The menstrual cycle involves many psychological changes, such as irritability, mood liability, depression and anxiety. The most prevalent physical symptoms of the menstrual cycle include breast tenderness, diarrhea, back pain, vomiting and fluid retention [1-4]. The duration of the menstrual cycle, which usually occurs every 28 days, varies from 4-10 days with an average of 6 days [5]. Moreover, some women reported increased appetite and food craving with chocolate being the most commonly craved food item [6]. Overweight, physical activity and stress increased the duration of the menstrual cycle of female college students in the United States [7]. Although the majority of women experience negative effects during the menstrual period, some find that it positively influences their mood and mental status [1-4].

The menstrual period has a notable role on the academic performance of students [8]. Women with heavy and painful menstrual periods have more problems affecting their academic and social lives [9]. Moreover, dysmenorrhea is one of the commonest gynecological problems among female adolescents and is the leading cause of shortterm school absenteeism, which negatively influences their social, academic and sports activities. A study on the menstrual pattern and common menstrual disorders among Turkish university students reported that dysmenorrhea caused absenteeism and physician consultation among female students [10]. The academic performance of women varies during their menstrual cycle, in a way that the mental status is decreased during and several days before the period. However, some research on the performance of well academically qualified women has shown that they were less likely to be negatively affected by menses [1-4].

The management of dysmenorrhea is through many pharmacological and non-pharmacological treatments. The non-steroidal antiinflammatory drugs (NSAIDs), the most common pharmacological type of treatment are highly effective. Resting, applying heating pads, drinking tea, eating low-fat diet, intake of herbs and exercising are some of the used non-pharmacological treatments [1-4].

As the menstrual period is known to affect women’s lives, the aim of our study was to determine the impact of the menstrual period on AGU female medical students’ physical conditions, academic performance and habits. The Arabian Gulf University (AGU) is a university serving the six Gulf Cooperation Council (GCC) countries and is located in the Kingdom of Bahrain. The university has two colleges; the College of Medicine and Medical Sciences (CMMS) and the College of Graduate Studies. CMMS offers an undergraduate program in medicine and graduate programs in health policy, medical education, laboratory medicine, and molecular medicine. The CMMS has adopted a Problem Based Learning (PBL) technique and self-directed student-centered education as its educational philosophy since its establishment in 1982. The medical curriculum is based on small group tutorials that encourage student knowledge exchange and teamwork [11]. It is a sixyear programme of three phases; phase 1 (year 1) followed by phase 2 (years 2-4) comprising of 3 years of PBL, and phase 3 (years 5-6), the clerkship phase that is divided into 4 rotations each year.

This study was a cross sectional study conducted in November 2011 on AGU female medical students. Two hundred twenty-six students were invited to participate in the study out of all the female students (508) enrolled at CMMS during the academic year 2011- 2012. The sample size was calculated with the assumption that 0.5% of the CMMS female medical students are affected by the menstrual period and an error of 0.05. The sample was stratified into six categories according to the distribution of the student population by academic year. Students were selected at random from English classes for phase 1 of the curriculum, tutorial groups for phase 2, and lecture attendees for phase 3. All the students in the selected classes /groups/rotations were included in the sample.

A self-administered questionnaire (appendix) was constructed for the study, which included demographic data (medical year, year of birth, nationality and accommodation), menstrual history, academic performance and habits (sleeping, appetite, exercise, mood and social relationships) during the menstrual period. Exercise was defined as doing any physical activity at least two times per week. The English teachers of phase 1 students whose groups were selected were given the questionnaires to distribute to the students. For all phase 2 students, the questionnaires were distributed and collected by three of the research members at the beginning of the Sunday and Thursday tutorial sessions. Female students in two rotations of years 5 and 6 were selected at random for phase 3. Clerkship phase students were identified from various rotations. The researchers asked all selected students if they are willing to participate.

The students were informed that the questionnaire is anonymous and that their participation in the study was not compulsory. They were also told in the study that the researches would clarify any query they had in filling the questionnaire. Ethical approval was obtained for the conduction of the research from the Research and Ethics Committee at CMMS. Permission was sought from the Vice Dean for Academic Affairs; Phase 1 Director, as well as the respective PBL tutors and English class teachers.

The Statistical Package for the Social Sciences (SPSS version 16) was used for data entry and analysis. Descriptive statistics and cross tabulations by academic year for the variables were done. The chi square test was applied for the qualitative data to evaluate if there were statistically significant differences.

The average age of the AGU female medical students was 21 years old with 42.5% Bahraini, 27.9% Saudi, 22.1% Kuwaiti and 7.5% Omani and other nationalities. Only 26.5% of the students lived at the university’s residence halls.

The mean age at menarche was 12.7 ± 1.5 years old. The average duration of the menstrual cycle lasted between 2-11 days with a mean of 6.6 ± 1.5 days. In addition, the average between two succeeding cycles was 28.0 ± 4.0 days.

The majority (90.7%) of the students experienced symptoms during their menstrual period with abdominal cramps (90.7%), backache (82.7%), tiredness (80.4%), pelvic pain (74.0%) and bloating (65.2%) the most reported (Figure 1). There were no statistically significant differences between medical years except for breast tenderness (0.048).

Figure 1: Experienced symptoms during menstruation.

Medication was the main method used for the management of abdominal cramps (50.8%) while resting was the commonest practice by the students for most of the other symptoms (backache, 59.9%; pelvic pain, 46.7%; and tiredness, 82.5%). As for bloating, 56.4% of the students did nothing at all (Table 1).

Table1: (%) Management of symptoms during menstruation by students.

Only 28.8% of the students usually exercise, 38% of whom continued to exercise and 62% stopped exercising during their period. The most reported reasons that stopped students from exercising were: pain (42.9%), mood change (15.9%), fear from leakage (14.3%), laziness (11.1%) and cultural reasons (4.8%). Further, exercise increased menstrual flow (60.7%) and menstrual pain (77.3%) of the students who exercised.

Academic performance was affected by menstruation in several ways mainly study time (76%), concentration (65.8%), participation in group activities (58.1%), examination performance (51.8%) and class attendance (40.8%).

Menstruation affected students’ sleep duration and quality. 73.3% of the students reported that the duration of their sleep changed and 60.0% had interrupted sleep. 44.7% of the students slept more, 28.3% slept less and the rest had the same hours of sleep during their menstrual period. Dietary intake changed in 73.9% of the students with almost equal proportions reporting eating more (36.4%) and eating less (37.3%). There was a high tendency to eat more chocolate (59.4%) and other sweets (43.9%) while consumption of savories, soft drinks, tea/coffee, dairy products and junk food were not that affected (Table 2). There were statistically significant differences by medical year for the intake of chocolate and soft drinks only. The proportions of students increasing their chocolate intake during the menstrual period were 61.5% (year 1), 54.1% (year 2), 60.0% (year 3), 70.7% (yea r4), 38.2% (year 5) and 68.4% (year 6). For soft drinks, the corresponding percentages were 28.9%, 16.2%, 14.7%, 15.4%, 6.2% and 10.8%, respectively.

Table 2: Effect of menstruation on food selection.

Over half (53.6%) of the students preferred to be alone, 2.7% became more sociable and the social life of the rest (43.7%) was not affected during menstruation.

This study examined the association between menstrual cycle and physical conditions, habits and academic performance among AGU female medical students. Abdominal cramps were the most reported symptoms similar to those US female adolescents [10]. Dysmenorrhea was the main cause limiting exercise, similar to that reported for Hispanic female adolescents [4]. The commonest methods used for the management for abdominal cramps was chemical medication (50.8%) similar to Isra University students (50 %) but higher than Kuwaiti female students (44%) who particularly used analgesics (28.2%) to relieve their pain [1,2,5].

The menstrual period affected the class concentration (65.8%) and participation in group activities (58.1%) of the majority of the students in this study. This is in accordance to the Kuwait study, which showed that 75.5% of the participants perceived menstrual discomfort as having negative effects on their participation [5] and the Hispanic study that reported that the class concentration of the students was highly affected [3].

Dysmenorrhea and migraine are the leading conditions of work or school absenteeism and substantially impact quality of life [12]. Reduced quality of life when experiencing menstrual pain in women with primary dysmenorrhea found that they had a significant reduction in quality of life at the time of experiencing severe menstrual pain compared with their pain-free phase [13].

The results of this study were in accordance to that of Hormones and Timko (2011) with respect to the increase of chocolate craving during the menstrual period. About 20% of American women experienced chocolate craving at the time around ovulation or at the onset of menstruation. Evidence does not support the role of hormonal fluctuations, rather it is hypothesized that craving occurs as a response to abstinence from high caloric foods in an attempt to manage cyclically occurring weight fluctuations [6]. Similar to other study findings, exercise affected the premenstrual physical symptoms, menstrual flow and pain of AGU students [3]. Exercise could reduce dysmenorrhea and improve emotional distress [3]. A study on the effects of the different phases of the menstrual cycle on physical working capacity showed that the female resting heart and respiratory rates during the menstrual cycle were decreased, having adverse effects on physical work output and sport participation [14].

Moreover, it has been reported that menstrual flow is affected by changes in dietary habits. Ramadan fasting showed that increased flow was found in those who fasted more than 15 days, compared to those who fasted less than this period [15]. Arab women usually do not publicly disclose when they have their menstrual period. In Ramadan, menstruating Arab Muslim women are excused from fasting for religious reasons. However, our study was not performed during the month of Ramadan for seeking further knowledge of this matter. AGU medical students’ quality and duration of sleep was affected during menstrual cycle. A study of midlife menstruating women reported that sleep efficiency declined [16].

Our study population was mainly young female adolescents, who are at higher risk of getting anemia secondary to poor nutrition as well as to menorrhagia. This may necessitate regular hemoglobin checkup, and provision of proper nutrition advice and iron supplements if necessary [17].

The social relationship of female AGU students is affected during the menstrual period, as most of the students preferred to be alone. This finding is in contrast to the results shown by a Turkish study, which reported no effect of menstrual period in the social life [18].

The results of this study cannot be generalized to the female population in the GCC countries due to the age of the study population and the proportion of female CMMS students by nationality. Further, the educational level of the medical students is not representative of the total female population.

It can be concluded that the menstrual cycle has a major impact on AGU female medical students’ physical conditions, whereby 90.7% had abdominal cramps, 82.7% backache and 80.4% felt tired. More than half of the students had their academic performance affected (student time, 76%; concentration, 65.8%; participation in group activities, 58.1%; examination performance, 51.8% and class attendance, 40.8%). The university administration and counseling services should be aware about the results of the study and provide further facilities and understanding to female students. Further research should be conducted to study the effect of menstruation on Arab females.