“Periods are supposed to be painful,” a patient’s mother told me recently. “She misses school the first few days of every period. Me too, it’s normal.”
This is a common view shared by many parents, guardians and patients – even some healthcare Professionals. Yes, menstrual cramps are common and affect 50% to 90% of people who menstruate, but it’s not necessary. Sometimes, it can also mean something more dangerous.
What is dysmenorrhea?
Most cramps associated with periods are called primary dysmenorrhea, meaning periods of pain without pathology (menstrual cramps). Sometimes there are anatomical or other reasons for especially painful menstruation – this is called secondary dysmenorrhea and affects about 10% of young people with dysmenorrhea. The most common cause of secondary dysmenorrhea is endometriosis, which can cause chronic pelvic pain even outside of menstrual periods. Adenomyosis and fibroids can also cause periods to be especially heavy and painful. In rare cases, obstructive Müllerian duct abnormalities can also cause periodic abdominal pain because the blockage prevents menstrual blood from draining completely.
But in the absence of any pathological primary dysmenorrhea, wouldn’t that make the pain normal?
While this means that there are no risk factors for pain, it doesn’t mean that if we have the medical knowledge and resources, doctors shouldn’t treat it to do so. About one in eight teens and young adults reported missing school or work because of menstrual cramps. If someone has a headache and it interferes with normal daily activities, it makes sense to treat the headache.
TREATMENTS
The good news: there are many options. I find it most helpful to discuss all available options with patients so they can decide the best plan for themselves. The first-line treatment for primary dysmenorrhea is a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen or naproxen. Dysmenorrhea is often caused by an increase in inflammatory markers that help the uterus contract and drain menstrual blood, so it’s logical that anti-inflammatory drugs would help. Most of the time, households do not use adequate doses of these drugs. It is most helpful to start 1 to 2 days before each menstrual period and take it throughout the day (eg, every 4-6 hours depending on the dose) to suppress pain.
Other options are hormonal drugs. Menstruation occurs due to the cyclical nature of hormonal changes each month, so it makes sense to treat menstrual problems with hormones. However, due to social stigma, many families, patients and even providers stop listening when hormone-containing medications are mentioned. Plus most of these drugs are also commonly known as birth control pills, and the walls are sure to rise. I prefer to call them hormonal suppression or menstrual management, which helps patients keep an open mind so we can at least discuss these options, especially with anxious parents and teens. I usually mention that these drugs maintain a thin endometrial lining so that periods are lighter, less painful, or don’t happen at all.
Discussing the usage, benefits, and potential side effects of each of each option can often be overwhelming for patients. There is no one best option for everyone, and I let them know that the best option for them is the one they choose. This choice can also change over time; most of these methods are easy to start and stop.
In some cases, patients feel like they have tried everything and nothing has helped. It is usually reasonable to treat dysmenorrhea with NSAIDs and hormonal drugs for 3 to 6 months, and if symptoms do not improve significantly, then evaluate for other secondary dysmenorrhea. This may sometimes mean an ultrasound evaluation of the pelvis and/or pelvic exam. Diagnostic laparoscopy (minimally invasive surgery to view the pelvis) is also sometimes required. The most important thing is to consider other etiologies and refer to other specialists if needed. Endometriosis, for example, can be a debilitating lifelong condition, especially if left untreated. Studies have shown that it takes 4 to 11 years from the onset of symptoms to the diagnosis of endometriosis. In such situations, listening to and following up with the patient is critical.
Healthcare professionals, patients and parents need to stay away from normalizing all menstrual cramps. Dysmenorrhea is common, but it doesn’t have to be endured.
Y. Frances Fei, MD, is a pediatric and adolescent gynecologist at Nationwide Children’s Hospital and an obstetrician at The Ohio State University Wexner Medical Center.
