1) Location

The study was conducted in the campus of Government Bilingual Secondary school Bafoussam Cameroon and in Lycée Classique de Bafoussam (GHS Bafoussam). Both schools are found in Bafoussam I municipality in the western region of Cameroon. They are one of the most populated in the region even more so this year with the influx of internally displaced persons from the neighbouring North west Region. The schools are about 2 kilometres apart.

2) Topography

Like many regions of the country the region has a mountainous topography.

3) Population

The city had an urban population of about 347,517 inhabitants (at the 2008 Census) spread on an area of about 402 km².

4) Culture and language and Religion

The people in Bafoussam town are a conglomeration of all ethnic troops of the country but the indigenous, generally called the Bamileke are the most popular. The most popular official language is the French language followed by English. The indigenous languages (which are very similar) are the most popular of the national languages, these include: the ngemba, the fefe, and others. However, other national languages are equally spoken here including houssa, foufoude, beti, etc., the main economic activity in the city is trading and agriculture. The people are predominantly Christians and a few are Muslims wile a very small group do not have any religious affiliation.

Our study was destined to apply to post pubertal high school girls in Bafoussam Cameroon.

• Any post pubertal female student in the class of lower and upper sixth or premiere and terminale from GBHS Bafoussam or Lycée Classique de Bafoussam present in class on the day of data collection and willing to participate.

• Decision to withdraw from the study by the participant or her next of kin at any point in time.

• Person with a diagnosed pelvic pathology.

• Improperly filled questionnaires.

• Students with visual disability.

• Premenarchal students.

We conducted a pilot study in Martin Luther King comprehensive college Bafoussam where we interviewed 15 English speaking students and 15 French speaking students. The outcome revealed a very low response rate due to students forgetting the questionnaires at home and some questions were not understandable by many. To avoid this in the study we went for an exhaustive sampling to make sure we end up with reasonable sample size and the difficult question were rephrased.

This was done at the end of each day data missing such as age and average score for the past trimester was addressed by sending a text message to the contact provided by the participant on the questionnaire, politely asking for the missing information. The information was completed for those who replied and those who did not were excluded.

1) Age distribution of participants

The mean age (±SD) of our study participants was 17.60 (1.60) year old. The youngest student was 14 years old and the oldest 24 years old. The age distribution was as on Table 1 below.

^a = Government Bilingual High School; N/A = Not Applicable.

2) Population distribution according to schools and class

Lycée Classique de Bafoussam 52.3% of our study participants came from and 47.7% from GBHS Bafoussam. Most of the students were lower sixth/premiere students (55.2%) while 44.8% were upper sixth and terminale students.

3) Religion

The large majority were of Christian denomination (96.5%) while only 2.1% were of Islamic faith the remaining 1.4% belonged to other unspecified denominations. Summary of sociodemographic characteristics on Table 1.

1) Age at menarche

The mean age (±SD) at menarche of the study participants was 13.07 (1.38) years, the youngest being 8 years and the oldest 17 years. The age distribution at menarche is displayed on Table 2 below.

2) Duration of menstrual cycle

The mean duration their menstrual cycle (±SD) was 28.11 (2.89) days. The shortest cycle was 21 days and the longest was 45 days. A great majority (75.4%) had a menstrual cycle lasting between 26 to 30 days more details on duration of menstrual cycle are displayed on Table 2 below.

N/A = Not Applicable.

3) Duration of menstrual period

The mean duration of their menstrual period (±SD) was 4.49 (±0.99) days. of the 885 student who responded to this question, 340 (38.4%) had a period lasting 4 days. Only 6 people (0.7%) had a period of 2 days which was the shortest period while 43 people (4.9%) had a period lasting 7 days which was the longest duration of menstrual flow in our study. See Table 2.

4) Regularity of menstrual cycle

As seen on Table 2, 506 (56.31%) of our study participants reported having regular menstrual cycles, meaning they can predict the date of their next period with some degree of certainty. The other 392 (43.7%) reported having irregular cycles.

1) Prevalence of primary dysmenorrhea

The number of students who reported having painful periods was 646 (71.9%) out of the 898 who took part in the study. The remaining 252 (28.1%) did not experience menstrual pains. Hence the prevalence of primary dysmenorrhea among our study population was 71.9%.

2) Grading Pain intensity among those affected

Of those who reported having primary dysmenorrhea, 75 (11.6%) characterised their pain to be mild, 339 (52.5%) characterised their pain as moderate and the remaining 232 (35.9%) characterised theirs as severe pain. This is elaborated on Table 3 below.

3) Duration of pain during menstruation

The mean duration (±SD) of pain during their period was 2.27 (±1.04) days. However, the majority of them (64.4%) had pain duration between one and two days. The longest duration of pain was 7 days but only one person (0.2%) experienced pains for this long. This is elaborated on Table 3 below.

4) Duration between menarche and onset of dysmenorrhea

The results were as on Table 4 below and Figure 2. Among the 399 who responded the question appropriately, the mean duration (±SD) between menarche and onset of primary dysmenorrhea was 10.75 (13.02) months but the mode was zero (Thus they began experiencing pain as from their first menstruation). In 58.4% of cases, pain started within the 1^st to sixth month post menarche. The longest duration between menarche and onset of dysmenorrhea was 60 months (5 years). The timing between menarche and onset of dysmenorrhea is a negative exponential relationship as seen on Figure 2 below.

N/A = Not Applicable.

Associated symptoms of primary dysmenorrhea: A few common symptoms associated to primary dysmenorrhea was asked to participants affected and they had to answer by yes or no, an open-ended question was asked for those who experience any other symptom not mentioned. The results revealed that abdominal pain was the most common symptom reported by 333 (56%) person, followed by loss of appetite 286 (48%) reported. Mood swings was the least reported symptom (0.2%) only one person reported the latter. The symptoms are classified in order of decreasing frequency of Table 5 below.

The method of management known to most of the students was drugs of the NSAIDs family followed by paracetamol. Oral contraceptive pill was the least known method of management. This is elaborated on below and Figure 3.

1) Method chosen by the students to manage pain

Of the 646 persons who reported having dysmenorrhea, 247 (38.24%) ignored their pain while 399 (61.76%) practiced at least one method of treatment. Bed rest was practiced by most (57.12%) of the participants, followed by medical treatment methods (NSAIDs derivatives, other forms of analgesics such as paracetamol and antispasmodics). Meanwhile there were rare methods of pain relieve practiced by some student such as Yoga (only one person), massage (one person) and intense sexual intercourse (1 person). The different methods of pain relieve carried out by the students are elaborated on Table 6 below.

2) Effect of treatment on pain relive

The effect of individual treatment methods on pain relief could not be accessed by this study because many students reported using more than one method during the same menstrual period or interchanged methods between periods. Nevertheless, we accessed the general effect of treatment on pain relief using a 4-point Likert scale ranging from no effect on pain through total relieve of pain of those who used at least one method of treatment, the effect of treatment

* = multiple response.

on pain relive was as on Table 6. 16.6% had total relieve of their pain, 57.7% had significant but not complete relive, to 24.3% of them it barely relived the pain and 1.5% said the treatment had no effect on their pain.

3) Source of knowledge on method of pain relieve

Among those who treated their pain, their main source of knowledge about the method (s) of pain relieve they practice was from family relatives (parent, sibling, aunt, …) (74.4%), 30.6% learned from friends, 29.4% learned from a health personnel (doctor, nurse, pharmacist, etc), 21.6% learned through personal research from books and or media and the least informative source was the school. See Table 7.

1) School absenteeism

Among the 646 students who experienced primary dysmenorrhea, 252 (39%) report to have absent classes at least once since they began experiencing painful periods. For the current academic year, 188 students (29.1%) report to have absented classes between one to five times, while 29 students (4.5%) report absenting classes between six to ten times and 16 students (2.5%) say they have absent classes more than 10 times. This is illustrated on Table 8 below.

2) Effect of pain on home studies

This was accessed using a three-point Likert score ranging from cannot study at all through has no effect on studies. Out of the 646 students affected by primary dysmenorrhea, 29.4% (190 students) says they cannot study at all when experiencing menstrual pain while 9.4% (61 students) say the pain has no effect on their studies at home. See Table 8.

3) Effect of pain on attention in class

This as equally accessed using a three-point Likert score ranging from no effect on attention to totally distracted, just present to avoid absences. Results

* = multiple reponse.

showed that 189 (23.9%) students are only present in class in class during their period just to avoid absences in their records while 31 (4.8%) students say that pain do not affect their attention. See Table 8.

4) Punishment because of something done under the influence of menstrual cramps

Out of the 646 students affected by primary dysmenorrhea, 95 (14.7%) said to have been punished at least once for something they did under the influence of pains. See Table 9 below. An open-ended question was asked to these students who said to have been punished. The question was on the type of punishment they were given and the reason for this punishment. The responses were grouped for simplification of analysis as on Table 9 below.

The most common thing done by the student was not taking note and or were lying on the desk during lectures and for this the most common punishment was expulsion from class. Their action and the punishments received are cross tabulated on Table 10 below.

A greater proportion of students not affected by primary dysmenorrhea had a pass average (for the past 4 trimesters) than those with dysmenorrhea. Among the students who had dysmenorrhoea, 75.6% had an average ≥ 10, while 24.4% had an average < 10. Meanwhile among those who did not have dysmenorrhea, 81.7% had an average ≥ 10 and only 18.3 had averages < 10 (Figure 4).

A Pearson chi-square goodness of fit test was conducted to determine if the difference in these proportions is statistically significant, results were as on Table 10.

Our literature search did not find any study on the relationship between menstrual problem and school activities or school performance in Cameroon. The fact that menstrual discomfort or disorder is not seen as any serious gynaecological problem could be responsible for the non-existence of such study. However, it should be noted that the burden of menstrual discomfort and disorderliness might be greater than any other gynaecological complaint among this population as observed in this study and others in the sub region; Nigeria and Ghana [3] [4] [20] [21].

The mean age (±SD) of our respondents was 17.60 (1.60) years, with a range of 14 to 24 years. The majority was within the age range 16 to 17. A large majority were of Christian denomination 867 (96.5%), while only 18 (2%) were Muslims and 13 (1.4%) had other faiths.

The mean age (±SD) at menarche was 13.07 (±1.38) years. Pasquet et al. [22] found 13.18 (±1.08) years among students in Yaoundé, 13.98 (±1.58) among student in Mfu and 14.27 (±1.65) in Campo. Our respondents being city dwellers like the ones in Yaoundé have figures similar to the latter. However this study date from 1998 but with the shift toward lowering menarcheal age at the rate of 1.1 month per decade [22] [23] [24], it is understandable that our value is slightly lower than theirs. Our value was also similar to results of studies in other countries 12.7 years in Nigeria [25], 13.0 years in Egypt [26], 13.3 years in Indonesia [27]. However it was smaller than that found by Derseh et al. [28] in Etheopia (15.1 years) and that of Amaede et al. [3] in egypt (13.7 years) but higher than that found by Banikarim et al. [14] among Hispanic females in the USA (12 years). Other countries reported 12.49 in Spain [6], 12.75 years in Australia [5]. This differences can be explained by the fact that menarche I influenced by both genetic an environmental factors [22] including nutrition, light exposure, growth status which vary in the different environments.

The mean (±D) duration of the menstrual cycle was 28.11 (±2.89) days with a range of 21 to 45 days with over 75% of respondents having a cycle lasting between 26 and 30 days concurring with the value of 28.4 (±5.9) found by Shehata et al. [11] in Egypt as well as studies in other countries round the world [5] [7] [8] [9] [10] [17]. 56.3% reported their cycle as being regular while 43.7% said theirs were irregular. In the study of Ameade et al. [3] in Ghana, 75% of their respondents reported a regular cycle while the rest said theirs were irregular. This difference is most likely due to difference in the understanding of the concept of regular cycle by the respondents. The mean (±SD) duration of menstrual flow was 4.49 (±0.99) days with a range of 2 to 8 days, comparable to 4.16 (±1.42) days found in Ethiopia [20] and 4.9 days in Ghana [10]. However, a little low compared 5.2 (±1.58) days, 5.93 days and 5.2 (±1.4) days described in Nigeria, Australia and Egypt respectively [5] [9] [11].

The prevalence of primary dysmenorrhea was 71.9% in our study. In the absence of comparable study in our country, this was similar to results obtained from related studies in the sub region; 78.1% in Ogun state Nigeria [15], 72% among university students in Kano Nigeria [9], 74.4% among adolescent girls in Accra Ghana [10]. But other studies reported lower values for example Titilayo and colleagues reported 64% among under graduate female students in Osum state Nigeria [4] while Darseh et al. reported 66.8% among undergraduate university students in Ethiopia [28]. On the other hand, Ameade et al. [3] in Ghana reported 83.4%, Shehata et al. [11] reported 92.1% among university students in Egypt. Other values reported across the world were 84.2% in Thailand [7], 93% in Australia [5], 74.8% in Spain [6], 53.6% in Turkey [8] and 85% in the USA [14]. The extreme variation in these estimates may be attributed to the use of selected groups of subjects and the absence of a universally accepted method of defining dysmenorrhea. Pain associated with dysmenorrhea is difficult to measure because it is usually accompanied by other unpleasant sensation and partly because the reaction component affects the judgement of pain [7]. 11.6% of our respondents scored their pain on the visual analogue scale as mild, 52.5% scored theirs as moderate while 35.9% reported severe pain. This was similar to a Ghanaian study [3] which using the same method of pain scoring obtained 21.2% mild pain, 56.3% moderate and 22.4% severe. There was a great variation of pain scoring among respondents in different studies [5] [7] [9] [14] [23]. The most likely explanation to this variation is that, perception and expression of pain is influenced by genetics, psychological, developmental, familial, social and cultural factors [3]. Therefore, the aforementioned factors as well as variability of pain threshold of the different categories of respondents who participated in all these studies could account for the differences in the description of their pains. The mean duration of pain was 2.27 (±1.04) days, most people had painting less than 48 hours (64%) similar to findings from other studies [3] [8] [14].

Primary dysmenorrhea presents with or shortly after menarche. It may start within 6 months after menarche because it occurs only during ovulatory cycles, which may not always be evident at menarche. Although it may occur as late as a year after menarche, it is less likely to do so later when it should raise suspicion of secondary dysmenorrhea [2]. We found the mean (±SD) duration between menarche and onset of dysmenorrhea to be 10.75 (±13.02) months. 17.3% of our respondents began experiencing pain from menarche, 58.4% started within the first six months, 72.4% started within 12 months and 88.2% within 24 months. The timing between menarche and the onset of primary dysmenorrhea is an inverse exponential relation. From this result we can assume that the students who reported dysmenorrhea starting beyond 24 months could be due to a memory decay or their dysmenorrhea was due to a secondary cause.

The symptoms associated with primary dysmenorrhea were: Abdominal pain, loss of appetite, lower back ache, nausea, headache, vomiting, facial pimples (acne), breast ache, fatigue, dizziness, mood swings, heat sensation and pain in the thigh. This was consistent with findings from other studies [3] - [9] [11] [14] [16]. Some of these studies however described other symptoms that we did not find such as irritability, lower limb oedema, sweating, frequent micturition and pain when emptying bowel. These symptoms can sometimes be more debilitating than the pain itself, hence health care workers should consider enquiring about these symptoms in conjunction with pain as this can also be the clue for determining whether the pain is primary or secondary dysmenorrhea.

Among the common conventional methods of treatment of primary dysmenorrhea, drugs of the NSAIDs family was the most known to our participants thou only 56.8% of them did. 51.7% knew of Paracetamol, but oral contraceptive pills were the least known only 3.3% knew it and probably used it as a method of managing menstrual pain. Few of them knew of non-pharmacological means such as physical exercise and heat packs. Tangchai et al. [7] in Thailand found that paracetamol was the drug most known as pain reliever to primary dysmenorrhea sufferers followed by NSAIDs then oral contraceptive pills. Up to 55.4% of affected subjects knew of OCPs and used them in contrary to our study and that of EL-Gilany et al. in Egypt where no one knew of oral contraceptives talk less of using. Egypt being an Islamic country this method is not an option for them reason why no one knew about it. In our setting, the low knowledge and use is most likely due to the myths and rumours spread on medias concerning oral contraceptives thus the person informing the people about treatment options for dysmenorrhea do not think about this as an option.

38% of the respondents ignored their pain, while others tried one or more methods of pain relive. Among these methods, bed rest was the most common followed by medical treatment including paracetamol and NSAIDs. Others took traditional preparations, application of heat packs, and physical exercise this was similar to findings from a Nigerian study [17]. The only practice done by their cohort which was not reported in our study was ingestion of holy water. However, we had other reports not found in literature such as enema and intense sexual intercourse (reported by 1 person). Sexual intercourse is an uncommon practice during menses because of the blood involved however endorphins released during orgasm has pain relieving properties which may explain this choice of management. The methods of treatment were basically the same across the globe, but there was a great difference in choice of management in the various studies. In Thailand [7], 92% did bed rest, 34% used heating pad, only 35% used analgesics while 12% used herbal medicine; in the Spain [6], 92% of affected persons took analgesics, 61% took oral contraceptives; in Egypt [16], nearly half of respondents (49.5%) ignored their pain, 42.6% did bed rest, 36.7% took herbal preparations and 34.7% took analgesics. Oral contraceptive pill was not an option in their country. These findings suggest that the choice of treatment is highly dependent upon the socio-cultural background of the individual. Hence health care providers should customise treatment in consideration of individual socio-cultural origins to promote compliance to treatment.

Most of the respondents (72%) reported significant to total relieve of pain after practicing their method (s) of pain reliever, for 23.4% it just took the edge off while 1.5% said treatment has no effect on pain. Individuals practiced more than one method of pain relieve so the efficacy of individual method of management could not be accessed. A study in Ghana [3], 82% of people who self-medicated agreed to strongly agreed to total pain relieve while 8.6% were uncertain and for 5.2% treatment had no effect. In both studies it can be seen that the majority of those who attempted therapy had significant pain relive, the few that did not get any relieve might have been due to inappropriate administration since most of them get the treatment over the counter by self-prescription and will take in inappropriate doses [3]. The medications are the standard and most effective treatment while the non-pharmacological treatments such as exercise of heat packs are often used as adjuvant therapy as reported by some participants in a Ghanaian study [18]. Most people got their knowledge on management of dysmenorrhea from their relatives (74.4%), while 30.60% learned from friends, 29.4% learned from a health personnel, 21% from personal research and media while the school was the least informative source on menstrual pain and its management. These findings were consistent with other studies [10] [11] [17] [19]. But in all these studies less than 10% of participants learned from health care providers compared to the 29% in our study. This is most likely because we grouped all nurses, doctors, pharmacist as he personnel more over some people do consider owners of drug stores as health personnel.

Among dysmenorrhea sufferers, 39% had absent at least a class in the past six months. 21.1% had absent between one to five time, 4.5% between six to ten time while 2.5% (16 person) had absent more than 10 times. Similarly, a Nigerian study found a school absenteeism rate of 37% among adolescent school girls. Absenteeism due to primary dysmenorrhea was reported by many other studies [5] [8] [9] [14] [15] [19] [21] and it ranged between 10% to 46% but was up to 87% among students with severe pain in some of the studies. Some student absent classes occasionally while others absent at least one day during every menstrual period. This was the case in the study of Iliyasu et al. [9] where 7% of students reported missing classes every menstrual period. This absenteeism might not be very noticeable in schools because some students cope by having catch up classes and planning their activities in anticipation of pain but the scenario would be different if they were working in a factory where they are paid per hour, this will represent a significant economic lost to both the factory and themselves.

For those who managed to attend classes, 95% reported that their attention in class was affected by pain during menses and 29% said they were only present in class to avoid being marked absent. Likewise, 91% said their home studies were affected by dysmenorrhea among which 29% said not being able to study at all when experiencing painful periods. Other studies [3] [8] [14] [15] also found decreased attention in class, inability to do assignments, inability to do home chores, inability to participate in sport activities, social withdrawal and depression. Sometimes when students will fail to perform some of the academic obligations such as failure to do assignment, not taking notes during lectures or absenting classes, they will be sanctioned. 14% (95 students) reported been punished at least once for such. The most common of all was students not taking notes and or lying on the desk during lectures. As punishment they were expelled from class and recorded absent. Other forms of sanctions were manual labour, absences in records among others. This highlights the disparity in the study conditions of students affected by primary dysmenorrhea and students who do not. For this reason, we decided to investigate whether there was a difference in academic performance of students having primary dysmenorrhea and students who did not. The results showed that students who did not have primary dysmenorrhea had more pass marks than students with dysmenorrhea but was not statistically significant. Our finding was similar to that of Alam et al. [24] in Indonesia who found no significant difference in academic performance of students with and without dysmenorrhea though their cut off mark for good and poor average was 7.5/20. We did not find a correlation between pain intensity and performance in contrast to findings from other studies [25] [28] who found a decrease in academic performance with increase dysmenorrhea severity. But their results were based on subjective report of the impact of pain on their performance by the students hence students were likely to express great impact on performance as a means of expressing the distress brought in to their academics by the pain.