Research Article
Self-Care Strategies
From the Chinese University of Hong
Kong, Nethersole School of Nursing,
Hong Kong.
Address correspondence to Cho Lee
Wong, PhD, The Chinese University of
Hong Kong, The Nethersole School of
Nursing, Room 628, Esther Lee
Building, Hong Kong. E-mail:
jojowong@cuhk.edu.hk
Received April 9, 2015;
Revised April 5, 2016;
Accepted April 6, 2016.
This study was supported by the As-
sociation of Hong Kong Nursing
Staff Professional Development
Fund.
1524-9042/$36.00
Ó 2016 by the American Society for
Pain Management Nursing
http://dx.doi.org/10.1016/
j.pmn.2016.04.001
among Chinese
Adolescent Girls with
Dysmenorrhea: A
Qualitative Study
--- Cho Lee Wong, PhD, Wan Yim Ip, PhD,
and Lai Wah Lam, PhD
- ABSTRACT:
Little is known about how Chinese adolescent girls manage
dysmenorrhea. This study aims to explore self-care strategies
among Chinese adolescent girls with dysmenorrhea. The study uses
a mixed methods design with two phases: a cross-sectional survey
in phase I and semistructured interviews in phase II. This paper
reports phase II. In line with the phase I findings, 28 adolescent
girls with different characteristics (high or low levels of self-care
behavior and pain intensity, who did or did not self-medicate, and
who had or had not received menstrual education) were recruited
for interviews. Content analysis was used for data analysis. Four
categories emerged from the data: lifestyle changes, symptom
management, communicating dysmenorrhea with others, and
seeking medical advice. Girls selected their diets carefully and
reduced physical activity during menstruation to avoid aggravating
symptoms. Heat therapy commonly was employed for symptom
management. A few girls self-medicated to obtain immediate relief
from pain, but the majority expressed reservations about using
medication because they worried about dependence and side ef-
fects. Some girls communicated dysmenorrhea with their family
and friends, but the majority did not seek medical advice. The pre-
sent study showed that girls employed various self-care strategies
for dysmenorrhea, including some strategies stemming from tradi-
tional Chinese medicine. The findings revealed menstrual etiquette
among Chinese adolescent girls with dysmenorrhea, and demon-
strated that self-medication was not part of most girls’ self-care.
Understanding the self-care strategies of these girls is important, as
it can help nurses develop a culturally-specific intervention to
promote self-care among adolescent girls with dysmenorrhea.
Ó 2016 by the American Society for Pain Management Nursing
Pain Management Nursing, Vol -, No - (--), 2016: pp 1-10
2 Wong, Ip, and Lam
INTRODUCTION
Dysmenorrhea is a common gynecological problem
among adolescent girls (Lentz, Lobo, Gershenson, &
Katz, 2012), its prevalence varying between 46% and
93% (Chiou & Wang, 2008; Eryilmaz, Ozdemir, &
Pasinlioglu, 2010; Parker, Sneddon, & Arbon, 2009;
Potur, Bilgin, & Komurcu, 2014). Excessive release of
prostaglandins, particularly prostaglandin F2 alpha,
originating in the secretory endometrium of the
menstrual fluid, is believed to cause the condition
(Dmitrovic, Branimir, Cvitkovic-Kuzmic, Strelec, & Ker-
eshi, 2003). According to traditional Chinese medicine,
yin and yang are complementary opposites; qi is
considered the motive force of all life (Maciocia &
Kaptchuk, 1998). The uterus is conceptualized as an
‘‘extraordinary’’ yang organ connected to the heart
and kidneys, and blood in the liver supplies blood to
the uterus. Kidney deficiency, liver–blood deficiency,
and ‘‘liver-qi’’ stagnation are considered major etiolog-
ical factors in the development of dysmenorrhea
because they cause blood to stagnate in the uterus,
thus leading to pain (Maciocia & Kaptchuk, 1998).
Dysmenorrhea not only affects the academic per-
formance, social life, and sports activity of adolescent
girls (Agarwal & Venkat, 2009; Seven, G€ uvenç, Aky€ uz,
& Eski, 2014), but also leads to a significantly lower
quality of life in the domains of general health and
social functioning than that enjoyed by others (Yang
& To, 2006). Despite the detrimental effects of dysmen-
orrhea, studies have found that adolescent girls seldom
seek help, preferring to rely on self-care to relieve their
symptoms (Banikarim, Chacko, & Kelder, 2000;
Eryilmaz & Ozdemir, 2009; Wong, Ip, Choi, & Shiu,
2013; Wong, Ip, Choi, & Lam, 2015; Wu, Gamble, &
Moyle, 2009).
Self-care is defined as practicing activities that indi-
viduals initiate and perform on their own behalf in main-
taining life, health, and well-being (Orem, 2001). Studies
consistently report that a moderate to large proportion
of Western adolescent girls self-medicate with non-
steroidal anti-inflammatory drugs (NSAIDs) and acet-
aminophen for dysmenorrhea (Agarwal & Venkat,
2009; Campbell & McGrath, 1997; O’Connell, Davis,
& Westhoff, 2006; Parker et al., 2009). Apart from
pharmacological strategies, heating pads, warm
beverages, sleep, massage, and keeping warm are
commonly reported means of relief (Campbell &
McGrath, 1999; Eryilmaz & Ozdemir, 2009; Hillen,
Grbacac, Johnston, Straton, & Keogh, 1999). Self-care
strategies uncommon in the West, such as simply
enduring the discomfort, eating chocolate or sweet
food or avoiding iced drinks, were reported in 557
Taiwanese nursing students, suggesting cross-cultural
differences in dysmenorrhea self-care (Chiou & Wang,
2008). However, studies on such self-care have been
largely quantitative—only one qualitative study was
found describing it in adolescent girls. Chen, Lin,
Heitkemper, and Wu (2006) brought together four focus
groups from among 23 Taiwanese nursing students aged
16 to 19 to explore their experiences of self-care for
dysmenorrhea. Seven themes emerged: reducing phys-
ical activity, modifying diet, using herbal remedies or
medication, applying complementary therapies, paying
attention to symptom clusters of discomfort, and ex-
pressing emotions. In addition, some culturally specific
self-care strategies, such as avoiding ‘ cold’’ food, drink-
ing brown sugar tea, and applying acupressure were re-
ported. Participants in this study were recruited from a
medical university and might therefore already have had
some knowledge of how to handle dysmenorrhea. In
addition, it was doubtful whether these findings could
be applied to Hong Kong adolescent girls because of
the socio-cultural differences between Taiwan and
Hong Kong. The aim of the present study was therefore
to explore the self-care strategies among Hong Kong
Chinese adolescent girls with dysmenorrhea.
METHODS
The study was of the sequential explanatory mixed-
method type, with two phases—a cross-sectional sur-
vey in phase I and semistructured interviews in phase
II. The purpose of phase I was to examine self-care stra-
tegies and their associated factors among adolescents
with dysmenorrhea. Phase II aimed to explore these
strategies in detail. The phase I findings have been re-
ported elsewhere (Wong, Ip, Choi, & Lam, 2015);
this paper presents phase II.
Girls age 13 and older who had experienced pain
during the last three cycles were selected from those
completing phase I. The selection criteria were based
on the path analysis results obtained, which allowed
those with different characteristics to share their self-
care strategies. In particular, those who had high or
low levels of self-care and pain intensity, whether or
not they had self-medicated or received menstrual ed-
ucation, were considered for recruitment. The initial
estimate of sample size was 30, and data collection
would continue until the stage at which no new infor-
mation could be generated (Morse, 2000).
PROCEDURE
Ethical approval was obtained from the study institu-
tion. Once potential participants were identified,
they were contacted through phone numbers they
 Dysmenorrhea in Adolescents
had provided in the phase I questionnaire. Semistruc-
tured face-to-face interviews were arranged at times
convenient for those who agreed to participate. Before
the interview, participants were given information
about the study and assured that their participation
was voluntary and that their right to withdraw at any
time would be upheld. They also were assured of the
confidentiality of all information collected. After
informed consent was obtained, interviews were con-
ducted, following an interview guide, by one of the
research team members. The interview captured the
adolescents’ experience of dysmenorrhea, with a
particular focus on their self-care. It began with a gen-
eral question, ‘‘Can you tell me about your periods?’’,
followed by other questions such as ‘‘Can you tell me
about how you manage dysmenorrhea?’’ Probing ques-
tions were used to gain a fuller understanding of the
data generated during the interview. Privacy was
assured to allow participants to talk freely about the
dysmenorrhea and self-care experience without
disruption (Berg, 2009). All the interviews were tape-
recorded, and lasted from 28 to 40 minutes.
DATA MANAGEMENT
All the interviews were conducted in Cantonese, the
native language of both researchers and participants.
After the interview, the tape was transcribed verbatim
to maintain consistency of meaning (Twinn, 1997).
Content analysis was employed to deal with the inter-
view data (http://www.sciencedirect.com/science/
article/pii/S0020748905001604Morse & Field, 1995).
Initial major coding was developed by grouping the re-
sponses according to the questions. Several important
topics then were identified as primary categories, each
of which was given a content-characteristic name
(Krippendorff, 2004). These categories were initially
broad so that a large amount of data might be sorted
into a few groups. Once the categories had ample
data, they were broken down into subcategories.
Content analysis was carried out using the re-
searcher’s first language to ensure the accuracy of data
interpretation (Twinn, 1997). Appropriate strategies
were undertaken to ensure the trustworthiness of the
study, including credibility, dependability, confirm-
ability, and transferability (Lincoln & Guba, 1985). Cred-
ibility was ensured by peer debriefing during the data
analysis process to prevent idiosyncratic interpretation
of data. Dependability also was ensured, as interviews
were conducted by a single researcher to maintain con-
sistency in data collection. All the interview transcripts
were checked for accuracy to ensure a complete ac-
count of each participant’s responses. For confirm-
ability, the researcher critically examined her own
3
assumptions and actions by being self-aware about the
research process, bracketing her preconceived ideas
and experience. An audit trail was established to ensure
an accurate record of all the decisions and processes un-
dertaken during the study. To facilitate transferability,
thick description was provided of the study context, se-
lection, and characteristics of the participants, data
collection, and process of analysis, to help readers
decide on the transferability of the findings to other
similar situations (Guba & Lincoln, 1994).
FINDINGS
Participants’ Characteristics
Individual qualitative interviews were conducted to
explore the girls’ self-care strategies regarding dysmen-
orrhea. Data collection and analysis were conducted
concurrently. After interviewing 28 girls, it was found
that no new information emerged and there was data
redundancy. The mean age of the participants was
15.25 years (SD 1.53). The mean pain intensity was
5.70 (SD 2.34) as measured on a 10-point visual
analogue scale. A brief overview of participant charac-
teristics is presented in Table 1. Four categories were es-
tablished: lifestyle changes, symptom management,
communicating dysmenorrhea with others, and seeking
medical advice (Table 2).
Lifestyle Changes
Careful Selection of Diet. All the girls often spoke of
carefully selecting certain kinds of foods and drinks to
control dysmenorrhea. A majority (n ¼ 26) reported
that they would avoid cold foods and drinks such as
ice cream or soft drinks during menstruation, believing
that cold foods would induce uterine contractions and
thus result in heavy menstrual flows, prolonged pe-
riods, and worsened pain.
28P178: ‘‘I like cold drinks very much. During hot
weather, they are really irresistible. I used to ignore the
consequences and drink them during my period, but
that resulted in severe pain. I will try to control myself
and avoid drinking cold beverages.’’
Apart from cold foods and drinks, girls said they
would avoid liang food. In traditional Chinese medi-
cine, women having menstrual symptoms should avoid
yin food to achieve a state of harmony in the body, and
liang is another Cantonese term to describe food that
is yin in nature. Many girls (n ¼ 22) said that they
would avoid watermelon, 24-herb tea, self-heal spike,
or tortoise jelly during their periods. They would eat
tortoise jelly when suffering from internal heat but
would avoid it during periods because it was too liang
for the body. Many girls said they experienced an im-
mediate increase of pain and blood loss after eating
4 Wong, Ip, and Lam

(n ¼ 22) said they would intentionally drink more

TABLE 1. warm beverages, such as warm water, during their pe-
A Brief Overview of the Characteristics of the riods. They explained that they would feel more
Participants comfortable afterwards, and some felt that it was
good for their general health. Girls also often described
Pain Received
Intensity Self- Menstrual drinking red date water, red sugar ginger water, luo-
Code Age (VAS) medication Education han guo water, wolfberry water, black hen soup, or an-
gelica soup, saying that such food and drink could
1 14 2.9 No Yes ‘‘enrich the blood’’ and replenish blood loss during
2 15 8 No Yes
menstruation. The girls also mentioned specific regi-
3 17 10 No No
4 14 1.1 Yes Yes mens concerning these foods or drinks, such as not
5 14 1.0 Yes Yes taking them either near or during the period. Instead,
6 14 4.9 No No they said that they should be consumed after their pe-
7 14 5.2 No Yes riods because they could enhance qi circulation,
8 14 9.0 No No
which in turn could help to alleviate the pain of the
9 16 4.6 No No
10 15 3.5 Yes No next period. Several girls (n ¼ 7) distinguished these
11 19 7.1 No No foods or drinks from Chinese herbal remedies or med-
12 13 5.5 No No icine by explaining that the latter required a Chinese
13 14 7.1 No Yes medicine practitioner’s prescription, whereas the
14 16 4.7 No No
former were commonly available ordinary foods that
15 17 7.9 No No
16 15 10.0 No No would not cause harm to their bodies, and they were
17 15 4.5 No No therefore willing to try them.
18 18 3.9 No No 11P192: ‘‘Red date soup should not be taken
19 15 5.7 No Yes before menstruation as it is used to enrich the blood
20 14 4.3 No Yes
and restore what you may have lost from your period.
21 15 6.5 No No
22 15 6.6 No Yes If you drink before or during your period, you will suf-
23 15 4.5 No No fer from heavy flow and increased pain.’’
24 15 6.6 Yes Yes Reduced Physical Activity. Reducing physical activ-
25 13 5.0 No Yes ity also was frequently employed by the girls. Some
26 18 4.4 No Yes
(n ¼ 17) indicated that they would avoid physical exer-
27 16 9.4 No Yes
28 17 5.8 No No cise such as riding a bicycle or running during dysmen-
orrhea. They said that exercise not only increased the
severity of pain but also enhanced blood and qi circu-
liang food during menstruation. A few (n ¼ 6) said that lation, resulting in a heavier flow. Several girls (n ¼ 9)
even if they had eaten liang food before the menstrual preferred simply going to sleep when they suffered
cycle began they would still experience severe pain from dysmenorrhea: As they explained, when they
during the period itself. were awake, they felt the pain but could do nothing
Apart from certain restrictions, some foods and about it, and so would just force themselves to go to
drinks were particularly preferred by the girls. Many sleep, to let their bodies rest, usually around half an
hour. After that, they usually would resume their activ-
ity but at a slower pace. In situations where going to
TABLE 2.
sleep was impossible, such as lessons or important
Summary of Categories and Subcategories meetings, they would just sit quietly and remain inac-
Derived from the Interview Data tive. Some girls (n ¼ 5) said that they could not ‘‘sit
Categories Subcategories straight’’ but had to lie on the table or curl their bodies
up. As for the effectiveness of taking a rest, some felt ‘‘it
Lifestyle changes Careful selection of diet didn’t help much.’’ However, when asked why they still
Reduction of physical activity did that, they said it was better than doing nothing.
Symptom management Heat therapy
Self-medication
Communicating Family Symptom Management
dysmenorrhea Friends Heat Therapy. The most common strategy that girls
with others used for managing the symptoms of dysmenorrhea was
Seeking medical advice Western medical practitioner heat therapy. Eighteen girls tried to relieve their pain
Chinese medicine practitioner
by applying hot pads, hot towels, or hot water bottles
 Dysmenorrhea in Adolescents
over their abdomens. A few (n ¼ 7) mentioned they
would have a hot shower, explaining that the warm
sensation could help distract them from pain and
make them feel better, thus providing immediate relief
of pain. However, they commented that heat therapy
only provided short-term relief and that the symptoms
would come back after a short time. They also
mentioned that they usually applied hot pads at
home and seldom used them at school because they
felt embarrassed when doing so at school, especially
if a male classmate sat nearby. When asked about
how they applied heat therapy, how hot the water
was, and how long the application lasted, most girls
said they did not keep to a standard regimen.
19P63: ‘‘I usually apply hot pads. They are quite
comforting, and when I apply them I feel a warm sensa-
tion that helps distract me from pain.’’
Self-medication. Among the 28 girls being inter-
viewed, four mentioned that they were currently self-
medicating with Western medicine, all of them using
acetaminophen, the only drug that they could name
for the relief of dysmenorrhea. The girls reported
that they self-medicated because they sought quick re-
lief from symptoms so they could return to school and
resume daily activity. When asked who had suggested
the use of acetaminophen, they said it was their
mother, teacher, or schoolmates. However, they would
not use acetaminophen regularly for every cycle and
only took it when the pain was unbearable.
By contrast, the remainder did not use self-
medication and said they would avoid taking medica-
tion for their problems. Most (n ¼ 19) worried about
the long-term consequences of using medication, such
as dependence or their bodies adapting to it. They
believed dysmenorrhea was a cyclical problem, and
that they needed to take the medication every month.
As a result, they worried about having to depend on
medication for their problem and needing to take it
for every period. For example, one girl said that, if she
used acetaminophen, in the long run her body would
adapt to it and its effectiveness would gradually taper
off. Then she would need either to increase the dosage
or to change to another type of medication. Though she
had no certain knowledge about medication, she would
not take the risk of using it for dysmenorrhea.
17P113: ‘ I feel that taking acetaminophen is not
good; I will not rely on these chemicals to help. If my
body adapts to it (acetaminophen), it will have no effect
on me later and I would probably need to change to
another type of medication. Yet I cannot find another
medication particularly indicated for dysmenorrhea, so
I will not take the risk of using it now.’’
In addition, many girls (n ¼ 14) believed that
medication should be taken as rarely as possible
5
because of its side effects. The notion that medication,
especially Western, had many side effects was quite
firmly fixed. However, when asked about what kinds
of side effects these were, most girls were uncertain
and just said that they were not good for the health.
Apart from that, several girls thought that medication
should only be used with a doctor’s prescription.
14C104: ‘‘I will not go and buy analgesics by
myself; I think they should not be used without a doc-
tor’s prescription.’’
Communicating Dysmenorrhea with Others
Family. Fifteen girls talked about dysmenorrhea with
their families, especially their mothers. However, they
did not seek advice from the family and said that they
would not tell their mothers directly about dysmenor-
rhea because of embarrassment. The girls said they had
been more inclined to communicate with or seek
advice from their mothers when they were younger.
Some also spoke about how their mothers helped
and advised them when they first experienced
menstruation. However, now that they were older,
they felt uneasy about telling their mothers directly.
Instead, they would often resort to nonverbal clues,
such as body position or facial expression to convey
their suffering to their mothers. Usually, when the
mothers noticed, they would ask their daughters ques-
tions like ‘‘Are you okay?’’ or ‘‘Do you feel any pain?’’
Mothers also told them to ‘‘sit down and have a rest’’
or suggested they avoid having liang drinks. Two girls
described how they were relieved of household chores
when their mother and sisters saw that they were
suffering from dysmenorrhea. One girl said her mother
prepared red date soup for her when she looked pale.
7P56: ‘‘If my mum noticed that I felt pain and
discomfort, she would go to the kitchen and prepare
a hot pad for me. She suggested I didn’t go out, but
had more rest instead. She also kept me from doing
any housework. She takes care of me and supports me.’’
A few girls admitted that they gradually became
lazy and relied on their mothers’ help to manage
dysmenorrhea. The girls knew that their mothers
would help them eventually so they waited for their
mothers to prepare things for them.
Friends. All the girls gathered information about
managing dysmenorrhea by means of informal discus-
sions with their female friends. However, they only
shared such information when no male friends were
present. One girl described how her friend took her
to the toilet and gave her a hot pad. Others described
how their friends provided advice or kept them from
doing things that were not good or helpful.
22P46: ‘‘My friends suggested that I avoid cold
drinks and herbal teas. Sometimes, if my friend
6 Wong, Ip, and Lam
discovered I had ordered a cold drink, she would stop
me and say ‘I don’t allow this’, and tell me to have a hot
drink instead.’’
The girls admitted that they did not get many sug-
gestions from friends, and that they often took friends’
advice selectively. For instance, the girls would follow
their friends’ advice to avoid herbal teas or cold drinks
during their periods, but for other things, such as
eating dark chocolate or drinking warm Pokari, they
expressed reservations and doubted the effectiveness
of such methods.
Seeking Medical Advice
Western Medical Practitioners. Only four girls
sought advice from Western medical practitioners.
The reason they did so was that they were not being
offered much help elsewhere, or they wanted quick re-
lief from dysmenorrhea by taking medication pre-
scribed by a doctor. The most common medication
prescribed was acetaminophen. Four girls reported
they had consulted Western medical practitioners
before but said would not seek medical advice for
dysmenorrhea any more. Two girls said they expected
to have a detailed examination and diagnosis instead of
only being prescribed medication. Others reported
that doctors had not taken their symptoms seriously
and trivialized their complaints by suggesting that
pain during menstrual periods was normal.
5P58: ‘‘I explained my problem to the doctor, and
he said every girl was different and there was no way to
cure dysmenorrhea. He only told me to keep myself
relaxed.’’
Other girls in this study chose not to seek Western
practitioners’ advice for dysmenorrhea because they
thought that it would be a waste of money, explaining
that their pain was not severe enough to see the doctor.
Girls regarded medical consultation as a step to be taken
reluctantly. Three girls said that only if the pain was se-
vere, to the degree that it made them ‘ close to fainting,’
did they consider a medical consultation. In addition to
this, the impression that a great many girls experienced
pain and therefore such pain was normal made it diffi-
cult for girls to question the importance of their own
pain and thus of seeking medical advice.
20P104: ‘‘I haven’t seen a Western practitioner for
my problem because it is not so severe that I can’t
move at all. Besides, all my classmates have the same
problem, so I think it is not a big deal, and that’s why
I haven’t seen a doctor for it.’’
Chinese Medicine Practitioners. Instead, girls said
they had more confidence in Chinese practitioners and
would choose to seek advice from them. According to
the girls, Western medicine was intended to treat the
symptoms and cure disease. They would consult
Western doctors if they cut their fingers or needed to
take medication for flu. However, Chinese medicine at-
tempts to treat the origin of the problem and could
help to adjust the physical condition of the body,
which in turn would help to relieve dysmenorrhea.
Moreover, they believed that Chinese medicine had a
long history and accumulated a great amount of expe-
rience. Thus, they preferred to seek out Chinese med-
ical practitioners for help.
14P84: ‘‘I prefer to consult a Chinese practitioner
for dysmenorrhea. It seems to me that Chinese medi-
cine treats the origin of the problem, helps to adjust
the physical condition of the body and in turn relieves
dysmenorrhea. but Western medicine only treats the
symptoms.’’
Despite all this, the girls did not actually know
what their Chinese practitioner prescribed for them.
They said they only received several packs of herbs,
but they could neither name the content nor identify
the actual therapeutic effect. A few even mentioned
that they gave up taking the herbs after one to two
times because of their bitter taste.
DISCUSSION
Self-Care Strategies among Adolescent Girls
with Dysmenorrhea
The findings suggested that traditional Chinese medicine
was widely trusted by adolescent girls, and also shaped
how they coped and practiced dysmenorrhea self-care
(Liu, Chen, & Peng, 2012). The self-care strategies of
the girls in this study included modifying their diet,
reducing physical activity, applying heat therapy, and
communicating dysmenorrhea with family and friends,
some of which methods are reported infrequently by
non-Chinese populations (Campbell & McGrath, 1999;
Eryilmaz & Ozdemir, 2009; Hillen et al., 1999).
Many girls observed cultural beliefs about diet in
managing dysmenorrhea and presented with different
dietary preferences and restrictions. Traditional Chinese
dietary items, such as red date water, red sugar ginger
water, Siraitia grosvenorii water, wolfberry water, or
black hen soup, were consumed commonly by girls af-
ter menstruation. This finding was consistent with that
of Chen et al. (2013), who found that Taiwanese girls
preferred traditional Chinese dietary items, such as
brown sugar tea, to prevent or alleviate dysmenorrhea.
However, these items have received less attention
in Western countries (Banikarim et al., 2000;
Campbell & McGrath, 1999; Hillen et al., 1999). A
possible reason could be Hong Kong girls’ belief in
the efficacy of traditional Chinese recipes for relieving
dysmenorrhea. For instance, they believed that these
foods not only ‘‘enhanced qi circulation’’ but also
 Dysmenorrhea in Adolescents
‘‘enriched the blood,’ and thus helped to relieve the
condition. Nevertheless, unlike girls in a Taiwanese
qualitative study who were reported to consume
Chinese herbal remedies such as Zhongjiang herbal
soup and Xiaoyao powder for dysmenorrhea (Chen
et al., 2006), the girls in this study did not mention using
such herbal remedies, although it is noteworthy that
they believed herbal remedies should only be pre-
scribed by a Chinese medicine practitioner. They would
not buy or consume herbal remedies without a consul-
tation. But they thought dietary items such as red date
water or black hen soup were commonly available
foods that would not harm their bodies, so that they
were more willing to use them for managing dysmenor-
rhea. Nevertheless, the findings enlarge understanding
that self-care strategies among adolescent girls differ
across Chinese populations.
Also, many girls avoided cold foods and drinks, such
as ice cream or soft drinks, during menstruation, a
finding that echoes two Taiwanese studies, Chiou and
Wang (2008) and Chen et al. (2006). Apart from cold
food, girls in this study also said that they avoided liang
food, such as 24-herb tea, self-heal spike, or tortoise jelly,
during menstruation. According to traditional Chinese
medicine, both cold and liang foods may cause qi stag-
nation, thus prolonging menstruation, inducing heavy
flow, and worsening the pain. Similarly, these methods
of self-care are culture specific and seldom reported in
Western studies, further indicating that self-care for
dysmenorrhea should be studied in a cultural context.
Girls avoided physical exercise, such as riding bi-
cycles or running, and preferred to sleep or rest
when suffering from dysmenorrhea. They thought ex-
ercise during menstruation would increase the blood
and qi circulation, resulting in more pain and a heavier
flow. This finding corresponded with that of Tang et al.
(2003), who reported that Chinese women experi-
encing menstrual discomfort usually rested to restore
their qi. This result was contrary to that of O’Connell
et al. (2006), who revealed that girls not only rested
but also exercised to manage dysmenorrhea. However,
the girls in this study did not mention exercising either
during or after menstruation. An earlier study reported
physical activity was inversely associated with the pain
severity and duration of dysmenorrhea (Tavallaee,
Joffres, Corber, Bayanzadeh, & Rad, 2011), but others
did not find any such association (Harlow & Park,
1996). Although some maintain that girls performing
physical activities are likely to experience less pain
because such activities reduce the level of prosta-
glandin (Martinez et al., 1999), the argument needs
more solid evidence to support it.
It was found that girls drank more warm water;
applied hot pads, hot towels, or hot water bottles on
7
their abdomen; and took hot showers as ways of manag-
ing dysmenorrhea. The finding reinforced previous
studies that reported heat therapy as the prevalent
self-care strategy among participants (Chiou & Wang,
2008; Eryilmaz & Ozdemir, 2009). It also was
perceived as an effective method of relieving
dysmenorrheal pain in Wu et al. (2009). Heat therapy
for dysmenorrhea also was supported by Akin et al.
(2001), with participants reporting that the warm sensa-
tion from heat therapy distracted them from pain. How-
ever, they also said that such therapy only provided
short-term relief, although this might be attributed to
their lack of proper technique in applying the heat.
Nevertheless, there is clearly a need to educate girls in
proper self-care technique in this respect.
Menstrual Etiquette among Adolescent Girls
with Dysmenorrhea
It was interesting to note that girls tried to obtain assis-
tance by simply communicating dysmenorrhea with
others, instead of seeking advice from them. Fewer
than half the girls communicated the condition with
their mothers directly. Similar to the findings of Tang
et al. (2003), girls usually relied on their mothers to
handle menstruation when they were young, but
when they grew older they were reluctant to talk
such experiences over with their mothers because of
embarrassment.
Girls used nonverbal clues such as body position
or facial expression to communicate with their
mothers indirectly that they were suffering pain, antic-
ipating that their mothers would help them subse-
quently. In fact, what their mothers did was what
they expected: provided immediate verbal or action
support when seeing they were in pain. This kind of
‘‘menstrual etiquette’’ in communicating on the subject
was specifically found in the Hong Kong context. Seear
(2009) showed that women with endometriosis prac-
ticed menstrual etiquette to conceal their symptoms,
while others described such etiquette as simply avoid-
ing discussion of their heavy menstrual flow with
others (Santer, Wyke, & Warner, 2008). The menstrual
etiquette revealed in this study referred to adolescent
girls not seeking advice from others directly but
communicating in an alternative way. Such behavior
might partly be attributed to girls wanting to display
their autonomy and independence regarding manage-
ment of their own issues (Pasley & Gecas, 1984), and
partly to their desire for support and attention. In
fact, Chinese people tend to be more conservative
and less willing to express their feelings openly
(Wong et al., 2013). However, such acts are likely to
be influenced and reinforced by the parenting style
of Hong Kong’s mothers. In Chinese culture, mothers
8 Wong, Ip, and Lam
have taken on the role of bearing all the responsibility
for their children and dealing with every aspect of their
care (Park & Chesla, 2007). In view of this, daughters
who suffered from dysmenorrhea would be met with
constant concern from their mothers. Nevertheless,
this kind of communication about dysmenorrhea
only applied to female family members. This finding
was supported by those of Tang et al. (2003), who sug-
gested that menstruation was still an inherently embar-
rassing or taboo subject in Hong Kong.
Girls described how, when suffering from dysmen-
orrhea at school, they would just lie on a table without
asking the teacher, suggesting that they did not consider
a teacher to be an important source of information
about dysmenorrhea. This was possibly because the
girls had seldom heard school teachers mentioning
menstruation-related issues, and were consequently
reluctant to seek their advice. Nevertheless, the girls’
behavior further revealed the etiquette of talking about
dysmenorrhea with others. Lying on a table seemed to
communicate a message to others that they were
suffering from menstrual discomfort, but their teachers
and classmates already knew what had happened and
allowed the practice, such behavior of course being
forbidden in normal circumstances. This further indi-
cates that girls regard dysmenorrhea as secret and em-
barrassing so that they will not mention it directly, but
employ other means to communicate their feelings of
pain by making them clear to others to raise their aware-
ness and in turn receive their support.
Similar to previous studies (Kumar & Srivastava,
2011), the girls primarily drew on information from
their friends to learn about dysmenorrhea, by informal
discussion. Contrary to Wong et al. (2013), who
showed that Hong Kong female undergraduates were
rather open-minded and would not keep menstruation
secret, secondary school girls in this study often spoke
of exchanging information and self-care strategies clan-
destinely. They were not given many suggestions by
friends, and even doubted the effectiveness of those
they did receive, such as drinking warm Pokari or
eating dark chocolate. Taken together, the reluctance
of girls to seek advice but seeking information infor-
mally suggested that girls in this study might have
had incomplete knowledge of dysmenorrhea and
consequently suffered unnecessary pain. The obvious
solution to this would be to encourage them to discuss
dysmenorrhea more openly, so that they could benefit
from additional information about self-care.
Self-Medication–Not Part of Self-Care among
Adolescent Girls
The findings revealed that self-medication was not
considered as part of self-care among Chinese
adolescent girls with dysmenorrhea, contrary to
what has been proposed by the World Health Organi-
zation (WHO, 2013) and the findings of other studies
(Campbell & McGrath, 1997; O’Connell et al.,
2006; Potur et al., 2014). According to the WHO,
self-medication should be part of self-care, and is
defined as the selection and use of medicines by indi-
viduals to treat self-recognized or self-diagnosed condi-
tions or symptoms (WHO, 2013). Although current
understanding of the pathophysiology of primary
dysmenorrhea indicates that the excessive release of
prostaglandins reduces uterine blood flow and causes
pain (Dmitrovic et al., 2003), while NSAIDs and oral
contraceptive pills (OCPs) are considered to be effec-
tive treatments for dysmenorrhea because they reduce
prostaglandin formation (Zahradnik, Hanjalic-Beck, &
Groth, 2010), a majority of girls in this study did not
self-medicate, as a previous local study had also found
(Wong, Ip, & Shiu, 2012). According to the girls, tak-
ing medication was a kind of medically oriented
behavior that required a doctor’s prescription or
advice and should not be self-initiated. Without a pre-
scription, they would not take medication or buy any
from a pharmacy. Interpreting a prescription as a ne-
cessity for medication explained why self-medication
was not relevant to the self-care construct of adoles-
cent girls with dysmenorrhea in a previous study
(Wong, Ip, Choi, & Shiu, 2013). In fact, many girls
had misconceptions about self-medication, and were
worried about drug dependence and side effects
(Wong & Ip, 2012). They thought that if they self-
medicated for dysmenorrhea, their bodies would
come to rely on medication for pain relief. Other girls
worried about the side effects of medication even
though they could not name any such effects. Taken
together, these worries further contributed to why
girls were reluctant to employ self-medication and
did not regard it as an appropriate form of self-care
for dysmenorrhea. These findings highlighted the
importance of improving understanding of self-
medication among Hong Kong adolescent girls. More-
over, they also shed light on the need to develop
appropriate educational interventions concerned
with the correct self-administration of medication.
The findings of this study should be interpreted
in the light of the following limitations. First, all the
interviews were conducted in Chinese with partici-
pants’ specific responses translated into English,
and the possibility of subtle changes in meaning
cannot be excluded. Second, as participants were
interviewed only once, further longitudinal study
is needed to expand our understanding of changes
in their self-care strategies for dysmenorrhea over
time.
 Dysmenorrhea in Adolescents
Implications for Nursing Research, Practice,
and Education
The findings of this study reveal a need to implement
a culturally specific educational intervention that en-
sures safe and appropriate dysmenorrhea self-care
for adolescent girls. As self-care is partly influenced
by traditional Chinese beliefs in this case, culture-
specific strategies, such as the use of Chinese
recipes, should be introduced, and knowledge of
self-medication promoted. Self-medication was not
commonly employed in our sample, probably
because the girls perceived it as involving prescrip-
tion drugs and associated it with side effects. Lack
of knowledge about medication might also be a
contributing factor, and information on how to select
the most appropriate analgesic, based on established
evidence, should be provided, as well as the best
times to start and continue taking it. Information
should likewise include the necessity of taking the
medication on a regular basis, in the recommended
therapeutic dose, and in accordance with instruc-
tions. As there is some evidence that exercise might
reduce the symptoms associated with dysmenorrhea
(Brown & Brown, 2010), the health benefits of exer-
cise should be discussed with girls experiencing
dysmenorrhea. Finally, because mothers played an
influential role in assisting adolescent girls with man-
aging dysmenorrhea, the importance was highlighted
of involving mothers in the educational intervention
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