When Stress Disrupts the Cycle: Menstrual Health Challenges among Female Healthcare Students

INTRODUCTION

Menstruation is a normal physiological process that reflects the functional integrity of the female reproductive and endocrine systems and serves as an important indicator of overall health and well-being in women of reproductive age. Variations in menstrual patterns are not merely biological events but are closely intertwined with physical comfort, emotional balance, daily functioning, quality of life and personal health.^[1-3] Among young women, particularly university students, menstrual health is increasingly recognised as a multidimensional issue influenced by lifestyle, psychological state, and environmental demands. Common menstrual problems such as dysmenorrhea, premenstrual symptoms, irregular cycles, and heavy menstrual bleeding are highly prevalent and can significantly interfere with academic participation, concentration, and routine activities.^[4] Research among medical and health-science students has shown that painful menstruation alone affects a substantial proportion of students and is associated with fatigue, irritability, and reduced energy for daily functioning.^[5,6] The university period represents a transition marked by demanding schedules, competitive learning environments, altered sleep patterns, and lifestyle changes, all of which may disturb hormonal regulation.^[7,8] Academic stress has been identified as a significant contributing factor that may intensify menstrual pain and symptom severity.^[9] Psychological stress can influence the hypothalamic-pituitary-ovarian axis, thereby altering cycle regularity and exacerbating menstrual symptoms.^[9] Studies have demonstrated that students experiencing higher perceived stress report more adverse menstrual complaints, including abdominal pain and functional limitations.^[10,11] These findings suggest that menstrual problems among students are not solely gynaecological concerns but are also psychosomatic responses shaped by emotional and academic pressures.

Healthcare students constitute a particularly vulnerable yet understudied group. Their rigorous academic workload, long clinical hours, and constant exposure to patient care responsibilities may predispose them to greater stress than other student populations.^[12] While they possess theoretical knowledge of health, they often neglect self-care, normalise symptoms, or fail to seek timely support, thereby compounding menstrual morbidity.^[13]

However, despite the increasing recognition of stress-related menstrual disturbances globally, evidence focusing specifically on healthcare students, particularly within the Indian context, remains limited. Despite growing recognition of the interaction between stress and reproductive health, limited research has specifically examined the relationship between perceived stress and menstrual problems among female healthcare students in the Indian context. The demanding academic curriculum, clinical exposure, and workload may influence both stress levels and menstrual symptoms in this population. Furthermore, there is a need to better understand how perceived stress interacts with menstrual symptoms in this group to inform context-specific interventions. Understanding this association is essential for developing targeted institutional interventions, including stress-management programs, menstrual health education, and supportive academic measures to improve students’ overall well-being.

Therefore, the present study aims to examine menstrual problems and their association with perceived stress among healthcare students, addressing an important gap at the intersection of reproductive health, mental well-being, and academic functioning. By focusing on future healthcare professionals, the study highlights the need to promote self-care practices within those who will ultimately be responsible for caring for others.

MATERIAL AND METHODS

This study adopted a cross-sectional survey design and was conducted at a selected university in Mangaluru, Karnataka. The study aimed to assess menstrual problems and examine their association with perceived stress among healthcare students. The required sample size was calculated using Cochran’s formula (n = Z² p(1−p)/E²), with a 95% confidence level (Z = 1.96), an anticipated proportion of 91%, and a margin of error of 2%, resulting in a minimum sample size of 786 participants.^[14] A purposive sampling technique was used to select eligible participants. The inclusion criteria comprised female students aged 18–25 years, studying in the 1^st or 2^nd year, and experiencing menstrual problems. Students with chronic illnesses, psychiatric disorders, or diagnosed pelvic pathology were excluded from the study. Prior to data collection, approval was obtained from the Scientific Review Board and the concerned university authorities, and ethical clearance was secured from the Institutional Ethics Committee. Participants were provided with an information sheet, and informed consent was obtained. The investigator approached students in their classrooms, and those who met the eligibility criteria were invited to participate and complete the questionnaire. Data were collected via a self-administered Google Form completed on participants’ mobile devices. The questionnaire required ∼15 min to complete.

Data were collected using three tools. Tool 1 was a demographic proforma consisting of 7 items: age, religion, year of study, course, place of residence, body mass index (BMI), and type of family. Tool 2 was a structured menstrual problems assessment questionnaire developed by the investigator, containing 10 items to assess menstrual symptoms. The structured menstrual problems questionnaire demonstrated acceptable internal consistency, assessed using Cronbach’s alpha. The content validity of both tools was established through a review by five experts, and modifications were incorporated based on their suggestions. Tool 3 was the standardised Perceived Stress Scale (PSS-10), a self-administered instrument with 10 items rated on a 5-point Likert scale (0 = never to 4 = very often). Total scores range from 0–40 and are categorised as low (0–13), moderate (14–26), and high stress (27–40).^[15]

RESULTS

The mean age of the students was 19.7 ± 1.46 years, and the average BMI was 21.4±3.86 kg/m². The mean age at menarche was 13 ± 2.06 years.

A majority of the students (624, 79.4%) were residing in hostels. Most participants (226, 28.8%) were from the Nursing College. In addition, a large proportion, 673(85.6%), belonged to nuclear families. Notably, 558 (71%) of the students reported difficulty attending classes during menstruation [Table 1].

The findings revealed that 78 (9.9%) of the students reported absence of menstruation for more than 6 months, while 102 (13%) experienced menstrual cycles lasting more than 35 days. About 282 (35.9%) reported shorter cycles of less than 21 days. Painful menstruation affecting daily routine was highly prevalent, reported by 586 (74.1%) of the participants. Intermenstrual bleeding was experienced by 325 (41.3%), and 336 (42.7%) reported heavy menstrual bleeding, whereas 48% reported light menstrual flow. Nearly half of the students experienced associated physical symptoms such as nausea, vomiting, or dizziness (370; 47.1%). Psychological symptoms were notably common, with 687 (87.4%) reporting mood changes, anxiety, or depression [Table 2].

The assessment of perceived stress revealed that a majority of the students (672, 85.5%) experienced high levels of stress, while 103 (13.1%) reported moderate stress and only 11 (1.4%) had low stress levels. Overall, most participants experienced high perceived stress.

Spearman’s rank correlation showed a significant, weak positive relationship between menstrual problems and perceived stress (ρ = 0.161, p <0.001), indicating that higher perceived stress was associated with greater menstrual problems.

Multiple regression analysis identified factors associated with specific menstrual problems. Difficulty in attending classes due to menstruation showed a highly significant association with mood changes/anxiety/depression (β = −0.902, p <0.001), painful menstruation affecting daily routine (β = −1.874, p <0.001), and nausea/vomiting/dizziness (β = −1.31, p <0.001), indicating greater symptom severity among those with class attendance difficulty. Course of study showed an association with mood changes/anxiety/depression (β = 0.15, p = 0.046). Age showed a significant association with bleeding between periods (β = −0.119, p = 0.033) [Table 3].

Regression analysis showed that age (β = –0.133, p = 0.047), difficulty attending classes due to menstruation (β = 0.475, p = 0.027), and BMI (β = -0.121, p = 0.012) were significantly associated with perceived stress. Other variables were not significantly associated with perceived stress (p >0.05). Overall, age, BMI, and difficulty attending classes during menstruation were significant predictors of perceived stress [Table 4].

DISCUSSION

The present study highlights a substantial burden of menstrual problems and high perceived stress among healthcare students. The mean age (19.7 ± 1.46 years) indicates that most participants were late adolescents or young adults, consistent with findings reported by Odongo et al.^[3] among university populations.

A large proportion of students were hostel residents, which may contribute to altered lifestyle patterns, including irregular sleep and dietary habits, thereby influencing both menstrual health and stress. Notably, 71% of students reported difficulty attending classes during menstruation, indicating a significant impact on academic functioning.

Dysmenorrhea affecting daily routine was highly prevalent (74.1%), aligning with findings reported by Durand et al.^[16] and Odongo et al.,^[3] who documented a high prevalence of menstrual pain interfering with daily activities. Menstrual irregularities were also common, with variations in cycle length observed in a considerable proportion of students. Similar variability has been reported by Mittiku et al.^[17] among college students. Abnormal bleeding patterns were frequent, consistent with findings by Salih et al.,^[18] who reported a high prevalence of abnormal uterine bleeding in young females.

A high prevalence of somatic and psychological symptoms was observed, with many students reporting nausea, dizziness, and mood disturbances. These findings are supported by Odongo et al.^[3] who emphasised the coexistence of physical and psychological symptoms among university students, indicating the multifaceted nature of menstrual health issues.

The majority of students in this study experienced high perceived stress. Similar observations have been reported by Alwhaibi et al.^[12] and Dasgupta et al.,^[19] who highlighted that healthcare students are particularly vulnerable to stress due to academic and clinical demands.

A significant weak positive correlation between menstrual problems and perceived stress was identified, indicating that higher stress levels were associated with greater menstrual symptoms. This finding is consistent with results reported by Yaşar^[10] who demonstrated a positive association between perceived stress and menstrual complaints. Liu et al.^[20] further explained that stress can disrupt the hypothalamic-pituitary-ovarian axis, leading to menstrual disturbances.

Regression analysis identified key factors influencing menstrual symptoms. Difficulty attending classes during menstruation was strongly associated with increased symptom severity, a finding supported by Matsuura et al.,^[21] who reported that menstrual symptoms are closely linked to functional impairment and stress. The course of study was also associated with psychological symptoms, which may reflect variations in academic workload, as noted by Upadhyay et al.^[22]

Age showed an association with both intermenstrual bleeding and perceived stress, suggesting that younger students are more vulnerable. Similar findings have been reported by Ajayi and Aloka,^[23] who identified higher stress levels among younger students due to adjustment challenges. Additionally, BMI showed an association with stress, as reported by Cha et al.,^[24] who found links between stress, body composition, and behavioural factors.

The limitations of the study were that perceived stress was measured at a single time point, although stress levels may fluctuate across different academic periods. In addition, menstrual problems were self-reported and not clinically verified, and potential confounding factors such as lifestyle behaviors and hormonal influences were not assessed.

CONCLUSION

Overall, the findings emphasise that menstrual problems and perceived stress are interrelated and influenced by academic and individual factors, highlighting the need for integrated stress management and menstrual health support within academic institutions to improve students’ overall well-being and academic performance. As menstrual health and perceived stress are common concerns among students, there is a need to increase awareness and encourage further research to build a stronger evidence base and support the development of effective strategies for student well-being.