Biopsychosocial factors associated with menstrual pain, menstrual attitudes, health literacy, and physical activity across age-based cohorts: a cross-sectional comparative study

Menstrual pain is influenced by biological, psychological, and sociocultural factors. This study compared menstrual pain, menstrual attitudes, health literacy, and physical activity across age-based cohorts of women and examined the associations between menstrual attitudes and menstrual pain. In this cross-sectional study, 1,220 women with primary dysmenorrhea were classified into three age-based cohorts corresponding to Generations Z ( n = 380), Y ( n = 440), and X ( n = 400). Menstrual pain, menstrual attitudes, health literacy, and daily step counts were assessed using validated instruments. Group differences were examined using χ² and Kruskal–Wallis tests followed by Dwass–Steel–Critchlow–Fligner post-hoc comparisons where appropriate. Spearman correlation and adjusted multiple linear regression analyses were performed. Significant differences were observed across the age-based cohorts in menstrual pain, menstrual attitudes, and health literacy (all p < 0.05), whereas physical activity did not differ significantly. Women in the youngest age-based cohort reported the highest pain levels and more positive menstrual attitudes, whereas women in the oldest age-based cohort had the lowest health literacy scores. Significant differences were identified across all MAQ subscales, with the largest effect observed for the Anticipation and Prediction of Menstruation subscale (ε²=0.084). Correlation analyses showed that the associations between menstrual attitude dimensions and pain varied across cohorts, although a weak negative association between pain and the Denial of the Effects of Menstruation subscale was consistently observed. In the adjusted regression model, perceiving menstruation as a bothersome event (β = 0.159, p < 0.001) and as a natural event (β = 0.062, p = 0.026) were positively associated with pain, whereas denial of the effects of menstruation was negatively associated with pain (β=−0.243, p < 0.001). Menstrual pain and menstrual attitudes differed across age-based cohorts, and specific dimensions of menstrual attitudes were independently associated with pain severity. These findings support a biopsychosocial perspective on menstrual pain and highlight the importance of age- and life-stage-sensitive approaches to menstrual health. Because of the cross-sectional design, causal inferences cannot be made.