Supporting young women with menstrual pain – Experiences of midwives working at youth clinics

Background: Menstrual pain is relatively common among young girls. Many girls turn to youth clinics when seeking care for menstrual problems. Objective: The objective of the study was to describe midwives ’ experiences of supporting girls with menstrual pain. Methods: This is a qualitative study with an inductive approach. Semi-structured interviews were conducted with 15 midwives working at Swedish youth clinics. Interviews were held in September 2021. The recordings were transcribed and analyzed using thematic analysis. Results: Two main themes, consisting of three subthemes each, emerged: Guiding and educating young women about menstrual pain and Striving toward pain relief. It was important to the midwives to increase young women ’ s knowledge of menstrual pain and coping strategies, and to guide them in finding a method for menstrual pain relief. Hormonal contraceptives were often a natural choice and an effective method for pain relief, although the midwives occasionally faced resistance from young women or their mothers when recommending this. The midwives also referred to a gynecologist if needed. Conclusion: The results highlight that midwives working at youth clinics have an important role in the care of young women with menstrual pain. The midwives found it important to increase young women ’ s knowledge about menstrual pain and coping strategies, since they had noticed knowledge gaps in these areas. The results suggest a need to improve education about menstrual pain and coping strategies for young women, preferably in school and in cooperation with healthcare professionals.


Introduction
Menstruation is a natural part of life for women of fertile age: a unique and complex experience including both positive and negative aspects [1].Around 30 % of young women (i.e., women aged 12-25) report having severe menstrual pain [2][3][4], which is often associated with symptoms like back pain, nausea, fatigue, headache, and diarrhea [2,3,5].For many young women the pain interferes with their daily life and hobbies, and leads to school absence.Those with severe pain report the highest interference with daily life [3,6].
Young women with menstrual pain use different coping strategies to manage the pain.Many use self-care strategies [7], defined as both nonpharmacological, such as rest, local heat, and exercise, and pharmacological strategies such as non-prescription analgesics.Nonsteroidal anti-inflammatory drugs (NSAID) and paracetamol are used by a majority of young women with menstrual pain [7,8].
Menstrual pain is also known as dysmenorrhea, which can be divided into a primary and secondary type.Most adolescents with menstrual pain have primary dysmenorrhea, without a pathological cause, in contrast to secondary dysmenorrhea, which may be caused by endometriosis, myoma or infections.The recommended basic pharmacological treatment for both primary and secondary dysmenorrhea is NSAID and hormonal contraceptives, which this is often efficient for adolescents with menstrual pain.However, should these treatments fail to relieve the pain, or if the young woman experiences symptoms that indicate pathology, the adolescent should be further evaluated [9].
Severe menstrual pain is the cardinal symptom of endometriosis, a chronic gynecological disease that can cause much suffering.The disease often has physical, psychological and social consequences [10,11].The prevalence of endometriosis is estimated to be around 10 % [12,13].The disease often debuts during adolescence [6] and about two thirds of women with endometriosis experience their first symptoms when they are younger than 20 years old [5].Many women with endometriosis face difficulties when meeting healthcare professionals (HCPs), and getting the correct diagnosis and treatment often takes a long time [11,14,15].In the Swedish National Guidelines of Endometriosis [16] it is recommended that HCPs, especially the ones who meet young women and women with suspected or confirmed endometriosis, should increase their knowledge about endometriosis to be able to detect anamnestic signs and symptoms of the disease, preferably by continuing education in this area to stay updated.This is also important to avoid normalization of the symptoms and to enable treatment at an early stage.It is likely that a delayed diagnostic process and treatment impairs quality of life and increases the risk of developing sub-or infertility and chronic pain [12,16].
Young women with menstrual pain primarily visit school nurses and midwives at youth clinics for menstruation-related problems [2,17], and therefore these HCPs have a significant role in supporting and relieving menstrual pain, and in finding women with symptoms that may be caused by endometriosis [16][17][18].However, the experiences of HCPs meeting young women with menstrual pain represent a limited research area.It has been stated that it is important for HCPs to be perceptive and acknowledge these women, but also that meeting them can be challenging.An aspect of this challenge is that there is no clear definition of abnormal menstrual pain [18].
A deeper knowledge about midwives' experiences of supporting, meeting and talking to these young women about menstrual pain could be helpful in the work on improving the care and treatment of young women with menstrual pain but it could also help shorten the diagnostic process related to endometriosis.
The purpose of this study was to describe midwives' experiences of supporting girls with menstrual pain.

Design
This was a qualitative inductive study with semi-structured interviews with midwives working at youth clinics in Sweden.

Study context
The Swedish youth clinics are focused on reproductive, sexual and psychosocial health.They, aim to promote health and to be easily accessible primary care facilities for young people.Midwives working at youth clinics meet young people, primarily between 12 and 25 years old.They also work with groups of young people, for example school classes, in the purpose of health prevention and promotion of sexual and reproductive health.The midwives prescribe contraceptives, provided that the purpose is to prevent pregnancy and the patient is healthy.Gynecologists have the medical responsibility for diagnosing and treating diseases at youth clinics, but midwives are the ones encountering the larger amount of adolescents [19].

Participants and sampling
The inclusion criteria to participate were being a midwife who had been working at a youth clinic for three months or longer.The participants were recruited via two different sampling strategies.First, approval was obtained from the heads of eight youth clinics in the southeast healthcare region of Sweden.The names and e-mail addresses of all the midwives working at the clinics were found via the region's internal contact list.The third author sent e-mails to the 17 midwives working at the youth clinics, informing them about the study and asking them to participate.Thirteen midwives wanted to participate, and they gave their written consent by answering the e-mail.Thereafter, dates and times for the interviews were agreed.
To reach participants from other parts of Sweden, the study was advertised in a magazine for midwives and in two Facebook groups targeting midwives.Interested midwives were asked to send their contact information to the third author by e-mail, who sent them written information about the study.Two midwives answered the advertisements and gave their consent to participate via e-mail.In total, 15 female midwives were interviewed.

Data collection
The telephone interviews were conducted by the first author in September 2021.Before the start of the interviews the participants were verbally informed about the study.After demographic questions, the interviews followed a semi-structured interview guide (Table 1).Follow up questions were used.A pilot interview refined the interviewing technique and interview guide and was included in the analysis due to its high quality.
The interviews lasted for 35 to 60 min and were digitally recorded and transcribed verbatim.

Data analysis
The transcripts were analyzed by thematic analysis, as described by Braun and Clarke [20].The analysis was made in Microsoft Word and was performed by the first author in close cooperation with the second and third author.The first phase of the thematic analysis began with the transcription of the interviews.It also included reading and re-reading the data.In the second phase, all data extracts that answered to the purpose of the study, were marked with color and inserted in another data file.Next, an initial coding was done, where the researcher provided each data extract with a code, i.e. a short explanation of the content of the extract.This was followed by a reflection of the codes and

Table 1
The interview guide with semi-structured interview questions.• Is there anything that you experience as challenging when it comes to talking about menstruation and menstrual pain with young girls?• What advice or tips would you like to give to other midwives when it comes to talking about menstruation and menstrual pain with young women?• Ending the interview: Is there something you want to add when it comes to your experiences of talking about menstruation and menstrual pain with young women?
their related data extracts, where the codes were interpreted and put together into subthemes and wider themes.The themes and subthemes were then discussed and modified by the whole research team.In the following phase, the themes were reviewed in relation to the coded data extracts and the entire data set.During the last phase the themes were further refined, defined, and named.All three authors participated in this final step.Example of the analysis and the relationships between data extracts, codes, subthemes and one of the main themes is presented in Table 2.

Ethical considerations
The study was planned and conducted in accordance with the ethical principles regarding consent, information and confidentiality according to the Declaration of Helsinki [21].According to the Swedish Ethical Review Authority, no formal ethical review was needed for this study, since no sensitive personal information was collected [22].The study was approved on April 19th 2021 by Linköping University's advisory board for studies conducted within the framework of university education according to standard procedure.

Results
In total, 15 female midwives between 28 and 63 years old (median 51 years) were interviewed.The midwives worked at youth clinics in cities of varying sizes.Their experiences of working at youth clinics ranged from four months to 26 years (median seven years) and their employment rate at youth clinics ranged from part time to full time (median 80 %) (Table 3).
From the interviews, two main themes emerged with three subthemes, each of which described different elements of the midwives' experiences (Fig. 1).Based on the assessment of the young women's menstrual pain, the midwives guided and educated the women about various aspects of menstrual pain to help them cope with it.Striving to relieve the young women's menstrual pain, the midwives also recommended adequate self-care strategies and hormonal contraceptives.They also identified those in need to be referred to further help when necessary.The subthemes also reflected the sometimes lacking knowledge about menstrual pain and coping strategies among young women.

Theme 1: Guiding and educating young women about menstrual pain Assessing the severity of menstrual pain
This subtheme is about midwives' experiences on the assessment of pain severity.To be able to guide the young women in coping with their menstrual pain, it was fundamental for the midwives to first assess the severity of pain.The midwives explored how the women experienced their pain and to what extent the pain interfered with their daily lives.Also, they asked about coping strategies, such as the usage and effect of pain killers.Furthermore, several midwives assessed the intensity and duration of pain, as well as symptoms that can be associated with pain, such as vomiting and fainting.
Menstrual pain was considered normal if the young women felt that they could manage the pain, without being restricted in their daily lives.However, if the pain restricted the women or prevented them from going to school, even though they had used non-prescription analgesics adequately, it was described as unacceptable or abnormal by most midwives.
Well, I think that if they have menstrual pain that's so difficult that they can't manage to go to school, /…/ then I think you should do something about it because then it affects her everyday life in a completely different way.-Participant 10 Occasionally, midwives and women seemed to have different views of severe menstrual pain.Several midwives explained that they sometimes had to raise the awareness of young women who suffered from severe menstrual pain but seemed unaware of this themselves.These women could lack knowledge or may have been taught to normalize menstrual pain, no matter its severity.
They have been taught from home that "this is completely normal, you should suffer", so it can be a bit hard to get them to realize that just because your grandmother and your mother have been in pain and stayed at home, eh, with pain, does not mean that you need to feel that way.-Participant 15

Increasing basic knowledge about menstrual pain
In this subtheme, the midwives reflect upon the importance to increase young women's basic knowledge about the menstrual cycle and menstrual pain.Using slightly varying content and quantity of information, the midwives explained the physiology and purpose of menstrual pain to the young women, focusing on the menstrual cycle.Most midwives shared the view that young women had poor knowledge in this area.In this context, several midwives talked about cultural aspects of menstrual knowledge, mentioning that young migrant women could sometimes lack knowledge or have been taught myths about menstruation.The midwives further described how, when needed, they reassured the young women that it was normal to experience menstrual pain to varying degrees, but also that it was possible to relieve the pain if it was bothersome.This was especially important to emphasize when meeting young women that were scared or disgusted by menstruation or menstrual pain.

Raising awareness about hormonal contraceptives
This subtheme describes the fact that the midwives also considered it important to increase the knowledge about hormonal contraceptives when prescribing them to young women with menstrual pain.They explained to the women how hormonal contraceptives affect the menstrual cycle and body, resulting in pregnancy protection and hopefully less menstrual pain.
However, sometimes it could be challenging to help young women suffering from menstrual pain because they did not want or were not allowed by their parents to use hormonal contraceptives.For example, the midwives experienced that especially many young migrant women tended to be skeptical towards hormonal contraceptives.They proposed that this skepticism could originate from a cultural context with different perceptions about sexuality and menstruation.The midwives further explained that resistance against hormonal contraceptives could be based on fear of negative consequences, often based on lacking or incorrect knowledge.To cope with this resistance, the midwives tried to raise awareness among the young women and their mothers about the true effects of hormonal contraceptives.However, it could be difficult to dispel myths and to challenge what the women had been taught.
An example can be that we recommend this extended use of combined birth control pills to really reduce the bleeding, but then they've heard from their mother that "no you can't do that, it can make you sterile".I had one [girl] yesterday who said that, and she had stopped immediately and then got her menstrual pain back and thought it was terrible.-Participant 6

Supporting adequate use of self-care strategies
This subtheme comprises the midwives' support for self-care strategies to relieve menstrual pain.The strategies varied and included both non-prescription analgesics and non-pharmacological strategies such as heat and exercise.Primarily, these recommendations were given when the woman had not tried them properly or at all before, or if she did not want or was not allowed to use hormonal contraceptives.

They can call and say that they are in so much pain /…/ and it affects their schoolwork but then they haven't even tried with one paracetamol, and then I think you have a little bit more to try before you start with hormonal contraception -Participant 5
It seemed especially important to the midwives to increase young women's knowledge of how to use analgesics adequately.They informed them about combinations and dosages of analgesics to achieve optimal pain relief.Several midwives also informed them about the importance of early and regular ingestion of analgesics to try to prevent the pain.
Overall, the midwives felt that there is a lack of knowledge regarding adequate dosage of analgesics among young women.
It's often like when they come here for menstrual pain, eh, you always ask them "do you take any pain relief?""Yeah sometimes I take one painkiller, but it doesn't help" and then maybe you take it when you're in the most pain.Then what we recommend is one Ibuprofen and two Paracetamol, and that they should take them as soon as they feel it starting in the stomach, and then that they take them regularly on those days when they're in pain, -Participant 8

The central role of hormonal contraceptives
In this subtheme, midwives stated that hormonal contraceptives could be used as a first step in trying to relieve young women's menstrual pain, or the next step if adequate use of analgesics was insufficient.Since the midwives met many young women in need of pregnancy protection, hormonal contraceptives seemed to be a natural choice for relieving menstrual pain.Furthermore, women could actively ask for hormonal contraceptives in order to regulate menstruation and menstrual pain.
I would say that in general the majority is already set on starting with some kind of birth control pill … that eh, the adolescent already know that birth control pills can help you relieve the pain -Participant 4 When the midwives met young women that needed pregnancy protection and suffered from severe menstrual pain, hormonal contraceptives were often central in trying to relieve the bleeding and pain.If prescribing oral contraceptive pills as pain relief, the midwives recommended continuous use.
Furthermore, on the occasions when young women or their mothers brought up the question of whether the women might be suffering from endometriosis, the midwives explained to them that the primary focus was to relieve menstrual pain, often by using hormonal contraceptives.
Because then we also have girls that come and say "I have endometriosis, I need help", /…/ they have thought that "I think that I have it because the symptoms match", and then you'll have to sort out and say "sure, absolutely, it might be true, and what we do now, is we try to help you relieve your symptoms", -Participant 9

Recognizing those who need further help
This subtheme describes why and when midwives decided to consult or refer to a gynecologist.The midwives experienced that hormonal contraceptives relieved the menstrual pain of many young women.However, if the pain persisted, it caused the midwives to suspect endometriosis and they consulted or referred to a gynecologist.Experiencing extreme pain, pain with extensive duration throughout the menstrual cycle, or pain during urinating, defecating, or intercourse could also lead to this suspicion, as well as the young woman having a close female relative suffering from endometriosis.None of the midwives reflected on other causes for menstrual pain, such as myoma or infections.
It can be like, that you don't get to grips with the pain using contraceptives, that they're in pain in the context of defecating or in pain when they pee, ehm, in pain for a very long time, maybe during the whole period, yeah… then, then the warning bells ring for me.-Participant 11 Most midwives felt confident in their role of helping relieve young women's menstrual pain, including knowing when to consult a gynecologist.However, a few midwives lacked a clear work routine regarding management of young women with menstrual pain.Regarding endometriosis, most midwives considered themselves to have basic knowledge about it, although many of them wanted to learn more.

Discussion
This study provides insights from a previously unexplored part of the care of young women with menstrual pain.Overall, the midwives felt confident in their role of helping to relieve the menstrual pain of young women, and consulting or referring to a gynecologist if pain relief was not achieved.However, the midwives considered their knowledge about underlying pathologies and possible causes of menstrual pain, such as endometriosis, to be basic and wanted further education on these matters.
The midwives' experiences clearly indicate that young women may have knowledge gaps regarding menstrual pain and methods to relieve it.The midwives described a need to increase young women's often lacking knowledge about the menstrual cycle and the physiology of menstrual pain to understand why and how menstrual pain normally occurs, and when to seek help for these problems.Adolescent girls have reported that school education taught them only basic details about a "normal" menstrual cycle, and they express a need for improved education in reproductive health [23].Therefore, school education about menstruation, including menstrual pain, might have to be improved, which could be done in cooperation with school health services and youth clinics.The school health service in Swedish schools include school nurses, school physicians and counselors.They work with promoting and supporting the children's physiological and psychosocial development.At least every third year, the school nurses are obligated to conduct a health discussion with each student.Students with acute caring needs may come for health consultations more frequently [24].The health consultations could be a good opportunity for school nurses to discuss menstruation and menstrual problems, as an addition to class education.
The midwives sometimes met young women that seemed unaware of their severe menstrual pain, who were seeking medical advice for some other reason.Previous research has shown that far from all young women that experience menstrual pain seek medical advice or treatment [3,8].According to the midwives, these women could have been taught to normalize their pain.This is in line with previous research that has suggested that normalization of menstrual pain among women can be an explanation for why women might delay or refrain from seeking medical advice [15,23].It has been argued that women also might be reluctant to discuss their menstrual problems with others, and actively hide them because of the stigma associated with menstruation, even though they might suspect their menstruation to be abnormal [25].Midwives working at youth clinics have a unique opportunity to decrease the menstrual stigma by educating and supporting young women in their sexual and reproductive health-literacy.
It was evident that the midwives considered it important to help relieve the menstrual pain of young women, irrespective of whether there was a suspicion of endometriosis or not.Hence, midwives had a generous attitude toward prescribing hormonal contraceptives for menstrual pain.This is a positive finding considering that international guidelines state that it is important to provide early treatment with hormonal contraceptives when there is a suspicion of endometriosis [12].
Another important finding is that the midwives sometimes faced resistance when wanting to prescribe hormonal contraceptives to relieve the menstrual pain of young women.This resistance, expressed by the young woman herself or by a parent, could be based on lacking or incorrect knowledge, and fear of negative consequences.It is of course the young woman herself, sometimes including her parents depending on her maturity [16,19], that should make the choice of using hormonal contraceptives or not.However, it could be problematic if she does not want or is not allowed to use hormonal contraceptives to relieve severe menstrual pain based on lacking or incorrect knowledge.The skepticism for hormonal contraceptives among young women has been reported earlier and has been expressed as an unwillingness of disturbing the balance of the women's "natural" bodies [26,27].Hence, midwives and other HCPs have an important role in increasing knowledge about the true effects of hormonal contraceptives and in dispelling myths about it, involving both young women and their parents in the decision of starting to take contraceptives.
When discussing resistance against using hormonal contraceptives as pain relief, it is also important to reflect upon cultural aspects that may be involved.Previous research show that migrant and refugee women in Australia and Canada have poor knowledge about sexual and reproductive health, and that they describe menstruation as something that should be concealed and not talked about [28,29].According to the midwives in this study, it is sometimes difficult to challenge culturally ingrained myths about menstruation and hormonal contraceptives.More education on how to face and discuss the cultural aspects of menstruation may be warranted in order to strengthen the sexual and reproductive health of young immigrant women.
A limitation of the study is that 13 of the 15 midwives that participated worked in the southeast healthcare region of Sweden.However, the midwives worked in eight different locations that were geographically widespread, in cities of varying sizes.The 15 interviews generated a large amount of rich and informative data, which was sufficient to achieve both depth and width in the analysis.No new information came up during the last four interviews, indicating data saturation.In the literature, a sample size of five to 25 participants is recommended for this type of research [30].
Various strategies were used to strengthen the trustworthiness of the study [30].The credibility and confirmability were strengthened by researcher triangulation (i.e.several researchers participated in the analysis) and quotes from the interviews showing consistency between the data and the results.To achieve dependability, the various steps of the study process were thoroughly described, and the analysis followed a well-established guideline.The results of qualitative research are not intended for generalization, but the results of this study might be transferable to similar contexts.
In conclusion, the results of this study highlight that midwives working at youth clinics have an important role in the care of young women with menstrual pain.The midwives felt it important to increase young women's knowledge about menstrual pain and coping strategies, since they had noticed knowledge gaps in these areas among young women.Our results suggest there is a need to improve school education about menstruation, menstrual pain and coping strategies for young women.This should preferably be done within the school health services and in close cooperation with HCPs, for example school nurses and midwives at youth clinics.Further research could explore the perceptions and experiences among young women, and possibly their parents, who are hesitant to hormonal contraceptives.Furthermore, interventions or policy changes may be needed to reach groups of women whose health-literacy may need to be strengthened, such as immigrant women and women with lower socio-economic conditions.

Declaration of Competing Interest
The authors declare that they have no competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
What do you think about what is called "normal" menstrual pain and what is not?• What knowledge would you say young women have about what is called "normal" menstrual pain and what is not?• To what extent do you feel that you have sufficient competence to handle and give advice and support in this situation?• Do you have access to any guidelines and knowledge support to be able to help these girls?• What does your collaboration with other caregivers look like in this context?• Studies have shown that endometriosis is quite common among young people, and severe menstrual pain is one of the most common symptoms.What knowledge do you have about endometriosis? • Do the girls have knowledge about endometriosis?

Table 2
Coding tree with examples of the analysis and the relation between data extracts, codes, subthemes and one of the main themes.
(continued on next page) L.Eldestrand et al.

Table 3
Demographic characteristics of the study participants.
Fig. 1.The main themes and their associated subthemes.L. Eldestrand et al.Often, it's important to explain because often they don't quite understand at all why the endometrium thickens in the first place /…/ I'm thinking that explaining what is really what can many times be helpful for them to understand that "oh, okay, now I get it".-Participant 7