Dietary Intake of Specific Vitamins and Minerals on the Prevalence of Primary Dysmenorrhea Among Adolescent Girls: A Cross-Sectional Study
Article information
Abstract
Objective
Primary dysmenorrhea is described as uterine cramping and painful menstruation with no underlying condition of the pelvis, and it is among the most prevalent gynecological problems seen in the reproductive years among adolescents and young women. Intake of fruits and vegetables that are rich in vitamins, minerals, and antioxidants appears to help alleviate menstrual pain, as shown by recent studies. Therefore, our study aimed to evaluate the dietary intake of vitamins and minerals and assess the prevalence of primary dysmenorrhea.
Methods
The study was conducted on adolescent schoolgirls. For assessing their dietary intake, a 3-day food recall questionnaire was used, which included one weekend day and two weekdays. Menstrual pain intensity was measured using a visual analog scale. The relationship between the intake of vitamins and minerals and the occurrence of primary dysmenorrhea was analyzed. Logistic regression analysis was used to assess the association of dietary habits with the risk of primary dysmenorrhea. A significance level of 0.05 was used for all tests.
Results
A strong negative correlation was observed in the occurrence of primary dysmenorrhea with respect to the intake of vitamins and minerals. The negative correlation was stronger for calcium as compared to vitamin E, vitamin C, and zinc. Therefore, it can be considered that adolescent girls who intake lesser vitamins and minerals than their recommended levels are at risk of primary dysmenorrhea.
Conclusion
Intake of adequate fruits and vegetables to meet the levels of vitamins and minerals could be considered to reduce the risk of primary dysmenorrhea.
INTRODUCTION
Painful menstrual cramps that originate in the uterus are commonly referred to as “dysmenorrhea” [1]. In postpubescent girls, it is a common gynaecological issue. Primary and secondary dysmenorrhea are the two categories of dysmenorrhea. Painful periods without pelvic disease are referred to as primary dysmenorrhea [2]. Secondary dysmenorrhea, on the other hand, is characterized by painful periods brought on by certain pelvic diseases [3]. Adolescent girls, in particular, have numerous difficulties after puberty due to dysmenorrheic pain. In fact, it impedes their day-to-day activities [4]. Common signs of dysmenorrhea include absenteeism from class, a lack of participation in social events, a negative attitude towards outdoor activities, and physical discomfort such as mood swings, back pain, mild to severe abdominal pain, nausea, and vomiting [5]. About 14% of girls missed 1–2 days of school due to dysmenorrhea, and 1% of women of reproductive age missed 24 to 72 hours of work per month due to the severity of the condition [6]. In addition to impairing day-to-day functioning, dysmenorrheic pain lowers academic achievement during adolescence and increases anxiety and sadness [7].
Increased consumption of fruits and vegetables has been associated with decreased menstrual pain [8,9]. These are important sources of vitamins and antioxidants [10]. Women suffering from dysmenorrhea consume fewer fruits and vegetables and have lower levels of vitamins in their blood [11,12]. Vitamin E acts as the body’s primary defense against membrane damage resulting from phospholipid peroxidation, and vitamin C is important in restoring the antioxidant activity of vitamin E. Zinc is an antioxidant [13] and anti-inflammatory [14] agent in the uterus. Several studies have also shown positive relationships between calcium intake and lower menstrual pain [15,16]. This study was, therefore, conducted to determine the effect of dietary intake of vitamin E, vitamin C, calcium, and zinc on the occurrence and severity of primary dysmenorrhea in adolescent girls.
METHODS
Study population
This study was conducted among adolescent schoolgirls aged 14 to 19 years in West Bengal, India, who experienced primary dysmenorrhea lasting 8 to 72 hours during their school hours. The study was approved by the Institutional Ethical Committee of Hooghly Mohsin College (HMC/IEC/PP/DEPT/2023/4). The prior written permission of the school authority was taken. Written consent from the parents of students who participated in the study was obtained. Participants are divided into four categories: no dysmenorrhea, mild dysmenorrhea, moderate dysmenorrhea, and severe dysmenorrhea, based on the severity of menstrual pain. A total of 240 adolescent girls (60 in each category) were recruited in this study based on their willingness. Participants were required to meet the following inclusion criteria: 1) age 14 to 19 years; 2) residency in the study regions for more than 6 months; 3) unmarried; and 4) completion of the questionnaire. We excluded 34 participants who met the following exclusion criteria: 1) taking regular drugs or hormonal therapy, 2) suffering from chronic disorders, including diabetes mellitus, clinically established hypertension, liver cirrhosis, and kidney disease, 3) suffering from polycystic ovarian disease/polycystic ovary syndrom, and 4) suffering in endometriosis. Consequently, a total of 216 participants were eligible for the analysis.
Questionnaire
The self-administered questionnaire collected information on participants’ age, marital status, menstrual health, eating habits (including missing meals and engaging in physical activity), and other relevant details. Additionally, a family history of primary dysmenorrhea was documented.
Dietary assessment
The study population’s diet was evaluated using a three-day diet recall questionnaire that included two weekdays and a weekend day [17]. The meal name and portion proportions based on average or natural portions consumed (cup, slice, piece, etc.) were among the information from the three-day recall. A table describing the nutritional value of Indian cuisine was used to determine the amounts of nutrients such as calcium, zinc, vitamin C, and vitamin E in the foods consumed [18].
Visual analog scale
A visual analog scale was used to measure the severity of menstruation pain [19]. The VAS measures discomfort on a 10 cm (100 mm) scale. The VAS categorizes discomfort into four levels: no pain (0–4 mm), mild (5–44 mm), moderate (45–74 mm), and severe (75–100 mm). Based on their VAS ratings, all participants were classified into these four groups.
Statistical analysis
Quantitative data was presented as a percentage and mean±standard deviation. The correlation coefficient (r) between dysmenorrhea and intake of vitamins and minerals was estimated. Also, the predictive relation of estimation of vitamins, minerals, and primary dysmenorrhea were evaluated using logistic regression analysis. The significance level of the tests was considered at a level of 0.05. Microsoft Office 2017 and SPSS version 24 (IBM Corp.) were used to perform all the statistical analysis.
RESULTS
Different demographic characteristics of the study groups and their comparisons were analyzed by analysis of variance and are mentioned in Table 1.
Comparison of demographic characteristics between the study groups
The correlation between vitamin and mineral intake with the degree of dysmenorrhea is given in Table 2. A significant negative correlation was noted between the degree of dysmenorrhea and the daily intake of vitamins and minerals. Maximum correlation was noted between the combined intake of vitamin E and vitamin C in comparison to individual intake.
Correlation between dysmenorrhea level with intake of minerals and vitamins
Table 3 represents the daily calcium and zinc intake of participants in respect to the degree of primary dysmenorrhea. More than 80% of participants in the group without dysmenorrhea take calcium as per the recommended dietary allowance (RDA). On the other hand, a lower percentage of participants with primary dysmenorrhea take calcium as per RDA. The percentage of participants of calcium intake as per RDA decreases gradually with increasing degree of primary dysmenorrhea (mild dysmenorrhea 60%, moderate dysmenorrhea 28%, severe dysmenorrhea 21%). Like calcium intake, similar results were noted for zinc intake.
Intake of calcium, zinc, vitamin E, and vitamin C on the basis of menstrual pain
Table 3 also represents the daily vitamin E and vitamin C intake of participants in respect to the degree of primary dysmenorrhea. More than 78% of participants in the group without dysmenorrhea take vitamin E as per RDA. On the other hand, a lower percentage of participants with primary dysmenorrhea take vitamin E as per RDA. The percentage of participants taking vitamin E as per RDA decreases gradually with increasing degree of primary dysmenorrhea (mild dysmenorrhea 65.5%, moderate dysmenorrhea 39%, severe dysmenorrhea 26.4%). Like vitamin E intake, similar results were noted for vitamin C intake. Only 10% of participants in the group without dysmenorrhea take vitamin C below RDA amounts. Compared to this group, a higher percentage of dysmenorrhea groups take vitamin C at below RDA amount. The percentage of participants taking vitamin C at below RDA amount increases gradually with increasing degree of primary dysmenorrhea (mild dysmenorrhea 43%, moderate dysmenorrhea 54%, severe dysmenorrhea 77%).
Logistic regression analysis was done to evaluate the intake of vitamins and minerals on the incidence of primary dysmenorrhea (Table 4). Considering intake as RDA amount as reference, intake of vitamins and minerals as below RDA amount significantly increases risk of incidence of primary dysmenorrhea for 4 to 13 folds (odds ratio: calcium, 13; zinc, 5; vitamin E, 4; vitamin C, 12).
Logistic regression analysis for intake of vitamins and minerals and incident primary dysmenorrhea
Table 5 represents the collective intake of vitamin E and vitamin C on the incidence of primary dysmenorrhea. Among the participants who take both vitamins below the RDA, 95% suffer from primary dysmenorrhea. Similarly, 91% of participants who meet the RDA for one vitamin but take the other below the RDA also experience primary dysmenorrhea. In contrast, among participants who take the RDA for both vitamins, only 41% have primary dysmenorrhea, with the lowest percentage experiencing severe dysmenorrhea.
Collective impact of vitamin E and vitamin C intake on the incidence of primary dysmenorrhea
Bivariate regression analysis was done to evaluate the intake of two antioxidant vitamins on the incidence of primary dysmenorrhea among adolescent girls (Table 6). The risk of incidence of primary dysmenorrhea was least among the participants who take both vitamins as RDA amounts. Maximum incidence was noted among participants who take both vitamins as below RDA amounts in comparison with those who take both as RDA amounts.
Bivariate regression analysis of intake of vitamin E and vitamin C based on RDA and its impact on dysmenorrhe
DISCUSSION
The overproduction of uterine prostaglandin is the cause of primary dysmenorrhea [20]. The late luteal phase withdrawal of progesterone causes the membrane phospholipid to oversecrete arachidonic acid. Myometrial hypercontractility may result from the production of prostaglandins (PGE2 and PGF2) from arachidonic acid by cyclooxygenases, peroxidases, and synthases. Ischemia and hypoxia of the uterine muscle are linked to vasoconstriction and myometrial contractions, resulting in discomfort and systemic symptoms [21,22].
Since calcium is linked to a variety of body processes, it is a crucial vitamin for people. Dietary calcium intake has been positively linked to a decrease in menstrual discomfort [15,16]. According to our research, females who consume enough calcium (beyond the recommended daily allowance) are far less likely to experience primary dysmenorrhea. By regulating muscle and nerve activity, calcium intake may lessen menstruation discomfort [23]. Muscle contractions, stiffness, and spasms can all be exacerbated by lowering calcium levels [15].
Zinc has anti-inflammatory and antioxidant properties in the uterus [13,14]. The release of inflammatory substances is associated with pain sensitisation [24]. We investigated the relationship between zinc intake in the diet and the prevalence of primary dysmenorrhea. Comparing teenagers with appropriate zinc consumption to girls with reduced (<RDA) dietary zinc intake, we discovered that the former experienced mild to severe forms of dysmenorrhea. A healthy zinc intake likely lowers the severity of dysmenorrhea by decreasing prostaglandin metabolism [25] in addition to its anti-inflammatory and antioxidant qualities.
Vitamin E and vitamin C are powerful antioxidants. Several studies found that vitamin E and vitamin C can effectively decrease menstrual pain [26,27]. Our results also showed that less (<RDA) vitamin C and E intake was significantly associated with increased severity of primary dysmenorrhea. Vitamin C in combination with vitamin E has an important role in the indices of oxidative stress and the severity of dysmenorrheic pain [28]. Vitamin C level was reduced in the blood of primary dysmenorrhea [12]. It plays a major role in the recycling of vitamin E to prevent the peroxidation of membrane fats [29]. Besides this, sufficient daily intake of vitamin C reduces the severity of menstrual pain, probably by regulating the production of various neuromodulators like serotonin, adrenaline, and endorphin [3], as well as reducing blood inflammatory markers [30-33]. Vitamin E may play a role in reducing pain by inhibiting the release of arachidonic acid and its conversion to prostaglandins [34].
In conclusion, the intake of certain minerals, such as calcium and zinc, and vitamins, such as vitamin E and vitamin C, is associated with a lower incidence of dysmenorrhea among adolescent girls. Adequate intake of minerals and vitamins plays an important role in managing the severity of dysmenorrhea. Sufficient intake of fruits and vegetables to provide the recommended amounts of vitamins and minerals may be considered a healthy dietary habit to minimize the risk of primary dysmenorrhea.
Notes
The authors have no potential conflicts of interest to disclose.
Availability of Data and Material
The datasets generated or analyzed during the study are not publicly available due to ethical and confidentiality considerations but are available from the corresponding author on reasonable request.
Author Contributions
Conceptualization: Payel Pramanik, Purushottam Pramanik. Data curation: Payel Pramanik. Formal analysis: Payel Pramanik, Purushottam Pramanik. Investigation: Purushottam Pramanik. Methodology: Salony Sreeya Pattnaik. Project administration: Purushottam Pramanik. Resources: Salony Sreeya Pattnaik. Software: Salony Sreeya Pattnaik. Supervision: Purushottam Pramanik. Validation: Purushottam Pramanik. Visualization: Purushottam Pramanik. Writing—original draft: Payel Pramanik, Salony Sreeya Pattnaik. Writing—review & editing: Purushottam Pramanik.
Funding Statement
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Acknowledgements
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