Fast Facts for Your Health: Severe Menstrual Pain

Basics of Severe Menstrual Pain

Many women experience painful menstrual cramps (dysmenorrhea) just before and during the first few days of their monthly periods. But if this pain is severe enough to interfere with your daily life, preventing you from attending school or work or participating in other usual activities, you should see your health care professional. You may have a condition called severe dysmenorrhea, which is the technical term for severe menstrual pain.

If you have severe dysmenorrhea, your health care professional will work with you to figure out whether there is a specific underlying structural cause, such as uterine fibroids or endometriosis. If there is, the condition is known as "secondary" dysmenorrhea, and treatment involves addressing the structural trigger of the pain.

When something structural can't be identified as causing the pain, your diagnosis most likely would be "primary" dysmenorrhea, a condition that affects anywhere from 20 to 90 percent of all menstruating women. This form of menstrual pain is believed to result from the release of prostaglandins, hormone-like substances involved in pain and inflammation, which trigger uterine muscle contractions.

The pain also may result from the stretching of the cervix as it expands to allow passage of blood clots from the uterus to the vagina. Primary dysmenorrhea is more common in adolescents and young adults; in fact, it is a leading cause of recurrent school or work absenteeism in this age group. The condition tends to improve as a woman grows older.

Some studies suggest that women who smoke, drink alcohol, are overweight or who started menstruating early in life (before age 11) have an increased risk of dysmenorrhea; however, the results of these studies are fairly inconsistent.

Symptoms of Dysmenorrhea

The most common symptom of dysmenorrhea is crampy abdominal pain, which may or may not radiate to the back of your legs or lower back. Other symptoms can include:

• nausea
  
• diarrhea
  
• vomiting
  
• fatigue
  
• fever
  
• headache
  
• light-headedness

Pain usually develops within hours of menstruation starting and peaks as the flow becomes heaviest during the first day or two.

Diagnosing Dysmenorrhea

Before recommending treatment, your health care professional will need to determine whether you have primary or secondary dysmenorrhea. He or she will start by asking you about your medical history and symptoms and by performing a pelvic examination.

If your symptoms began during your teenage years or early adulthood and your examination is normal, you likely have primary dysmenorrhea. But if your painful periods began after age 25, with no previous history of such pain, and have not been helped by over-the-counter pain relievers, you may have an underlying problem that is causing dysmenorrhea.

Some women with primary dysmenorrhea may find their cramps worsening over the years, suggesting they may have developed secondary dysmenorrhea as well. In addition to the pelvic exam, you may need to have one or more of the following tests to investigate:

• Imaging tests. These noninvasive tests enable your health care professional to look for abnormalities inside your pelvic cavity. Test examples include ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI).
  
• Laparoscopy. Your health care professional makes a small incision in your abdomen and uses a fiber-optic tube called a laparoscope to examine the pelvic region.
  
• Hysteroscopy. In this procedure, your doctor inserts an instrument into your vagina and through your cervical canal to examine the inside of your uterus.

Some of the more common causes of secondary dysmenorrhea include:

• Endometriosis, a condition in which endometrial tissue, which makes up the uterine lining, grows outside the uterus
  
• Pelvic inflammatory disease, a bacterial infection of the pelvic organs that is usually sexually transmitted
  
• Use of an intrauterine device (IUD), a small, plastic, T-shaped birth control device inserted into the uterus
  
• Uterine fibroids and uterine polyps, abnormal growths that can protrude from the lining of the uterus.

Treating Severe Menstrual Pain

Treatment for secondary dysmenorrhea is determined by the underlying cause. Depending on the condition, medications and/or surgery may be needed.

For primary dysmenorrhea, the first line of treatment is usually a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen (Motrin), which inhibits the production of prostaglandins. These medications generally are most effective when started 24- to 48-hours before the onset of menstruation and continued for one or two days after onset. You may need to try several over-the-counter medications before finding one that works for you. Or you may need a prescription-strength NSAID.

Oral contraceptives, or birth control pills, are another effective treatment option, and many women with primary dysmenorrhea experience complete relief in response to oral contraceptives. The birth control pill inhibits ovulation and reduces menstrual flow.

Either an NSAID or an oral contraceptive is usually sufficient to treat the pain, although some women find they require both. For approximately one out of 10 women, however, neither medication will work. If this is true for you, continue working with your health care professional to find other solutions. Some women have found relief with alternative treatments such an acupuncture and dietary changes and supplements.

Other lifestyle changes that you may find helpful include reducing stress, exercising regularly, getting enough sleep and eating a healthy diet.

Questions to Ask Your Health Care Professional

You may find the following questions useful in starting a conversation with your health care professional:

1. Why are my menstrual periods so painful?
2. What tests will you use to figure out what's causing the pain?
3. Can you do these tests or will I need to go to another medical professional or facility?
4. Which treatments will work best for me? Will they cure the pain?
5. If you need to refer me to a specialist, is there someone you can recommend?
6. Will any of the medications you're recommending cause side effects or interact with food or other medications I take?

Resources

Your Guide to Uterine Health
National Women's Health Resource Center
1-877-986-9472
www.healthywomen.org
An online overview of uterine health, including fibroids. Also available in print.

"Menstrual cramps (dysmenorrhea)"
Comprehensive overview from the Mayo Clinic
www.mayoclinic.com

American College of Obstetricians and Gynecologists
202-638-5577
www.acog.com
Patient education pamphlet on "Dysmenorrhea" available online or by calling the number.

National Women's Health Information Center
1-800-994-9662
www.4woman.org
Sponsored by the U.S. Department of Health and Human Services and the Office on Women's Health, site is the federal government source for women's health information.

Medline Plus
www.nlm.nih.gov/medlineplus
Provided by the U.S. National Library of Medicine and the National Institutes of Health, site provides clear and thorough information on dysmenorrhea and other menstrual disorders.

American Academy of Family Physicians
1-800-274-2237
www.aafp.org
National organization of family physicians provides articles from the American Family Physician journal, as well as other current information and links.

Sources Consulted

Coco AS. "Primary dysmenorrhea." American Family Physician 1999 Aug; 60 (2): 489-96.

"Dysmenorrhea." MayoClinic.com. www.mayoclinic.com.

Harel Z. "Cyclooxygenase-2 specific inhibitors in the treatment of dysmenorrhea." Journal of Pediatric Adolescent Gynecology 2004 April; 17(2): 75-9.

Jones AE. "Managing the pain of primary and secondary dysmenorrhea." Nursing Times 2004 March 9-15; 100 (10): 40-3.

Marjoribanks J, Proctor ML, Farquhar C. "Non-steroidal anti-inflammatory drugs for primary dysmenorrhea." Cochrane Database System Review 2003; (4): CD001751.

"Primary Dysmenorrhea" and "Secondary Dysmenorrhea," in The Merck Manual of Diagnosis and Therapy, eds. Mark H. Beers, M.D. and Scott Berkow, M.D., Whitehouse Station, NJ: Merck and Co., 1999. page 1933.

Sonnenstuhl, Pat. "A Young Woman's Guide to Painful Menstrual Cramps (AKA: Dysmenorrhea)." OBGYN.net. www.obgyn.net.

For more information about severe menstrual pain, visit: "Questions to Ask about Severe Menstrual Pain" and "Menstrual Disorders."