Prevalence, severity and correlates of dysmenorrhea among postpartum women in Western Kenya: A cross-sectional study

Figures Abstract Dysmenorrhea is the most common menstrual disorder globally, contributing the highest disease burden of any gynecological issue in low- and middle-income countries (LMICs). Yet, limited data exist on dysmenorrhea among women in LMICs, particularly in Sub-Saharan Africa, including countries like Kenya. We conducted a cross-sectional analysis using data from the PrIMA-Extension Study, a large prospective cohort study that enrolled women during pregnancy and followed mother-child pairs up to 60 months post-delivery in four clinics in Western Kenya. At 24 months post-delivery, we assessed prevalence, severity, and correlates of dysmenorrhea using the Cox Menstrual Symptom Scale. Moderate-to-severe dysmenorrhea was defined as ≥1 symptom that was moderately to very severely bothersome. Poisson regression models identified correlates of moderate-to-severe dysmenorrhea. Among 277 women (median age: 27 years, IQR: 24–31), 24% (n = 67) had moderate-to-severe dysmenorrhea. Women predominantly reported cramps (46%), abdominal pain (34%), headaches (13%), weakness (8%), and dizziness (8%), lasting 3–7 hours or longer. Severe symptoms of dysmenorrhea most often reported were cramps (17%), abdominal pain (12%), headaches (4%), and weakness (3%). In a multivariate analysis adjusted for age and current breastfeeding status, moderate-to-severe dysmenorrhea was associated with high scores of adverse childhood experiences (ACEs; adjusted PR [aPR]=1.71, 95% CI: 1.04–2.79, p = 0.03), spending time in bed due to menstrual problems (aPR = 3.11, 95% CI: 1.88–5.14, p < 0.001), and taking painkillers (aPR = 4.12, 95% CI: 2.52–6.73, p < 0.001). Adjusting for age, current breastfeeding was associated with a higher frequency of moderate-to-severe dysmenorrhea (aPR = 1.66, 95% CI: 1.02–2.71, p = 0.04). At 2 years postpartum, nearly 1 in 4 women reported moderate-to-severe dysmenorrhea, associated with ACEs and resulting in daily functional interruptions. These findings underscore the need for routine menstrual health assessment during care and integrated approaches addressing pain management and psychosocial support. Citation: Khwepeya M, Pintye J, Abuna F, Bhat A, Enquobahrie DA, Gomez L, et al. (2026) Prevalence, severity and correlates of dysmenorrhea among postpartum women in Western Kenya: A cross-sectional study. PLOS Glob Public Health 6(5): e0006466. https://doi.org/10.1371/journal.pgph.0006466 Editor: Julia Robinson, PLOS: Public Library of Science, UNITED STATES OF AMERICA Received: November 26, 2025; Accepted: April 27, 2026; Published: May 26, 2026 Copyright: © 2026 Khwepeya et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: All relevant data are within the paper and its Supporting Information files. Funding: The study was supported by a grant from the National Institutes of Health (US) to JP, Grant Number: R01 HD100201. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. Introduction Dysmenorrhea is the most prevalent menstrual disorder globally with the highest disease burden of any gynecological issue in low- and middle-income countries (LMICs) [1]. The global prevalence of dysmenorrhea ranges from 20% to 90% across different populations, depending on the method of assessment [2,3]. Approximately 10–15% of women experience dysmenorrhea severe enough to prevent normal daily functioning [1,2,4–7]. Dysmenorrhea presents as lower abdominal pain or cramping commonly accompanied by backache, nausea and vomiting, headache, dizziness, diarrhea, loss of appetite, bloating, leg pains, and irritability [8]. Dysmenorrhea symptoms especially when moderate to severe, often negatively impact women’s quality of life, work productivity, and healthcare utilization [9–12]. Yet, there are limited data on the frequency and severity of dysmenorrhea in LMICs, particularly in Sub-Saharan Africa (SSA) [9,12]—a region with persisting gaps in women’s health. Data on dysmenorrhea in this context could inform clinical and public health interventions and improve health and quality of life for those impacted. Factors associated with dysmenorrhea include age, parity, marital status, menstrual bleeding characteristics, cigarette smoking, and alcohol consumption [9,10,12,13]. Hormonal contraceptive use may protect against dysmenorrhea symptoms [11,5]. Furthermore, experiences of dysmenorrhea are associated with anxiety, embarrassment, discomfort, and depression among women, especially younger women and adolescents [11]. Several studies demonstrate an increased risk of depression in women with dysmenorrhea, especially in the period after pregnancy, when postpartum depression is a health concern [14]. There is a dearth of data on dysmenorrhea among women in SSA [15]. Particularly, data are sparse regarding dysmenorrhea during the postpartum period in SSA, where high fertility rates in many countries mean many women spend a substantial proportion of their reproductive years in pregnant or postpartum states [16,17]. Understanding the burden and risk factors for dysmenorrhea up to 24 months post-delivery can inform postpartum health services to alleviate the negative impacts of dysmenorrhea and improve the quality of life. We conducted a secondary analysis to determine the prevalence, severity, and correlates of moderate-to-severe dysmenorrhea at 24 months post-delivery, using data from a large cohort of women in Kenya. We hypothesized that the prevalence of moderate-to-severe dysmenorrhea would be high, and be associated with low parity, younger age, and irregular menstrual cycles, while hormonal contraceptive use would be inversely associated. Methods Study design and participants We conducted a secondary cross-sectional analysis, leveraging data from women enrolled in the Pre-Exposure Prophylaxis (PrEP) Implementation for Mothers in Antenatal Care (PrIMA) Extension (PrIMA-X) Study (R01 HD100201), a longitudinal observational cohort study assessing the safety of PrEP during pregnancy and postpartum. PrIMA-X enrollment was conducted at four maternal and child health (MCH) clinics in Western Kenya between October 26, 2020, and June 6, 2023, and eligible participants were at least 15 years old, living without HIV, and were receiving MCH services at the study sites. Mother-child pairs were followed prospectively for up to 60 months postpartum. In September 2022, data collection for dysmenorrhea symptoms was incorporated into study procedures. Data were included in the present analysis among women who had menstruation data recorded at their 24-month post-delivery visit from the time that dysmenorrhea measurement was activated through Dec 2, 2024. Among 1,191 women enrolled in PrIMA-X, 277 participants met the inclusion criteria for this analysis. Ethical consideration Inclusivity in global research Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information (S1 Checklist). Data collection and measurements Data were collected by trained study nurses using tablet-based Research Electronic Data Capture (REDCap) questionnaires [18]. Questionnaires were administered in English, Swahili, or Dholuo based on participant preference. All measures or variables used in this analysis were collected at various time points, including at 24 months post-delivery. They included items related to sociodemographic characteristics (age: ≥ 24 vs. 25–35 vs. > 35 years, marital status, employment, education level: ≥ 8 vs. < 8 years, etc.), obstetric information (pregnancy outcomes, breastfeeding, mode of delivery, non-permanent birth control methods, etc.), psychosocial characteristics (alcohol/tobacco, etc.) and menstrual patterns (length of menstrual cycle, bleeding days per period, nature of menstrual flow, hours spent on bed and/or pills taken in last menstrual period for menstrual relief). Dysmenorrhea. We used the Cox Menstrual Symptom Scale (CMSS) to measure duration and severity of physical and emotional dysmenorrhea symptoms [19]. The CMSS evaluates 18 symptoms of dysmenorrhea in terms of duration and severity, respectively, including general aching, headaches, stomachaches, backaches, cramps, leg aches, dizziness, facial blemishes, flushing, nausea, vomiting, loss of appetite, diarrhea, weakness, insomnia, gloominess, irritability, and nervousness, using a 5-point Likert scale. Duration is rated from 0 (“did not occur”) to 4 (“lasted several days”), and severity from 0 (“not noticeable”) to 4 (“very severely bothersome”). Item-level scores for duration and severity are summed to produce a total score ranging from 0 to 144, where higher scores indicate more severe symptoms [20]. Although the CMSS has not been formally validated in Swahili or Dholuo, the scale was translated and back-translated by bilingual experts and pilot-tested with local women to ensure conceptual clarity and linguistic appropriateness. In the present analysis, the primary outcome was moderate-to-severe dysmenorrhea, defined as reporting at least one menstrual symptom that was moderately to very severely bothersome (CMSS severity score ≥2 vs. score <2). Depressive symptoms. Depressive symptoms were assessed using the 10-item Center for Epidemiologic Studies Depression Scale (CESD-10), a shortened version of the original CESD that has been validated in diverse populations, including adolescents and adults in SSA [21,22]. The CESD-10 includes 10 items rated on a 4-point Likert scale ranging from 0 (“rarely or none of the time”) to 3 (“most or all of the time”) based on symptom frequency in the past week. Total scores range from 0 to 30, with higher scores indicating greater severity of depressive symptoms. Consistent with prior research, scores were dichotomized as low (<10) and high (≥10) depressive symptoms to identify clinically meaningful distress [23,24]. Perceived stress. Perceived stress was measured using the 10-item Perceived Stress Scale (PSS-10), a widely used psychological instrument designed to measure the degree to which individuals perceive life situations as stressful during the past month, on a 5-point Likert scale ranging from 0 (“never”) to 4 (“very often”) [25]. Four positively worded items were reverse-scored, and total scores ranged from 0 to 40, with higher scores indicating greater levels of perceived stress. For this analysis, perceived stress was dichotomized as low (<10) and high (≥10), with the threshold of 10 reflecting elevated stress in population-based studies [26]. Adverse childhood experiences (ACEs). ACEs were measured using the 31-item of Adverse Childhood Experiences International Questionnaire (ACE-IQ), capturing exposure to a range of adversities during childhood and adolescence, including physical, emotional, and sexual abuse; neglect; household dysfunction (e.g., caregiver substance use, incarceration, mental illness, death, or separation); bullying; and exposure to violence in the home, school, or broader community [27,28]. These items were grouped into 13 domains based on established ACE frameworks, with each domain coded as either present or absent. A cumulative ACE score (range: 0–13) was then calculated by summing the number of domains experienced. For analysis, ACE exposure was dichotomized as high (≥6) and low (<6), thresholds supported by evidence linking higher ACE burden to increased risk of adverse mental, behavioral, and physical health outcomes [28,29]. Intimate partner violence (IPV). IPV was assessed using the Hurt, Insult, Threaten, and Scream (HITS) scale, a validated 4-item screening tool designed to measure the frequency of physical and emotional abuse by a partner [30]. The scale includes the items: Hurt, Insult, Threaten, and Scream, each rated on a 5-point Likert scale ranging from 1 (“never”) to 5 (“frequently”), yielding a total score range of 4–20. Higher scores indicate greater IPV exposure. We defined IPV based on thresholds established for identifying individuals at risk of IPV in clinical and research settings (HITS score ≥10 vs. < 10) [30]. Mother-child engagement. Mother-child engagement was measured using items from the Multiple Indicator Cluster Survey (MICS) Early Childhood Development module, which assesses the frequency and quality of developmental stimulation activities provided by caregivers [31]. Mothers were asked whether they engaged in key activities with their child in the past three days, such as reading, storytelling, singing songs, playing, or naming/counting objects. Responses were used to create a binary variable indicating high engagement (if the mother participated in at least four of the six recommended activities) and low engagement (if fewer than four activities were reported), consistent with global early childhood development benchmarks [31]. Data analysis Descriptive statistics were used to summarize symptom duration and severity. Poisson regression with robust variance estimation, clustered by facility level, was used to assess the associations between moderate-to-severe dysmenorrhea and potential correlates. For the adjusted analyses, we selected age (as a continuous variable) and current breastfeeding status (Yes/No) as a priori confounders based on previous literature and a conceptual model of dysmenorrhea etiology [5]. Each variable with p ≤ 0.05 in univariate analysis was then entered into a separate multivariable Poisson model controlling for these covariates. R software (version 4.3.1, 2023-06-16) was used for analysis. Results Participant characteristics A total of 277 women met the inclusion criteria and were included in the final analysis (Fig 1). The participants had a median age of 27 years [interquartile range (IQR) of 24–31, absolute range: 15–41, and most were aged between 25–35 years (59%)]. The majority were married or living with a partner (94%), in monogamous relationships (82%), and had completed more than eight years of education (77%). Nearly all had more than one child (93%) and reported a vaginal delivery (94%) for their most recent birth. At the time of data collection, nearly half were still breastfeeding (44%) and 97% were on contraception; the most commonly reported contraceptive methods were injectables (32%), followed by implants (28%) and other non-permanent methods (e.g., condoms; 26%). Psychosocial distress factors were relatively rare. Only 2% of women reported depressive symptoms, 4% reported elevated stress, and less than 1% reported IPV. However, 27% reported exposure to six or more ACEs, and 16% had lower levels of mother-infant engagement. A full description of participant characteristics is provided in Table 1. Dysmenorrhea symptoms Overall, the median dysmenorrhea total score was 2 (IQR: 0–6), with 24% (n = 67) of mothers reporting moderate-to-severe dysmenorrhea symptoms defined as having at least one moderate to very severely bothersome symptom that lasted at least one full day on the CMSS. Over half of the women reported regular cycles (51%), and most had menstrual bleeding lasting 3–5 days (68%). The majority reported moderate flow levels (63%), while a smaller proportion spent additional time in bed (21%) or used painkillers to manage menstrual symptoms (18%) (Table 1). Among those reporting any experience of individual dysmenorrhea symptoms, the most commonly experienced dysmenorrhea symptoms were cramps (46%), followed by abdominal pains (34%), headaches (13%), weakness (8%), and dizziness (8%), that varied in duration and typically lasted 3–7 hours or longer, with approximately 19% (n = 44) reporting symptoms that persisted for an entire day or more (Table 2). Among women with severe dysmenorrhea, 17% of women reported cramps, followed by abdominal pain (12%), headaches (4%), and weakness (3%) (Table 3). Correlates of dysmenorrhea symptoms In the univariate analysis, several factors were significantly associated with moderate-to-severe dysmenorrhea (Table 4). Women who reported higher scores of ACEs were more likely to have moderate-to-high dysmenorrhea than those with fewer ACEs (36.0% vs. 19.8%, prevalence ratio [PR]=1.82, 95% confidence interval [CI]: 1.10–2.95, p = 0.02). Women who were still breastfeeding at 24 months post-delivery had a higher risk of moderate-to-severe dysmenorrhea compared to those not breastfeeding (32.2% vs. 19.2%, PR = 1.68, 95% CI: 1.04–2.74, p = 0.04). Likewise, each unit increase in depressive symptom score was associated with a higher risk of moderate-to-severe dysmenorrhea (PR = 1.10, 95% CI: 1.01–1.18, p = 0.02). Moderate-to-severe dysmenorrhea was also related to pain relief behaviors: women with moderate-to-severe symptoms were more likely to use painkillers (67.3% vs. 14.9%, PR = 4.52, 95% CI: 2.79–7.30, p < 0.001) and spend additional hours in bed (55.2% vs. 16.0%, PR = 3.45, 95% CI: 2.13–5.58, p < 0.001) for symptom relief compared to those with less severe dysmenorrhea. Although age, irregular menstrual cycles, and hormonal contraceptives were not significantly associated with having moderate-to-severe dysmenorrhea as hypothesized, they demonstrated trends in the expected direction, warranting further investigation. Being ≤24 years (20.0%, PR = 0.74, 95% CI: 0.42–1.26, p = 0.28) or >35 years (20.8%, PR = 0.77, 95% CI: 0.27–1.77, p = 0.58) compared to 25–35 years (27.0%) was associated with a lower risk of moderate-to-severe dysmenorrhea. Similarly, using oral contraceptive pills compared to other methods such as abstinence or periodic abstinence was associated with a slightly lower risk of moderate-to-severe dysmenorrhea (21.4% vs. 23.1%, PR = 0.93, 95% CI: 0.22–2.69, p = 0.90), while injectable or implants use showed a slightly higher risk of moderate-to-severe dysmenorrhea (24.8% vs. 23.1%, PR = 1.08, 95% CI: 0.64–1.86, p = 0.78). Irregular menses posed a greater risk of moderate-to-severe dysmenorrhea than regular menses (29.4% vs. 19.1%, PR = 1.54, 95% CI: 0.95–2.53, p = 0.09). In multivariate analyses, several associations remained statistically significant after adjusting for maternal age and current breastfeeding. Participants who reported higher ACEs more frequently experience moderate-to-severe dysmenorrhea than those with fewer ACEs (adjusted PR [aPR]=1.71, 95% CI: 1.04–2.79, p = 0.03). Women who were breastfeeding at 24 months post-delivery had a higher likelihood of reporting moderate-to-severe dysmenorrhea compared to those who were not breastfeeding (aPR = 1.66, 95% CI: 1.02–2.71, p = 0.04), after adjustment for age. Pain relief behaviors were also significantly associated with severity: women with moderate-to-severe dysmenorrhea reported using painkillers more frequently (aPR = 4.12, 95% CI: 2.52–6.73, p < 0.001) and spending additional hours in bed than those without moderate-to-severe dysmenorrhea (aPR = 3.11, 95% CI: 1.88–5.14, p < 0.001). Discussion This study aimed to assess the prevalence and severity of dysmenorrhea and identify its correlates among women at 2 years postpartum in Western Kenya. We found that 24% of women reported moderate-to-severe dysmenorrhea on the severity subscale of the CMSS, defined as experiencing at least one symptom that was moderately to very severely bothersome. Consistent with our hypothesis, abdominal cramps and pain were the most commonly reported symptoms, both in terms of duration and severity. These findings highlight a significant symptom burden among postpartum women in this setting, which is often underrecognized in both clinical and research contexts. The overall prevalence of moderate-to-severe dysmenorrhea in our study was higher than previously reported estimates in LMICs, which typically range from 10% to 15% for dysmenorrhea severe enough to disrupt daily functioning, particularly among adolescents and young adult’s women, using a variety of symptom-based scales [1,2,4–7]. Our focus on a postpartum population with previous pregnancies and current caregiving responsibilities may account for this discrepancy. While parity is often associated with reduced risk of dysmenorrhea [5], other factors such as postpartum hormonal changes, uterine recovery, and caregiving demands may influence the menstrual pain trajectories. After childbirth, the uterus undergoes involution and physiological adaptation, including reduced prostaglandin production and decreased nerve fiber density, which can lower uterine contractility and pain sensitivity during menstruation [32]. Additionally, cultural normalization of menstrual pain and underreporting in face-to-face surveys may have contributed to the lower estimates elsewhere [15]. These findings highlight the complex biopsychosocial dimensions of menstrual pain in postpartum populations and point to the need for integrated postpartum care that considers trauma, caregiving demands and cultural norms surrounding help seeking and pain management. Our finding that high ACEs were associated with moderate-to-severe dysmenorrhea in our study aligns with a growing body of evidence that early life adversity increases pain sensitivity and risk for chronic pain conditions, including menstrual disorders [33–35]. ACEs have been shown to dysregulate the hypothalamic-pituitary-adrenal (HPA) axis, heighten systemic inflammation, and alter pain processing pathways, all of which may predispose women to gynecological pain syndromes later in life [33,36,37]. Systematic reviews and cohort studies indicate that childhood exposure to violence, neglect, or household dysfunction is associated with both primary and secondary dysmenorrhea, as well as pelvic pain and endometriosis [34,35]. Specifically, women with a history of sexual abuse or emotional trauma are more likely to report severe menstrual pain, even after adjusting for sociodemographic factors [34,35]. These findings support a biopsychosocial framework for dysmenorrhea, emphasizing that menstrual pain is shaped not only by physiological and hormonal processes but also by the long-term psychological and neurobiological consequences of early trauma [33,38]. Integrating trauma-informed approaches into menstrual health care may be essential for addressing the needs of women with high ACE exposure. The association between breastfeeding and moderate-to-severe dysmenorrhea observed in our study adds to a limited and conflicting body of evidence. Some research suggests that prolonged breastfeeding may delay the return of regular ovulatory cycles, potentially modulating ovarian hormone production and uterine activity, thereby offering temporary protection against menstrual pain [39–41]. For instance, a prospective observational study found that breastfeeding, particularly if exclusive, may cause improvement in dysmenorrhea and chronic pelvic pain proportional to the duration of breastfeeding, as well as a reduction in the size of ovarian endometriomas [42]. However, our finding that extended breastfeeding was associated with increased likelihood of moderate-to-severe dysmenorrhea may reflect the hormonal fluctuations and uterine involution that occur during lactation, particularly in the transition to regular menses [43]. Oxytocin-induced uterine contractions during breastfeeding accelerate involution but can also cause postpartum afterpains, which may intensify discomfort as regular menstruation resumes [43]. Additionally, the physical and emotional stress associated with caregiving and lactation demands might exacerbate pain perception in some women [44–46]. These findings suggest that the relationship between breastfeeding and dysmenorrhea is likely mediated by complex physiological and psychosocial mechanisms, underscoring the importance of considering postpartum status in menstrual health research. Moderate-to-severe dysmenorrhea was associated with spending additional time in bed or taking painkillers during menstruation. These behaviors may reflect greater symptom intensity and also may indicate reliance on passive coping strategies that could unintentionally reinforce pain-related interruptions to functioning. Prolonged rest or withdrawal from daily activities has been associated with heightened pain sensitivity and reduced psychological resilience in individuals with chronic pelvic pain [47,48]. These findings emphasize the importance of equipping women with proactive, evidence-based pain management strategies and addressing structural barriers to care that may limit access to treatments, including trauma histories and caregiving demand. We found that moderate-to-severe dysmenorrhea was associated with depression in univariate analysis. While this association was no longer significant after adjusting for age and breastfeeding, the point estimate remained high. Our findings are consistent with previous research indicating a strong co-occurrence between menstrual pain and depressive symptoms, potentially influenced by shared neuroendocrine, inflammatory, and psychological mechanisms [49–51]. Evidence also suggests that dysmenorrhea is associated with an increased risk of postpartum depression, highlighting a potential bidirectional relationship between pain and mood [14]. Meta-analyses and genetic studies further indicate that women with primary dysmenorrhea are more likely to experience depressive symptoms, and that depression may be linked to an increased risk of dysmenorrhea through pathways involving sleep disturbances and serotonin regulation [52]. Our results reinforce the importance of screening for mood symptoms in dysmenorrhea care. Further studies that are specifically designed to evaluate associations between mood and dysmenorrhea are needed to better understand the nature and strength of this relationship, particularly among women in the extended postnatal period. Contrary to our secondary hypotheses, moderate-to-severe dysmenorrhea was not significantly associated with younger age, low parity, or irregular menstrual cycles, factors that have been associated with higher dysmenorrhea risk in previous studies among adolescents and nulliparous women [5,53,54]. The lack of association in our study may reflect the postpartum status of participants, who were generally older, multiparous, and currently breastfeeding. Pregnancy and childbirth may physiologically reduce menstrual pain through mechanisms such as hormonal reset or uterine recovery [5,55]. Multiparity was found to be protective against dysmenorrhea in prior studies, likely due to long-term changes in uterine innervation, reduced prostaglandin sensitivity, and anatomical changes that follow repeated pregnancies [5]. Additionally, since all participants had given birth, our sample may underrepresent individuals with conditions such as endometriosis, chronic pelvic inflammatory disease, or other conditions associated with subfertility, which are often associated with severe dysmenorrhea [56–58]. This selection bias may partially account for the absence of associations seen in broader populations [59]. Our study is among the first to provide epidemiological data from a large, well-characterized cohort on the prevalence, severity, and correlates of dysmenorrhea among postpartum women in Kenya, addressing a significant gap in this region. However, the study is not without limitations, which should be considered when interpreting results. First, the findings are based on a sample enrolled from two counties in Kenya, which may limit generalizability to other regions. However, over 90% of pregnant women in these counties attend at least one antenatal care visit; thus, enrolling in antenatal care clinics is likely to result in a representative sample of pregnant women [60]. Second, our study only included women who were pregnant within the past 24 months; therefore, our findings are not generalizable to women without prior pregnancies and those with conditions that may prevent successful pregnancies (e.g., infertility). Pre-pregnancy dysmenorrhea status was not assessed, and pregnancy and childbirth may alter menstrual pain through hormonal and physiological changes, limiting our ability to assess changes in symptom severity across reproductive stages. Furthermore, selection bias maybe possible if women with fewer symptoms or lower healthcare needs were less likely to return for follow-up. Third, although menstrual flow characteristics (light, moderate, or heavy) were collected, they were not significantly associated with moderate-to-severe dysmenorrhea in the univariate analysis and thus, was not included in the multivariate model; nevertheless, heavy menstrual bleeding may still contribute to dysmenorrhea severity in other populations. Fourth, the assessment and determination of dysmenorrhea relied on self-report questionnaires rather than clinical diagnosis, meaning we were unable to fully distinguish primary from secondary dysmenorrhea, and diagnoses such as endometriosis, pelvic inflammatory disease, or other reproductive tract conditions may have been missed. In addition, data on postpartum infections (e.g., sepsis), sexually transmitted infections other than HIV, and other comorbidities that may influence menstrual pain were not collected. Fifth, while education level and employment status were included as proxy indicators of socioeconomic status, more comprehensive measures (e.g., income or household wealth) were not available and may influence health-seeking behaviors, pain management strategies, and psychological distress. Finally, the scarcity of local studies assessing the prevalence and correlates of dysmenorrhea in Kenya may hinder external validity and limit comparisons. Future research should incorporate approaches for clinical exclusion of underlying pathology when possible. Despite these limitations, this study contributes valuable epidemiological data to bridge existing gaps and highlights the need for future research to explore associations between menstrual health and psychological distress among perinatal African women, including the need for longitudinal, clinically informed studies that capture menstrual health across the reproductive life course. Conclusion This study assessed the prevalence, severity, and correlates of dysmenorrhea among postpartum women in Western Kenya. Nearly 1 in 4 women in this cohort experienced moderate-to-severe dysmenorrhea, with abdominal cramps and pain being the most commonly reported symptoms. 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