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RAJIV GANDHI UNIVRSITY OF HEALTH SCIENCES

KARNATAKA, BENGALURU.

ANNEXURE-II

SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1NAME OF THE

CANDIDATE AND

ADDRESS

SMITHA. M.

RAJEEV COLLEGE OF NURSING,

HASSAN.

2NAME OF THE

INSTITUTION

RAJEEV COLLEGE OF NURSING,

K R PURAM

HASSAN, KARNATAKA.

3.COURSE OF STUDY

AND SUBJECT

1ST YEAR M. Sc. NURSING

MASTER OF SCIENCE IN NURSING, OBSTETRICS &

GYNAECOLOGY NURSING

4.DATE OF ADMISSION

TO THE COURSE

07-07-2010

5. TITLE OF THE TOPIC“CONTRIBUTING FACTORS FOR IRREGULAR

MENSTRUATION”.

5.1STATEMENT OF THE

PROBLEM

“A STUDY TO ASSESS THE KNOWLEDGE ON THE

CONTRIBUTING FACTORS FOR IRREGULAR

MENSTRUATION AMONG ADOLESCENT GIRLS OF

SELECTED PU COLLEGES AT HASSAN WITH A VIEW TO

DEVELOP INFORMATION GUIDE SHEET.”

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6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“ Puberty for a girl is like floating down a broadening river into an open sea.” ---GRANVILLIE STANLEY HALL

Puberty, a period of physical growth and sexual maturation, is a gradual process

that occurs during early adolescence. Girls enter puberty at increasingly young ages and

hence the age at which they attain menarche is occurring as early as 9 years of age.

Adolescence is a very crucial time in girls where they undergo rapid physical and

emotional changes with an evidence of menstruation every month. Menstruation is the

visible manifestation of cyclic physiologic uterine bleeding due to shedding of the

endometrium. It is controlled by a feedback system of three cycles: endometrial, hypo-

thalamic-pituitary, ovarian.1

The period extending from the beginning of a menses to the beginning of the next

one is called Menstrual Cycle. The average length of a menstrual cycle is 28 days, but

variations are normal (21-35days). The average duration of menstrual flow is 5 days

(range of 3 to 6 days), and the average blood loss is 50ml (range of 20 to 80ml), but these

vary greatly. The menstrual discharge mainly contains of dark altered blood, mucus,

vaginal epithelial cells, fragments of endometrium, prostaglandins, enzymes and

bacteria.1

The menstrual cycle is a vital sign whose normalcy suggests an overall good

health and whose abnormality requires evaluation. The disturbance or any marked

alteration in the normal pattern of menstrual cycle i.e., length, amount and duration of

flow is called as Irregular Menstruation. It is important to be able to educate young

adolescent girls and their parents regarding the irregularity in the range of normal cycle

length of subsequent menses.2

By the studies made it is estimated that the actual menstrual regularity will be

established by an average of 20 months from menarche. This duration may vary in girls

who have attained early menarche and may extend longer. It is equally important for

clinician to have an understanding of bleeding patterns in girls and adolescent, the ability

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to differentiate between normal and abnormal menstruation and the skill to know how to

evaluate the condition appropriately. Hence, irregular menstrual cycles consider as a vital

indicator which adds a powerful tool to the assessment of normal physiological and

reproductive development & the exclusion of pathological condition.4

Many or the irregular menstruation problems are related to the sequential,

physiologic events of puberty and can be effectively handled by the well-trained general

clinician. Specific, complex situations should be referred to the appropriate specialists,

preferably someone with an understanding of adolescence. There may be a number of

problems falls under the category of irregular menstruation in adolescent girls. Some of

them included as common problems are Dysmenorrhea, menorrhagia, irregular menses

and menstrual related mood changes. Early identification, diagnosis and management of

these problems will not only improve the current health status of adolescent girls but also

improves sense of well-being, and overall quality of life. It may also helps to lower her

risks for future disease and ill-health.5

6.1 NEED OR THE STUDY

The process of menstruation is a complex interplay of events. The menstrual cycle

prepares the uterus for pregnancy. The studies reveals that the following factors may have

effect on irregular menstruation- genetic, nutrition, body weight, psychologic state,

exposure to light, adequate body weight and the girls mother & sisters have history of

early menarche.3

Irregular menstruation may be associated with many conditions, including

pregnancy, endocrine disorders, and acquired medical conditions, because all of these

conditions are associated with derangement of hypothalamic-pituitary endocrine function.

Commonly, polycystic ovary syndrome (PCOS) causes prolonged intervals between

menstrual periods, especially in patients with signs of androgen excess.3

There are many studies which presented a review of irregular menstruation in

adolescent girls. Disturbances of menstruation have become major social and medical

problems for the young women specially and account for high percentage of

gynecological visit. It is necessary for the young adolescents to know the contributing

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factors of irregular menstruation and this area should not to be ignored. As this study will

encourage the adolescent girls to be aware of her body and its normal changes.6

There was around 9.0% of adolescent girls have irregular menstruation out of

which 12.5% reported with academic disturbances. Amidst of this irregularity only

around 10.5% of the cases are seeking medical help. Studies reported from the survey on

an awareness of menstrual abnormality in view to recognize the irregular menstruation as

a physiology of the adolescence or to intimate the diagnostic procedures to exclude

pathology, although irregular menstruation during first 3 years after menarche is quiet

common in young adolescents.6

Some studies have reported that average age of the adolescent girls with irregular

menstruation was 16.2 years (min 12.5, max 20), average age of menarche was 12.5

years. Evidence of androgens excess was found in 48 patients (63.2%). The girls were

coming to the clinic most often because of rare menses, most rarely because of primary

lack of menstruation. Depending on the type of disorders they were divided into five

groups: group I--amenorrhoea primaria--4 patients (5.3%), group II--amenorrhoea

secondaria --14 patients (18.4%), group III--oligomenorrhoea--38 patients (50%), group

IV--polymenorhea--8 patients (10.5%), group V--mixed disorders--12 patients (15.8%).

The causes of menstrual disorders depended on the group.7

A study on Obesity and Menstrual Irregularity aimed to examine the association

between different body composition measures, menstrual cycle characteristics, and

hormonal factors in a population-based sample of young women.8

"Compared with women with a usual cycle length of 26 to 31 days at age 18 to 22

years, the relative risk of type 2 diabetes among women with a menstrual cycle length

that was 40 days or more or was too irregular to estimate was 2.08."

They adjusted for body mass index at age 18 years and several other confounding

variables: age, family history of diabetes in first-degree relatives, smoking, weight

change and use of oral contraceptives.9

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It is considered essential to explore the knowledge of adolescent girls regarding

the contributing factors of irregular menstruation. At the same time there is a need to

educate them about other common types of irregular menstruation in order to improve

their health seeking behavior. Asking the patient to begin to chart her menses may be

beneficial, especially if the bleeding history is too vague or considered to be inaccurate.

Although uncommon, abnormalities do occur but knowledge regarding the normal and

abnormal irregularities of menstruation is very important. Screen adolescent girls for

menstruation related problems and provide them with counseling services and relevant

information on possible treatment options. Besides, there is a need to emphasize on

designing menstrual health programmes for adolescents.7

Menstrual problems may be as common in developing countries and that when

services are available, this will prompt the adolescent girls to seek care for the complaints

of irregular menstruation.10

6.2 REVIEW OF LITERATURE

Literature review is a standard requisition of scientific research and a vital key

step in research process. The review of literature gives a summary of current knowledge

about a particular problem and helps in understanding better about the proposed topic. It

also support and explains why the problem is taken for research and avoid unnecessary

duplication, explore feasibility and illuminate way to new research.11

i. Studies related to Non-modifiable contributing factors: Metabolic disorders,

PCOS, Mood disorders.

ii. Studies related to modifiable contributing factors: Obesity, environmental

influences (socioeconomic factors, family, parental factors), habits of alcohol,

stress, diet, sports activity and exercises.

Studies related to Non-modifiable contributing factors:

A study on Menstrual irregularities are even more frequently observed in

adolescents with T1D prospectively studied 24 adolescents and observed that 54%

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showed menstrual irregularities, associated with a poorer metabolic control and higher

BMI. Menstrual disorders during adolescence rise dramatically in girls with T1D when

HbA1c levels increase above 10%.12

The presence of menstrual irregularities suggests that anovulatory cycles are

frequently present in T1D adolescents. Recently a group of T1D girls during the first 3

years after menarche, evaluating the presence of ovulation through salivary progesterone.

A similar frequency of anovulatory cycles during the first year after menarche in T1D

and healthy girls. However, during the second year, control girls experience a higher

frequency of ovulatory cycles than T1D girls, suggesting that anovulatory cycles may

cause the menstrual abnormalities.9

Studies on Menstrual irregularities in Mood disorders evidenced depressive

symptoms have been associated with changes in the menstrual cycle that may lead to

reduced female fertility. In a large, study on adolescent girls reported that depressive

symptoms were associated with late menarche, secondary amenorrhea and irregular

menstrual cycles. Studies have also reported that women with a current or past history of

depression report a history of early menstrual irregularity.13

Study conducted on a control group in comparing 245 young adolescent girls with

major depression to 619 healthy controls, and found no statistical significance between

the two groups regarding history of menstrual abnormalities prior to the diagnosis and

treatment of a mood disorder. However, in the 295 bipolar adolescents in this study, a

history of menstrual abnormalities was more common (34%) than in the depressed

(24.5%) or the control group (21%).13

Studies revealing irregular menstruation with PCOS as a more prevailing contributing

factors. Polycystic Ovarian syndrome (PCOS) was described in 1935 by Stein &

Leventhal. The adolescent girls and young women with PCOS usually has a history of

menstrual disturbances dating back to menarche.14

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Polycystic ovarian syndrome (PCOS) is a very common reproductive disorder.

Adolescent girls with PCOS constitute the largest group at risk for the development of

metabolic abnormality and irregular menstruation. Genetic studies support that the

increased frequency of PCOS in first-degree relatives of affected girls. Several genes are

involved in the development of this heterogeneous syndrome. Given the strong evidence

that excess insulin plays a role in the development of PCOS, it is reasonable to assume

that reducing circulating levels of insulin may help restore normal reproductive function.

This may be accomplished by weight loss, improved nutrition, and exercise.15

Studies have shown that based on symptomatology incidence varies between 4-

5% to 21% (menstrual abnormalities) and 3.5 to 9% (hyperandrogenism). It is important

to remember that, 40% of girls and women have the irregular menstruation in association

with PCOS. Girls with PCOS frequently have irregular menstrual cycles, excessive body

hair, are overweight, and suffer from infertility.15

Studies related to modifiable contributing factors

As studies conducted on evidencing obesity with irregular menstruation have

shown that, obese adolescent girls are more likely to experience menstrual cycle

irregularity than non-obese. Many of these studies, however, have been limited by small

sample sizes and the selection of study participants from patients with gynecological

problems or infertility, or from adolescents participating in weight reduction programs.16

Some studies have relied on self-reported height and weight and the definitions

of menstrual irregularity have varied widely. Given the rising prevalence of overweight

and obesity, it is important to investigate their effects on their reproductive health and to

better quantify the strength of association with menstrual irregularity in population-based

samples.17

Studies also have suggested that centrally distributed body fat may be more

strongly associated with menstrual abnormalities and adverse hormonal profiles than

measures of peripheral body fat or overall adiposity such as BMI. Body size parameters,

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such as weight or BMI and height are strongly correlated with the age at menarche. They

also proposed a critical body weight and weight gain for the onset of menarche. Higher

subcutaneous fat levels and BMI at prepubertal ages (5-9 years) are associated with

increased likelihood of early (<11 years) menarche of menstrual flow. On the other hand,

studies related that menarcheal age to height rather than weight, suggesting that skeletal

maturation is more important than body fat accumulation for menarche, a finding that

was also supported by a survey performed among schoolgirls in Taiwan.18

Studies revealing the irregular menstruation with Environmental influences

informs that-- Socioeconomic factors or life setting, such as urban/rural residence, family

size, family income, level of parental education, may also influence pubertal

development. Girls from families with a high socioeconomic status experience menarche

at an earlier age than girls from families with lower socioeconomic status.19

Furthermore, higher parental education has been associated with earlier timing of

puberty. Absence of a biological father, the presence of half- and step-brothers is

associated with early menarche, whereas the presence of sisters, especially older ones, in

the household while growing up, was associated with delayed menarche. The prevalence

of early menarche is even higher when stepfather presence is combined with a stressful

family environment and with maternal mood disorders. Girls raised in urban

environments have earlier menarcheal ages than those raised in rural environment.20

Studies relates irregular menstruation with alcohol use also negatively affects puberty

and disrupts normal sexual reproductive functioning, which may result in a number of

menstrual and reproductive problems, including irregular menstrual cycles, absence of

ovulation, endometriosis and infertility. Another key sex difference for young women

who consume alcohol is the risk of unwanted, unplanned, or unintended pregnancy due to

unprotected and unplanned sex.21

Studies have revealed a lack of specific guidelines addressing the unique problems

related to menstruation in the group of adolescents. Moreover, responses to a

questionnaire has been sent to pediatric endocrinologists to assess the current practice of

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Menstrual control in these girls indicated great variability in management approach. The

study also gives an overview of the major clinical and reproductive concerns affecting

adolescent females with developmental delay. Special attention is given to contraceptive

management of menstruation, and practical guidelines for clinical care are provided.21

Study on Irregular menstruation in relation with Stress is perhaps the most common

cause of irregular periods in young girls. Stress may leads to enormous physiological

changes in the body. Hormonal imbalance is also developing from excess stress is

responsible for irregular periods.22

Prolonged stress disrupts the menstrual cycles and increase the prolactin hormones

secretion from the pituitary gland. Studies have shown that 10 to 20% of cases of

irregular menstruation is due to increased levels of prolactin secretion from stress.23

Tension and anxiety make the body create more stress chemicals, which

the delicate balance between the hormones that regulate your period, and

disrupt. However, in periods of intense stress or busy, your period

stop and also , Stress or mood disorders can cause a delay in ovulation or menstruation,

causing your cycle to be longer, and from time to time shorter, than usual.24

Studies reveal that Diet and eating disorders have resulted in too much weight loss,

and can also lead to irregular menstruation. The reason is that the female hormone

estrogen is stored in body fat. So if there is too little fat, there is simply not enough

estrogen to support menstruation. Sometimes the absence of menstruation or severe

irregularity of menstruation is often a classic sign of anorexia nervosa.25

Studies also revealed that young adolescent girls who regularly exercise and do

sports, often suffer, as their fitness increases, fewer problems with their menstruation.

Extreme sports however, like many female athletes do, the ovaries do block,

which stood for several months or even years to months absence. Studies reveal that

some medications specially taken for the chronic illnesses, artificial postponement for

menstrual flow in the adolescent girls repeatedly will also result in menstrual

irregularities.26

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STATEMENT OF THE PROBLEM

“A STUDY TO ASSESS THE KNOWLEDGE ON THE CONTRIBUTING

FACTORS FOR IRREGULAR MENSTRUATION AMONG ADOLESCENT

GIRLS OF SELECTED PRE-UNIVERSITY COLLEGES AT HASSAN WITH A

VIEW TO DEVELOP INFORMATION GUIDE SHEET.”

6.3 OBJECTIVES

1. To assess the knowledge of adolescent girls regarding the irregular menstruation.

2. To find the association of knowledge scores with selected socio-demographic

variables.

6.3.1 HYPOTHESES

H1- There will be a significant association between the knowledge scores with the

selected socio-demographic variables.

6.3.2 ASSUMPTION

1. The adolescent girls have less knowledge on the contributing factors for irregular

menstruation.

2. The information guide sheet will help in improving the knowledge of adolescent

girls regarding irregular menstruation.

6.3.3 OPERATIONAL DEFINITIONS

Assess:

It refers to a process of statistical measurement of knowledge regarding

contributing factors for irregular menstruation.

Knowledge:

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Here, the word knowledge means awareness of adolescent girls regarding the

contributing factors irregular menstruation as measured by knowledge questionnaire.

Contributing factors:

These are the factors responsible for a common purpose or problem. The factors are

intake of alcohol, metabolic disorders, obesity, environmental factors, mood disorders,

diet, eating disorders, sports and exercises.

Irregular menstruation:

The disturbance or any marked alterations in the normal pattern of menstrual cycle

i.e., length, amount and duration of flow is called Irregular menstruation.

Adolescent girls:

It refers to the age of girls between 16 to 20 years who studying in the selected Pre

University Colleges

6.3.4 THEORETICAL FRAME WORK

J.W. Kenny’s open system model is used for the study.

6.3.5 DELIMITATIONS OF THE STUDY

The study is limited to

The adolescent girls aging 16 to 20 years.

The study period of 4 to 6 weeks.

The sample size of 100 adolescent girls.

Non experimental method.

7. MATERIALS AND METHODS

7.1 SOURCE OF DATA

The data will be collected among adolescent girls who are studying in selected PU

colleges at Hassan.

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7.1.1 SIGNIFICANCE OF THE STUDY

The study signifies the knowledge of adolescent girls regarding the contributing

factors for irregular menstruation.

7.1.2 RESEARCH DESIGN

It is a non-experimental descriptive research design.

7.2 METHODS OF DATA COLLECTION

It comprises of interview and questionnaires

Section A: - Deals with seeks information regarding knowledge on anatomy and

physiology of reproductive organs.

Section B: - Deals with the questionnaire giving information regarding knowledge on

irregular menstruation.

7.2.1 SAMPLING CRITERIA

Inclusion criteria: Adolescent girls who are:

Aging between 16 to 20 years.

Have the history of irregular menstruation.

Willing to participate.

Exclusion criteria:

Adolescent girls who have undergone any teaching or workshop on the

irregular menstruation.

Adolescent girls who are not available during the data collection.

7.2.2 SAMPLING PROCEDURE

7.2.2.1 Population

The Population of present study comprises of adolescent girls who studying in the

selected Pre-University colleges at Hassan.

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7.2.2.2 Samples

Adolescent girls who fulfilled the inclusion criteria.

7.2.2.3 Sample size

The sample size of the present study will be 100 adolescent girls.

7.2.2.4 Sampling technique

Non-probability convenient sampling technique is adopted.

7.2.2.5 Setting of the study

Setting is the general location and condition in which data collection takes place

in the study. Setting for the study are Gnanadhare Pre-University College, Hassan and

Sujala Pre-University College, Hassan. In Gnanadhare college there are around 60-80

students get admission every year for the course of Pre-University of different

combination and in Sujala college there are about 80-100 students get admission for

Pre-University course every year in different combinations.

7.2.2.6 Pilot study

10% of total sample size is planned for the pilot study.

7.2.2.7 Variables

Socio-demographic variables

Age

Education of the father and mother

Dietary habit

Habitant

Occupation of the father and mother

Income of the family

Clinical Variables

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Body mass index

Age at the onset of menarche

Practicing any exercises

7.2.2.7 Plan for data analysis

It includes descriptive and inferential statistics.

Descriptive statistics

To describe the demographic variables and level of knowledge, number,

frequency, percentage, mean and standard deviation will be used.

Inferential statistics

The chi square test will be used to find the association between the demographic

variables with knowledge scores

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR

INTERVENTIONS TO BE CONDUCTED ON PATIENT OR OTHER

HUMANS OR ANIMALS?

Yes, the study requires interventions to be conducted on Adolescent girls

regarding contributing factors for irregular menstruation.

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION?

Yes, ethical clearance obtained from authority of Rajeev College of Nursing and

Authority of Sujala and Gnanadhare Pre-University College of Hassan. Individual

consent will also be obtained from the study participants.

8. LIST OF REFERENCES

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1. D. C. Dutta, Text book of Gynaecology including contraception, 4th edition, New

Central Book Agency, 2006. Page no: 46, 74.

2. Lowder milk, Perry, Bobak. Maternity Nursing, 5th edition, Mosby publication,

1999. Page no: 70-71, 90.

3. Gloria Hofffmann Wold. Text book of Contemporary maternity nursing, 1st

edition, Mosby publication, 1997. Page no: 28, 38.

4. Peacock, N. S. Allvi, T. Mushtaq. Period problems: Disorders of menstruation in

adolescents. Accepted on 17th March, published on 2010, June 24.

5. Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a vital sign.

Pediatric volume 118, published online on 2006, Nov 1.

6. EsimaiO, Esan GO. Awareness of menstrual abnormality amongst college

students in urban area, Nigeria. Indian Journal community medicine, 2010 Jan

35(1): 63-6.

7. Adams Hillard PJ, Deitch HR. Menstrual disorders in the college age female.

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8. Obesity and Menstrual regularity: Association with SHBG, Testostetone &

Insulin, Obesity(2009) 175, 1070-1076; published online on 2009, Jan 29.

9. Ethel Codner, Fernando Cassorla. Puberty & Ovarian function in girls with Type1

Diabetes Mellitus, Horm Res 2009; 71:12-21.

10. O’Connell K, Davis AR, Westhoff C. Self treatment patterns among adolescent

girls with dysmenorrhoea, J Pediatric & Adolescent Gynecology, 2006; 19:285-9.

11. Polit DF, Hungler BP. Research principles and methods, Philadelphia:

J.B.Lippincott Company; 1999.

12. Ethel Codner & Hector F. Escobar, Morreale. The jrnl of clinical Endocrinology

& metabolism, Volume 92, No 4, 1209-1216, copyright 2007.

13. Katherine E. Willi. Menstrual abnormalities in unipolar & Bipolar disorders,

Joffee, Rasgon, Rowland, & Harlow. Humupd. oxfordjournals.org/disorder Ref-

79, 2006

14. Robert J. Ferry Jr. Polycystic Ovarian Syndrome : e Medicine Pediatrics: updated

on 2010, April 27.

15. Vikas Gupta, Uttam Singh Baghul & Manmohan Singhal. Polycystic Ovary

Syndrome: A major cause of female infertility. 2010, June 30.Volume 8. Issue 2.

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16. Article: Reproductive Biology& Endocrinology 2010, 8:11 5, published online on

2010, September 30.

17. Lassek WD, Gualin SJ: Menarche is related to fat distribution. Am J Phys

Anthropol 2007, 133: 1147-1151.

18. Chang SH, Tzeng SJ, Cheng JY, Chie WC: Height and weight change across

menarche of school girls with early menarche. Arch Pediatric Adolescent Med

2000, 154: 880-884.

19. Wronka I, Pawlinska-Chmara R: Menarcheal age and socioeconomic factors in

Poland. Ann Hum Biol 2005, 32: 630-638.

20. Ellis BJ, Garber J: Psychosocial antecedents of variation in girls’ pubertal timing:

maternal depression, step-father presence and marital and family stress. Child

Development 2000, 71: 485-501.

21. Young women and Alcohol abuse/ Canadian Women Health Network,

www.cwhn.ca

22. Ruth T. Tricky, Women Hormone & The Menstrual Cycle, 2003.

23. Arpita. Irregular periods: Causes of Irregular menstrual cycles, published online

2010, March 18. www.us.ayushveda.com.

24. Reasons behind irregular periods: Posts tagged irregular menstrual cycles, posted

on 2008, . > Ayurvedic Product’s Blogs reddiff.com.

25. Ellie Vyver, Cathleen Steinegger, Debra K. Katzman. Eating disorders &

Menstrual Dysfunction in Adolescents. Article first published online: 2008, 25

July.

26. Irregular menstrual Cycles: Factors that affect period, Published on 2010,

February 3.

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