Help for Painful Periods

What is Dysmenorrhea?

Dysmenorrhea is a condition that refers to the pain or discomfort associated with menstruation. Although not a serious medical problem, it’s usually meant to describe a woman with menstrual symptoms severe enough to keep her from functioning for a day or two each month.

Many young women don't suffer from dysmenorrhea, as their uterus is still growing, and yet they may get it several years after their first period begins. Symptoms may begin one to two days before menses, peak on the first day of flow, and subside during that day or over several days.The pain is typically described as dull, aching, cramping and often radiates to the lower back. The pain from your period that is severe enough to be given this name by your health care provider is thought to be the result of uterine contractions, caused by prostaglandins (a hormone-like substance, normally found in your body). Prostaglandins are known to stimulate uterine contractions. In addition to pain other symptoms may include, headache, diarrhea, constipation, and urinary frequency and fainting.

How Can I Get Relief? There are many over-the-counter drugs NSAIDs -- (ibupofen and naproxen), and acetaminophen that may provide relief. A heating pad works well for cramps when used OTC pain meds. Some women benefit from exercise, some from rest. There are also prescription drugs to help alleviate this painful disorder. Talk to your health care provider about them. Before you diagnose yourself, see your health care provider to be sure the pain you are having is not associated with another condition like PID, endometriosis, or any other medical conditions.

Help with Cramps By Jennifer Johnson, MD

Menstrual cramps are a very common problem for adolescent girls and women. They may be mild, moderate, or very severe. In fact, they are the single most common cause of days missed from school and work. About ten percent of girls are incapacitated for up to three days each month.

What are cramps? About 80 percent of the time, cramps are part of the primary dysmenorrhea syndrome. Cramps are caused by hormones called prostaglandins, which cause painful cramping of the uterus during menstruation. The production of prostaglandins in the uterus is stimulated by the hormone progesterone, which is made by the ovary after ovulation has occurred. These prostaglandins can affect other organs as well. Frequently, back pain, headaches, nausea and vomiting, dizziness, and/or diarrhea accompany menstrual cramps. These symptoms may begin a day or so before the menstrual flow begins; they usually peak by the second day of flow. Medications are the single best treatment for cramps. Other remedies are helpful also. I’ll discuss both in the following sections.

Medications for Treating Cramps: Many teens and women do not realize that there are very effective medications that can relieve not only menstrual cramps, but also the other symptoms that may accompany them. Generally these medications fall in the category of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. Some NSAIDs are available in both non-prescription strength (over-the-counter, or OTC) and in larger doses by prescription only. Other NSAIDs are only available by prescription.For some girls, cramps begin a day or so before their period starts; girls may also notice signs that their period is coming, such as abdominal bloating or constipation. In this case, it can be very helpful to begin taking the medication before the period actually begins.

For mild cramps, I recommend starting with acetaminophen or ibuprofen at the lower dose, at the lower number of daily doses. Acetaminophen is not an NSAID but is a pain reliever. It works well for some women. Increase as needed to the maximum dosage and frequency indicated in Table I (and on the bottle); if relief is not achieved, switch to a different medication at the higher dosage and frequency.

For moderate to severe cramps, I recommend starting with ibuprofen 200 milligrams four times daily or naproxen sodium 220 milligrams twice daily. Again, increase as needed to the maximum dosage and frequency. If cramps are moderate or severe, it is also important to continue taking the pain reliever regularly, even if there is no pain when the dosage is due. The regimen should be continued until the day when symptoms would subside, which is usually by the third day of the menstrual period. If ibuprofen or naproxen sodium at the maximum daily dose does not relieve symptoms adequately, it’s time to contact your health care provider. Also, there are prescription-only medications that are especially effective against the other problems such as nausea, vomiting, and diarrhea. Don’t give up hope. Under medical supervision, higher doses and other medications are safe and effective

Practical Suggestions for Medications:Since many schools restrict access to medications and because it is simply more often recommend that patients select medications that can be administered three times a day or less. Take the first dose in the morning, the second right after school, and the third about eight hours later. I recommend taking any of these medications with a meal or small snack and a glass of milk, juice, or other liquid. Rarely, a large tablet or capsule may have trouble making its way all the way down the esophagus; the liquid helps wash it down. Review the package directions and warnings carefully, and heed them. Do not take one of the listed drugs together with another one on the list, or with any other NSAID. A girl taking any medication on a daily basis should check with her doctor before starting any of these medications. Sometimes, though, more help is needed for primary dysmenorrhea than just NSAIDs. Of the prescription-only NSAIDs, I find mefenamic acid (Ponstel ®) to be especially useful. It not only works to eliminate cramps, but it can really help with diarrhea, nausea, and vomiting.

What if Pain Medications Don’t Work? I generally work with patients to adjust NSAID treatment regimens for three to six months. Occasionally, we find that even the highest-strength prescription regimens still don’t help. Before changing to other medications, I schedule a pelvic examination to evaluate for other, far less common causes of menstrual cramps. If one of these causes exists, the dysmenorrhea is referred to as secondary dysmenorrhea. Causes of secondary dysmenorrhea include infection in the genital tract, a narrow passageway connecting the inside of the uterus to the vagina (the cervical canal), and endometriosis.

Endometriosis is a condition in which nodules (bumps) of tissue just like the lining of the uterus are found on internal organs in the lower abdomen. It can cause very severe, debilitating pain that is not necessarily limited to the menstrual period. Sometimes the tissue nodules can be found during careful pelvic examination. Under these circumstances, I also need to insert a gloved finger into the patient's rectum during the examination.

Hormonal Treatment for Period Cramps: Assuming the pelvic examination is normal and I don't suspect endometriosis or another condition, I recommend adding hormonal treatment for girls with severe dysmenorrhea that has not responded to NSAIDs alone. The hormones prevent ovulation, and thus prevent the ovary from causing the production of the pain-causing prostaglandins. As you probably know, the oral contraceptive pill (OCP) prevents ovulation. And this is the easiest, least expensive way to use hormones to treat severe primary dysmenorrhea. OCPs are 80 percent to 90 percent effective when used for this purpose.

The Pill: -- Once in a while, a parent asks me, “Won’t Ashley think that if she's taking the pill, it's license to have sex?” In one sense, the answer might be yes. Not knowing how to get the pill does indeed prevent some careful teenagers from having sexual intercourse. Therefore, I suppose that occasionally a girl who has not had sex because of this concern might start having sex if she were put on the pill for medical reasons. However, most teenagers know that condoms alone are very effective in preventing pregnancy and many sexually transmitted infections. In other words, any concern over the absence of the added protection provided by the pill will not discourage most teens from engaging in sex if they so desire.

Natural Remedies for Cramps - Menstrual cramps have been around for thousands of years, and so have many non-medical treatments. I recommend that nonmedical remedies be used in addition to the pain medications described above. Rest and stress reduction Like many other conditions, cramps may be made worse by fatigue from too many late nights and by anxiety. So, getting enough rest before a period is due can actually help prevent bad cramps.

Heat, in the form of a warm bath or a heating pad applied to the lower abdomen, can be very helpful (and comforting).

Exercise -- A young woman who exercises regularly, and who feels up to it despite having cramps, may find that continued participation in her usual activities helps relieve the cramps. I encourage my patients to continue their daily routine during their period as much as possible.

Bed rest is not a documented remedy for cramps; some doctors believe instead that walking about helps expel the menstrual products, and the prostaglandins they contain, from the uterus. Additionally, anxiety generally increases as a girl worries about making up missed school assignments. On the other hand, cramps are occasionally truly incapacitating, and trying to force a “stiff upper lip” won’t help.