Menstrual pain

Many women have pain with their periods, especially when they are in their teens age years. In most cases, menstrual pain does not indicate a serious problem, although sometimes it can be associated with noncancerous tumors in the uterus, including endometriosis or uterine fibroids.

The medical term for menstrual pain is primary dysmenorrhea. Primary dysmenorrhea usually starts shortly after the first period, as a woman begins to ovulate regularly. Pain usually starts a day or two before menstrual flow, and may continue through the first 2 days of the period. Often, pain gets better as a woman gets older, or after she has a child. Dysmenorrhea is twice as common among women with irritable bowel syndrome (IBS) compared to those who do not have IBS.

Secondary dysmenorrhea is caused by underlying conditions, such as endometriosis and pelvic inflammatory disease (PID).

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Signs and Symptoms

Symptoms and degree of pain vary, and may include the following:

• Abdominal cramping or dull ache that moves to lower back and legs
• Heavy menstrual flow
• Headache
• Nausea
• Constipation or diarrhea
• Frequent urination
• Vomiting (not common)
• Low back pain
• Diarrhea

What Causes It?

Primary dysmenorrhea is caused by strong contractions of the uterus triggered by prostaglandins, chemicals in the body that are involved in inflammation and pain. Generally, the higher the levels of prostaglandins, the more menstrual pain.

Secondary dysmenorrhea can be caused by:

• Endometriosis, inflammation of the uterine lining
• Blood and tissue being passed through a narrow cervix
• Uterine fibroid or ovarian cyst
• Uterine infections
• PID
• Intrauterine device (IUD)

What to Expect at Your Provider's Office

A pelvic examination may include an internal examination, laparoscopy, and ultrasound. You may need a Pap test. Your doctor may also ask for blood and urine samples.

Treatment Options

Drug Therapies

Initial treatment is focused on relieving pain.

Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs help relieve pain. They can cause stomach upset, so taking them with food may help. Long-term use can increase the risk of stomach bleeding. NSAIDs include over-the-counter (OTC) medications such as aspirin, ibuprofen (Motrin, Advil), and naproxen (Aleve). Prescription NSAIDs are also available.

Cyclooxygenase-2 (COX-2) inhibitors. Help relieve pain and have fewer gastrointestinal side effects than NSAIDs.

Birth control pills and patches. Can help relieve pain and may be prescribed for problems such as endometriosis.

Intrauterine devices. Reduce menstrual bleeding and dysmenorrhea.

For menstrual pain results caused by pelvic inflammatory disease (PID), your doctor will prescribe antibiotics.

Complementary and Alternative Therapies

Some women find that changing their diets makes cramps less severe. Mind-body techniques such as meditation and acupuncture, and exercises such as yoga and tai chi, can also help relieve pain. Aromatic essential oils and massage may also help relieve pain.

Nutrition and Supplements

• Eat foods that are rich in calcium, including beans, almonds, and dark green leafy vegetables, such as spinach and kale.
• Eat foods that are high in antioxidants, including fruits, such as blueberries, cherries, and tomatoes, and vegetables, such as squash and bell pepper.
• Avoid refined foods, such as white breads, pastas, and sugar.
• Eat more lean meats, cold-water fish, tofu (soy, if no allergy), or beans for protein.
• Use healthy cooking oils, such as olive oil or vegetable oil.
• Some women find that adding soy milk to their diet helps relieve menstrual pain.
• Eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
• Avoid caffeine, alcohol, and tobacco.
• Drink 6 to 8 glasses of filtered water daily.
• Exercise at least 30 minutes daily, 5 days a week.

Some studies also suggest following a gluten-free diet helped reduce painful symptoms of endometriosis.

The following supplements may also help relieve menstrual pain:

• Omega-3 fatty acids, such as fish oil to help lower inflammation. A few studies have found that women who took fish oil had less menstrual pain than those who took placebo. Omega-3 fatty acids may raise the risk of bleeding, especially for people who take blood thinners such as clopidogrel (Plavix), warfarin (Coumadin), or aspirin. Ask your doctor before taking omega-3 fatty acids.
• Calcium citrate. Your body needs calcium for healthy bones. Calcium may also help reduce menstrual pain because it helps maintain muscle tone. However, evidence isn't clear. Calcium citrate is the form of calcium that your body absorbs most easily. Remember that you may be getting some calcium in the food you eat, so ask your doctor before taking calcium supplements.
• Vitamin D, helps your body use calcium and may reduce inflammation. Vitamin D may interact with a number of medications, so ask your doctor before taking more than the recommended daily allowance.
• Vitamin E, may help reduce menstrual pain. In one study, 100 young women took either 500 IU of vitamin E or placebo for 5 days (2 days before and 3 days after their periods started). Those who took vitamin E reported less pain than those who took placebo. Vitamin E may increase the risk of bleeding, especially if you already take blood thinners. People with heart disease, diabetes, retinitis pigmentosa, or cancer of the head, neck, or prostate, should avoid high doses of vitamin E without first asking their doctor.
• Magnesium. Preliminary studies suggest that magnesium may help reduce menstrual pain. Too much magnesium can cause diarrhea and lower blood pressure. If you have digestive problems or heart disease, ask your doctor before taking magnesium. Magnesium can interact with many medications, including antibiotics such as ciprofloxacin (Cipro), levofloxacin (Levaquin), and tetracycline; bone-building drugs such as alendronate (Fosamax), and risedronate (Actonel); diuretics (water pills); and other drugs.

Herbs

Herbs are generally available as standardized dried extracts (pills, capsules, or tablets), teas, tinctures, or liquid extracts (alcohol extraction, unless otherwise noted). Mix liquid extracts with favorite beverage.

Some researchers think the following herbs act like estrogen in the body. Women who have a history of hormone-related cancer, who are taking hormone replacement therapy, or who have a bleeding disorder or are taking blood-thinning medication should ask their doctor before taking these herbs:

• Chaste tree or chaste berry (Vitex agnus castus). Chaste tree may interact with a number of medications, including chlorpromazine (Thorazine), haloperidol (Haldol), levodopa, metoclopramide, olanzapine (Zyprexa), prochlorperazine (Compazine), quetiapine (Seroquel), ropinirole (Requip), risperidone (Risperdal). It may also make birth control pills less effective.
• Cramp bark (Viburnum opulus), taken as a tea. People who take diuretics (water pills) or lithium should ask their doctors before taking cramp bark.
• Black cohosh (Actaea racemosa) standardized extract, 20 to 40 mg, 2 times a day. Black cohosh may interact with medications processed by the liver, including acetaminophen (Tylenol), atorvastatin (Lipitor), carbamazepine (Tegretol), isoniazid (INH), methotrexate (Rheumatrex), and others.
• Evening primrose oil (Oenothera biennis). Some studies have found evening primrose oil to be effective at relieving symptoms of premenstrual syndrome (PMS). People with a history of seizures should not take evening primrose oil. Evening primrose oil can increase the risk of bleeding, particularly in people who already take blood-thinning medications, such as coumadin (Warfarin), plavix (Clopidogrel), or aspirin.
• Turmeric (Curcuma longa), for inflammation. Turmeric can increase the risk of bleeding, particularly in people who already take blood-thinning medications, such as coumadin (Warfarin) and aspirin. Speak to your doctor before taking it. People with gallstones or gallbladder problems should ask their doctor before using turmeric.
• Fennel, for nausea and weakness during menstruation. Preliminary studies suggest fennel may reduce the severity of symptoms.

Homeopathy

Few studies have examined the effectiveness of specific homeopathic remedies. However, a professional homeopath may recommend one or more of the following treatments for menstrual pain based on his or her knowledge and clinical experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type, includes your physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for a particular individual.

• Belladonna. For acute menstrual pain that often resembles labor pains; for pain often described as sharp, throbbing pressure in the pelvis accompanied by heavy bleeding; and for pain that may extend to the back and tends to worsen with walking or moving.
• Chamomilla. For menstrual pain with mood changes, including irritability and anger, and pain occurring after bouts of anger. The individual may have the sensation of a weight on her pelvis.
• Cimicifuga. For pain that moves from one side of the abdomen to the other, and that is worsened by movement.
• Colocynthis. For sharp pain accompanied by anger and irritability.
• Lachesis. For pain and pressure that extend to the back. Symptoms tend to worsen at night.
• Magnesia phos. For cramps or sharp, shooting pains that are relieved by warmth, pressure, and bending forward.
• Nux vomica. For cramping pains that extend to the lower back; these pains are often accompanied by nausea, chills, irritability, and a sensitivity to light, noise, and odors.
• Pulsatilla. For menstrual pains accompanied by irritability, moodiness (including feelings of sadness), dizziness, fainting, nausea, diarrhea, back pain, and headaches; there may be more pain when there is no menstrual flow.

Physical Medicine

The following methods may help relieve pelvic pain:

• Castor oil pack. Apply oil directly to skin, cover with a clean soft cloth (for example, flannel) and plastic wrap. Place a heat source (hot water bottle or heating pad) over the pack and let sit for 30 to 60 minutes. For best results use 3 consecutive days in 1 week.
• Contrast sitz baths. Use two basins that you can comfortably sit in. Sit in hot water for 3 minutes, then in cold water for 1 minute. Repeat three times to complete 1 set. Do 1 to 2 sets per day, 3 to 4 days per week.
• Topical heat. Continuous low level topical heat therapy has been shown to be as effective as ibuprofen (Advil) for the treatment of dysmenorrhea.

Acupuncture

Acupuncture has become a popular treatment for menstrual pain. The National Institutes of Health recommends acupuncture, either by itself or along with other treatments, for menstrual pain. In a well-designed study of 43 women with menstrual pain, women treated with acupuncture had less pain and needed less pain medication.

Acupuncturists treat people with dysmenorrhea based on an individualized assessment of the excesses and deficiencies of energy (called qi) located in various meridians. In the case of dysmenorrhea, a qi deficiency is usually detected in the liver and spleen meridians. Moxibustion (a technique in which the herb mugwort is burned over specific acupuncture points) is often added to enhance needling treatment, and qualified practitioners may also recommend herbal or dietary treatments.

Acupressure also works to relieve pain. A study of 216 female students found that acupressure and ibuprofen were better than placebo at reducing pain.

Chiropractic

Some people with menstrual pain may find relief with spinal manipulation, particularly in areas that supply sensory and motor impulses to the uterus and lower back.

Following Up

If your symptoms change, or treatment does not help, tell your provider.

Special Considerations

Avoid caffeine, alcohol, and sugar before your period starts.

Supporting Research

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Barnard ND, Scialli AR, Hurlock D, Bertron P. Diet and sex-hormone binding globulin, dysmenorrhea, and premenstrual symptoms. Obstet Gynecol. 2000;95(2):245-50.

Bernstein MT, Graff LA, Avery L, Palatnick C, Parnerowski K, Targownik LE. Gastrointestinal symptoms before and during menses in healthy women. BMC Womens Health. 2014;14:14.

Bope & Kellerman: Conn's Current Therapy 2013. 1st ed. Philadelphia, PA: Elsevier Saunders; 2012.

Chen YW, Wang HH. The effectiveness of acupressure on relieving pain: a systematic review. Pain Manag Nurs. 2014;15(2):539-50.

Dennehy CE. The use of herbs and dietary supplements in gynecology: an evidence-based review. J Midwifery Womens Health. 2006;51(6):402-9.

Ferri: Ferri's Clinical Advisor 2016. Philadelphia, PA: Elsevier; 2016.

Fjerbaek A, Knudsen UB. Endometriosis, dysmenorrhea and diet -- what is the evidence? Eur J Obstet Gynecol Reprod Biol. 2007;132(2):140-7.

Ghodsi Z, Asltoghiri M. The effect of fennel on pain quality, symptoms, and menstrual duration in primary dysmenorrhea. J Pediatr Adolesc Gynecol. 2014;27(5):283-6.

Grimes DA, Hubacher D, Lopez LM, Schulz KF. Non-steroidal anti-inflammatory drugs for heavy bleeding or pain associated with intrauterine-device use. Cochrane Database Syst Rev. 2006;(4):CD006034.

Guerrera MP, Volpe SL, Mao JJ. Therapeutic uses of magnesium. Am Fam Physician. 2009 Jul 15;80(2):157-62. Review.

Habek D, Cortez Habek J, Bobic-Vukovic M, Vujic B. Efficacy of acupuncture for the treatment of primary dysmenorrheal. Gynakol Geburtshilfliche Rundsch. 2003 Oct;43(4):250-3.

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Letzel H, Megard Y, Lamarca R, Raber A, Fortea J. The efficacy and safety of aceclofenac versus placebo and naproxen in women with primary dysmenorrhoea. Eur J Obstet Gynecol Reprod Biol. 2006;129(2):162-8.

Liu CZ, Xie JP, Wang LP, et al. Immediate analgesia effect of single point acupuncture in primary dysmenorrhea: a randomized controlled trial. Pain Med. 2011 Feb;12(2):300-7. doi: 10.1111/j.1526-4637.2010.01017.x. Epub 2010 Dec 17. Erratum in: Pain Med. 2011 Apr;12(4):685.

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Marziali M, Venza M, Lazzaro S, Lazzaro A, Micossi C, Stolfi VM. Gluten-free diet: a new strategy for management of painful endometriosis related symptoms? Minerva Chir. 2012;67(7):499-504.

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Proctor ML, Latthe PM, Farquhar CM, Khan KS, Johnson NP. Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhea. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD001896.

Tugay N, Akbayrak T, Demirturk F, et al. Effectiveness of transcutaneous electrical nerve stimulation and interferential current in primary dysmenorrhea. Pain Med. 2007;8(4):295-300.

Wong CL, Farquhar C, Roberts H, Proctor M. Oral contraceptive pill for primary dysmenorrhoea. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD002120. Review.

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Review Date: 2/4/2016  

Reviewed By: Steven D. Ehrlich, NMD, Solutions Acupuncture, a private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network. Also reviewed by the A.D.A.M. Editorial team.

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