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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.”
2
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
4
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
5
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%
6
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
7
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,
8
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
9
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
10
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:
11
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
15
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.
Pediatri Clin North Ame. 2005 Feb; 52(1): 179-97, IX-X.
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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