Dysmenorrhea (Menstrual Cramps)


Is your period cramping your lifestyle?

The uterus is a muscle, and like all muscles, it contracts and relaxes. This happens throughout your menstrual cycle, but during your period, the contractions are stronger, and therefore may be more noticeable.

Menstrual cramps, or dysmenorrhea, affect an estimated 75% of women. Fifteen percent of these women report incapacitating symptoms, including nausea, vomiting, bloating, and diarrhea. You may also experience headache, fatigue, and weakness. Painful periods are the leading cause of women missing work and school. The problem usually begins soon after you get your very first period. Fortunately, the condition generally responds well to simple drug therapy and changes in lifestyle, and often becomes less severe after pregnancy and as you grow older..

Synonyms

  • Dysmenorrhea (pronounced dis-men-or-REE-uh)

Detailed Description

The term menstrual cramps refers to cramping pain in the lower abdomen and pelvis that occur before, during, and sometimes after menstruation. (The synonym dysmenorrhea literally means "difficult monthly flow"). The cramping pain may spread to your lower back and thighs.

There are two different kinds of menstrual cramps: primary dysmenorrhea and secondary dysmenorrhea.

Primary dysmenorrhea is pelvic pain associated with beginning your period during adolescence. This pain is thought to result from contractions of the uterus caused by an excess of prostaglandin, a substance made by the lining of your uterus (the endometrium). (Prostaglandins are found throughout your body, but this one causes contractions in the uterus and intestines). When there's too much prostaglandin, the usually painless contractions of the uterus become longer and tighter, keeping oxygen from the muscular uterus, similar to having leg cramps. The lack of oxygen is what you feel as pain. Prostaglandins in semen (from the prostate gland of men) are also the source of menstrual cramps experienced during orgasm of sexually active women using no barrier contraception.

The level of prostaglandins in your uterus increases before your period and is lowered (because it is released) when your period starts. As you menstruate, prostaglandin levels drop, which explains why your cramps tend to lessen after the first few days of your period.

A heavy menstrual flow with blood clots that cause the cervix to widen (dilate), can also cause intense cramping. Other factors that may worsen pain include a uterus that tips backward instead of forward (producing a partial obstruction), lack of exercise, and stress.

Secondary dysmenorrhea is menstrual pain that is produced by some other cause than menstruation itself. One of the most common causes of secondary dysmenorrhea is endometriosis. Other causes include a tight cervical canal, fibroids, and the use of an intrauterine devices (IUD). Secondary dysmenorrhea usually lasts longer than normal cramps.

How Common Are Menstrual Cramps?

According to the American College of Obstetricians and Gynecologists, about 75% of women experience primary dysmenorrhea and 15% report severe symptoms. Thirthy-eight percent report that the cramps started with one year of getting their first period.

Menstrual cramps tend to get worse and occur more often soon after the time you start menstruating until you're in your early 20s; then begin to decrease. Most women who suffer from primary dysmenorrhea are in their teens to early 20s while secondary dysmenorrhea is more often experienced in women who are older. Many women with primary dysmenorrhea have much less of the problem after childbirth.

What You Can Expect

You will probably feel better after taking a nonsteroidal anti-inflammatory drug (NSAID) such as Tylenol (acetaminophen), Advil or Motrin (ibuprofen ), or Aleve (naproxen). If pain is severe and occurs every time you get your period, your doctor may suggest putting you on oral contraceptives.

If secondary dysmenorrhea is suspsected, your doctor will probably perform several tests to try to determine the cause of your cramping. These tests may include a pelvic exam, Pap test, uterine cavity sounding, ultrasound, and-- in some cases-- laparoscopy. During this procedure, the doctor inserts a fiber-optic viewing tube (a laparoscope) into your abdomen through a small incision just below your navel and inspects your abdomen internally.


Established Causes

Menstrual cramps not related to any physical abnormality or other disease, also known as primary dysmennorhea, are caused by the following:

  • A rise in the level of prostaglandin, a substance produced among other places, in the lining of your uterus. Prostaglandin causes your uterus to contract in such a way that it is deprived of oxygen, which produces cramping.

Menstrual cramps produced by causes other than menstruation (secondary dysmenorrhea) may be attributed to:

  • Anatomical variations such as a uterus that tilts backward instead of forward (retroverted uterus)
  • Endometriosis: a condition in which the tissue that usually lines the uterus grows in other parts of the body.
  • Noncancerous tumors called fibroids on the outside, inside, or in the wall of the uterus.
  • An intrauterine device (IUD): a device placed in the uterus to prevent pregnancy.

Risk Factors

The risk factors for primary dysmenorrhea differ from those for secondary dysmenorrhea.

Primary dysmenorrhea

  • Family history of menstrual cramps
  • Not having given birth vaginally to a child (also known as nulliparity)
  • Caffeine intake
  • Stress (the degree of pain may be affected by stress, but cramps are not caused by stress)
  • Lack of exercise

Secondary dysmenorrhea

  • Family history of fibroid tumors
  • An infection of the uterus, fallopian tubes, or ovaries called pelvic inflammatory disease (PID) that causes pelvic adhesions (tissue connections) that restrict normal movement of pelvic organs
  • History of sexually transmitted disease (STD)
  • Endometriosis: a condition in which the tissue that usually lines the uterus grows in other parts of the body.
  • A noncancerous condition in which the uterine lining invades the muscular wall of the uterus, a condition called adenomyosis.
  • Use of an intrauterine device (IUD), a device placed in the uterus to prevent pregnancy.
  • A narrow cervical canal (cervical stenosis)

Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.


Symptoms & Diagnosis

Women who suffer from menstrual cramps may experience the following symptoms:

Although the symptoms of primary and secondary dysmenorrhea are similar, secondary dysmenorrhea (menstrual cramps that are caused by something other than menstruation itself) usually lasts longer than normal cramps. It may begin long before your period starts, and last longer than your period. The majority of women have minor degrees of these symptoms. However, if and when they disrupt normal daily activities, they are regarded as abnormal. They also suggest Premenstrual Syndrome (PMS). Cramps from PMS subside as the menstruation begins.

Conditions That May Be Mistaken for Menstrual Cramps

Menstrual cramps and pain may be confused for the following conditions:

How Dysmenorrhea Is Diagnosed

Physicians will diagnose menstrual cramps on the basis of your history, physical exams, and tests. You will be asked to describe your medical history, symptoms, and menstrual cycle. Your doctor will probably then perform a Pap test and may take cervical cultures and blood samples. An ultrasound exam and/or laparoscopy may be advised to look for physical abnormalities.

Pap test

During the Pap test (or Pap smear, as it is often called), your doctor takes cells from your cervix and vagina to be stained and examined under a microscope. This procedure is done after inserting a speculum into the vagina to open it, before swabbing the cervix to obtain cells. This test is part of a routine gynecological exam.

Ultrasound

Ultrasound scanning uses sound waves to make pictures of your internal organs. It is a nearly painless test. The doctor presses a small probe against your abdomen or into your vagina and moves the probe to produce images of the pelvic structures. The images are displayed on a video screen during the exam and may be recorded on film.

Laparoscopy

During this surgical procedure, the doctor inserts a fiber-optic viewing tube (a laparoscope) into your abdomen through a small incision near your navel for directly examining your abdomen. In some cases, the doctor may have to remove a small sample of the tissue for examination under a laboratory microscope (biopsy) to make the diagnosis. This procedure usually requires general anesthesia, but "minilaparoscopy" can be done under local anesthesia and sedation.

Sometimes physicians are able to find a cause for menstrual cramps and treat that condition. But often there is no known cause, in which case, you and your doctor will discuss and determine the best way to alleviate your symptoms.

Goals of Treatment

The goal of treating primary dysmenorrhea is to alleviate the symptoms and while observing for underlying causes that may require specific therapy, whereas the goal of treating secondary dysmenorrhea is to treat the condition causing the menstrual cramps, thereby alleviating the symptoms.

Women who suffer from primary dysmenorrhea often find relief from over-the-counter or prescription pain killers or oral contraceptives, which prevent ovulation and the related hormonal changes that cause cramps. Changes in diet and lifestyle may also provide relief. Menstrual cramps of this degree of severity (or of this type) tend to diminish with age and after childbirth. And since they only occur following ovulation, menopause effectively ends the problem. However, as women near their menopause, they may bleed heavily because of fluctuating levels of ovarian hormones, and may have severe cramps even without ovulation.

Although secondary dysmenorrhea may be temporarily halted by medication, this type of menstrual pain usually requires surgery to correct the underlying condition since it is often caused by some type of uterine abnormality.

Drug Therapy

Your doctor can suggest medications to relieve your discomfort:

Anti-inflammatory drugs

Most women who suffer from menstrual cramps get relief from drugs called nonsteroidal anti-inflammatory drugs (NSAIDs) that block the production of the prostaglandins that cause menstrual cramps. NSAIDs work best when you take them at the first sign of pain. You usually only need to take NSAIDs for one to two days.

Look for these common NSAIDs, which you can buy without a prescription:

Or, your doctor might suggest one of these prescription NSAIDs:

Oral contraceptives

Taking birth control pills (oral contraceptives) also reduces menstrual pain for many women. The Pill works by lowering the amount of prostaglandin produced so there are fewer strong contractions, less menstrual flow, and less pain. You can take NSAIDs in addition to the Pill if necessary. Oral contraceptives may also benefit anemia caused by excessive loss of menstrual blood.

Your doctor will probably prescribe oral contraceptives with combined synthetic estrogen and progesterones, such as:

Surgery

Surgery is rarely used to treat primary dysmenorrhea.

Depending on its cause, secondary dysmenorrhea may be treated with surgery. For instance, various types of surgery, from minor to major, may be performed to treat endometriosis and a narrow cervical canal (cervical stenosis) can be dilated surgically.

Appropriate Healthcare Setting

Primary dysmenorrhea is treated on an outpatient basis.

Some cases of secondary dysmenorrhea are treated on an outpatient basis, but inpatient treatment is usually required depending on the underlying condition.

Healthcare Professionals Who May Be Involved in Treatment

The following healthcare providers may be involved with your care:

  • Family medicine physicians
  • Gynecologists
  • Internists
  • Endocrinologists

Activity and Diet Recommendations

In addition to medical treatment, there are certain lifestyle changes may help ease your menstrual pain.

  • Women who exercise regularly often have less pain. Take a walk, run a few miles, go for a swim, or try cardio kickboxing. Any aerobic exercise can be helpful.
  • Using other stress-management techniques, such as meditation or yoga, may help alleviate the problem. While stress itself does not cause menstrual cramps, relaxation techniques may help you manage your pain more effectively.
  • Have sex. Some women report that orgasm relieves menstrual pain. An exception may be the pain from endometriosis, which is aggravated by sex for many women.
  • Get a good night's sleep. Making sure your body gets enough rest before and during your period can help you cope with discomfort.
  • Take a warm bath or try resting with a heating pad or hot water bottle on your abdomen.
  • Some experts recommend a diet low in animal fats, dairy products, and eggs, with an emphasis on fresh fruits and vegetables. Eliminating caffeine from your diet may also help.
  • Avoid constipation, by eating high-fiber foods.

Monitoring the Condition

Be sure to discuss any changes in the pattern of pain (pain spreading to other areas of the body, pain at other times of the month) or unusual symptoms with your doctor.

Possible Complications

Women may experience depression or anxiety related to dysmenorrhea. Secondary dysmenorrhea may result in infertility, depending on the underlying cause of the condition.


Supplements

  • Fish oil: may help relieve cramps. Ohio gynecologists studied 42 teens who took ibuprofen (Motrin, Advil) to control their cramps. The young women were told to take as much medication as necessary, and in addition, the researchers gave them either a placebo or fish oil (1,720 mg/day). Two months later, 68% called fish oil "moderately" to "completely" effective. And while the teens taking the placebo averaged 10 doses of ibuprofen per period, those taking the fish oil took just 5 doses. [1]

Herbs

  • Raspberry leaf: In 1941, British scientists discovered that raspberry leaves contain a compound (called oligomeric procyanidin, or OPC) that relaxes the uterus. Since then, raspberry leaf tea has been used to treat cramps and the uterine irritability of pregnancy. In one study, half the women who took OPC (200 mg/day) for two months experienced noticeable relief. Try drinking raspberry leaf tea, or take OPC in its supplement form, Pycnogenol. [2]
  • Black cohosh: Native American women used black cohosh (Cimicifuga racemosa) to treat their cramps. Modern research has shown that black cohosh contains plant estrogens, or phytoestrogens, that can help relieve cramps. Germany's Commission E, the expert panel that judges the safety and effectiveness of medicinal herbs for the German government, endorses black cohosh for menstrual cramps. Try two to four droppers full of black cohosh tincture two to three times a day before and during your period. [3]

Relaxation

Monthly cramps produce a conditioned reflex. As your period approaches, you get anxious and tense in anticipation of the pain, which in turn tends to amplify the pain. Relaxation regimens reduce cramps by relieving your stress. Practice the relaxation therapies that appeal to you: meditation, deep breathing, massage, hot baths, yoga, or imagery/visualizations. Exercise can offer similar benefits.

Chiropractic

In one study, 45 women with severe menstrual cramps received either real chiropractic spinal manipulation or phony chiropractic treatment consisting of back rubs but not spinal manipulation. The group that received genuine chiropractic treatment reported less cramping. [4]

Acupuncture

An ancient Chinese practice, acupuncture consists of inserting very fine needles into the skin along a series of energy channels or paths known as meridians. It stimulates particular areas or systems of the body to promote healing and wellness.

Acupuncture may help ease cramps. One study placed 43 women with severe cramps into one of four groups, which received either genuine acupuncture, phony acupuncture (needles in the wrong places), counseling, or no treatment at all. Among those women receiving real acupuncture, 91% reported improvement, compared with just 36% in the phony-acupuncture group, 10% in the counseling group, and 18% in the no-treatment group. [5]

1 Harel, Z. et al. "Supplementation with Omega-3 Fatty Acids in the Management of Dysmenorrhea in Adolescents," American Journal of Ob/Gyn 174:1335, 1996.

2 Duke, James. The Green Pharmacy. Rodale Press, Emmaus, PA, 1997.

3 Hobbs, C. "Black Cohosh," Herbs for Health 3-98.

4 KokJohn, K., et al. "Effects of Spinal Manipulation on Pain and Prostaglandin Levels in Women with Primary Dysmenorrhea," Journal of Manipulative and Physiological Therapy 15:279, 1992.

5 Helms, J.M. "Acupuncture for the Management of Primary Dysmeorrhea," Obstetrics & Gynecology 69:51, 1987.

Self-Care Measures

Adopting the following healthy habits can help to minimize the effects of dysmennorrhea:

  • Drink more nonalcoholic fluids. Even minor dehydration triggers the release of vasopressin, a hormone that conserves water -- and aggravates cramps.
  • Try to limit your intake of salt, meat, junk food, and chocolate, as they can increase they body's production of prostaglandins (compounds involved in cramps).
  • Exercise can help minimize cramps. Physical activity -- especially aerobic activity -- stimulates production of endorphins, the body's own pain-relievers.
  • Consider taking a break from tampons, which aggravate some women's cramps. Try using sanitary napkins instead to see if the change helps. If you use tampons, avoid large/super types that absorb for long periods of time, a factor in causing toxic shock syndrome, a potentially fatal condition.

 

Websites & Organizations

American College of Obstetrician & Gynecology
409 12th St. SW
Washington, DC 200024-2188

American Medical Women's Association
801 N. Fairfax St., Suite 400
Alexandria, VA 22314
Voice Mail: 703-838-0500
Fax: 703-549-3864
Email: info@amwa-doc.

Gynecologic Health Center

Health Answers

Health Resource Center at the McKinley Health Center
Room 222, East Building
1109 S. Lincoln Avenue
Urbana, IL 61801

About.com: Women's Health

National Women's Health Resource Center, Inc.
120 Albany Street, Suite 820
New Brunswick, New Jersey 08901
Phone: 877-98-NWHRC or (877-986-9472)
Email: NatlWHRC@aol.com

The Red Spot

Resolve, Inc.
P.O. Box 474
Belmont, MA 02178
Phone: 617-484-2424

Sources for This Article

Books

Bennett, J. Claude and Plum, Fred. Cecil Textbook of Medicine, eds. Philadelphia: W. B. Saunders, 1996.

Duke, James. The Green Pharmacy. Rodale Press, Emmaus, PA, 1997.

Fauci, Anthony J., et. al. Harrison's Principles of Internal Medicine, eds. New York: McGraw-Hill, 1998.

Hardman, Joel G. and Limbird, Lee E. Goodman and Gilman's The Pharmacological Basis of Therapeutics eds. New York: McGraw-Hill, 1996.

Hurst, J. Willis. Medicine for the Practicing Physician eds. Stamford, CT: Appleton & Lange 1996.

Murray, Michael T. Encyclopedia of Natural Medicine. Prima, 1998.

Noble, John. Primary Care Medicine ed. St. Louis: Mosby, 1996.

Physicians' Desk Reference. Montvale, NJ: Medical Economics Co., 1998.

Rakel, Robert E. Conn's Current Therapy eds. Philadelphia: W.B. Saunders, 1998.

Taylor, Robert B. Family Medicine: Principles and Practice. New York: Springer-Verlag, 1998.

Tierney, LM, McPhee, SJ, and Papadakis, MA. Current Medical Diagnosis and Treatment eds.

Articles

Bieglmayer, C, Hofer, G, Kainz, C, Reinthaller, A, Kopp, B, Janisch, H. "Concentrations of Various Arachidonic Acid Metabolites in Menstrual Fluid are Associated with Menstrual Pain and are Influenced by Hormonal Contraceptives." Gynecol Endocrinol. 9(4):307-12. Dec 1995.

Chen, FP, Soong, YK. "The Efficacy and Complications of Laparoscopic Presacral Neurectomy in Pelvic Pain." Obstet Gynecol. 90(6):974-7. Dec 1997.

Endrikat, J, Jaques, MA, Mayerhofer, M, Pelissier, C, Muller, U, Dusterberg, B. "A Twelve-month Comparative Clinical Investigation of Two Low-dose Oral Contraceptives Containing 20 Micrograms Ethinylestradiol/75 Micrograms Gestodene and 20 Micrograms Ethinylestradiol/150 Micrograms Desogestrel, with Respect to Efficacy, Cycle Control and Tolerance." Contraception. 52(4):229-35. Oct 1995.

Gokhale, LB. "Curative Treatment of Primary (Spasmodic) Dysmenorrhoea." Indian J Med Res. 103():227-31. Apr 1996.

Golomb, LM, Solidum, AA, Warren, MP. "Primary Dysmenorrhea and Physical Activity." Med Sci Sports Exerc. 30(6):906-9. Jun 1998.

Harel, Z. et al. "Supplementation with Omega-3 Fatty Acids in the Management of Dysmenorrhea in Adolescents," Am. J. of Ob/Gyn, 174:1335, 1996.

Helms, J.M. "Acupuncture for the Management of Primary Dysmeorrhea," Obstetrics & Gynecol, 69:51, 1987.

Hobbs, C. "Black Cohosh," Herbs for Health, 3-98.

Jamieson, DJ, Steege, JF. "The Prevalence of Dysmenorrhea, Dyspareunia, Pelvic Pain, and Irritable Bowel Syndrome in Primary Care Practices." Obstet Gynecol. 87(1):55-8. Jan 1996.

KokJohn, K. et al. "Effects of Spinal Manipulation on Pain and Prostaglandin Levels in Women with Primary Dysmenorrhea," J. Manipulative and Physiological Therapy, 15:279, 1992.

Marchini, M, Tozzi, L, Bakshi, R, Pistai, R, Fedele, L. "Comparative Efficacy of Diclofenac Dispersible 50 mg and Ibuprofen 400 mg in Patients with Primary Dysmenorrhea. A Randomized, Double-blind, Within-patient, Placebo-controlled Study." Int J Clin Pharmacol Ther. 33(9):491-7. Sep 1995.

Muzii, L, Marana, R, Pedulla, S, Catalano, GF, Mancuso, S. "Correlation between Endometriosis-associated Dysmenorrhea and the Presence of Typical or Atypical Lesions." Fertil Steril. 68(1):19-22. Jul 1997.

Rabinerson, D, Kaplan, B, Fisch, B, Braslavski, D, Ner,i A. "Membranous Dysmenorrhea: The Forgotten Entity." Obstet Gynecol. 85(5 Pt 2):891-2. May 1995.

Vance, AR, Hayes, SH, Spielholz, NI. "Microwave Diathermy Treatment for Primary Dysmenorrhea." Phys Ther. 76(9):1003-8. Sep 1996.

 

 

 

 

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