Education

Is Your Period Ruining Your Life?

By: Dr. Ruth O. Arumala

There are a number of reasons why “that time of the month” is widely dreaded but pain is chief of them all. Painful periods are the most common gynecologic problem in humans who menstruate with rates up to 90% (Nasir, 2004). For centuries, painful periods have been normalized by society and the medical community at large. This has resulted in people refraining from seeking medical care. Thankfully, pain during menses is now recognized and assigned the term, dysmenorrhea. It is helpful to use this term when communicating with healthcare providers. This can foster shared decision making and the use of evidence-based treatments that are now available. Dysmenorrhea, which typically begins soon after puberty, is a common reason for missing school, work, social, academic and athletic events. Given the undesirable but significant impact of dysmenorrhea, let’s explore the condition more.


TYPES OF DYSMENORRHEA

There are two types of dysmenorrhea: primary and secondary. Primary dysmenorrhea is menstrual pain without structural or anatomical conditions. When the pain has associated symptoms such as abnormal bleeding patterns, pain with intercourse, pain when not on your cycle, one-sided pain, this suggests there may be underlying causal pathology. Painful periods that are caused by pelvic abnormality is known as secondary dysmenorrhea. 


PRIMARY DYSMENORRHEA

You may be saying to yourself, “well slow down Doc! How do I know what type of dysmenorrhea I have?” Well, the typical symptoms of primary dysmenorrhea include lower abdominal or pelvic pain that may or may not radiate to your lower back or thighs. This crampy pain usually begins right before or during bleeding and lasts two to three days. This pain is caused by the release of substances including prostaglandins and vasopressin at the time of menses which lead to uterine contractions. These contractions are felt by the body as crampy pain.

Although this condition is diagnosed clinically, your health provider may rule out pregnancy and/or infection. In addition, if sexually active, your provider may conduct a bimanual pelvic exam. If your provider opts not to do any of these, this approach is not necessarily wrong as the condition is diagnosed by clinical acumen. 

SECONDARY

Secondary dysmenorrhea requires a detailed evaluation because treating the underlying issue is the best approach to treating the pain. Unfortunately the physiology of pain is quite complex. In my experience as a gynecologic surgeon, surgical procedures don’t always resolve pain. Surgery simply resolves anatomy. This can be a source of frustration to the surgeon and patient alike. Surgery is a “buyer beware” approach when dealing with pelvic pain and should be used judiciously.

Endometriosis is the most common cause of secondary dysmenorrhea. It is most commonly diagnosed in ages 25-29. Although studies show that Black women have 40% lower incidence of endometriosis than white women (Osayande, 2013), practitioners believe that endometriosis like other pain conditions are underreported and underdiagnosed in Black women. Other causes inclyde adenomyosis, fibroids, interstitial cystitis & chronic pelvic pain syndrome. Paradoxically, uterine cancer rarely produces pain. 

ENDOMETRIOSIS 

Endometriosis is a condition characterized by cells and tissues that are normally located in the lining of the uterus (womb) located outside of the uterus entirely. These cells respond to the hormonal signals the body gives during menstrual cycles. Consequently, humans with this condition have pain on and off menses, with intercourse, when urinating and/or defecating. In addition, this condition is associated with infertility or subfertility. 

When examined by a gynecologist, there can be findings of a uterus retroverted (titled to the back), retroflexed (stuck down towards the back), fixed and immobile. In addition, there may be cysts in the ovary called an endometrioma or nodules on ligaments close to the rectum. 

Imaging such as transabdominal/vaginal ultrasounds, and magnetic resonance imaging (MR) can be useful in establishing the diagnosis. Currently, a definitive diagnosis is only done via surgery using a laparoscope (a small camera inserted via the abdomen into the pelvis). When a diagnostic laparoscopy is performed, biopsies of visible lesions are taken and examined under a microscope. If endometrial tissue is visualized outside of the uterus, a definitive diagnosis is made.

If your gynecologist suspects endometriosis and you make a shared decision not to perform surgery, your physician may employ a regimen that treats endometriosis-like pain. They may also refer you to a pelvic floor physical therapist and/or a pelvic floor pain specialist. Endometriosis may affect the bowel and/or the bladder. If you have gastrointestinal or urinary symptoms, your gynecologist may involve a Gastroenterologist or Urologist in your care. 

ADENOMYOSIS 

Adenomyosis is similar to endometriosis as it involves endometrial tissue found outside of the lining of the uterus. In this case, however, endometrial cells are found in the lining of the uterus rather than outside the uterus. 

A typical person with adenomyosis tends to have painful, heavy periods that usually is persistent and increases in intensity on a crescendo pattern. On physical exam, the uterus tends to be uniformly large unlike fibroids which tend to have an irregular contour. Ultrasound and MRI are useful in this diagnosis, however a definitive diagnosis is made after the uterus is removed in a hysterectomy and the tissue is viewed under a microscope.

Adenomyosis is a complex condition to treat. Currently, the only definitive treatment is a hysterectomy.

OTHER CAUSES OF PAINFUL PERIODS 

Although endometriosis and adenomyosis comprise a big portion of the causes of secondary dysmenorrhea, there are some other significant conditions that result in similar outcomes. These include:

  • fibroids
  • interstitial cystitis
  • chronic pelvic pain syndrome
  • pelvic inflammatory disease 

If secondary dysmenorrhea is suspected or diagnosed, comprehensive management by a qualified gynecologist is recommended. 

CONSERVATIVE WAYS TO ADDRESS PAINFUL PERIODS 

Now we understand the basic mechanisms of primary and secondary dysmenorrhea, what are some things you can do to manage your monthly symptoms.

  • Heat therapy using hot water bottles and heating pads 
  • Exercise especially light cardio helps to release endorphins and reduce bloat 
  • Eliminating or decreasing gas producing foods including dairy and beans; processed foods and sugary drinks
  • Nutritional interventions such as increasing omega 3 fatty acids, vitamin B1, and magnesium supplementation 
  • Acupuncture is a method of therapy that has been practiced in China for over 3000 years. This method involves puncturing a needle into the body at a certain angles for the purpose of relieving pain. Based on a number clinical experiments, acupuncture treatments tailored for dysmenorrhea are effective (Ying Guo, 2021). 
  • Massage 
  • Herbal products are when two or more herbs are boiled in water then processed into extracts, pills or capsules. Chinese herbal preparations are traditionally found to be more effective than other herbal compounds. They are used as an alternative to pharmacologic therapy (Ying Guo, 2021). 
  • Nonsteriodal anti-inflammatory drugs (NSAIDs) which include over the counter medications such as ibuprofen and naproxen and prescription medications such as celecoxib and mefenamic acid are effective in preventing and managing painful periods. They should be taken one to two days as a scheduled medication before the anticipated onset of blood flow and should be continued on a fixed schedule for two to three days (Osayande, 2013). This is important as missed doses may result in pain flares that require catch up and can prolong discomfort

HONEY POT HERBAL PADS 

I personally recommend honey pot herbal pads for anyone who experiences period pain. These pads use the power of mint and lavender to provide an immediate cooling sensation that soothes and calms. In addition to this immediate relief, this fresh feeling lasts all day.

MEDICAL APPROACH TO PAINFUL PERIODS

The mainstay of this approach is to suppress or eliminate periods. This is done by various formulations and delivery methods of combined estrogen-progesterone or progesterone only medications. This is done under the careful guidance of a gynecologist.

BOTTOM LINE

Although many of us in the hive have painful periods, they are not normal! In fact, they may be a window into a developing condition and should be investigated. Cheers to pain free periods.

REFERENCES

Proctor M, Farquhar C. Diagnosis and management of dysmenorrhoea. BMJ. 2006;332(7550):1134-1138

Nasir L, Bope ET. Management of pelvic pain from dys- menorrhea or endometriosis. J Am Board Fam Pract. 2004;17(suppl):S43-S47.

Ying Gyo et al. Complenentary and Alternative Medicine for Dysmenorrhea casued by endometriosis: A review of Utilization and mechanism. Evidence Based Complementary and Alternative Medicine; 2021.  
Osayande, A., Mehulic, S.. Diagnosis and Initial Management of Dysmenorrhea. Amer Fam Physician. March 1, 2014. Vol 89, Number 5 341-326