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Menstrual pain

Also listed as: Dysmenorrhea

• Signs and Symptoms
• What Causes It?
• What to Expect at Your Provider's Office
• Treatment Options
• Following Up
• Special Considerations
• Supporting Research

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 to 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 medications such as aspirin, nonsteroidal anti-inflammatory medications (NSAIDS) such as ibuprofen and prescription medications. (Note: Long-term use of NSAIDS can cause gastrointestinal bleeding.)

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

If menstrual pain results from 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

• Increase intake of essential fatty acids, found in cold-water fish, nuts, and seeds. Reduce intake of saturated fats (meat and dairy products). Eliminate refined foods, sugar, dairy products, and methylxanthines (coffee and chocolate). Increase intake of fresh fruits and vegetables, proteins, and whole grains.
• Magnesium (400 mg per day) with B6 (100 mg per day) throughout the menstrual cycle to promote hormone production and induce relaxation. You may take higher doses during your period (magnesium up to 600 mg per day, and B6 up to 300 mg per day) for pain relief.
• Vitamin E (400 to 800 IU per day) to improve blood supply to muscles
• B-complex (50 to 100 mg per day) to reduce the effects of stress
• Essential fatty acids (Omega-3 and Omega 6 oils such as flaxseed, evening primrose, or borage oil) to reduce inflammation and/or support hormone production
• Niacinamide (50 mg twice a day) to reduce pain. Begin 7 days before your period until the end of flow. Add rutin (60 mg per day) and vitamin C (300 mg per day) to increase effects.

Herbs

Herbs come in the form of dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Make teas with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, 10 to 20 minutes for roots. Drink 2 to 4 cups per day.

• Chaste tree (Vitex agnus-cactus) and black cohosh (Cimicifuga racemosa), 30 drops each, twice a day, to reduce dysmenorrhea.
• Red raspberry (Rubus idaeus) tea strengthens uterine tissue.
• Tea of chamomile (Matricaria recutita) and ginger root (Zingiber officinale) can help reduce ovarian cyst pain.
• Use tinctures of cramp bark (Viburnum opulus), black cohosh, Jamaica dogwood (Piscidia piscipula), and wild yam (Dioscorea villosa) together in equal parts to relieve pain and cramping. Use 20 drops every half hour for 4 doses, then as needed up to 8 doses per day for 7 days.

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, which is a person's 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; pain is often described as sharp, throbbing pressure in the pelvis accompanied by heavy bleeding; pain may extend to the back and tends to worsen with walking or moving
• Chamomilla  -- for menstrual pain with mood changes including irritability and anger; pain may occur after bouts of anger and be relieved by warmth; the individual may have the sensation of a weight on her pelvis
• Cimicifuga -- for pains that move from one side of the abdomen to the other and that are worsened by movement
• Colocynthis -- for sharp pains 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 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 this three times to complete one set. Do one to two sets per day 3 to 4 days per week.

Acupuncture

The National Institutes of Health recommend acupuncture as either a supplemental or alternative treatment for dysmennorhea. 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.

Massage

Therapeutic massage is helpful in reducing the effects of stress.

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.

Supporting Research

American Medical Association. Encyclopedia of Medicine . New York, NY. Random House; 1989:383.

Batchelder HJ, Scalzo R. Allopathic specific condition review: dysmenorrhea. Protocol J Botan Med . 1995;1(1).

Berkow R, ed. The Merck Manual of Diagnosis and Therapy . 16th ed. Rahway, NJ: Merck Research Laboratories; 1992.

Branch WT Jr. Office Practice of Medicine . 3rd ed. Philadelphia, Pa: WB Saunders Co; 1994.

Cummings S, Ullman D. Everybody's Guide to Homeopathic Medicines . 3rd ed. New York, NY: Penguin Putnam; 1997: 186-187.

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):250-253.

Helms JM. Acupuncture for the management of primary dysmenorrhea. Obstet Gynecol . 1987;69(1):51-56.

Hondras MA, Long CR, Brennan PC. Spinal manipulative therapy versus a low force mimic maneuver for women with primary dysmenorrhea: a randomized, observer blinded, clinical trial. Pain . 1999;891:105-114.

Jonas WB, Jacobs J. Healing with Homeopathy: The Doctors' Guide . New York, NY: Warner Books; 1996: 185-186.

Kokjohn K, Schmid DM, Triano JJ, Brennan PC. The effect of spinal manipulation on pain and prostaglandin levels in women with primary dysmenorrhea. J Manipulative Physiol Ther . 1992;15(5):279-285.

NIH Consensus Statement: Acupuncture. National Institutes of Health, Office of the Director. 1997;15(5):1-34. Available at http://odp.od.nih.gov/consensus/cons/107/107_statement.htm  .  Accessed September 24, 2001.

Penland JG, Johnson PE. Dietary calcium and manganese effects on menstrual cycle symptoms. Am J Obstet Gynecol . 1993;168:1417-1423.

Pouresmail Z, Ibrahimzadeh R. Effects of acupressure and ibuprofen on the severity of dysmenorrheal. J Tradit Chin Med 2002 Sep;22(3):205-210.

Werbach MR. Nutritional Influences on Illness . New Canaan, Conn: Keats Publishing Inc; 1987.

Ullman D. Homeopathic Medicine for Children and Infants . New York, NY: Penguin Putnam; 1992: 190-191.

• Review Date: 10/28/2005
• Reviewed By: A.D.A.M. editorial, previously reviewed by: Gary Guebert, DC, DACBR, (Chiropractic section October 2001) Login Chiropractic College, Maryland Heights, MO; Pamela Stratton, MD, Chief, Gynecology Consult Service, National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD; Joseph Trainor, DC, (Chiropractic section October 2001) Integrative Therapeutics, Inc., Natick, MA; Marcellus Walker, MD, LAc, (Acupuncture section October 2001) St. Vincent's Catholic Medical Center, New York, NY; Leonard Wisneski, MD, FACP, George Washington University, Rockville, MD; Ira Zunin, MD, MPH, MBA, (Acupuncture section October 2001) President and Chairman, Hawaii State Consortium for Integrative Medicine, Honolulu, HI.

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