Recognizing the usage of analgesics among Saudi women with primary dysmenorrhea

1. Introduction

Dysmenorrhea is a painful uterine cramp that commonly affects women of reproductive age. Such pain occurs throughout the menstrual cycle (MC) is the most common reason for pelvic pain in females [1, 2]. Dysmenorrhea is classified into primary dysmenorrhea (PD) and secondary dysmenorrhea (SD). SD presents with the deterioration of progressive pain, atypical uterine blood loss and dyspareunia. PD is described by painful contractions in the lower abdomen, that begin just prior to or at menses and may last for three days. The international prevalence of PD varies from 45% to 95% among women of reproductive age [3]. This difference in rate may be caused by differences in the assessment of PD, the designated population, age clusters, ethnicity and pain perception [4]. Previous evidence suggested that the risk of PD was increased by certain factors, including smoking, early menarche, asymmetrical MC, a long MC duration, heavy menstrual bleeding, and a family history of dysmenorrhea [5, 6]. However, the risk and severity of dysmenorrhea can be reduced by vaginal child delivery and exercise [7].

The pathophysiology of primary dysmenorrhea is associated with the cyclooxygenase pathway which induces increases in the levels of prostanoids, mainly prostaglandins (PGs). The increased levels of PGs induces uterine contractions which limit blood flow and cause anaerobic metabolites that trigger pain receptors [8].

PD is the foremost cause for the short-term non-attendance of females from school or work, thus exerting a significant influence on their quality of life (QOF); this also creates a significant burden on health care expenditure [9]. In addition, numerous women do not consult with a doctor; therefore, the precise influence of PD on daily activity remains largely unknown [10].

Collective decision making is an efficient strategy with which to manage PD effectively and maximize the compliance and satisfaction of patients [11]. PD can be treated by numerous methods, including pharmacological, non-pharmacological and surgical approaches. Effective empiric therapy and non-steroidal anti-inflammatory drugs (NSAID) represents the first line of treatment. In women who require contraception, the use of oral contraceptives (OCP) is recommended [12]. Unconventional management strategies, include topical heat, lifestyle adjustment, transcutaneous electrical nerve motivation, dietary additions, acupuncture and acupressure [13].

The efficacy of typical management strategies using NSAIDs and OCP is acceptable. Nevertheless, failure may occur in 20% to 25% of patients; there is also a risk of drug-associated adverse effects. Only 6% of adolescents obtain medicinal instruction to treat PD whereas 70% practice self-management [7]. A previous systematic Cochrane review compared 20 different NSAIDs to determine whether NSAIDs are effective and safe for the treatment of PD. This review concluded that NSAIDs represent an effective treatment method, although women need to be aware of the adverse effects associated with this treatment [14].

In the Kingdom of Saudi Arabia (KSA), a small-scale cross-sectional study supported by the College of Health Sciences at King Khalid University revealed that around 70% of the study participants experienced dysmenorrhea which was associated with lower back pain, nausea, bloating and dizziness. This research also investigated the prevalence of NSAIDs and the use of herbal medication but did not investigate the rationale for preferring one treatment over another [15]. Another cross-sectional study investigated the self-management attitudes for PD between female students in the Asir region in KSA. The study concluded that community pharmacists are the most available healthcare practitioners and that collaboration between educational institutions and community pharmacies could play an indispensable role in promoting self-care practices among young women with PD [4]. irrational drug use remains a serious problem that can cause distress in public health [16].

Even though PD is a regular gynecological complaint, it has received only very limited attention in the Middle East, and is usually neglected. The increased prevalence of this condition and the minimal awareness of menstrual disorders and its management, there is a clear need for further investigations in this field of research. Dysmenorrheic females are not equipped with adequate facts and are therefore poorly informed. Therefore, in this study, we aimed to gain an overview of the prevalence of PD along with associated risk factors, concomitant symptoms, the influence on everyday activities, and the management practices available in the KSA. Our findings provide important guidelines for dysmenorrheic females with regards to the appropriate use of treatments.

2. Materials and methods

A cross-sectional survey study was preformed using an electronic questionnaire targeting Saudi females with dysmenorrhea from June 2022 to January 2023. The inclusion criteria included Saudi females who agreed to participate, female in the reproductive-age aged ≤20, age 20–40, ≥40 years, suffering from primary dysmenorrhea. Exclusion criteria included mental disorders, breastfeeding, expecting to get pregnant, being pregnant right now, or having a chance of getting pregnant (positive human chorionic gonadotropin test), non-menstruating females and female diagnosed with secondary dysmenorrhea due to pelvic pathology, such as uterine fibroids, adenomyosis, endometriosis or pelvic inflammatory diseases.

3. Results

3.3 The use of analgesics during dysmenorrhea among Saudi women

With regards to the prevalence of analgesic use during dysmenorrhea among Saudi women, we found that 770 (76.2%) of females used analgesics during dysmenorrhea while 241 (23.8%) did not use any analgesics (Fig. 1).

Fig. 1.The prevalence of analgesic use during dysmenorrhea among Saudi women.

With regards to the use of analgesics, most subjects reported using Paracetamol (56.6%), followed by Ibuprofen (26.4%) and Diclofenac (8.1%); 9% used other drugs/herbs. A total of 691 (89.7%) subjects reported using analgesics with pain whereas only 79 (10.3%) of subjects reported the use of analgesics before the pain began. With regards to the timing of analgesic intake with meals, 515 (66.9%) of females reported using analgesics prior to meals whereas (22.5%) reported they took analgesics before meals. In addition, 249 (32.3%) females reported that they had analgesics recommended by their family and/or friends while 154 (20%) subjects reported that they took analgesics following doctor/pharmacist recommendation; 329 (42.7%) subjects took analgesics on their own accord. In total, 663 (86.1%) subjects took 1–2 analgesic tablets per day while 89 (11.6%) took 3–4 tablets per day. A total of 142 (18.4%) subjects reported taking a second dose within 5–6 hours of the previous dose while 416 (54%) of subjects left more than a 12 hours interval between two successive doses. A total of 505 (65.8%) subjects reported that they used analgesics for 1–2 days, 83 (10.8%) used analgesics for more than 2 days, and 120 (15.6%) only used analgesics during pain attacks; 60 (7.8%) of subjects used analgesics according to physician recommendations. If the pain was not relieved, 475 (61.7%) of Saudi women reported that they used another analgesic, whereas only 202 (26.2%) of females consulted another hospital and/or physician; 47 (6.1%) of subjects used hot fluid and/or hot foments and rest while 46 (6%) of subjects did nothing but wait for the pain to subside (Table 3).

Table 3.Pattern of analgesic use during dysmenorrhea among Saudi women.

Pattern of use	No	%
Type of used analgesics
	Paracetamol (500 mg)	436	56.6%
	Ibuprofen (400 mg)	203	26.4%
	Diclofenac (50 mg)	62	8.1%
	Others	69	9.0%
Time at which analgesics were taken
	Before pain	79	10.3%
	With pain	691	89.7%
Analgesics intake is
	Before meal	196	25.5%
	After meal	515	66.9%
	With meal	59	7.7%
Who advised you to have analgesics?
	None	329	42.7%
	Family/friend	249	32.3%
	Physician/pharmacist	154	20.0%
	Social/mass media	38	4.9%
Do you take more than one painkiller pill a day?
	Yes	372	48.3%
	No	398	51.7%
Number of analgesics pills/day
	1–2 pills	663	86.1%
	3–4 pills	89	11.6%
	5–6 pills	15	1.9%
	>6 pills	3	0.4%
Duration between 2 analgesics doses
	1–2 hours	43	5.6%
	3–4 hours	95	12.3%
	5–6 hours	142	18.4%
	6–12 hours	74	9.6%
	>12 hours	416	54.0%
Duration of using analgesics
	1–2 days	505	65.8%
	>2 days	83	10.8%
	Only during pain	120	15.6%
	According to physician prescription	60	7.8%
Have you tried other methods other than medication to relieve pain?
	Yes	675	87.7%
	No	95	12.3%
What do you do if the pain does not go away?
	Use another analgesic/increase the dose	475	61.7%
	Go to hospital/physician	202	26.2%
	Had hot fluid/hot foments and rest	47	6.1%
	Nothing/just wait	46	6.0%

3.4 Side effects associated with analgesic use during dysmenorrhea among Saudi women

The most reported side effect of analgesics use included heart burn (12.3%), menstrual disturbance (10.8%), abdominal pain (8.8%), and nausea and vomiting (1%); 65.3% reported no complications at all (Fig. 2).

Fig. 2.Side effects associated with analgesic use during dysmenorrhea among Saudi women.

4. Discussion

In this study, we highlight a relatively elevated prevalence of PD, the most common gynecological condition, among Saudi women. In Arab nations, the stated prevalence rate of dysmenorrhea was reported to be 85.9% [18], 88% [19] and 80% [7] in Iraq, Syria and Lebanon respectively. National Saudi studies reported an incidence of 60.9–89.7% amongst university students in the KSA [20, 21]. Another cross-sectional survey showed that the prevalence of PD reached 92.3% in Saudi women [22]. Another study reported that the prevalence of PD was 80.9% among medical female students in the KSA [20].

In the current study, family history had showed no significant influence. These outcomes are inconsistent with earlier studies which showed that the prevalence of dysmenorrhea was greater among women who had a family history of PD in KSA [23, 24]. This deviation in the prevalence rates of PD might relate to variation in PD assessment procedures, the designated population, age clusters, ethnicity and pain sensitivity variances.

Dysmenorrhea may exert significant effects on health, psychological status and the daily actions of females, thus disrupting their QOL as well as their productivity. An earlier study showed that PD is one of the main reasons of absenteeism from school or work, causing a loss of 600 million hours per year in the USA alone [25]. In the current study, 68.5% females reported that dysmenorrhea pain affected their daily activities. Similarly, earlier studies showed that PD disturbed the daily activities of 87.9% of Turkish female university students [26]. In Saudi Arabia, an earlier study examined the effect of PD on the QOL amongst female medical students in the KSA. These authors concluded that PD exerted a substantial influence on academic performance since PD was associated with a negative impact on attendance, concentration, the period of study and class contribution [27]. Similarly, previous studies revealed that a range of daily activities were influenced by PD, including homework, daily activities, attention, attendance and academic achievement [28, 29].

The main objective of PD management is to offer dysmenorrheic women with satisfactory pain relief that allows them to achieve their usual activities, enhances the QOL and reduces absenteeism [1, 30]. The first-line treatments suggested are NSAIDs and OCP, as these methods can prevent the synthesis of prostaglandins which are directly linked to menstrual pain [13]. Irrational medication handling may have deleterious consequences, including inadequate treatment, the risk of adverse events, a higher possibility of drug interactions, excessive costs, as well as economic burden [16].

Acetaminophen is a rational pain-relieving drug for dysmenorrheic women who do not require contraception and are unable to endure NSAIDs [31]. On the other hand, numerous reports have revealed that acetaminophen has inferior efficiency when related to NSAIDs and OCP; thus, acetaminophen is favored merely for mild-to-moderate dysmenorrheic pain [25, 32]. NSAIDs are the cornerstone for dysmenorrhea management as they prevent the release of Cyclooxygenase (COX) enzyme which inhibits the synthesis of prostaglandins [33, 34]. Consequently, NSAIDs are suggested as the first-line therapy for females who prefer to use analgesics or when contraceptives are contraindicated [35, 36]. However, there is no superiority of a specific NSAID over the other [37].

With regards to the timing of analgesic administration, around majority reported that they used analgesics with pain whereas 10.3% reported using analgesics before the pain began; this latter approach was associated with lower analgesic efficacy. The timing of NSAID administration is associated with efficiency. For optimum efficiency and safety, NSAIDs should be initiated one to two days prior to the predicted onset of menses, managed with meals to limit gastrointestinal adverse effects, with a regular dosing schedule, and sustained throughout the first two to three days of bleeding [13]. The initiation of NSAIDs should be initiated before the induction of the COX-2 cascade to obtain the widespread suppression of prostaglandin synthesis. Thus, the deferral of NSAIDs produces partial suppression only [38]. Females who are unresponsive to NSAIDs may be swapped to hormonal and/or non-pharmacological therapies [39]. Remarkably, in the current study, none of the dysmenorrheic females received OCP to accomplish pain relief although they are recommended as first-line therapy. This finding concurs with the restricted use of OCP for unmarried women in the Middle East [40]. A previous study revealed that the majority of females take OCP for pregnancy prevention, and few use OCP for non-contraceptive causes, such as acne and PD [41].

With regards to the intake of analgesics with meals, our analysis showed that 66.9% of females reported using analgesics after meals whereas 22.5% used analgesics before meals. These reports are alarming since 22.5% of females are at a greater risk of developing adverse gastrointestinal effects. As few as 20% of the participants used analgesics after consulting healthcare personnel, including doctors and pharmacists. Therefore, with regards to management-seeking attitudes, this investigation was consistent with an earlier finding in which women displayed reluctance in pursuing medicinal instruction and preferred to ask family members, friends, and consult internet resources [42, 43]. The main reasons for such behavior were the normalization of menstrual pain and the preference for self-medication [44]. The majority of females considered that MC pain is a normal physiological state that ought to be tolerated. This false conception is generally imposed by family members, society and culture, thus causing females to seek self-care approaches rather than appropriate medicinal assistance.

The outcomes of the current study revealed that 61.7% of Saudi women expressed that they use another analgesic if pain is not relieved, whereas only 26.2% go to hospital or consult a physician.

Community pharmacists, being easily accessible healthcare providers, play an exceptional role in instructing PD females as well as adjusting their management approach. Pharmacists ought to guide dysmenorrheic females with the selection of appropriate analgesics and instruct them that they should be taken 1–2 days before the predicted onset of menses rather than on an as-needed basis to attain acceptable pain relief. Females should also be instructed to take NSAIDs every 6 to 8 h after meal intake, and not to exceed the recommended dose. Furthermore, pharmacists should counsel females with regards to the anticipated outcomes and side effects of the selected painkiller.

In addition, study recognized that drugs were superior to non-pharmacological procedures in reducing the pain score. Thus, consuming drugs for pain relief is considered a keystone in managing dysmenorrhea, whereas non-pharmacological procedures can be adopted as adjunctive therapy and for those who cannot tolerate analgesics.

This study had some limitations that needed to be considered. First, this was a cross-sectional investigation; thus, outcomes may not be generalized since the participants were limited to a specific region in the KSA. In addition, pain perception differs from one individual to another; therefore, it is not appropriate to compare our results regarding pain with those of other studies that used scales for measuring pain. Another limitation in the current study is the study did not use any established scale for dysmenorrhea such as WALLiDD scale [45].

5. Conclusions

PD is a largely ignored gynecological disorder characterized by menstrual pain related with several physical and psychological indicators that affect the daily activities of the female involved. PD is typically managed by NSAIDs and OCP in addition to other non-pharmacological therapies. Despite the adverse impact of PD, the majority of females do not pursue recognized healthcare assistance; rather, they perceive this as a normal physiological cycle. In the current study, most dysmenorrheic females received optium medications to manage their pain; nevertheless, the onset of drug initiation was delayed with respect to menstrual bleeding, and a sub-therapeutic dose was administered; subsequently, suboptimal effectiveness for pain relief was achieved. Moreover, none of the participants acknowledged using contraceptives which is probably due to the common perception in the Arab public that contraceptives are utilized only for contraception. Our conclusions revealed a clear absence of understanding of the optimal management of PD. Hence, instructive programs and interventions relating to PD, its modifiable risk factors, and self-management care, should be developed and applied to avoid the unnecessary pain and disturbances to daily activities. Moreover, there is an indispensable requirement for primary healthcare practitioners to provide counseling services relating to PD and to augment its management outcomes.

Availability of data and materials

Date are available upon request.

Author contributions

FMA, WAA and NSY—conceptualization; software; formal analysis. FMA and WAA—methodology; writing-original draft preparation. NSY—supervision; writing-review and editing; funding acquisition. All authors have read and agreed to the published version of the manuscript.

Ethics approval and consent to participate

This study was approved by the Institutional Review Board (IRB) of King Faisal University in the eastern region of Saudi Arabia (IRB approval number: KFU-REC-2022-DEC-ETHICS360). Informed consent was obtained from each participant prior to data collection.

Acknowledgment

The authors thank the Deanship of Scientific Research, Vice Presidency for Graduate Studies and Scientific Research, King Faisal University for the financial support.

Funding

This work was supported by the Deanship of Scientific Research, Vice Presidency for Graduate Studies and Scientific Research, King Faisal University, Saudi Arabia (GRANT4742).

Conflict of interest

The authors declare no conflict of interest.