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Background : Primary dysmenorrhea is painful menstrual bleeding that occurs in the absence of any underlying pelvic disease. It is the most common gynecological problem among women, especially in teens. Objective : This study aims to determine the prevalence and management of primary dysmenorrhea among female high schools in Yangon Adventist Seminary. Method: A descriptive study was carried out among female high school students at Yangon Adventist Seminary. 69 students participated voluntarily in this study, which was selected using a purposive sampling method. The questionnaire was distributed through a google form


Background
Dysmenorrhea is a medical word for pain that occurs just before and/or during the menstrual period. This word is derived from the Greek words "dys" and "rrhea," which mean "difficult, painful, or unnatural flow". 1 Dysmenorrhea is uncommon in the first or two years of menstruation since early menstrual cycles are frequently anovulatory (without ovulation) due to immaturity of the hypothalamic-pituitary-ovarian axis. Menstrual pain begins with the onset of ovulation. 2 Dysmenorrhea can be classified into primary (spasmodic) and secondary (congestive).

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production causes uterine hypercontractility, which reduces blood supply to the uterus and increases nerve sensitivities, resulting in pain in primary dysmenorrhea. Women with primary dysmenorrhea have a level of prostaglandin that is 10 times higher than asymptomatic women. 3 The pain normally starts a few hours before menstrual bleeding and lasts no more than 72 hours. 4 The pain is the most intense during the first 24-36 hours of menstruation. 5 A sharp, muscle spasms pain that commonly occurs in the suprapubic (lower abdomen) area, and it may spread to the lower back or down to the legs. It frequently follows other symptoms, including diarrhea, abdominal distention, nausea, vomiting, breast tenderness and other biological symptoms. 2 Secondary dysmenorrhea is menstrual pain caused by pelvic or uterine diseases. The causes of secondary dysmenorrhea include endometriosis, fibroids, adenomyosis, pelvic inflammatory disease, ovarian cysts, cervical stenosis and vaginal anomalies. 1 Among all pelvic diseases, endometriosis is the leading cause of secondary dysmenorrhea. 3 Endometriosis is the growth of tissue outside of the uterus that resembles endometrium and reacts to hormonal stimuli similar to the uterine lining. 4 In the case of secondary dysmenorrhea, the pain may get worse at the end of the menstruation. 6 The percentage of women of reproductive age who experience dysmenorrhea ranges between 45 and 95 percent. 7 It is the most prevalent gynecological condition among women, especially common in teens. 8 Young and nulliparous women are the most likely to experience primary dysmenorrhea. 4 It is one of the most common reasons for missing school or work, and it has a detrimental impact on quality of life, everyday activities, work productivity, and academic activities. 9 Dysmenorrhea also impacts the mental health of an individual. The study by Sahin et al. (2018), showed that adolescents with dysmenorrhea have higher depression and anxiety levels and lower quality of life than other adolescents. 10 Primary dysmenorrhea, on the other hand, gets better after childbirth. 11 Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, aspirin and naproxen are the first-line treatments for primary dysmenorrhea. They are very effective in relieving pain, and can prevent other symptoms such as nausea and diarrhea. 12 If symptoms are not improved with NSAIDs, a low dose of the combination of estrogen and progestin oral contraceptives (COCs) can be taken. 2 Myometrial contractility and prostaglandin synthesis are decreased as a result of hormonal contraception's suppression of ovulation and the development of an atrophic endometrium. 3 Endometriosis should be further investigated in cases of dysmenorrhea that do not improve with the use of NSAIDs and COCs. 2 However, women with dysmenorrhea seek alternative or traditional medicine and non-pharmacological treatments due to pharmacologic side effects. 9 Non-pharmacologic treatments that are successful at reducing the symptoms of primary dysmenorrhea include yoga, exercise, acupuncture, acupressure, heating pad and transcutaneous electrical nerve stimulation. 13 There had been few studies on dysmenorrhea among women in Myanmar. As a result, with the aim to improve awareness and quality of life among young women with primary dysmenorrhea, the aim of this research is to determine the prevalence and management of primary dysmenorrhea among female high school students in "Yangon Adventist Seminary".

Method
This research is a cross-sectional study that is aimed to determine the prevalence and management of primary dysmenorrhea among female high schools in Yangon Adventist OAJJHS Seminary. The most common symptoms of dysmenorrhea before and during the menstruation period are also collected in this study. The sample in this study was high school female students from ninth grade through twelfth grade with an age range from 13 to 19 years old. The sample was selected using purposive sampling, and 69 students were willing to participate voluntarily in this study.
Data were collected by using the self-administered questionnaire which was created for this study. The questionnaire "Prevalence and Management of Dysmenorrhea" was anonymously completed by each respondent who voluntarily consented to participate in this study. The questionnaire consists of two parts. The first part of the questionnaire is to select respondents who have dysmenorrhea and those who have never. Respondents who experienced dysmenorrhea and were willing to participate voluntarily in the study were welcome to fill out the second part of the questionnaire. The second part of the questionnaire accessed the frequency, severity, general symptoms before and during the menstrual period, and the management of primary dysmenorrhea. The effectiveness of each treatment for dysmenorrhea is classified into four levels; very effective (4), effective (3), less effective (2), and not effective (1). Data collection was carried out on August 21 to 23, 2022.
Statistical Package for Social Sciences 23 (SPSS 23) was used to analyze the data. Demographic data and history of the menstrual period, the prevalence of dysmenorrhea, its frequency and intensity are presented in the table. The symptoms of dysmenorrhea before and after the menstrual period are shown by using bar graphs. The management and its level of effectiveness are presented in the table. The data is presented in frequency, percentage, standard deviation, and mean.
The study was approved by the University of Adventist Indonesia, Nursing Faculty Ethic Committees on August 8, 2022. The permission to conduct the study at Yangon Adventist Seminary was obtained from the school. Prior to filling out the questionnaire the aim of the study was explained to the respondents and allowed them to ask if there was any question related to this study. The informed consent was obtained in the google form. Personal identification was omitted from the questionnaire to ensure confidentiality, and the data obtained was secured to prevent disclosure. Out of 92 students in grades 9 through 12 at Yangon Adventist Seminary, 69 (75%), between the ages of 13 and 18, willingly decided to participate and filled out the questionnaire. Table 1 shows the demographical data and the history of the menstrual period of the respondents. The average age of the participants was 16.19 years with a standard deviation + +/-1.19 years. Most respondents 31 (45%) are from grade 9. The majority of the respondents are Bamar (36%) and Karen (30.4%). Menarche (the first menstruation or bleeding) occurred at an average age of 12.07 years, with a +/-1.03-year standard deviation. Out of 69 participants, 59.4% have normal menstrual cycles, while the rest respondents have irregular cycles. The majority of the respondents' 34 (49.3%) periods lasted 3-5 days. Nearly 44% of the respondents have a family history of dysmenorrhea.  Table 2 is presenting the prevalence of primary dysmenorrhea, its frequency and its severity. The results of this study showed that 57 (82.6%) of the students reported that they were suffering from primary dysmenorrhea. We assessed and categorize how frequently the students had primary dysmenorrhea, and the respondents reported that 21 (36.8%) of them had The three most common symptoms of primary dysmenorrhea experienced by the respondents before the menstrual period were mood swings 40 (70.2%), depression 29 (50.9%), abdominal pain and back pain 28 (49.1%). Other symptoms reported by the respondents before the menstrual period were the appearance of acne 22 (38.6%), fullness and tenderness of the breast 15 (26.3%), headache 15 (26.3%), leg pain 1 (1.8%), and pelvic pain 1 (1.8%). The three most common symptoms of primary dysmenorrhea among these high school students during the menstrual period were similar to those of the symptoms before the menstrual period, and they were mood swings 39 (68.4%), depression 28 (49.1%), and back pain 27 (47.4%). Other symptoms reported by respondents included changes in appetite 17 (29.8%), fullness and tenderness of breast 16 (21.8%), bloating in the lower abdomen 14 (24.6%), headache 13 (22.8%), fatigue 9 (15.8%), constipation 7 (12.3%), diarrhea 7 (12.3%), nausea 4 (7%), abdominal pain 2 (3.5%), insomnia 1 (1.8%), and leg pain 1 (1.8%).

Discussion
The result of the study showed that the prevalence of primary dysmenorrhea was high (82.6%) among female high school students in Yangon Adventist. The prevalence of dysmenorrhea was higher than the study carried out among Jordan medical students 75.4%, 14 Chinese university students 41.7%, 8 Gondar university students 77.6%, 9 Ghana adolescents 68.1%, 15 Palembang high school students 67.5%. 16 On the other hand, the prevalence of dysmenorrhea was lower than in the study conducted among Turkey university students 90.1%, 17 Swedish adolescents 89%, 7 Kuwait high-school students 85.6%, 18 Indian college girls 84.2%, 19 northern Ghana university students 83.6%. 20 The prevalence differed from one place to another place, and this may be due to differences in the study setting, age of the respondents, type of dysmenorrhea, tool used for data collection, simple size, and the respondents' perception of pain.
The majority of respondents experienced dysmenorrhea sometimes (43.9%) with a moderate level of pain (42.1%). Physical symptoms such as back pain (49.1%) and abdominal pain (49.1%) were common symptoms before the menstrual period. However, abdominal pain abruptly decreased (3.5%) during the menstrual bleeding. According to this study mood swings were the most prevalent physiological symptoms before (before 70.2%) and during (68.4%) menstrual period among respondents. This finding is in accordance with the study of dysmenorrhea among high-school students and its associated factors in Kuwait. 18 Therefore, women with dysmenorrhea need understanding, affection, patience, care and social support from families, friends, and spouses during painful periods. 21 Depression (before 50.9%-after 49.1%) was the second most common psychological symptom. Depression is characterized by either a dysphoric mood or a loss of interest and enthusiasm in daily activities. 22 24 it showed that dysmenorrhea and depression have a positive relationship. However, it is still questionable whether dysmenorrhea is more common among depressed women or whether depressed women have a higher likelihood of developing the condition. 10

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According to this study, respondents were using a combination of pharmacology and non-pharmacology methods to manage menstrual pain. Bed rest and applying heating pads or hot compression (98.2%) were the most common and effective methods utilized by the respondents to handle menstrual pain. Similarly to this, bed rest and hot compress/ heating pads were the most common complementary and alternative therapies chosen by undergraduate pharmacy students in Malaysia. Applying heat promotes blood circulation, and results in the uterine muscles relaxing, which results in pain reduction. 25 Self-medication was chosen by 96.5% of respondents and 93% chose medication prescribed by a physician. We can infer that 93% of the respondents used other medications in addition to those that were prescribed by a doctor. According to previous studies, less than 40% of women with dysmenorrhea seek health services and consult with healthcare providers related to their condition. 26,27,28 In this study, we didn't assess the types of medications the respondents used for self-medication. A small percentage of responders (3.5%) indicated that drinking wine helps to significantly reduce menstruation pain. To determine whether wine can effectively reduce menstrual pain, research and evidence are still needed.
As a limitation, this is a cross-sectional study and uses a small sample size. Due to this Covid-19 pandemic, data was collected through an online survey. Future studies need to assess and find out the impact of dysmenorrhea on mental health and provide interventions to improve the mental well-being of students with primary dysmenorrhea.

Conclusion
The prevalence of dysmenorrhea is high among female high school students in Yangon Adventist Seminary. Mood swings and depression are the most prevalent symptoms of primary dysmenorrhea before and during the menstrual period. This showed that primary dysmenorrhea has a negative impact on mental health. This finding reminds public healthcare providers that treating and caring the women with primary dysmenorrhea needs a holistic approach. Bed rest and applying heating pads are the most common ways of managing dysmenorrhea among these high school students.

Conflicts of Interest
The researchers have no conflict of interest in conducting and publishing this research.