Painful Periods

More than half of women experience pain during their periods. With the average age of starting periods being 10-12 years old and the average age of menopause being 51, that results in numerous painful episodes over a lifetime. The big questions for most women with painful periods are:

1. What is causing the pain?
2. What are some treatments?
3. Is there reason to be concerned?

Dysmenorrhea

There are two types of dysmenorrhea—primary and secondary. Primary dysmenorrhea is cramping/pelvic pain during a period not caused by other diseases. Secondary dysmenorrhea is cramping/pelvic pain due to a medical problem like endometriosis. Painful periods are caused by excess amounts of prostaglandins being released in the lining of the uterus. Prostaglandins are substances that come from cells causing blood vessels to dilate and muscles, such as the uterus and the gastrointestinal tract, to contract, resulting in nausea/vomiting and diarrhea. These are the same substances released at the time of injury, which similarly cause pain. Medications like Aleve, Midol, and Ibuprofen help block the production of prostaglandins, explaining why these medications can help with pain/cramping. When someone presents for a consult, the most important starting point is to determine if dysmenorrhea is primary or secondary. Obtaining a good history is important.

Questions to Consider

• What has been tried?
• Family history?
• Sexual history?
• Other medical problems?

An abdominal exam and a pelvic exam (in some cases) are part of the evaluation. A pelvic ultrasound can also be helpful. Primary dysmenorrhea can be due to less common causes like a misshaped uterus or imperforate hymen. Secondary dysmenorrhea is often due to endometriosis. Endometriosis is the lining of the uterus found outside of the uterus. The only way to confirm the diagnosis of endometriosis is by performing a minimally invasive surgery called laparoscopy. The endometriosis implants secrete pro-inflammatory factors and are fed by estrogen from the ovaries. This inflammation can also cause bowel and/or bladder problems as well as scarring. Pelvic inflammatory disease due to prior infection can also cause secondary dysmenorrhea.

Treatments

• Anti-inflammatories:

  Taking anti-inflammatories, particularly before the period starts, can be very helpful. Tylenol (acetaminophen) doesn’t work as well as Motrin (Ibuprofen), Naproxen, Mobic, Midol, or Aleve. A healthy adult should not take more than 3200 mg of Ibuprofen in a 24-hour period. Taking anti-inflammatories on a scheduled basis a couple of days before the period or as soon as the period starts works better than starting when the pain is in “full swing.”

• Magnesium oxide: 400 mg three times a day for the first few days of the period can be as helpful for many women as taking Vitamin B1.
• Hormones: Progesterone-only pills, combination oral contraceptives, or a progesterone intrauterine device are all very helpful in decreasing dysmenorrhea as well. They decrease prostaglandin production. If endometriosis is the cause, these hormonal agents can help stop pain flare-ups.
• Laparoscopy: An outpatient minimally invasive surgery that can be done to evaluate for causes of ongoing painful periods if not responding to other treatments.
• Exercise, acupuncture, and massage: The importance of these additional methods to help alleviate pain cannot be underestimate.