The prevalence of various menstrual disorders and its association with psychological stress in medical faculties students. A Cross-sectional study.

doi:10.21203/rs.3.rs-2349778/v2

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The prevalence of various menstrual disorders and its association with psychological stress in medical faculties students. A Cross-sectional study.

https://doi.org/10.21203/rs.3.rs-2349778/v2

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Background: Menstrual disorders are of the most prevalent health issues in young female students studying in health science faculties. The purpose of this study was to provide an insight on the menstrual patterns among medical faculties students, and to determine whether stress can be an identified factor for its various disorders.

Methods: This was a cross-sectional study conducted in the Faculties of Medicine, Dentistry and pharmacy in the Syrian Private University, Damascus, Syria, between October and November of 2022. Nine hundred and eighty female students anonymously completed the identification of menstrual problems and Perceived Stress Scale (PSS) questionnaire. The date was analyzed with Social Science Statistics Package.

Results: The mean age of the students was 21.52 ± 2.06 years. The most common menstrual disorders in this study were dysmenorrhea (88%), premenstrual syndrome (87%), and irregular menstrual cycle (21%). We found a statistically significant relationship between the occurrence of irregular menstrual cycle and amenorrhea, polymenorrhea, and oligomenorrhea. 82% had mild to moderate stress, 10% had high stress, while 8% had low stress. There was a statistically significant relationship between stress and abnormal vaginal bleeding, oligomenorrhea, and menstrual irregularity.

Conclusion: There was a really high prevalence of stress among these students, which was also associated with the occurrence of various menstrual disorders, both of which can not only have an impact on a student's ability to function academically, but also may potentially have detrimental impacts on their reproductive and mental health. It is for that reason we advise that all students of medical faculties get brief courses on stress management strategies as part of their curriculum. Additionally, all medical faculties universities should set up procedures for the early detection of individuals with stress and menstruation disorders. The identified students with high stress levels should also get prompt gynaecological and psychiatric counselling.

Obstetrics & Gynecology

Menstrual disorders

academic stress

gynecology

medical faculties

Syria

During a woman's reproductive life, menstruation—a naturally occurring phenomena involving the release of blood from the uterus via the vagina—occurs at about monthly intervals. It is a natural physiological process that can cause some amount of pain and discomfort, but not enough to prevent them from going about their everyday lives normally [1]. Teenagers between the ages of 11 and 14 initially experience regular menstruation, with periods lasting no more than seven days and cycles typically lasting 21 to 45 days with an average blood loss of 20 to 80 ml [2]. According to studies, many women of reproductive age experience health problems connected to their periods [3–5]. Menstrual problems can take many different forms, such as dysmenorrhea, oligomenorrhea, premenstrual syndrome (PMS), polymenorrhea, abnormal vaginal bleeding, menorrhagia, amenorrhea, and irregular menstruation [6]. Dysmenorrhea or painful menstruation, which affects over 90% of women of reproductive age, is a common reason for gynecological consultation among adolescents and women [7–9]. When the referred pain is associated with a regular ovulatory cycle and has no connection to a past pelvic condition, dysmenorrhea is classified as primary. Conversely, secondary dysmenorrhea occurs when there are symptoms of pelvic pathology [10]. When a patient has primary dysmenorrhea, they typically describe low abdomen discomfort that ranges from mild to severe and is accompanied by other symptoms including nausea, fatigue, irritability, headaches, dizziness, vomiting, and diarrhea. The symptoms may start one day prior to menstruation, continue during it, and linger up to three days after menstruation [11]. Menarche at a young age, a family history of dysmenorrhea, prolonged menstrual cycles, alcohol and caffeine consumption, poor sleep hygiene, particular dietary habits, inactivity, obesity, and leading a stressful lifestyle are some of the risk factors associated with episodes of primary dysmenorrhea and identified in the literature [11–13].

Women who have dysmenorrhea may potentially become bedridden, and this is of particular concern, as it is a very common condition as previously stated [14]. Countries across the world have varying levels of dysmenorrhea prevalence, ranging from 50–90% [15–18]. This is partially a result of how dysmenorrhea is defined and/or assessed [7–9]. Premenstrual syndrome (PMS) is another another menstruation condition that may interfere with a woman's day-to-day activities. A systematic review revealed that the combined prevalence of PMS was 47.8% [19].

Moreover, nearly 12% of gynecologist referrals are for menstrual problems such polymenorrhea, abnormal uterine bleeding, and menorrhagia, which are often linked to a very high likelihood of surgical intervention [20]. Furthermore, 60% of women received a hysterectomy within five years of receiving a referral for menorrhagia, according to a study by Coulter et al [21].

These illnesses are widely acknowledged as contributing to social, physical, psychological, and economic issues. They could also negatively affect a woman's day-to-day activities. Regardless of socioeconomic status, culture, physical characteristics, or ethnicity, the symptoms affect every woman in the reproductive age range [22]. Among young academic or working women, these problems are of a particular concern, as they are among the main reasons for absences and subpar academic performance among young women [23, 24]. Age, ethnicity, family history, smoking, physical activity, and nutritional choices are just a few of the variables that might have an impact on menstrual cycles [25]. One other important and often discussed factor is stress, as previous studies found a correlation between stress and the occurrence of menstrual problems. A study previously conducted on female university students in Saudi Arabia by Rafique N. et Al, found a strong correlation between high perceived stress (HPS) and menstrual problems [26].

Students with high perceived stress showed odds ratios that were 4 times higher, 2 times higher, and 2.8 times higher for amenorrhea, dysmenorrhea, and premenstrual syndrome, respectively.

In this research, we analyze the prevalence of menstrual problems among health science students in Damascus, Syria. We also evaluate the correlation between these conditions and stress.

Study design, setting and participants

A cross-sectional study was conducted at the Syrian Private University between October and November of 2020, in which 995 students participated.

Inclusion criteria: female students currently studying in one of the medical field colleges (pharmacy, medicine, dentistry) at the previously mentioned university.

Exclusion Criteria: Pregnant or lactating females, females with any type of psychiatric disorder or chronic disease, and females diagnosed with any type of pelvic pathology (pelvic inflammatory disease, fibroids).

In total, 980 students were included in this study after meeting the inclusion criteria.

All participants provided informed consent before participating.

Data Collection Instruments

Female students studying medicine, dentistry, and pharmacy were asked to complete a questionnaire that identifies menstruation problems and measures individual stress levels. This questionnaire was taken from a previous similar study conducted by Rafique N. et Al [26] and was completed by each participant anonymously. The questionnaire included questions regarding the participants' demographics as well as their menstrual pattern (menarche age, menstrual regularity, flow duration in days and its quantity, and cycle length in days), and history of dysmenorrhea, amenorrhea, and premenstrual symptoms. The terms used in the questionnaires were explained to participants during a quick briefing to decrease the chances of error. The terms for regular menstruation and various menstrual disorders were defined as follows:

Normal menstrual cycle: A cycle that lasts between 21 and 35 days, with a menstrual flow that lasts between 2 and 6 days and an average blood loss of between 20 and 80 ml (which can be determined by the number of sanitary pads used a day). Cycle irregularity: The term "irregular" refers to any abnormal variation in the length of the menstrual cycle. Variation in cycle length between 8 and 20 days is considered moderately irregular, while variation of 21 days or more is considered extremely irregular. Amenorrhea is not having a period. The absence of menstruation by the age of 16 despite normal secondary sexual characteristics is known as primary amenorrhea. secondary amenorrhea is the absence of menstruation for six months or for three normal cycles. Oligomenorrhea occurs when the menstrual cycle lasts longer than 35 days. Hypomenorrhea involves uterine bleeding that is either brief (less than two days) or of a small volume. Polymenorrhea is cyclic bleeding that occurs too frequently at intervals of less than 21 days but is normal in volume. Menorrhagia is a cyclic bleeding at normal intervals with either an excessive amount of bleeding (> 80 ml), or with a prolonged duration. Primary dysmenorrhea refers to menstrual pain that cannot be explained by an underlying condition. The hypogastrium is usually where the pain is felt, but it can also spread to the front of the thighs. Additionally, the condition may or may not be associated with lower back pain, as well as autonomic symptoms like sweating, nausea, and diarrhea. The psychological and physical changes that occur a few days before menstruation are known as premenstrual symptoms and are resolved as soon as menstruation is established. In the current study, all of the aforementioned definitions were applicable if the symptoms were present for at least the last three menstrual periods. In some females, these manifestations become sufficiently exaggerated to constitute premenstrual syndrome (PMS).

Statistical analysis

The Statistical Package for Social Sciences (SPSS) for Windows, Version 28.0, was used to analyze the data. The demographic information, menstrual patterns, and prevalence of various menstrual problems among the participants were all determined using descriptive statistics. A p-value of 0.05 was regarded as statistically significant when using the Chi-square test to determine the presence or absence of menstrual irregularities among the students with various menstrual disorders and the association between psychological stress and various menstrual disorders.

980 students participated in this study of which 348 (36%) were studying medicine, 333 (34%) were studying dentistry, and 299 (31%) were studying pharmacy. The mean age of participants was 21.52 ± 2.06 years, and their mean BMI was 22.70 ± 3.70 kg/m2. Demographic data is shown in more detail in Table 1.

Table 1

Demographics
Age	21.52 (± 2.06)
Hight	162.50 (± 5.75)
Weight	60.00 (± 10.46)
Body Mass Index (BMI)	22.70 (± 3.70)
Residence
Home	872 (89)
hostels	100 (10)
other	8 (1)
Faculty
Medicine	348 (36)
Dentistry	333 (34)
Pharmacy	299 (31)
Year
First	47 (5)
Second	149 (15)
Third	217 (22)
Fourth	227 (23)
Fifth	231 (24)
Sixth	109 (11)
Marital status
Single	857 (87)
Married	24 (2)
Divorced	3 (0.003)
In relationship	96 (10)
Do you have kids?
Yes	19 (2)
No	961 (98)
Number of the kids	0.02 (± 0.25)
Work
Yes	70 (7)
No	910 (93)
Hours of working per week	1.19 (± 5.56)

The mean age of menarche in this study was 13.29 ± 1.8 years. The mean duration of the cycle was 23.6 ± 3.2 days and was regular in 775 (79%) students. The mean duration of menstruation was 4.67 ± 1.03 days. 474 (48%) students had a small amount of bleeding during menstruation, 435 (44%) had an average amount, while 71 (7%) had heavy bleeding. Menstrual patterns are shown in more detail in Table 2.

Table 2

Menstrual Patterns
Menarche age	N (%)
<10 years	8 (1)
10–12 years	155 (16)
13–14 years	626 (64)
15–16 years	175 (18)
>16 years	16 (2)
Duration of flow in days (in the last 3 months)
<4 days	140 (14)
5–6 days	680 (69)
>7 days	160 (16)
Menstrual blood loss
Scarce	474 (48)
Average	435 (44)
Abundant	71 (7)
Cycle length in days (in the last 3 months)
<21 days	152 (16)
21–27 days	522 (53)
28–35 days	259 (26)
>35 days	47 (5)
Menstrual regularity (in the last 3 months)
Regular	775 (79)
Irregular	205 (21)

861 (88%) students had a history of dysmenorrhea, and 857 (87%) had a history of premenstrual syndrome (PMS), both of which were the most common menstrual disorders in this study. Regarding dysmenorrhea, the most common pain location was lower abdomen accompanied with back pain which was prevalent in 727 (74%) students, followed by legs pain in 364 (37%) students and isolated lower abdominal pain in 268 (29%) students. Dysmenorrhea moderately affected 369 (43%) students' daily activities, slightly affected 292 (34%), and was severe enough to inhibit it in 126 (15%) students. Most common PMS symptoms were backache which was prevalent in 670 (68%) of the students, followed by mood swings in 667 (67%), and Tiredness in 600 (61%) of them. 71 (7%) students had menorrhagia, which was most associated with anemia symptoms in 30 (42%), followed by having to wake up during the night to change sanitary protection in 29 (41%), and passing large blood clots with the menstruation flow in 28 (39%) of them. Table 3 presents the frequency of incidence of various menstrual disorders, their symptoms and associations.

Table 3

Menstrual disorders and its associated symptoms:
	N (%)
Primary amenorrhea	16 (2)
Amenorrhea for ≥ 3 months	57 (6)
Polymenorrhea	152 (16)
Oligomenorrhea	47 (5)
Irregular menstruation (in the last 3 months)	205 (21)
Current history of secondary amenorrhea for ≥ 3 months	57 (6)
Past history of secondary amenorrhea for ≥ 3 months	142 (14)
Menorrhagia	71 (7)
Menorrhagia’s associated symptoms:
Soaking through one or more sanitary pads every hour for several consecutive hours	18 (25)
Needing to use double sanitary protection to control your menstrual flow	24 (34)
Needing to wake up to change sanitary protection during the night	29 (41)
Passing large blood clots with menstrual flow	28 (39)
Restricting daily activities due to heavy menstrual flow	23 (32)
Symptoms of anemia, such as tiredness, fatigue or shortness of breath	30 (42)
History of abnormal vaginal bleeding	88 (9)
Abnormal vaginal bleeding associations:
Polycystic ovarian diseases (PCO)	29 (33)
IUCD (Intra Uterine Contraceptive Device)	4 (5)
Hormonal Family Planning	12 (14)
Taking any other medication	12 (14)
Do not have any problem	43 (49)
Premenstrual syndrome	857 (87)
Premenstrual syndrome associated symptoms:
Generalized pains	430 (50)
Headache	332 (39)
Backache	592 (69)
Abdominal Cramps	487 (57)
Tiredness	533 (62)
Bloating	268 (31)
Tender breast	369 (43)
Acne	426 (50)
Loss of appetite	350 (41)
Mood swings	585 (68)
Anger	449 (52)
Feeling drowsy	362 (42)
Dysmenorrhea	861 (88%)
Pain location:
Lower abdomen	238 (28)
Lower abdomen and back	648 (75)
Right side of abdomen	114 (13)
Left side of abdomen	75 (9)
Legs pain	323 (38)
Pain severity
Doesn’t affect daily activities	74 (9)
Slightly affects daily activities	292 (34)
Moderately affects daily activities	369 (43)
Inhibits daily activities	126 (15)

When evaluating the presence or absence of menstrual irregularity in the participants with various menstrual problems, there was a statistically significant relationship between the occurrence of irregular menstrual cycle and amenorrhea, polymenorrhea, and oligomenorrhea. Details are shown in Table 4.

Table 4

Association of various menstrual disorders and menstrual irregularity:
Menstrual problems	Menstrual regularity		P value
Menstrual problems	Yes	no	P value
Amenorrhea	31 (54)	26 (46)	< 0.0001*
Dysmenorrhea	684 (80)	177 (20)	0.455
Abnormal vaginal bleeding	69 (87)	19 (13)	0.870
Premenstrual symptoms	671 (78)	186 (22)	0.110
Menorrhagia	22 (81)	5 (19)	0.755
Polymenorrhea	104 (68)	48 (32)	0.0004*
Oligomenorrhea	15 (32)	32 (68)	< 0.0001*

760 (78%) students indicated that they felt stressed most of the time, 488 (64%) of those specified that their stress was related to their studies, 445 (59%) indicated that it was related to social stress, and 372 (49%) indicated that it was related to their assignments and exams. 805 (82%) students had moderate perceived stress, while 98 (10%) had highly perceived stress, and 77 (8%) had low perceived stress. Table 5 represents perceived stress levels and its identified factors.

Table 5

stress and its identified factors and levels.
Are you stressed most of the time	N (%)
Yes	760 (78)
No	220 (22)
Identified stress factor
Related to study	488 (64)
Related to exams	372 (49)
Related to work	82 (11)
Social stress	445 (59)
Do not feel stressed	220 (22)
Perceived stress scale questionnaire (PSS)
Low stress	77 (8)
Mild to moderate stress	805 (82)
Highly perceived stress	98 (10)

Regarding the relationship between the various menstrual disorders and perceived stress, there was a statistically significant relationship between abnormal vaginal bleeding, oligomenorrhea, and cycle regularity and perceived stress. Table 6 presents the relationship between different stress levels and the different menstrual disorders.

Table 6

Relationship between stress and various menstrual disorders
Various menstrual problems	Stress			P value
Various menstrual problems	Low	Moderate	High	P value
Amenorrhea				0.156
Yes	1 (2)	51 (89)	5 (9)
No	76 (8)	754 (82)	93 (10)
Dysmenorrhea				0.252
Yes	66 (8)	704 (82)	91 (11)
No	11 (9)	101 (85)	7 (6)
Abnormal vaginal bleeding				0.0410*
Yes	13 (15)	67 (76)	8 (9)
No	64 (7)	738 (83)	90 (10)
Premenstrual symptoms				0.139
Yes	63 (7)	704 (82)	90 (11)
No	14 (11)	101 (82)	8 (7)
Menorrhagia				0.928
Yes	2 (7)	22 (81)	3 (11)
No	75 (8)	783 (82)	95 (10)
Polymenorrhea				0.540
Yes	14 (9)	126 (83)	12 (8)
No	63 (8)	679 (82)	86 (10)
Oligomenorrhea				0.0469*
Yes	3 (6)	34 (72)	10 (21)
No	74 (8)	771 (83)	88 (9)
Regularity				0.028*
Yes	65 (8)	642 (83)	68 (9)
No	12 (6)	163 (80)	30 (15)

Menstrual disorders are of the most prevalent health issues in young female students studying in health science faculties [26]. The purpose of this study was to provide an insight on the menstrual patterns among medical faculties students, and to determine whether stress can be an identified factor for its various disorders.

The mean age of menarche in our study was 13.29 ± 1.8 years, while it was at 12.49, 13.8, and 13.07 years in a Lebanese, Jordanian, and Turkish studies respectively, all of which are neighboring countries of Syria [27–29], and 12.06 to 12.88 years in an American study [30]. The variance of menarche age can be due to differences in socioeconomic status, diet, and genetic factors, other environmental stressors and Illness burden can also affect the timing of it [31–34].

In this study, the duration of the menstrual cycle was normal (between 21 to 35 days) in 79% of the students, which was lower than it was in a Lebanese, Nigerian, and Irish studies [27, 35, 36], all of which included female university students from various faculties, where the cycle duration was normal in 84.5%, 92%, and 87.6% respectively. However, our finding was consistent with the Saudi study in which all the participants were studying in health care faculties where the menstrual cycle duration was normal in 77%[26].

The mean duration of menstruation was 4.67 ± 1.03, the amount of bleeding was assessed by asking how many sanitary pads were used a day during menstruation, and it was light in 48%, moderate in 44% and heavy in 7%. In comparison to a Saudi study that was also conducted on health faculty students, the amount of blood loss was 27.7%, 65.8%, 3.4% respectively. Light menstrual bleeding was more prevalent in our study than the Saudi one [26]. Nevertheless, this condition isn’t concerning and several causes can lead to it, such as hormonal contraceptives, as they may reduce the menstrual flow up to 50%, Polycystic Ovary Syndrome (PCOS), higher peak LH levels and higher levels of estrogen and progesterone in the luteal phase, and anovulation [37–39]. Menorrhagia is defined as a cyclic bleeding at normal intervals with either excessive amount of bleeding (> 80ml), or with a prolonged duration (> 7 days of bleeding). 16% of the participants in this study had a duration of flow longer than 7 days, while 7% had an abundant loss of blood. 18.8% of the participants in the saudi study had a duration of flow longer than 7 day which was slightly higher than it was in our study, while only 3.4% had abundant amount of bleeding which was half of those in our study [26]. In the participants with heavy menstrual bleeding in our study, the blood loss was severe enough to cause anemia symptoms in 42%, pass large blood clots with the blood flow in 39%, and completely restrict daily activities in 32%. Heavy menstrual bleeding can be a serious condition especially if associated with prolonged duration of menstrual bleeding and/or bleeding disorders, as it may cause anemia, fatigue, and hemodynamic instability, eventually requiring hospitalization, blood products transfusion and therapies to stop the blood loss [40]. Causes of menorrhagia are divided into organic and functional causes, Organic causes include uterine fibroids, diffuse adenomyosis, endometrial polyps and, rarely, chronic pelvic infection, bleeding disorders, and hypothyroidism. Functional causes include dysfunction of endocrine or endometrial local control of menstruation [37].

88% of the participants had dysmenorrhea, which was the most prevalent disorder in our study. Its incidence in the participants of this study was higher than it was in most of other similar studies conducted on university students as it was prevalent in 66%, 72%, 74.8%, and 85.1% in an Egyptian, Nigerian, Spanish, and Palestinian studies where the participants studied in various faculties [41, 35, 42, 16]. However, dysmenorrhea was prevalent in 89.7% in the Saudi study conducted on healthcare sciences students, which was the closest to our finding [26]. Nevertheless, in an Irish study that included students from various university faculties, dysmenorrhea was prevalent in 91.5% [11]. Although our finding regarding dysmenorrhea was higher than most of the other studies, it was still consistent with statistics published in the literature, according to which 50–90% of university students may experience dysmenorrhea [16, 18].

A significant finding in this study was that 87% of the participants had premenstrual syndrome (PMS). The incidence rate of this disorder was remarkably high when comparing it to other studies’, where the incidence rate was between 35.6% and 56.1% in studies conducted on university students. [44–46]. The most prevalent symptoms in PMS varies in frequency between a population and another. For example, in this study the most common PMS symptom was backache (69%), followed by mood swings (68%), and tiredness (62%), while the most common symptom in the previously mentioned Saudi study was mood swings (46%), followed by tiredness (43.5%), and generalized pains (37.4%)[26]. Additionally, in an Ethiopian study conducted on university students in 2021, the most common PMS symptoms were abdominal cramps (78.8%), depression (73.3%), and fatigue (72.9%) [45]. Causes of PMS and the variation of its symptoms incidence rates aren’t well understood yet. There may be a genetic factor, but the current theory is that premenstrual syndrome is multifactorial. The fluctuation of estradiol levels during the luteal phase is an underlying disorder that can cause symptoms directly or by decreasing serotonin activity in the brain. The problem with accepting this theory is that there are no steady fluctuations that can be detected during daily observation [37].

Irregular menstrual cycle is defined as an abnormal variation in the duration of the cycle for at least 8 days. However, a female may have a regular cycle while having polymenorrhea or oligomenorrhea if the interval between these cycles is constant or with a variation of less than 8 days. In contrast, oligomenorrhea and polymenorrhea may be associated with irregular menstrual cycle, as in our study there was a statistically significant relationship between the previously mentioned disorders and irregular menstruation. An expected finding in this study was the statistically significant relationship between secondary amenorrhea and irregular menstrual cycle, as secondary amenorrhea is defined as the absence of menstrual cycle for 3 normal cycles or for 6 months. This finding was consistent with the finding of the Saudi study [26].

Regarding the association between stress and various menstrual disorders, our study showed an association between perceived stress and abnormal vaginal bleeding, oligomenorrhea, and menstrual irregularity. However, the Saudi study found association between stress and other menstrual disorders, as they found a statistically significant relationship between stress and amenorrhea, dysmenorrhea, and PMS [26]. Other studies also found that stress may cause various menstrual disorders [48, 49]. Nevertheless, some studies conducted on medical students showed no association between stress and menstrual disorders [50, 51]. These inconsistencies might be caused by variations in the study designs, the influence of other confounding variables, and individual variations in stress tolerance [52]. Numerous students in the current study who had about the same level of stress were still having regular menstruation. One potential physiological cause of abnormal vaginal bleeding, irregular menstruation and oligomenorrhea in students with perceived stress, is the extended activation of the hypothalamic-pituitary adrenal axis by stress, which may change hormonal profiles and cause the disruption of normal ovulation and menstrual cycles. [53]

Study limitations: While using a validated stress questionnaire, this study enrolled a sizable sample size to examine the relationship between psychological stress and menstruation problems. Nevertheless, the current study does have a number of limitations, such as the fact that it was cross-sectional and hence unable to draw a causal link between psychological stress and menstruation disorders. Other confounding variables including body mass index, oral contraceptive pill use, insufficient sleep, and parents' socioeconomic level were not taken into account and might have had an impact. Additionally, no history was recorded, no medical examinations or investigations were conducted, and the analysis simply used data from the questionnaire. This study's findings suggest that medical faculties' students in the Syrian Private University have a significant prevalence of menstruation disorders and stress. Furthermore, there was shown to be a considerable positive correlation between psychological stress and various menstrual disorders. It is advised that all students of medical faculties get brief courses on stress management strategies as part of their curriculum. Additionally, all medical faculties universities should set up procedures for the early detection of individuals with stress and menstruation issues, since both of these disorders can not only have an impact on a student's ability to function academically, but also may potentially have detrimental impacts on their reproductive and mental health. The identified students with high stress levels should get prompt gynaecological and psychiatric counselling, as well as guidelines and tactics for averting issues in the future. We urge other universities and colleges to carry out comparable research on the influences of confounding variables such body mass index, usage of oral contraceptives, sleep deprivation, and parental socioeconomic position in producing psychological stress and menstruation problems.

Acknowledgments:

We are thankful to the management of the Syrian Private University and Damascus Hospital for their support in the field of medical training and research.

Funding:

This research received no specific grant from SPU or any other funding agency in the public, commercial or non-profit sectors.

Availability of data and materials:

All data related to this paper’s conclusion are available and stored by the authors. All data are available from the corresponding author at a reasonable request.

Conflict of interest:

The authors declare that they have no conflict of interest.

Authors’ contributions:

SA, and FK conceptualized the study, participated in the design, wrote the study protocol, participated in data collection, did a literature search, and drafted the manuscript. SK preformed the statistical analysis. OA, AA, AT, AA, AA, SA, MM, GA, MJ, SA, HS, SA, and MM participated in the design and data collection. KS did a literature search and revision of the draft. All authors read and approved the final draft.

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The prevalence of various menstrual disorders and its association with psychological stress in medical faculties students. A Cross-sectional study.

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