Menstrual Pains

Overview

Menstrual cramps, also known as dysmenorrhea or period pains, are painful sensations felt in the lower abdomen that can occur both before and during a woman's menstrual period. The pain ranges from dull and annoying to severe and extreme. Menstrual cramps tend to begin after an egg is released from the ovaries and travels down the fallopian tube (ovulation).

What are painful menstrual periods?

Menstruation is a monthly occurrence for women in which the body sheds the lining of the uterus (womb), which is then passed through a small opening in the cervix and out through the vaginal canal.

Some pain, cramping, and discomfort during menstrual periods is normal. However, excessive pain that causes you to regularly miss work or school is not.

The medical term for painful menstruation is dysmenorrhea. Primary dysmenorrhea occurs in women who experience pain just before and during menstruation, but who are otherwise healthy. Women who have had normal periods that later become painful may have secondary dysmenorrhea. This condition is usually accompanied by a problem affecting the uterus or other pelvic organs.

What Are the Causes?

There may not be an identifiable cause of your painful menstrual periods. Certain women are at a higher risk for having painful menstrual periods. Risk factors include:

• being under age 20
• having a family history of painful periods
• smoking
• having heavy bleeding with periods
• having irregular periods
• never having had a baby
• having experienced early puberty, which is puberty before the age of 11

Hormone-like substances called prostaglandins trigger muscle contractions to help your uterus expel its lining each month. These contractions can cause pain and inflammation. Women with higher levels of prostaglandins may experience more severe menstrual cramping and pain.

In some cases, such as with secondary dysmenorrhea, painful menstrual periods can be the result of an underlying medical condition, such as:

• premenstrual syndrome (PMS)
• endometriosis (a painful medical condition in which cells from the lining of the uterus grow in other parts of the body)
• fibroids in the uterus (noncancerous tumors)
• pelvic inflammatory disease, an infection of the uterus, fallopian tubes, or ovaries often caused by sexually transmitted infections
• sexually transmitted infections (STIs)
• adenomyosis, a rare condition in which the uterine lining grows into the muscular wall of the uterus
• cervical stenosis, a rare condition in which the cervix is so small it slows menstrual flow (NLM)

Certain types of birth control, specifically intrauterine devices (IUDs) made of copper, are associated with increased pain during menstruation.

When to Call a Doctor

If menstrual pain is interfering with your ability to perform basic tasks each month, it may be time to talk to your gynecologist about your symptoms. Talk to your doctor if you experience any of the following:

• pain after IUD placement
• painful menstrual periods that have lasted longer than three months
• passing blood clots
• cramping accompanied by diarrhea and nausea
• pelvic pain when not menstruating

Sudden cramping or pelvic pain could also be signs of infection. An untreated infection can cause scar tissue that damages the pelvic organs and may lead to infertility. If you have symptoms of an infection, seek prompt medical attention. Symptoms include:

• fever
• severe pelvic pain
• sudden pain, especially if you may be pregnant
• foul-smelling vaginal discharge

Home Treatment

Home care treatments may be successful in relieving painful menstrual periods. Home treatment includes:

• using a heating pad on your pelvic area or back
• massaging the abdomen
• taking a warm bath
• regular physical exercise
• eating light, nutritious meals
• practicing relaxation techniques or yoga
• taking an anti-inflammatory medication such as ibuprofen several days before your expected period
• taking vitamin B-6, vitamin B-1, vitamin E, omega-3 fatty acids, calcium, and magnesium supplements while reducing your intake of salt, alcohol, caffeine, and sugar to prevent bloating
• raising your legs or lying with your knees bent

Medical Treatment

If home treatment is not successful in relieving your menstrual pain, there are a number of medical treatment options. Treatment will depend on the severity and underlying cause of your cramps. If your pain is caused by PID or STIs, these need to be treated. Your doctor will prescribe antibiotics to clear the infection. Your doctor may prescribe a medication to help with the pain. These medications include:

• non-steroidal anti-inflammatory drugs (NSAIDs)
• pain relievers, such as narcotics
• antidepressants

Your doctor may also suggest that you try hormonal birth control. Hormonal birth control is available in the form of a pill, patch, vaginal ring, injection, or implant. Hormonal birth control uses hormones to prevent ovulation, which can control your menstrual cramps.

Surgery is an option if your pain is caused by endometriosis or uterine fibroids and other treatment options have not been successful. Surgery will be done to remove any endometriosis implant, uterine fibroids, or cysts.

In very rare cases, a hysterectomy (surgical removal of the uterus) is also an option if other treatments have not worked and pain is severe.

What Is Menorrhagia?

The duration and severity of menstrual bleeding varies from woman to woman. If a woman’s menstrual period is excessively heavy, prolonged, or irregular, it is called menorrhagia.

Symptoms of menorrhagia include a menstrual period that lasts longer than seven days and bleeding is so heavy that you must change your tampon or pad more than once per hour. You should see your doctor if you have excessively heavy or prolonged menstrual periods that interfere with your daily life.

Excessive bleeding can cause anemia (iron deficiency) or signal an underlying medical condition. In most cases, abnormal periods can be successfully treated.

What Is a Normal Menstrual Period?

The length of the menstrual cycle and amount of blood flow is unique to each woman. However, most women have a cycle that ranges from 24 to 34 days. Blood flow averages about four or five days, with a blood loss of about 40 cc (3 tablespoons). It is important to remember that these are just averages and that your “normal” may fall outside of these ranges.

Symptoms of Abnormal Menstrual Periods

A blood loss of 80cc (5 tablespoons) or more is considered an abnormally heavy flow. Signs that your flow may be abnormally heavy include:

• You are soaking through more than one tampon or sanitary pad in an hour, for several hours at a time.
• You need to double-up on sanitary pads or need both a tampon and a pad.
• You wake up during the night because you need to change protection.
• You notice large blood clots in your flow.
• Your period lasts more than a week.
• You can’t participate in your normal activities because your flow is too heavy.
• You have signs of anemia, which include fatigue, pale skin, shortness of breath and dizziness.

While every woman’s cycle is different, irregularities such as bleeding mid-cycle or bleeding after intercourse are considered abnormal symptoms.

What to Do About Heavy or Irregular Menstrual Periods

Keep track of your menstrual cycles, how long your blood flow lasts, and how many tampons or sanitary pads you use during each cycle. This information will be helpful at your next gynecological appointment. Avoid products that contain aspirin because they may increase bleeding.

When to Seek Medical Care

You should see your gynecologist once a year for a check-up. However, you should make an appointment right away if you have:

• bleeding or spotting between periods
• bleeding or spotting after intercourse
• bleeding or spotting while pregnant
• bleeding or spotting after menopause
• periods that require more than one tampon or sanitary pad in an hour, for two or three consecutive hours
• periods that consistently last for more than a week
• severe pain
• fever
• abnormal discharge or abnormal odor
• unexplained weight gain or loss
• unusual hair growth, new acne, or discharge from your nipples

Risks of Heavy Menstrual Periods

Heavy blood flow is not always a sign that something is wrong. However, excessive loss of blood can deplete the body’s supply of iron and cause anemia. A mild case of anemia can cause fatigue and weakness. A more severe case can result in headaches, dizziness, shortness of breath, and rapid heart rate.

A very heavy flow can also cause painful cramping (dysmenorrhea), which sometimes requires medication.

Diagnosing Heavy or Irregular Menstrual Periods

If you have abnormal menstrual periods, your doctor will probably begin with a pelvic examination. You should also be prepared to give your medical history and list all the medications and supplements you are taking.

Depending on your specific symptoms, diagnostic testing may include:

• a pap smear to check for various infections or cancerous cells
• blood tests to check for anemia, blood-clotting problems, and thyroid function
• pelvic ultrasound to produce images of your uterus, ovaries, and pelvis
• endometrial biopsy to analyze a sample of uterine tissue
• hysteroscopy to view the inside of your uterus
• pregnancy test

Causes of Heavy or Irregular Menstrual Periods

Heavy or irregular periods can be caused by a variety of factors, including:

Medications: Some anti-inflammatory drugs, anticoagulants, or hormone medications can affect menstrual bleeding.

• Intrauterine devices (IUD): Heavy bleeding can be a side effect of intrauterine devices used for birth control.
• Hormonal imbalance, abnormal thyroid or pituitary function: The build-up of the lining of the uterus is regulated by the hormones estrogen and progesterone. An excess of these hormones can cause heavy bleeding. Hormone imbalances are most common among girls who began mestruating in the past year and a half, and women who are getting close to menopause.
• Pelvic inflammatory disease or other infections
• Endometriosis: This is a condition in which tissue that lines the inside of the uterus begins to grow elsewhere inside the body, which can cause heavy bleeding as well as pain.
• Fibroids: Noncancerous tumors in the uterus can cause heavy bleeding or long periods.
• Polyps: Benign growths in the uterine lining (endometrium) can cause a heavy or prolonged period.
• Ovary dysfunction: Lack of ovulation (anovulation) results in a lack of progesterone, causing heavy periods.
• Adenomyosis: When glands from the uterine lining embed in uterine muscle, heavy bleeding can occur.
• Complications of pregnancy: Contact your doctor if you bleed during pregnancy. Normal pregnancy interrupts menstruation; however, some spotting during pregnancy, especially during the first trimester, is often nothing to worry about. Seek immediate medical attention if you bleed heavily during pregnancy, it can be a sign that the fertilized egg has implanted in the fallopian tube rather than the uterus (ectopic pregnancy). It can also indicate a miscarriage.
• Bleeding disorders: Heavy menstrual bleeding can be caused by some inherited blood disorders that affect clotting.
• Cancer: Cervical, ovarian, or uterine cancer can all cause heavy bleeding, but this is rare.

Treatment for Heavy or Irregular Menstrual Periods

Treatment will be based on your overall health, the reason for your menstrual abnormalities, and your reproductive history and future plans. Any underlying medical conditions, such as thyroid dysfunction, will need to be addressed.

Medication

Mild blood loss can be reduced with the use of nonsteroidal anti-inflammatory drugs, such as ibuprofen or naproxen, and anemia can be treated with iron supplements. If your irregularities are caused by medications, you can work with your doctor to find alternatives. Hormonal imbalances may be treated with hormone replacement injections. Oral contraceptives can also be used to regulate your cycle and shorten periods.

Medical Procedures

Dilation and curettage (D&C) is a procedure in which the doctor dilates your cervix and scrapes tissue from the lining of your uterus. This is a fairly common procedure and generally cuts down on menstrual bleeding.

Cancerous tumors are generally removed through surgery. Surgery is also an option to treat fibroids, but is not always necessary. Polyps can be removed in a procedure called a hysteroscopy, in which the doctor uses a lighted tube to view the uterus and remove the polyp.

Endometrial ablation is a procedure used in women who have had no success with medications to control heavy bleeding and related symptoms. In this procedure, the doctor will destroy the uterine lining, leaving little or no menstrual flow. Endometrial resection removes the uterine lining. This procedure significantly decreases your chances of a future pregnancy, so women who plan on having children should discuss other possible treatment options.

Hysterectomy is the surgical removal of the uterus and cervix, and may be recommended in the case of cancers, to remove fibroids, and to treat endometriosis that has not responded to other less-invasive forms of treatment. A hysterectomy will end your ability to bear children. If necessary, the ovaries are also removed, resulting in premature menopause.