IJG-07911; No of Pages 3 International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
BRIEF COMMUNICATION
Prevalence and etiology of menstrual disorders in Lebanese university students Rayane Kabbara a, Fouad Ziade b, Marie-Hélène Gannagé-Yared c,⁎ a b c
Faculty of Pharmacy, Saint-Joseph University, Beirut, Lebanon Faculty of Public Health, Lebanese University, Tripoli, Lebanon Department of Endocrinology, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
a r t i c l e
i n f o
Article history: Received 9 October 2013 Received in revised form 13 January 2014 Accepted 19 March 2014 Keywords: Lebanon Menstrual disorders University students
A small number of publications, primarily from Europe [1,2], have reported on menstrual disorders in a broad set of adolescents and medical students. Publications from Lebanon have focused on dysmenorrhea and premenstrual syndrome in select samples of students from a single university [3,4] or town in South Lebanon [5], but did not investigate all menstrual cycle abnormalities or their relationship with lifestyle. The present cross-sectional study was performed on a population-based sample of 18 − 25-year-old students from 6 universities in Lebanon. The study was approved by the Saint-Joseph University Ethics Committee. All participants provided written, informed consent for inclusion. The questionnaire was distributed in French and English to a large student population via university classes (360 students) and Facebook (359 students). A total of 502 students took part (325 and 177 from each group). The final analysis was performed on 452 completed questionnaires after exclusion of respondents using contraceptive pills (41 students) and non-valid responses (9 students). The questionnaire included 25 items on anthropometric and menstrual cycle characteristics. Additional information concerning lifestyle (smoking habits, physical activity, adherence to low-calorie or vegetarian diets, and degree of daily stress) was also collected. The results were analyzed using SPSS version 19 (IBM, Armonk, USA) using ANOVA, Pearson coefficient correlation, and χ2 test. P b 0.05 was considered statistically significant.
⁎ Corresponding author at: Division of Endocrinology, Hotel-Dieu de France Hospital, Boulevard Alfred Naccache Achrafieh, Beirut, Lebanon. Tel.: +961 3291301; fax: +961 1615295. E-mail address: [email protected] (M.-H. Gannagé-Yared).
The general characteristics of the study population and subgroups, according to university discipline, are shown in Table 1. The students’ mean age at menarche was lower than their mothers’ age (P b 0.001). There was a significant difference in age between the 3 university disciplines (P b 0.001). Students from medical schools had the lowest body mass index compared with others (P = 0.009). They also reported the highest percentage of daily stress (as a total of both low and significant daily stress) and followed a low-calorie diet more frequently (P = 0.09 and P = 0.29, respectively). Students from paramedical schools were the most adherent to a vegetarian diet (P = 0.007). Although a high percentage of participants presented a normal duration of bleeding (84.5%), normal menstruation interval (85.9%), and normal bleeding intensity (80.5%), 89.6% of respondents suffered from pain before (40.0%) and/or during menses (86.5%), and 30.5% described the pain as severe (Table 2). The most commonly reported menstrual cycle abnormalities were: dysmenorrhea (severe pain during menses) 26.8%; hypermenorrhea (heavy bleeding and/or bleeding N7 days) 23.9%; oligomenorrhea (menstrual interval N35 days) 9.6%; hypomenorrhea (low bleeding and/or bleeding b 3 days) 6.9%; and polymenorrhea (menstrual interval b 21 days) 4.5%. Premenstrual pain was positively associated with the degree of daily stress and negatively associated with adherence to a vegetarian diet (P b 0.05 for both variables). Dysmenorrhea was negatively associated with adherence to both vegetarian and low-calorie diets (P b 0.01 and P b 0.05, respectively), while duration of bleeding was negatively associated with smoking (P b 0.01). Oligomenorrhea was positively associated with age (P b 0.05). No significant relationship was observed between intensity of bleeding and the studied parameters. According to the multi-regression analysis, vegetarian and low-calorie diets were the only independent factors inversely associated with premenstrual pain and dysmenorrhea respectively (P b 0.05 for both). The present study showed that approximately 85% of students had a normal menstrual interval, duration of bleeding, and intensity of bleeding. However, 90% suffered from pain before and/or during menses, of which 26.8% had dysmenorrhea. In another Lebanese study [4], dysmenorrhea (defined as pain during menses) affected 74.3% of adolescents. This result was almost 50% higher than the results of the present study, possibly owing to a stricter definition of dysmenorrhea. In comparison with an Italian study [1], dysmenorrhea was more prevalent in the present study (10% vs 27%). Ethnic differences could explain these findings since significant heterogeneity is found between countries. It is also surprising to note that in the Lebanese study [4] the frequency of a bleeding
http://dx.doi.org/10.1016/j.ijgo.2014.01.010 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Kabbara R, et al, Prevalence and etiology of menstrual disorders in Lebanese university students, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.01.010
2
R. Kabbara et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
Table 1 General characteristics of Lebanese university students included in the study (n = 452).a Characteristics
Total sample (n = 452)
Paramedicalb (n = 155)
Medicalc (n = 175)
Otherd (n = 122)
P value
Age, y Body mass index Weight, kg Height, cm Birth weight, kg Age at menarche, y Mother's age at menarche, y Degree of daily stress No stress Low stress Significant stress Low calorie diet No Yes Strictly vegetarian diet No Yes Physical activity None Once/week Twice/week 3 times/week N3 times/week Smoking No b10 cigarettes/day N10 cigarettes/day
20.83 ± 1.71 21.30 ± 3.47 57.81 ± 8.95 164.5 ± 6.10 3.11 ± 0.64 12.49 ± 1.40 12.80 ± 1.43
20.13 ± 1.46 21.96 ± 3.78 58.47 ± 10.7 163.6 ± 6.63 3.06 ± 0.65 12.65 ± 1.39 13.00 ± 1.46
21.51 ± 1.33 20.75 ± 3.04 56.82 ± 7.56 165.0 ± 5.96 3.19 ± 0.64 12.30 ± 1.51 12.65 ± 1.47
20.69 ± 1.99 21.34 ± 3.57 58.45 ± 8.42 164.7 ± 5.58 3.03 ± 0.61 12.56 ± 1.22 12.83 ± 1.33
b0.001 0.009
45 (10.0) 210 (46.4) 197 (43.6)
22 (14.2) 79 (51.0) 54 (34.8)
11 (6.3) 81 (46.3) 83 (47.4)
12 (9.8) 50 (41.0) 60 (49.2)
363 (80.3) 89 (19.7)
132 (85.2) 23 (14.8)
136 (77.7) 39 (22.3)
95 (77.9) 27 (22.1)
425 (94.0) 27 (6.0)
139 (89.7) 16 (10.3)
170 (97.1) 5 (2.9)
116 (95.1) 6 (4.9)
217 (48.0) 90 (19.9) 80 (17.7) 33 (7.3) 32 (7.1)
71 (45.8) 31 (20.0) 30 (19.4) 14 (9.0) 9 (5.8)
91 (52.0) 36 (20.6) 26 (14.9) 9 (5.1) 13 (7.4)
55 (45.1) 23 (18.9) 24 (19.7) 10 (8.2) 10 (8.2)
417 (92.2) 23 (5.1) 12 (2.7)
142 (91.6) 9 (5.8) 4 (2.6)
163 (93.1) 10 (5.7) 2 (1.2)
112 (91.8) 4 (3.3) 6 (4.9)
a b c d
0.13 0.83 0.62 0.094
0.288
0.007
0.606
0.311
Values are given as number (percentage) or mean ± SD unless otherwise indicated. Nutrition, physiotherapy, nursing, psychology, optometry, midwife. Medicine, pharmacy, dentistry. Business, art, engineering, political science, public health, architecture, education, law, communication, biochemistry, economics, letters, sociology, marketing, finance, literature.
duration of more than 7 days and excessive bleeding were much higher among adolescents than in the present study (55.3% vs 13.9% for bleeding duration; 27% vs 13.7% for intensity of bleeding). The results of the present study were similar to the Italian study for bleeding duration of more than 6 days (19%). Finally, 9.6% of students had a menstruation interval of more than 35 days. This percentage is similar to that observed in a study of Lebanese nursing students (10.5%) [3], but higher than in the Italian study (3.4%). Different socioeconomic levels and/or a higher prevalence of polycystic ovary syndrome in Lebanon
Table 2 Characteristics of the respondents’ menstrual cycle (n = 452). Characteristics Bleeding period, d b3 3−7 N7 Length of menstruation interval, d b21 21 − 35 N35 Pain before or during the menstrual cycle No pain Yes, before Yes, during 1st and 2nd days Yes, during 3rd and 4th days Intensity of the pain Low pain Moderate pain Severe pain Intensity of bleeding Low bleeding Normal bleeding Excessive bleeding
No. (%) 7 (1.6) 382 (84.5) 63 (13.9) 21 (4.5) 388 (85.9) 43 (9.6) 47 (10.4) 183 (40.5) 359 (79.4) 32 (7.1) 66 (14.5) 248 (55.0) 138 (30.5) 26 (5.8) 364 (80.5) 62 (13.7)
may explain these variations. The present study and the Italian study [1] showed a similar short menstruation interval (4.5% vs 3%). While the Lebanese study found a negative association between age and dysmenorrhea [4] and the Italian study found a positive relationship between age and dysmenorrhea [1], the results of the present study were similar to a French study [2] in which age did not influence menstrual pain. The present study also found that age was associated with increased menstrual interval. Similarly, age was associated with irregular cycles in another Lebanese study [3]. Finally, no relationship was found between body mass index and menstrual disorders. Daily stress was positively associated with premenstrual pain, while adherence to a vegetarian diet was inversely associated with this disorder. Previous studies have found an impact of daily stress on dysmenorrhea [6]. In addition, a US study showed that a low-fat, vegetarian diet reduced dysmenorrhea and premenstrual symptoms [7]. This finding was attributed to an increase in sex hormone binding globulin concentration, which resulted in decreased estrogen levels. Moreover, the present study found that a low-calorie diet had an independent beneficial effect on dysmenorrhea. Age at menarche of both students and their mothers were similar to the results of an Italian study [1]. The declining age of menarche observed in the present study has also been demonstrated in WesternEuropean countries and could be explained by better living standards [1]. In conclusion, menstrual cycle abnormalities are uncommon in Lebanese university students. However, pain before or during menses is a frequent complaint. In addition, diet (whether strictly vegetarian or low calorie) is the only independent protective factor against dysmenorrhea. Education should focus on the importance of a healthy low-calorie diet to reduce painful symptoms. Conflict of interest The authors have no conflicts of interest.
Please cite this article as: Kabbara R, et al, Prevalence and etiology of menstrual disorders in Lebanese university students, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.01.010
R. Kabbara et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
References [1] Rigon F, De Sanctis V, Bernasconi S, Bianchin L, Bona G, Bozzola M, et al. Menstrual pattern and menstrual disorders among adolescents: an update of the Italian data. Ital J Pediatr 2012;38:38. [2] Potter J, Bouyer J, Trussell J, Moreau C. Premenstrual syndrome prevalence and fluctuation over time: results from a French population-based survey. J Womens Health (Larchmt) 2009;18(1):31–9. [3] Karout N, Hawai SM, Altuwaijri S. Prevalence and pattern of menstrual disorders among Lebanese nursing students. East Mediterr Health J 2012;18(4):346–52.
3
[4] Attieh E, Maalouf S, Richa S, Kesrouani A. Premenstrual syndrome among Lebanese medical students and residents. Int J Gynecol Obstet 2013;121(2):184–5. [5] Santina T, Wehbe N, Ziade F. Exploring dysmenorrhoea and menstrual experiences among Lebanese female adolescents. East Mediterr Health J 2012;18(8): 857–63. [6] Ju H, Jones M, Mishra G. The prevalence and risk factors of dysmenorrhea. Epidemiol Rev 2014;36(1):104–13. [7] Barnard ND, Scialli AR, Hurlock D, Bertron P. Diet and sex-hormone binding globulin, dysmenorrhea, and premenstrual symptoms. Obstet Gynecol 2000;95(2): 245–50.
Please cite this article as: Kabbara R, et al, Prevalence and etiology of menstrual disorders in Lebanese university students, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.01.010
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
BRIEF COMMUNICATION
Prevalence and etiology of menstrual disorders in Lebanese university students Rayane Kabbara a, Fouad Ziade b, Marie-Hélène Gannagé-Yared c,⁎ a b c
Faculty of Pharmacy, Saint-Joseph University, Beirut, Lebanon Faculty of Public Health, Lebanese University, Tripoli, Lebanon Department of Endocrinology, Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
a r t i c l e
i n f o
Article history: Received 9 October 2013 Received in revised form 13 January 2014 Accepted 19 March 2014 Keywords: Lebanon Menstrual disorders University students
A small number of publications, primarily from Europe [1,2], have reported on menstrual disorders in a broad set of adolescents and medical students. Publications from Lebanon have focused on dysmenorrhea and premenstrual syndrome in select samples of students from a single university [3,4] or town in South Lebanon [5], but did not investigate all menstrual cycle abnormalities or their relationship with lifestyle. The present cross-sectional study was performed on a population-based sample of 18 − 25-year-old students from 6 universities in Lebanon. The study was approved by the Saint-Joseph University Ethics Committee. All participants provided written, informed consent for inclusion. The questionnaire was distributed in French and English to a large student population via university classes (360 students) and Facebook (359 students). A total of 502 students took part (325 and 177 from each group). The final analysis was performed on 452 completed questionnaires after exclusion of respondents using contraceptive pills (41 students) and non-valid responses (9 students). The questionnaire included 25 items on anthropometric and menstrual cycle characteristics. Additional information concerning lifestyle (smoking habits, physical activity, adherence to low-calorie or vegetarian diets, and degree of daily stress) was also collected. The results were analyzed using SPSS version 19 (IBM, Armonk, USA) using ANOVA, Pearson coefficient correlation, and χ2 test. P b 0.05 was considered statistically significant.
⁎ Corresponding author at: Division of Endocrinology, Hotel-Dieu de France Hospital, Boulevard Alfred Naccache Achrafieh, Beirut, Lebanon. Tel.: +961 3291301; fax: +961 1615295. E-mail address: [email protected] (M.-H. Gannagé-Yared).
The general characteristics of the study population and subgroups, according to university discipline, are shown in Table 1. The students’ mean age at menarche was lower than their mothers’ age (P b 0.001). There was a significant difference in age between the 3 university disciplines (P b 0.001). Students from medical schools had the lowest body mass index compared with others (P = 0.009). They also reported the highest percentage of daily stress (as a total of both low and significant daily stress) and followed a low-calorie diet more frequently (P = 0.09 and P = 0.29, respectively). Students from paramedical schools were the most adherent to a vegetarian diet (P = 0.007). Although a high percentage of participants presented a normal duration of bleeding (84.5%), normal menstruation interval (85.9%), and normal bleeding intensity (80.5%), 89.6% of respondents suffered from pain before (40.0%) and/or during menses (86.5%), and 30.5% described the pain as severe (Table 2). The most commonly reported menstrual cycle abnormalities were: dysmenorrhea (severe pain during menses) 26.8%; hypermenorrhea (heavy bleeding and/or bleeding N7 days) 23.9%; oligomenorrhea (menstrual interval N35 days) 9.6%; hypomenorrhea (low bleeding and/or bleeding b 3 days) 6.9%; and polymenorrhea (menstrual interval b 21 days) 4.5%. Premenstrual pain was positively associated with the degree of daily stress and negatively associated with adherence to a vegetarian diet (P b 0.05 for both variables). Dysmenorrhea was negatively associated with adherence to both vegetarian and low-calorie diets (P b 0.01 and P b 0.05, respectively), while duration of bleeding was negatively associated with smoking (P b 0.01). Oligomenorrhea was positively associated with age (P b 0.05). No significant relationship was observed between intensity of bleeding and the studied parameters. According to the multi-regression analysis, vegetarian and low-calorie diets were the only independent factors inversely associated with premenstrual pain and dysmenorrhea respectively (P b 0.05 for both). The present study showed that approximately 85% of students had a normal menstrual interval, duration of bleeding, and intensity of bleeding. However, 90% suffered from pain before and/or during menses, of which 26.8% had dysmenorrhea. In another Lebanese study [4], dysmenorrhea (defined as pain during menses) affected 74.3% of adolescents. This result was almost 50% higher than the results of the present study, possibly owing to a stricter definition of dysmenorrhea. In comparison with an Italian study [1], dysmenorrhea was more prevalent in the present study (10% vs 27%). Ethnic differences could explain these findings since significant heterogeneity is found between countries. It is also surprising to note that in the Lebanese study [4] the frequency of a bleeding
http://dx.doi.org/10.1016/j.ijgo.2014.01.010 0020-7292/© 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: Kabbara R, et al, Prevalence and etiology of menstrual disorders in Lebanese university students, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.01.010
2
R. Kabbara et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
Table 1 General characteristics of Lebanese university students included in the study (n = 452).a Characteristics
Total sample (n = 452)
Paramedicalb (n = 155)
Medicalc (n = 175)
Otherd (n = 122)
P value
Age, y Body mass index Weight, kg Height, cm Birth weight, kg Age at menarche, y Mother's age at menarche, y Degree of daily stress No stress Low stress Significant stress Low calorie diet No Yes Strictly vegetarian diet No Yes Physical activity None Once/week Twice/week 3 times/week N3 times/week Smoking No b10 cigarettes/day N10 cigarettes/day
20.83 ± 1.71 21.30 ± 3.47 57.81 ± 8.95 164.5 ± 6.10 3.11 ± 0.64 12.49 ± 1.40 12.80 ± 1.43
20.13 ± 1.46 21.96 ± 3.78 58.47 ± 10.7 163.6 ± 6.63 3.06 ± 0.65 12.65 ± 1.39 13.00 ± 1.46
21.51 ± 1.33 20.75 ± 3.04 56.82 ± 7.56 165.0 ± 5.96 3.19 ± 0.64 12.30 ± 1.51 12.65 ± 1.47
20.69 ± 1.99 21.34 ± 3.57 58.45 ± 8.42 164.7 ± 5.58 3.03 ± 0.61 12.56 ± 1.22 12.83 ± 1.33
b0.001 0.009
45 (10.0) 210 (46.4) 197 (43.6)
22 (14.2) 79 (51.0) 54 (34.8)
11 (6.3) 81 (46.3) 83 (47.4)
12 (9.8) 50 (41.0) 60 (49.2)
363 (80.3) 89 (19.7)
132 (85.2) 23 (14.8)
136 (77.7) 39 (22.3)
95 (77.9) 27 (22.1)
425 (94.0) 27 (6.0)
139 (89.7) 16 (10.3)
170 (97.1) 5 (2.9)
116 (95.1) 6 (4.9)
217 (48.0) 90 (19.9) 80 (17.7) 33 (7.3) 32 (7.1)
71 (45.8) 31 (20.0) 30 (19.4) 14 (9.0) 9 (5.8)
91 (52.0) 36 (20.6) 26 (14.9) 9 (5.1) 13 (7.4)
55 (45.1) 23 (18.9) 24 (19.7) 10 (8.2) 10 (8.2)
417 (92.2) 23 (5.1) 12 (2.7)
142 (91.6) 9 (5.8) 4 (2.6)
163 (93.1) 10 (5.7) 2 (1.2)
112 (91.8) 4 (3.3) 6 (4.9)
a b c d
0.13 0.83 0.62 0.094
0.288
0.007
0.606
0.311
Values are given as number (percentage) or mean ± SD unless otherwise indicated. Nutrition, physiotherapy, nursing, psychology, optometry, midwife. Medicine, pharmacy, dentistry. Business, art, engineering, political science, public health, architecture, education, law, communication, biochemistry, economics, letters, sociology, marketing, finance, literature.
duration of more than 7 days and excessive bleeding were much higher among adolescents than in the present study (55.3% vs 13.9% for bleeding duration; 27% vs 13.7% for intensity of bleeding). The results of the present study were similar to the Italian study for bleeding duration of more than 6 days (19%). Finally, 9.6% of students had a menstruation interval of more than 35 days. This percentage is similar to that observed in a study of Lebanese nursing students (10.5%) [3], but higher than in the Italian study (3.4%). Different socioeconomic levels and/or a higher prevalence of polycystic ovary syndrome in Lebanon
Table 2 Characteristics of the respondents’ menstrual cycle (n = 452). Characteristics Bleeding period, d b3 3−7 N7 Length of menstruation interval, d b21 21 − 35 N35 Pain before or during the menstrual cycle No pain Yes, before Yes, during 1st and 2nd days Yes, during 3rd and 4th days Intensity of the pain Low pain Moderate pain Severe pain Intensity of bleeding Low bleeding Normal bleeding Excessive bleeding
No. (%) 7 (1.6) 382 (84.5) 63 (13.9) 21 (4.5) 388 (85.9) 43 (9.6) 47 (10.4) 183 (40.5) 359 (79.4) 32 (7.1) 66 (14.5) 248 (55.0) 138 (30.5) 26 (5.8) 364 (80.5) 62 (13.7)
may explain these variations. The present study and the Italian study [1] showed a similar short menstruation interval (4.5% vs 3%). While the Lebanese study found a negative association between age and dysmenorrhea [4] and the Italian study found a positive relationship between age and dysmenorrhea [1], the results of the present study were similar to a French study [2] in which age did not influence menstrual pain. The present study also found that age was associated with increased menstrual interval. Similarly, age was associated with irregular cycles in another Lebanese study [3]. Finally, no relationship was found between body mass index and menstrual disorders. Daily stress was positively associated with premenstrual pain, while adherence to a vegetarian diet was inversely associated with this disorder. Previous studies have found an impact of daily stress on dysmenorrhea [6]. In addition, a US study showed that a low-fat, vegetarian diet reduced dysmenorrhea and premenstrual symptoms [7]. This finding was attributed to an increase in sex hormone binding globulin concentration, which resulted in decreased estrogen levels. Moreover, the present study found that a low-calorie diet had an independent beneficial effect on dysmenorrhea. Age at menarche of both students and their mothers were similar to the results of an Italian study [1]. The declining age of menarche observed in the present study has also been demonstrated in WesternEuropean countries and could be explained by better living standards [1]. In conclusion, menstrual cycle abnormalities are uncommon in Lebanese university students. However, pain before or during menses is a frequent complaint. In addition, diet (whether strictly vegetarian or low calorie) is the only independent protective factor against dysmenorrhea. Education should focus on the importance of a healthy low-calorie diet to reduce painful symptoms. Conflict of interest The authors have no conflicts of interest.
Please cite this article as: Kabbara R, et al, Prevalence and etiology of menstrual disorders in Lebanese university students, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.01.010
R. Kabbara et al. / International Journal of Gynecology and Obstetrics xxx (2014) xxx–xxx
References [1] Rigon F, De Sanctis V, Bernasconi S, Bianchin L, Bona G, Bozzola M, et al. Menstrual pattern and menstrual disorders among adolescents: an update of the Italian data. Ital J Pediatr 2012;38:38. [2] Potter J, Bouyer J, Trussell J, Moreau C. Premenstrual syndrome prevalence and fluctuation over time: results from a French population-based survey. J Womens Health (Larchmt) 2009;18(1):31–9. [3] Karout N, Hawai SM, Altuwaijri S. Prevalence and pattern of menstrual disorders among Lebanese nursing students. East Mediterr Health J 2012;18(4):346–52.
3
[4] Attieh E, Maalouf S, Richa S, Kesrouani A. Premenstrual syndrome among Lebanese medical students and residents. Int J Gynecol Obstet 2013;121(2):184–5. [5] Santina T, Wehbe N, Ziade F. Exploring dysmenorrhoea and menstrual experiences among Lebanese female adolescents. East Mediterr Health J 2012;18(8): 857–63. [6] Ju H, Jones M, Mishra G. The prevalence and risk factors of dysmenorrhea. Epidemiol Rev 2014;36(1):104–13. [7] Barnard ND, Scialli AR, Hurlock D, Bertron P. Diet and sex-hormone binding globulin, dysmenorrhea, and premenstrual symptoms. Obstet Gynecol 2000;95(2): 245–50.
Please cite this article as: Kabbara R, et al, Prevalence and etiology of menstrual disorders in Lebanese university students, Int J Gynecol Obstet (2014), http://dx.doi.org/10.1016/j.ijgo.2014.01.010
