Reproductive morbidity is a broad concept that encompasses health problems related to reproductive organs and functions, including childbearing. Assessing menstrual characteristics is an indicator of women’s reproductive biology [1]. Menstrual disorders include menstrual cycle irregularities (of duration or length), hyperor hypomenorrhoea, poly or oligomenorrhoea, dysmenorrhoea, amenorrhoea, menorrhagia and premenstrual syndrome (PMS) [2,3]. Menstrual disorders have economic consequences in terms of health care costs involving expensive hormonal drugs and laboratory tests [4-6]. Prospective studies have clearly established a link between menstrual disorders and socioeconomic status, body mass index (BMI), life styles and other complications such as polycystic ovary syndrome (PCOS), hirsutism or infertility [6-8]. Menstrual disorders have multiple etiologies [9] and studies of associated variables have found relationship with diet and eating disorders [10], exercise [11], stress [12] and chronic diseases [13]. Several studies have reported variation in menstrual patterns and their correlates across the population groups [2]. Thus, it is important to understand whether, and to what extent the modifiable risk factors explain the variation in the prevalence rate of menstrual characteristics. Studies in this respect are very few especially from developing countries like India. Hence, the present study has been undertaken to assess the menstrual characteristics and their association with life style and socioeconomic conditions of free-living rural women.

The present research work intends to study the menstrual characteristics and their association with other confounding factors among the rural women aged 20 to 40 years. The design of the study was cross sectional in nature. A multistage random sampling technique was applied to draw the sample. There are three revenue divisions in Chittoor District. All the revenue divisions were taken into consideration. Each revenue division consists of 22 mandals of which two mandals were randomly selected from each division. In each mandal, 4 villages were randomly selected. In the selected villages 1155 houses were enlisted. Door to door survey was carried out to recruit the sample. After administering the inclusion and exclusion criteria, 854 women were found fit and finally, 752 women gave consent to participate in the study. The participation rate was 86 percent. Pilot study was conducted for befriending and explaining to the women participants the purpose of the study. Data collection took place between Dec 2011 and Jan 2013. The exclusion criteria were women with lactation, women who had undergone surgical menopause and having gross abnormality. The study was approved by the Departmental Ethics Committee of Sri Venkateswara University, Tirupati. Electoral roles were checked to ascertain the age of the participant to establish the correct age. Each person was interviewed privately at her residence and encouraged to describe any other health related problems she may have faced in her life.

Standard social survey methods like structured interview schedule, and in-depth interviews were used to collect the data. A schedule consisting of multidimensional questions on individual’s demographics, like age, age at menarche, age at marriage, life styles, fertility, education, occupation and income was procured. Information about women’s perception on their own health problems, menstrual hygiene, menstrual problems, regularity of the cycle, use of hormonal contraceptives, bowel habit and prevalence of reproductive tract infections and sexual transmitted diseases (RTI/STDs) were collected. The prevalence of self reported non-communicable diseases was recorded. Regarding the birth control measures, 83 percent of the women have undergone tubectomy. In the remaining sample, no participant was found practicing temporary birth control measures. Hence, we dropped the variable for further statistical analysis to see its effect on menstrual characteristics.

Educational level of the participants and their family income were recorded through their public distribution cards. Physical activity was assessed based on subjects occupational and leisure time activities [14]. Participants were requested to recall their first experience of menstrual bleeding to ascertain the age at menarche. Information on age at marriage, first and last pregnancies, and number of pregnancies was gathered. Menstrual cycle length was defined as the gap between first day of one bleeding episode to previous day of next bleeding episode. Duration of menstrual flow was defined as the number of days from first bleeding initiation to last bleeding. Further, different problems related to menstruation were enquired. Since the sample is from rural background, there will be ample possibility that women may use materials other than sanitary napkin, which may exert adverse effect on menstrual health. To test this, women were enquired regarding the usage of sanitary material during menstruation. Precautionary measures were taken to check the recall bias on self reported information provided by the subject.

Statistical analysis was carried out via SPSS 16.0 and alpha level was set at p < 0.05. Qualitative variables were provided with percentages. Chi square test has been applied to see the strength of association with independent variables. Age adjusted multivariate (binary) logistic regression model with forward conditional entry was employed in predicting the menstrual characteristics. The independent variables entered were education, income, physical activity, duration of menstrual flow, menstrual problems, material used during menstruation, diabetes, hypertension, history of RTI/STDs and bowel habits. In each step the variables were entered at 0.05 and removed at 0.10. This model consists of five steps with variables like history of RTI/STDs, diabetes, menstrual problems, duration of menstrual flow and material used during menstruation. 91.2 percent of the cases were correctly classified. The false positives were 4 and false negatives were 62.

In the present study, mean age of the women was 30.74 ± 4.85 yrs. Data on socioeconomic status, life styles and prevalence of self reported disease was shown in Table 1. Illiteracy was noticed to an extent of 16 percent. 11 percent of the women’s income was below <24,000 INR and 52 percent of the women’s income was in the range of 25,000- 44,000 INR. Women with sedentary and heavy physical activity were 24 percent and 27 percent respectively. Self reported prevalence of diabetes and hypertension were 10 percent and 13 percent respectively.

Table 1: Socioeconomic status, life styles and prevalence of self-reported noncommunicable diseases of the study sample.

Table 2 depicts the data on demographic and menstrual characteristics. 66 percent of the women got married at below 20 years of age. Age at first conception was <20 yrs for 31 percent of the women respondents. In the sample one fourth of the women attained menarche when they were less than 11 years old. Oligomenorrhea and hypermenorrhea were noticed to an extent of 12 percent and 9 percent respectively. During menstruation, 32 percent of the women suffered from different menstrual problems. Primary dysmenorrhea (stomach ache and back ache, head ache, vomiting) was the predominant ailment suffered by 30% of subjects. Menorrhagia was noticed to an extent of 2.1 percent. 43 percent of the women were using domestic cloth as material during the menstruation, whereas 57 percent of the women were using commercial pad. Data on RTI/STDs and bowel habits were shown in Table 3. RTI/STDs were present in 19 percent of the women. Irregular bowel habits were noticed to an extent of 15 percent.

Table 2: Data on demographic and menstrual characteristics of the study sample.

Table 3: Data on RTI/STDs and bowel habits of the study sample.

Percentage frequencies and strength of association between menstrual characteristics and other confounding factors were shown in Tables 4-6. The frequency of irregular menstrual cycle decreases when subject’s education increases (P<0.03). As the women’s income (P<0.02) and physical activity (P<0.04) increases, irregular menstruation frequency decreases. It was also found that irregular menstrual cycle is associated significantly with other problems such as hypermenorrhea (χ²=10.35; P<0.00), menstrual problems (χ²=31.47: P<0.00), diabetes (χ²=57.98: P<0.00), hypertension (χ²=8.62: P<0.00), RTI/STDs (χ²=89.76: P<0.00), domestic cloth as material used during menstruation (χ²=25.72: P<0.00) and irregular bowel habits (χ²=14.56: P<0.00).

Table 4: Percentage frequencies of menstrual cycle by socioeconomic status and physical activity.

Table 5: Percentage frequencies of menstrual cycle by confounding factors.

Table 6: Percentage frequencies of menstrual cycle by diabetes, hypertension, infections and bowel habits of the study sample.

Results of the binary logistic regression are presented in Table 7. The results show that the chance of having irregular menstrual cycle was higher among the women who are reported to have RTI/STD followed by the diabetes. Menstrual hygiene (domestic cloth as material during menstruation), menstrual problems and duration of menstrual flow exerted an effect leading to irregular menstrual cycle. The results further indicate that none of the socioeconomic variables were found to be significant predictors of irregular menstrual cycle.

Table 7: Multivariate (binary) logistic regression model to predict the menstrual characteristics.

Menstrual disorders represent an important area of unmet need for reproductive health services for women in developing countries. The current study delineates the effect of socioeconomic and life styles on menstrual characteristics. The prevalence of different menstrual characters in the study population were comparatively lower than studies of Hong et al. [15] and higher than that reported by Khatri and Gupta [16] and Bang et al. [17]. Bachmann and Kemmann [18] observed oligomenorrheae to an extent of 12 percent and amenorrheae 2.6 percent in their sample. In the present study, the observed prevalence of oligomenorrhea is in line with other works [19].

Although irregular cycling is not generally associated with adverse health outcomes, oligomenorrhea may be associated with infertility, which is a major concern of women in many developing countries [20]. Oligomenorrhea may also be problematic when it is a symptom of other health problems that require treatment, such as hypothyroidism [21], endometrial tuberculosis [22] or AIDS wasting [23]. The outcome of the Gambian study found an association between cervical and uterine tumors with irregular bleeding [24]. Thus an elevation of oligomenorrhea in the rural women of the present study indicates the risk of developing menstrual disorders.

Dysmenorrhea is one of the most common complaints and gynecological problems among worldwide women [25-27]. The prevalence of dysmenorrhea varies between 16% and 91% in women of reproductive age, with severe pain in 2% to 29% [15]. Agarwal and Agarwal [27] reported high prevalence of dysmenorrhea (71.96%) among adolescent girls of Gwalior. Similar findings were reported by McKay and Diem [28]: (67%), Jayashree and Jayalakshmi [29]: (74%), and Harlow and Park [30]: (71.6%). In the present study, approximately one third of the women (32.0%) exhibited menstrual problems like dysmenorrhea as primary dysmenorrhea and menorrhagia. Our results are in good agreement with Burnett et al. [31] and low when compared to Northern India (76.9%) [32], Chennai (61%) [33] and Delhi (63.5%) [34]. In the present study dysmenorrhea and hepermenorhea were risk factors for about 2.778 and 2.593 times. This indicates that menstrual disorder is an important public health problem and those who were living freely in rural areas were experiencing severe or moderate dysmenorrhea, which might have a negative effect on health related quality of life (HRQoL) as evinced by self reported health status (40% as fair/poor).

Oligomenorrhea may also be associated with other reproductive morbidities like RTI/STDs. RTIs/STDs may result in serious health consequences among women such as infertility, ectopic pregnancy, preterm labor, miscarriage, stillbirth, pelvic inflammatory disease, cervical cancer, increased susceptibility to opportunistic infections and pregnancy associated complications [35]. A cross examination of the data on reproductive health status of the women indicates that 19 percent had the history of RTIs/STDs and exhibited risk for about 6.156 times pertaining to oligomenorrhea. This will add additional burden apart from menstrual problems affecting reproductive health and overall quality of life.

Self reported disease history of diabetes was found to be another significant risk factor in developing menstrual disorders. The odds of oligomenorrhea were 4.353 for diabetes. Diabetic women are prone to menstrual problems emphasizing the hazardous effect of hyperglycemia on menstrual regularity and menstrual problems. Similar observations were made in other population groups [36]. Women in the reproductive age require using proper sanitary napkins to maintain the menstrual hygiene. About half of the women interviewed during the study were using cloth as sanitary napkin during menstruation and were experiencing about 3 times higher risk in developing oligomenorrhea. This indicates poor attention paid to the menstrual hygiene by rural women in India. In the present study, 65 percent of the women who were using cloth as sanitary napkins stated that inaccessibility of the commercial pad in rural areas is the predominant reason. Similar results were observed in a rural community of Northern India [37].

Reproductive health of women permeates with social, cultural and lifestyle significance [38]. A number of population based studies, investigated variations in menstrual function vis-à-vis menstrual problems and their correlates [39]. In the present study, though the factors like education, income, physical activity and bowel habits have independently shown significant association with irregular menstrual cycle, yet these effects were nullified in the presence of other confounding factors. Ciccone et al. [40] study has clearly demonstrated that educating the subject on health and management will have greater impact in reducing the burden of risk. The outcome of the work warrants a strong partnership between the care manager and the subject and collaboration between the physician and the care manager in the health management. Our results are in agreement with the above study. These results will help us in training community health advisors who could play a key role in the advising rural women regarding the importance of these risk factors.

The potential limitations of our study are 1) Even though the questionnaire is standardized, certain practical problems like birth control measures and stressful events limit us in gaining the reliable data 2) Lack of data on diet and nutritional anthropometry are expected to have significant effect on menstrual characteristics. Further, classification of the subjects based on the economic levels in rural settings of India is a laborious exercise, because the window between low and high income groups is narrow.

The findings of our study could be generalized and applied to all the rural women of India with similar socioeconomic and cultural background. In conclusion, it is inferred that a significant portion of the women in the present study was suffering with oligomenorrhea, dysmenorrhea, and hypermenorrhea. The confounding factors for the promotion of the irregularities were duration of menstrual flow, menstrual problems, history of RTI/STDs, diabetes and material used during menstruation. Hence advocation of preventive strategies in the form of improving healthy life styles could be effective in correcting the menace.

Conceived and designed the study: KKR, TB, PG, KSNR. Data Collection: PG, TB, CP, RBS. Analyzed the data: PG, KKR. Wrote the paper: KKR, KSNR, PG

The authors greatfully acknowledge the financial assistance provided by University Grants Commission, New Delhi under Centre for Advanced Studies- Phase-1 (F. No. F-6-6/2013(SAP-3). We express our gratitude to all the subjects who volunteered into the study and provided necessary information.

None of the authors has a personal or financial conflict that has an interest in the subject of this Manuscript.