Millions of women of reproductive age face various challenges related to their menstrual cycles, including pain, discomfort, anxiety, feelings of shame, and a sense of isolation (1). The term dysmenorrhea is defined as a condition of menstruation-associated pelvic pain (2). It is classified into two types: primary and secondary dysmenorrhea (3). Primary dysmenorrhea (PD) is defined as spasmodic and painful cramps in the lower abdomen that begin shortly before or at the onset of menses in the absence of any pelvic pathology and radiate to the inguinal area and buttocks (4, 5). Secondary dysmenorrhea is caused by menstrual pain in the presence of underlying organic disease. It could be of either gynecological origin such as endometriosis, myometrial pathologies such as adenomyosis and fibroids, postoperative adhesion syndrome, pelvic inflammatory disease (PID), ovarian cyst, or non-gynecological causes where the pain often results from gastrointestinal diseases or urinary tract diseases (6). PD is more common in adolescent girls and usually appears 6 to 12 months after menarche (3, 7). The severe pelvic pain and cramps in PD are accompanied by headache, vomiting, anorexia, nervousness, breast tenderness, and mood swings before or during periods (8, 9). The precise mechanism of PD remains unknown, but recent studies related it with the increased production and release of prostaglandin and a decrease in the progesterone in the luteal phase resulting in increased contractility of myometrium, uterine muscles ischemia, and decreased pain threshold (10–12). Previous studies reported that high-intensity pain and associated complications in patients with PD negatively affect quality of life resulting in higher rates of absenteeism from educational and professional settings leading to poor performance and productivity compared to their male counterparts (13–16). These challenges related to menstruation are evident as “gender-based obstacles” that result in early low retirement savings (17, 18).

Previous studies demonstrated that PD is a widespread gynecologic problem in young and adult women with a global prevalence of 60–93% (19, 20). However, the prevalence varies due to sociocultural, ethnic, or biological factors in various populations (21). Women afflicted with dysmenorrhea often refrain from seeking medical assistance, and when left unaddressed, it is prone to impede their work performance (10). The higher prevalence percentage in developed countries like Japan and Australia is believed to be linked to poor menstrual literacy (22, 23). In contrast, lower-middle-income countries like Ghana, Nigeria (24), and Pakistan considers menstruation a cultural taboo and a shameful burden (25). Similar neglectful and cultural stigma exists in high-income Asian countries like India and China (26). The countries that include menstrual health and hygiene (MHH) in their health and education agenda seem to focus primarily on period poverty but often neglect serious issues such as debilitating menstrual pain, a decline in mental health, disrupted physical activity, and inability to perform effectively in the workplace (27). So, to conclude despite being a primary health issue of every other menstruating female dysmenorrhea is unaddressed in most countries around the globe.

Some studies have focused on lifestyle modifications (28), MHH (29), pain intensity, and poor academic performance (30). A previous study demonstrated differences in pain severity by 23.5% from severe pain requiring pharmacological intervention to mild and moderate pain categories 23. Similarly, a study investigating lifestyle-focused approaches reported that nutrition, physical activity, Body Mass Index (BMI), herbs, essential oils, and medical plants help manage PD (31). Although Pakistan is the world’s fifth most populated country, no such health-related quality of life (HRQoL) study among menstruating university students has been conducted, even though dysmenorrhea affects almost 78% of these women (32). Furthermore, this age group population is critical to investigate because most of them experience this condition and symptoms at the onset or during their reproductive age. Recognizing the impact of primary dysmenorrhea (PD) on health, quality of life, and daily activities; is crucial (33). Therefore, the present study aimed to investigate the HRQoL of PD menstruating university students, as well as the lifestyle modification approaches used to manage PD.

The objective of this study is to examine how the severity of dysmenorrhea affects the health-related quality of life (HRQoL) among female university students in Pakistan. The study reveals a strikingly high prevalence of PD, which may be attributed to a lack of menstrual literacy. This contributes to the baseline data, shedding light on the emotional and physical challenges that Pakistani women face every month, resulting in poor HRQoL across all five domains of EQ-5D-5L: mobility, self-care, usual activities, depression/anxiety, and pain/discomfort. Through the exploration of the relationship between PD and HRQoL of female university attendees, this study uncovers notably a high prevalence of dysmenorrhea, reaching 91.5% which closely aligns with findings from a previous study conducted in a university in Ireland (40), and is comparable to rates observed in King Saud University (80.1%) and females in Nigeria (69.8%) (41, 42). Similarly, the prevalence of PD among Brazilian women was found to be 90.7% in the last menstrual cycle considering mild moderate, and severe pain levels (43). The mean age of the students selected for this study was 22.4 ± 3.5 years, almost similar to an Indian study where the mean age was India (21.99 ± 3.75 years) (44) as Pakistan and India share a close culture and ethnicity. Though Pakistan also shares a close boundary with China the mean age (19.0 ± 1.2 years) was quite different from our study results (20).

From the EQ-5D-5L dimensions, 34.1% experienced moderate impairment in mobility. At the same time, 27.9% reported having moderate problems with self-care. It is worth noting that about 40.9% of females reported moderate problems with usual activities 33.5% of the participants reported extreme pain or discomfort, and 26.2% reported being extremely anxious/depressed, as shown in Table 4.

Regarding pain severity, 30.2% of women in our study reported mild pain, which aligns closely with the reported prevalence among Japanese adult females (33.1%) (13). However, for moderate and severe pain, our study revealed 48.9% moderate and 20.8% reporting severe pain closely following a Saudia study where participants were having moderate 50%, and severe pain 27%, respectively, (41). Overall, the findings from our study suggested that dysmenorrhea significantly impacts the quality of life, affecting not only physical aspects such as mobility and self-care but also influencing usual activities and contributing to pain, discomfort, anxiety, and depression. Additionally, the p-value revealed that EQ-5D index scores were significantly associated with the family history (p = 0.027), cycle regularity (0.022), bleeding duration (0.015), the length of the menstrual cycle (0.004), how long PD symptoms last (< 0.001), and the season in which you experience pain the most (< 0.001). These results were consistent with previously reported literature (3) (see Table 5).

In our study, the prevalence rates of challenges reported in mobility (67.9%), personal care (70.7%), and daily activities (60.3%) among participants. Another study conducted by Fernández-Martínez et al. (45), reported mobility problems (3%), personal care problems (0.7%), manifested problems regarding daily activities, (5.3%) discomfort/pain (16.5%), and 24.2% had problems related to anxiety/depression. Statistical significance was noted between these dimensions and dysmenorrhea in our study, with a p-value of <0.001 for all dimensions of the HRQol scale. The findings of a Spanish study revealed significant differences regarding problems in the dimension of pain and discomfort in women with dysmenorrhea (p = 0.036). However, for the remaining dimensions, statistically significant differences were not found (45). In Jordanian women, dysmenorrhea was found to adversely affect university performance and social attitudes toward family and friends (46). Most female medical students in Saudia Arabia suffer from PD, which adversely affects their quality of life and academic performance (41).

The study further disclosed that 51.7% of females experiencing severe pain use heat application as a method for pain relief, consistent with findings in Ireland (79%) and Spain (68.6%) (45). The same practice of sleep and the application of warm objects on the abdomen was used by midwife trainees and nurses in Ghana to reduce pain (47).

In contrast, a notable 41.8% of Nigerians use the hot water bottle method (42), hot tea was common among Japanese females with severe pain (13). Among other non-pharmacological pain-relieving methods, massage was selected by (10.3%) of our study respondents, whereas 25.9% were reported by a Nigerian study (42). Additionally, only 1% preferred yoga as compared to 5.2% of Spanish females who opted for yoga (45). Interestingly Japanese females seem not inclined toward yoga (13).

Numerous studies reveal that Engaging in exercise, which encompasses endurance and various physical activities, has been recognized as beneficial in managing menstrual pain. In our study, 7% of participants chose endurance, and 9.7% preferred sleep, while in another study almost 8% of individuals experiencing severe and moderate pain utilized mind–body medicine, such as endurance activities and 11% of those with moderate pain addressed their discomfort through sleep (48).

For females who prefer to use analgesics, medical treatment with NSAIDs is advised as the first-line therapy (49–51). They should be started one to 2 days before menstruation, taken with meals to reduce gastrointestinal side effects, followed on a regular dosage schedule, and continued for the first 2 to 3 days of bleeding to achieve the best possible treatment efficacy and safety (50–52). Acetaminophen is a safe analgesic alternative with manageable gastrointestinal side effects; it decreases prostaglandin synthesis and has a mild COX inhibitory action (53). Therefore, acetaminophen is only recommended for mild to moderate dysmenorrheic pain (4). Female patients who do not respond to NSAIDs, hormone-based therapies, or non-pharmacological treatments are considered (54). Levonorgestrel intrauterine systems, subcutaneous depot medroxyprogesterone acetate, combined oral contraceptives (COCs), contraceptive transdermal patches or vaginal rings, and other hormonal therapy methods are effective in treating PD (4).

We employed the EQ-5D-5L questionnaire to assess the impact of dysmenorrhea on QoL among female university attendees, the same instrument was used in a study conducted in Spain (45). The validated questionnaire was selected because it provides a standardized method for assessing health-related quality of life (HRQoL) across different health conditions (55). Also, there is a substantial body of research supporting the validity, reliability, and responsiveness of the EQ-5D-5L questionnaire, making it a trusted tool in health outcomes research (56). Other investigations have utilized various questionnaires such as the quality of life enjoyment and satisfaction questionnaire (Q-LES-Q-SF) (57), Short Form-36 (SF-36) (58), and health-related QoL questionnaire WHO/QOL-26 (59). Regardless of the specific scale used, findings consistently indicate a significant impairment in the HRQoL of females experiencing issues with dysmenorrhea across all or certain dimensions of the respective scales.

Menstrual hygiene management (MHM) is a socially taboo topic in Pakistan. Students and teachers have limited access to information about it, MHM (menstrual health and hygiene) is not covered in the curriculum, and Pakistan’s educational system lacks policy guidelines for MHM practices (60). PD should not be seen as a barrier; instead, it can serve as an incentive to research effective solutions for this complaint. This includes exploring both individual treatments and combinations with therapies that have already been validated in scientific studies. In this regard, researchers should aim for consensus while planning their investigations and use reliable methods to improve quality of life.

The current study found that PD negatively impacts the overall health-related quality of life (HRQoL) of university students, adversely affecting both their mental and physical health. This research marks the very first attempt in Pakistan to evaluate the HRQoL of females who had complaints of PD, acknowledging the significant influence of lifestyle and cultural background on women’s health and perception of pain.