You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


Introduction
============

Background
----------

The terms "menstrual pain" and "dysmenorrhea" are commonly considered synonymous in clinical practice and literature. They indicate a cramp-like, dull, throbbing pain that usually emanates from the lower abdomen, and that occurs just before and/or during menstruation.[@b1-jpr-5-169] Some authors suggest that a type of menstrual pain that is lighter than dysmenorrhea, called normal menstrual cramps, could exist.[@b2-jpr-5-169],[@b3-jpr-5-169] Dysmenorrhea seems to be associated with late[@b4-jpr-5-169]--[@b6-jpr-5-169] or early[@b7-jpr-5-169],[@b8-jpr-5-169] menarche, prolonged and heavier than normal menstrual flow,[@b9-jpr-5-169] low bodyweight and body mass index, inadequate physical exercise,[@b10-jpr-5-169],[@b11-jpr-5-169] genetic predisposition,[@b12-jpr-5-169] active and passive cigarette smoking,[@b9-jpr-5-169],[@b13-jpr-5-169]--[@b15-jpr-5-169] low socioeconomic status, diet,[@b5-jpr-5-169],[@b16-jpr-5-169],[@b17-jpr-5-169] stress, and mental illness.[@b18-jpr-5-169]

Dysmenorrhea appears to have an impact on public and occupational health,[@b19-jpr-5-169],[@b20-jpr-5-169] but its prevalence is unclear, with studies performed in different populations reporting rates of between 20% and 94%.[@b4-jpr-5-169],[@b5-jpr-5-169],[@b21-jpr-5-169]--[@b27-jpr-5-169] This wide variation may derive from ethnic, sociocultural, or biological factors of the study populations,[@b21-jpr-5-169]--[@b27-jpr-5-169] and also from the range of definitions of dysmenorrhea.

The proposed distinction between dysmenorrhea and normal menstrual cramps is "the need for medication and the inability to function normally in the latter situation." A recent large-scale survey demonstrated that the reporting of painful periods was more common than the reporting of problematic periods,[@b3-jpr-5-169] indicating that pain alone is not sufficient to make a period a clinical problem. Accordingly, categorizing dysmenorrhea on the basis of pain intensity using a visual analog scale (VAS)[@b4-jpr-5-169],[@b5-jpr-5-169] fails to consider a woman's capacity to cope with pain, and so may not directly relate to the need for medication or the ability of a woman to function normally when suffering from dysmenorrhea.

Objectives
----------

The principal aim of this study was to evaluate the prevalence of dysmenorrhea as identified by different definitions, and to demonstrate that rates and impacts of dysmenorrhea can vary significantly depending on the definition used. Factors associated with menstrual pain were also investigated.

The present study is reported according to the STROBE statement for improving the quality of observational studies (<http://www.strobe-statement.org>).

Materials and methods
=====================

Study design and setting
------------------------

A cross-sectional analytical survey was carried out at the University of Modena and Reggio Emilia in April 2010. The study was approved by the internal review board of the Department of Obstetrics, Gynecology, and Pediatrics, Azienda Ospedaliero Universitaria Policlinico of Modena. Permission to distribute the questionnaires in university classrooms was obtained from the university.

A sample of academic years and the degree courses offered in different disciplinary areas (faculties of medicine, law, economy, and engineering) was randomly selected, and provided a total of 500 female students. Those who agreed to participate in the research were enrolled in the classroom prior to lessons, with participation being voluntary, and written consents gathered before any data was collected. A self-assessment questionnaire was anonymously completed by each participant.

Participants
------------

The eligibility criteria for this study were:

1.  All participants were female students enrolled in a randomly selected academic year of a degree course of the university.

2.  Participants must have been present in the classroom when the researcher visited to collect data.

3.  Informed consent was required for participation.

Data sources
------------

The questionnaire was based on previous studies in the literature and the results of a pilot study.[@b25-jpr-5-169] It comprised 26 questions investigating each participant's menstrual pattern and specific personal, family, educational, physical, and gynecological factors.

Women who reported that they had suffered from menstrual pain completed an additional eleven questions regarding the onset of symptoms, length of pain, relation of pain with menstrual flow, pain intensity using a VAS, use and effectiveness of painkillers, and whether menstrual pain interfered with school or social activities.

Statistical methods
-------------------

The characteristics of women with and without pain were analyzed and compared. Possible features related to menstrual pain were evaluated with independent factors defined by logistic regression analysis for categorical variables (dependent variable: presence/absence of menstrual pain) or multiple regression analysis for continuous variables (dependent variable: intensity of pain by VAS). In the multiple regression analysis, categorical data were entered as dummy variables. Sugar and salt consumption (minimal, moderate, excessive) and breakfast frequency (daily, 2/3 times a week, never) were entered into the analysis as two dummy variables, while the presence of a sentimental relationship, smoking, physical activity, coffee consumption, fish consumption, use of hormonal contraception, gynecological pathology and surgery in the participant's medical history, and alcohol consumption were entered as a single dummy variable.

Prevalence of dysmenorrhea was calculated according to the association of different features and in accordance with the only definition reported in literature,[@b2-jpr-5-169] in which dysmenorrhea is considered to be menstrual pain associated with a need for medication and inability to function normally. Accordingly, we evaluated the prevalence of menstrual pain per se, of menstrual pain associated with a need for medication, and of menstrual pain associated with an inability to function at, or absenteeism from, school or social events. Prevalence of a combination of the above parameters was also evaluated. Similarly, menstrual pain was stratified by VAS scores into mild, moderate, and severe categories, and their prevalence was calculated. When necessary, prevalence was compared by contingency tables and the Chi square test.

Statistical analysis was performed using the statistical package StatView (v 5.01.98; SAS Institute Inc, Cary, NC). Correlations were considered to be significant at *P* \< 0.05. The results of continuous data are expressed as mean ± standard deviation (SD).

Results
=======

Participants
------------

Of the 500 women selected, 63 (12.6%) were not present in the classroom when the researcher visited. Twenty-nine (5.8%) of the women who were present declined to participate in the study.

Descriptive data
----------------

The final study group consisted of 408 subjects, whose features are reported in [Table 1](#t1-jpr-5-169){ref-type="table"}.

Sixty-five of these 408 subjects (15.9%) reported that they had never experienced menstrual pain, while 343 (84.1%) reported having experienced menstrual pain, either during every period (176/408, 43.1%) or during some periods (167/408, 41%).

Key results
-----------

### Presence/absence of pain

Women with menstrual pain had an earlier menarche (*P* = 0.0002), longer menstrual flow (*P* = 0.006) ([Table 1](#t1-jpr-5-169){ref-type="table"}), were more likely to smoke (*P* = 0.031), and were less likely to use hormonal contraception (*P* = 0.015) ([Table 2](#t2-jpr-5-169){ref-type="table"}). The major features of menstrual pain are reported in [Table 3](#t3-jpr-5-169){ref-type="table"}.

Menstrual pain influenced quality of life and decreased school performance in 164/343 (47.8%) and social functioning in 153/343 (44.6%) women with menstrual pain. Overall, 130/343 (37.9%) women with menstrual pain reported a certain degree of absenteeism during the last menstrual flow.

The association of menstrual pain and the need for medication was reported in 225/408 (55.2%) subjects. The association of menstrual pain and reduction of school and social performance occurred in 164 (40.2%) and 153 (37.5%) subjects, respectively. Menstrual pain was associated with absenteeism in 130 (31.9%) women. Menstrual pain associated with the need for medication and absenteeism was present in 103 (25.3%) women. These prevalences were significantly different (*P* \< 0.0001).

### Pain intensity

Mean pain intensity was 50.2 ± 22.4 mm on a 100 mm VAS scale. Among subjects reporting menstrual pain, pain intensity by VAS was related independently (*r* = 0.302, *P* \< 0.0001) and directly to menstrual flow length (CR = 0.336), history of abortions (CR = 3.640), and gynecological pathologies (CR = 0.948), and inversely related to age at menarche (CR = −0.225), use of hormonal contraception (CR = −0.787), and history of gynecological surgery (CR = −2.115).

When stratified by menstrual pain VAS score, 82/408 (20.1%) women had mild menstrual pain, 192/408 (47.0%) moderate menstrual pain, and 69/408 (17.0%) severe menstrual pain.

In these three categories the need for medication was 37%, 69.3%, and 89.9%, respectively. Similarly, absenteeism was 16%, 58.5%, and 62.3%, respectively. The need for medication plus absenteeism was 8.6%, 29.2%, and 58%, respectively ([Figure 1](#f1-jpr-5-169){ref-type="fig"}).

Stratification by VAS score was not coincident with the figures representing a need for medication and absenteeism. Indeed, only 58% of individuals with severe menstrual pain had a disorder that concomitantly required treatment and impaired quality of life to the point of inducing absenteeism.

Discussion
==========

Key results
-----------

In this survey-based study, the total prevalence of menstrual pain experience was very high with 84.1% of participants reporting pain at some point. Some 43.1% of participants reported having painful menstruation in every menstrual period, and 41% reported pain in some periods. These results are comparable with other data reported in the literature.[@b9-jpr-5-169],[@b25-jpr-5-169]--[@b27-jpr-5-169] It was found that the group of women who suffered from menstrual pain were more likely to smoke and less likely to use hormonal contraception. Those with menstrual pain also tended to have a longer menstrual flow and an early menarche.

The association between smoking and menstrual pain has previously been reported,[@b8-jpr-5-169],[@b13-jpr-5-169]--[@b15-jpr-5-169] and a dose-response relationship has been observed.[@b15-jpr-5-169] The observed association with menarche is controversial, and both an early[@b7-jpr-5-169],[@b8-jpr-5-169] and late[@b4-jpr-5-169]--[@b6-jpr-5-169] menarche have been considered risk factors for menstrual pain in women.

Higher pain intensity is associated with longer menstrual flow, a history of abortions or gynecological pathologies, and not being on hormonal contraception, further supporting the protective role exerted by hormonal contraception on this disease.

In some studies,[@b5-jpr-5-169],[@b7-jpr-5-169],[@b25-jpr-5-169] mild to intermediate menstrual pain has been considered sufficient to define dysmenorrhea. Others have considered dysmenorrhea to be menstrual pain associated with "the need for medication and the inability to function normally."[@b2-jpr-5-169] These two definitions are quite different, and the current study found that the intensity of menstrual pain does not coincide with a need for medication or the inability to function normally. Approximately 55% of the women in the current study reported menstrual pain and a need for medication, with poor social functioning or absenteeism (features of not functioning normally) as a result of menstrual pain ranging from 32% to 40%. When evaluating the most complete picture of dysmenorrhea characterized by menstrual pain, absenteeism, and a need for medication, prevalence is about 25%. How dysmenorrhea is defined will have an impact on figures regarding its prevalence.

Limitations
-----------

There are several limitations to the current research. It was not possible to discriminate between primary and secondary dysmenorrhea, and menstrual pain as a whole was considered. The self-reporting nature of this study may have resulted in recall bias and over-reporting of the condition. Women were randomly selected, but some did not complete the questionnaire. This may have had an impact on the reported prevalence of the disease.

Generalizability
----------------

All participants were university students, and thus the educational level of participants was high. However, the Italian Ministry of University and Research reported in 2010 that 71.5% of individuals in the study region who graduate from secondary school go on to study at university. Accordingly, the data may reasonably be expected to apply to most but perhaps not all women. Finally, this study was conducted in only one university, so the results cannot be extended to other regions of Italy or to other countries. Nevertheless, the collected data provide a clear indication that the prevalence of dysmenorrhea may vary depending on how it is defined. It can be concluded that a more concrete definition of dysmenorrhea should be given in order to obtain reliable and comparable results from independent trials.

The authors thank all the students that participated in this study.

**Disclosure**

The authors report no conflicts of interest in this work.

![Prevalence of disturbances associated with menstrual pain in all women and in women stratified by intensity of menstrual pain as evaluated by a visual analogic scale.](jpr-5-169f1){#f1-jpr-5-169}

###### 

Mean (±SD) characteristics of women stratified by presence of menstrual pain

                        All women (n = 408)   Women with pain (n = 343)   Women without pain (n = 65)
  --------------------- --------------------- --------------------------- ---------------------------------------------------------
  Age                   22.90 ± 3.03          22.89 ± 2.95                22.92 ± 3.44
  Height (m)            1.66 ± 0.06           1.66 ± 0.06                 1.66 ± 0.06
  Weight (kg)           57.88 ± 7.99          57.83 ± 8.02                58.11 ± 7.88
  BMI (kg/m^2^)         20.94 ± 2.77          20.89 ± 2.81                21.17 ± 2.56
  Births (n)            0.03 ± 0.24           0.03 ± 0.25                 0.03 ± 0.17
  Miscarriages (n)      0.01 ± 0.11           0.01 ± 0.09                 0.03 ± 0.17
  Abortions (n)         0.01 ± 0.14           0.02 ± 0.15                 0.00 ± 0.00
  Menarche (years)      12.56 ± 1.32          12.45 ± 1.36                13.13 ± 1.17[\*](#tfn2-jpr-5-169){ref-type="table-fn"}
  Cycle length (days)   28.91 ± 4.12          28.97 ± 4.40                28.62 ± 2.03
  Flow length (days)    4.56 ± 1.19           4.63 ± 1.21                 4.18 ± 1.03[\*\*](#tfn3-jpr-5-169){ref-type="table-fn"}

**Notes:**

*P* = 0.0002;

*P* = 0.006 versus women with pain, by Student's *t*-test.

###### 

Prevalence of familiar, educational, dietary, physical activity, and obstetrical-gynecological features in women stratified by the presence of menstrual pain

                                    Women with pain (n = 343)   Women without pain (n = 65)   *P*-value
  --------------------------------- --------------------------- ----------------------------- -----------
  Stable sentimental relationship   195 (56.85%)                38 (58.46%)                   0.801
  Active smoking                    109 (31.78%)                12 (18.46%)                   0.031
  Physical exercise                 273 (79.59%)                52 (80%)                      0.940
  Coffee consumption                316 (92.13%)                57 (87.69%)                   0.242
  Attitude to have breakfast        317 (92.42%)                60 (92.31%)                   0.975
  Alcohol consumption               275 (80.17%)                52 (80%)                      0.974
  Excessive sugar consumption       72 (20.99%)                 16 (24.61%)                   0.424
  Excessive salt consumption        29 (8.45%)                  6 (9.23%)                     0.837
  Fish consumption                  326 (95.04%)                62 (95.38%)                   0.907
  Gynecological visits              274 (79.88%)                53 (81.54%)                   0.759
  Contraception users               96 (27.99%)                 28 (43.08%)                   0.015
  Regular cycle                     285 (83.09%)                54 (83.08%)                   0.998
  Past gynecological pathology      68 (19.82%)                 10 (15.38%)                   0.461
  Past gynecological surgery        11 (3.21%)                  5 (7.69%)                     0.087

###### 

Major features of menstrual pain

  ---------------------------------------- -------
  Pain onset versus menarche               
   With menarche                           67.4%
   After 6--12 months                      21%
   After 1 year                            11.6%
  Pain onset versus menstrual flow         
   2 days before                           18.7%
   1 day before                            22.2%
   With menstrual flow                     50.7%
   After beginning of menstrual flow       8.4%
  Duration of pain during menstrual flow   
   1 day                                   49.8%
   2 days                                  38.5%
   3 days                                  9.6%
   All flow                                2.1%
  Associated symptoms                      83.7%
   Depression                              36.7%
   Headache                                34.7%
   Acne                                    33.5%
   Nausea/vomiting                         16.8%
   Lack of appetite                        10%
  Use of medicines                         65.6%
  School performance reduced               47.8%
  Social performance reduced               44.6%
  Absenteeism                              37.9%
  ---------------------------------------- -------