Dysmenorrhoea

Dysmenorrhoea, the medical term for painful menstrual periods, affects more than half of women who menstruate and is one of the most common reasons for school and work absence among those of reproductive age.

Table of contents

• What is dysmenorrhoea?
• Types of dysmenorrhoea
• How common is dysmenorrhoea?
• What causes dysmenorrhoea?
• Symptoms of dysmenorrhoea
• Risk factors
• How is dysmenorrhoea diagnosed?
• Treatment options
• What is the outlook?

menstrual cramps, painful periods, period pain, painful menstruation

What is dysmenorrhoea?

Dysmenorrhoea is the medical term for painful menstrual periods or menstrual cramps. The pain is usually located in the lower abdomen and may radiate to the lower back and thighs^[1]. In addition to cramping, you might have other symptoms, such as nausea, fatigue and diarrhea^[1].

The pain typically begins just before or at the start of your period. For most people, symptoms subside after about two or three days^[1]. The pain can range from mild discomfort to severe pain that interferes with daily activities^[1].

Types of dysmenorrhoea

There are two types of dysmenorrhoea: primary and secondary^[1].

Primary dysmenorrhoea is menstrual pain that is not associated with any underlying disease or identifiable cause. It is a diagnosis of exclusion, meaning it is diagnosed when no other condition is found^[3]. Pain usually begins one or two days before your period or when the bleeding actually starts. You may feel pain ranging from mild to severe in your lower abdomen, back or thighs. The pain usually subsides within two or three days^[1]. Primary dysmenorrhoea typically begins within about two years of menarche (first menstrual period) or once ovulatory cycles have been established^[3]. It is more often a diagnosis made in adolescents and young adults^[3].

Secondary dysmenorrhoea is menstrual pain resulting from a disorder in the reproductive organs or other identifiable medical condition^[2]. Pain from secondary dysmenorrhoea usually begins earlier in your menstrual cycle and lasts longer than typical menstrual cramps. For example, you may experience cramping several days before your period and the pain may last until the bleeding completely stops^[1]. The pain tends to get worse over time^[2]. Secondary dysmenorrhoea is less common and is most often observed in women aged 30 to 45 years^[5].

How common is dysmenorrhoea?

Dysmenorrhoea is extremely common. Estimates of how many women experience it vary widely, from 50% to 90% of women of reproductive age^[2][3]. More than half of women who menstruate have some pain for one to two days each month^[2].

About 60% of people with a uterus have mild cramps during their period. About 5% to 15% of people report period pain that is so severe that it affects their daily activities. However, this number is likely higher, as healthcare providers believe many people don’t report menstrual pain^[1]. Up to 15% of women with dysmenorrhoea find the discomfort so disruptive and debilitating that they stay home from school or work to recuperate^[4].

Dysmenorrhoea is responsible for significant absenteeism from work and school. It is the most common reason for school absence among adolescents^[5]. Studies show that 13% to 51% of women have been absent at least once, and 5% to 14% are often absent owing to the severity of symptoms^[12].

What causes dysmenorrhoea?

Menstrual cramps happen when a chemical called prostaglandin makes your uterus contract or tighten up^[1]. During menstruation, prostaglandin levels are higher, which means your uterus contracts more strongly. This is the cramping and discomfort you feel. These contractions help shed your uterine lining, which is the blood and tissue that comes out of your vagina during your period^[1].

If the uterus contracts too strongly, it can press against nearby blood vessels, cutting off the oxygen supply to muscle tissue. You feel pain when part of the muscle briefly loses its supply of oxygen^[4]. Prostaglandin levels rise right before menstruation begins. As bleeding continues and the lining of the uterus is shed, the level goes down. This is why pain tends to lessen after the first few days of a period^[2].

Experts aren’t entirely sure why some people have more painful periods, but they think it may be because they have higher levels of prostaglandins^[1]. Some theories also note abnormal uterine position and abnormalities in the shape or length of the cervix as potential contributing factors^[3].

Secondary dysmenorrhoea can be caused by various conditions, including^[2]:

• Endometriosis – when tissue similar to the lining of the uterus grows in other areas of the body, such as on the ovaries and fallopian tubes, behind the uterus, and on the bladder. This tissue breaks down and bleeds in response to hormonal changes, causing pain, especially around the time of a period. Scar tissue called adhesions may form inside the pelvis where the bleeding occurs^[2].
• Fibroids (uterine leiomyomas) – growths that form on the outside, on the inside, or in the walls of the uterus. Fibroids located in the wall of the uterus can cause pain^[2].
• Adenomyosis – develops when tissue that normally lines the uterus begins to grow in the muscle wall of the uterus. This condition is more common in older women who have had children^[2].
• Pelvic inflammatory disease – infection of the reproductive organs^[2].
• Uterine abnormalities – certain defects that a woman is born with can result in pain during menstruation^[2].
• Other conditions – some medical conditions can flare up during a period and cause pain, such as Crohn’s disease and urinary disorders^[2].

• Uterus
• Ovaries
• Fallopian tubes
• Cervix

Symptoms of dysmenorrhoea

If you have painful periods, you may feel^[1][6]:

• Aching, throbbing pain in your abdomen (pain may be severe at times)
• Throbbing or cramping pain that can be intense
• Feeling of pressure in your abdomen
• Pain in your hips, lower back and inner thighs
• Dull, continuous ache
• Pain that radiates to your lower back and thighs

Other symptoms that may accompany dysmenorrhoea include^[1][6]:

• Nausea and vomiting
• Diarrhea or loose stools
• Headaches
• Dizziness
• Fatigue
• Constipation

In most cases, the pain begins in the 24 to 48 hours before your period. Pain that starts one to three days before your period typically peaks 24 hours after the onset of your period and subsides in two to three days^[6].

Risk factors

The following factors have been associated with dysmenorrhoea^[3][5]:

• Age – particularly frequent during adolescence and commonly affecting women younger than 30 years
• Earlier age at menarche (starting menstrual periods before age 11 or 12)
• Long menstrual periods
• Heavy menstrual flow
• Smoking
• Positive family history of dysmenorrhoea
• Body mass index – increased prevalence with BMI less than 20 or BMI greater than 30
• Nulliparity (never having given birth) or lower parity
• Being overweight
• Alcohol consumption (in some studies)
• History of pelvic inflammatory disease
• Stress

Protective factors include regular exercise and oral contraceptive use^[3]. In most cases, painful periods become less painful as you get older. They may also improve after giving birth^[1][2].

How is dysmenorrhoea diagnosed?

Primary dysmenorrhoea is a diagnosis of exclusion. A complete history including menstrual, gynecologic, psychosocial, and dietary factors, as well as a physical examination, is necessary^[20]. Your healthcare provider will review your medical history and perform a physical examination^[14].

The history is critical in establishing the diagnosis of dysmenorrhoea and should include an assessment of the onset, duration, type, and severity of pain. A thorough menstrual history is also essential^[5]. It can be helpful to record information about your periods so you can discuss this with your doctor, including when you get your period, how long it lasts, how heavy it is and how it impacts your daily life^[7].

A pelvic examination should be performed in all sexually active patients with dysmenorrhoea. For younger adolescents who have never been sexually active, a careful abdominal examination is appropriate^[5]. During the pelvic exam, your provider checks for anything unusual with the reproductive organs and looks for signs of infection^[14].

Typically, when the history and physical examination support the diagnosis of primary dysmenorrhoea and the pain responds to treatment, no further evaluation is necessary^[20]. Abnormal uterine bleeding, pain with intercourse, noncyclic pain, changes in intensity and duration of pain, and abnormal pelvic examination findings suggest underlying pathology (secondary dysmenorrhoea) and require further investigation^[10].

Additional diagnostic tests may include^[14]:

• Ultrasound – this test uses sound waves to create an image of your uterus, cervix, fallopian tubes and ovaries. Transvaginal ultrasonography should be performed if secondary dysmenorrhoea is suspected^[10].
• Other imaging tests – computed tomography (CT) scan or magnetic resonance imaging (MRI) scan provides more detail than an ultrasound and can help diagnose underlying conditions^[14].
• Laboratory testing – pregnancy should be ruled out in sexually active women. Other tests may include cultures for gonorrhea and chlamydia, urinalysis, and complete blood count^[20].
• Laparoscopy – although not usually necessary to diagnose dysmenorrhoea, this outpatient surgery allows your doctor to view your abdominal cavity and reproductive organs. It may be indicated for the diagnosis and treatment of endometriosis and as therapy for fibroids, adhesions, ovarian cysts, and other pelvic pathologies^[14][20].

Treatment options

Treatment of dysmenorrhoea is aimed at providing symptomatic relief as well as inhibiting the underlying processes that cause symptoms^[13]. Mainstays of treatment include reassurance and education in addition to pain relief^[5].

Medications

Nonsteroidal anti-inflammatory drugs (NSAIDs) should be used as first-line treatment for primary dysmenorrhoea^[10]. These pain relievers reduce the amount of prostaglandins that your uterus makes and lessen their effects, which helps to lessen the cramps^[1]. Over-the-counter pain relievers, such as ibuprofen or naproxen sodium, at regular doses starting the day before you expect your period to begin can help control the pain of cramps^[14]. Start taking the pain reliever at the beginning of your period, or as soon as you feel symptoms^[14].

Hormonal contraceptives are an alternative first-line treatment or an adjunct to NSAIDs for primary dysmenorrhoea^[10]. Your healthcare provider might recommend hormonal birth control, such as the pill, patch, ring, or intrauterine device (IUD)^[1]. Combined estrogen-progestin oral contraceptives may be effective for relieving symptoms of primary dysmenorrhoea^[10]. Hormonal contraceptives are also the first-line treatment for dysmenorrhoea caused by endometriosis^[10]. Because most progestin or estrogen-progestin combinations are effective, secondary indications, such as contraception, should be considered^[19].

Non-pharmacologic therapies

If you have painful periods, you can try^[7]:

• Applying heat – using a heating pad or hot water bottle on your lower abdomen and lower back to help relax the muscles, taking a hot bath, or relaxing in a hot shower^[7][18]. Good evidence supports the effectiveness of heat therapy^[19].
• Regular exercise – even gentle exercise releases natural chemicals called endorphins that make you feel happy, reduce pain and relax your muscles^[7][18]. Fifteen minutes of yoga, light stretching or walking might be helpful^[18]. Good evidence supports the effectiveness of exercise^[19].
• Relaxation techniques (such as meditation) to relieve stress^[7].
• Transcutaneous electrical nerve stimulation (TENS) – a small device that blocks pain signals. Good evidence supports the effectiveness of high-frequency TENS^[19].
• Self-acupressure – good evidence supports its effectiveness^[19].
• Complementary therapies like acupuncture or naturopathy, or supplements like fish oil and magnesium^[7].

Other recommendations

• Drink more water – drinking water regularly throughout the day can help reduce bloating during your period and alleviate some of the pain it causes. Drinking hot water can increase blood flow throughout your body and relax your muscles^[18].
• Eat anti-inflammatory foods – foods like berries, tomatoes, pineapple, and spices like turmeric, ginger or garlic can offer natural relief. Leafy green vegetables, almonds, walnuts and fatty fish, like salmon, can also help reduce inflammation^[18].
• Avoid foods high in sugar, trans fat and salt – these can cause bloating and inflammation, which makes muscle pain and cramps worse^[18].
• Drink decaf coffee – caffeine causes your blood vessels to narrow, which can constrict your uterus, making cramps more painful^[18].
• Get enough rest and avoid using alcohol and tobacco^[1].

When to see your doctor

You should contact your healthcare provider if^[1][6]:

• NSAIDs and self-care measures don’t help, and the pain interferes with your life
• Your cramps suddenly get worse
• Menstrual cramps disrupt your life every month
• Your symptoms progressively worsen
• You are over 25 and you get severe cramps for the first time
• You have a fever with your period pain
• You have the pain even when you are not getting your period

Talk to your doctor if simple treatments for period pain don’t help or if your symptoms are so painful they impact your quality of life^[7]. If secondary dysmenorrhoea is suspected, nonsteroidal anti-inflammatory drugs or hormonal therapies may be effective, but further workup should include pelvic examination and ultrasonography. Referral to an obstetrician-gynecologist may be warranted for further evaluation and treatment^[10].

What is the outlook?

Dysmenorrhoea may be associated with significant negative emotional, psychological, and functional health impacts^[3]. It leads to decreased quality of life, absenteeism, and increased risk of depression and anxiety^[19].

Despite this substantial effect on quality of life and general wellbeing, few women with dysmenorrhoea seek treatment as they believe it would not help^[12]. However, medication and other treatments can help with painful periods^[1].

A prospective longitudinal study revealed that most people with dysmenorrhoea have persistent symptoms throughout their years of menstruation, although some improvement in severity may occur, for example, after childbirth^[19]. In most cases, painful periods become less painful as you get older. They may also improve after giving birth^[1].

About half of all women diagnosed with the condition experience primary dysmenorrhoea, which usually occurs within the first few years of menstruation. The problems tend to become less common with age; pain and other symptoms may gradually fade over time. Some may notice their symptoms improve after childbirth^[4].