The goals of the current study are to:

1) Detect the prevalence of premenstrual syndrome (PMS) and primary dysmenorrhea (PD) among female medical students at BMC Medical School.

2) List the predictors and risk factors of PMS and PD among undergraduate female medical students.

3) Identify the effects of PMS and PD on the daily activities and academic performance of female medical students.

4) Recognise how female medical students typically cope with pain and discomfort among the available standard coping measures.

This is a prospective, cross-sectional, observational study that included answering online a pre-designed, structured, self-administered questionnaire directed to undergraduate female medical students of the General Medicine Practice Program at the Batterjee Medical College (BMC) in Jeddah, Saudi Arabia. The collection of data extended for five months (from February 1st to June 30^th, 2023).

The selection criteria included all undergraduate female medical students of the General Medicine Practice Program (from the 1^st to the 6^th medical grades) at BMC, of any nationality (Saudi and non-Saudi), and of any marital status (married or not), for the academic year 2022 - 2023.

The excluding criteria include all undergraduate male medical students of the General Medicine Practice Program, as well as postgraduate doctors of both sexes. Adding all female students who were not willing to participate or to give a signed online consent, as well as those who were pregnant or lactating. Similarly, female students with diagnosed or suspected pelvic pathology (such as endometriosis, pelvic inflammatory disease, and/or leiomyomas) and those who were on any medications for other illnesses (including combined hormonal contraceptives, antipsychotics, antidepressants, sedatives, antispasmodics, and corticosteroids).

The minimal sample size required for a valid study was 157 students according to the total number of female students. This calculated online at http://www.calculator.net/ and rechecked by the Raosoft® programme at http://raosoft.com/samplesize.html .

Considering the total population size of 431 female medical students, the percentage of PMS and PD in our community is 80%, at a confidence level of 95% (Z-score 1.96), and the margin of error is ± 5%. By using mathematical equations, we used the following single population proportion formula:

$n=\frac{z^2\times p\left(1-p\right)}{{\epsilon }^2}$

$n=\frac{{1.96}^2\times 0.80\left(1-0.80\right)}{{0.05}^2}=245.9$

where:

n = minimal sample size;

z = z-score of 95% confidence level (1.96);

p = expected population proportion (50%);

ε = margin of error (5%).

Since our population was known (431 total female medical students for the academic year 2022-23), we used the additional correction formula:

$fn=\frac{P}{1+P/n}$

$fn=\frac{431}{1+431/245.9}=156.7$

where:

n: minimal sample size;

fn: corrected sample size;

P: known population (431 female students).

We preferred to target a large number of female students and thus increase our sample size for two reasons: firstly, to compensate for a possible 20% non-response rate, and secondly, to minimise the margin of error. Accordingly, the actual number of recruited female students in the current study was 300, with a response rate of 69.61% and a margin of error of ± 2.5% ( Chart 1 ).

5) Assessment of Primary Dysmenorrhea (PD): By using the WaLIDD (Working ability, Location, Intensity, Days of pain, and Dysmenorrhea) score that designed to diagnose dysmenorrhea and predict the needs for a medical leave [20] . The final score ranges from 0-12 points, which is subdivided into mild, moderate, and severe dysmenorrhea (Appendix 4).

Screening for Associated Side-effects:

1) Assessment of Pain: By using a combined 10-scale Visual Analogue Scale (VAS), and numerical Analogue Scale—NAS (Appendix 5).

2) Assessment of Depression: The used scale in our study called The Patient Health Questionnaire (PHQ-9). The total score ranges from 0-27, which is subdivided into minimal, mild, moderate, moderately-severe, and severe depression (Appendix 6).

3) Assessment of Stress: By using the Perceived Stress Scale (PSS-10). A modification is done for the test where proper scoring is resorted for each question according to the positive and negative statements, which may confuse many researchers during the interpretation of the test. Such modification was termed “Kamel’s Perceived Stress Scale”. Total score ranges from 0 - 40, which is subdivided into low (0 - 13), moderate (14 - 26), and high stress (27 - 40) (Appendix 7).

4) Assessment of Quality of Life (QOL): By using EQ-5D-5L questionnaire introduced by the Euro Quality of Life Group in 2009 (Appendix 8). Mobility, self-care, activities, pain or discomfort, and anxiety or depressive symptoms are the five health status variables that are incorporated into the descriptive system. There are five levels for each dimension: none, minor, moderate, major, and extreme difficulties. In each of the five aspects, the patient has been asked to tick the box next to the statement that most accurately characterizes her health. This decision produces a 1-digit number that represents the level selected for that dimension. The five dimensions’ digits can be used to represent the patient's health state as a five-digit number. On a visual analogue scale with endpoints denoted as “the best health you can imagine” and “the worst health you can imagine,” the EQ-VAS captures the respondent's self-rated health.

The Institutional Review Board (IRB) of the Batterjee Medical College in Jeddah, Saudi Arabia, approved the study. All procedures adhered to the ethical and scientific research committee requirements, as well as the Helsinki Declaration of 1964 and its subsequent updates. All medical students who took part in our study provided informed consent. Data were obtained anonymously, and participants’ confidentiality was ensured.

The data were statistically analysed using Microsoft Office, Excel^® 2016, and IBM’s Statistical Package for Social Studies (SPSS^®) version 26.0. IBM in Chicago, Illinois, USA, created SPSS. The Pearson Chi-square test, Fisher’s exact test for categorical variables, and Student’s t-test for continuous data variables were used to assess the effects of various socio-demographic factors and character traits. The significance cut-off was 0.05, and it was used as the p-value. Our results are presented using numbers, percentages, mean values, and standard deviations (SD).

In our study, 230 students, or 76.67% of the total, were unmarried and belonged to the age group of students with PMS who were younger than 20 years old. 70 students (23.33%) participated from the second medical grade, and 60 students (20.0%) participated from the first medical grade. 180 pupils (or 60.0%) of the class have PMS and live with their families. 15 pupils (5.0%) had a chronic ailment, such as diabetes mellitus, hypertension, or a mental health issue. The majority of female students with PMS (141 students, or 47.0%) had a normal BMI, compared to 74 students (24.67%) who were underweight and 20 students (6.67%) who were overweight.

According to Mitsuhashi R. et al. [21] , the prevalence of PMS was found to be significantly correlated with physical characteristics like age and BMI, menstrual characteristics like longer menstrual periods and irregular cycles, family history, and lifestyle factors like smoking, sleeping patterns, and stress. In our study, sociodemographic characteristics such as city residency, parent-child living arrangement, favourable family history, median family income, and Rh-ve blood type were strongly correlated with the occurrence of PMS. Students’ age, religion, country, ethnicity, year of study, and ABO blood grouping were not shown to be significantly related. Additionally, there was a strong relationship between the occurrence of PMS and lifestyle factors such as eating too many fatty and oily foods, having a high body mass index, smoking, drinking too much tea or coffee, sleeping too much, doing poorly in school, and having a chronic condition. There was no discernible connection to daily activity. Regarding reproductive characteristics, PMS was substantially connected with students' marital status, parity, age at menarche, gynaecological age, cycle length, cycle duration, amount, and type of blood loss. No conclusive relationship was found between cycle regularity and blood loss colour.

In Rasheed P. and Al-Sowielem LS’s study [4] , carried out in Dammam, Saudi Arabia, the premenstrual syndrome (PMS) frequency was found to be substantially correlated with a mother’s prior history of the condition, as well as with one’s own impression of mental stress, physical activity, consumption of fatty foods, and coffee. Similar findings were found in the study done by Seedhom AE et al. [3] , which found that 80.2% of the participants had experienced varying degrees of PMS symptoms. These symptoms were significantly correlated with family history of the condition, physical inactivity, habitual excessive coffee consumption, BMI, frequent fast food consumption, and smoking. All of these results concurred with our own study, with the exception of physical activity (p-value: 1.029).

Salem IM, et al. [22] , conducted a study on 400 high-school female students with a mean age of 16.7 ± 1.16 years old in Jeddah city in 2020 to estimate PMS at younger ages in Saudi females. A 37.0% prevalence of PMS was observed. The PMS group included 55.4% more Saudis than non-Saudis (44.4% versus 55.4% Saudis). Since our study was conducted in a medical school, the average age of the participants was higher (22.5 ± 1.2), and Saudi women had a higher prevalence of PMS than non-Saudi women (175 out of 220, 79.55% versus 60 out of 80, 75.0%, respectively).

The study by Dinh Trieu Ngo V, et al. [23] , published in 2023, identified the negative Rhesus blood type as a new risk factor for PMS. This was also supported by our study, where we found that 206 out of 270 participants (76.3%) with positive Rhesus blood type had PMS, compared to 29 out of 30 students (96.67%) with negative Rhesus blood type.

In 2018, Rafique N. and Al-Sheikh M. [24] at Immam Abdulrahman Bin Faisal University in Dammam, Saudi Arabia, found a high correlation between stress and the two most common menstrual disorders in the target population: PMS and PD. In the study by Syed A and Rao SB [2] , in 2020, irritation (35% of affective symptoms) and breast soreness (41% of symptoms) were the most prevalent somatic symptoms of PMS in their study. Al-Shahrani AM, et al. [25] , found a 64.9% prevalence of PMS in Bisha city, Saudi Arabia, in 2021. In 2022, Altamimi LA et al. [26] , observed that the physical symptoms were recorded more frequently than the psychological symptoms at King Saud University in Riyadh, Saudi Arabia. Similar to our findings, breast pain with swelling was the most common somatic symptom of PMS (78.33%), and emotional lability was the most common affective symptom (61.67%).

In a systematic review and meta-analysis conducted by Mitsuhashi R. et al. [21] , in 2023, the following symptoms were listed as being experienced by women with PMS in descending order of frequency: irritability, fatigue, anxiety-tension, fatigue, changes in appetite, changes in sleep, breast tenderness, headache, decreased concentration, abdominal pain, low back pain, tearfulness, inflammation of the skin, oedema, decreased interest, abdominal distension, nausea, mood elevation In contrast, our study discovered that the following PMS symptoms appeared less frequently, in descending order of severity: breast tenderness with swelling, arthralgia, myalgia, lower abdominal cramping pain radiating to the thighs, low backache, mood swings, tearfulness, irritability, decreased interest in academic and social activities, lethargy with easy fatigue, anxiety, feeling hopeless, depressed thoughts, lack of concentration, poor performance in exams, hypersomnia, and a sense of being overwhelmed.

The prevalence of PMS was reported to be 39% in a 2019 study by Suboohi S. et al. [27] . Of those, 79.31% had mild symptoms, 17.24% had moderate symptoms, and 3.44% had severe PMS. In Pakistan, Yunus S. et al. [28] , discovered in 2020 that 19.2% of undergraduate medical students had PMS. Undergraduate medical students ranged in age from 18 to 25 years old. BMI was 19.9 kg/m2 on average. Ten (6.2%) students were married. Among 31 females (19.2%), PMS was discovered to be mild in 4.3% of cases, moderate in 8.1%, and severe in 6.8%. In Iraq in 2023, Hussein EA, et al. [29] , evaluated PMS symptoms and cycle regularity in 1270 female university students during the COVID-19 epidemic (viewing it as a stressful factor). 76.6 percent of subjects reported having PMS. 36.9% of individuals reported having moderate PMS symptoms. In addition, respondents reported worsening PMS (26.3%) and worsening menstrual discomfort (18.3%), respectively. Comparable to our data, the prevalence of PMS was 78.33%, and according to the DRSP grading method, 16.67% of these individuals displayed minimum symptoms, 16.67% mild symptoms, 25.0% moderate symptoms, 8.33% severe symptoms, and 11.67% extreme symptoms. The frequency of the severe type of PMS (PMDD) was 11.67% in our study.

According to Yanjmaa E. et al. [30] , moderate to severe PMS and PMDD were prevalent among Mongolian college students in 2022 at a rate of 23.8% and 4.7%, respectively. The signs that appeared most frequently were lethargy or lack of energy, rage or irritation, crying, difficulty concentrating, and anxiety or tension. Therefore, with identical presentation symptoms, the prevalence of moderate to severe PMS was 33.33% in our sample, while that of PMDD was 11.67%.

According to a study conducted in Nigeria in 2023 by Monday N. et al. [5] , the prevalence of PMS among university students was high, at 59.4%. Individual symptom evaluations showed that cognitive difficulties, bed rests (90.3%), wanting to stay at home (86.0%), and irritation (85.9%) were the most frequently reported symptoms. While Govind LKV and Chellamma VK. [31] , discovered in 2023 that PMS and PMDD were common in a considerable number of medical colleges (89 out of 318, 27.99%), and that they had a significant detrimental impact on behaviour, emotional health, and academic performance, A total of 44 students (13.84%) who reported feeling angry, upset, anxious, or depressed met the criteria for PMDD. Contrary to our findings, the prevalence of PMS was higher (235 students out of 300, 78.33%) while the prevalence of PMDD was lower (35 students out of 300, 11.67%) among female medical students at BMC.

The largest incidence was PMS (28%) and PD (25%). 38% of participants reported missing household activities as a result of them, and 31% said they had to take a sick day because of menstrual problems. In 2022, Mohamed AA et al. [32] , who did a cross-sectional survey at the University of Hail in Saudi Arabia, found that the majority (95.3%) of the female students were single and that 55.8% of them were enrolled in medical schools. The majority of individuals (78.33%) claimed that PMS interfered with their regular routine. However, in our study, Batterjee Medical College (BMC) had a higher than average prevalence of PMS (78.33%) with a significant impact on students' academic performance (p-value < 0.00001).

In regards to the severe type of PMS, a 2016 study in Makkah by Goweda R. et al. [6] , found that 36.6% of students had PMDD. A study conducted by Minichil W. et al. [33] , at the University of Gondar in Ethiopia in 2019 found that the prevalence of PMDD was 34.7%. In 2022, Alshammari E. and Aldossary K. [7] , attempted to gauge the prevalence of PMS in Riyadh, Saudi Arabia. 10.7% were noted to have PMDD. In contrast to our findings, 11.67% (35 out of 300) of female medical students at BMC reported having PMDD.

Tolossa FW and Bekele ML. [34] , in 2014, found that 144 medical students (83.2%) in Ethiopia had at least one PMS symptom along with their menstrual cycle at Mekelle University College of Health Sciences. Regarding 28.3% of respondents, 9.8% said they frequently missed classes, 8.1% said they had inadequate grades, and 1.7% said they had stopped trying to study. Only 48.0% of individuals got help for their PMS from a doctor. Painkillers (36.4%), hot beverages including coffee and tea (7.5%), massage therapy, and exercise (4.0%) were the treatment techniques used. In Jordan, Alshdaifat E. et al. [35] , discovered that in 2022, the majority of students were in their fifth and sixth years of college, 75.4% of whom reported experiencing dysmenorrhea, 45.8% of whom used pharmacological painkillers, and 54.2% of whom used non-pharmacological painkillers. Akpoigho EC and Ukamaka NC. (10), conducting an observational study at the University of Benin in Nigeria, found that the majority (88.3%) of people engaged in unhealthy health-seeking behaviours and that the most popular coping mechanisms were resting (66.9%), sleeping (64.7%), and embracing the process as natural. Compared to our findings, we found that 8.33% of assignments were submitted late and that 16.67% of students performed poorly on exams. We also found that 25.0% of college students were absent from class, 45.0% had poor extracurricular activities, and 8.67% had poor classroom performance. Thirty students (ten percent) did not receive any treatment for PMS, while 24 students (eight percent) used hot water bottles and herbal teas, 49 students (16.33 percent) used analgesics, 74 students (24.6 percent) used NSAIDs, 24 students (eight percent) used combined oral contraceptives, and 34 students (eleven percent) used antidepressants.

In the study by Mohamed MA et al. [36] , conducted in 2021, the prevalence of PMS among the Jouf University College of Pharmacy was close to 35%. The academic performance of students seemed to be negatively impacted by the severity of premenstrual psychological and physical symptoms. For the most part, analgesics and/or hot beverages were used to treat severe PMS symptoms. Therefore, Maity S. et al. [1] , observed a significant frequency of PMS and dysmenorrhea among female medical students in a comprehensive review and meta-analysis they conducted in 2022. However, in the same demographic, the prevalence of PMDD is quite low. Menstrual symptoms affect the academic and social quality of life for the majority of female students in the reproductive age group. The menstrual abnormalities may be influenced by lifestyle, sociodemographic, genetic, and psychological variables. In our general medicine programme, the frequency was 78.33%, and NSAIDs were the most often prescribed drug (74 out of 300 students, or 24.67%).

Recent studies have demonstrated that, both locally and worldwide, PD is common. While national studies in Saudi Arabia have revealed an incidence of 60.9–89.7% among students [24] [37] - [41] , international research has shown a prevalence ranging from 56 to 80% [37] [38] . The quality of life and mental health of women can be impacted by PD, according to earlier studies [42] . For instance, research at King Saud University found that 80.1% of the students there had dysmenorrhea, and it also revealed the detrimental effects it had on their academic performance, such as lower involvement and attendance [40] . A study conducted in India likewise revealed a high frequency of PD (71.96%) and showed a substantial relationship between dysmenorrhea and psychiatric symptoms, including depression [43] . There isn’t much research in the literature that examines the prevalence of PD and its connection to depression [37] [43] [44] . However, the majority of these were either conducted abroad or lacked a dysmenorrhea tool that had been approved [41] .

In the study of Fathi M. et al. [45] , PD prevalence was 83.6% in 2022. In the current study, 227 out of 300 students (75.67%) had PD of varying severity, which was assessed using the WaLIDD grading system with sensitivity (63.7%) and specificity (72.2%).

According to a study done on teenagers in Assiut City, Egypt, there are substantial correlations between dysmenorrhea and earlier menarche, longer cycles, excessive bleeding, and irregular cycles [46] . Another study from Jordan focused on the connection between family history and dysmenorrhea [47] . Hormonal contraception, higher parity, and giving birth to the first child at a younger age all contributed to risk reduction. According to Bakhsh H. et al.’s study [19] , there was no correlation between the incidence of PD and age group or marital status among Saudi women of reproductive age in 2022; however, there was an increasing prevalence of non-pathological dysmenorrhea (92.3%). In our research, we discovered significant correlations between menarchal age (p-value < 0.00001), cycle length (p-value < 0.00001), cycle duration (p-value < 0.00001), amount of blood loss (p-value < 0.00001), marital status (p-value < 0.00001), and parity (p-value < 0.00001) and dysmenorrhoea. PD and cycle regularity did not significantly correlate with one another (p-value 0.587).

Since a link between a high stress score and dysmenorrhea cannot be established, additional research is necessary to see whether there are other factors that affect menstrual function. Sima R-M. et al. [16] , gathered information from 1720 students (at five university sites in Romania) in 2022 and calculated the prevalence of PD to be 78.4%. Most female students reported feeling more anxious or apprehensive (72.7%), more exhausted (66.9%), as though they had less energy for everyday activities (75.9%), and severely stressed (57.9%) during their menstrual cycle. Similar results were seen in our study, where 227 out of 300 students (75.67%) had PD. Female medical students who had PMS or PD reported stress, but there was no statistically significant difference (p = 0.0673). Tension with anxiety was at 20.33%, easy fatigability was at 75.67%, and irritability was at 43.33%.

The majority of the female medical students in research by Kannan LS et al. [12] , at Imam Abdulrahman Bin Faisal University in Saudi Arabia in 2020 were single (73.97%) and living with their families (90.4%), according to an analysis of demographic characteristics. These results agreed with those of Ibrahim NK et al. (39), who conducted their study in 2015. After PD symptoms and indicators were evaluated, abdominal pain was shown to be the most common result in 73.28% of the female medical sciences students. With a p-value of ≤ 0.05, it was determined to be very statistically significant. This conclusion is consistent with those of Yesuf TA et al. [48] , who reported that 67.4% of university students reported having abdominal pain as a result of PD in 2018. Additionally, 64% of female students studying medical sciences cited dysmenorrhea as a notable side effect. This conclusion is corroborated by a study conducted in Saudi Arabia, which found that dysmenorrhea caused sleep disturbances in 54% of female medical students [39] The same survey also revealed that 67.5% of the individuals reported having emotional instability.

Only unmarried, healthy, nulliparous Nepalese female medical students in the age range of 16 to 24 years were included in the study by Katwal PC et al. [18] , conducted in the School of Medical Sciences at Kathmandu University in 2016. Sixty-seven percent of the subjects had dysmenorrhea. Nine out of ten women reported that the intensity and duration of their dysmenorrhea increased after enrolling in medical school, and 65% of participants thought that medical school was stressful.

In our study, there were 175 students (58.33%) who were living with their parents and 222 students (74.0%) who were unmarried students with PD. Similarly, 227 students (75.67%) reported abdominal pain that was primarily accompanied by a little backache, with a p-value of <0.00001. Otherwise, 146 pupils (48.67%) reported having a sleep issue. According to a study by Mitsuhashi R. et al. [21] published in 2023, identifying risk variables might be used to develop a suitable strategy for enhancing menstruation symptoms and promoting women’s health.

According to a study conducted in 2015 at King Abdul-Aziz University in Jeddah, Saudi Arabia, by Ibrahim NK et al. [39] , the prevalence of PD was 60.9% and the prevalence of severe dysmenorrhea among those affected was 38.6%. The most prevalent symptom of PD (80.8%) was a depressed mood. As a result, 67.5% of the patients experienced emotional instability, and 28.3% reported being absent from school. The frequency of PD, however, was 75.67% in our sample, whereas the prevalence of its severe form was 11.67%. Reduced interest in routine tasks and a sense of weakness were the most prevalent manifestations (75.67%). College absence rates and reported emotional lability both came in at 45.0%.

According to a cross-sectional study done in 2012 by Amaza DS et al. [49] , among medical sciences students in Nigeria, dysmenorrhea is quite common among medical students and is associated with obesity, socioeconomic status, physical activity, and eating habits. In 2016, Mohapatra D. et al. [50] , demonstrated that those with a lower BMI felt more pain. The BMI of the subjects in the survey by Ju H. et al. [51] , was comparable. In contrast to earlier studies, the study by Hashim RT et al. [40] , conducted at King Saud University in 2020, found no connection between BMI, diet, and PD. All of those conclusions agreed with ours, with the exception of the link to obesity, as the majority of our students with PD (137 students, 45.67%) had normal BMIs, which was also true of previous studies [52] .

The majority (64.7%) of female students at Haramaya University in eastern Ethiopia reported having dysmenorrhea. Early menarche, tea use (4 glasses per day), consumption of fat- and oil-containing foods, and consumption of meat-based foods were all strongly linked to dysmenorrhea [53] , according to research. These results concurred with what we found. This may be explained by the fact that drinking tea and eating a lot of fattening foods are linked to high levels of oestrogen production. As oestrogen levels rise, the endometrium is stimulated and multiplies more, resulting in menstrual pain.

The first predictor of dysmenorrhea in the study conducted by Ibrahim NK et al. (39), in 2015 was a heavy period. Likewise, a study from Athens, Greece, discovered a strong connection between painful and heavy periods [54] . Other investigations examining cycle irregularities showed findings that were comparable [52] [55] . The majority of students (175, 58.33%) in our study had average blood loss (20–80 ml3/cycle); hence, there was no association between blood loss and PD.

A statistical correlation between family history of dysmenorrhea and the occurrence of PD in students was discovered (p-value < 0.00001), which is consistent with findings from Iran [55] and Dammam [56] . According to our findings, dysmenorrhea was more common among non-smokers than smokers (p = 0.0059). This result is different from those from Turkey [57] , and it could be because fewer students smoke in the current study than in Turkey.

In contrast to Dammam’s [56] findings, the current study demonstrated a significant relationship between the age of menarche and dysmenorrhea (p-value < 0.00001). Our results, however, were consistent with those from Egypt [58] . Premenstrual symptoms were 75.67% common in the current study, which is consistent with research from Jordan [59] and Spain [60] . Tabassum S. et al. [61] from Pakistan, on the other hand, reported a lower rate (53%).

In terms of the effects of dysmenorrhea, Hillen TIJ et al. [62] , discovered that 53% of young Western Australian girls who experienced it were limited in their activities, which is consistent with the findings of our study (44.33%). Additionally, Bergsj et al.’s [63] findings from an earlier study are supported by the findings of our investigation, which revealed a rate of absence owing to dysmenorrhea of 45.0%. However, given the disparities between the two target populations, this incidence is significantly lower than the rate among adolescent girls in the USA [64] . In the present study, only 11.67% of students sought medical treatment for dysmenorrhea, which is significantly less than the rate of 18% reported from Australia [62] . This could be due to the students’ lack of confidence in visiting a gynaecologist or the fact that they think painful periods are normal and don't require medical attention [65] [66] .

The study by Alateeq D. et al. [14] , conducted in 2022 at Princess Norah bint Abdulrahman University in Saudi Arabia, supported our findings by reporting that younger female age and earlier menarche were significant predictors of severe dysmenorrhea. The WaLIDD scale was used and the levels of dysmenorrhea were severe, moderate, and mild (45.6%, 39.8%, and 14.6% respectively) [14] . Studies conducted domestically and abroad report varying degrees of dysmenorrhea [39] [40] [67] . The prevalence of severe dysmenorrhea among students in our study (11.67%) was lower than the prevalence of the condition among students at King Abdul-Aziz University and Al-Jouf University (34% and 29%, respectively) in local studies [39] [41] . Additionally, it was lower than the published results among teenagers in Jordan and Iraq (32.9% and 19.85%, respectively) [67] [68] In contrast, research from Greece found that a higher number of nursing students (52.5%) had severe dysmenorrhea [69] .

Varying percentages between ethnicity and pain perception may be influenced by the different scales used to gauge the severity of dysmenorrhea and the different target women [40] [70] . Similar to this, a study done in Georgia found a strong link between PD and depression. Additionally, it was discovered that women with mental illnesses typically have lower pain thresholds [71] .

Joshi T. et al. [72] , reported that dysmenorrhea has a detrimental effect on quality of life (QoL), which is consistent with our study. Physical activity considerably decreased pain related to dysmenorrhea, according to a clinical trial by Kannan P. et al. [73] , even if it had no impact on the occurrence of discomfort. Exercise and physical activity were found to lessen the severity of menstrual pain and other symptoms, according to a meta-analysis study [74] . According to Ortiz MI et al. [75] , 50 minutes of exercise three times a week may help to lessen menstrual pain. Home exercise was found to significantly improve the quality of life (QoL) for patients with dysmenorrhea in terms of their health and pain, according to another study [76] .

According to a study conducted in 2014 by Rakhshaee Z et al. [77] , severe dysmenorrhea reduced people's daily and social activities as well as increased absences from school. In the current study, 45.0% of college absences were attributable to PD.

In a 2018 study by Alsaleem MA. [78] , conducted in Abha, Saudi Arabia, respondents reported experiencing severe pain 35.2% of the time. Two-thirds of the respondents said they took prescription painkillers, while the use of herbal remedies was also extremely common (69.1%). In the study, 64.7% of participants admitted to taking NSAIDs for pain management. In a study from Iran that was published, similar outcomes were attained [77] . In contrast, an Indian study from 2016 found that the majority of girls relied on herbal remedies and other non-pharmacological pain relief techniques, with only a small percentage of females (25.5%) seeking pharmacological care [79] . In the majority of published research, female students frequently sought out herbal medicines [80] - [82] . 218 females (63.7%) out of 342 participants, according to Gupta S. et al. [83] , had a history of dysmenorrhea in 2018. Mefenamic acid was the most often prescribed drug (90.5%). Only 30.2% of females took medications on a doctor’s instruction, whereas the majority of females (69.8%) self-medicated.

According to Syed A and Rao SB's article [2] published in India 2020, NSAIDs used to treat dysmenorrhea can raise the risk of heart attack, stroke, gastrointestinal bleeding, kidney, liver, and heart failure, anaemia, asthma attacks, and allergic responses. The frequency of PD was 91.5%, according to a study by Durand H. et al. [84] , which was published in 2021. The most widely used non-pharmacological management techniques were warm water bottle, rest, hot shower, and exercise. The percentage of our PD students who did not take any medication was 22 students (9.69%), while the percentage who used home remedies, analgesics, preferred NSAIDs, hormonal treatment, and antidepressants was 24 students (10.57%), 49 students (21.59%), 74 students (32.6%), and 34 (14.98%).