By Lori Montgomery, MD, CCFP and Magali Robert, MD, FRCSC
Dysmenorrhea (say: dis-men-uh-REE-uh) is the medical term for menstrual cramps. Most women who have menstrual periods have some cramping. For some, this is merely annoying. For others, it is severe and disabling.
Signs and symptoms
- lower abdominal cramping, sometimes that extends into the low back, hips, and legs
- begins shortly before or at the start of the menstrual period, and most often lasts from one to three days
- some women will also have nausea, headache, diarrhea, or constipation
Dysmenorrhea is either primary or secondary. Primary dymenorrhea is pain that is not due to any underlying gynecologic disorder. These are the kind of cramps that most women have. Prostaglandins are hormone-like chemicals that are released during a woman’s normal menstrual period. It seems that these are what cause uterine contraction and pain. It has also been found that women with more severe dysmenorrhea also have higher levels of a hormone called vasopressin. It makes these uterine contractions more intense, and perhaps more painful.
Secondary dysmenorrhea refers to pain that is caused by an underlying gynecologic disorder, such as endometriosis, uterine fibroids, or adenomyosis (a non-cancerous growth, similar to endometriosis, in the muscular wall of the uterus). There are many more causes for secondary dysmenorrhea. There are too many to list them all here.
The relationship between endometriosis and pain is not at all clear. Many women have endometriosis found when they have exams performed for other reasons, but have no pain at all. At the same time, many women have a very small amount of endometriosis, but severe pain. Women should be cautious about multiple surgeries to try to eliminate endometriosis that keeps coming back. This can irritate the abdominal wall muscles, and has the potential to make pain worse.
Your doctor will do a physical exam, including a pelvic (internal) exam. Sometimes an ultrasound will be needed to make sure there are not fibroids or structural abnormalities of the uterus or cervix causing pain. If there is reason to suspect endometriosis or other problems with the pelvic organs, sometimes a laparoscopy will be performed. This is a surgery that involves a small incision (cut) and insertion of a scope to look at the uterus and other structures in the pelvis.
Treatment will depend on whether a cause for the pain is found, although initial therapy for both primary and secondary dysmenorrhea is the same. If your diagnosis is secondary dysmenorrhea, there will be a certain treatment that the doctor may recommend for that problem (such as shrinking a fibroid or removing a growth). If the diagnosis is primary dysmenorrhea, there are a number of things that can be helpful.
The most effective treatment for primary dysmenorrhea is anti-inflammatory medicine such as:
- mefenamic acid
Your doctor may suggest that you start taking it one or two days before your menstrual period starts, and take it regularly for two or three days. It is important to take it early and consistently (for 24 to 48 hours). Otherwise it is not likely to work as well.
Birth control pills
You may choose to take a birth control pill, especially if you also need contraception. This makes menstrual periods lighter and lowers prostaglandin release. It is also more predictable. The birth control pill can be taken all of the time to stop menstrual periods entirely, if needed.
The levonorgestrel intrauterine device (or Mirena IUD) has also been studied in dysmenorrhea, with promising results. It is different than the older IUDs, because it releases a small amount of progesterone. This makes menstrual periods lighter and decreases prostaglandin production.
The menstrual cycle can be suppressed with synthetic hormones like danazol (Danocrine) or leuprolide acetate (Lupron) as well. These are very expensive medicines. They also have potentially serious side effects, including elevated cholesterol, liver problems, depression, abnormal hair growth or hair loss, and lowering of the voice. They are not often used.
Exercise before and during your period can ease some pain. Both acupuncture/acupressure and transcutaneous electrical nerve stimulation (TENS) have been shown to be helpful for some women as well.
Yoga and supplements
Some patients also find yoga helpful. There is not much research to prove that it is effective. Use of supplements such as vitamin B1, vitamin B6, or fish oil may be helpful. Studies have shown that non-drug therapies can help to reduce pain levels and enhance pain coping. These include:
- activity pacing
- cognitive behavioural therapy
These self-management strategies can help you to improve your function so you can do more and enjoy life more.
French L. Dysmenorrhea. American Family Physician. January 2005;15;71(2):285-91.
Society of Obstetricians and Gynecologists of Canada. Primary Dysmenorrhea Consensus Guideline. www.sogc.org/guidelines/public/169E-CPG-December2005.pdf Journal of Obstetrics and Gynecology Canada. 2005;169:1117-1130.