Abdul-Razzak Et Al-2010-Journal of Obstetrics and Gynaecology Research

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Influence of dietary intake of dairy productson dysmenorrhea jog_1159 377..383

Khalid K. Abdul-Razzak1, Nehad M. Ayoub1, Ahmed A. Abu-Taleb2 andBayan A. Obeidat3

1Department of Clinical Pharmacy, Faculty of Pharmacy, 2Department of Mathematics and Statistics, Faculty of Arts andScience, 3Department of Nutrition and Food Technology, Faculty of Agriculture, Jordan University of Science and Technology,Irbid, Jordan

Abstract

Aim: To determine the frequency of dysmenorrhea and its associated symptoms amongst a number of adolescent female students and to investigate the possible association between daily dairy product intake and

dysmenorrhea. Methods: A self-assessment questionnaire was completed by 127 female university students aged between 19and 24 years. Participants gave information that included demographics, the nature, type, and severity of painassociated with menstruation if any, management used to relieve dysmenorrhea, associated symptoms, and ageneral assessment of dietary intake of dairy products.

Results: The prevalence of primary dysmenorrhea in the population studied was 87.4% with the majority of the participants’ pain symptoms beginning a few days before and continuing through the first two days of menstruation. Forty-six percent of students were found to have severe dysmenorrhea. Abdominal bloating wasthe most frequently expressed symptom associated with dysmenorrhea amongst the population studied.Dysmenorrhea and associated symptoms were found in significantly fewer female students who consumedthree or four servings of dairy products per day as compared to participants who consumed no dairy products.

Conclusion: Primary dysmenorrhea is common in young women. This study helps us to better understand the

relationship between low dietary intake of dairy products and the risk of dysmenorrhea.Key words: calcium, dairy products, dysmenorrhea, pain, symptoms.

Introduction

Dysmenorrhea (painful menstrual cramps of uterineorigin) is the most common gynecological complaintamong female adolescents and young women.1,2 Dys-menorrhea occurs in up to 50% of menstruating girlsand women3 and some degree of dysmenorrhea may bepresent in as many as 90%.4 Primary dysmenorrhea,

which is defined as painful menses in women withnormal pelvic anatomy, usually begins during adoles-cence. The typical age range for occurrence of primarydysmenorrhea is 17–22 years while secondary dysmen-

orrhea becomes more common as a woman ages, whichmay be secondary to pelvic organ pathology.5 Dysmen-orrhea is characterized by lower abdominal pain thatoccurs during menstruation, but may start two or moredays before menstruation.6 Sometimes, pain is associ-ated with headache, nausea, vomiting, backache,general weakness, gastrointestinal symptoms, andothers.6 Besides the obvious physical concerns about

underlying pelvic pathology, dysmenorrhea can disruptdaily activities causing significant social disabilities.7

Pain may inconvenience a woman during holidays,social activities, or sometimes when high performance

Received: July 17 2008.Accepted: May 20 2009.Reprint request to: Professor Khalid K. Abdul-Razzak, Department of Clinical Pharmacy, Jordan University of Science andTechnology, Faculty of Pharmacy, PO Box 3030, Irbid-22110, Jordan. Email: [email protected]

doi:10.1111/j.1447-0756.2009.01159.x J. Obstet. Gynaecol. Res. Vol. 36, No. 2: 377–383, April 2010

© 2010 The Authors 377 Journal compilation © 2010 Japan Society of Obstetrics and Gynecology

mailto:[email protected]

mailto:[email protected]



is required. Chronic recurrent pain of dysmenorrheacauses absence from school or work and significantcosts to the health-care system.7 The pathogenesis of primary dysmenorrhea is not always understood. Pros-taglandins seem to be intimately involved, causinguterine contractions and pain.8 Abnormalities in plasmasteroid levels could also account for the disturbance,especially significantly elevated plasma levels of estra-diol in the luteal phase.9

Generally, dysmenorrhea is under-treated becausephysicians are not fully aware of its high prevalenceand morbidity.10 Most adolescents self-medicate withover-the-counter medicines, and few consult a physi-cian about dysmenorrhea.11 Currently, non-steroidalanti-inflammatory drugs (NSAIDs) are the best estab-lished initial therapy for dysmenorrhea.12 These drugshave a direct analgesic effect through inhibition of prostaglandins synthesis and decreasing the volume

of menstrual flow.12 Furthermore, treatment of dys-menorrhea is a well-accepted off-label use for oral con-traceptives (OC).13 However, despite the considerableefficacy of conventional treatments, for many women,current medical therapies offer inadequate treatmentwith a failure rate of 20–25%.14 Besides, some womenprefer not to use NSAIDs or OC because of side-effectsor for cultural reasons.

Many sufferers are now seeking alternatives to con-ventional medicine, such as herbal and dietary thera-pies.14,15 A Japanese herbal combination,16,17 thiamine,18

vitamin E,19 fish oil supplements,20 and a low-fat veg-

etarian diet21

have been proven as having a beneficialeffect in the published reports.Knowledge of beneficial food-related practices can

enable better management for this population of girlsand women. Hence, this research was undertaken toelucidate the possible relationship between daily dairyproduct intake and dysmenorrhea and other associatedsymptoms as there is a very limited number of studiesthat have examined the effect of dairy product intakeon the management of dysmenorrhea.

Methods

SampleA total of 127 healthy adolescent college students aged

between 19 and 24 were enrolled in this study at JordanUniversity of Science and Technology (JUST). Studentswho admitted to taking dietary supplements (multivi-tamins or minerals and calcium supplements) on aregular basis, or who were vegetarians were excludedfrom this investigation.

Study design

Adolescent female students who agreed to participatein the study were instructed to complete a self-assessment questionnaire including their demograph-ics, information regarding menstruation, and an

assessment of their dietary intake of dairy products.Demographic evaluation included information regard-ing the student’s age, height, and weight. Participantswere also asked to answer questions regarding men-struation. Other questions included the age at firstonset of menses, regularity of menstrual cycles, theduration of menstruation (<5 or 5 days), the type of menstruation (slight, normal, or heavy), and the sever-ity of menstrual cramps or pain if present. Pain severitywas graded as the following:

Mild: pain that resolved without the need formedication.

Severe: pain that is resolved with simple analgesics(NSAIDs, paracetamol).

Very severe: pain that is not relieved with simple anal-gesics and may interfere with usual daily activities.

In addition, participants were asked for possiblesymptoms associated with dysmenorrhea (e.g. nauseaand vomiting, sweating, abdominal bloating, andothers). Students were also investigated regarding anymedication or alternative therapies administered torelieve pain associated with menstruation, if any(NSAIDs, paracetamol, antispasmodics, herbal rem-edies, and others). Frequency and type of diary

product intake (milk, yogurt, cheese, and labanah,which is a soft cream cheese made by removal of wheyfrom yogurt through cheese cloths) were recorded.

Intake of dairy products was determined on a daily basis as none, single, two, three, or up to four dairyservings per day.

A dairy serving is defined as: 1 cup of milk or yogurt,2 full table spoons (2 oz) of labanah, and a 1-ouncepiece of cheese (about the size of a domino or twofingers).

Statistics

The data were analyzed using statistical softwareMinitab 14.

To study the effect of the total number of dairy serv-ings per day on dysmenorrheal pain, the proportion of female students who experience dysmenorrheal painwas compared to the proportion of female studentswho experience no dysmenorrheal pain for a givennumber of servings using the Z-test. The c2 procedure

K. K. Abdul-Razzak et al.

378 © 2010 The Authors Journal compilation © 2010 Japan Society of Obstetrics and Gynecology



was used to measure the association between variablesof interest. P-values < 0.05 were considered statisticallysignificant.

Results

A total of 127 university students at JUST were enrolledin this investigation. Their ages ranged between 19 and24, with a mean age value of 21 1.5 years. Theaverage body mass index was 21.8 3.3, and theaverage age for the onset of menstruation in the samplewas 13 1.4 years.

Among the 127 participants included in this study,111 participants (87.4%) were dysmenorrheic. Thehighest proportion of students (36.6%) had their dys-menorrheal pain onset within one to two days beforemenstruation, which continued through the first twodays of menses. In comparison, 28.6% of participants

acknowledged the occurrence of dysmenorrheal pain afew days before menstruation, while 34.8% expressedpain only during the first and/or second days of theirmenstrual cycle. Thirty-eight and a half percent of par-ticipants described the duration of their menstruationas <5 days while 61.5% of participants described theduration of their menstruation as 5 days. Approxi-mately half of the sample studied graded their dys-menorrheal pain as severe and only a small percentageof the participants reported very severe menstrual pain(Fig. 1). It was noticed that in the majority of students(92.9%), the pain was more frequently in the abdominal

area and 79.5% of participants had their dysmenorrhealpain radiating to the lower back and/or thighs. Themajority of participants (60.4%) reported that dysmen-orrhea affected their daily activity for several days eachmonth. Besides pain, participants reported a variety of symptoms associated with dysmenorrhea. Abdominal

bloating was the most frequently presented symptomin the sample studied and this was followed by loose

stools, dizziness, sweating, and nausea and vomiting ina descending order (Fig. 2).

With respect to treatment options for dysmenorrhealpain, 65% of participants were found to use medication.Simple analgesics were the most utilized therapies byparticipants as a self-managed guide to pain-relief.NSAIDs were most popular, followed by paracetamol,and herbal remedies, while antispasmodics were usedthe least (Fig. 3).

In regard to the association between the daily intakeof dairy products and frequency of dysmenorrhea, ourresults revealed a significant difference between highand low intakes of dairy products. Those women

44%

47%

9%

Figure 1 Grading pain severity in population studied. ,mild; , severe; , very severe.

20.47

29.13

78.74

40.1635.43

20.47

0

20

40

60

80

P e r c e n t a g

e

N and V S AB LS DZ Others

Symptom

Figure 2 The most common symptoms associated withdysmenorrhea among the sample studied were nauseaand vomiting (N and V), sweating (S), abdominal bloat-ing (AB), loose stools (LS) and dizziness (DZ). Othersymptoms were various and distributed betweenheadache, cold sensation, anxiety, generalized weak-ness, and sleepiness.

37.1

6.3

29.92

21.26

0.79

0

10

20

30

40

P e r c e n t a g e

N S

A I D s

A n t i s

p a s m

o d i c s

P a r a c e

t a m o l

H e r b a l

r e m

e d i e s

O

t h e r s

Therapy

Figure 3 Most commonly used self-therapies for dys-menorrhea in the population studied. Other therapiesinvolved the use of heat therapy and exercise. NSAIDs,non-steroidal anti-inflammatory drugs.

Dysmenorrhea and dairy products




reporting an increased intake of dairy of three to fourservings a day reported a marked reduction in dys-menorrhea compared to women reporting no dailydairy intake (P = 0.000). There was no significant differ-ence in the prevalence of dysmenorrhea between thoseparticipants taking one compared two dairy servingsdaily or even in those consuming three compared tofour dairy servings daily (Table 1).

A similar pattern was found regarding severity of dysmenorrheal pain with the number of dairy serv-ings. A significantly lower number of female studentsnoted mild, severe or very severe dysmenorrheal painwhen their intake of dairy products were three or fourservings per day as compared to participants who con-

sumed none. No female student claimed to have verysevere pain as their dairy intake was increased to fourservings per day (Fig. 4).

Furthermore, the beneficial effect of dairy productson most of the dysmenorrhea-associated symptomswas observed as symptom frequency was analyzedagainst the number of daily servings of different dairyproducts. Dysmenorrhea-associated symptoms likesweating, abdominal bloating, loose stools, and dizzi-ness were significantly influenced by a greater intake of dairy products (three or four servings daily). On theother hand, nausea and vomiting were not found to besignificantly influenced by increasing dietary intake of dairy products (Table 2).

Table 1 Dysmenorrhea in relation to daily intake of dairy products

Parameter Total number of dairy servings/day

0 1 2 3 4

Number(%) of female students who experienceddysmenorrheic pain (total number = 111)

36 (32.4) 26 (23.4) 26 (23.4) 11 (9.9)* 12 (10.8)**

Number of female students who experienced nodysmenorrheic pain (total number = 16)

1 (6.3) 3 (18.7) 7 (43.8) 4 (25) 1 (6.3)

Total number 37 29 33 15 13

There was significant reduction in dysmenorrheic pain in participants who consumed three daily servings (* P-value = 0.000) or four dailyservings (**P-value = 0.000) of dairy products compared to participants who consumed none.

Figure 4 The relationship betweendaily intake of dairy servingsand pain severity. †P = 0.028.‡P = 0.002. , mild; , severe; ,very severe.





Discussion

The prevalence of dysmenorrhea is difficult to deter-mine because of different definitions of the condition.

However, dysmenorrhea seemsto be themost commongynecological condition in women regardless of ageand nationality. It is estimated that the prevalence of dysmenorrhea variesfrom 45% to 95%.22–25 The resultsof this study confirm that dysmenorrhea is common inyoung women as 87.4% of our sample experienceddysmenorrhea. Besides pain, abdominal bloating, loosestools, dizziness, sweating, nausea, and vomiting werecommon symptoms associated with dysmenorrhea inthe sample investigated. These findings are in agree-ment with other studies from different parts of theworld.24–26 In agreement with our results, a study of 664

femalestudentsin secondaryschools in urban andruralareas in Egypt showed that 75% of the students experi-enced dysmenorrhea, and that fatigue, headache, back-ache, and dizziness were the commonest associatedsymptoms.25

Current understanding of the pathogenesis inprimary dysmenorrhea implicates excessive imbal-anced amounts of prostanoids and possibly eicosanoidsreleased fromthe endometrium.27 The uterus is inducedto contract frequently and dysrhythmically, withincreased basal tone and increased active pressure.3

Eventually, uterine hypercontractility, reduced uterine blood flow, and increased peripheral nerve hypersensi-

tivity induce pain.27 Thus, the level of prostaglandinscan be reduced to below normal with NSAIDs, whichare considered an effective treatment. Unfortunately,little attention is usually given to a woman’s dietaryhistory with respect to her gynecological complaints.Interestingly, our study appears to elucidate the rela-tionship between dietary intake of dairy products andthe risk of dysmenorrhea. Participating female students

who consumed three or four diary servings per dayshowed a significantly lower risk of dysmenorrhea.

The preliminary findings of this research suggest apossible positive role for calcium in the management of

primary dysmenorrhea, as more than 70% of dietarycalcium comes from dairy products28 and participatingfemale students who had consumed no dairy productshad dysmenorrhea more frequently than those whoconsumed one or three servings of dairy products daily.This finding supports the previous suggestions of Penland and Johnson29 that dietary calcium intake pro-vides a protective effect against menstrual pain. In con-trast Di Cintio et al.30 reported little positive association

between cheese and egg intake and dysmenorrhea.With respect to the association between dysmenor-

rheic pain and associated symptoms and daily intake

of dairy products, our results revealed no significantdifference in the prevalence of dysmenorrheal pain between participants takingone or two and three or fourdairy servings per day. Such a finding is expected andattributed to a difference of calcium content in similardairy products. In view of that, sheep’s milk is richer incalcium than cow’s milk (473 and 276mg/cup, respec-tively).31 On the contrary, pasteurized white cheesemade from sheep’s milk supplies a smaller amountof calcium than that made from cow’s milk (140 and162 mg/oz, respectively) because sheep’s milk yields18–25% cheese while cow’s milk yields 9–10% cheese asa result of different solid content among different

milks.32 Labanah supplies the lowestamount of calciumper serving, 101mg/oz (company nutritional fact).Dairy productsmade from sheep’s milk as well as cow’smilk are widely consumed in the Middle East.

The mechanism by which calcium reduces the risk of dysmenorrhea is unknown. Nevertheless we believethat calcium could play a role in reducing dysmenor-rheic pain through controlling neuromuscular activity.

Table 2 The association between intake of daily dairy servings and dysmenorrhea-associated symptoms

Symptom Total number of daily servings0n (%)

1n (%)

2n (%)

3n (%)

4n (%)

Nausea and vomiting 7 (26.92) 5 (19.23) 8 (30.77) 3 (11.54) 3 (11.54)

Sweating 13 (35.14) 10 (27.03) 8 (21.62) 4 (10.81)* 2 (5.41)Abdominal bloating 32 (32.32) 24 (24.24) 23 (23.23) 10 (10.10)** 10 (10.10)Loose stools 17 (34.00) 16 (32.00) 12 (24.00) 4 (8.00)*** 1 (2.00)Dizziness 17 (37.78) 9 (20.00) 11 (24.44) 3 (6.67)**** 5 (11.11)Others 7 (26.92) 5 (19.23) 7 (26.92) 2 (7.69) 5 (19.23)

*P-value = 0.009; **P-value = 0.000; ***P-value = 0.001; ****P-value = 0.000. A significant reduction in dysmenorrhea-associated symptoms wasfound in participants who consumed three daily servings of dairy products compared with participants who consumed no daily servings of dairy products. n, number of students experiencing the symptom.





Conversely, a reduction in calcium concentrationmay increase neuromuscular excitability, resulting inincreased spasms and muscular contractions.29 In addi-tion, adequate calcium intake leads to considerablehealth benefits including reduction of the risk of osteoporosis, as most of the world’s population doesnot satisfy their calcium needs28 and in adults >19 yearsof age, three dairy servings per day are recommended.33

Recently, evidence has demonstrated the efficacy of calcium in the treatment of premenstrual syndrome(PMS). Clinical trials showed that calcium supplemen-tation can alleviate mood and somatic symptoms asso-ciated with PMS.34 In addition, a case–control studyconducted by Bertone-Johson and colleagues demon-strated that a high intake of calcium and vitamin D mayreduce the risk of PMS.35 An interesting finding in ourstudy is that 36.6% of participants experienced symp-toms of dysmenorrhea 1–2 days prior to the onset of

menses. Such a finding may suggest that those stu-dents may suffer from PMS also, which is expected to

be significantly alleviated by calcium therapy.

Conclusion

The results of this study suggest that dietary calciummay have a functional role in future management of dysmenorrheal pain and may be considered a promis-ing nutritional therapy for the relief of pain and symp-toms associated with dysmenorrhea. However, large,prospective, and controlled studies will be necessary to

establish the findings of this study.

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