More than 50% of women have some level of pain during their periods. Pain typically lasts for a few days and in most cases it’s defined as mild pain. Sometimes, pain can be moderate to severe, preventing normal daily activities, which is called dysmenorrhea. Dysmenorrhea is relatively common and results in missed days of school and work.
Uterus has a strong muscular layer which contracts and relaxes. Whereas this happens throughout the menstrual cycle, during the period it happens more strongly. Typically, these contractions are a result of prostaglandins (PG) that increase prior to the period and decrease towards the end of menstruation. This is one of the reasons why pain eases towards the end of the period. There are two types of dysmenorrhea that include primary and secondary depending on whether the pain is just due to the period itself or another cause.
Primary dysmenorrhea presents with a wide variety of symptoms such as pain or cramps in the lower back and abdomen or pelvis, dizziness, nausea, vomiting, headaches, diarrhea and shooting pains to the thighs and legs as well as the back. Primary dysmenorrhea is a result of pain caused by the menstrual changes and the release of prostaglandins. It typically begins following the first period (menarche) and over time pain becomes less and more tolerable. After having a baby, the pain may also improve, but is some cases it continues through the reproductive years. It’s also common to have some cycles more painful than others.
Secondary dysmenorrhea is having painful periods due to another cause in addition to menstruation. It may present with more severe pain that primary dysmenorrhea and in most cases lasts longer as well. Some of the common causes of secondary dysmenorrhea include the following:
Endometriosis is a relatively common gynecological condition that results in the presence of endometrial cells in certain areas of the pelvis, other than the inside of the uterus. Endometriotic lesions can be found on or inside the ovary, fallopian tubes, outside of the uterus, intestines, bladder and on the peritoneum (membrane that wraps abdominal organs). Endometrial tissue outside of the uterus responds to monthly hormonal changes the same way it does inside the uterus. It creates an inflammatory reaction in the pelvis because it swells, breaks and bleeds. Endometriosis can result in scar tissue in the pelvis as well and contribute to painful periods or pelvic pain in general.
Fibroids are non-cancerous tumors of the uterus and arise from the muscle layer. They can cause heavy periods, painful periods, pelvic pain, recurrent miscarriages and infertility. The size, number and the location of the fibroids are important factors that contribute to symptoms.
Intrauterine Device (IUD):
IUD use is a common contraceptive method that requires the device to be placed inside the uterine cavity. In the first few months following its insertion, dysmenorrhea and generalized pelvic pain can be observed. In most cases, pain eases over time, but in some cases it may be persistent that may necessitate the removal of the device.
Pelvic Inflammatory Disease (PID):
PID is the infection of the uterus, fallopian tubes and the ovaries that commonly results from a sexually transmitted disease (STD). Two most common causes are chlamydia and gonorrhea infections that may be present in the genital tract as silent infections. They can result in an inflammatory reaction in the pelvis and cause scar tissue that can result in pelvic pain, infertility and dysmenorrhea.
Diagnosis of Dysmenorrhea:
Dysmenorrhea is diagnosed by pelvic examination and certain tests. Initially, a detailed medical history is taken to describe the pain and menstrual symptoms followed by a pelvic examination to check for anything abnormal in the reproductive organs. A pap test and cultures to check for infections along with blood testing should be done. An ultrasound of the pelvis can provide additional information such as the presence of fibroids, ovarian cysts or other pelvic abnormalities.
In some cases, a procedure called laparoscopy may be necessary to directly look inside the abdomen and pelvis. Laparoscopy is a minimally invasive type of surgery done under general anesthesia as an outpatient. Laparoscopy allows diagnosis as well as treatment during the same procedure and patients can go home the same day. Endometriosis, pelvic adhesions and fibroids can be easily diagnosed and treated with good clinical outcomes.
Treatment of Dysmenorrhea:
Treatment of dysmenorrhea depends on the cause of the problem. In secondary dysmenorrhea, it is ideal to treat the underlying cause by a medical or the surgical approach. In most cases, laparoscopy can diagnose and treat the problem in secondary dysmenorrhea, and patients report a significant relief in their pain symptoms. In cases of primary dysmenorrhea, pain killers such as NSAIDs (non-steroidal anti-inflammatory drugs) are commonly used in conjunction with birth control pills with good outcomes.
NSAIDs block the production of prostaglandins that cause menstrual cramps and pain. They can also prevent other symptoms caused by prostaglandins such as nausea, vomiting and diarrhea. They are available over the counter and the two most commonly used ones are ibuprofen and naproxen. They should be taken with the onset of pain and continued until the pain resolves. The side effects include bleeding, liver damage, stomach disorders, gastritis and ulcers.
Birth control pills (BCPS) result in less growth of the endometrium, less bleeding, less prostaglandin production, fewer uterine contractions and overall less pain. Commonly, they are used along with NSAID type pain killers.
In addition to the options above, exercise appears improve menstrual pain and pelvic pain overall. Jogging, swimming and any aerobic exercise can be helpful in relieving pain. Application of heat to the lower abdomen also has been suggested to be soothing for dysmenorrhea. Additionally, relaxation techniques, meditation, and yoga have helped many women with pelvic pain. It is also important to get enough sleep and manage stress. Interestingly enough, some women have reported improvement of dysmenorrhea symptoms following orgasms along with other measures.
Dysmenorrhea is a common gynecological condition that most women experience during their reproductive years. Most of the time, pain in relieved by over the counter pain medications, but in moderate to severe cases it requires medical treatment. If there is severe pain for 2-3 cycles or pain killers do not result in any improvement in a single cycle, it is recommended that women seek gynecological assessment and possible testing for severe dysmenorrhea. Dr. Bayrak recommends a detailed evaluation of such cases for secondary causes of dysmenorrhea because once the exact cause is treated, pain typically resolves and patients feel more comfortable.