopy is
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the golden standard for the diagnosis of endometriosis. However, it is an invasive procedure
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and should be offered to adolescents only with the aim of surgical treatment when medical
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therapy with non-steroidal anti-inflammatory drugs (NSAID) and cyclic or continuous
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combined oral contraceptives or progestin has failed.4 At present, the diagnosis by
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laparoscopy is obtained with an average delay of 6.7 years after the onset of symptoms 5, and
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the mean age at first surgery is typically 29.6–35.8 years.5-8
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Severe menstrual pain is the most typical symptom of endometriosis. Among adolescent
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girls the prevalence is reported to be 8-33%9-13, and the increasing severity is associated with
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interference with life activities, social relationships and school attendance.9 Principally, such
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symptoms are considered as primary dysmenorrhea and treated with NSAID and/or oral
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contraceptives.14 When medical therapy offers insufficient symptom alleviation, a suspicion
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for endometriosis should be raised and adequate clinical assessment offered.4
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Adolescent girls wait three times longer before seeking help for their symptoms suggestive
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of endometriosis as compared with women with adult onset of symptoms (6.0 ± 0.2 vs. 2.0 ±
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0.3 years, p<0.001).7 In addition, adolescents typically first contact primary health care units
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instead of specialist care, and this is associated with a longer delay probably due to
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insufficient recognition of endometriosis.5,
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These two characteristics of adolescents
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endometriosis patients may hamper timely diagnosis and treatment, and thus, cause
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unnecessary suffering and reduced quality of life. 9, 15
69 Adolescents with endometriosis typically have both cyclic and acyclic abdominal pain.15-20
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In adult endometriosis the typical symptoms are dysmenorrhea, chronic abdominal or pelvic
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pain, dyspareunia, dyschezia and bladder pain.21, 22 All these pain symptoms15, 20 as well as
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all ASRM stages23 and disease types, i.e. peritoneal, ovarian and deep endometriosis, have
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been confirmed in adolescent patients.19, 20, 24, 25 However, no previous study has evaluated
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the prevalence and severity of these five pain symptoms among general adolescent
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population.
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The aim of this study was to estimate how common and severe pain symptoms suggestive of
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endometriosis are among general adolescent female population. We also evaluated the
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characteristics of menstruation with special interest on dysmenorrhea related medication,
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absenteeism from school or hobbies and family history of endometriosis.
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Materials and methods
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This cross sectional questionnaire study was designed and organized at the Department of
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Obstetrics and Gynaecology at Turku University Hospital, Finland. The target population
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was the 15-19 year old girls attending elementary school, high school or vocational institute
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at the cities of Turku, Lieto and Kaarina in Southwest Finland. The study was named
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TEENMAPS according to “Teenage Menstrual and Abdominal Pain Symptoms”.
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We designed a 49-point questionnaire to be used in this study, focusing on menstrual
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characteristics and pain symptoms suggestive of endometriosis, i.e. dysmenorrhea, acyclic
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abdominal pain, dyspareunia, dyschezia and dysuria. The participants were asked whether
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they “presently have” any of the pain symptoms. They estimated the severity of each pain
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symptom “at it´s worst” by completing an 11-point (0-10) numerical rating scale (NRS) with
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0 meaning “no pain” and 10 meaning, “pain as bad as you can imagine”. NRS pain scores
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were further divided into three categories: mild (1-4), moderate (5-7) and severe (8-10) pain.
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These cut offs were chosen based on recent findings of pain scale perception among 2982
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adolescents aged 11-17 years.26 The participant’s satisfaction of overall general health was
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evaluated similarly with NRS, 0 meaning, “totally unsatisfied” and 10 meaning “totally
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satisfied”. The questionnaire was available in both official languages in Finland, Finnish and
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Swedish.
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The original estimated study population was 3814 based on figures received from school
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health nurses working in the participating schools. In Turku the data was collected during
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spring 2010 and in the cities of Lieto and Kaarina in spring 2011, when the secondary school
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graduates were no longer attending school. Thus, the majority of the oldest age group was
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not reached. The school nurses delivered altogether 2582 questionnaires to the participants,
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and this was considered the initial study population. Participation was voluntary and
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anonymous. The school nurses were allowed to decide whether to initiate the study in the
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classroom or to let participants fill in the questionnaire at home and return it in a sealed
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envelope.
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Statistical analyses
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Analyses were performed using PASW Statistics 19 software (SPSS Inc., IBM, Chicago,
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USA). The baseline clinical characteristics were compared using Chi-Square Test or Two-
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sample T-test, as appropriate. Chi-Square Test for Trend was used to analyze dysmenorrhea
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prevalence and severity according to age or time since menarche. T-test was used to compare
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pain severities (NRS) between different subgroups, since the variables were normally
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distributed. P-value <0.05 was considered statistically significant. Correlations between
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variables were analyzed by Spearman’s correlation coefficient. To evaluate the effect size of
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selected variables, we computed the odds ratio (OR).
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The incidence of each parameter was calculated based on the answers received for each
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question (valid %). The number of answers received for each question varied to some
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degree.
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129 Ethical Approval
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The Ethics Committee of Hospital District of Southwest Finland approved the study
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protocol. As the participation was voluntary and anonymous, the completion of the
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questionnaire was considered as consent.
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Results
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Characteristics of the study population
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Response rate
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The number of distributed questionnaires was 2582 and 1117 of those were returned. The
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overall response rate, thus, was 43% and it varied greatly between the schools (0-100%) and
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the cities (Lieto 24%, Turku 41% and Kaarina 91%). Fourteen responses were excluded
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because the age criterion was not fulfilled or the age was not given. Thus, 1103 answers
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were included in the statistical analysis.
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Because of the lower response rates in Turku and Lieto, we first compared the main
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parameters of interest (prevalence and severity of pain symptoms, smoking, BMI and OC
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use) between the participating cities. However, no statistically significant differences were
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found, while the participants in Kaarina were somewhat younger than the girls in the other
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two cities (mean age 16.5 vs. 16.8, p<0.001).
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Clinical characteristics
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The mean age of the participants was 16.8 years. The mean age at menarche was 12.6 years
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(range 9-16) and only two girls reported not having menses yet. The mean BMI was normal
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(21.5, range 15.4-59.9), and the BMI did not correlate with the prevalence of pain
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symptoms. However, higher BMI correlated negatively with the perception of general health
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(r=-0.21, p<0.001). A quarter of the participants were at least occasional smokers and 10.7%
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smoked regularly. Smokers were less satisfied with their general health than non-smokers
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(mean NRS 7.4 vs. 8.1, p<0.001). The percentage of smokers increased with age (p=0.01 for
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trend). Smoking was not a risk factor for severe dysmenorrhea (p=0.84). The clinical
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characteristics of the participants are presented in Table 1.
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Only 23% of all participants (n=245) were familiar with the word endometriosis and 2.7%
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reported having a first-degree relative with the disease. However, in 53% the family history
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of endometriosis was unknown. Two participants reported being previously operated for
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endometriosis and both had moderate dysmenorrhea (NRS 7).
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The prevalence of dysmenorrhea was 67.6% (n=738/1092). Thirty-two percent
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(n=354/1089) had no menstrual pain, 9% (n=101/1089) had mild pain, 26% (n=279/1089)
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moderate pain and 33% (n=355/1089) severe pain (Figure 1). When dysmenorrhea was
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present, the mean NRS was 7.0 (SD 2.0). The duration of menstrual pain was typically 1-2
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days (86%), but in 14% of the girls it lasted for 3 or more days (n=102/726, 9.2% of all
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participants). The increasing severity of dysmenorrhea (NRS 0-10) correlated negatively
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with the participant’s conception of general health measured with NRS (r=-0.13, p<0.001).
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Nearly 16% of participants with dysmenorrhea (15.8%, n=116/733) had visited a doctor and
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83.1% (n=557/670) had spoken about dysmenorrhea symptoms to their family members.
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We further compared the clinical characteristics between girls with severe dysmenorrhea and
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girls with absent, mild or moderate dysmenorrhea (Table 1). Girls who reported severe
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dysmenorrhea had more often an irregular menstrual cycle (≠ 23-35 days; p=0.016) as
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compared with girls not having severe menstrual pain. Both these groups used OC as often,
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but girls with severely painful periods had dysmenorrhea or menorrhagia as one indication
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for OC use more often (p=0.001 and p=0.003, respectively).
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The prevalence of dysmenorrhea increased with age (p=0.041 for trend). Subsequently, we
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calculated the time since menarche and divided it into four categories: 0-1, 2-3, 4-5 and 6-10
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years since menarche. When the prevalence of dysmenorrhea and severe dysmenorrhea were
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analyzed accordingly, a more pronounced rising trend was noticed (p=0.002 and p<0.001 for
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trend, respectively; Figure 2). Similarly, the mean NRS of dysmenorrhea increased with time
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since menarche (p<0.001 for trend).
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Eighty percent of girls (n=588/735) who had dysmenorrhea used pain medication for their
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complaint, mostly NSAIDs, and 18% (n=106) of those girls needed medication for three
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days or longer (Figure 1). Surprisingly, in 43% (n=253) the medication offered only little or
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no relief at all. Unfortunately, the dosage was not recorded, and thus, we could not evaluate
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wheather the dosing was appropriate.
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Other pain symptoms
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Dyspareunia, dyschezia and dysuria were quite rare symptoms, while acyclic abdominal pain
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was more commonly reported (Table 2a). Interestingly, girls with severe menstrual pain had
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an increased risk of having concomitant acyclic abdominal pain and dyschezia (Table 2a). In
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addition, girls with severe dysmenorrhea experienced more severe acyclic abdominal pain
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compared with girls with absent or less severe menstrual pain (Table 3). The correlation
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between severe dysmenorrhea and acyclic abdominal pain and dyschezia remained
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significant, when only girls not using OC were included (Table 2b).
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Nearly half of the participants (45.7%, n=498/1090) had experienced at least one
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intercourse, and 43.6% (n=217) of them had felt pain during the first intercourse. Thirty-
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seven percent of the participants (n=406/1090) reported having intercourse’s sporadically
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(more than three times) or regularly, and 11% (n=45) of them reported having pain during
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intercourse repeatedly.
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The prevalence of acyclic abdominal pain, dyspareunia and dysuria, but not dyschezia,
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increased with age (p=0.028, p=0.02, p=0.012, and p=0.082 for trend, respectively). When
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these symptoms were evaluated according to years since menarche, the prevalence of
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dyschezia and dysuria, but not acyclic abdominal pain and dyspareunia, increased
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significantly with longer time since menarche (p=0.003, p=0.001, p=0.37 and p=0.08 for
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trend, respectively).
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Oral contraceptive pill use
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OC were commonly used among schoolgirls (Table 1), and the number of OC users
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increased with years since menarche (0-1 years 16.7%, 2-3 years 23.6%, 4-5 years 37.1%
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and 6-10 years 42.7%). Contraception was the most common indication for OC use (Table
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1). Furthermore, dysmenorrhea was one of the indications in 61.4% of the girls (n=151, 14%
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of all participants). Surprisingly, the prevalence and the severity (mean NRS) of
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dysmenorrhea were similar in OC users and non-users, 63.8% vs. 68.9% (p=0.10) and 7.0
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vs. 7.0 (p=0.65), respectively.
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Absenteeism from school or hobbies
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Half of the girls who suffered from dysmenorrhea reported absenteeism from school or
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hobbies because of menstrual pain (49.9%, n=368/738; Figure 1), and eight percent
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(n=55/738, 5% of all participants) were absent regularly, i.e. monthly or during most
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months. The severity of dysmenorrhea (mild, moderate, severe) correlated positively with
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the risk of absenteeism (never/seldom vs. most months/monthly, p<0.001 for trend). Mild
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dysmenorrhea was not related to absenteeism while moderate and severe dysmenorrhea
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caused regular absenteeism in 2.2% (6/279) and 13.8% (49/355), respectively. Girls with
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severe dysmenorrhea had an increased risk for regular absenteeism as compared with girls
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with mild or moderate pain (Table 1)
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Sixteen girls using OC for menstrual pain still reported regular absenteeism from school or
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hobbies. When the menstrual pain lasted for 3 or more days the girls were more often
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regularly absent when compared with pain duration of 1-2 days (16.7% vs. 5.9%, p<0.001).
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Risk groups with symptoms suggestive of endometriosis
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We calculated the proportions of girls with symptoms suggestive of endometriosis among
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the whole study population using different anamnestic criteria (Table 4). A subgroup of 53
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girls with severe dysmenorrhea (4.8 % of entire study population) was considered as poor
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responders for medical therapy (using OC and reporting inadequate effect of pain
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medication). However, we did not ask whether these girls used cyclic or continuous OC.
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Fifty-nine girls needed painkillers for at least 3 days but the drug helped only little (n=55) or
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not at all (n=4).
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Forty-nine participants (4% of all girls) presented with severe dysmenorrhea and were absent
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from school or hobbies monthly or most months. Half of them had visited a doctor (n=26),
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21 used OC and all except one used pain medication for their complaint. Yet, 24 girls
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reported inadequate relief of pain with the medication, only three reported being suspected
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for endometriosis and none had been operated.
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The subgroup of 23 girls who reported having endometriosis or suspicion of the disease was
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comparable to the overall study population in severity of dysmenorrhea, acyclic abdominal
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pain, dyspareunia, dyschezia and dysuria. Furthermore, there were no significant differences
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in duration of dysmenorrhea, effectiveness and duration of pain medication, OC use or in the
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frequency of absenteeism from school or hobbies. A positive correlation was detected
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between known or suspected endometriosis and a positive family history (p<0.001).
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Discussion
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In the present study we evaluated the prevalence of pain symptoms that are often considered
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suggestive of endometriosis among 15-19 year old schoolgirls living in three cities in
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Southwest Finland by using an anonymous and voluntary questionnaire. As expected,
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dysmenorrhea was a common symptom (68%). Severe dysmenorrhea was reported by one
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third (33%) of all girls and they had a 10-fold risk of regular absenteeism from school or
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hobbies due to dysmenorrhea compared with girls with mild or moderate pain. Other pain
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symptoms i.e. acyclic abdominal pain, dyspareunia (among girls with > one intercourse),
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dyschezia and dysuria were less frequent (19%, 12%, 8% and 5%, respectively). Girls with
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severe menstrual pain presented with significantly increased risk of concomitant acyclic
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abdominal pain and dyschezia. Possibly, this clustering of pain symptoms could indicate the
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evolvement of endometriosis at least in part of these participants.
292 The number of participants (n=1103) was high, and represents approximately 29% of the
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whole population of 15-19 year old girls living in this area. The overall response rate was
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43% among girls present at school during the initiation of the study, and it varied greatly
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between the schools (0-100%) and the three cities (Lieto 24%, Turku 41% and Kaarina
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91%). The nurse in each school was given freedom in organizing the distribution and
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collection of the questionnaires. Varying enthusiasm of each nurse to motivate the girls to
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take part was considered to be the strongest underlying reason for these high differences.
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Secondly, the option of initiating the study either at school or at home probably influenced
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the response rate. Although there were no significant differences in measured main
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parameters between the cities, we cannot completely rule out some degree of selection bias.
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Primary dysmenorrhea is a very common symptom. In publications from the 1950s and
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1960s the prevalence varied between 5 and 50%, and in Finland it was reported to be 54% in
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1971 among 5155 participants.27 In recent cohort studies with large sample sizes, the
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prevalence has been 68-93%. 9, 12, 13, 28, 29
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In our study, the prevalence of dysmenorrhea increased with years since menarche (p=0.002
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for trend; Figure 2). Similarly, two previous studies have reported an increase in
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dysmenorrhea prevalence with increasing time since menarche.11, 30 In addition, in one study
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dysmenorrhea frequency increased during the first three postmenarcheal years and decreased
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thereafter.31 However, no statistics were provided in these previous publications. The
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increasing prevalence is likely explained by the fact that primary dysmenorrhea is related to
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ovulatory cycles and it may take up to 2-3 years to obtain regular ovulations.32 However, the
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increase several years after menarche, as described in this study and by two other authors11,
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girls.
, may also be partly explained by the onset of symptomatic endometriosis in a subgroup of
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The prevalence of severe dysmenorrhea has been widely studied. In a recent similar large
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cross-sectional study from Australia, the prevalence of severe menstrual pain (NRS 8-10)
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was 21% (n = 217/1051) among 15-19 year old girls.9 In agreement with our study,
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Banikarim et al.12 reported 33% prevalence of severe dysmenorrhea among Hispanic
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American girls (n=234/706) with mean age of 16 years by using visual analogue scale (VAS,
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no cut-off levels mentioned). In other studies from Sweden, USA, Finland and Singapore,
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severe menstrual pain has been reported to occur in 8%-20% of all responders. In these
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studies mostly a verbal rating scale (VRS) was used. 10, 11, 13, 30
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Oral contraceptive pills were commonly used among teenagers in our study (31%). Majority
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of users needed contraception (73%) and 61% reported dysmenorrhea as one indication for
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OC use. Contrary to our preconception, dysmenorrhea prevalence and severity were equal
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between OC users and non-users (64% and 69%, mean NRS 7.0 and 7.0, respectively).
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Possibly some OC users had severe dysmenorrhea before starting OC and the treatment had
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either erased this symptom or decreased its severity. Unfortunately, the questionnaire did not
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evaluate the effectiveness of OC treatment for painful periods.
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Similarly to our data, Teperi and Rimpelä11 did not observe any difference in dysmenorrhea
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prevalence between OC-users and non-users in sixteen and eighteen year old Finnish girls
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(n=1155 and n=1170, respectively). In contrast, in the study of Andersch and Milsom10 from
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Sweden, the prevalence and severity of dysmenorrhea were significantly reduced (p<0.01)
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among OC users (n=270) as compared with non-users (n=306).
342 We calculated the proportions of girls at risk of having endometriosis among all 1103
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participants based on suggestive pain symptoms and anamnestic factors (Table 4). Five
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percent of participants (n=53) had severe dysmenorrhea and used both OC and NSAIDs with
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inadequate response. Of those, twenty-one (2% of all participant) were absent from school or
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hobbies monthly or most months. Parker et al.9 obtained similar results. They reported a 5%
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prevalence of severe menstrual pain while using OC and pain medication among girls at the
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age of 15-19 years. Furthermore, in a previous Finnish study, 3% of sixteen and eighteen
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year old girls used pain medication and were repeatedly absent from school due to
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dysmenorrhea.11
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According to the ESHRE guideline, diagnostic/therapeutic laparoscopy should be offered to
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adolescents, if their pain symptoms suggestive of endometriosis are not sufficiently
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alleviated with medical treatment.4 However, in many cases proper information on dosing
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and timing of NSAID use and changing from cyclic to continuous use of OC would lead to
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sufficient response. The probability of finding visually confirmed endometriosis in
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adolescents with chronic pelvic pain (CPP) not responding to medical treatment has been
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reported to be high, i.e. 75%.25 According to such estimation, laparoscopy in our study
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population would identify 40 girls with endometriosis. This hypothetical assumption would
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lead to a minimum of 3.6% incidence of symptomatic adolescent endometriosis.
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One previous study9 has reported the rates of dyspareunia, dyschezia and dysuria in a general
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adolescent population, and the prevalence’s were comparable to those observed in our study
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(13% vs. 12%, 12% vs. 8% and 10% vs. 5%, respectively). However, in this study the
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prevalence of acyclic abdominal pain was not reported.
367 Adolescents with endometriosis present similar symptoms as adult patients. In a recent
369
cohort of seventeen adolescents with histologically proven endometriosis, the most common
370
pain symptoms were dysmenorrhea (82%), chronic pelvic pain (77%), dyschezia (77%) and
371
bladder pain (53%), while dyspareunia was not as common (18%).20 In another cohort of 63
372
adolescent endometriosis patients, the most common reasons for hospital visits were cyclic
373
(71%) and chronic pelvic pain (21%).19 In our study, 2.5% of all girls had dysmenorrhea
374
combined with dyschezia and acyclic abdominal pain.
M AN U
SC
RI PT
368
375
Adolescent dysmenorrhea impacts many aspects of social life and this should not be
377
underestimated. Severe dysmenorrhea interferes with school attendance, hobbies, social
378
relationships as well as sexual activity.9, 33 Similarly, adolescent endometriosis impacts the
379
quality of life15 and medical and surgical therapies relieve pain symptoms and improve
380
quality of life.21 Yet, symptomatic adolescents don´t actively seek for help.7 More resources
381
should be invested into the active detection of the girls with notable symptoms, and
382
professional evaluation and proper care should be offered when required.
EP
AC C
383
TE D
376
384
In conclusion, this study shows that 5% of 15-19 year old adolescent girls in Finland suffer
385
from severe dysmenorrhea not responding to medical therapy. Furthermore, 5% of
386
participants had severe dysmenorrhea and were absent from school monthly or most months.
387
Whereas the majority of girls with dysmenorrhea used pain medication, only 57% obtained
388
satisfactory relief for their symptoms. Girls with severe dysmenorrhea had an increased risk
389
of concomitant chronic abdominal pain and dyschezia. These findings clearly suggest that
17
ACCEPTED MANUSCRIPT 390
teenagers have significant symptoms suggestive of endometriosis and that they receive
391
inadequate attention and treatment. Further research is needed to evaluate how well these
392
symptoms correlate with the presence of endometriosis.
393 Acknowledgements
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394 395
We wish to warmly thank all the enthusiastic school nurses and teachers for their invaluable
397
contribution during the data collection.
SC
396
399
Funding
400
M AN U
398
The PhD study of P.S. was supported by the Government Research Foundation (EVO
402
funding) and the National Graduate School of Clinical Investigation, Finland. A.P. was
403
supported by EVO funding.
404 405
References
406
1.
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Brosens I, Gordts S, Benagiano G. Endometriosis in adolescents is a hidden, progressive and severe disease that deserves attention, not just compassion. Hum
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Reprod. 2013;28:2026-2031.
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2.
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Batt RE, Mitwally MF. Endometriosis from thelarche to midteens: pathogenesis and
prognosis, prevention and pedagogy. J Pediatr Adolesc Gynecol. 2003;16:337-347.
3.
412 413
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ACOG. ACOG Committee Opinion. Number 310, April 2005. Endometriosis in adolescents. Obstet Gynecol. 2005;105:921-927.
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Dunselman GA, Vermeulen N, Becker C, et al. ESHRE guideline: management of women with endometriosis. Hum Reprod. 2014;29:400-412.
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5.
Nnoaham KE, Hummelshoj L, Webster P, et al. Impact of endometriosis on quality
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of life and work productivity: a multicenter study across ten countries. Fertil Steril.
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2011;96:366-373.e368.
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6.
Liu X, Yuan L, Shen F, Guo SW. Patterns of and factors potentially influencing the age at first surgery for women with ovarian endometriomas. Gynecol Obstet Invest.
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2008;66:76-83.
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7.
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Greene R, Stratton P, Cleary SD, Ballweg ML, Sinaii N. Diagnostic experience among 4,334 women reporting surgically diagnosed endometriosis. Fertil Steril.
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2009;91:32-39. 8.
Gylfason JT, Kristjansson KA, Sverrisdottir G, Jonsdottir K, Rafnsson V, Geirsson
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RT. Pelvic endometriosis diagnosed in an entire nation over 20 years. Am J
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Parker MA, Sneddon AE, Arbon P. The menstrual disorder of teenagers (MDOT) study: determining typical menstrual patterns and menstrual disturbance in a large
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Teperi J, Rimpelä M. Menstrual pain, health and behaviour in girls. Soc Sci Med. 1989;29:163-169.
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Andersch B, Milsom I. An epidemiologic study of young women with dysmenorrhea.
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Banikarim C, Chacko MR, Kelder SH. Prevalence and impact of dysmenorrhea on
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Agarwal A, Venkat A. Questionnaire study on menstrual disorders in adolescent girls in Singapore. J Pediatr Adolesc Gynecol. 2009;22:365-371.
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Harel Z. Dysmenorrhea in adolescents and young adults: an update on
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pharmacological treatments and management strategies. Expert Opin Pharmacother.
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Roman J. Adolescent endometriosis in the Waikato region of New Zealand--a comparative cohort study with a mean follow-up time of 2.6 years. Aust N Z J Obstet
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Gynaecol. 2010;50:179-183. 16.
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Health Care. 1980;1:37-41. 17.
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Goldstein DP, De Cholnoky C, Emans SJ. Adolescent endometriosis. J Adolesc
Reese KA, Reddy S, Rock JA. Endometriosis in an adolescent population: the Emory experience. J Pediatr Adolesc Gynecol. 1996;9:125-128.
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Laufer MR, Goitein L, Bush M, Cramer DW, Emans SJ. Prevalence of endometriosis
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Pediatr Adolesc Gynecol. 1997;10:199-202. 19.
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Yang Y, Wang Y, Yang J, Wang S, Lang J. Adolescent endometriosis in china: a
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retrospective analysis of 63 cases. J Pediatr Adolesc Gynecol. 2012;25:295-299. 20.
Yeung P, Sinervo K, Winer W, Albee RB. Complete laparoscopic excision of endometriosis in teenagers: is postoperative hormonal suppression necessary? Fertil
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Steril. 2011;95:1909-1912, 1912.e1901. 21.
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Johnson NP, Hummelshoj L, Consortium WESM. Consensus on current management
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of endometriosis. Hum Reprod. 2013;28:1552-1568.
22.
Fauconnier A, Staraci S, Huchon C, Roman H, Panel P, Descamps P. Comparison of
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patient- and physician-based descriptions of symptoms of endometriosis: a
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qualitative study. Hum Reprod. 2013;28:2686-2694.
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23.
ASRM. Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril. 1997;67:817-821.
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Stavroulis AI, Saridogan E, Creighton SM, Cutner AS. Laparoscopic treatment of endometriosis in teenagers. Eur J Obstet Gynecol Reprod Biol. 2006;125:248-250.
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Janssen EB, Rijkers AC, Hoppenbrouwers K, Meuleman C, D'Hooghe TM. Prevalence of endometriosis diagnosed by laparoscopy in adolescents with
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dysmenorrhea or chronic pelvic pain: a systematic review. Hum Reprod Update.
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2013;19:570-582.
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26.
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Hirschfeld G, Zernikow B. Cut points for mild, moderate, and severe pain on the VAS for children and adolescents: what can be learned from 10 million ANOVAs?
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Pain. 2013;154:2626-2632. 27.
473 474
Widholm O. Dysmenorrhea during adolescence. Acta Obstet Gynecol Scand Suppl.
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1979;87:61-66. 28.
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Eryilmaz G, Ozdemir F, Pasinlioglu T. Dysmenorrhea prevalence among adolescents in eastern Turkey: its effects on school performance and relationships with family
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and friends. J Pediatr Adolesc Gynecol. 2010;23:267-272. 29.
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of Korean adolescent girls in Seoul. Korean J Pediatr. 2011;54:201-206. 30.
480 481
1981;68:661-664. 31.
482 483
Flug D, Largo RH, Prader A. Symptoms related to menstruation in adolescent Swiss
girls: a longitudinal study. Ann Hum Biol. 1985;12:161-168.
32.
484 485
Klein JR, Litt IF. Epidemiology of adolescent dysmenorrhea. Pediatrics.
EP
479
Lee JC, Yu BK, Byeon JH, Lee KH, Min JH, Park SH. A study on the menstruation
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477
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475
Peacock A, Alvi NS, Mushtaq T. Period problems: disorders of menstruation in
adolescents. Arch Dis Child. 2012;97:554-560. 33.
Zannoni L, Giorgi M, Spagnolo E, Montanari G, Villa G, Seracchioli R.
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Dysmenorrhea,
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endometriosis in adolescents. J Pediatr Adolesc Gynecol. 2014;27:258-265.
absenteeism
from
school,
and
symptoms
suspicious
for
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ACCEPTED MANUSCRIPT 488 489
FIGURE LEGENDS
490 Figure 1. Dysmenorrhea characteristics among 1103 15-19 year old Finnish girls
492
participating the TEENMAPS Study (a) and among 738 of the girls who reported having
493
dysmenorrhea (b-f).
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491
494
Figure 2. The prevalence of dysmenorrhea and severe dysmenorrhea according to the time
496
since menarche among 1103 15-19 year old Finnish girls participating the TEENMAPS
497
Study. Linear trend lines of both parameters are presented (p-value of trend 0.002 and
498
<0.001, respectively).
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495
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Table 1. Clinical characteristics of 15-19 year old Finnish girls participating the TEENMAPS Study Severe dysmenorrheaa
n=1103
Yes (n=355)
RI PT
All participants
P-valuea
16.8 (1.0)
16.7 (1.0)
0.184
21.6 (3.5)
21.3 (3.0)
0.156
SC
No (n=734)
16.8 (1.0)
Mean BMI (SD)
21.5 (3.3)
Mean age at menarche (SD)
12.6 (1.2)
12.3 (1.3)
12.7 (1.1)
<0.001*
Regular menstrual cyclec, % (n)
81.9 (880/1074)
77.8 (279/347)
83.6 (607/724)
0.016*
Smoking, % (n)
24.6 (268)
25.1 (89)
24.5 (179)
0.844
10.7 (116)
11.8 (42)
10.1 (74)
NA
14.0 (152)
13.2 (47)
14.4 (105)
NA
30.5 (333/1091)
28.4 (99/348)
31.3 (229/731)
0.337
73.3 (250)
67.0 (69)
76.7 (181)
0.062
61.4 (151)
75.0 (69)
53.6 (81)
0.001*
42.9 (85)
56.9 (41)
35.0 (43)
0.003*
Current OC use, % (n) Indications for OC used (%) Contraception Dysmenorrhea Menorrhagia
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Irregularly, % (n)
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Regularly, % (n)
M AN U
Mean age (SD)
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37.3 (22)
45.5 (65)
0.286
Regular absenteeisme, % (n)
7.5 (55/758)
13.8 (49/355)
1.6 (6/380)
<0.001*
Known or suspected endometriosis, % (n)
3.1 (23/737)
5.5 (13/237)
2.0 (10/497)
0.012*
Endometriosis in 1° relativesf, % (n)
6.5 (30/461)
10.0 (15/150)
4.8 (15/311)
0.035*
Familiar with the word endometriosis, % (n)
22.7 (245/1081)
26.6 (92/346)
20.8 (150/722)
0.034*
RI PT
42.6 (87)
SC
Irregular cycle
Note: SD = standard deviation, BMI = Body mass index, OC = oral contraceptive pill, NRS = numerical rating scale, % = valid percent NRS 8-10
b
Comparison between severe dysmenorrhea Yes/No with T-test or χ2 test as appropriate
c
Menstrual cycle length 23-35 days
d
Several indications per participant possible
e
Absenteeism from school or hobbies monthly or most months due to dysmenorrhea, only girl having dysmenorrhea included
f
55.5% of the participants (581/1042) answered “I do not know” and they were excluded from this analysis
*
Statistically significant (P < 0.05)
AC C
EP
TE D
M AN U
a
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Table 2. The prevalence of pain symptoms suggestive of endometriosis and their correlation with severe dysmenorrhea among a) all 15-19 year old Finnish girls participating the TEENMAPS Study and b) participants not using combined oral contraceptive pills (OC). Severe
All participants (n=1103)
Severe dysmenorrhea Yes (n=355)
SC
a)
RI PT
dysmenorrhea was present in 33% of all participants (n=355/1089) and in 33% of non-OC-users (n=248/748).
No (n=734)
%
n
P-valuea
OR (95% CI)
30.0
106/353
13.9
101/729
<0.001*
2.67 (1.96-3.64)
10.8
17/157
12.0
36/301
0.719
0.89 (0.49-1.65)
13.0
46/353
5.6
41/732
<0.001*
2.56 (1.62-3.93)
5.9
21/353
4.0
29/729
0.148
1.53 (0.86-2.72)
%
Acyclic abdominal pain
19.1
207/1085
Dyspareuniab
11.6
53/458
Dyschezia
8.0
87/1088
Dysuria
4.6
50/1084
b)
All non-OC-users (n=753)
AC C
EP
TE D
n
M AN U n
%
%
n
Severe dysmenorrhea Yes (n=248)
No (n=500)
%
%
n
n
P-valuea
OR (95% CI)
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16.6
125/753
28.6
71/248
10.8
54/500
<0.001*
3.31 (2.23-4.92)
Dyspareuniab
7.9
17/215
6.8
5/73
9.9
11/111
0.471
0.67 (0.22-2.01)
Dyschezia
6.4
48/753
10.5
26/248
4.4
22/500
0.001*
2.55 (1.41-4.59)
Dysuria
2.9
22/749
4.0
10/248
2.4
12/497
0.219
1.70 (0.72-3.99)
χ2 test, compared between groups of severe dysmenorrhea Yes/No
b
Only girls who have had more than one intercourse included
*
Statistically significant (P < 0.05)
AC C
EP
TE D
M AN U
SC
a
RI PT
Acyclic abdominal pain
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Table 3. The severity of pain symptoms suggestive of endometriosis and the overall perception of general health measured with numerical rating scale (NRS) among 15-19 year old Finnish girls participating the TEENMAPS Study. Pain severity was calculated
RI PT
among participants having each pain symptom (NRS>0).
Severe dysmenorrhea
SC
All participants
No (n=734)
Mean (SD)
Mean (SD)
P-valuea
8.7 (0.8)
5.4 (1.5)
<0.001*
6.8 (2.1)
5.7 (2.3)
<0.001*
7.0 (2.0)
Acyclic abdominal pain (n=207)
6.3 (2.3)
Dyspareunia (n=53)b
5.6 (2.3)
6.1 (2.4)
5.3 (2.2)
0.218
Dyschezia (n=85)
4.9 (2.4)
5.2 (2.5)
4.8 (2.2)
0.386
Dysuria (n=47)
5.0 (2.4)
5.4 (2.7)
4.7 (2.1)
0.358
7.8 (1.5)
8.1 (1.4)
0.018*
AC C
General healthc (n=1099)
TE D
Dysmenorrhea (n=735)
EP
Mean (SD)
Yes (n=355)
M AN U
(n=1103)
7.9 (1.5)
Note: SD = standard deviation, CI = confidence interval a
T-test, compared between groups of severe dysmenorrhea Yes/No
b
Only girls with more than one intercourse included
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c
0 meaning “Totally unsatisfied” and 10 meaning “Totally satisfied”
*
Statistically significant (P < 0.05)
AC C
EP
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M AN U
SC
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s
ACCEPTED MANUSCRIPT Table 4. Proportions of girls with symptoms suggestive of endometriosis estimated using different self-reported criteria among 15-19 year old Finnish girls participating the TEENMAPS Study (n=1103).
%a
28
2.5
59
5.3
64
5.8
Severe dysmenorrheac combined with acyclic abdominal pain
106
9.6
Severe dysmenorrheac, using OC and pain medication, inadequate reliefb
53
4.8
Severe dysmenorrheac and absent from school monthly or most months
49
4.4
Severe dysmenorrheac, using OC, absent from school monthly or most months
21
1.9
Dysmenorrea, dyschezia and acyclic abdominal pain
M AN U
Severe dysmenorrheac lasting three or more days
SC
Pain medication 3 ≥ days for dysmenorrhea with inadequate reliefb
RI PT
n
Criteria
TE D
Note: OC = oral contraceptive pill, NRS = numerical rating scale Prevalence among all 1103 participants
b
No or minimal help of pain medication
c
Severe dysmenorrhea = NRS 8-10
AC C
EP
a
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b) Frequency of dysmenorrhea
a) Dysmenorrhea severity (NRS)
c) Duration of dysmenorrhea (days) 2%
32%
33%
No dysmenorrhea (0) 26%
Mild (1-4)
43%
Severe (8-10)
d) Duration of pain medication use (days)
25%
M AN U
26%
12%
Every month Most times Sometimes Seldom
1-2 3-4 >4
SC
Moderate (5-7) 9%
RI PT
6%
e) Effect of pain medication
TE D
2%
86%
f) Absenteeism from school and hobbies 7%
1%
11%
18%
82%
EP
3 or more
41%
AC C
1-2
Total relief Helps quite well Helps little
46%
No help
42%
50%
Never Seldom Often Every month
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90 80 65.4
70
70.3
45.3 36.1
40 28.1
30 19.4
10 0 0-1 years
2-3 years
4-5 years
Dysmenorrea
Severe dysmenorrhea
6-10 years
EP
TE D
M AN U
Time since menarche
RI PT
55.2
50
20
74.4
SC
60
AC C
Prevalence of dysmenorrhea (%)
100
S1083-3188(15)00261-2
DOI:
10.1016/j.jpag.2015.07.001
Reference:
PEDADO 1874
To appear in:
Journal of Pediatric and Adolescent Gynecology
Received Date: 6 May 2015 Revised Date:
26 June 2015
Accepted Date: 1 July 2015
Please cite this article as: Suvitie PA, Hallamaa MK, Matomäki JM, Mäkinen JI, Perheentupa AH, Prevalence of Pain Symptoms Suggestive of Endometriosis Among Finnish Adolescent Girls (TEENMAPS study), Journal of Pediatric and Adolescent Gynecology (2015), doi: 10.1016/ j.jpag.2015.07.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1
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PREVALENCE OF PAIN SYMPTOMS SUGGESTIVE OF ENDOMETRIOSIS
2
AMONG FINNISH ADOLESCENT GIRLS (TEENMAPS study)
3 4 P.A. Suvitie MD1,2,4,*, M.K. Hallamaa MD1,2, J.M. Matomäki MSc3, J. I. Mäkinen Prof.1,2,
6
and A. H. Perheentupa MD, PhD1,2,4
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5
7 8
1
9
Finland
SC
Department of Obstetrics and Gynecology, Turku University Hospital, FI-20520 Turku,
2
Department of Obstetrics and Gynecology, University of Turku, FI-20520 Turku, Finland
11
3
Department of Pediatrics, Turku University Hospital, FI-20520 Turku, Finland
12
4
Department of Physiology, Institute of Biomedicine, University of Turku, FI-20520 Turku,
13
Finland
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*Correspondence: Pia Suvitie, MD, Department of Obstetrics and Gynecology, Turku
16
University Hospital, Kiinamyllynkatu 4-8, FI-20520 Turku, Finland; Phone: +358 2
17
3130917; fax +358 2 3132340; E-mail address: [email protected]
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2
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Study Objective: To evaluate the prevalence of pain symptoms suggestive of endometriosis
19
among adolescent girls aged 15-19 years.
20
Design: Cross sectional study.
21
Setting: University Hospital.
22
Participants: Adolescent girls aged 15-19 years attending elementary school, high school or
23
vocational institute at three cities in Southwest Finland in 2010-2011.
24
Interventions: The school nurses distributed a detailed questionnaire to 2582 girls attending
25
school at the time of the study. Answering was voluntary and anonymous.
26
Main Outcome Measures: Prevalence and severity of dysmenorrhea, acyclic abdominal
27
pain, dyspareunia, dyschezia and dysuria. Severity was evaluated with 11-point numerical
28
rating scale (NRS).
29
Results: A total of 1103 eligible answers were analyzed. The prevalence of dysmenorrhea
30
was 68% with mean NRS of 7.0 (SD 2.0). Acyclic abdominal pain, dyspareunia, dyschezia
31
and dysuria were less frequent (19%, 12%, 8% and 5%, respectively). The prevalence of
32
severe dysmenorrhea (NRS 8-10) was 33%. Severe dysmenorrhea was associated with
33
increased risk of concurrent acyclic abdominal pain (OR 2.7, 95% CI 2.0-3.6), dyschezia
34
(OR 2.5, 95% CI 1.6-3.9) and regular absenteeism from school or hobbies (OR 10.0, 95% CI
35
4.2-23.6). By using different criteria, 2-10% of all girls could be identified as having
36
symptoms suggestive of endometriosis. Five percent of girls (n=53) had severe
37
dysmenorrhea, used OC and reported inadequate relief of pain medication.
38
Conclusions: One third of 15-19 year old girls have severe menstrual pain and 14% of them
39
are regularly absent from school or hobbies. Five percent of all teenage girls are poor
40
responders to conventional therapy for primary dysmenorrhea.
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18
41 42
Keywords: adolescent, dysmenorrhea, endometriosis, pain symptoms, epidemiology
3
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Introduction
44 Endometriosis in adolescence is a poorly recognized and understood disease.1 It is likely to
46
appear after puberty, induced by ovarian estrogen synthesis.2 The majority of endometriosis
47
patients (66-67%) experience the onset of symptoms before the age of 20.3 Laparoscopy is
48
the golden standard for the diagnosis of endometriosis. However, it is an invasive procedure
49
and should be offered to adolescents only with the aim of surgical treatment when medical
50
therapy with non-steroidal anti-inflammatory drugs (NSAID) and cyclic or continuous
51
combined oral contraceptives or progestin has failed.4 At present, the diagnosis by
52
laparoscopy is obtained with an average delay of 6.7 years after the onset of symptoms 5, and
53
the mean age at first surgery is typically 29.6–35.8 years.5-8
M AN U
SC
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45
54
Severe menstrual pain is the most typical symptom of endometriosis. Among adolescent
56
girls the prevalence is reported to be 8-33%9-13, and the increasing severity is associated with
57
interference with life activities, social relationships and school attendance.9 Principally, such
58
symptoms are considered as primary dysmenorrhea and treated with NSAID and/or oral
59
contraceptives.14 When medical therapy offers insufficient symptom alleviation, a suspicion
60
for endometriosis should be raised and adequate clinical assessment offered.4
EP
AC C
61
TE D
55
62
Adolescent girls wait three times longer before seeking help for their symptoms suggestive
63
of endometriosis as compared with women with adult onset of symptoms (6.0 ± 0.2 vs. 2.0 ±
64
0.3 years, p<0.001).7 In addition, adolescents typically first contact primary health care units
65
instead of specialist care, and this is associated with a longer delay probably due to
66
insufficient recognition of endometriosis.5,
7
These two characteristics of adolescents
4
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endometriosis patients may hamper timely diagnosis and treatment, and thus, cause
68
unnecessary suffering and reduced quality of life. 9, 15
69 Adolescents with endometriosis typically have both cyclic and acyclic abdominal pain.15-20
71
In adult endometriosis the typical symptoms are dysmenorrhea, chronic abdominal or pelvic
72
pain, dyspareunia, dyschezia and bladder pain.21, 22 All these pain symptoms15, 20 as well as
73
all ASRM stages23 and disease types, i.e. peritoneal, ovarian and deep endometriosis, have
74
been confirmed in adolescent patients.19, 20, 24, 25 However, no previous study has evaluated
75
the prevalence and severity of these five pain symptoms among general adolescent
76
population.
M AN U
SC
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70
77
The aim of this study was to estimate how common and severe pain symptoms suggestive of
79
endometriosis are among general adolescent female population. We also evaluated the
80
characteristics of menstruation with special interest on dysmenorrhea related medication,
81
absenteeism from school or hobbies and family history of endometriosis.
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Materials and methods
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This cross sectional questionnaire study was designed and organized at the Department of
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Obstetrics and Gynaecology at Turku University Hospital, Finland. The target population
88
was the 15-19 year old girls attending elementary school, high school or vocational institute
89
at the cities of Turku, Lieto and Kaarina in Southwest Finland. The study was named
90
TEENMAPS according to “Teenage Menstrual and Abdominal Pain Symptoms”.
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We designed a 49-point questionnaire to be used in this study, focusing on menstrual
93
characteristics and pain symptoms suggestive of endometriosis, i.e. dysmenorrhea, acyclic
94
abdominal pain, dyspareunia, dyschezia and dysuria. The participants were asked whether
95
they “presently have” any of the pain symptoms. They estimated the severity of each pain
96
symptom “at it´s worst” by completing an 11-point (0-10) numerical rating scale (NRS) with
97
0 meaning “no pain” and 10 meaning, “pain as bad as you can imagine”. NRS pain scores
98
were further divided into three categories: mild (1-4), moderate (5-7) and severe (8-10) pain.
99
These cut offs were chosen based on recent findings of pain scale perception among 2982
100
adolescents aged 11-17 years.26 The participant’s satisfaction of overall general health was
101
evaluated similarly with NRS, 0 meaning, “totally unsatisfied” and 10 meaning “totally
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satisfied”. The questionnaire was available in both official languages in Finland, Finnish and
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Swedish.
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The original estimated study population was 3814 based on figures received from school
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health nurses working in the participating schools. In Turku the data was collected during
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spring 2010 and in the cities of Lieto and Kaarina in spring 2011, when the secondary school
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graduates were no longer attending school. Thus, the majority of the oldest age group was
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not reached. The school nurses delivered altogether 2582 questionnaires to the participants,
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and this was considered the initial study population. Participation was voluntary and
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anonymous. The school nurses were allowed to decide whether to initiate the study in the
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classroom or to let participants fill in the questionnaire at home and return it in a sealed
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envelope.
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Statistical analyses
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Analyses were performed using PASW Statistics 19 software (SPSS Inc., IBM, Chicago,
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USA). The baseline clinical characteristics were compared using Chi-Square Test or Two-
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sample T-test, as appropriate. Chi-Square Test for Trend was used to analyze dysmenorrhea
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prevalence and severity according to age or time since menarche. T-test was used to compare
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pain severities (NRS) between different subgroups, since the variables were normally
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distributed. P-value <0.05 was considered statistically significant. Correlations between
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variables were analyzed by Spearman’s correlation coefficient. To evaluate the effect size of
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selected variables, we computed the odds ratio (OR).
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The incidence of each parameter was calculated based on the answers received for each
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question (valid %). The number of answers received for each question varied to some
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degree.
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129 Ethical Approval
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The Ethics Committee of Hospital District of Southwest Finland approved the study
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protocol. As the participation was voluntary and anonymous, the completion of the
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questionnaire was considered as consent.
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Results
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Characteristics of the study population
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Response rate
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The number of distributed questionnaires was 2582 and 1117 of those were returned. The
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overall response rate, thus, was 43% and it varied greatly between the schools (0-100%) and
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the cities (Lieto 24%, Turku 41% and Kaarina 91%). Fourteen responses were excluded
146
because the age criterion was not fulfilled or the age was not given. Thus, 1103 answers
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were included in the statistical analysis.
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Because of the lower response rates in Turku and Lieto, we first compared the main
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parameters of interest (prevalence and severity of pain symptoms, smoking, BMI and OC
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use) between the participating cities. However, no statistically significant differences were
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found, while the participants in Kaarina were somewhat younger than the girls in the other
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two cities (mean age 16.5 vs. 16.8, p<0.001).
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Clinical characteristics
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The mean age of the participants was 16.8 years. The mean age at menarche was 12.6 years
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(range 9-16) and only two girls reported not having menses yet. The mean BMI was normal
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(21.5, range 15.4-59.9), and the BMI did not correlate with the prevalence of pain
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symptoms. However, higher BMI correlated negatively with the perception of general health
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(r=-0.21, p<0.001). A quarter of the participants were at least occasional smokers and 10.7%
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smoked regularly. Smokers were less satisfied with their general health than non-smokers
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(mean NRS 7.4 vs. 8.1, p<0.001). The percentage of smokers increased with age (p=0.01 for
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trend). Smoking was not a risk factor for severe dysmenorrhea (p=0.84). The clinical
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characteristics of the participants are presented in Table 1.
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Only 23% of all participants (n=245) were familiar with the word endometriosis and 2.7%
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reported having a first-degree relative with the disease. However, in 53% the family history
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of endometriosis was unknown. Two participants reported being previously operated for
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endometriosis and both had moderate dysmenorrhea (NRS 7).
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173 Dysmenorrhea
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The prevalence of dysmenorrhea was 67.6% (n=738/1092). Thirty-two percent
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(n=354/1089) had no menstrual pain, 9% (n=101/1089) had mild pain, 26% (n=279/1089)
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moderate pain and 33% (n=355/1089) severe pain (Figure 1). When dysmenorrhea was
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present, the mean NRS was 7.0 (SD 2.0). The duration of menstrual pain was typically 1-2
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days (86%), but in 14% of the girls it lasted for 3 or more days (n=102/726, 9.2% of all
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participants). The increasing severity of dysmenorrhea (NRS 0-10) correlated negatively
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with the participant’s conception of general health measured with NRS (r=-0.13, p<0.001).
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Nearly 16% of participants with dysmenorrhea (15.8%, n=116/733) had visited a doctor and
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83.1% (n=557/670) had spoken about dysmenorrhea symptoms to their family members.
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We further compared the clinical characteristics between girls with severe dysmenorrhea and
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girls with absent, mild or moderate dysmenorrhea (Table 1). Girls who reported severe
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dysmenorrhea had more often an irregular menstrual cycle (≠ 23-35 days; p=0.016) as
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compared with girls not having severe menstrual pain. Both these groups used OC as often,
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but girls with severely painful periods had dysmenorrhea or menorrhagia as one indication
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for OC use more often (p=0.001 and p=0.003, respectively).
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The prevalence of dysmenorrhea increased with age (p=0.041 for trend). Subsequently, we
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calculated the time since menarche and divided it into four categories: 0-1, 2-3, 4-5 and 6-10
195
years since menarche. When the prevalence of dysmenorrhea and severe dysmenorrhea were
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analyzed accordingly, a more pronounced rising trend was noticed (p=0.002 and p<0.001 for
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trend, respectively; Figure 2). Similarly, the mean NRS of dysmenorrhea increased with time
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since menarche (p<0.001 for trend).
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Eighty percent of girls (n=588/735) who had dysmenorrhea used pain medication for their
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complaint, mostly NSAIDs, and 18% (n=106) of those girls needed medication for three
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days or longer (Figure 1). Surprisingly, in 43% (n=253) the medication offered only little or
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no relief at all. Unfortunately, the dosage was not recorded, and thus, we could not evaluate
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wheather the dosing was appropriate.
206 207
Other pain symptoms
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Dyspareunia, dyschezia and dysuria were quite rare symptoms, while acyclic abdominal pain
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was more commonly reported (Table 2a). Interestingly, girls with severe menstrual pain had
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an increased risk of having concomitant acyclic abdominal pain and dyschezia (Table 2a). In
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addition, girls with severe dysmenorrhea experienced more severe acyclic abdominal pain
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compared with girls with absent or less severe menstrual pain (Table 3). The correlation
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between severe dysmenorrhea and acyclic abdominal pain and dyschezia remained
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significant, when only girls not using OC were included (Table 2b).
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Nearly half of the participants (45.7%, n=498/1090) had experienced at least one
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intercourse, and 43.6% (n=217) of them had felt pain during the first intercourse. Thirty-
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seven percent of the participants (n=406/1090) reported having intercourse’s sporadically
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(more than three times) or regularly, and 11% (n=45) of them reported having pain during
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intercourse repeatedly.
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The prevalence of acyclic abdominal pain, dyspareunia and dysuria, but not dyschezia,
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increased with age (p=0.028, p=0.02, p=0.012, and p=0.082 for trend, respectively). When
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these symptoms were evaluated according to years since menarche, the prevalence of
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dyschezia and dysuria, but not acyclic abdominal pain and dyspareunia, increased
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significantly with longer time since menarche (p=0.003, p=0.001, p=0.37 and p=0.08 for
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trend, respectively).
228 229
Oral contraceptive pill use
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OC were commonly used among schoolgirls (Table 1), and the number of OC users
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increased with years since menarche (0-1 years 16.7%, 2-3 years 23.6%, 4-5 years 37.1%
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and 6-10 years 42.7%). Contraception was the most common indication for OC use (Table
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1). Furthermore, dysmenorrhea was one of the indications in 61.4% of the girls (n=151, 14%
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of all participants). Surprisingly, the prevalence and the severity (mean NRS) of
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dysmenorrhea were similar in OC users and non-users, 63.8% vs. 68.9% (p=0.10) and 7.0
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vs. 7.0 (p=0.65), respectively.
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238 239 240
Absenteeism from school or hobbies
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Half of the girls who suffered from dysmenorrhea reported absenteeism from school or
242
hobbies because of menstrual pain (49.9%, n=368/738; Figure 1), and eight percent
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(n=55/738, 5% of all participants) were absent regularly, i.e. monthly or during most
244
months. The severity of dysmenorrhea (mild, moderate, severe) correlated positively with
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the risk of absenteeism (never/seldom vs. most months/monthly, p<0.001 for trend). Mild
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dysmenorrhea was not related to absenteeism while moderate and severe dysmenorrhea
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caused regular absenteeism in 2.2% (6/279) and 13.8% (49/355), respectively. Girls with
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severe dysmenorrhea had an increased risk for regular absenteeism as compared with girls
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with mild or moderate pain (Table 1)
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Sixteen girls using OC for menstrual pain still reported regular absenteeism from school or
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hobbies. When the menstrual pain lasted for 3 or more days the girls were more often
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regularly absent when compared with pain duration of 1-2 days (16.7% vs. 5.9%, p<0.001).
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Risk groups with symptoms suggestive of endometriosis
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We calculated the proportions of girls with symptoms suggestive of endometriosis among
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the whole study population using different anamnestic criteria (Table 4). A subgroup of 53
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girls with severe dysmenorrhea (4.8 % of entire study population) was considered as poor
260
responders for medical therapy (using OC and reporting inadequate effect of pain
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medication). However, we did not ask whether these girls used cyclic or continuous OC.
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Fifty-nine girls needed painkillers for at least 3 days but the drug helped only little (n=55) or
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not at all (n=4).
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Forty-nine participants (4% of all girls) presented with severe dysmenorrhea and were absent
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from school or hobbies monthly or most months. Half of them had visited a doctor (n=26),
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21 used OC and all except one used pain medication for their complaint. Yet, 24 girls
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reported inadequate relief of pain with the medication, only three reported being suspected
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for endometriosis and none had been operated.
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The subgroup of 23 girls who reported having endometriosis or suspicion of the disease was
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comparable to the overall study population in severity of dysmenorrhea, acyclic abdominal
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pain, dyspareunia, dyschezia and dysuria. Furthermore, there were no significant differences
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in duration of dysmenorrhea, effectiveness and duration of pain medication, OC use or in the
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frequency of absenteeism from school or hobbies. A positive correlation was detected
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between known or suspected endometriosis and a positive family history (p<0.001).
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Discussion
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In the present study we evaluated the prevalence of pain symptoms that are often considered
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suggestive of endometriosis among 15-19 year old schoolgirls living in three cities in
283
Southwest Finland by using an anonymous and voluntary questionnaire. As expected,
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dysmenorrhea was a common symptom (68%). Severe dysmenorrhea was reported by one
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third (33%) of all girls and they had a 10-fold risk of regular absenteeism from school or
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hobbies due to dysmenorrhea compared with girls with mild or moderate pain. Other pain
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symptoms i.e. acyclic abdominal pain, dyspareunia (among girls with > one intercourse),
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dyschezia and dysuria were less frequent (19%, 12%, 8% and 5%, respectively). Girls with
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severe menstrual pain presented with significantly increased risk of concomitant acyclic
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abdominal pain and dyschezia. Possibly, this clustering of pain symptoms could indicate the
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evolvement of endometriosis at least in part of these participants.
292 The number of participants (n=1103) was high, and represents approximately 29% of the
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whole population of 15-19 year old girls living in this area. The overall response rate was
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43% among girls present at school during the initiation of the study, and it varied greatly
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between the schools (0-100%) and the three cities (Lieto 24%, Turku 41% and Kaarina
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91%). The nurse in each school was given freedom in organizing the distribution and
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collection of the questionnaires. Varying enthusiasm of each nurse to motivate the girls to
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take part was considered to be the strongest underlying reason for these high differences.
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Secondly, the option of initiating the study either at school or at home probably influenced
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the response rate. Although there were no significant differences in measured main
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parameters between the cities, we cannot completely rule out some degree of selection bias.
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Primary dysmenorrhea is a very common symptom. In publications from the 1950s and
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1960s the prevalence varied between 5 and 50%, and in Finland it was reported to be 54% in
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1971 among 5155 participants.27 In recent cohort studies with large sample sizes, the
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prevalence has been 68-93%. 9, 12, 13, 28, 29
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In our study, the prevalence of dysmenorrhea increased with years since menarche (p=0.002
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for trend; Figure 2). Similarly, two previous studies have reported an increase in
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dysmenorrhea prevalence with increasing time since menarche.11, 30 In addition, in one study
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dysmenorrhea frequency increased during the first three postmenarcheal years and decreased
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thereafter.31 However, no statistics were provided in these previous publications. The
314
increasing prevalence is likely explained by the fact that primary dysmenorrhea is related to
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ovulatory cycles and it may take up to 2-3 years to obtain regular ovulations.32 However, the
316
increase several years after menarche, as described in this study and by two other authors11,
317
30
318
girls.
, may also be partly explained by the onset of symptomatic endometriosis in a subgroup of
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The prevalence of severe dysmenorrhea has been widely studied. In a recent similar large
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cross-sectional study from Australia, the prevalence of severe menstrual pain (NRS 8-10)
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was 21% (n = 217/1051) among 15-19 year old girls.9 In agreement with our study,
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Banikarim et al.12 reported 33% prevalence of severe dysmenorrhea among Hispanic
324
American girls (n=234/706) with mean age of 16 years by using visual analogue scale (VAS,
325
no cut-off levels mentioned). In other studies from Sweden, USA, Finland and Singapore,
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severe menstrual pain has been reported to occur in 8%-20% of all responders. In these
327
studies mostly a verbal rating scale (VRS) was used. 10, 11, 13, 30
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Oral contraceptive pills were commonly used among teenagers in our study (31%). Majority
330
of users needed contraception (73%) and 61% reported dysmenorrhea as one indication for
331
OC use. Contrary to our preconception, dysmenorrhea prevalence and severity were equal
332
between OC users and non-users (64% and 69%, mean NRS 7.0 and 7.0, respectively).
333
Possibly some OC users had severe dysmenorrhea before starting OC and the treatment had
334
either erased this symptom or decreased its severity. Unfortunately, the questionnaire did not
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evaluate the effectiveness of OC treatment for painful periods.
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Similarly to our data, Teperi and Rimpelä11 did not observe any difference in dysmenorrhea
338
prevalence between OC-users and non-users in sixteen and eighteen year old Finnish girls
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(n=1155 and n=1170, respectively). In contrast, in the study of Andersch and Milsom10 from
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Sweden, the prevalence and severity of dysmenorrhea were significantly reduced (p<0.01)
341
among OC users (n=270) as compared with non-users (n=306).
342 We calculated the proportions of girls at risk of having endometriosis among all 1103
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participants based on suggestive pain symptoms and anamnestic factors (Table 4). Five
345
percent of participants (n=53) had severe dysmenorrhea and used both OC and NSAIDs with
346
inadequate response. Of those, twenty-one (2% of all participant) were absent from school or
347
hobbies monthly or most months. Parker et al.9 obtained similar results. They reported a 5%
348
prevalence of severe menstrual pain while using OC and pain medication among girls at the
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age of 15-19 years. Furthermore, in a previous Finnish study, 3% of sixteen and eighteen
350
year old girls used pain medication and were repeatedly absent from school due to
351
dysmenorrhea.11
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According to the ESHRE guideline, diagnostic/therapeutic laparoscopy should be offered to
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adolescents, if their pain symptoms suggestive of endometriosis are not sufficiently
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alleviated with medical treatment.4 However, in many cases proper information on dosing
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and timing of NSAID use and changing from cyclic to continuous use of OC would lead to
357
sufficient response. The probability of finding visually confirmed endometriosis in
358
adolescents with chronic pelvic pain (CPP) not responding to medical treatment has been
359
reported to be high, i.e. 75%.25 According to such estimation, laparoscopy in our study
360
population would identify 40 girls with endometriosis. This hypothetical assumption would
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lead to a minimum of 3.6% incidence of symptomatic adolescent endometriosis.
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One previous study9 has reported the rates of dyspareunia, dyschezia and dysuria in a general
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adolescent population, and the prevalence’s were comparable to those observed in our study
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(13% vs. 12%, 12% vs. 8% and 10% vs. 5%, respectively). However, in this study the
366
prevalence of acyclic abdominal pain was not reported.
367 Adolescents with endometriosis present similar symptoms as adult patients. In a recent
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cohort of seventeen adolescents with histologically proven endometriosis, the most common
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pain symptoms were dysmenorrhea (82%), chronic pelvic pain (77%), dyschezia (77%) and
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bladder pain (53%), while dyspareunia was not as common (18%).20 In another cohort of 63
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adolescent endometriosis patients, the most common reasons for hospital visits were cyclic
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(71%) and chronic pelvic pain (21%).19 In our study, 2.5% of all girls had dysmenorrhea
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combined with dyschezia and acyclic abdominal pain.
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Adolescent dysmenorrhea impacts many aspects of social life and this should not be
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underestimated. Severe dysmenorrhea interferes with school attendance, hobbies, social
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relationships as well as sexual activity.9, 33 Similarly, adolescent endometriosis impacts the
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quality of life15 and medical and surgical therapies relieve pain symptoms and improve
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quality of life.21 Yet, symptomatic adolescents don´t actively seek for help.7 More resources
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should be invested into the active detection of the girls with notable symptoms, and
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professional evaluation and proper care should be offered when required.
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In conclusion, this study shows that 5% of 15-19 year old adolescent girls in Finland suffer
385
from severe dysmenorrhea not responding to medical therapy. Furthermore, 5% of
386
participants had severe dysmenorrhea and were absent from school monthly or most months.
387
Whereas the majority of girls with dysmenorrhea used pain medication, only 57% obtained
388
satisfactory relief for their symptoms. Girls with severe dysmenorrhea had an increased risk
389
of concomitant chronic abdominal pain and dyschezia. These findings clearly suggest that
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teenagers have significant symptoms suggestive of endometriosis and that they receive
391
inadequate attention and treatment. Further research is needed to evaluate how well these
392
symptoms correlate with the presence of endometriosis.
393 Acknowledgements
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We wish to warmly thank all the enthusiastic school nurses and teachers for their invaluable
397
contribution during the data collection.
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Funding
400
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The PhD study of P.S. was supported by the Government Research Foundation (EVO
402
funding) and the National Graduate School of Clinical Investigation, Finland. A.P. was
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supported by EVO funding.
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References
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Batt RE, Mitwally MF. Endometriosis from thelarche to midteens: pathogenesis and
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Dunselman GA, Vermeulen N, Becker C, et al. ESHRE guideline: management of women with endometriosis. Hum Reprod. 2014;29:400-412.
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Greene R, Stratton P, Cleary SD, Ballweg ML, Sinaii N. Diagnostic experience among 4,334 women reporting surgically diagnosed endometriosis. Fertil Steril.
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Parker MA, Sneddon AE, Arbon P. The menstrual disorder of teenagers (MDOT) study: determining typical menstrual patterns and menstrual disturbance in a large
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Agarwal A, Venkat A. Questionnaire study on menstrual disorders in adolescent girls in Singapore. J Pediatr Adolesc Gynecol. 2009;22:365-371.
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Harel Z. Dysmenorrhea in adolescents and young adults: an update on
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Laufer MR, Goitein L, Bush M, Cramer DW, Emans SJ. Prevalence of endometriosis
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Pediatr Adolesc Gynecol. 1997;10:199-202. 19.
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Yang Y, Wang Y, Yang J, Wang S, Lang J. Adolescent endometriosis in china: a
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Yeung P, Sinervo K, Winer W, Albee RB. Complete laparoscopic excision of endometriosis in teenagers: is postoperative hormonal suppression necessary? Fertil
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Johnson NP, Hummelshoj L, Consortium WESM. Consensus on current management
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Fauconnier A, Staraci S, Huchon C, Roman H, Panel P, Descamps P. Comparison of
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ASRM. Revised American Society for Reproductive Medicine classification of endometriosis: 1996. Fertil Steril. 1997;67:817-821.
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Hirschfeld G, Zernikow B. Cut points for mild, moderate, and severe pain on the VAS for children and adolescents: what can be learned from 10 million ANOVAs?
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Widholm O. Dysmenorrhea during adolescence. Acta Obstet Gynecol Scand Suppl.
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Eryilmaz G, Ozdemir F, Pasinlioglu T. Dysmenorrhea prevalence among adolescents in eastern Turkey: its effects on school performance and relationships with family
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Klein JR, Litt IF. Epidemiology of adolescent dysmenorrhea. Pediatrics.
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Lee JC, Yu BK, Byeon JH, Lee KH, Min JH, Park SH. A study on the menstruation
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477
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Peacock A, Alvi NS, Mushtaq T. Period problems: disorders of menstruation in
adolescents. Arch Dis Child. 2012;97:554-560. 33.
Zannoni L, Giorgi M, Spagnolo E, Montanari G, Villa G, Seracchioli R.
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Dysmenorrhea,
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endometriosis in adolescents. J Pediatr Adolesc Gynecol. 2014;27:258-265.
absenteeism
from
school,
and
symptoms
suspicious
for
21
ACCEPTED MANUSCRIPT 488 489
FIGURE LEGENDS
490 Figure 1. Dysmenorrhea characteristics among 1103 15-19 year old Finnish girls
492
participating the TEENMAPS Study (a) and among 738 of the girls who reported having
493
dysmenorrhea (b-f).
RI PT
491
494
Figure 2. The prevalence of dysmenorrhea and severe dysmenorrhea according to the time
496
since menarche among 1103 15-19 year old Finnish girls participating the TEENMAPS
497
Study. Linear trend lines of both parameters are presented (p-value of trend 0.002 and
498
<0.001, respectively).
AC C
EP
TE D
M AN U
SC
495
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Table 1. Clinical characteristics of 15-19 year old Finnish girls participating the TEENMAPS Study Severe dysmenorrheaa
n=1103
Yes (n=355)
RI PT
All participants
P-valuea
16.8 (1.0)
16.7 (1.0)
0.184
21.6 (3.5)
21.3 (3.0)
0.156
SC
No (n=734)
16.8 (1.0)
Mean BMI (SD)
21.5 (3.3)
Mean age at menarche (SD)
12.6 (1.2)
12.3 (1.3)
12.7 (1.1)
<0.001*
Regular menstrual cyclec, % (n)
81.9 (880/1074)
77.8 (279/347)
83.6 (607/724)
0.016*
Smoking, % (n)
24.6 (268)
25.1 (89)
24.5 (179)
0.844
10.7 (116)
11.8 (42)
10.1 (74)
NA
14.0 (152)
13.2 (47)
14.4 (105)
NA
30.5 (333/1091)
28.4 (99/348)
31.3 (229/731)
0.337
73.3 (250)
67.0 (69)
76.7 (181)
0.062
61.4 (151)
75.0 (69)
53.6 (81)
0.001*
42.9 (85)
56.9 (41)
35.0 (43)
0.003*
Current OC use, % (n) Indications for OC used (%) Contraception Dysmenorrhea Menorrhagia
TE D EP
Irregularly, % (n)
AC C
Regularly, % (n)
M AN U
Mean age (SD)
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37.3 (22)
45.5 (65)
0.286
Regular absenteeisme, % (n)
7.5 (55/758)
13.8 (49/355)
1.6 (6/380)
<0.001*
Known or suspected endometriosis, % (n)
3.1 (23/737)
5.5 (13/237)
2.0 (10/497)
0.012*
Endometriosis in 1° relativesf, % (n)
6.5 (30/461)
10.0 (15/150)
4.8 (15/311)
0.035*
Familiar with the word endometriosis, % (n)
22.7 (245/1081)
26.6 (92/346)
20.8 (150/722)
0.034*
RI PT
42.6 (87)
SC
Irregular cycle
Note: SD = standard deviation, BMI = Body mass index, OC = oral contraceptive pill, NRS = numerical rating scale, % = valid percent NRS 8-10
b
Comparison between severe dysmenorrhea Yes/No with T-test or χ2 test as appropriate
c
Menstrual cycle length 23-35 days
d
Several indications per participant possible
e
Absenteeism from school or hobbies monthly or most months due to dysmenorrhea, only girl having dysmenorrhea included
f
55.5% of the participants (581/1042) answered “I do not know” and they were excluded from this analysis
*
Statistically significant (P < 0.05)
AC C
EP
TE D
M AN U
a
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Table 2. The prevalence of pain symptoms suggestive of endometriosis and their correlation with severe dysmenorrhea among a) all 15-19 year old Finnish girls participating the TEENMAPS Study and b) participants not using combined oral contraceptive pills (OC). Severe
All participants (n=1103)
Severe dysmenorrhea Yes (n=355)
SC
a)
RI PT
dysmenorrhea was present in 33% of all participants (n=355/1089) and in 33% of non-OC-users (n=248/748).
No (n=734)
%
n
P-valuea
OR (95% CI)
30.0
106/353
13.9
101/729
<0.001*
2.67 (1.96-3.64)
10.8
17/157
12.0
36/301
0.719
0.89 (0.49-1.65)
13.0
46/353
5.6
41/732
<0.001*
2.56 (1.62-3.93)
5.9
21/353
4.0
29/729
0.148
1.53 (0.86-2.72)
%
Acyclic abdominal pain
19.1
207/1085
Dyspareuniab
11.6
53/458
Dyschezia
8.0
87/1088
Dysuria
4.6
50/1084
b)
All non-OC-users (n=753)
AC C
EP
TE D
n
M AN U n
%
%
n
Severe dysmenorrhea Yes (n=248)
No (n=500)
%
%
n
n
P-valuea
OR (95% CI)
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16.6
125/753
28.6
71/248
10.8
54/500
<0.001*
3.31 (2.23-4.92)
Dyspareuniab
7.9
17/215
6.8
5/73
9.9
11/111
0.471
0.67 (0.22-2.01)
Dyschezia
6.4
48/753
10.5
26/248
4.4
22/500
0.001*
2.55 (1.41-4.59)
Dysuria
2.9
22/749
4.0
10/248
2.4
12/497
0.219
1.70 (0.72-3.99)
χ2 test, compared between groups of severe dysmenorrhea Yes/No
b
Only girls who have had more than one intercourse included
*
Statistically significant (P < 0.05)
AC C
EP
TE D
M AN U
SC
a
RI PT
Acyclic abdominal pain
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Table 3. The severity of pain symptoms suggestive of endometriosis and the overall perception of general health measured with numerical rating scale (NRS) among 15-19 year old Finnish girls participating the TEENMAPS Study. Pain severity was calculated
RI PT
among participants having each pain symptom (NRS>0).
Severe dysmenorrhea
SC
All participants
No (n=734)
Mean (SD)
Mean (SD)
P-valuea
8.7 (0.8)
5.4 (1.5)
<0.001*
6.8 (2.1)
5.7 (2.3)
<0.001*
7.0 (2.0)
Acyclic abdominal pain (n=207)
6.3 (2.3)
Dyspareunia (n=53)b
5.6 (2.3)
6.1 (2.4)
5.3 (2.2)
0.218
Dyschezia (n=85)
4.9 (2.4)
5.2 (2.5)
4.8 (2.2)
0.386
Dysuria (n=47)
5.0 (2.4)
5.4 (2.7)
4.7 (2.1)
0.358
7.8 (1.5)
8.1 (1.4)
0.018*
AC C
General healthc (n=1099)
TE D
Dysmenorrhea (n=735)
EP
Mean (SD)
Yes (n=355)
M AN U
(n=1103)
7.9 (1.5)
Note: SD = standard deviation, CI = confidence interval a
T-test, compared between groups of severe dysmenorrhea Yes/No
b
Only girls with more than one intercourse included
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c
0 meaning “Totally unsatisfied” and 10 meaning “Totally satisfied”
*
Statistically significant (P < 0.05)
AC C
EP
TE D
M AN U
SC
RI PT
s
ACCEPTED MANUSCRIPT Table 4. Proportions of girls with symptoms suggestive of endometriosis estimated using different self-reported criteria among 15-19 year old Finnish girls participating the TEENMAPS Study (n=1103).
%a
28
2.5
59
5.3
64
5.8
Severe dysmenorrheac combined with acyclic abdominal pain
106
9.6
Severe dysmenorrheac, using OC and pain medication, inadequate reliefb
53
4.8
Severe dysmenorrheac and absent from school monthly or most months
49
4.4
Severe dysmenorrheac, using OC, absent from school monthly or most months
21
1.9
Dysmenorrea, dyschezia and acyclic abdominal pain
M AN U
Severe dysmenorrheac lasting three or more days
SC
Pain medication 3 ≥ days for dysmenorrhea with inadequate reliefb
RI PT
n
Criteria
TE D
Note: OC = oral contraceptive pill, NRS = numerical rating scale Prevalence among all 1103 participants
b
No or minimal help of pain medication
c
Severe dysmenorrhea = NRS 8-10
AC C
EP
a
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b) Frequency of dysmenorrhea
a) Dysmenorrhea severity (NRS)
c) Duration of dysmenorrhea (days) 2%
32%
33%
No dysmenorrhea (0) 26%
Mild (1-4)
43%
Severe (8-10)
d) Duration of pain medication use (days)
25%
M AN U
26%
12%
Every month Most times Sometimes Seldom
1-2 3-4 >4
SC
Moderate (5-7) 9%
RI PT
6%
e) Effect of pain medication
TE D
2%
86%
f) Absenteeism from school and hobbies 7%
1%
11%
18%
82%
EP
3 or more
41%
AC C
1-2
Total relief Helps quite well Helps little
46%
No help
42%
50%
Never Seldom Often Every month
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90 80 65.4
70
70.3
45.3 36.1
40 28.1
30 19.4
10 0 0-1 years
2-3 years
4-5 years
Dysmenorrea
Severe dysmenorrhea
6-10 years
EP
TE D
M AN U
Time since menarche
RI PT
55.2
50
20
74.4
SC
60
AC C
Prevalence of dysmenorrhea (%)
100