Some people consider period pain to be part and parcel of being female. For centuries, some mothers have, guided by good intentions, assuaged their daughters’ concerns about their monthly cramps: “I had very painful cramps during my periods too; it’s part of growing up” and so on. But is this correct? When does ‘normal’ period pain become ‘not normal’? When do you need to do something about your period pain?

 

What is period pain (or dysmenorrhoea)?

‘Dysmenorrhoea’ is the medical term for painful menstrual periods. Dysmenorrhoea can be broken down into two different types of period pain: primary and secondary dysmenorrhoea. Primary dysmenorrhoea is cramping pelvic pain that occurs before and / or during your period, without any underlying cause. Secondary dysmenorrhoea is period pain that is due to an underlying disease process.

 

How common is period pain?

It is estimated that approximately 80% of all women experience period pain at some stage. The incidence among women in the 16 – 25yo age group has been reported to be as high as 88%: that’s eight out of nine young women!
Primary dysmenorrhoea is much more common than secondary dysmenorrhoea. But because secondary dysmenorrhoea is indicative of an underlying condition, it’s important to differentiate between ‘normal’ and ‘not normal’ period pain.

 

How painful do periods have to be, to be considered problematic?

There are several different ways to consider the severity of your period pain. For example:

– How would you rate your period pain out of ten, if 0 is no pain, and 10 is the worst pain you can imagine?
– Do you ever take pain relief tablets to manage your period pain?
– Do you ever need to miss school or work because of your period pain?
– Do you ever need to change your social plans because of your period cramps?
– Is your period pain holding you back from living your best life?

Just as for heavy menstrual bleeding (click here to read our blog post on heavy periods): if you think your period pain is problematic, it is!

 

Risk factors for dysmenorrhea

Factors that increase your risk of experiencing painful periods include:

– If you’re younger than 30yo
– If you started getting periods at 11yo or earlier
– If you also have heavy, irregular, and / or long periods
– If other women in your family also have painful periods
– If you smoke
– If you drink alcohol during your period
– If you have never been pregnant
– If you are above a healthy weight range

Sometimes, these risk factors can be difficult to tease apart, due to so-called ‘confounding factors’ (characteristics that are related to one or more risk factor). For example: if you’re younger than 30yo, you are more likely to have never been pregnant, compared to an older woman.

 

What causes primary dysmenorrhoea?

As noted above, primary dysmenorrhoea is cramping pelvic pain that occurs before and / or during your period, without any underlying disease process.

Primary dysmenorrhoea is due to the muscle of your uterus (or womb) contracting, in order to shed its lining: it is the uterine lining shedding, and coming out of your vagina, that causes vaginal bleeding during your period. Family studies suggest that your genetic background influences the severity of your period paid, but these mechanisms are not well understood.

Primary dysmenorrhoea usually starts within the first few years of getting your period as a teenager. This type of period pain is most often localised to your pelvis (ie. between your belly button and your pubic bone), but it can also be felt in your lower back and / or the front of your thighs. It may feel like a constant ache, a heaviness, and / or a cramping, gripping pain.

The timing of primary dysmenorrhoea often follows a similar pattern each month: it starts a day or two leading up to your period, is at its worst on the first day or two of your period, and then eases off.

 

What causes secondary dysmenorrhoea?

As noted above, secondary dysmenorrhoea is period pain that is associated with an underlying disease process: I’ll outline the two most common underlying causes below.

Women with secondary dysmenorrhoea may not have had painful periods as teenagers. Over time (particularly from their late 20s and into their 30s and 40s), their periods may become increasingly painful.

 

Endometriosis

Endometriosis is a very common condition: it is thought to affect more than 11% of Australian women of reproductive age. There are many theories as to how endometriosis occurs: the prevailing theory is that of so-called ‘retrograde menstruation’.

When any woman has a period, the lining of the uterus sheds, and comes out of her vagina as blood. In some women, for some reason, some of this blood goes in the wrong direction: up through the Fallopian tubes and into her abdominal and pelvic cavity. These blood cells can then land on and stick to the outside of various pelvic structures: these collections of menstrual blood can grow, and become endometriotic deposits (or nodules). During future periods, these endometriotic nodules respond to the circulating female hormones by becoming inflamed, and causing pain wherever they have implanted.

However, there is far more to this story. We know that endometriosis has a genetic component, as it seems to run in families, and daughters of mothers with endometriosis are more likely to suffer from it themselves. We know there is an inflammatory component, with the release of all kinds of inflammatory markers in the pelvis, causing pain and sometimes impacting on fertility.

By far the most common symptom of endometriosis is severe period pain. When endometriosis is severe (or “stage four”), it can also cause: subfertility or infertility; cyclical bowel symptoms; blood in the urine during your period; and / or blood in your poo during your period.

Ultrasound (especially a so-called “deeply-infiltrative endometriosis ultrasound”) is very good at diagnosing moderate and severe endometriosis. However, the only way to diagnose mild endometriosis is to look around the pelvic organs during keyhole surgery.

The management of endometriosis essentially has two prongs, from the day of your first period (as a teenager) to the day of your last (when you go through menopause). The first prong is keyhole surgery, to look for and cut out all endometriotic deposits. The second prong is slowing the ‘retrograde menstruation’ process by using medicines to make periods lighter and / or less frequent. Examples of such medicines include: tranexamic (to lighten heavy periods); the contraceptive pill; a Mirena® intrauterine device; three-monthly injections to lighten periods; or a short (six month) course of a medicine to induce a temporary menopausal state.

 

Adenomyosis

Adenomyosis is a non-cancerous condition in which the cells that line the uterine cavity grow a little too deeply, into the muscle layer of the uterus. These cells then swell and bleed when stimulated by monthly female hormones, causing both painful and heavy periods.

Adenomyosis tends to get worse with age, and is a common cause of both heavy and painful periods in women in their 40s and 50s in particular.

To some extent, the symptoms of adenomyosis can be managed with medications, such as pain relief tablets and tranexamic acid. If medicines aren’t enough, surgical management may be needed. Unfortunately, there are no great surgical options that both treat adenomyosis, and retain a woman’s fertility. Options such a endometrial ablation (burning the lining of the uterus) and / or a Mirena® intrauterine device may help somewhat. The only definitive management of adenomyosis is hysterectomy (permanent surgical removal of the uterus, or womb).

 

What should you do if your periods are too painful?

WIthout needing to see a doctor, there are several things you can try, to help manage painful periods. Broadly speaking, these can be categorised as: lifestyle measures; self-help measures; nutritional supplements; and pain-killers.

 

Lifestyle measures

As noted in the ‘risk factors’ section above, there are several lifestyle factors that can worsen period pain. So, if appropriate, it may help to: stop smoking; reduce your alcohol intake during your period; and maintain a healthy weight (which is easier said than done!)

Women who exercise regularly are less likely to suffer from period pain. This may be because vigorous exercise releases so-called ‘natural pain-killers’ like endorphin and serotonin.
Maintaining a diet that is rich in omega-3 fatty acids, calcium, and vitamin D, while being low in animal fats, salt and caffeine may improve some troublesome menstrual symptoms.

 

Self-help measures

Additional things you can do to manage your period pain include:

– Using a heat pack or hot water bottle on your tummy (or wherever your pain is worst)
– Relaxing by resting, having a soothing warm bath, or meditating
– Exploring complementary therapies such as acupuncture

 

Nutritional supplements

Some women find that some vitamins, minerals and / or amino acids help with their period pain. Check with your doctor before taking any such supplements. Below is a list of supplements which have some (limited) evidence of benefit, although much more research is required:

– Calcium
– Fish oils
– Magnesium
– Vitamins B6, B1, D and E (the ‘natural alpha-tocopherol’ form)
– Zinc

 

Pain-killers

There are several pain-killer medications that can be bought ‘over-the-counter’ (ie. without a doctors’ prescription).

These include:
– Paracetamol
– Ibuprofen
– Diclofenac
– Naprogesic

The above pain-killers work best if you start taking them as soon as your period pain starts, and take them regularly on the most painful days of your cycle. They are best taken with meals, to reduce stomach irritation. Discuss the pros and cons with your GP.

If you’ve tried some of the above management options, and are still troubled by period pain, please see your GP. They may suggest additional pain-killer medicines that require a prescription, such as:

– Mefenamic acid
– The contraceptive pill
– Stronger pain relief tablets

 

When should you worry about painful periods?

As noted in this blog post’s introduction: if your periods are too painful for you, they are a problem! Every woman has a different pain threshold, and the same level of period pain may affect different women very differently.
While it’s important to try some of the above approaches to help ease your pain, it’s also important to know when to get your GP’s advice on what else can be done. See your GP about your period pain if:

– Your period pain still troubles you, despite trying some of the simple medicines and management strategies listed above
– Your period pain disrupts your life
– Your period pain is getting worse and worse over time
– You experience a sudden worsening of your period pain
– You start to experience pain in different places (eg. on one side of your tummy, rather than in the middle)
– You start to experience new types of pelvic pain (eg. at times in your cycle when you didn’t used to, or pain during penetrative sex)
– You develop additional symptoms during your period (eg. nausea, vomiting, fainting)
Please do not suffer in silence every month: when in doubt, see your GP!

 

Conclusion

Ultimately, whether your period pain is “normal” or “not normal” is less relevant: what is more important is to know that there are options to manage your period pain. If your period pain is troubling you, please see your GP! They can suggest various other management approaches, which may include a pelvic ultrasound and / or referral to a gynaecologist. You can then work with your healthcare team, to find approaches that work for you!