Menstrual pain, is it normal?

Menstruation is part of a woman’s life and, as such, we have to deal with it whilst carrying on with the rest of our daily activities. However, in many cases this becomes a major limitation because of the pain it causes, then it is advisable to start treatment.

What is the menstrual cycle? And menstrual pain?

Menstruation is a cyclin bleeding every 28-35 days, from the endometrium desquamation – lining covering the uterus cavity – after an ovulating cycle where pregnancy has not taken place.

About 50-90% of women around the world suffer or has suffered menstruation related pain or dysmenorrhea, and it’s one of main causes for employee and school absence, causing an economic loss in the annual productivity. However, only 15% of women come to the doctor for this reason. 

Menstrual pain is a kind of colic, and is usually felt as “cramps” or throbbing in the lower abdomen or lumbar area.

Possible risk factors for menstrual pain are adolescent and young age, smoking and stress, and possibly, family predisposition. On the contrary, pregnancies and young age at the time of the first child, as well as the use of hormonal contraceptives, are considered protective.

What causes dysmenorrhea or painful menstrual cycles?

According to its origin, dysmenorrhea can be:

• Primary, when no pathology or organic alteration that justifies it is observed. It is believed to be due to an excess of uterine contractions, derived from an imbalance in the local production of the uterine muscle’s regulatory factors: prostaglandins F2 alpha and prostaglandin E2. These factors also stimulate the gastro-intestinal tract, which can cause nausea, vomiting or diarrhoea.
• Secondary or organic, when there’s a disease or underlying anatomic anomaly.
• Malformations in genital tract, such as cervical stenosis, vaginal septum or imperforated hymen, condition or impossibility the menstruation exit flow, causing pain and even superinfections. It is usually diagnosed in adolescence when first periods begin. Cervix stenosis, although uncommon, can also occur after surgeries such as cervical conization, which may condition the closure of the cervical canal due to abnormal healing.
• Pelvic inflammatory disease: it is an infection that affects the uterus, fallopian tubes and even ovaries, whose main agents are Chlamydia and Gonococcus; sexually transmitted. In the most severe cases can leave sequelae such as adhesions and abscesses and condition pain with menstrual cycles, with sexual intercourse or chronic pelvic pain.
• Endometriosis: is a chronic disease from the development of tissue similar to the endometrium outside the uterus cavity. The pain produced by endometriosis does not usually have an abrupt onset in adolescence, but rather worsens over time, and can be cyclical, with periods and ovulations, or continuous.
• Adenomyosis: similar to endometriosis, the tissue similar to the endometrium infiltrates the muscle that constitutes the uterine walls, increasing its size, producing an alteration in its normal contractility and causes abundant and painful periods.
• Uterine myomas or fibroids: these are benign tumors of the uterine muscle, often asymptomatic, but which can sometimes cause heavy and painful bleeding like adenomyosis.

When do I have to see the gynaecologist for menstrual cramps?

Whenever menstrual pain causes an impact in life quality, it should be evaluated in consultation by a specialist.

On the contrary, it is necessary to go to the emergency room when suffering very intense acute pain, which does not improve with regular analgesia, especially if it comes with menorrhagia (heavy menstrual bleeding, with clots) or metrorrhagia (not cycle bleeding). On these cases, other causes such as abortion or ectopic pregnancy must be ruled out.

How is severe menstrual pain studied?

Most of dysmenorrhea cases are primary, so when pain is mild-moderate, the first approach can be empirical, improving lifestyle habits and adding analgesic therapy.

In cases where there’s no improvement applying these initial measures, or when the pain is intense, out of menstruation cycles or is accompanied by other symptoms such as heavy bleeding or dizziness or intestinal disorders, we should do a gynaecological study. This begins with the medical history, gynaecological physical examination, and transvaginal ultrasound. On some occasions, additional studies such as pelvic magnetic resonance imaging (more useful in these cases than tomography or CT) or even laparoscopy are necessary to directly assess the abdominopelvic cavity.

What can I do to relieve menstrual pain?

• Life-style: regular physical exercise improves menstrual pain. Also, application of local dry heat to the lower abdomen appears to be as efficient as ibuprofen in treating pain.
• Oral analgesics: they are usually the first line in drugs treatment, especially non-steroidal anti-inflammatory drugs such as ibuprofen, dexketoprofen … which inhibit the production of prostaglandins and are therefore very useful in primary dysmenorrhea. Always under medical prescription, since they are not exempt from side effects.
• Hormonal contraceptive methods: they block ovulation and the prostaglandins’ synthesis, reduce menstrual flow and sometimes allow to spaced or suppress periods. Today there are many alternatives beyond the conventional pill. Your gynaecologist will study your case and recommend the one that best suits your circumstances.
• Transcutaneous electrostimulation (TENS). There appears to be some scientific evidence in favour of high-frequency percutaneous stimulation; applied weekly for at least 12 weeks, as an adjunct and second-line treatment for severe dysmenorrhea.
• Surgery: in cases of severe secondary dysmenorrhea that doesn’t improve with medical treatment, surgery may be necessary depending on the underlying disease.

Alternative therapies: Its efficiency have not been scientifically proven, so they are considered as complementary. Natural compounds such as ginger, evening primrose and fish oil, vitamin D3, B1 and B6 supplements, the vegetarian diet, as well as behavioural therapy, hypnosis, and acupuncture have been proposed.

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Dra. Esperanza de la Torre, gynecologist at Instituto Bernabeu