Title: COPING WITH DYSMENORRHEA: A QUALITATIVE ANALYSIS OF PERIOD
PAIN MANAGEMENT AMONG STUDENTS WHO MENSTRUATE
Version: 1 Date: 10 May 2022
Reviewer:  Lester E. Jones
Reviewer's report:
Well done on exploring this important topic. I enjoyed reading the manuscript and have some
minor suggestions you might consider.
I think when trying to make a case that dysmenorrhea is underacknowledged or undertreated,
you need to be cautious about  making statements that are easily challenged.
There is a sentence  in the opening paragraph that begins "PD incurs debilitating physical
symptoms..." I feel this may misrepresent the variability of PD presentation as it is not always
debilitating - I think tempering this sentence with "PD can be debilitating ..." might be more
appropriate.
Also the statement, "PD is a leading cause of educational absenteeism and presenteeism"
might be interpreted as being drawn from institutional statistics where, from what I gather,
this is from the report of self-selecting participants in surveys. Perhaps rephrase to prevent this
misinterpretation.
Perhaps this also goes for the opening statements about overall prevalence "... up to 95%" this
may true but offering a range may be more balanced - especially as  Armour et al indicate
"...individuals with more severe pain and symptoms are more likely to respond".
Indeed, for me the most  glaring limitation of the study is the potential for the recruitment strategy
to heavily skew the findings in terms of  PD prevalence and severity. You could state this more
strongly. It also requires some qualification to statements like  "Overall, students with PD in
Ireland face debilitating recurrent symptoms of PD and receive little guidance on effectively
managing menstrual pain during education." [Line 349]  May be  try: "Overall, students with
PD from this self-selecting sample, face debilitating..."
One thing that  appears to have little attention in your background and discussion is the apparent
benefit of exercise on PD symptoms. This seems a consistent finding in the literature. As it was
only briefly  mentioned as a finding and not considered in background,  perhaps it may have
some value in the discussion - particularly around the role of passive approaches versus active
approaches to pain management -  passive versus active coping might also be relevant in the
deductive CSM analysis - maybe?
Paloma Carroquino-Garcia, José Jesús Jiménez-Rejano, Esther Medrano-Sanchez, Maria de
la Casa-Almeida, Esther Diaz-Mohedo, Carmen Suarez-Serrano, Therapeutic Exercise in the
Treatment of Primary Dysmenorrhea: A Systematic Review and Meta-Analysis, Physical
Therapy, Volume 99, Issue 10, October 2019, Pages 1371–1380, https://doi.org/10.1093/ptj/
pzz101
Also there maybe value in incorporating the potential link between dysmenorrhea and persistent
pain conditions as support for the need to optimise  pain management early.
Li, R., Li, B., Kreher, D. A., Benjamin, A. R., Gubbels, A., & Smith, S. M. (2020). Association
between dysmenorrhea and chronic pain: a systematic review and meta-analysis of population-
based studies. American journal of obstetrics and gynecology, 223(3), 350-371.
Finally, I would suggest rephrasing this - maybe break into two sentences  to improve impact
"By examining the influence of PD beliefs on behavioural responses, Chen and colleagues (20)
reported that the majority of respondents characterised PD as a ‘normal’ aspect of womanhood,
a view which may influence perceptions of PD as a medical condition. " [line 109] - I had to read
it more than once and was still not sure of the exact point you were making. Might just be me! ;-)
Well done again - and I hope you find these suggestions helpful.