Painful menstrual periods (dysmenorrhea)
Author
Roger P Smith, MD
Andrew M Kaunitz, MD Section Editor
Robert L Barbieri, MD Deputy Editor
Leah K Moynihan, RNC, MSN
Vanessa A Barss, MD
INTRODUCTION — Painful menstruation, also known as dysmenorrhea, is one of the most common gynecologic problems. Most women begin having dysmenorrhea during adolescence, usually within four to five years of the first menstrual period. Painful periods become less common as women age.
This topic review discusses the causes, symptoms diagnosis, and treatment of dysmenorrhea in women who do not have an underlying cause for their pain (eg, endometriosis, fibroids, bowel or bladder disease, etc). Separate topic reviews discuss the management of these problems. (See “Patient information: Endometriosis” and see “Patient information: Fibroids” and see “Patient information: Chronic pelvic pain in women”).
CAUSE OF DYSMENORRHEA — Prostaglandins are chemicals that are formed in the lining of the uterus during menstruation. These prostaglandins cause muscle contractions in the uterus, which decrease blood flow and oxygen to the uterus. Similar to labor pains, these contractions can cause significant pain and discomfort.
DYSMENORRHEA SYMPTOMS — The pain of dysmenorrhea is crampy and usually located in lower abdomen above the pubic bone (the suprapubic region); some women also have severe pain in the back or thighs. The pain usually begins just before or as menstrual bleeding begins, and gradually diminishes over one to three days. Pain usually occurs intermittently, ranging from mild to disabling.
Other symptoms that may accompany cramping include nausea, diarrhea, dizziness, fatigue, headache, or a flu-like feeling.
DYSMENORRHEA DIAGNOSIS — The diagnosis of dysmenorrhea is based upon a woman’s medical history and physical examination.
Physical examination — Women with dysmenorrhea should have a complete abdominal and pelvic examination. During the examination, the healthcare provider will observe and feel the size and shape of the vagina, cervix, uterus, and ovaries. An internal pelvic examination may not be necessary in adolescent girls who are not sexually active.
Other tests — If the medical history and physical examination show no suggestion of an underlying disease (eg, endometriosis, ovarian cyst, pelvic infection), further evaluation with laboratory or imaging tests (eg, x-ray, ultrasound) is not usually necessary.
DYSMENORRHEA TREATMENT — There are a number of treatments available for women with dysmenorrhea.
Non-steroidal antiinflammatory drugs (NSAIDs) — NSAIDs are a class of medications that are very effective in reducing pain associated with dysmenorrhea. Some NSAIDs are available without a prescription while others require a prescription; prescription NSAIDs are probably no more effective than non-prescription NSAIDs as long as an adequate dose is taken. The table lists some of the most common NSAIDs and the recommended doses (show table 1).
NSAIDs are most effective if they are started as soon as bleeding or other menstrual symptoms begins, and then taken on a regular schedule for two to three days.
Birth control pills — Birth control pills and other forms of hormonal birth control (eg, patch, vaginal ring, injection, hormone-releasing intrauterine device) are effective treatments for women with dysmenorrhea. These treatments work by thinning the lining of the uterus, where prostaglandins are formed, thereby decreasing the uterine contractions and menstrual bleeding that contribute to pain and cramping.
Obviously, hormonal methods of birth control do not make sense for women who are trying to become pregnant. However, women who are not actively trying to become pregnant usually have significantly less dysmenorrhea after using a hormonal birth control treatment for two to three months, even if the woman does not need to prevent pregnancy (eg, if the woman is not sexually active or has had her tubes tied). (See “Patient information: Hormonal methods of birth control”).
Traditionally, hormonal birth control treatments (pills, patch, ring) are taken so that the woman has monthly bleeding. However, women who prefer NOT to have bleeding each month and those who wish to minimize dysmenorrhea can take the treatment continuously to avoid or minimize pain associated with the menstrual period. Taking the treatment continuously means the following:
Women who take a birth control pill would take one “active” pill per day for 21 or 24 days (depending upon the brand of pill), and then open a new pack of pills and do the same. This can be done indefinitely, although many women stop taking their pill for several days every nine to 12 weeks; most women will have some menstrual bleeding during this time.
Women who use the patch (Ortho Evra®) would apply a new patch once per week for nine to 12 weeks, and then use no patch for several days; most women will have some menstrual bleeding during this time.
Women who use the vaginal ring (Nuvaring®) would insert a new ring every three weeks for nine to 12 weeks, and then use no ring for several days; most women will have some menstrual bleeding during this time.
Women who use injections of medroxyprogesterone acetate (Depo-Provera®) are given one injection every 12 weeks. Most women have some intermittent spotting or bleeding for the first few months; this usually decreases with time. Most women who use Depo-Provera® have unpredictable spotting and bleeding initially; within one year, most women have little to no bleeding.
Women who take a hormonal birth control treatment continuously often have intermittent bleeding, especially during the first two to three months of treatment; this usually declines with time. When bleeding occurs, it is usually lighter and associated with less severe cramping compared to before the treatment.
Intrauterine device (IUD) — The intrauterine device that contains the hormone levonorgestrel (Mirena®) can reduce dysmenorrhea by as much as 50 percent [1] . In contrast, other non-hormonal IUDs, such as those that contain copper, can worsen dysmenorrhea. The levonorgestrel IUD is discussed in detail in a separate topic review. (See “Patient information: Long-term methods of birth control”).
Non-pharmacologic treatments — Treatments that do not require the use of a medication can also help to reduce the pain of dysmenorrhea. These treatments are not as effective as medications, although they can be combined with a medication to increase the pain-relief benefit.
Heat — Applying heat to the lower abdomen with a heating pad, hot water bottle, or self-heating patch can significantly reduce pain, often as well as treatment with an NSAID. It is important to avoid burning the skin with a heating pad or hot water bottle that is too hot; a temperature of approximately 104ºF (40ºC) is recommended. The heat can be applied as often as it is needed. Using heat in addition to ibuprofen may speed the relief of pain [2] .
Dietary, vitamin, and herbal treatments — A variety of dietary and vitamin therapies have been studied for the relief of dysmenorrhea [3] . However, the studies involved a small number of women and do not provide sufficient data regarding safety or efficacy. We do not recommend dietary, vitamin, or herbal remedies for dysmenorrhea.
Exercise — Exercise seems to reduce menstrual symptoms, including pain, in some studies [4] . There are a number of benefits of exercise, so it is reasonable to try exercising to reduce painful periods. (See “Patient information: Exercise”).
Complementary or alternative medicine — There is some evidence that complementary medicine practices such as yoga or acupuncture are effective in reducing painful periods [5] . However, further study is needed to confirm the safety and efficacy of these treatments. Further information about complementary and alternative medicine is available from the National Center for Complementary and Alternative Medicine (http://nccam.nih.gov/).
Transcutaneous electrical nerve stimulation — Transcutaneous electrical nerve stimulation (TENS) is a treatment that involves the use of electrode patches, which are applied to the skin near the area of pain. TENS has been used to treat pain caused by many conditions, and may help to reduce dysmenorrhea in some women.
The patient wears a small battery pack on a belt, which generates a mild electrical current that passes to the electrodes. The electrical current is believed to stimulate the release of chemicals that block or reduce painful nerve impulses.
An analysis of several studies showed that TENS does not relieve pain as well as medications, although it may be a useful alternative for women who cannot or prefer not to take pain-relieving medications [6] .
Surgical options — At least two surgical procedures have been developed to treat dysmenorrhea. Both of these surgeries involve cutting or destroying the uterine nerves, which prevents the transmission of pain signals. However, no surgery has been shown to provide long-term relief of pain. This may be related to regrowth of nerves or pain signals being transferred by alternate routes [7] . As a result, surgical treatments for dysmenorrhea are not generally recommended.
IF THE INITIAL DYSMENORRHEA TREATMENT FAILS — The most effective treatments for dysmenorrhea include NSAIDs and/or hormonal birth control treatments. If one of these treatments does not sufficiently relieve pain within two to three months, another treatment may be offered. As an example, if a woman tries NSAIDs but does not improve or cannot tolerate the treatment, a hormonal birth control treatment may be recommended instead of or in addition to the NSAID (or vice versa).
If neither NSAIDs nor a hormonal birth control treatment adequately improve pain, the next step depends upon the woman’s age, symptoms, and other medical conditions. The options include:
Diagnostic laparoscopy may be recommended to determine if endometriosis, or another condition, could be causing the pain. Laparoscopy is a minimally invasive surgery that uses small incisions and a thin telescope with a camera to determine if there are signs of endometriosis or other abnormalities on or near the uterus, ovaries, or other areas inside the pelvis.
Assume the pain is caused by endometriosis and treat with a gonadotropin-releasing hormone (GnRH) agonist, such as nafarelin (Synarel®) or leuprolide (Lupron®). If dysmenorrhea improves within two to three months of starting treatment, it was probably caused by endometriosis.
These options are discussed in full detail in a separate topic review. (See “Patient information: Endometriosis”).
WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.
This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.
A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.
National Library of Medicine
(www.nlm.nih.gov/medlineplus/ency/article/003150.htm)
The American College of Obstetrics and Gynecology
(www.acog.org/publications/patient_education/bp046.cfm)
[1-7]
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REFERENCES
1 Baldaszti, E, Wimmer-Puchinger, B, Loschke, K. Acceptability of the long-term contraceptive levonorgestrel-releasing intrauterine system (Mirena): a 3-year follow-up study. Contraception 2003; 67:87.
2 Akin, MD, Weingand, KW, Hengehold, DA, et al. Continuous low-level topical heat in the treatment of dysmenorrhea. Obstet Gynecol 2001; 97:343.
3 Wilson, ML, Murphy, PA. Herbal and dietary therapies for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev 2001; :CD002124.
4 Golomb, LM, Solidum, AA, Warren, MP. Primary dysmenorrhea and physical activity. Med Sci Sports Exerc 1998; 30:906.
5 Helms, JM. Acupuncture for the management of primary dysmenorrhea. Obstet Gynecol 1987; 69:51.
6 Proctor, ML, Smith, CA, Farquhar, CM, Stones, RW. Transcutaneous electrical nerve stimulation and acupuncture for primary dysmenorrhoea (Cochrane Review). Cochrane Database Syst Rev 2002; :CD002123.
7 Proctor, ML, Latthe, PM, Farquhar, CM, et al. Surgical interruption of pelvic nerve pathways for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev 2005; :CD001896.
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