Selection and Efficacy of Self-Management Strategies for Dysmenorrhea in Young Taiwanese Women

Selection and efficacy of self-management strategies for dysmenorrhea

in young Taiwanese women

Han-Fu Cheng and Yu-Hua Lin

Aims. This study investigates the selection and efficacy of various strategies employed by young Taiwanese women in the self-management of dysmenorrhea.

Background. Dysmenorrhea is the common gynaecological problem in reproductive-aged women. In the past, non-specific treatments such as heat and exercise were found to be less effective. Current therapies for dysmenorrhea include prostaglandin synthetase inhibitors and herbal remedies.

Design. Descriptive survey.

Method. The researcher-designed questionnaire listed common strategies used in Taiwan to self-manage dysmenorrhea. Con-tent validity was applied for the determination of conCon-tent items in measures. The total reliability of menstrual distress ques-tionnaire was 0Æ95, menstrual symptoms quesques-tionnaire was 0Æ92 and coping strategies quesques-tionnaire was 0Æ94. The participants were asked to indicate if they used any of the methods over the past 12 months and, if so, if they were effective. Chi-square test comparisons were used to analyse the data collected.

Results. Of the 616 individuals who completed the questionnaire, 570 reported experiencing dysmenorrhea at least once in the past year. Of these, 180 reported dysmenorrhea at every period and were categorised as Group I. The remaining 390 women were classified as Group II. Women in Group I used all of the listed strategies more frequently; however, they benefited less from all therapies except paracetamol. The most effective strategies in both groups were found to be paracetamol and Dang-Qui-Shao-Ya-San.

Conclusions. Paracetamol and Dang-Qui-Shao-Ya-San are the most effective strategies in relieving dysmenorrhea in young Taiwanese women, while other less effective strategies are used more frequently.

Relevance to clinical practice. Identification of the most effective therapies for dysmenorrhea among commonly used strategies will help women choose the right therapy for them. As some young, inexperienced women might take two or more medications simultaneously because of ineffectiveness, thus increasing the risk of adverse effects, this study is of critical importance in promoting the safe use of medication for self-management of dysmenorrhea.

Key words: Dang-Qui-Shao-Ya-San, dysmenorrhea, paracetamol, self-management, young Taiwanese women

Accepted for publication: 17 April 2010

Introduction

Dysmenorrhea is the occurrence of severe menstrual cycle cramps and pain that lasts for at least two days (Andersch &

Milsom 1982, Proctor & Murphy 2001). Dysmenorrhea is the most common gynaecological problem in women of reproductive ages (McEvoy et al. 2004). It is estimated that more than half of all women in adolescence suffer from

Authors: Han-Fu Cheng, RN, MSN, PhD, Assistant Professor, Department of Midwifery, School of Nursing, Fooyin University; Yu-Hua Lin, RN, PhD, Assistant Professor, Department of Nursing, School of Nursing, I-Shou University, Kaohsiung, Taiwan

Correspondence: Han-Fu Cheng, Assistant Professor, Department of Midwifery, School of Nursing, Fooyin University, 151 Chin-Hsueh

Rd., Ta-Liao Hsiang, Kaohsiung, Taiwan. Telephone: +886 7 7811151 ext. 6130.

dysmenorrhea. Primary dysmenorrhea refers to painful men-ses despite normal pelvis anatomy and ovulation. It usually occurs right before or at the onset of menses and more frequently in adolescent girls. Secondary dysmenorrhea is associated with pelvic pathology (Klein & Litt 1981, Campbell & McGrath 1997, French 2005). Dysmenorrhea results from the withdrawal of progesterone near the end of a menstrual cycle (Harel 2006). This withdrawal has been shown to increase the synthesis of prostaglandins F2(PGF2)

and E2 (PGE2) (Friederich 1983, Tolman et al. 1985) and

stimulate the uterine contraction as prostaglandins are known to induce myometrial contractions, causing menstrual cramps (Pickles et al. 1965, Pickles 1967, Chan & Hill 1978, Dawood 2006, Harel 2006).

Dysmenorrhea often interferes with daily function and impacts the physical and emotional aspects (Andersch & Milsom 1982, Proctor & Murphy 2001). In addition, menstrual cramps are also the leading cause of short-term school absence and are associated with a negative impact on academic and daily activities (Klein & Litt 1981, Andersch & Milsom 1982, McEvoy et al. 2004). As such, dysmenorrhea is a symptom-complex, which not only affects quality of life but also reduces productivity (Andersch & Milsom 1982). One study showed that of 706 Hispanic female adolescents, 85% reported dysmenorrhea, 38% reported missing school and 33% reported missing individual classes during three menstrual cycles (Banikarim et al. 2000). Another study reported that of 664 students who experienced dysmenor-rhea, 55Æ3% reported mild cramping, 30% moderate cramp-ing and 14Æ8% severe crampcramp-ing (El-Gilany et al. 2005). Moreover, one study conducted in 1,546 dysmenorrheal women in Canada, 60% experienced severe or moderate pain, 51% had limitation on activities and 17% missed school (Burnett et al. 2005).

Dysmenorrhea relates to many risk factors. For example, Proctor and Farquhar (2006) reported that risk increases with heavy menstrual flow, young age, stress, smoking and alcohol drinking. Emotional problems, such as depression and anxiety, are also associated with dysmenorrhea (French 2005). Among 1,744 menstruating USA women, dysmenor-rhea was reported by 67% (Barnard et al. 2003). Another study showed that of 760 vocational nursing students in Taiwan, 73Æ3% reported dysmenorrhea (Chiou & Wang 2008). According to Pawlowski (2004), 43% to 90% of women younger than 25 years old reported dysmenorrhea. One study conducted in Japan with 2,282 college women reported that the prevalence of menstrual pain was 82Æ8%. Thirty-four per cent (34%) experienced dysmenorrhea monthly, 49% had menstrual pain occasionally and 17% experienced menstrual pain infrequently (Hirata et al. 2002).

Based on a five-year longitudinal study, there is a lower prevalence and severity of dysmenorrhea among older age women than among younger women. The prevalence of dysmenorrhea decreased from 72% at the age of 19–67% at the age of 24 among the 589 women studied and among these 10% limited their daily activity (Sundell et al. 1990).

Currently, treatment of dysmenorrhea focuses on the use of non-steroidal anti-inflammatory drugs (NSAIDs) and herbal therapy (Harel 2002). The efficacy of both herbal therapy and NSAIDs in the treatment of dysmenorrhea has been studied. NSAIDs have a reported efficacy of 20–25% (Dawood 2006). Magnesium and vitamin B1 were shown to be more effective than placebo (Proctor & Murphy 2001). Oral contraceptive pills are also effective (Campbell & McGrath 1997, Proctor & Farquhar 2002). Additionally, traditional Chinese medicine (TCM) for dysmenorrhea has been broadly used in Asian cultures, and its efficacy has been established (Zhu et al. 2008). In Taiwanese culture, less emphasis was placed on oral analgesics than on the century-old TCM treatment.

Most research on dysmenorrhea in Taiwan focused on adolescent population and few contributed to early adults aged 20–24 years. Therefore, it is important to know the prevalence of dysmenorrhea in this young adult population and the coping strategies used by this group, to provide them with appropriate care. This study was aimed at understand-ing the selection and efficacy of various self-management strategies for dysmenorrhea that are used by young Taiwan-ese women.

Methods

This study was a retrospective examination of young Taiwanese women’s use of strategies to self-manage dysmen-orrhea and was conducted in 2006. Three questionnaires were used for the purpose of data collection. Participants were obtained from a nursing school and a business school in two different universities in the Kaohsiung area in southern Taiwan. Recruitment efforts were extended to 626 students who were considered to be eligible for this study. Of these, 616 students were invited to participate, but 10 participants were excluded because of incomplete data. The questionnaire listed a series of known strategies used in Taiwan to self-manage dysmenorrhea. These include bed rest, paracetamol (panadol or acetaminophen), heat, Dang-Qui-Shao-Ya-San (DQSYS), exercise, brown sugar drinks, ginger tea and low fat diet. The participants were asked to indicate if they used any of these methods and, if so, if they were effective.

To make sure the design was appropriate for the popula-tions, ten Taiwanese female students were piloted. The researcher gave instructions to the students before conducting the measures and checked the answers to determine the level of agreement among different persons using the same tools. The result of this study is a useful guide for explaining the selection and efficacy of self-management strategies for dysmenorrhea in young Taiwanese women. Moreover, this pilot study offers the researcher an experience of conducting research and it helps for the further research skill.

Study population and sampling

To be included, participants must be female students and ‡18 years of age. Students <18 years of age were excluded. A total of 616 convenience samples were recruited from two schools. Students ‡18 years of age from the nursing school were all recruited, 304 female students were invited to participate in the study. Students ‡18 years of age from the business school were randomly selected, 312 students were included in this study. Participations were voluntary and no risks were met. At a prescheduled class time, the researcher was invited to address the study. All their instructors were asked to leave the room. The researcher explained the study and subjects filled out the questionnaires. Those eligible participants were asked standardised questions regarding the lived experience and self-management strategies of dysmen-orrhea over the past 12 months. If students did not finish the surveys, envelop with mailing address was provided to participants. Complete questionnaires were returned within one week to the researcher and return of the complete questionnaire indicated consent to participate.

Although this was a low risk study, students remained a vulnerable population. The role of the researcher was unrelated to her role as a teacher. Therefore, the researcher was in no way academically responsible for the students enrolled in the study. In addition, there was no communica-tion between the researcher and their instructors regarding who did or did not enrol. Nor did the researcher reveal any response provided by students.

Ethical considerations

The Institutional Review Boards from two schools, where the surveys were conducted, have reviewed and approved this study regarding the use of human subjects. Data were collected using questionnaires that were completed during classes. Participants were asked to complete questionnaires after explanation of study with a special emphasis on their confidentiality and anonymity.

Measurements

In addition to demographic data, three instruments were used to collect data and measure outcome variables, including a menstrual distress questionnaire (MDQ), a menstrual symp-toms questionnaire (MSQ) and a menstrual distress coping strategies questionnaire (CSQ). The questions were made by researchers based on the personal experiences, relative references and specific cultural considerations.

Content validity was applied for the determination of content items in measures. To establish judgment content validity, the researchers generated the items and identified each domain then came up with the instruments based on the literature reviews and personal experiences. After the mea-sures were taken by the researchers, three experts were asked to judge the qualification of the measures. The experts possess high educational degrees (one master and two doctorates) and are experienced in the medical field and in research; and they are also clinical experts and are all females. Each reviewer received a detailed package that included a description of the purpose of three measures and instructions for assessing content validity. The experts were requested to put the comments and suggestions regarding clarity and readability of each item. The researchers made corrections based on the experts’ suggestions until three experts agreed with the point. In addition, the exploratory factor analysis was used to establish factorial construct of the instruments. Factor analysis is used to analyse the interrela-tionships among a set of variables and to explain these interrelationships in terms of a latent variable. The psycho-metric properties of MDQ, MSQ and CSQ provide conver-gent and discriminant validity evidence to support the construct validity.

To assess the consistency of results across items in a test, internal consistency reliability was applied. Cronbach’s alpha coefficient, a most common form of internal consistency reliability coefficient, was used to estimate the average correlation among items in an instrument and to determine the internal consistency of the factors. The reliability of the MDQ, MSQ and CSQ were evaluated by considering the (1) Cronbach’s alpha coefficient, (2) a corrected item-total correlation coefficient and (3) the alpha estimated when an item was dropped from the scale. Poorly functioning items were defined as (1) items that when deleted increased the coefficient alpha by more than 0Æ10 or (2) items that had a correlation of less than 0Æ30 with the total scale score. The total reliability of MDQ was high (a = 0Æ95) compared with the results of those found in the literature. The reliabilities of the literatures varied from 0Æ64–0Æ93. In the MSQ, the total reliability of this scale was 0Æ92. The internal consistency

reliability alpha coefficient of the third measure of CSQ was 0Æ94.

Menstrual distress questionnaire

MDQ is a self-report inventory, originally applied for the gathering of normative information on symptom prevalence and severity in the sample of normal married young women. Researcher based on personal experience and relative refer-ences developed the MDQ, a scale consists of physical, emotional and social aspects. An 11-item questionnaire, including frequency and degree of menstrual distress, was used to assess distress level during menstruation.

Menstrual symptoms questionnaire

The MSQ included 17-item scale for measuring the intensity of menstrual symptoms depending on different chief com-plains. The measurement questions consist of physical symptoms, affective symptoms and changes in appetite. Subjects were asked to rate their level of symptoms with each item on a five-point scale. The higher the score, the more the experiences of symptom for each one would be.

Coping strategy of menstrual distress questionnaire

The CSQ included a 10-item questionnaire that consists of physical adjustment, medication treatment, alternative ther-apy and diet supplement. This was used to assess attitudes regarding menstruation and to measure coping strategies of menstrual distress and the efficacy of the strategies.

Data analysis

Data entry begins after the survey was completed. Data were coded and entered into the programme of Statistical Package of the Social Science (SPSSSPSS) version 15.0 (SPSS Inc., Chicago, IL,

USA) for data analysis.SPSSSPSSsyntax files were stored to prevent

the need to rerun the data. The dataset was checked for accuracy, entry errors and missing values to decrease the possibility of misinterpreting the results. For purposes of entering data into SPSSSPSS, each survey had a prefilled survey

number attached to it. The survey number identified each survey to preserve the anonymity of the subjects. Frequencies, means, standard deviations and chi-square tests were calcu-lated where appropriate for each of the items of questionnaires.

Results

Participant background information

Out of a total of 626 participants recruited to the study, 10 were excluded because of failure to complete the survey,

resulting in a response rate of 98%. The remaining 616 participants were included in the study, and their demo-graphic characteristics are described in Table 1. The mean age of the study population was 20Æ2 years old (ranged from 18–28 years) with a standard deviation of 1Æ56. Specific to this study, a total of 570 (or 92Æ7%) participants reported experiencing menstrual pain and 577 (or 92Æ2%) reported experiencing one or more premenstrual symptoms in a one-year period. Among the 616 participants, 301 (or 48Æ9%) were from the nursing school and 315 (or 51Æ1%) were from the business school. The grade distributions of students were as following: freshman, 184 (or 30Æ2%); sophomores, 179 (or 29Æ3%); junior, 163 (or 26Æ7%) and senior, 84 (or 13Æ8%).

Other participant demographic characteristics

Most (67Æ9%) of the participants have no special religions. The mean score of schoolwork stress was 55Æ9 (ranged 0-100). Table 2 indicates that only 2Æ3% of 616 participants consumed coffee regularly with a cup per day, while 47% drank coffee irregularly. For the eating style, Taiwanese students prefer low fat diet. Among the 616 participants, most students had no regular exercise and only 1Æ6% exercise everyday.

Frequency distribution of perimenstrual symptoms

Of the 616 individuals who completed the questionnaire, 577 (92Æ2%) reported experiencing perimenstrual symptoms within a year. The most frequently reported symptoms were

Table 1 Participant background information

Variables Frequency n (%) Mean (min–max) Age (years) 20Æ2 (18–28) Dysmenorrhea Yes 570 (92Æ5) No 46 (7Æ5) Perimenstrual symptom Yes 577 (92Æ2) No 49 (7Æ8) Department of study Nursing school 301 (48Æ9) Business school 315 (51Æ1) Grade of study Freshman 184 (30Æ2) Sophomore 179 (29Æ3) Junior 163 (26Æ7) Senior 84 (13Æ8) n = 616.

as following: abdominal pain, fatigue and impatience (Table 3). Anxiety/nervousness, insomnia and extremities oedema were the least reported (Table 4). To determine if any risk factors, such as eating style, coffee drinking and stress, are related to perimenstrual symptoms, chi-square test analyses were conducted (Table 5). We found no significant association between perimenstrual symptoms and any of these risk factors.

The frequency and distribution of reported dysmenorrhea were as following: 29Æ2% (n = 180) reported dysmenorrhea in every menstruation, 18% (n = 111) reported 5–6 times within one year, 19Æ3% (n = 119) reported 3–4 time per year, 26% (n = 160) reported 1–2 times per year and 7Æ5% (n = 46) never had experienced dysmenorrhea in the past year (Table 6).

Of the 616 individuals who completed the questionnaire, 570 reported experiencing dysmenorrhea at least once in the past year. Of these, 180 reported dysmenorrhea at every period and were categorised as frequent dysmenorrhea Group I. The remaining 390 women were classified as infrequent dysmenorrhea Group II (Table 7).

For interventions used in the self-management of dysmen-orrhea, we found that women in Group I with frequent dysmenorrhea used more frequently strategies like bed rest, brown sugar drink and heat (Table 7). Similar results were found Group II participants. However, Group I benefited less than Group II from all of these interventions except parac-etamol (Table 8). Chi-square tests were performed to deter-mine differences between these two groups for the use of interventions and their efficacies. The results showed that paracetamol, heat and DQSYS displayed significant differ-ences (p < 0Æ001) for their use frequency between these two groups (Table 7). Specifically, Group I participants used these

Table 3 Most frequently reported perimenstrual symptoms Variables Frequency Per cent Abdominal pain 548 87Æ5

Fatigue 542 86Æ6

Impatience 524 83Æ7

n = 616.

Table 2 Participants’ other demographic characteristics

Variables Frequency n (%) Mean (min–max) Religion Yes 197 (32Æ1) No 417 (67Æ9) Stress score 55Æ9 (0–100) Coffee drinking No 266 (50Æ7) Irregular 259 (47) Regular (a cup per day) 12 (2Æ3) Exercise behaviour

No 258 (42Æ5) Irregular 339 (45Æ9) Every day 10 (1Æ6) n = 616.

Data are reported as n (%) unless otherwise noted.

Table 4 Least frequently reported perimenstrual symptoms Variables Frequency Per cent Anxiety/nervousness 148 23Æ6

Insomnia 233 37Æ2

Extremities oedema 347 55Æ4 n = 616.

Table 5 Risk factors and perimenstrual symptoms

Domains PMS v2 df p Eating style 0Æ204 1 0Æ979 (ns) Coffee drinking 0Æ061 1 0Æ464 (ns) Stress 0Æ211 1 0Æ380 (ns) ns, non-significant.

Table 6 Frequency of dysmenorrhea

Variables Frequency Per cent

Every time 180 29Æ2 Five-six/year 111 18 Three-four/year 119 19Æ3 One-two/year 160 26 Never 46 7Æ5 n = 616.

Table 7 Distribution and frequency of interventions used in self-managing dysmenorrhea Variables Group I (frequent dysmenorrhea), n (%) Group II (infrequent dysmenorrhea), n (%) p-value Bed rest 171 (95Æ0) 339 (86Æ9) 0Æ003 Paracetamol 98 (54Æ4) 96 (24Æ6) <0Æ001 Heat 109 (60Æ6) 174 (44Æ6) <0Æ001 Exercise 40 (22Æ2) 72 (18Æ5) 0Æ29 DQSYS 63 (35Æ0) 58 (14Æ9) <0Æ001 Ginger tea 49 (27Æ0) 87 (22Æ3) 0Æ012 Brown sugar 129 (71Æ7) 233 (59Æ7) 0Æ006 Low fat food 29 (16Æ1) 56 (14Æ4) 0Æ25 Group I, n = 180; Group II, n = 390.

three interventions more frequently than Group II partici-pants.

In addition to higher use frequencies, we found that paracetamol, heat and DQSYS were also the most effective interventions in Group I participants. In contrast, the most helpful interventions for Group II participants were DQSYS, paracetamol, low fat diet and ginger tea (Table 8). Chi-square test comparisons for the efficacies of these strategies showed that only bed rest had significant difference between Group I (87Æ8%) and Group II (95Æ9%) participants (p < 0Æ001).

Discussion

As more than half of all girls and women suffer from dysmenorrhea, this study is important in determining the use frequency and efficacy of various common interventions employed by young Taiwanese women in the self-manage-ment of dysmenorrhea. In this study, we obtained a very high response rate (98%), which minimises potential response bias because a response rate of greater than 60% is considered sufficient (Pilot & Beck 2004). There are two possible reasons for the high response rate in this study. First, the researcher is a faculty member in the same school as the subjects. Students might worry that not to respond may influence grades. These worries were lessened by: (1) The survey had no identifiers other than age and (2) The researcher was not in the same department as the student subjects, nor taught any courses to these students. Consequently, the researcher did not know who responded and who did not. The second reason is cultural influence. Even when a teacher is not responsible for grades, students are likely to obey teachers as a sign of respect in Asian culture. Nevertheless, students were informed before answering the survey that they could: (1) leave now, (2) take survey and not turn it in, or (3) take survey and turn it in, in

which case the submission of the survey represented implied consent.

Although the age range among participants is relatively wide (18–28 years), the mean age was 20Æ2 . The young age of the respondents is important as their answers to questions about perimenstrual symptoms may be influenced by hor-monal changes commonly encountered in this age group. For example, it is estimated from 43–90% of all women in adolescence experience dysmenorrhea (Harel 2002, Pawlow-ski 2004). In this study, we found that 92Æ5% of these young Taiwanese women reported dysmenorrhea.

Dysmenorrhea is directly related to elevated level of prostaglandin F2(PGF2) and is typically treated with drugs

that inhibit synthesis of prostaglandins in the USA (Wenzloff & Shimp 1984). In Taiwan, paracetamol (panadol/acetami-nophen) is one of the popular over-the-counter Western medicines and it is known as an analgesic as are the NSAIDs. TCMs have been used for centuries in treating different diseases or symptoms, including dysmenorrhea pain but also used to prevent dysmenorrhea. Usually, they are not taken just when pain occurs. This notion is consistent with the current recommendation in the U.S. to begin NSAID therapy three to five days prior to the onset of menses to prevent dysmenorrhea. In both TCMs and NSAIDs, the anti-prosta-glandin anti-inflammatory effects require a few days of therapy to prevent the prostaglandin-related dysmenorrhea (French 2005).

Limitations

The generalisability of the findings in this study is limited by the self-selection of the participants. Convenience sampling techniques produced a sample that was not representative of the greater population. Furthermore, the use of a self-report inventory, which may differ from actual observed behaviours, may yield a higher rate of false data, a threat to construct validity affected by participant motivation. Thus, duplication of the study in other areas is recommended to examine the coping strategies in different groups. Although the use of a multiple sites would improve the ability to generalise the finding beyond a single site, this study still has value that populations are large enough.

Despite its limitations, this study makes some valuable contributions to the subjects, society and health providers. There are some benefits to the subjects and society including: (1) the recognition that these students will contribute to the advancement of knowledge; (2) the recognition that their contributions may enhance the safe use of medication for dysmenorrhea and (3) the results may provide useful infor-mation to healthcare providers for taking care of those

Table 8 Efficacies of various interventions used in self-managing dysmenorrhea Variables Group I (frequent dysmenorrhea), n (%) Group II (infrequent dysmenorrhea), n (%) p-value Bed rest 158 (87Æ8) 374 (95Æ9) <0Æ001 Paracetamol 179 (99Æ4) 386 (98Æ9) 0Æ58 Heat 174 (96Æ9) 382 (97Æ9) 0Æ36 Exercise 170 (94Æ4) 381 (97Æ7) 0Æ045 DQSYS 173 (96Æ1) 386 (99Æ0) 0Æ021 Ginger tea 172 (95Æ6) 385 (98Æ7) 0Æ019 Brown sugar 166 (92Æ2) 371 (95Æ1) 0Æ156 Low fat food 172 (95Æ6) 386 (98Æ9) 0Æ008 Group I, n = 180; Group II, n = 390.

population. As a result, the findings will contribute to the development of health promotion and disease prevention knowledge. Moreover, the results will benefit school nurses responsible for the care of young women. The researchers identified the frequency and distribution of medications used by Taiwanese nursing students for dysmenorrhea. The information will help improve medication safety and pro-mote future research. Additionally, the results may advance the knowledge base underlying the nursing assessment and management of dysmenorrhea under Taiwanese culture.

Future research

Because both Western medications and traditional Chinese medications may associate with some side effects, it would be interesting in the future to explore more thoroughly the side effects associated with them. Importantly, it is also necessary to modify the instruments to obtain more valuable and reliable data and to administer an improved survey to quantify the severity of perimenstrual symptoms and side effects.

Conclusions

Understanding the strategies used by young Taiwanese women in coping with dysmenorrhea will increase the probability of providing culturally sensitive care. We found that paracetamol and DQSYS were the most effective strategies in relieving dysmenorrhea among both frequent and infrequent sufferers. Nonetheless, other strategies were used more frequently as time-honoured cultural therapies (such as brown sugar drinks and ginger tea). These findings have important implications for health care education regarding menstruation and for health and nursing sciences provided to adolescents and young adults.

Relevance to clinical practice

In Taiwan, people conceptualise TCMs differently than the way medication is conceived in the West. On the one hand, Taiwanese may use one or more TCMs daily, not for specific health problems but for health maintenance. On the other hand, Taiwanese do use TCMs for specific health problems as well (Cheng et al. 2008). Identification of the most effective therapies for dysmenorrhea among commonly used strategies will help women choose the right therapy for them. As some young, inexperienced women might take two or more medications simultaneously because of ineffectiveness, thus increasing the risk of adverse effects, this study is of critical importance in promoting the safe use of medication for self-management of dysmenorrhea.

Acknowledgements

The authors thanks Fooyin University and I-Shou University for providing supports for this study, the IRB committee for reviewing the proposed study on human subjects and the students who participated in this study. The authors also thank professor J. Don Chen (UMDNJ-Robert Wood John-son Medical School, Piscataway, NJ) for critical review and help in the preparation of this manuscript.

Contributions

Study design: HFC and YHL; data collection and analysis: HFC and YHL; manuscript preparation: HFC and JDC.

Conflict of interest statement

All authors have no conflict of interest in this study.

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Reasons to submit your paper to JCN:

High-impact forum: one of the world’s most cited nursing journals and with an impact factor of 1Æ194 – ranked 16 of 70 within Thomson Reuters Journal Citation Report (Social Science – Nursing) in 2009.

One of the most read nursing journals in the world: over 1 million articles downloaded online per year and accessible in over 7000 libraries worldwide (including over 4000 in developing countries with free or low cost access).

Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur.

Early View: rapid online publication (with doi for referencing) for accepted articles in final form, and fully citable. Positive publishing experience: rapid double-blind peer review with constructive feedback.

Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley Online Library, as well as the option to deposit the article in your preferred archive.