Menstrual Cramps

Menstrual cramps or primary dysmenorrhea occurs in the absence of any significant pathologic cause for the pain.

• Menstrual cramps are throbbing or cramping pains that occur in a woman's lower abdomen caused by contractions of the uterus. These contractions are related to the levels of prostaglandins that rise and fall during the menstrual cycle. Cramps usually begin just before or during the first few days of a menstrual period.
• Risk factors for menstrual cramps include the following:
  • The first menstrual period occurs younger than 11 years of age
  • Menstrual periods that last five days or more
  • Cigarette smoking
  • Never been pregnant
  • Family history of severe menstrual cramps
• Prostaglandins may play a role in menstrual cramps, and pathologic conditions, for example, endometriosis, fibroids, infections, and other conditions also may contribute to menstrual cramps.
• Menstrual cramps can produce one or more of the following symptoms:
  • Low back pain, pain in legs or hips
  • Irritability
  • Bloating
  • Nausea, vomiting, and/or diarrhea (gastrointestinal symptoms)
  • Headaches
  • Fatigue or malaise
  • Fainting spells
• A woman should contact a healthcare professional if menstrual cramps become painful for a longer time than usual if the pain is different if bleeding is excessive (for example, one pad or tampon per hour), has fever, chills, or body aches; suspects pregnancy or have menstrual cramps for the first time past the age of 25, has fainting, dizziness and/or passes tissue with menstrual blood.
• Menstrual cramps usually are diagnosed by taking a detailed medical history along with a physical exam (including a pelvic exam) and a pregnancy test. Other diagnostic tests may include ultrasound, MRI, laparoscopy, or hysteroscopy.
• Menstrual cramps usually are treated initially with natural home remedies and nonsteroidal anti-inflammatory drugs (NSAIDs). Some females may be prescribed hormonal birth control or medications such as mefenamic acid (Ponstel) or meclofenamate (Meclomen).
• Some women may require surgery such as endometrial ablation, endometrial resection, or hysterectomy.
• Some healthcare professionals and naturopaths recommend alternative medical treatment that may include acupuncture, nitroglycerin patches, A TENS (transcutaneous electrical neural stimulation) device, or supplements such as thiamine, vitamin D, and Omega-3 fatty acids; however, there is little data to support such treatments.
• Menstrual cramp prevention, or more likely, menstrual cramp reduction can be accomplished by maintaining a healthy lifestyle that includes good nutrition, weight control, and exercise along with smoking cessation.
• The prognosis for menstrual cramps varies from good to fair as sometimes they will disappear after pregnancy and often are well-controlled by NSAIDs. Underlying causes such as fibroids, when removed or treated, can cause menstrual cramps to stop.

• Menstrual cramps are sharp pains in a woman's lower abdomen that start when her menstrual period begins and may continue for 2-3 days or longer. Symptoms can range in severity from mild annoyance to severe pain that interferes with normal activities.
• Menstrual cramps are the leading cause of absenteeism in women younger than 30 years of age. Although over half of women who have menstrual periods experience some discomfort, only a small percentage are disabled by the symptoms. The medical term for painful menstruation is dysmenorrhea.
• The following circumstances may make a woman more likely to experience menstrual cramps:
  • The onset of the first menstrual period at an early age (younger than 11 years)
  • Menstrual periods lasting 5 days or more
  • Cigarette smoking
  • A woman has never been pregnant (null gravity)
  • Relatives with severe menstrual cramps

Menstrual cramps or primary dysmenorrhea occurs in the absence of any significant pathologic cause for the pain. This type of menstrual pain is most commonly seen in young women during the years following the onset of menstruation.

Secondary dysmenorrhea refers to painful menstrual cramps that occur as a result of a true pathological condition (for example, endometriosis). This condition is more commonly seen in older women (30-45 years of age).

Prostaglandins and menstrual pain: Prostaglandins are chemicals that a woman's body produces that cause many of the symptoms associated with menstrual discomfort. The tissue that lines the uterus (endometrium) produces these chemicals, and they are released with the onset of menses when the uterine lining breaks down. Prostaglandins stimulate the uterine muscle to contract. Women who have high levels of prostaglandins experience more intense contractions of their uterus, and these produce more pain. Prostaglandins also may be responsible for vomiting, diarrhea, and headaches that frequently accompany painful periods.

What causes secondary dysmenorrhea?

Other menstrual-type pain or secondary dysmenorrhea can be caused by conditions of the reproductive tract, such as the following:

• Endometriosis: uterine tissue that appears outside the uterus
• Fibroids: non-cancerous (benign) tumors that involve the uterus
• Adenomyosis: migration of endometrial glands downward into the muscular wall of the uterus
• Infections: infections involving the reproductive organs
• Ectopic pregnancy: a pregnancy that occurs outside of the uterus such as in the Fallopian tubes
• IUD (intra-uterine device) used for birth control
• Ovarian cysts
• Narrow cervix: cramps due to passing clots of blood and tissue through an anatomically narrow cervical canal
• Stress

In addition to cramps in the lower abdomen, a woman may also experience additional symptoms. These symptoms may include:

• Lower back pain
• Leg pain and/or hip pain
• Nausea
• Vomiting
• Diarrhea
• Headaches
• Bloating
• Irritability
• Fatigue or malaise
• Fainting spells (in extreme cases)

Most women have significant improvement with natural and home remedies (see the Natural and Home Remedies section). However, a woman should call her healthcare professional if she experiences any of the following:

• Menstrual cramps that continue to be painful for longer than usual
• The pain is suddenly worse or different from what you may have previously experienced
• Bleeding is excessive and requires using more than one pad or tampon per hour
• Signs of infection, such as fever, chills, and body aches, occur during your period
• Menstrual cramps began for the first time in a woman older than 25 years of age.
• You suspect you may be pregnant.

A healthcare professional can help manage most symptoms. However, a woman should go to a hospital's emergency department if any of the following problems occur:

• Fainting
• Dizziness on standing
• The sudden onset of intense pelvic pain
• Passage of discrete tissue along with menstrual blood
• Tissue often appears silvery or grayish
• Possible pregnancy associated with the onset of severe pain

Although many primary care doctors can treat menstrual cramps, women with more severe symptoms may require consultation with an OB/GYN.

The healthcare professional will take a detailed medical history, and will inquire specifically about the menstrual cramps and related symptoms. A woman should anticipate questions regarding:

• The timing of the cramps in relation to the start of the menstrual period
• Type and duration of pain
• The age when the cramps first began and the age of the onset of menstruation
• Any recent change in the pain
• History of irregular periods
• Any unusual vaginal discharge
• Any history of pain with intercourse
• Infertility
• Any history of pelvic infections
• Current medications including birth control measures

The doctor will perform a pelvic exam to explore any problems. If there are concerns in regard to a possible infection, a culture of the cervix and a blood test may confirm the diagnosis. Additional tests may be ordered.

• The doctor may order a pregnancy test if the menstrual periods are irregular, or if the woman is not using birth control on a regular basis.
• An ultrasound examination is necessary if the doctor discovers any abnormal masses during the pelvic exam. The doctor also may order special imaging tests, such as magnetic resonance imaging (MRI), if a pelvic ultrasound is not helpful.
• A doctor may perform a laparoscopy, a minor surgical procedure allowing the doctor to look directly into the pelvic cavity with a fiber-optic scope.
• A hysteroscopy is another possible procedure. By inserting a hysteroscope (a lighted instrument) through the cervix, a doctor can visualize the cervix and interior of the uterus.

Some of the above tests may assist in ruling out certain causes of menstrual pain and cramping such as ectopic pregnancy, pelvic inflammatory disease (PID), or other abnormalities.

If anti-inflammatory medication is not an option, or if additional relief is needed, the following natural therapies strategies may help relieve menstrual cramping and pain:

• Lay a heating pad over the pelvic area
• Massage to the back and lower abdomen
• Exercise, especially prior to the start of a menstrual period may be helpful to some women

If taking hormonal birth control is not an option because of health problems, or the woman is among the few who do not respond to this treatment, some researchers have proposed other alternative treatments including:

• Acupuncture
• Nitroglycerin patch
• Wearing a TENS (transcutaneous electrical neural stimulation) unit, a small electrical device that interferes with pain signals as they travel to the brain. Some researchers have reported that thiamine, vitamin E, or omega-3 fatty acid supplementation can be effective remedies for menstrual cramps. However, definitive studies of all of these alternative treatments are lacking.

The best way to initiate relief of painful menstrual cramps is to take an anti-inflammatory medication. Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit the formation of prostaglandins, thereby reducing pain and inflammation. Ibuprofen (Advil is a familiar brand name), naproxen (Aleve, Naprosyn), and ketoprofen (Orudis) are available over-the-counter without a prescription. They are all effective in blocking the effects of prostaglandins.

• These medications work better if they are begun prior to the onset of menstruation. They can be continued for as long as the cramps persist. If one type of OTC medication is not effective, another should be tried because they are not equally effective in every female.
• Anti-inflammatory medicine such as these can be harsh on the stomach. If a woman has a history of kidney disease or stomach problems (such as ulcers or reflux), consultation with the appropriate healthcare professional may be appropriate prior to initiation of therapy. Taking the medication with meals may help prevent an "upset stomach."

If a woman with menstrual cramps is not already taking anti-inflammatory medicine, the healthcare professional may advise her to take one of the OTC (over-the-counter pain) relievers or prescribe an anti-inflammatory drug.

Starting some form of hormonal birth control is another option to relieve or stop menstrual cramps. This can take the form of

• oral contraceptive pills (OCPs),
• an injection,
• a transdermal patch, or
• a hormone-releasing intrauterine device.

All these methods reduce menstrual flow and the mid-cycle pain that may occur with it. There are a number of different types of hormonal birth control methods available, and no studies have been done to show that one preparation or form of hormonal contraception is superior to another in reducing menstrual cramps. Oral contraceptive pills are a common choice for women who suffer from significant menstrual discomfort and who do not wish to become pregnant.

In many cases, a combination of NSAIDs and hormonal contraceptive methods such as oral contraceptive pills may be needed to relieve menstrual cramping and pain. Prescription medications (mefenamic acid [Ponstel] or meclofenamate [Meclomen]) also may be prescribed.

Surgery may be necessary to relieve menstrual cramps, but it should be reserved for those cases in which non-invasive therapies have been shown to be unsuccessful. Such refractory cases are usually secondary to true pathologies, such as endometriosis. The exact surgical procedure chosen depends upon the type of abnormality that is being treated. Examples include:

• Endometrial ablation: This procedure destroys the lining of the uterus.
• Endometrial resection: This procedure removes the lining of the uterus.
• Hysterectomy: This surgical procedure completely removes the uterus.

• Often it is possible to entirely eliminate menstrual cramps. Anti-inflammatory medications are highly effective.
• Hormonal birth control is also useful in decreasing menstrual pain.
• Cramps also tend to diminish in intensity as a woman ages. They will sometimes disappear after a woman's first term pregnancy.
• In cases in which anatomical abnormalities are thought to contribute to the pain, treatment of the underlying abnormality or condition can bring about relief.

It may not be possible to entirely prevent menstrual cramps. However, maintaining a healthy lifestyle that includes adequate nutrition, a healthy diet, body weight control, and exercise may be helpful. One preventative step that can directly lessen the severity of menstrual cramps is to stop smoking.