Title: COPING WITH DYSMENORRHEA: A QUALITATIVE ANALYSIS OF PERIOD
PAIN MANAGEMENT AMONG STUDENTS WHO MENSTRUATE
Version: 3 Date: 29 Jul 2022
Reviewer's report:
Dear authors,
Thank you for your attentive and detailed response to the review comments and suggestions and
for amending this paper.
I enjoyed reading this amended version and I think that it adds valuable qualitative data to a
field where this type of evidence is sorely needed.
I would still support considering use of the term dysmenorrhea or undifferentiated
dysmenorrhoea or a reflection somewhere that while none of the participants had known
diagnoses, they may have actually had underlying conditions. I recognise that the term PD is
commonly used, but I think reflection on the uncertainty about this would be of benefit for this
paper throughout, and notably within the discussion section.
The paper cites a phenomenological approach, but I remain unclear that there is clear evidence
of this through the results and discussion, over and above a thematic qualitative approach.
I have a few outstanding  comments:
Abstract: when you say opportunity sampling approach – do you mean opportunistic?
When you conclude that students are not equipped to cope with primary dysmenorrhoea, might
this be better written as dysmenorrhoea, acknowledging the uncertainty about whether the un-
investigated cohort has primary or secondary? What you describe is managing pain.
Introduction:
I wonder whether it would be helpful to define secondary dysmenorrhoea earlier on in this
section, perhaps? Without this context, the early reference (page 3 line 53) to the possibility
of endometriosis lacks context and reads as a little disconnected. It might be that defining
endometriosis as a potential contributor to secondary dysmenorrhoea helps contextualise this
for readers?
This could also be used to reflect or expand on the added sentence about perceptions of PD as a
medical condition at the top of page 6? I think this sentence warrants clarification, as it is unclear
what this means to me as it stands.
Method:
Thank you for the addition of the sentence that the participants had undifferentiated
dysmenorrhoea. As above, I wonder if this is worth also reflecting on in the discussion section,
noting the higher than perhaps expected rate of medical consultation in this group?
Results:
I do not think that having a percentage adds to this reporting of an IPA qualitative study, and also
note that this necessitates references embedded in the results section.  I think this is a meaningless
statistic in the context of a sample of 21 self identified individuals and I think should be removed.
Page 12 line230, should leading be led?
Page 13, 245-247: cultural factors seem to be relevant to concealment throughout your
participants as demonstrated by your included quotes. I am not sure what this comparison adds
or how this could be interpreted. Might it be appropriate to say that cultural responses  may differ
but were impediments to communications identified by both Irish national and international
students? There is a nice descriptive sentence about this on page 20, line 361.
Some of the newly introduced quotes are also both embedded within the article text and within
the quotation boxes. This may be intentional, but is not consistent, and so am pausing for
reflection.
Page 19 line 329. Participants expressed that ‘doctors medicalise menstruation’ – I think this is
participants felt that expressed their view that?
Page 19 342-344. This is a long sentence. Could this be simplified or clarified.
Page 19 344-346 see earlier comment about comparisons.  You present powerful data showing
that culture impacts on concealment pervasively, across different cultures. I am not sure what
‘more likely’ adds without more context or evidence.
However, I note that on page 20, line 361, censorship is specifically described in the context
of Ireland although two participants are able to offer personal comparative experience. This
descriptive element helps and possibly could stand alone?
Page 20, the additions here are hugely appreciated. Thank you.
Discussion and conclusion:
Page 25 line 431. The expansive influence of negative social attitudes towards menstruation
may impact on perceptions of access to medical offices. As it stands, this risks the implication
that HCP hold negative attitudes, which cannot be evidenced from this paper. Please review.
Page 28 line 474 primary dysmenorrhoea or dysmenorrhoea?
Page 28 line 484. Please remove without incurring negative social implications. This is an
important and interesting initiative, but is as far as I am aware, as yet unevaluated for intended/
unintended/positive and negative consequences? This is therefore a current unknown.