Painful Periods (Dysmenorrhea)

Most women have some pelvic pain during their menstrual periods. It is usually mild requiring no treatment or just mild pain-killers. In about 1:10 women, the painful periods (dysmenorrhea) can be severe enough to affect day to day activities. It is common in teenagers and young adults, but become less of a concern, after childbirth and as they get older. There are two types of painful periods – primary dysmenorrhea where there is no underlying problem of the uterus (womb), tubes or pelvis and secondary dysmenorrhea caused by a problem of the uterus, tubes or pelvis.

Primary dysmenorrhea

In this type of painful periods, there is build up of normal body chemicals called prostaglandins within the lining of the uterus. These prostaglandins normally help the uterus to contract and shed the lining of the uterus during a period. In women with bad period pains there seems to be a build-up of too much prostaglandins, or the uterus may be too sensitive to the prostaglandins. This causes the uterus to contract too hard, which reduces the blood supply to the uterus, leading to pain, – similar to the pain of angina. The main symptom is crampy pain in the lower abdomen, which often spreads to the lower back, and upper thigh and usually starts just before or as the bleeding starts, lasting between 12-72 hours. The pain may also be associated with headaches, tiredness, faintness, breast tenderness, feeling sick, bloating, feeling down or diarrhoea. There is usually nothing abnormal found during examination and doing further tests, such as pelvic ultrasound. The information you give to your doctor, is often sufficient to allow treatment to start, immediately.

Treatment options for primary dysmenorrhea

There are a number of treatments that may help if you have primary dysmenorrhoea.

• Heat Therapy (Warmth): Use of hot water bottle, safely, or having a warm bath can help.
• Simple analgesics such as non-steroidal anti-inflammatory painkillers or paracetamol, with or wiothout codeine, are usually sufficient for majority of women. These are usually quite effective in about 80% of cases. They work by blocking the effect of the prostaglandin chemicals that are thought to cause the pain. It is useful to use the painkillers regularly three to four times per day, for about 2-3 days.
• Hormonal Contraceptives: this is a suitable option where contraception is required. The pill causes the lining of the uterus to become thin, and the amount of prostaglandin is much reduced, leading to less bleeding. Progestogen contraceptives : such as Cerazette® contraceptive pill or Depo-Provera – an injectable progestogen contraceptive is also useful.
• The intra-uterine system (IUS): Mirena coil is a special intra-uterine contraceptive device which slowly releases a progestogen hormone called levonorgestrel. This ‘thins’ the lining of the uterus and reduces the amount of pain and bleeding during periods
• Transcutaneous electrical nerve stimulation (TENS) machine: work by interfering with pain signals which are sent to the brain from the nerves, by giving out small electrical currents. This could be useful in women who prefer not to use any medication.
• Alternative medicine treatments : there is not enough evidence so far to support the use of other treatments for painful periods. For example, herbal and dietary supplements, acupuncture, exercise and spinal manipulation.

Secondary dysmenorrhea

Causes: Secondary dysmenorrhea occurs because there is an underlying problem affecting the pelvic organs. Such problems include, endometriosis, large uterine polyps, fibroids, or infection of the uterus and Fallopian tubes (pelvic inflammatory disease). In some women, the use of certain type of intrauterine contraceptive device may also cause painful periods.

Symptoms: The most important factor in this type of painful period is that the period has been generally normal, with minimal pain previously. There is recent onset of unusually painful – moderate to severe – crampy lower abdominal pain, often begining a few days before the period starts, and continuing through it, sometimes getting worse, as the menstrual bleeding reaches its maximum flow. There are usually other symptoms that may be associated, such as; irregular periods, bleeding in between periods, pains between periods or during sex.

Diagnosis: Once you‘ve related your symptoms to your doctor, you will be examined in your tummy and internally – vaginal examination – this may include taking some swabs, to test for the presence of infection. Your doctor will want to feel for possible abnormality, such as an enlarged womb, and see if there is any area that is particularly tender or swollen in your pelvis. It may be necessary to arrange other tests, such as an ultrasound of the pelvis. Your gynaecologist may need to be involved, to carry out further investigations, such as a telescope examination of the linning of the womb (see hysteroscopy) or of the internal organs of the pelvis ( see laparoscopy). The laparoscopy may be reveal that treatment should be done at the same time, such as breaking down scar tissues (adhesiolysis), involving the pelvic organs.

Treatment options for secondary dysmenorrhoea?

Certainly the treatment options include controlling the pain in general, as in primary dysmenorrhea, and it can aslo be helpful to control the hormone effects, to keep the organs in a state where they can cause less pain. Options are:

• Heat Therapy (Warmth): Use of hot water bottle, safely, or having a warm bath can help, so also is the use of TENS machine (see primary dysmenorrhea).
• Simple analgesics such as non-steroidal anti-inflammatory painkillers or paracetamol, often with codeine, are usually helpful for many women. It is useful to use the painkillers regularly three to four times per day, for the duration of the pain.
• Hormonal Control: using injections such as Depo-Provera, or implants, scuh as Implanon or other preparations such as Gonadotrophin Releasing Hormonal analogue – can help in the treatment of seocndary dystmenorrhea due to endometriosis.
• The intra-uterine system (IUS): Mirena coil is a special intra-uterine contraceptive device which slowly releases a progestogen hormone called levonorgestrel. This can also be useful in some cases of endometriosis.

The most effective treatment of secondary dysmenorrhoea depends on the underlying cause. See information under ‘Endometriosis‘ ‘Uterine Fibroids’ and ‘Pelvic Inflammatory Disease’, which

describe the treatments available for these conditions. If the presence of an IUCD is identified to be the cause, this will need to be removed, and alternative contraceptive method arranged.