Introduction:

Menstrual pain is a common gynecological complaint in adolescents, but the majority of cases are not associated with a disease.

Primary dysmenorrhea is the medical term for menstrual pain.

Primary dysmenorrhea usually begins 2 - 3 years after the first period, once ovulation is established. Pain usually begins a day or two before menstrual flow, and may continue through the first 2 days of menstruation. Discomfort tends to decrease over time and after pregnancy.

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

Signs and Symptoms:

Symptoms and degree of pain vary, but 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)

What Causes It?:

Primary dysmenorrhea is caused by strong uterine contractions brought on by an increase in prostaglandin. Prostaglandin is a hormone that causes muscle spasms of the uterus (endometrium).            

Secondary dysmenorrhea can be caused by:

• Endometriosis (inflammation of the lining of the uterus)
• Blood and tissue being discharged through a narrow cervix
• Uterine fibroid or ovarian cyst
• Infections of the uterus
• Pelvic inflammatory disease (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 or D&C to analyze tissue. Blood and urine samples may be required.

Treatment Options:

Drug Therapies

Initial treatment is focused on relief of pain. Anti-inflammatory medications can be helpful. This includes over-the-counter (OTC) medications such as aspirin, nonsteroidal anti-inflammatory medications (NSAIDs) such as ibuprofen (Motrin, Advil), and prescription medications. (Note: Long-term use of NSAIDs can lead to gastrointestinal bleeding.)

Oral contraceptives may be prescribed in severe cases for disorders such as endometriosis.

If menstrual pain results from pelvic inflammatory disease (PID), antibiotics will be prescribed.

Complementary and Alternative Therapies

Dysmenorrhea may be effectively treated with nutritional support and mind-body techniques (such as meditation) and exercises (such as yoga and tai chi).

Nutrition and Supplements

• Eliminate potential food allergens, including dairy, wheat (gluten), corn, soy, preservatives, and food additives. Your health care provider may want to test for food sensitivities.
• Eat calcium-rich foods, including beans, almonds, and dark green leafy vegetables (such as spinach and kale).
• Eat antioxidant foods, 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 fewer red meats and 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.
• Drink soy milk for bone health and symptoms of menstrual pain.
• Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
• Avoid coffee and other stimulants, alcohol, and tobacco.
• Drink 6 - 8 glasses of filtered water daily.
• Exercise at least 30 minutes daily, 5 days a week.

Nutritional deficiencies may be addressed with the following supplements:

• A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-complex vitamins and trace minerals such as magnesium, calcium, zinc and selenium.
• Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tbsp. oil daily, to help decrease inflammation.
• Acidophilus (Lactobacillus acidophilus), 5 - 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and vaginal health. Some acidophilus products may require refrigeration. It is important to read the label carefully.
• Calcium citrate, 500 - 1,000 mg daily, for bone support and symptoms of menstrual pain.
• Vitamin D, 400 IU daily, for bone support and symptoms of menstrual pain.
• Ipriflavone (soy isoflavones) standardized extract, 200 mg three times a day, for bone loss and symptoms of menstrual pain.
• Progesterone cream, 1/8 - ¼ teaspoonful (depending upon extract strength) applied topically daily on days 7 - 28 of cycle, for symptoms of menstrual pain.
• Omega-3 fatty acids, such as flaxseed and fish oils, 1 - 2 capsules or 1 tbsp. oil daily, to help decrease inflammation.
• Melatonin, 2 - 5 mg before bed, for sleep regulation. Talk to a health care provider before using melatonin if you are taking antidepressant medications.

Herbs

Herbs are generally available as standardized dried extracts (pills, capsules, or tablets), teas, or tinctures/liquid extracts (alcohol extraction, unless otherwise noted). Mix liquid extracts with favorite beverage. Dose for teas is 1 - 2 heaping teaspoonfuls/cup water steeped for 10 - 15 minutes (roots need to be steeped longer).

The following herbal remedies may provide relief from symptoms:

• Chaste tree (Vitex agnus castus) standardized extract, 20 - 40 mg daily before breakfast, for symptoms of menstrual pain.
• Black cohosh (Actaea racemosa) standardized extract, 20 - 40 mg two times a day, for symptoms of pre-menstrual syndrome.
• Evening primrose oil (Oenothera biennis) standardized extract, 500 - 1000 mg daily, as a source of gamma linolenic acid (GLA), for symptoms of menstrual pain.
• Cat's claw (Uncaria tomentosa) standardized extract, 20 mg three times a day, for inflammation.
• Bromelain (Ananus comosus) standardized extract, 40 mg three times daily, for pain and inflammation.
• Turmeric (Curcuma longa) standardized extract, 300 mg three times a day, for inflammation.

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 -- 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 occuring 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 can 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 - 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 one set. Do one to two sets per day, 3 - 4 days per week.

Acupuncture

The National Institutes of Health recommend acupuncture as either a supplemental or alternative treatment for dysmenorhea. This recommendation is supported by a well-designed trial involving 43 women with dysmenorrhea. Women treated with acupuncture showed a dramatic reduction in both pain and the need for pain medication

Acupuncture has become a popular treatment for dysmenorrhea. 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 is also effective at reducing the pain. A study of 216 female students found that acupressure and ibuprofen were significantly better than a placebo, or “dummy pill,” at reducing pain.

Chiropractic

Some people with dysmenorrhea may benefit from spinal manipulation (particularly in areas that supply sensory and motor impulses to the uterus and lower back). Studies of women with a diagnosis or history of primary dysmenorrhea have found that spinal manipulation improves symptoms, but no more effectively than sham manipulation. Sham manipulation refers to maneuvers that shift soft tissues surrounding the bone but do not actually adjust the spine or joint. Sham manipulation has been compared to placebo because both procedures look and feel the same. Interestingly, however, experts are now questioning whether sham is a fair placebo because the massage quality of the manipulation may also have a beneficial effect.

Following Up:

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

Special Considerations:

Avoid caffeine, alcohol, and sugar prior to onset of your period.

Alternative Names:

Dysmenorrhea