Pain during periods (Menstruation)

Introduction:

Pain during periods is also known as dysmenorrhoea. It is very common, but most cases are mild and do not require medical attention. It is of two types

(a) Primary dysmenorrhoea: When pain occurs as part of an otherwise normal menstruation cycle & associated with ovular cycles without any pathologic findings

(b) Secondary dysmenorrhoea: When painful periods caused by a problem that has developed in the uterus (womb), suchas fibroid tumours or an infection

Primary (functional) dysmenorrhoea:   

This pain usually starts within 1–2 years after the menarche and becomes less severe with age. It affects around 50% of menstruating women and up to 95% of adolescents

Causes:

High levels of prostaglandins which is 

• Natural substances produced by the lining of the uterus 
• Causes the muscles of the uterus to contract tightly, thus producing cramping sensations

☝Presents with following clinical features:

• Lower midline abdominal pain 
• Pain radiates to back or thighs 
• Varies from a dull dragging pain to a severe cramping pain
• Maximum pain at beginning of the periods
• May start up to 12 hours before the menses appear
• Usually lasts for 24 hours but may persist for 2–3 days
• May be associated with nausea and vomiting, headache, syncope or flushing 
• No abnormal findings on examination 

 💊Management is done as

First line treatment:

• Full explanation and appropriate reassurance 
• Adaptation of a healthy lifestyle: regular exercise, avoid smoking and excessive alcohol
• Do relaxation techniques such as yoga 
• Avoid exposure to extreme cold
• If you get severe pain, rest in bed
• Place a hot water bottle over the painful area and curl the knees onto the chest   

Second line treatment:

Medication options include (trying in order):

• Simple analgesics (e.g. Aspirin or Paracetamol) 
• NSAIDs (e.g. Naproxen, Ibuprofen 200–400 mg per oral thrice a day at first suggestion of pain in the first 3 days of the period ( and if simple analgesics ineffective) 
• Vitamin B1 (Thiamine) 100 mg daily 
• Combined oral pills (OCPs- low-oestrogen triphasic pills preferable)  
• Progestogen-medicated IUDs 

Secondary dysmenorrhoea 

It usually begins after the menarche (after years of pain-free menses) & as a dull pelvic ache 3–4 days before the menses and becomes more severe during menstruation The patient is usually over 30 years of age. 

Causes: 

• Endometriosis (a major cause)
• PID (a major cause) 
• IUCD 
• Submucous myoma
• Intra-uterine polyp 
• Pelvic adhesions     

Diagnostic tests include:

• Laparoscopy 
• Ultrasound and (less commonly) 
• Assessment of the uterine cavity by dilation and curettage 
• Hysteroscopy or hysterosalpingography  

💊Management involves treating the main cause

🚗When to visit the doctor?

Consult your Physician/Gynecologist if the pain worsens or if you develop period pain following 3 or 4 years of relatively pain-free periods.

References:

1. John M. Murtaghs Patient Education. of 6th revised ed edition. North Ryde NSW: McGraw-Hill Australia. 2012
2. Murtagh J, Leggat PA. John Murtagh’s General Practice Companion Handbook.
3. John M. Murtaghs Patient Education. of 6th revised ed edition. North Ryde NSW: McGraw-Hill Australia. 2012