Title: COPING WITH DYSMENORRHEA: A QUALITATIVE ANALYSIS OF PERIOD
PAIN MANAGEMENT AMONG STUDENTS WHO MENSTRUATE
Version: 1 Date: 23 May 2022
Reviewer's report:
Dear authors,
Thank you for this paper, which I enjoyed reading. I was very glad to see a qualitative study
about lived experiences of menstrual pain.  I liked the use of the common sense model. The
context of data captured during COVID is novel and interesting.
General observations:
I would support considering use of the term dysmenorrhoea or undifferentiated dysmenorrhoea
or a reflection somewhere that while none of the participants had known diagnoses, they may
have actually had underlying conditions. This is perhaps important to consider in the context
of the high number who had sought medical advice for this problem, and noting the quote you
cite of a participant who thought they might have endometriosis? This is an observation that you
may wish to consider throughout this manuscript.
I would observe a potential disconnect in the narrative about framing the word normal and
concepts of normalisation. If period pain affects 95% of the population, then it is arguably
normal. The problem is that normalising pain implies a lack of awareness that it could also be
normal to treat it and seek help for the pain!
I enjoyed the use of the common sense model and that this was situated in the analysis methods,
but wonder whether it could have been used more consistently in analysis and discussion than
it currently is. The paper cites a phenomenological approach, but there is no clear evidence of
this through the results and discussion.
Figure one was a good representation of the themes and I thought this was very helpful.
Specific observations:
Abstract:
If it were possible to weave in how learning about how period pain could be navigated evolved
through pandemic and lockdown experiences, that could be interesting?
Introduction:
The OTC analgesia section does not reflect on commonly used OTC NSAIDS such as ibuprofen.
Naproxen can be OTC for menstrual cramps. This observation could be contextualised for an
international readership, where rules on medication access may be different? Medication being
only available via consultation is a potential barrier to access – but it may not follow that this
is aligned with lower awareness?
The potential for dysmenorrhoea to reflect an underlying condition is important but is mentioned
twice. This could be reviewed and perhaps brought together? Likewise, could the sections on
health literacy be brought together?
Line 61: I am not sure it is only low menstrual health literacy that leads to the difficulties
in establishing whether there is an underlying medical cause for dysmenorrhoea, and wonder
whether starting the sentence with ‘There are concerns’ might broaden this reflection.
Line 77: I think you mean here that the impact of dysmenorrhoea on study is a particular worry
for students, but this could read as dysmenorrhoea being more of a problem for students (whereas
it is actually a problem for all who experience it?) and if my reading of this is correct, then I
think this could be clarified.
Line 85: I do not think that the reference cited for ‘The legitimacy of PD has also been questioned
by HCP’ (ref 20) meets this sentence’s wording. This reference is a qualitative study about
women’s experiences. The following sentence is appropriate but you cannot extrapolate from
this to what HCP think. Perhaps Women fear or believe that HCP doubt the legitimacy?
Line 118: what authoritative sources of menstrual health information might this refer to? And
are students and young people amongst those most likely to not be able to access them????
Line 120: is there a reference for this?
Methods:
This is described clearly with detailed description, but please see comment earlier about
phenomenological approach. Will the topic guide be made available as supplementary material?
Results:
Line 216: I do not think that the statistic about the percentage of participants who sought help
is of value in reading this paper or appropriate to reporting a qualitative study.  If you have any
data or analysis around understanding who has (and has not) sought help and why, then I wonder
whether this might enhance this report.
Theme 1: I thought the consideration of the interface between how and when menstruation was
discussed at home or school was interesting.
Culture is equally part of and relevant to the Irish narratives and ascribing cultural impediments
only to the international participants does not feel balanced – and in the absence of any quotes
or evidence to support this, it is hard to contextualise or interpret this. This reflection is also
applicable in the discussion section. I note that in theme 5 you reflect that socio-cultural
discourse is relevant to all participants. More reflection or data on what aspects of culture or
what is meant or described in this context could potentially add value.
The reflections on education in schools are largely situated in Ireland, and could be
contextualised there. Is there any background that could help? This is also something that
potentially has changed with time and I note the different ages of your participants. Is there
anything about the culture of age and time?
I liked the hit and miss phrasing, - but looking at the observation about how it is helpful to have
options at menarche, and the quotation offered, are there not some positive aspects of learning
what works for individuals from a menu of options? This is relevant to how this is discussed
in the final section also, when this is framed as problematic – but how I read your results and
the quotations perhaps suggest more nuance is possible? This also overlaps with theme 2 – that
some of what helps is easier to navigate at home?
Theme 2: The findings here are of notable relevance to COVID and this is a point where this
study adds new information. It might be interesting to reflect on the recent introduction of
menstrual leave in Spain in the discussion? (recognising that that happened long after you drafted
this!).
Theme 3: The descriptions of uncertainty about the legitimacy of menstrual pain or feeling
enabled to use this as the explanation for when menstruation impacted on productiveness was
powerful, including what it might mean for employment in future and I think an interesting
contribution.
Theme 4: I think that the reflections on the interface of considering and navigating hormonal
treatments for menstrual pain, including menstrual suppression are interesting and could be
expanded. However, I think caution is needed in the framing of some of this, noting that this
is an evidence-based strategy for menstrual pain. What you uncover here feel like education,
information and support opportunities and needs to help this communication and shared
decision-making process? Framing offering a first line treatment as medicalising, in the context
of someone coming to seek medical advice, or as not offering pain relief, does not feel entirely
comfortable to me.
Theme 5: I would value some explanation of how and why the tampons and tea advert were
problematic or described or perceived, and some background information to allow me as a reader
to contextualise this.
Discussion section:
Line 387: In the discussion of trial and error, and noting your findings about how having options
explained at menarche and also the importance of education, is there some middle ground where
trial and error risks periods of unresolved pain, which is clearly problematic, but also could
enable options for self-efficacy? And that what is needed to under-pin this are resources that
explain what could be tried and might help?
Line 395: Where you say that ‘some doctors may not have regarded their pain as a valid concern’
– I think this needs to be contextualised in some way so that it is clearer that some respondents
felt that some doctors etc.
Line 398: the lack of investigations or tests to look into pain is not in the results section?
Line 401: Eliminating periods is an option that can be an effective pain management technique.
Please review.
Line 370: Emergent symptoms should be a concern for students. And clinicians. Apologies if I
have missed it but I do not see this in the results, so needs caution in the discussion section.