Dysmenorrhea: Painful Menstrual Periods

Dysmenorrhea, a medical term for painful periods, affects more than half of women who menstruate. It is characterized by throbbing or cramping pain in the lower abdomen. The pain often radiates to the back or legs. For some women, the pain is mild to moderate, accompanied by symptoms such as nausea, fatigue, and vomiting. However, there are others whose lives are significantly impacted by severe pain that is not relieved by painkillers. Hence, dysmenorrhea can range from mild discomfort to intense pain.

The pain in dysmenorrhea is caused by the contraction of the uterine muscles during the process of shedding the endometrial lining, which leads to menstrual bleeding. Typically, the pain begins one or two days before the start of the period and continues for an additional two to three days.

What are the types of dysmenorrhea?

There are two types of dysmenorrhea based on the presence or absence of other pelvic diseases.

Primary dysmenorrhea is recurring pain during periods that is not caused by any underlying medical condition; instead, it is a normal physiological response to the menstrual cycle. Primary dysmenorrhoea typically starts a few months after the onset of the first period (menarche). It usually occurs on the day when the period starts and lasts for 8-72 hours. The pain is characterized by discomfort in the lower abdomen and back, which may radiate toward the inner thigh and pelvic region. Other accompanying symptoms may include vomiting, nausea, mood changes, and headaches. Primary dysmenorrhoea is the most common type of dysmenorrhoea.

Secondary dysmenorrhea refers to pain during periods that is caused by an identifiable disease of the reproductive system. There may be an underlying medical condition or infection of the pelvic organs that produces the pain. This type of pain typically occurs in females over the age of 25 years, after the development of the disease, and it usually begins a few days before the onset of the period, lasting for a longer duration. Along with pain, significant symptoms such as irregular periods, heavy bleeding, and spotting between periods may be experienced.

What are the symptoms associated with dysmenorrhea?

Dysmenorrhoea is characterized by persistent, gripping pain during periods. Most females typically experience the following symptoms:

• Aching, throbbing pain in the abdomen
• Pain in the inner thighs
• Radiates to the lower back or legs
• Pain in the pelvic area
• Headache
• Nausea
• Bloating
• Vomiting
• Diarrhea or constipation
• Dizziness
• Mood swings.

These above symptoms are commonly associated with primary dysmenorrhea. However, in secondary dysmenorrhea, there are additional distinguishing symptoms, which include:

• Heavy periods
• Irregular periods
• Unusual vaginal discharge
• Spotting or bleeding between periods
• Dyspareunia (painful sexual intercourse)
• Infertility
• Poor response to oral analgesics (pain-relieving medications).

It is important to note that these symptoms can vary in intensity and may not be present in all females with dysmenorrhoea.

What may cause painful periods?

Causes of primary dysmenorrhea

During the menstrual period, the uterine lining is shed off through strong muscular contractions of the uterus. These intense contractions of the uterine muscles lead to the constriction of blood vessels around the uterus, resulting in reduced blood flow and causing ischemia. This ischemia is the main cause of pain in primary dysmenorrhoea.

The contraction of the uterus is mediated by natural chemicals called prostaglandins. Endometrial cells release higher levels of prostaglandins just before the onset of menstrual bleeding, with levels peaking on the first day of the period. As bleeding begins, the levels of prostaglandins gradually decrease, ultimately alleviating the pain. Prostaglandins play a role in triggering muscular contractions that help expel the uterine lining during menstruation.

Some females naturally produce higher levels of prostaglandins, leading to more severe pain.

Causes of secondary dysmenorrhoea 

However, secondary dysmenorrhoea is due to an underlying medical condition. The causes of secondary dysmenorrhea include:

• Endometriosis: It occurs when tissue similar to the lining of the uterus (endometrium) grows outside of the uterus, such as on the ovaries, fallopian tubes, or pelvic lining. During the menstrual cycle, these misplaced endometrial tissues also respond to hormonal changes, thickening, and shedding, leading to inflammation, scarring, and pain.
• Uterine polyps: They are abnormal growths that develop on the inner lining of the uterus. Uterine polyps can disrupt the normal shedding of the endometrium, causing increased pain during menstruation.
• Uterine fibroids: They are noncancerous growths that form in the muscular wall of the uterus. Depending on their size and location, uterine fibroids can cause increased menstrual pain and heavy bleeding.
• Adenomyosis: It is a condition characterized by the presence of endometrial tissue within the muscular wall of the uterus. The abnormal growth and shedding of this tissue during the menstrual cycle can lead to pain, as the enlarged uterus puts pressure on surrounding structures.
• Pelvic inflammatory disease (PID): PID is an infection of the reproductive organs, often caused by sexually transmitted bacteria. Inflammation and scarring from PID can affect the normal functioning of the reproductive organs, leading to painful menstruation.
• Cervical stenosis: It refers to the narrowing of the cervix, the lower part of the uterus that connects to the vagina. This narrowing can impede the flow of menstrual blood, causing increased pressure and pain during menstruation.
• Polycystic ovary syndrome (PCOS): PCOS is a hormonal disorder characterized by imbalances in reproductive hormones. These imbalances can disrupt the normal menstrual cycle, leading to irregular periods, increased androgen levels, and pelvic pain.
• Ovarian cysts: They are fluid-filled sacs that can develop on or within the ovaries. Large cysts or those that rupture can cause pain and discomfort during menstruation.
• Presence of a copper intrauterine device (IUD): While IUDs are generally well-tolerated, some females may experience increased menstrual pain with the presence of a copper IUD.
• Congenital conditions: Certain congenital conditions, such as abnormalities in the shape of the uterus or structural defects in the fallopian tubes or ovaries, can contribute to painful periods.
• Pelvic adhesions: Adhesions are bands of scar tissue that form between pelvic organs, often as a result of previous surgeries, infections, or endometriosis. These adhesions can cause organs to stick together, leading to pain and discomfort during menstruation.
• Ovarian torsion: It occurs when an ovary twists around its supporting ligaments, causing a disruption in blood flow to the ovary. Ovarian torsion can cause severe pelvic pain, especially during menstruation.
• Irritable bowel syndrome (IBS): IBS is a chronic gastrointestinal disorder that can cause abdominal pain and discomfort, which may worsen during menstruation.
• Psychological factors: Emotional stress, anxiety, or depression can contribute to increased sensitivity to pain and may worsen the perception of dysmenorrhoea.

Primary dysmenorrhea	Secondary dysmenorrhea
It refers to pain during periods that is not caused by an underlying medical condition. It is related to normal menstruation.	It refers to pain during periods that is caused an underlying medical condition or infection of the pelvic organs.
Often starts in adolescence, within a few years of the onset of menstruation.	Generally starts later in life, often after 20-30 years of age.
The pain usually starts just before or at the start of menstruation and often lasts for 2 to 3 days.	The pain usually begins a few days before the onset of the period, lasting for a longer duration.
Medical conditions such as endometriosis, fibroids, adenomyosis, and pelvic inflammatory disease are the major causes.	Have similar symptoms to primary dysmenorrhea but is also associated with other symptoms such as abnormal menstrual bleeding and pain during intercourse.
Prostaglandins are believed to be a major cause. They are involved in inflammation and pain.	Medical conditions such as endometriosis, fibroids, adenomyosis, and pelvic inflammatory disease are the major underlying causes.
Management includes non-steroidal anti-inflammatory drugs (NSAIDs), hormonal contraceptives, and lifestyle modifications such as exercise and diet.	Management depends on the underlying cause.

What are the risk factors associated with dysmenorrhea?

Certain females are more likely to experience dysmenorrhoea due to the presence of various risk factors, including:

• Heavy bleeding or menorrhagia: Experiencing excessive or prolonged menstrual bleeding can increase the likelihood of dysmenorrhoea.
• Prolonged periods: Having periods that last longer than seven days can be a risk factor for dysmenorrhoea.
• Early menarche: The onset of first period (menarche) before the age of 12 is associated with an increased risk of dysmenorrhoea.
• Younger age: Girls who are younger than 20 years of age are more prone to experiencing dysmenorrhoea.
• Smoking cigarettes: Smoking has been identified as a risk factor for dysmenorrhoea, potentially exacerbating pain and discomfort during periods.
• Stress: High levels of stress can contribute to dysmenorrhoea or worsen existing symptoms.
• Obesity: Being overweight or obese has been associated with an increased risk of dysmenorrhoea.
• Family history of dysmenorrhoea: Having a family history of dysmenorrhoea may indicate a genetic predisposition to experiencing the condition.

What is the impact of dysmenorrhea on daily life?

Dysmenorrhea, although not posing a direct threat to one’s health, can lead to numerous complications that adversely affect a female’s overall quality of life. The following are different complications associated with this disorder:

• Diminished quality of life: Intense menstrual pain can severely disrupt daily activities such as work, school, and social engagements, which consequently leads to a deterioration in well-being.
• Absenteeism and low productivity: Women who have dysmenorrhea often have to skip their responsibilities due to the unbearable pain they experience, thus negatively affecting their attendance and output.
• Impact on relationships: The physical and emotional challenges associated with dysmenorrhoea can strain relationships with partners, family members, and friends.
• Mental health implications: Long-term struggles with pain may result in psychosomatic disorders, including, but not limited to, depression, anxiety, agitation, or fluctuations in temperament.

How to diagnose primary and secondary dysmenorrhea?

Primary dysmenorrhea

Primary dysmenorrhoea can be easily diagnosed by a doctor as it is not associated with any underlying abnormalities. However, the doctor still needs to rule out any other potential diseases. Diagnosis of primary dysmenorrhoea typically relies on a thorough medical history and physical examination.

• Medical history: The doctor will take a detailed medical history, including information about your menstrual cycle, the onset, and duration of pain, the location and severity of pain, as well as any factors that alleviate or worsen the symptoms.
• Physical examination: Following the medical history, a physical examination of the abdomen and pelvis will be performed. In the case of primary dysmenorrhoea, this examination will typically reveal no abnormal findings.

Secondary dysmenorrhea

Diagnosing secondary dysmenorrhoea requires identifying the underlying medical condition causing the pain. The following steps are typically taken in the diagnostic process:

• Medical history: The doctor will inquire about your menstrual cycle health, including the regularity, length, and symptoms associated with pain. They will also ask about any other relevant medical conditions or symptoms.
• Physical examination: A physical examination will be conducted, which may involve an external examination of the abdomen and an internal examination of the cervix and vagina. This examination aims to check for tenderness, abnormalities, or signs of an underlying condition.
• Diagnostic tests: Based on the medical history and physical examination, additional tests may be recommended to evaluate the underlying cause. These tests can include:
  • Pelvic ultrasound: This imaging test provides visualizations of the pelvic organs, helping to detect abnormalities such as uterine polyps, fibroids, ovarian cysts, or other structural irregularities.
  • Laparoscopy: In cases where other tests do not provide a clear reason for painful periods, laparoscopy may be performed. It is a minimally invasive surgical procedure that allows direct visualization of the pelvic organs, helping to confirm the presence of conditions like endometriosis.
  • Imaging studies: Additional imaging studies, such as CT scans or MRI scans, may be conducted to obtain more detailed information about the medical conditions causing secondary dysmenorrhoea.
  • Hysteroscopy: If ultrasound and imaging studies do not provide a conclusive reason for painful periods, hysteroscopy may be performed. It involves visualizing the inside of the uterus using a thin, lighted tube to identify any abnormalities.

How to manage painful periods?

For the treatment and management of dysmenorrhea, there are various methods to relieve pain. In the case of secondary dysmenorrhea, it is important to address the underlying medical condition in addition to managing the pain.

Lifestyle and self-care

• Heat therapy: Applying heat packs or using a hot water bottle on the lower abdominal region helps relax muscles and decrease pain.
• Adequate rest: Getting extra rest and avoiding excessive physical exertion allows the body time to recover and eases discomfort.
• Regular exercise: Engaging in regular exercise has been shown to reduce the intensity and frequency of painful periods. Exercise helps with period cramps by improving blood circulation and releasing endorphins, which are natural pain relievers.
• Caffeine avoidance: Avoiding caffeine is recommended as it can cause the contraction of blood vessels and increase prostaglandin synthesis, potentially worsening menstrual cramps.
• Massage therapy: Massaging the painful area promotes vasodilation, improves blood flow, and relaxes muscles, providing relief from menstrual pain.
• Nutritional supplements: Certain supplements such as Vitamin B1, B3, magnesium, and omega-3 fatty acids have been found to be beneficial in managing dysmenorrhea and reducing pain.
• Alcohol and smoking avoidance: It is advisable to avoid alcohol consumption and smoking, as these habits can worsen symptoms and increase discomfort during menstruation.

Medications

• Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs work by reducing the production of prostaglandins, the main chemicals that trigger contractions and cause pain. They include ibuprofen and naproxen sodium.
• Painkillers: Acetaminophen is an analgesic that stops the pain, but it does not have anti-inflammatory properties.
• Hormonal contraceptives: They are available in the form of pills, patches, and vaginal rings, helping to regulate the menstrual cycle and reduce pain.
• GnRH agonists: Gonadotropin-releasing hormone (GnRH) agonists work by temporarily suppressing estrogen production, minimizing growth, and relieving pain. They are used specifically in endometriosis-associated dysmenorrhea.
• Prostaglandin inhibitors: Certain medicines and contraceptive pills inhibit the action of prostaglandins.
• Intrauterine device (IUD): IUDs function by releasing progesterone, making periods lighter and decreasing pain.

Alternate therapies

• Transcutaneous electrical nerve stimulation (TENS): TENS is a technique that involves applying a mild electrical current to the skin via electrodes. This electrical stimulation helps alleviate cramps and reduce pain by interfering with pain signals and promoting the release of endorphins, the body’s natural pain-relieving chemicals.
• Acupuncture: Acupuncture is a traditional Chinese medicine practice that involves the insertion of fine needles into specific points of the body. This stimulation is believed to balance the flow of energy and promote pain relief. Acupuncture has shown promise in reducing dysmenorrhea symptoms, although further research is needed to establish its effectiveness.
• Herbal remedies: Some herbal remedies have been used traditionally to alleviate menstrual pain. Ginger tea and cinnamon tea are commonly consumed for their potential anti-inflammatory properties. These herbs may help prevent inflammation and reduce associated pain. Incorporating anti-inflammatory foods into the diet, such as turmeric, green leafy vegetables, and fatty fish rich in omega-3 fatty acids, may also provide additional benefits in managing dysmenorrhea.

Treatment of underlying conditions

In cases of secondary dysmenorrhea, it is crucial to address and treat the underlying medical condition that is causing pain during periods. Simply focusing on symptomatic relief without addressing the root cause will not provide long-term relief and may result in recurring pain in future menstrual cycles.

How to prevent painful periods?

While it is not possible to completely prevent dysmenorrhea, there are measures you can take to potentially reduce the intensity of cramps and manage the associated symptoms. A balanced diet, heat therapy, and regular exercise may be beneficial to reduce pain.

When to seek medical advice?

It is not a cause for concern if you experience mild to moderate pain during periods. However, if you notice any of the following, it is advisable to consult a healthcare professional:

• Over-the-counter medications do not provide relief
• Severe pain that significantly limits daily activities
• Abnormal bleeding
• Difficulties in conceiving
• Symptoms worsen over time.

Menstrual Portal also offers free online consultation, regarding all your menstrual health concerns.

Frequently asked questions

What does dysmenorrhea pain feel like?

The intensity and character of dysmenorrhea pain can vary among females. Some may experience constant throbbing pain in the lower abdominal region, while others may have intermittent pinpricking pain. The pain often radiates to the back or legs.

How long does dysmenorrhea last?

Primary dysmenorrhea typically lasts from 8 to 72 hours after onset. On the other hand, secondary dysmenorrhea can persist even after the cessation of menstrual bleeding. Additionally, secondary dysmenorrhea may start days before the onset of periods.

Do periods become more painful with age?

Primary dysmenorrhea tends to decrease with age, as it is most common in the first few months after the onset of menstruation. However, in the 30s and 40s, secondary dysmenorrhea can develop due to pelvic abnormalities. Therefore, secondary dysmenorrhea may worsen with age.

Are there any specific dietary recommendations for females with dysmenorrhea?

Some dietary recommendations for females with dysmenorrhea include increasing the intake of anti-inflammatory foods such as fruits, vegetables, whole grains, and fatty fish, reducing consumption of processed foods and foods high in saturated fats, and staying hydrated.

Can stress and emotional factors affect the severity of dysmenorrhea symptoms?

Yes, stress and emotional factors can contribute to the severity of dysmenorrhea symptoms. Increased stress levels and emotional disturbances may worsen pain perception and overall discomfort during menstruation.