Dysmenorrhea and use of oral contraceptives in adolescent women attending a family planning clinic J. Courtland Robinson, MD: Stacey Plichta, BA,b Carol S. Weisman, PhD,b Constance A. Nathanson, PhD,b and Margaret Ensminger, PhDb
Baltimore, Maryland OBJECTIVES: This study examined the prevalance of dysmenorrhea in female adolescents and the effect of experiencing a reduction in dysmenorrhea on oral contraceptive use. STUDY DESIGN: This was a prospective panel study in which 308 adolescent women at an inner-city family planning clinic were interviewed about their experiences with dysmenorrhea and their oral contraceptive use at three points in time over a 6-month period. A x2 test and multiple logistic regression analysis were done. RESULTS: The overall prevalence of dysmenorrhea in this population was 79.6%; 18.2% reported severe dysmenorrhea. Those who had severe dysmenorrhea and also experienced the reduction of dysmenorrhea as a result of oral contraceptives were eight times more likely to be consistent oral contraceptive users (p:s; 0.02). CONCLUSIONS: It is important to screen female adolescents for dysmenorrhea, provide them with information about the beneficial side effects of oral contraceptives, and follow up these young women to make sure they are experiencing the alleviation of their symptoms. (AM J OBSTET GVNECOl 1992;166: 578-83.)
Key words: Dysmenorrhea, oral contraceptives, adolescents
Factors influencing effective oral contraceptive use among young women, and in particular adolescents, have been extensively researched. Age, degree of sexual activity, adverse effects, and attitudes of clinic personnel have all been examined, and varying degrees of impact have been ascribed. Missing, for unknown reasons, is the impact of dysmenorrhea. Primary dysmenorrhea is an important clinical and social problem affecting more than 50% of menstruating women. I Factors associated with and influencing this problem have been carefully reported in a study of over 600 young women at age 19 and again in the same women at age 24}-< Time, parity, and the use of oral contraceptives were found to be associated with reduction in pain and improved physical and mental attitude. The beneficial impact of oral contraceptives is well established:-6 It was the reverse question (does reduction of dysmenorrhea favorably influence oral contraceptive use?) which prompted the inclusion, in a recent study of adolescents' contraceptive use, of an investigation of dysmenorrhea. This paper reports the results of an analysis of the From the Schools of Medicine" and Hygiene and Public Health,' The Johns Hopkins University. Supported by grant No. R01 HD22275 from the National1nstitute of Child Health and Development. Received for publication February 15, 1991 .. revised July 12, 1991 .. accepted July 15, 1991. Reprint requests: Carol S. Weisman, School of Hygiene and Public Health, The Johns Hopkins University, 624 N. Broadway, Baltimore, MD 21205. 611 /32396
impact of dysmenorrhea and the experienced reduction of dysmenorrhea on oral contraceptive use over a 6-month period in a panel of adolescent clients of an inner-city family planning clinic.
Material and methods Subjects. The data for this analysis are from a threewave panel study of female adolescents who obtained prescriptions for oral contraceptives at a Planned Parenthood clinic in Baltimore during 1988. These women underwent follow-up for 6 months regardless of any return visits to the clinic. At baseline, 430 women were enrolled in the study and interviewed immediately after the clinic visit. Eligibility was limited to those aged::::; 18 years who were unmarried, not pregnant, and attending the clinic for purposes of initiating contraception (in some cases after an abortion). The enrolled subjects were 72% of all those eligible during 1988. The major reason for refusing to participate at baseline was reluctance to spend additional time in the clinic. There were no differences in participation rates by age or reason for clinic visit. Two follow-up interviews were conducted by telephone 3 and 6 months after each subject's baseline interview. Eighty-nine percent (n = 382) of baseline respondents completed both follow-up interviews, and there were no differences in completion rates by age, race, or reason for the initial clinic visit. The major reason for attrition was failure to locate the respondent. This analysis focuses on a subset of the panel (n = 308) who reported at least one instance of sexual
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Table I. Verbal scoring system for assessment of severity of dysmenorrhea* Severity
Sometimes or always experience cramps
Cramps are very painful
No dysmenorrhea Mild dysmenorrhea Moderate dysmenorrhea Severe dysmenorrhea
Yes Yes Yes
No
No No
Yes Yes
Sometimes or always cut back on activities
No No No
Yes
*The questions used in constructing this scale are: (1) How often do you usually get cramps while you are having your menstrual period-always, sometimes, or never? (2) Would you describe these cramps as very painful or a little painful? (3) On the days when you are having your period, how often do you cut back on your regular activities like staying home from school or staying away from work? Would you say always, sometimes, or never?
intercourse during the follow-up period. These subjects were primarily black (77%), resided in Baltimore City (89%), and were 16 years old on average. Twenty-two percent of them had mothers who were not high school graduates, 58% had mothers who were themselves teenage mothers, and 39% lived with both their mother and a father or stepfather. For those subjects who had initiated sexual activity by baseline (n = 293), the mean age at first intercourse was 14.5 years, and they had an average of 2.9 sex partners. Pregnancy was not uncommon; 58% had been pregnant and 12% had given birth. In general, these subjects are typical of an inner-city population in which sexual activity is initiated at a relatively young age and teenage pregnancy is prevalent. The interviews were conducted by female interviewers employed by Survey Research Associates, Inc., and not affiliated with the clinic. The baseline interview included questions about sexual and contraceptive history, including ones about the severity and frequency of dysmenorrhea. The two follow-up interviews contained detailed questions about instances of vaginal sexual intercourse and contraceptive use. Additionally, each respondents' clinic record was abstracted at the end of her 6-month follow-up period to obtain information on return visits to the clinic and pregnancies. Statistical methods. Significance tests for relationship between the severity of dysmenorrhea and subject characteristics and sexual, contraceptive, and health behaviors were calculated with the X" test. The change in odds of being a consistent oral contraceptive user for each variable considered was calculated with multiple logistic regression. The improvement X2 test was used to determine the significance of individual predictors in the regression model. Dependent variable. The dependent variable in this analysis is consistency of oral contraceptive use during the 6-month follow-up period, as reported by the respondent in the follow-up interviews. An extensive discussion of this measure has been reported elsewhere.' Briefly, on the basis of information on the date of the index clinic visit, clinic instructions regarding when to start the first package of pills and the respondent'S reported pill use (including missed pills), the measure computes the number of days on which each respon-
dent used oral contraceptives divided by the total number of days it was possible for her to have taken oral contraceptives. On average, subjects used oral contraceptives on 65% of possible pill days during the followup period; nine subjects never initiated oral contraceptive use, and 19 subjects reported perfect oral contraceptive use. Because the measure of oral contraceptive use was skewed toward perfect use, it was dichotomized for analysis on the basis of clinical significance of missed pills, according to clinic protocol. 8 Subjects missing three or fewer pills per pack were classified as consistent pill users (38% of all subjects) and those missing more than three pills per pack were classified as inconsistent users (62% of all subjects). Validation for the dichotomized measure of consistent oral contraceptive use was confirmed by significant associations with several criterion variables. Compared with inconsistent oral contraceptive users, consistent users had significantly more return visits to the clinic for additional prescriptions (58% vs 40%, P ~ 0.05), significantly fewer acts of unprotected intercourse (2% vs 39%, P ~ 0.05), significantly fewer pregnancy scares (20% vs 33%, P ~ 0.05), and fewer pregnancies (6% vs 12%, P ~ 0.08). Dysmenorrhea severity scale. The scale used in this analysis to measure the severity of dysmenorrhea is based on the one created by Andresch and Milsom 2 in a study of 19-year-old women. It ranks the severity of dysmenorrhea using information on how often the women experiences menstrual cramps, how painful she perceives them to be, and how often she cuts back on activities because of them (Table I). This information was gathered at the baseline interview and refers to the time period before oral contraceptive use was initiated and, for the postabortion patients, before the pregnancy resulting in the abortion at the index visit. The main difference between this scale and the Andresch and Milsom scale is that this one does not incorporate the use of analgesics as part of the measure. Experiencing any reduction in severe dysmenorrhea due to oral contraceptive use was hypothesized to be related to consistent use of oral contraceptives. It was measured by asking respondents about positive side effects of oral contraceptives during the first 3 months
580
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February 1992 Am J Obstet Gynecol
Table II. Prevalence and severity of dysmenorrhea in female adolescents attending a family planning elinic (n = 308) Severity
No dysmenorrhea Mild dysmenorrhea Moderate dysmenorrhea Severe dysmenorrhea
Cumulative percent, any dysmenorrhea
o 1
2 3
63 141 48 56
o
20.5 45.8 15.6 18.2
45.8 61.4 79.6
Table III. Dysmenorrhea by subject characteristics Severity Characteristic
Demographic factor Mean age (yr) Black (%) Mother's education (did not graduate from high school) (%) Parous before baseline (%) Early onset of menstruation (before age 12) (%) Sexual! contraceptive behavior Consistent pill users (%) Experiencing positive side effects (%) Intercourse at least once a week on average* (%) Somewhat or very happy about sext (%)
Intercourse is sometimes or always painfult (%) Health behavior (%) Return clinic visit§ Called clinic during follow-up Drink alcohol once a month or more Smoke once a month or more
0
1
1
J
2
I
All
3
subjects
p Value
16.3 76.2 22.2
16.1 75.2 18.4
16.1 81.3 22.9
16.1 76.8 26.8
16.2 76.6 21.4
1.00 0.86 0.62
22.2 24.6
12.1 31.2
4.2 47.9
8.9 33.9
12.3 33.0
0.03 0.07
38.1 55.6 27.0
37.6 66.7 33.3
35.4 76.6 35.4
42.9 69.6 41.1
38.3 66.0 33.8
0.88 0.12 0.44
69.8
74.5
62.5
62.5
69.5
0.26
14.3
27.0
29.2
37.5
26.6
0.04
33.3 25.4 15.9 12.7
46.8 30.5 24.8 22.0
60.4 33.3 22.9 18.8
48.2 25.0 19.6 32.1
46.4 28.9 21.8 21.1
0.04 0.70 0.52 0.08
*A count of the instances of vaginal intercourse reported was dichotomized at the mean (mean = 24 acts or an average of once a week). tSubjects were asked at baseline how they felt about having intercourse. Responses were on a five-point scale, ranging from very unhappy to very happy. tSubjects were asked at baseline if they ever experienced pain during intercourse, and if so how often it occurred. Responses were "almost never hurts," "sometimes hurts," "almost always hurts." §This is a return visit, to obtain oral contraceptives, to the same clinic where oral contraceptives were initially obtained.
of use and combining this information with their baseline reports of dysmenorrhea. Positive side effects measured in the first follow-up interview were reduced menstrual cramping and reduced menstrual bleeding; those experiencing either one or both of these (66% of subjects) were coded as having positive side effects of oral contraceptives. Experienced reduction of dysmenorrhea was calculated as an interaction term between having severe dysmenorrhea and experiencing positive side effects during the first 3 months of oral contraceptive use. Subjects were counted as experiencing a reduction in dysmenorrhea if they had both severe dysmenorrhea and experienced positive side effects (12.7% of subjects). The analysis also reports associations between dysmenorrhea and other variables relevant to dysmenorrhea and oral contraceptive use. (These variables, in-
eluding sociodemographic factors, sexual history, and health behaviors, are listed in Table III).
Results The overall prevalence of dysmenorrhea in this population was 79.6%; 45.8% (141 subjects) reported mild dysmenorrhea, 15.6% (48) reported moderate dysmenorrhea, and 18.2% (56) reported severe dysmenorrhea (Table II). These figures are similar to those reported by Andresch and Milsom 2 ; the overall prevalence is somewhat lower than that found in a study of 88 adolescent females. 9 The relationship between subject characteristics and severity of dysmenorrhea are displayed in Table III. There were no significant differences by age, race, or mother's education. Previous literature suggested that parity (parous vs non parous) would be negatively
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Table IV. Multiple logistic regression analysis of predictors of consistent oral contraceptive use* Predictor
Regression coefficient
Standard error
Relative oddst
p Value
Severe dysmenorrhea Experience one or more positive side effects Severe dysmenorrhea and one or more positive side effects (interaction term) Parous before baseline interview Started menstruation before age
- 1.250 0.297
0.821 0.300
0.29 1.35
0.13 0.32
2.080
0.903
8.04
0.02
-0.040 -0.113
0.427 0.274
0.96 0.89
0.93 0.68
-0.602
0.343
0.55
0.08
0.463
0.273
1.59
0.09
-0.368
0.293
0.69
0.21
0.500
0.255
1.65
0.05
12
Smoke cigarettes at least once a month Intercourse once a week or more Sometimes or always have painful intercourse Return visit to clinic
*All coefficients are adjusted for age, race, and mother's education. tThis is the antilog of the regression coefficient. It shows the expected change in odds of the outcome corresponding to a unit change in the predictor.
related to dysmenorrhea and that early onset of menstruation would be positively related to dysmenorrhea. 2 . 10 Early onset of menstruation was marginally significant (p ::; 0.07); those who began menstruating before age 12 were somewhat more likely to have dysmenorrhea. Parity was the only subject characteristic that was significant (p ::; 0.03). Those who were parous before baseline were less likely to report any degree of dysmenorrhea. Table III also presents information on the relationship of dysmenorrhea to contraceptive and sexual behaviors. In these bivariate analyses, dysmenorrhea was not significantly related to consistent oral contraceptive use or to experiencing less cramping or less bleeding during menstruation. It is of clinical interest that 30.4% of those with severe dysmenorrhea experienced neither of these positive side effects of oral contraceptives. Also notable is that the severity of dysmenorrhea was significantly associated with sometimes or always experiencing dyspareunia. Experiencing painful intercourse at least some of the time was reported by 14.3% of those without dysmenorrhea, 27% of those with mild dysmenorrhea, 29.2% of those with moderate dysmenorrhea, and 37.5% of those with severe dysmenorrhea. Although intercourse appears to be painful for a significant percentage of women with a dysmenorrhea, the latter subjects are just as likely to report having frequent intercourse (once a week or more) and to report being somewhat or very happy about having intercourse. Table III also presents the relationship of dysmenorrhea to a set of health behaviors. Those with any degree of dysmenorrhea are significantly more likely to return to the clinic where they initially received the pills over the 6-month follow-up period, although they are no more likely to call the clinic for advice during this time.
The relationship of dysmenorrhea to cigarette and alcohol use was also explored. On the basis of previous findings, it was hypothesized that there would be a positive relationship between dysmenorrhea and alcohol use lO and a relationship, although the literature has been mixed on the direction, with cigarette use. 2 . 3. I() Although no significant association between alcohol use and severity of dysmenorrhea was found, there was a positive and marginally significant association with cigarette use (p ::; 0.08). A multiple logistic regression analysis was used to examine the effects of severe dysmenorrhea, experiencing positive side effects of oral contraceptives, and an interaction term that represents experiencing a reduction of dysmenorrhea as a result of oral contraceptive use on consistent oral contraceptive use. The analysis controlled for variables that were potentially related to dysmenorrhea or oral contraceptive use. Three sociodemographic variables were included as covariates: age, race, and mother's education (a proxy for socioeconomic status). Previous research suggested that older adolescents, whites, and those with higher socioeconomic status are more compliant with contraception. II-II The results of this analysis appear in Table IV. The most statistically and clinically significant predictor of consistent oral contraceptive use was experiencing the reduction of dysmenorrhea as a result of oral contraceptive use; those with severe dysmenorrhea who reported positive side effects of the pill were eight times as likely to be consistent oral contraceptive users as others (p ::; 0.02). The only other statistically significant predictor of oral contraceptive use was returning to the same clinic for oral contraceptives (1.65 times as likely, p ::; 0.05) Two predictors, tobacco smoking and frequency of
582
Robinson et al.
intercourse, were marginally significant. Those who smoked cigarettes at least once a month were about half as likely (0.55, P :5 0.08) to be consistent oral contraceptive users. Those who had intercourse at least once a week were 1.59 times more likely to be consistent oral contraceptive users (p :5 0.09). Other studies have reported similar findings. Frequency of intercourse was thought to increase the perceived risk of pregnancy, and thus those with more frequent intercourse would be expected to be more consistent oral contraceptive users. 15·17
Comment This analysis demonstrates that an important predictor of consistent oral contraceptive use among adolescent women attending an inner-city family planning clinic was experiencing the alleviation of dysmenorrhea during the first 3 months of oral contraceptive use. Both this finding and the finding of a high prevalence of dysmenorrhea in the adolescent population underscore the importance of screening for dysmenorrhea all women who are seen at family planning clinics. This screen can be as straightforward as the three-question scale used in this analysis, with further probing if a woman responds positively to these questions. Adolescents are often poorly informed about menstrual events. One studylS reported finding substantial ignorance and misinformation among female adolescents regarding the causes and treatment of dysmenorrhea. Once it is determined that an adolescent suffers from dysmenorrhea, it is important to presensitize her to the potential positive side effects of oral contraceptives. Many clinics routinely stress the negative side effects of oral contraceptives without giving similar emphasis to the positive ones. Without adequate information, an adolescent woman with dysmenorrhea may not connect the relief of her symptoms to consistent oral contraceptive use, nor might she use oral contraceptives long enough to experience relief. It is also important to follow up on women with dysmenorrhea to determine if they are experiencing alleviation of their symptoms. Fully 30.5% of the women with severe dysmenorrhea did not perceive experiencing any positive side effects of oral contraceptives. Having severe dysmenorrhea alone was not predictive of oral contraceptive use. Consistency of care, as measured by a return visit to the clinic, is important in the provision of health care to adolescent women. It was significantly and positively related to both having dysmenorrhea at baseline and using oral contraceptives consistently over the followup period. This implies that clinics should encourage their clients to return to the same site for care. This analysis also found several other health problems that were significantly related to dysmenorrhea. The prevalence of dyspareunia is so high in this pop-
February 1992 Am J Obstet Gyneco1
ulation that it is important for clinicians to ask about dyspareunia and to provide information on how to alleviate it. It is apparent that reproductive health care for adolescents needs to include an open and thorough discussion about sexual functioning. There was also a positive association between the severity of dysmenorrhea and smoking. Although the findings in the literature are mixed, one possibility is that adolescents with dysmenorrhea use cigarette smoking in an attempt to alleviate symptoms. If this is the case, it is vital that clinicians counsel these women on the health risks inherent in smoking and on alternate ways to relieve symptoms (such as consistent oral contraceptive or analgesic use). Although this study had several findings relevant to understanding dysmenorrhea and oral contraceptive use in female adolescents, it does have some limitations which need to be noted. The major limitation is that the population consisted of female adolescents who were motivated to seek contraception; they may not be representative of all sexually active adolescents or of all adolescents with dysmenorrhea. Another limitation is that the subjects were all recruited in one family planning clinic and may not be representative of all adolescents who seek contraceptive services. There have been few studies of the effect of dysmenorrhea on health behavior in female adolescents. A replication of this study is needed to confirm some of the findings and to further explore the relationship between dysmenorrhea, sexual health, and contraceptive use. We thank the clients, staff, and administrators of the Planned Parenthood clinic from which the respondents were recruited. REFERENCES 1. Dawood MY, McGuire JL, Demers LM, eds. Premenstrual syndrome and dysmenorrhea. Baltimore: Urban & Schwarzenberg, 1985:6, 79, 177. 2. Andresch B, Milsom I. An epidemiologic study of young women with dysmenorrhea. AM J OBSTET GYNECOL 1982; 144:655-60. 3. Sundell G, Milsom I, Andresch B. Factors influencing the prevalence and severity of dysmenorrhea in young women. Br J Obstet Gynaecol 1990;97:588-94. 4. Milsom I, Sundell G, Andresch B. The influence of different combined oral contraceptives on the prevalence and severity of dysmenorrhea. Contraception 1990; 42:497-506. 5. Lalos 0, Jeolsson I. Effect of an oral contraceptive on uterine tonicity in women with primary dysmenorrhea. Acta Obstet Gynecol Scand 1981;60:229-32. 6. Mathews AEB, Clarke JFE. Double-blind trial of a sequential contraceptive (Sequencs) in the treatment of dysmenorrhea. J Obstet Gynaecol Br Commonw 1968; 75: 11l7-22. 7. Weisman CS, Plichta S, Nathanson CA, Chase GA, Ensminger M, RobinsonJC. Adolescent women's contraceptive decision making. J Health Soc Behav 1991;32:13044. 8. Hatcher RA, Guest F, Stewart F, Stewart GK. Contraceptive technology 1986-1987. New York: Irvington, 1986.
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9. Wilson CA, Keye WR. A survey of adolescent dysmenorrhea and premenstrual symptom frequency . .l Adoles Health Care 1989;10:317-22. 10. Teperi .l, Rimpela M. Menstrual pain, health and behaviour in girls. Soc Sci Med 1989;29: 163-9. 11. Emans S.l, Grace E, Woods ER, Smith DE, Klein K, Merola J. Adolescents' compliance with the use of oral contraceptives . .lAMA 1990;257:3377-81. 12. Furstenberg FF, SheaJ, Allison P, Herceg-Baron R, Webb D. Contraceptive continuation among adolescents attending family planning clinics. Fam Plann Perspect 1983;15:211-17. 13. Hofferth SL. Contraceptive decision making. In: Hayes CD, ed. Risking the future: adolescent sexuality, pregnancy and childbearing. Washington: National Academy Press 1987, vol 2.
Dysmenorrhea and use of oral contraceptives
14. Philliber S, Nameroe PB, Kaye .lW, Kunkes CH. Pregnancy risk taking among adolescents. .l Adolesc Res 1986; 1:463-81. 15. Durant RH,Jay MS. A social psychologic model offemale adolescents' compliance with contraceptives. Semin Adolesc Med 1987;3:135-44. 16. Durant RH, Sanders JM. Sexual behavior and contraceptive risk taking among sexually active adolescent females. J Adolesc Health Care 1989;10:1-9. 17. White HR, Johnson V. Risk taking as a predictor of adolescent sexual activity and use of contraception. J Adolesc Res 1988;3:317-31. 18. Johnson J. Level of knowledge among adolescent girls regarding effective treatment for dysmenorrhea. J Adolesc Health Care 1988;9:398-402.
Nonsurgical management of penetrating uterine trauma in pregnancy: A case report Debra K. Grubb, MD Los Angeles, California A woman at 30 weeks' gestation with stab wounds entering the uterus was managed nonsurgically by serial examinations and continuous fetal monitoring. Delivery occurred 4 weeks later with good maternal and fetal outcome. (AM J OasTET GYNECOL 1992;166:583-4.)
Key words: Abdominal injuries, pregnancy, stab wounds
Penetrating abdominal trauma is an uncommon complication of pregnancy, with gunshot wounds much more common than stab wounds. I We report a case of multiple stab wounds to the abdomen of a pregnant woman, with documented penetration of the uterus, which was managed non surgically with a good outcome.
Case report A 26-year-old Hispanic woman at 30 weeks of gestation in her first pregnancy was brought to the hospital by ambulance after her husband inflicted multiple stab wounds to the abdomen and upper extremities with a steak knife. On admission, the patient was hemodynamically stable and the fetal heart rate was 140 From the Department of Obstetrics and Gynecology, Universit} of Southern California. Received for publication June 18, 1991; accepted August 8, 1991. Reprint requests: Debra K. Grubb, MD, Women's Hospital, Room 5K40, 1240 N. Mission Road, Los Angeles, CA 90033. 611133027
beats/min. Stab wounds to the hands, right upper arm, and abdomen were cleaned and dressed. Obstetric ultrasonography revealed a single fetus in a breech presentation, with an estimated fetal weight of 1928 gm and no evidence of fetal injury. The fetal head was directly below one of the wounds. There was a normal amniotic fluid volume, and the placenta was anterior with no evidence of retroplacental blood clot. Continuous fetal heart rate monitoring, serial hematocrit determinations, and serial abdominal examinations were undertaken. A Kleihauer-Betke test for fetal erythrocytes was negative. An amniocentesis was performed to rule out amnionitis. The amniotic fluid was grossly bloody, but Gram stain and subsequent culture did not reveal any organisms. The hematocrit was stable over 24 hours at 30%, the fetal heart rate was reactive without decelerations, and no signs of peritonitis developed. The patient was then observed in the hospital for an additional 48 hours. No signs of infection developed, and she was discharged from the hospital. In the obstetrics clinic, there were normal heart tones and her wounds were healing well. At 34 weeks of
583
Baltimore, Maryland OBJECTIVES: This study examined the prevalance of dysmenorrhea in female adolescents and the effect of experiencing a reduction in dysmenorrhea on oral contraceptive use. STUDY DESIGN: This was a prospective panel study in which 308 adolescent women at an inner-city family planning clinic were interviewed about their experiences with dysmenorrhea and their oral contraceptive use at three points in time over a 6-month period. A x2 test and multiple logistic regression analysis were done. RESULTS: The overall prevalence of dysmenorrhea in this population was 79.6%; 18.2% reported severe dysmenorrhea. Those who had severe dysmenorrhea and also experienced the reduction of dysmenorrhea as a result of oral contraceptives were eight times more likely to be consistent oral contraceptive users (p:s; 0.02). CONCLUSIONS: It is important to screen female adolescents for dysmenorrhea, provide them with information about the beneficial side effects of oral contraceptives, and follow up these young women to make sure they are experiencing the alleviation of their symptoms. (AM J OBSTET GVNECOl 1992;166: 578-83.)
Key words: Dysmenorrhea, oral contraceptives, adolescents
Factors influencing effective oral contraceptive use among young women, and in particular adolescents, have been extensively researched. Age, degree of sexual activity, adverse effects, and attitudes of clinic personnel have all been examined, and varying degrees of impact have been ascribed. Missing, for unknown reasons, is the impact of dysmenorrhea. Primary dysmenorrhea is an important clinical and social problem affecting more than 50% of menstruating women. I Factors associated with and influencing this problem have been carefully reported in a study of over 600 young women at age 19 and again in the same women at age 24}-< Time, parity, and the use of oral contraceptives were found to be associated with reduction in pain and improved physical and mental attitude. The beneficial impact of oral contraceptives is well established:-6 It was the reverse question (does reduction of dysmenorrhea favorably influence oral contraceptive use?) which prompted the inclusion, in a recent study of adolescents' contraceptive use, of an investigation of dysmenorrhea. This paper reports the results of an analysis of the From the Schools of Medicine" and Hygiene and Public Health,' The Johns Hopkins University. Supported by grant No. R01 HD22275 from the National1nstitute of Child Health and Development. Received for publication February 15, 1991 .. revised July 12, 1991 .. accepted July 15, 1991. Reprint requests: Carol S. Weisman, School of Hygiene and Public Health, The Johns Hopkins University, 624 N. Broadway, Baltimore, MD 21205. 611 /32396
impact of dysmenorrhea and the experienced reduction of dysmenorrhea on oral contraceptive use over a 6-month period in a panel of adolescent clients of an inner-city family planning clinic.
Material and methods Subjects. The data for this analysis are from a threewave panel study of female adolescents who obtained prescriptions for oral contraceptives at a Planned Parenthood clinic in Baltimore during 1988. These women underwent follow-up for 6 months regardless of any return visits to the clinic. At baseline, 430 women were enrolled in the study and interviewed immediately after the clinic visit. Eligibility was limited to those aged::::; 18 years who were unmarried, not pregnant, and attending the clinic for purposes of initiating contraception (in some cases after an abortion). The enrolled subjects were 72% of all those eligible during 1988. The major reason for refusing to participate at baseline was reluctance to spend additional time in the clinic. There were no differences in participation rates by age or reason for clinic visit. Two follow-up interviews were conducted by telephone 3 and 6 months after each subject's baseline interview. Eighty-nine percent (n = 382) of baseline respondents completed both follow-up interviews, and there were no differences in completion rates by age, race, or reason for the initial clinic visit. The major reason for attrition was failure to locate the respondent. This analysis focuses on a subset of the panel (n = 308) who reported at least one instance of sexual
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Table I. Verbal scoring system for assessment of severity of dysmenorrhea* Severity
Sometimes or always experience cramps
Cramps are very painful
No dysmenorrhea Mild dysmenorrhea Moderate dysmenorrhea Severe dysmenorrhea
Yes Yes Yes
No
No No
Yes Yes
Sometimes or always cut back on activities
No No No
Yes
*The questions used in constructing this scale are: (1) How often do you usually get cramps while you are having your menstrual period-always, sometimes, or never? (2) Would you describe these cramps as very painful or a little painful? (3) On the days when you are having your period, how often do you cut back on your regular activities like staying home from school or staying away from work? Would you say always, sometimes, or never?
intercourse during the follow-up period. These subjects were primarily black (77%), resided in Baltimore City (89%), and were 16 years old on average. Twenty-two percent of them had mothers who were not high school graduates, 58% had mothers who were themselves teenage mothers, and 39% lived with both their mother and a father or stepfather. For those subjects who had initiated sexual activity by baseline (n = 293), the mean age at first intercourse was 14.5 years, and they had an average of 2.9 sex partners. Pregnancy was not uncommon; 58% had been pregnant and 12% had given birth. In general, these subjects are typical of an inner-city population in which sexual activity is initiated at a relatively young age and teenage pregnancy is prevalent. The interviews were conducted by female interviewers employed by Survey Research Associates, Inc., and not affiliated with the clinic. The baseline interview included questions about sexual and contraceptive history, including ones about the severity and frequency of dysmenorrhea. The two follow-up interviews contained detailed questions about instances of vaginal sexual intercourse and contraceptive use. Additionally, each respondents' clinic record was abstracted at the end of her 6-month follow-up period to obtain information on return visits to the clinic and pregnancies. Statistical methods. Significance tests for relationship between the severity of dysmenorrhea and subject characteristics and sexual, contraceptive, and health behaviors were calculated with the X" test. The change in odds of being a consistent oral contraceptive user for each variable considered was calculated with multiple logistic regression. The improvement X2 test was used to determine the significance of individual predictors in the regression model. Dependent variable. The dependent variable in this analysis is consistency of oral contraceptive use during the 6-month follow-up period, as reported by the respondent in the follow-up interviews. An extensive discussion of this measure has been reported elsewhere.' Briefly, on the basis of information on the date of the index clinic visit, clinic instructions regarding when to start the first package of pills and the respondent'S reported pill use (including missed pills), the measure computes the number of days on which each respon-
dent used oral contraceptives divided by the total number of days it was possible for her to have taken oral contraceptives. On average, subjects used oral contraceptives on 65% of possible pill days during the followup period; nine subjects never initiated oral contraceptive use, and 19 subjects reported perfect oral contraceptive use. Because the measure of oral contraceptive use was skewed toward perfect use, it was dichotomized for analysis on the basis of clinical significance of missed pills, according to clinic protocol. 8 Subjects missing three or fewer pills per pack were classified as consistent pill users (38% of all subjects) and those missing more than three pills per pack were classified as inconsistent users (62% of all subjects). Validation for the dichotomized measure of consistent oral contraceptive use was confirmed by significant associations with several criterion variables. Compared with inconsistent oral contraceptive users, consistent users had significantly more return visits to the clinic for additional prescriptions (58% vs 40%, P ~ 0.05), significantly fewer acts of unprotected intercourse (2% vs 39%, P ~ 0.05), significantly fewer pregnancy scares (20% vs 33%, P ~ 0.05), and fewer pregnancies (6% vs 12%, P ~ 0.08). Dysmenorrhea severity scale. The scale used in this analysis to measure the severity of dysmenorrhea is based on the one created by Andresch and Milsom 2 in a study of 19-year-old women. It ranks the severity of dysmenorrhea using information on how often the women experiences menstrual cramps, how painful she perceives them to be, and how often she cuts back on activities because of them (Table I). This information was gathered at the baseline interview and refers to the time period before oral contraceptive use was initiated and, for the postabortion patients, before the pregnancy resulting in the abortion at the index visit. The main difference between this scale and the Andresch and Milsom scale is that this one does not incorporate the use of analgesics as part of the measure. Experiencing any reduction in severe dysmenorrhea due to oral contraceptive use was hypothesized to be related to consistent use of oral contraceptives. It was measured by asking respondents about positive side effects of oral contraceptives during the first 3 months
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February 1992 Am J Obstet Gynecol
Table II. Prevalence and severity of dysmenorrhea in female adolescents attending a family planning elinic (n = 308) Severity
No dysmenorrhea Mild dysmenorrhea Moderate dysmenorrhea Severe dysmenorrhea
Cumulative percent, any dysmenorrhea
o 1
2 3
63 141 48 56
o
20.5 45.8 15.6 18.2
45.8 61.4 79.6
Table III. Dysmenorrhea by subject characteristics Severity Characteristic
Demographic factor Mean age (yr) Black (%) Mother's education (did not graduate from high school) (%) Parous before baseline (%) Early onset of menstruation (before age 12) (%) Sexual! contraceptive behavior Consistent pill users (%) Experiencing positive side effects (%) Intercourse at least once a week on average* (%) Somewhat or very happy about sext (%)
Intercourse is sometimes or always painfult (%) Health behavior (%) Return clinic visit§ Called clinic during follow-up Drink alcohol once a month or more Smoke once a month or more
0
1
1
J
2
I
All
3
subjects
p Value
16.3 76.2 22.2
16.1 75.2 18.4
16.1 81.3 22.9
16.1 76.8 26.8
16.2 76.6 21.4
1.00 0.86 0.62
22.2 24.6
12.1 31.2
4.2 47.9
8.9 33.9
12.3 33.0
0.03 0.07
38.1 55.6 27.0
37.6 66.7 33.3
35.4 76.6 35.4
42.9 69.6 41.1
38.3 66.0 33.8
0.88 0.12 0.44
69.8
74.5
62.5
62.5
69.5
0.26
14.3
27.0
29.2
37.5
26.6
0.04
33.3 25.4 15.9 12.7
46.8 30.5 24.8 22.0
60.4 33.3 22.9 18.8
48.2 25.0 19.6 32.1
46.4 28.9 21.8 21.1
0.04 0.70 0.52 0.08
*A count of the instances of vaginal intercourse reported was dichotomized at the mean (mean = 24 acts or an average of once a week). tSubjects were asked at baseline how they felt about having intercourse. Responses were on a five-point scale, ranging from very unhappy to very happy. tSubjects were asked at baseline if they ever experienced pain during intercourse, and if so how often it occurred. Responses were "almost never hurts," "sometimes hurts," "almost always hurts." §This is a return visit, to obtain oral contraceptives, to the same clinic where oral contraceptives were initially obtained.
of use and combining this information with their baseline reports of dysmenorrhea. Positive side effects measured in the first follow-up interview were reduced menstrual cramping and reduced menstrual bleeding; those experiencing either one or both of these (66% of subjects) were coded as having positive side effects of oral contraceptives. Experienced reduction of dysmenorrhea was calculated as an interaction term between having severe dysmenorrhea and experiencing positive side effects during the first 3 months of oral contraceptive use. Subjects were counted as experiencing a reduction in dysmenorrhea if they had both severe dysmenorrhea and experienced positive side effects (12.7% of subjects). The analysis also reports associations between dysmenorrhea and other variables relevant to dysmenorrhea and oral contraceptive use. (These variables, in-
eluding sociodemographic factors, sexual history, and health behaviors, are listed in Table III).
Results The overall prevalence of dysmenorrhea in this population was 79.6%; 45.8% (141 subjects) reported mild dysmenorrhea, 15.6% (48) reported moderate dysmenorrhea, and 18.2% (56) reported severe dysmenorrhea (Table II). These figures are similar to those reported by Andresch and Milsom 2 ; the overall prevalence is somewhat lower than that found in a study of 88 adolescent females. 9 The relationship between subject characteristics and severity of dysmenorrhea are displayed in Table III. There were no significant differences by age, race, or mother's education. Previous literature suggested that parity (parous vs non parous) would be negatively
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Table IV. Multiple logistic regression analysis of predictors of consistent oral contraceptive use* Predictor
Regression coefficient
Standard error
Relative oddst
p Value
Severe dysmenorrhea Experience one or more positive side effects Severe dysmenorrhea and one or more positive side effects (interaction term) Parous before baseline interview Started menstruation before age
- 1.250 0.297
0.821 0.300
0.29 1.35
0.13 0.32
2.080
0.903
8.04
0.02
-0.040 -0.113
0.427 0.274
0.96 0.89
0.93 0.68
-0.602
0.343
0.55
0.08
0.463
0.273
1.59
0.09
-0.368
0.293
0.69
0.21
0.500
0.255
1.65
0.05
12
Smoke cigarettes at least once a month Intercourse once a week or more Sometimes or always have painful intercourse Return visit to clinic
*All coefficients are adjusted for age, race, and mother's education. tThis is the antilog of the regression coefficient. It shows the expected change in odds of the outcome corresponding to a unit change in the predictor.
related to dysmenorrhea and that early onset of menstruation would be positively related to dysmenorrhea. 2 . 10 Early onset of menstruation was marginally significant (p ::; 0.07); those who began menstruating before age 12 were somewhat more likely to have dysmenorrhea. Parity was the only subject characteristic that was significant (p ::; 0.03). Those who were parous before baseline were less likely to report any degree of dysmenorrhea. Table III also presents information on the relationship of dysmenorrhea to contraceptive and sexual behaviors. In these bivariate analyses, dysmenorrhea was not significantly related to consistent oral contraceptive use or to experiencing less cramping or less bleeding during menstruation. It is of clinical interest that 30.4% of those with severe dysmenorrhea experienced neither of these positive side effects of oral contraceptives. Also notable is that the severity of dysmenorrhea was significantly associated with sometimes or always experiencing dyspareunia. Experiencing painful intercourse at least some of the time was reported by 14.3% of those without dysmenorrhea, 27% of those with mild dysmenorrhea, 29.2% of those with moderate dysmenorrhea, and 37.5% of those with severe dysmenorrhea. Although intercourse appears to be painful for a significant percentage of women with a dysmenorrhea, the latter subjects are just as likely to report having frequent intercourse (once a week or more) and to report being somewhat or very happy about having intercourse. Table III also presents the relationship of dysmenorrhea to a set of health behaviors. Those with any degree of dysmenorrhea are significantly more likely to return to the clinic where they initially received the pills over the 6-month follow-up period, although they are no more likely to call the clinic for advice during this time.
The relationship of dysmenorrhea to cigarette and alcohol use was also explored. On the basis of previous findings, it was hypothesized that there would be a positive relationship between dysmenorrhea and alcohol use lO and a relationship, although the literature has been mixed on the direction, with cigarette use. 2 . 3. I() Although no significant association between alcohol use and severity of dysmenorrhea was found, there was a positive and marginally significant association with cigarette use (p ::; 0.08). A multiple logistic regression analysis was used to examine the effects of severe dysmenorrhea, experiencing positive side effects of oral contraceptives, and an interaction term that represents experiencing a reduction of dysmenorrhea as a result of oral contraceptive use on consistent oral contraceptive use. The analysis controlled for variables that were potentially related to dysmenorrhea or oral contraceptive use. Three sociodemographic variables were included as covariates: age, race, and mother's education (a proxy for socioeconomic status). Previous research suggested that older adolescents, whites, and those with higher socioeconomic status are more compliant with contraception. II-II The results of this analysis appear in Table IV. The most statistically and clinically significant predictor of consistent oral contraceptive use was experiencing the reduction of dysmenorrhea as a result of oral contraceptive use; those with severe dysmenorrhea who reported positive side effects of the pill were eight times as likely to be consistent oral contraceptive users as others (p ::; 0.02). The only other statistically significant predictor of oral contraceptive use was returning to the same clinic for oral contraceptives (1.65 times as likely, p ::; 0.05) Two predictors, tobacco smoking and frequency of
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Robinson et al.
intercourse, were marginally significant. Those who smoked cigarettes at least once a month were about half as likely (0.55, P :5 0.08) to be consistent oral contraceptive users. Those who had intercourse at least once a week were 1.59 times more likely to be consistent oral contraceptive users (p :5 0.09). Other studies have reported similar findings. Frequency of intercourse was thought to increase the perceived risk of pregnancy, and thus those with more frequent intercourse would be expected to be more consistent oral contraceptive users. 15·17
Comment This analysis demonstrates that an important predictor of consistent oral contraceptive use among adolescent women attending an inner-city family planning clinic was experiencing the alleviation of dysmenorrhea during the first 3 months of oral contraceptive use. Both this finding and the finding of a high prevalence of dysmenorrhea in the adolescent population underscore the importance of screening for dysmenorrhea all women who are seen at family planning clinics. This screen can be as straightforward as the three-question scale used in this analysis, with further probing if a woman responds positively to these questions. Adolescents are often poorly informed about menstrual events. One studylS reported finding substantial ignorance and misinformation among female adolescents regarding the causes and treatment of dysmenorrhea. Once it is determined that an adolescent suffers from dysmenorrhea, it is important to presensitize her to the potential positive side effects of oral contraceptives. Many clinics routinely stress the negative side effects of oral contraceptives without giving similar emphasis to the positive ones. Without adequate information, an adolescent woman with dysmenorrhea may not connect the relief of her symptoms to consistent oral contraceptive use, nor might she use oral contraceptives long enough to experience relief. It is also important to follow up on women with dysmenorrhea to determine if they are experiencing alleviation of their symptoms. Fully 30.5% of the women with severe dysmenorrhea did not perceive experiencing any positive side effects of oral contraceptives. Having severe dysmenorrhea alone was not predictive of oral contraceptive use. Consistency of care, as measured by a return visit to the clinic, is important in the provision of health care to adolescent women. It was significantly and positively related to both having dysmenorrhea at baseline and using oral contraceptives consistently over the followup period. This implies that clinics should encourage their clients to return to the same site for care. This analysis also found several other health problems that were significantly related to dysmenorrhea. The prevalence of dyspareunia is so high in this pop-
February 1992 Am J Obstet Gyneco1
ulation that it is important for clinicians to ask about dyspareunia and to provide information on how to alleviate it. It is apparent that reproductive health care for adolescents needs to include an open and thorough discussion about sexual functioning. There was also a positive association between the severity of dysmenorrhea and smoking. Although the findings in the literature are mixed, one possibility is that adolescents with dysmenorrhea use cigarette smoking in an attempt to alleviate symptoms. If this is the case, it is vital that clinicians counsel these women on the health risks inherent in smoking and on alternate ways to relieve symptoms (such as consistent oral contraceptive or analgesic use). Although this study had several findings relevant to understanding dysmenorrhea and oral contraceptive use in female adolescents, it does have some limitations which need to be noted. The major limitation is that the population consisted of female adolescents who were motivated to seek contraception; they may not be representative of all sexually active adolescents or of all adolescents with dysmenorrhea. Another limitation is that the subjects were all recruited in one family planning clinic and may not be representative of all adolescents who seek contraceptive services. There have been few studies of the effect of dysmenorrhea on health behavior in female adolescents. A replication of this study is needed to confirm some of the findings and to further explore the relationship between dysmenorrhea, sexual health, and contraceptive use. We thank the clients, staff, and administrators of the Planned Parenthood clinic from which the respondents were recruited. REFERENCES 1. Dawood MY, McGuire JL, Demers LM, eds. Premenstrual syndrome and dysmenorrhea. Baltimore: Urban & Schwarzenberg, 1985:6, 79, 177. 2. Andresch B, Milsom I. An epidemiologic study of young women with dysmenorrhea. AM J OBSTET GYNECOL 1982; 144:655-60. 3. Sundell G, Milsom I, Andresch B. Factors influencing the prevalence and severity of dysmenorrhea in young women. Br J Obstet Gynaecol 1990;97:588-94. 4. Milsom I, Sundell G, Andresch B. The influence of different combined oral contraceptives on the prevalence and severity of dysmenorrhea. Contraception 1990; 42:497-506. 5. Lalos 0, Jeolsson I. Effect of an oral contraceptive on uterine tonicity in women with primary dysmenorrhea. Acta Obstet Gynecol Scand 1981;60:229-32. 6. Mathews AEB, Clarke JFE. Double-blind trial of a sequential contraceptive (Sequencs) in the treatment of dysmenorrhea. J Obstet Gynaecol Br Commonw 1968; 75: 11l7-22. 7. Weisman CS, Plichta S, Nathanson CA, Chase GA, Ensminger M, RobinsonJC. Adolescent women's contraceptive decision making. J Health Soc Behav 1991;32:13044. 8. Hatcher RA, Guest F, Stewart F, Stewart GK. Contraceptive technology 1986-1987. New York: Irvington, 1986.
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9. Wilson CA, Keye WR. A survey of adolescent dysmenorrhea and premenstrual symptom frequency . .l Adoles Health Care 1989;10:317-22. 10. Teperi .l, Rimpela M. Menstrual pain, health and behaviour in girls. Soc Sci Med 1989;29: 163-9. 11. Emans S.l, Grace E, Woods ER, Smith DE, Klein K, Merola J. Adolescents' compliance with the use of oral contraceptives . .lAMA 1990;257:3377-81. 12. Furstenberg FF, SheaJ, Allison P, Herceg-Baron R, Webb D. Contraceptive continuation among adolescents attending family planning clinics. Fam Plann Perspect 1983;15:211-17. 13. Hofferth SL. Contraceptive decision making. In: Hayes CD, ed. Risking the future: adolescent sexuality, pregnancy and childbearing. Washington: National Academy Press 1987, vol 2.
Dysmenorrhea and use of oral contraceptives
14. Philliber S, Nameroe PB, Kaye .lW, Kunkes CH. Pregnancy risk taking among adolescents. .l Adolesc Res 1986; 1:463-81. 15. Durant RH,Jay MS. A social psychologic model offemale adolescents' compliance with contraceptives. Semin Adolesc Med 1987;3:135-44. 16. Durant RH, Sanders JM. Sexual behavior and contraceptive risk taking among sexually active adolescent females. J Adolesc Health Care 1989;10:1-9. 17. White HR, Johnson V. Risk taking as a predictor of adolescent sexual activity and use of contraception. J Adolesc Res 1988;3:317-31. 18. Johnson J. Level of knowledge among adolescent girls regarding effective treatment for dysmenorrhea. J Adolesc Health Care 1988;9:398-402.
Nonsurgical management of penetrating uterine trauma in pregnancy: A case report Debra K. Grubb, MD Los Angeles, California A woman at 30 weeks' gestation with stab wounds entering the uterus was managed nonsurgically by serial examinations and continuous fetal monitoring. Delivery occurred 4 weeks later with good maternal and fetal outcome. (AM J OasTET GYNECOL 1992;166:583-4.)
Key words: Abdominal injuries, pregnancy, stab wounds
Penetrating abdominal trauma is an uncommon complication of pregnancy, with gunshot wounds much more common than stab wounds. I We report a case of multiple stab wounds to the abdomen of a pregnant woman, with documented penetration of the uterus, which was managed non surgically with a good outcome.
Case report A 26-year-old Hispanic woman at 30 weeks of gestation in her first pregnancy was brought to the hospital by ambulance after her husband inflicted multiple stab wounds to the abdomen and upper extremities with a steak knife. On admission, the patient was hemodynamically stable and the fetal heart rate was 140 From the Department of Obstetrics and Gynecology, Universit} of Southern California. Received for publication June 18, 1991; accepted August 8, 1991. Reprint requests: Debra K. Grubb, MD, Women's Hospital, Room 5K40, 1240 N. Mission Road, Los Angeles, CA 90033. 611133027
beats/min. Stab wounds to the hands, right upper arm, and abdomen were cleaned and dressed. Obstetric ultrasonography revealed a single fetus in a breech presentation, with an estimated fetal weight of 1928 gm and no evidence of fetal injury. The fetal head was directly below one of the wounds. There was a normal amniotic fluid volume, and the placenta was anterior with no evidence of retroplacental blood clot. Continuous fetal heart rate monitoring, serial hematocrit determinations, and serial abdominal examinations were undertaken. A Kleihauer-Betke test for fetal erythrocytes was negative. An amniocentesis was performed to rule out amnionitis. The amniotic fluid was grossly bloody, but Gram stain and subsequent culture did not reveal any organisms. The hematocrit was stable over 24 hours at 30%, the fetal heart rate was reactive without decelerations, and no signs of peritonitis developed. The patient was then observed in the hospital for an additional 48 hours. No signs of infection developed, and she was discharged from the hospital. In the obstetrics clinic, there were normal heart tones and her wounds were healing well. At 34 weeks of
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