Many women who have some pain with their periods do not need or want treatment. All they want is reassurance there is no serious problem. About 10 per cent of women, however, have pain severe enough to cause them to miss work or school. These women need treatment so they can go about their normal activities without fear of painful, often unpredictable, interruptions.
What causes painful periods? To understand this, we should know what happens during menstruation. The uterus is made up of a thick outer wall of muscle, and a thin inner lining endometrium is shed from the uterus through the vagina, causing the menstrual flow.
The thick muscle wall of the uterus clamps down, or contracts, to help shed the lining. It is this contracting muscle that is felt as the mild cramps of a normal period.
Painful periods can result when the contractions are harder than normal. This is called primary dysmenorrhea and is more common in teenage girls and young women. Abnormal tissue of the uterus, called secondary dysmenorrhea, is the more common cause of painful periods in women in their 30s and 40s.
Primary dysmenorrhea does not usually occur until several years after a girl begins menstruating; that is when she is in her mid to late teens. This is because painful periods are typical of menstrual cycles in which an egg is produced. Most cycles in the first few years after periods begin do not involve the production of an egg.
There have been many incorrect psychological explanations about why some women have painful periods and others do not. These include the theory that women with painful periods reject their female role, thus finding menstruation upsetting and painful. Fortunately, we now have a better understanding of the causes of painful periods and women with this condition are not made to feel it is “all in their heads.”
Although our understanding of the cause of painful periods is quite recent, descriptions of the complaint date back several thousand years. Hippocrates stated that painful menstruation was due to blockage of the cervix (the outlet of the uterus that projects into the vagina). He felt that this caused stagnant menstrual blood in the uterus.
Hippocrates probably had this theory because primary dysmenorrhea is seen mainly in women who have not had children. For these women, the opening of the cervix is narrower than in women who have had children. Perhaps he believed the uterus had to contract harder to push out the menstrual products in those women who had not had children.
Prostaglandins are hormones produced just before and during menstruation. They have a strong effect on the uterus wall. These hormones cause the muscle to contract, which in turn causes the menstrual products to be expelled from the uterus. Women with primary dysmenorrhea have been found to produce more prostaglandins than other women. This causes greater contractions which in turn causes more cramping and thus more pain.
The treatment of primary dysmenorrhea is to reduce the level of prostaglandins made. This should reduce the amount of painful cramping of the uterus. Anti-inflammatory medications such as naproxyn and ibuprofen are effective for this in some women. If this does not work, the birth control pill may reduce cramping. The birth control pill stops production of an egg during each cycle that the pill is taken. Since cramping from primary dysmenorrhea is seen only when an egg is produced, no egg production should mean relief from painful periods.
While it is no longer believed that psychological factors cause painful periods, there is no doubt that they can affect how a person copes with pain. A women may find that periods seem more painful when she is going through stressful times and the pain may improve when the stress is resolved. Some women are helped by regular exercise programs because they feel better about themselves. Exercise can also reduce the amount of prostaglandins made so there is less cramping.
The other major group of conditions causing painful periods is known as secondary dysmenorrhea. There are many different diseases that can cause this, but most are quite unusual.
Two common ones are endometriosis and adenomyosis. Both of these are caused when the endometrium spreads beyond its normal lining of the uterus. If it persists outside the uterus, it is endometriosis. If the lining moves into the muscle wall of the uterus, it is adenomyosis. Once the lining gets to these places, it tends to stay and often causes painful menstruation.
Endometriosis is common. It may cause pain a few days to a week before the period starts then decrease with the start of the menstrual flow. The amount of pain is not related to the amount of stray lining. Some women with lots of pain may have very little endometriosis and others with little pain may actually have a large amount of endometriosis.
Besides pain, endometriosis is a cause of reduced fertility, although how this happens is poorly understood. It can also cause heavy periods, spotting between periods and painful intercourse.
When a woman sees a doctor with one or more of these complaints, endometriosis may be suspected. If the pain is not severe and there are no signs of serious disease, it may be treated by medications. The type of medication depends on the extent of the endometriosis, the amount of pain it is causing, and problems besides the pain, such as infertility.
Often antiinflammatory pills at the time of the period are all that is needed. Women who also need birth control may benefit from taking the birth control pill that can help stop pain and regulate the menstrual cycle. Not everyone can take the birth control pill, however, and it is obviously not a good choice for women who are trying to get pregnant.
More severe disease may need strong medications. Two types used are DanazolR and a new group of drugs called LH-RH agonists. Both drugs stop the ovaries from producing their normal monthly cycle of hormones. Without the hormones the areas of endometriosis will shrink and may even disappear.
If the pain is disabling or a woman is unable to get pregnant and endometriosis is the suspected cause, a small operation called a laparoscopy may be done. The laparoscope is like a small telescope that is put through the wall of the abdomen just below the navel. The doctor can look through a viewer into the abdomen and see the uterus, ovaries and all the tissues surrounding them.
It may be possible to treat the endometriosis during the procedure. The spots of disease that can be seen can be removed with surgical instruments or vaporized by a laser.
Endometrium can grow into the muscle wall of the uterus. Women with this condition are usually older (in their 40s) and have had children. They may have heavy, painful periods caused by the swelling of the endometrium inside the uterus. A painful bruise develops inside the muscle. The only treatment that effectively stops this is hysterectomy (removal of the uterus.)
Women with painful periods should seek help from the family doctor. The doctor will be able to determine whether there is any other cause for the pain. If not, as is usually the case, the doctor can provide reassurance. Treatment is very effective in helping these women to stop being disabled by painful periods.
There is no doubt that painful menstrual periods “can be a pain.” For many women, however, there are treatments to help ease the discomfort. If you are one of the many women who suffer from dysmenorrhea each month, talk to your doctor to discover what might work for you.