We’ve all been there. Laid up on day one of menstrual flow pondering the need for such torture. Painful cramps that occur with menstruation, is known as dysmenorrhea. It is the most common gynecologic problem in women of all ages and races, and one of the most common causes of pelvic pain.
Estimates of the prevalence of dysmenorrhea vary widely, but rates as high as 90% of women have been recorded. Classic symptoms include lower abdominal or pelvic pain that may radiate to the back or legs. Pain typically lasts eight to 72 hours and usually occurs at the onset of menstrual flow (day 1 of the menstrual cycle). Other associated symptoms may include low back pain, headache, diarrhea, fatigue, nausea, or vomiting. Typically, the onset of dysmenorrhea is about six to 12 months after menarche (start of menstruation), with peak occurrence in the late teens or early twenties. Symptoms can, at times, be so severe that it may lead to school and work absenteeism, as well as limitations on social, academic, and sports activities.
Why does this happen? Our female hormones are responsible for the beautifully complicated menstrual cycle. As part of this cycle if no fertilization occurs, the lining of the uterus (endometrium) that was once preparing for implantation, begins losing its blood supply and ultimately sloughs off. As the endometrial sloughing progresses, prostaglandins are released which play a major role in inducing uterine contractions to aid in expulsion of the old endometrial tissue. But because these contractions are nonrhythmic and incoordinate, they are different than those experienced in active child labor. Nonetheless, they can occur at high frequency resulting in high uterine pressures felt as “cramping” and other symptoms. Prostaglandins may also contribute to the nausea and diarrhea that some women experience. There are some risk factors that are thought to increase dysmenorrhea: heavy menstrual loss, premenstrual symptoms, irregular menstrual cycles, Menarche before 12 years of age, and low body mass index.
Dysmenorrhea is classically considered a problem for adolescent and young women, and often viewed as a miserable, but normal, part of the menstrual cycle. The incidence of dysmenorrhea drastically decreased with age (as well as after pregnancy). However, about 10% of young adults and adolescents with dysmenorrhea have an underlying pathology (known as secondary dysmenorrhea). The most common cause is endometriosis, and is highest among women 25 to 29 years of age. Changes in timing and intensity of the pain, pain with intercourse, and infertility may suggest endometriosis. Women with a family history of endometriosis in first-degree relatives are more likely to have it or another cause secondary dysmenorrhea. Older women with no history of previous dysmenorrhea need further evaluation by a healthcare professional.
A review of 73 randomized controlled trials (the gold standard for clinical research) demonstrated strong evidence to support nonsteroidal anti-inflammatory drugs (NSAIDs) as the first-line treatment for primary dysmenorrhea. NSAIDs inhibit the production of prostagladins thereby minimizing their effects and subsequent symptoms. As a plus, many NSAIDs (ibuprofen, naproxen, etc.) are readily available over the counter and are relatively inexpensive. No one NSAID has been proven more effective than others, and so the choice should be based on effectiveness, tolerability, and cost for the individual woman. For the best results, medications should be taken one to two days before the anticipated onset of menses, and continued on a fixed schedule for two to three days. Not sure when you menstrual cycles might start? There’s an app for that! There are many smart phone apps for tracking the days, flow, and symptoms. Some even predict when your next cycle will be and send you an email or text reminder. Keeping track of the when and what of your symptoms will also help your provider in making a diagnosis and managing your dysmenorrhea. What did women do before smart phones?
Hormonal contraceptives have been recommended for management of primary dysmenorrhea, but there is limited evidence supporting their effectiveness. However, oral contraceptive have demonstrated effectiveness and are first-line treatment for dysmenorrhea caused endometriosis, as well as the etonogestrel implant (Nexplanon), and the levonorgestrel-releasing intrauterine system (Mirena).
There is limited and inconsistent evidence on the effectiveness of nonpharmacologic therapies for primary dysmenorrhea (e.g. not endometriosis). Expert consensus and one small study suggest that topical heat may be as effective as NSAIDs, but there is insufficient evidence for acupuncture, yoga, and massage. Exercise may provide some benefit, but the evidence is limited to small trials. Then again, exercise couldn’t hurt and is therapeutic in so many ways.