Differences in Menstrual Profil 2010

Are there any cross-ethnic differences in menstrualprofiles? A pilot comparative study on Australian andChinese women with primary dysmenorrheajog_1250 1093..1101

Xiaoshu Zhu1, Felix Wong2, Alan Bensoussan1, Sing Kai Lo3, Chunxiang Zhou4 andJin Yu5

1Centre for Complementary Medicine Research, School of Biomedical and Health Sciences, University of Western Sydney,2Department of Obstetrics and Gynaecology, University of New South Wales, Sydney, Australia; and 3Faculty of Arts andSciences, The Hong Kong Institute of Education, Hong Kong, 4Nanjing University of Traditional Chinese Medicine, Nanjingand 5Kun Tai Women’s Health Centre, Shanghai, China

Abstract

Aim: To explore and compare the features of menstruation, perception and management of menstrual painbetween two cohorts of Australian and Chinese women.Methods: A pilot comparison study was carried out using modified valid menstrual questionnaires. The studyincluded 120 Australian women and 122 Chinese women aged from 18 to 45 years with primary dysmenorrhea.Results: Australian women rated menstrual pain as more intense than Chinese women (8.5 � 1.5 on a 10-pointpain scale vs 7.3 � 1.8, P < 0.001), duration of pain was 36% longer (3.0 � 2.5 vs 2.2 � 0.9 days, P = 0.002) andmenarche commenced earlier (12.7 � 1.5 vs 14.2 � 1.4 years, P < 0.001). The mean reported menstrual intervalwas also shorter (29.2 � 5.3 vs 30.52 � 3.7, P = 0.020) with heavier overall menstrual flow (P = 0.002) and fewerclots in menstrual blood (83% vs 95.8%, P = 0.001). There was no significant difference in duration of men-struation (5.2 � 1.3 vs 5.4 � 1.1 days; P = 0.180). Correlations were found between earlier menarche andincreased intensity of menstrual pain (r = -0.16, P = 0.011), and between heavier menstrual flow and increasedintensity of menstrual pain (r = 0.19, P = 0.003).Conclusion: Evidence from this pilot study suggested that the clinical menstrual presentations in the cohortsof Australian and Chinese women were different. Although the findings are preliminary, evaluating ethnicdifferences in menstruation and experimental menstrual pain models may not only provide some informationabout underlying mechanisms but may also predict or explain group differences.Key words: dysmenorrhea, ethnic, menstrual cycle, menstruation, women.

Introduction

The cultural and ethnic group in which an individual israised has been found to influence how they perceiveand interpret phenomena.1 An emerging literature sug-gests that demographic factors, such as ethnicity,should be considered when evaluating an individual’shealth, including their experience of pain.2

A study of Batswana girls found relatively delayedmenarche, a shorter length of menstrual bleeding, andlower prevalence of dysmenorrhea in comparison withChinese girls.3 Some studies suggest that Caucasiansexperience more menstrual pain than Afro-Caribbeanwomen and women of East Asian origin.4–6 Woods alsofound that African-American women (8.6%) were sig-nificantly less likely than Caucasians to experience

Received: January 18 2009.Accepted: October 8 2009.Reprint request to: Dr Xiaoshu Zhu, Campbelltown Campus, University of Western Sydney, Locked Bag 1797, Penrith South DC,NSW 1797, Australia. Email: [email protected]

doi:10.1111/j.1447-0756.2010.01250.x J. Obstet. Gynaecol. Res. Vol. 36, No. 5: 1093–1101, October 2010

© 2010 The Authors 1093Journal of Obstetrics and Gynaecology Research © 2010 Japan Society of Obstetrics and Gynecology

mailto:[email protected]

menstrual cramps (20.2%).7 As such differences be-tween ethnicities and cultures may have significantimplications in understanding the disease mechanismand clinical intervention, ethnic diversity should beexplored further.

This pilot comparative study has two components.The first part of the study compared the basic featuresof menstruation in Australian and Chinese women, andcompared the menstrual pain profiles of these groupsdiagnosed with primary dysmenorrhea, includingtheir perception and management of menstrual pain.The findings of this part of the study are reported in thepresent paper. The second part of the study exploredthe differences, if any, between Australian and Chinesewomen in terms of diagnosis and categorization oftheir clinical presentation according to traditionalChinese medicine (TCM) diagnostic theory. The find-ings were reported and published separately.8

MethodsSubjects and setting

This pilot study was carried out in parallel with a ran-domized controlled trial (RCT) on the use of Chineseherbal medicine (CHM) for primary dysmenorrhea inAustralia. In order to explore whether the TCM pro-tocol used to diagnose primary dysmenorrhea andguide treatment that was originally used for Chinesewomen needs to be adapted when used with Australianwomen, comparisons were chosen between two co-horts of Chinese and Australian women with primarydysmenorrhea.

This study draws on data from an examination of 120Australian and 122 Chinese women aged 18–45 yearswho had been diagnosed with primary dysmenorrheaduring the period from January 2005 to April 2006. TheAustralian women were recruited as part of the RCT.Ethics approval for the Australian component of thestudy was granted by the Human Research EthicsCommittees of the University of Western Sydney andSouth Western Sydney Area Health Services, Australia.Data from ethnic Chinese women were excluded forthe purpose of this pilot survey.

The Chinese participants were recruited from thoseseeking CHM for primary dysmenorrhea from fourChinese hospital outpatient departments, namely theWomen and Children’s Hospital of Changzhou, thePeople’s Hospital of Jiangyin, the Changzhou Hospitalof Traditional Chinese Medicine, and the YangzhouHospital of Traditional Chinese Medicine (the Affili-ated Hospital of the Medical College of Yangzhou

University). Informed consent was obtained from indi-vidual Chinese participants whilst no ethics approvalwas required for such a type of survey at the time inChina.

Diagnostic criteria and assessment

For the purposes of this study, primary dysmenorrheawas defined as lower abdominal pain associated withmenstruation for three consecutive menstrual cycles,with no positive abnormality detected either throughpelvic examination, ultrasound examination or laparos-copy. Both cohorts were screened for primary dysmen-orrhea by medical practitioners with Western medicinequalifications, and also interviewed and examined byCHM practitioners.

All Australian and Chinese clinicians who con-ducted the interview based on the defined question-naire had similar qualifications and training, with aminimum of a bachelor’s degree in medicine fromNanjing University of Traditional Chinese Medicineand a minimum of 15 years’ work experience in theChinese hospital system.

Instruments

Questionnaires were used in the study. For the Chinacomponent of the study, the questionnaire and data-recording sheets were translated into Chinese and thenback into English to ensure accuracy of the translation.The questionnaires were completed by cliniciansthrough personal interviews with the participants.

In order to measure menstrual and dysmenorrhealvariables, the questionnaire comprises items drawnfrom previously validated scales including the Men-strual Symptom Questionnaire (MSQ),9 the MenstrualDistress Questionnaires (MDQ)10 and the Faces PainRating Scale (FPRS)11 (which employs a face painscale integrated with numeric rates). The interviewquestions gathered self-reported data on:

• Menstruation profile, such as menarche, length ofcycle, bleeding period, menstrual flow, includingpresence of blood clots;

• Menstrual pain profile including duration and inten-sity of pain;

• Other relevant information including family historyand life-style factors.

Statistical analysis

All data are presented as percentages of participants forcategorical data, with mean and standard deviationsfor continuous data. Comparisons between Australian

X. ZHU et al.

1094 © 2010 The AuthorsJournal of Obstetrics and Gynaecology Research © 2010 Japan Society of Obstetrics and Gynecology

and Chinese women were made with the use of theindependent t-test and Pearson’s c2-test, where appro-priate, at the 0.05 significance level. The data were ana-lyzed using spss V. 14 for Windows.

ResultsDemographics

A majority of participants from both countries wereurban residents. There was no significant difference inage distribution between the two groups (26.7 � 5.8 vs26.6 � 5.6, P = 0.810).

Menstrual characterization

The menstrual variables for the two cohorts are shownin the Table 1.

The mean age reported for menarche in Australianwomen was 12.7 years. This was significantly differ-ent from Chinese women (12.7 � 1.5 vs 14.2 � 1.4,P < 0.001). While the length of menstrual cycle (men-strual interval) was, on average, one and a half daysshorter for Australian women than Chinese women(29.2 � 5.3 vs 30.52 � 3.7, P = 0.020), no significant dif-ference was found in the reported length of menstrualbleeding (5.2 � 1.3 vs 5.4 � 1.1 days; P = 0.180).

Participants were asked to classify the overall heavi-ness of their menstrual flow, using one of three des-criptors: ‘heavy’, ‘medium’, and ‘light’. The differencebetween the two cohorts was significant (P = 0.002); agreater proportion of Australian women reported a‘heavy’ flow (48.3% vs 27.0%), but most Chinese womenclassified their menstrual flow as ‘medium’ (63.9% vs43.3%). Similar numbers of Australian and Chinesewomen rated their menstrual bleeding as ‘light’ (8.3% vs9.0%).

Australian women also reported fewer ‘clots’ in theirblood flow compared with their Chinese counterparts,this difference being statistically significant (83% vs95.8%, P = 0.001).

Menstrual pain characteristics

Table 2 sets out the menstrual pain profile of the studyparticipants and is summarized below.

More Australian women than Chinese womenreported experiencing pain prior to bleeding (69.2%vs 37.7%, P < 0.001). Chinese women reported theirperiod pain starting on the first day of bleeding (52.5%vs 28.3%, P < 0.001). The mean duration of dysmenor-rhea reported by Australian women was significantlylonger than that reported by Chinese women (3.0 � 2.5vs 2.2 � 0.9 days, P = 0.002). There was a significantdifference between the cohorts in the perception of theintensity of menstrual pain: the mean intensity of painin Australian women was 8.5 � 1.5 on a 10-point painscale; in contrast, the mean intensity of pain in Chinesewomen was 7.2 � 1.8. The difference was statisticallysignificant (P < 0.001).

Correlation of menstrual characteristics andmenstrual pain variables

For the sample group as a whole, the correlationbetween menarche and intensity of pain was significant(r = -0.16, P = 0.011), that is, women who had their firstmenstruation at a younger age reported more severepain associated with their last three menstrual periods.Furthermore, a significant correlation was foundbetween menstrual flow and intensity of pain (r = 0.19,P = 0.003). The mean intensity of pain increased from7.57 to 7.63 to 8.26 for light, medium and heavy flows(P = 0.024), respectively.

Table 1 Menstrual characteristics (profiles) in Australian and Chinese women

Australian (n = 120) Chinese (n = 122) P-value

Menarche (age in years)* 12.7 � 1.5 14.2 � 1.4 0.001Menstrual interval (days)* 29.1 � 5.3 30.5 � 3.7 0.020Length of menstruation

(days)*5.2 � 1.3 5.4 � 1.1 0.171

Overall menstrual flow (%) 0.002Heavy 48.3 27.0Medium 43.3 63.9Light 8.3 9.0

Clots in menstrual blood (%) 83.3 95.8 0.001

*Data reported are mean � standard deviation.

Ethnic differences in menstrual profiles


No correlation was found between length of men-struation (bleeding period) and intensity of menstrualpain (r = -0.01, P = 0.932); between length of menstrualcycle (menstrual interval) and menstrual clotting(r = -0.07, P = 0.257); or between length of menstrualcycle and reported intensity of pain (r = -0.03,P = 0.703).

Coping strategies and family history

Subjects were also asked about coping strategies theyhave adopted. A higher proportion of Chinese women(27.1% vs 10.0%, P = 0.001) reported taking no action totreat their menstrual pain. When they took action, theytended to rely less on non-pharmaceutical treatmentsthan Australian women did. More Australian womenreported taking pain-relieving medication thanChinese women, the difference being statistically sig-nificant (80% vs 31.4%, P < 0.001). No Chinese womenreported taking the oral contraceptive pill as a strategyto relieve period pain, compared with 7.5% of Austra-lian women, the difference being statistically signifi-cant (P = 0.002). Use of hot-water bottles was adoptedalmost equally by the two groups of women (67% vs62%, P = 0.308). There was no significant differencein the reported use of herbal medicine (14% vs 12%,P = 0.308). However, more Chinese women (22.9%)reported using massage for easing their menstrualpain, compared with Australian women (11.7%), thedifference also being statistically significant (P = 0.017).A significantly larger proportion of Australian partici-

pants reported a family history of period pain com-pared with Chinese participants (66.1% vs 39.3%,P < 0.001).

DiscussionCorrelation of menstrual characteristics andmenstrual pain

The findings of this study are consistent with earlierresearch that found statistically significant associationsbetween menarche age and the intensity of perceivedmenstrual pain in primary dysmenorrhea, that is, earlymenarche is associated with an increase in the severityof primary dysmenorrhoea.12,13 Balbi et al.12 reportedthat primary dysmenorrhea most frequently occurredin subjects whose age at menarche was younger than 12(88% of total sample); the frequency of primary dys-menorrhea was less in subjects whose age at menarchewas older than 12 (81% of total sample). Chineseresearchers also found that there was no associationbetween severity of dysmenorrhea and the age of sub-jects, but that there was a positive association betweenearlier menarche age and greater intensity of menstrualpain (P < 0.05).13

The findings of the present study support the viewthat higher intensity of menstrual pain reported byAustralian women may be related, in part, to the factthat the average age of onset of menarche was earlierthan that of Chinese women.

Table 2 Menstrual pain variables in Australian and Chinese women

Australian women(n = 120)

Chinese women(n = 122)

P-value

Severity of pain (0–10) 8.5 � 1.5 7.3 � 1.8 0.001Length of menstrual pain (days) � mean (standard deviation) 3.0 � 2.5 2.2 � 0.9 0.002Onset time of pain (%) Prior to bleeding 69.2 37.7 0.001

1st day of bleeding 28.3 52.52nd day of bleeding 1.7 6.63rd day of bleeding 0.8 0.8End of bleeding 0.0 2.5

Known family history (yes/no) (%) 66.1 39.3 0.001Strategies of coping with

pain (%)Nothing 10.0 27.1 0.001Hot-water bottles 66.7 62.7 0.308Pain-relieving medication 80.0 31.4 0.001Oral contraceptive pill 7.5 0.0 0.002Massage 11.7 22.9 0.017Herbs 14.2 11.9 0.369

Life-style Consumption of colddrinks duringmenstruation (%)

61.7 20.5 0.001

X. ZHU et al.


The findings also support previous research thatreported an increase in the severity of primary dys-menorrhea associated with an increase in menstrualflow.12 There are difficulties in objectively measuringmenstrual blood flow when relying on self-reporting,given the variety of sanitary products available and thevariability of menstrual blood loss among the women.Significant variation has been found between womenin terms of menstrual blood loss during a menstrualperiod.14,15 In the present study, participants were askedto rate their menstrual flow as either ‘heavy’, ‘medium’or ‘light’, with the three levels of menstruation leftundefined in the questionnaire. The results showedthat more Australian women reported a heavier flow ofmenstrual bleeding compared with Chinese women.

Contrary, though, to the findings of Balbi et al.12 andGe et al.,13 no correlation was found between durationof the bleeding period and increased intensity of men-strual pain.

The present study found the mean length of men-strual cycle among the Chinese women to be30.5 � 3.7 days. This was consistent with the meanlength of 31 days reported in an earlier Chinese study.16

The mean length of menstrual cycle in Australianwomen was 29.2 � 5.3 days. A set of data collected in1988 indicated that the mean cycle length of Australianwomen was 27.7 days.17 These data were based on asmall sample size (25 subjects), however it suggests thatAustralian women have a shorter length of cycle. Ourstudy found that Chinese women reported the men-strual cycle to be one day longer than Australianwomen. However, no correlation was found betweenthe intensity of menstrual pain and the length of men-strual cycle. This echoes previous findings.13

In TCM diagnostic protocol, the condition of excessclotting implies more severe stagnation of bloodflow, this symptom being a fundamental pathology inprimary dysmenorrhoea.18 No correlation, however,was found between the intensity of menstrual pain andclots in the blood; this absence of correlation was not inaccordance with TCM diagnostic theory.

Menstrual pain

Australian women also reported not only a higherintensity of menstrual pain, but also slightly longerduration of pain than Chinese women. This findingcorrelates with findings from a 1983 study of Austra-lian women aged 16–49 years that showed that womenreporting menstrual pain were more likely to speakEnglish at home than women without dysmenor-

rhoea.19 Although the ethnicity of the subjects wasnot identified in this study, it may suggest a similarfinding.

Age of menarche

Menarche is a milestone of female puberty that indi-cates the approaching cessation of physical growthand the maturation of reproductive potential.20 Whenmenarche occurs, it confirms that a girl has had agradual estrogen-induced growth of the uterus, espe-cially the endometrium.

Previous studies indicate that there are significantdifferences between ethnic groups in the average age atmenarche. A survey conducted in North Americafound that the mean age at menarche for all US girlswas 12.43 years. The age at menarche of non-Hispanicblack girls was significantly earlier than that of non-Hispanic white and Mexican-American girls.21 Koreanresearchers reported that the mean age of menarche of1237 women was 13.4 � 1.5 years (published in 2005)20

or 13.2 years of 11 424 teenage girls (published in1996).22 In a study conducted in China, of 131 410women, average age at menarche was 15 years.16

In developed countries, the average age at menarchehas shown a historical trend towards earlier onset.23

The mean menarche age remained higher in under-developed and developing countries, with the averagemenarche age of Batswana girls in urban areas being14.83 � 1.03 years3 and the average menarchal age ofTurkish girls 13.28 � 1.09 years.24 Chumlea found adecline in the average age of menarche in US girlsof two to three months from the mid-1970s to themid-1990s.21

In the present study, the mean menarche age of Aus-tralian women was 12.73 � 1.5, although the samplesize was limited. Chinese women were on averagemore than one year older (14.15 � 1.4), this figurebeing closer to that reported earlier by Zhang et al.(1984).16

The present findings support the view that significantdifferences exist between ethnic groups in relation toage of onset of menarche. Various studies have foundlinks between the timing of puberty and a wide rangeof factors, such as genetic, nutritional, climactic, psy-chological, bodyweight and other environmentalfactors.23,25–27 The causes are likely to be multifactorial,and may be mediated through their effect on bodilyestrogen levels in the female body. The decline in theaverage age of menarche in girls in developed countriesis commonly attributed to larger body size and



increased body fat and the likely impact of these factorson estrogen levels.25,28,29

Potential contributing factors

An earlier age of menarche, a shorter menstrual inter-val and heavier menstrual flow are known to be medi-ated by estrogenic influences. Increased estrogen mayalso increase the occurrence of menstrual cramps.16 Theassociation between estrogen and menstrual cramps isa consequence of prostaglandin synthesis stimulatedby increased oestrogen.27 There is increasing experi-mental evidence to show that inhibitors of prostaglan-din synthesis, such as use of the oral contraceptive pilland non-steroidal anti-inflammatory drugs can reducemenstrual cramps.30

Genetic variations may also influence the incidenceof primary dysmenorrhea and the sensitivity to andperception of menstrual pain.31–33 This may be associ-ated with a process of metabolic gene polymorphisms.For example, glutathione S-transferase-theta was foundto correlate with the severity of primary dysmenor-rhea, whilst cytochrome P4501A1 HincII might alsohave a role in primary dysmenorrhoea.34,35 A study ofAustralian twins gathered data on menstrual flow andmenstrual pain, and found evidence to support agenetic contribution to reproductive characteristics,including menstrual pain.36 The present study foundthat a total of 66.1% Australian women and 39.3%Chinese women reported a family history of dysmen-orrhea, with the higher rate reported by Australianwomen statistically significant (P = 0.001).

In analyzing the role of ethnicity in the perceptionof menstrual pain, it is also necessary to understandthat ethnicity encompasses both genetic and culturaldifferences. There are cultural differences related tolanguage, religion, diet and so on. For example, theinfluence of culture on pain perception and descriptionwas illustrated by a comparison of Americans andChinese.37 Anglo-Americans described muscle pain as‘deep’, but this indicator was used by only half of theMandarin Chinese subjects. Similarly, most Chineseregard the sensation of having a tooth drilled as‘sourish’, while Americans rarely used this word. It hasalso been suggested that culture may influence themeaning that individuals ascribe to symptoms such aspain.38

The present study did not examine the impact oflanguage on the reporting of menstrual pain. However,participants were asked to report on both the natureand intensity of the menstrual pain. In general Chinese

women tended to use more indicators when reportingthe nature of their pain, for example, ‘burning’ pain,‘cold’ pain or ‘cutting’ pain, than Australian womendid, the interviews in China being conducted in Man-darin. This finding suggests more research is needed toinvestigate the role that language may play in the per-ception of menstrual pain.

The present study did not investigate the role of dietas a contributing factor in menstrual pain. However,given that a link has been found between poor clear-ance of estrogen from the body and menstrualcramps,39 it is reasonable to assume that a Western dietthat is high in fat may be a contributing factor in anincreased incidence of primary dysmenorrhea incertain populations.

Coping strategies

Coping styles and strategies have been found to varywith culture, social learning, and attitudes.32 Forexample, African-Americans reported greater use ofpassive pain-coping strategies.40,41 Similarly, in thepresent study more Chinese women reported using‘nothing’ for their monthly cramps, whereas Australianwomen reported a higher incidence of use of ‘painrelieving medication’ or ‘oral contraceptive pills’.These results are consistent with the findings of a com-parative study of Italian and Chinese women withprimary dysmenorrhea, where the consumption ofnon-steroidal anti-inflammatory analgesic tablets wasfound to be far lower in Chinese women than that inItalian women.42

A randomized, active-controlled, single-blind(investigator) trial reported that low-level, topicalheat therapy was superior to acetaminophen for thetreatment of dysmenorrhoea.43 In the present study,there was no significant difference found betweenAustralian and Chinese women in their reliance onthe use of a ‘hot-water bottle’, and it appears that thistraditional method of pain relief knows no culturalbarriers.

The study found a lower incidence of use of non-pharmaceutical treatment by Chinese women com-pared with Australian women. The reasons for this arenot known. However cultural differences as well asdifferences in rating of intensity of menstrual painbetween the two groups may be influencing factors.

Despite epidemiological surveys consistently report-ing a high prevalence of primary dysmenorrhea, thefindings of this study support other studies thatsuggest many women, especially Chinese women, donot seek treatment.13,42

X. ZHU et al.


In summary, there are indications that biomedical,ethnic and cultural factors may contribute to differ-ences in menstruation and menstrual pain profiles ofAustralian and Chinese women. Such ethnic differ-ences should be taken into consideration in evaluatingclinical information for making clinical diagnosis andin designing clinical research in relation to primarydysmenorrhea. Interestingly, these differences betweenthe two cohorts of women found in the same study didnot translate into differences in the underlying diag-nostic patterns according to TCM diagnostic categories.This suggests the TCM protocol used to diagnoseprimary dysmenorrhea and guide treatment is unlikelyto require adaptation for use with Australian women.The TCM findings were reported in detail in a separatepublication.8

Limitations of the study

This pilot comparative study provides new informationregarding ethnic differences in the clinical presentationof menstruation and the perception of menstrual painin Australian and Chinese menstruating women.However the study has limitations.

This study drew on a relatively small sample size,which may affect the results. No correlation was foundbetween duration of the bleeding period and increasedintensity of menstrual pain, which is contrary to previ-ous findings;12,13 the study did not show a correlationbetween the intensity of menstrual pain and clots in theblood, this finding being at variance with TCM diag-nostic theory. Therefore, a further test with increasedsample size is needed.

The two groups of participants were recruited fromhomogenous geographic populations, that is, urbanresidents. Generalization of the results to other popu-lations is unknown. The Chinese women in this surveywere all of Han nationality, a native ethnic group toChina. The ethnicity of the cohort of Australian womenwas, however, not identified, although they weremainly Caucasian. Further research should look at spe-cific ethnic groups within the larger Australian group.

Although the items in the questionnaires measuringmenstrual profiles and dysmenorrhea were drawnfrom previously validated scales, further research onthe validation and reliability of the questionnaires usedis still required.

It might be reasonable to presume that recall biaswas limited in this study as most of the retrospectivedata were related to activities occurring during the lastthree menstrual cycles at the time when the survey wascarried out. A piece of survey data could be subject to

recall bias to a certain degree,44,45 which may influencethe results of the survey. Hence, recall bias should betaken into consideration while processing the data forthe findings. In other words, the reliability and consis-tency of respondents’ answers should be assessed infuture research.

Factors such as the impact of diet, language and othercultural differences on the rating of intensity of men-strual pain were not explored. The experimental designalso did not include an evaluation of the effect of bodymass index on menstruation and menstrual pain pro-files of the two cohorts. When designing the study, themain focus was to minimize the workload for partici-pants in the questionnaires.

To summarize this section, areas to pay attention toin future research are: specifying particular ethnicgroups within the larger Australian group; increasingthe size of the groups appropriately; reliability andvalidity of the instruments used; consideration of recallbias and other factors relevant to menstruation andmenstrual pain.

Conclusion

This is the first study to compare menstruation andmenstrual pain in Australian and Chinese women. Thedata suggest that given the differences in menstruationand menstrual pain profiles of these groups, it is nec-essary to consider biological, cultural and social factorsin the approach to diagnosis and treatment of primarydysmenorrhea in the fields of clinical practice andresearch.

Acknowledgments

We thank Ms Anne-Louise Carlton who initially editedthis manuscript with her sound knowledge in TCM.Our thanks also go to Mr James Flowers for providingfinal editing support. We are grateful to Dr Y. L. Liewfor reviewing and commenting on this manuscript. Wealso thank the following medical consultants whoallowed us to access their clinics in Australia: Dr Y. L.Liew, Dr Michael Cao, Dr Sue Carr, Dr Edwina Wong,Dr David Parkinson, and other doctors who assisted inthis study. We appreciate support from our Chinesecolleagues including Dr Lin Zhu, Dr Meiyan Xue, Pro-fessor Jing Qian, and Dr Peixia Cao. We thank MsNadine Licht for assisting this study and we thank allparticipants.



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