Dysmenorrhoea

For many individuals, menstruation is an ordinary monthly occurrence. Yet, for a significant number, it brings with it a wave of discomfort, sometimes so severe it disrupts daily life. This isn't just "normal period pain"; it's a recognised medical condition called dysmenorrhoea. Often underestimated and dismissed, dysmenorrhoea refers to painful menstrual cramps that can range from mild to debilitating. 

Understanding this condition is the first step towards effective management and improving the quality of life for those affected. This page will cover the intricacies of dysmenorrhoea, from its root causes to various treatment options, offering practical advice and dispelling common myths.

Dysmenorrhoea is the medical term for painful periods or menstrual cramps. The pain typically occurs in the lower abdomen, but can also radiate to the back, hips, and inner thighs. It usually begins shortly before or at the onset of menstruation and can last for several days. While some discomfort during menstruation is common, dysmenorrhoea is characterised by pain severe enough to interfere with normal activities, such as work, school, or social engagements. It's a condition that affects millions, often silently, and can have a significant impact on an individual's well-being.

Dysmenorrhoea is remarkably common, affecting a large proportion of individuals who menstruate. While precise figures can vary due to differences in definition and study methodology, estimates suggest that between 45% and 97% of women of reproductive age experience some form of dysmenorrhoea. Of these, a significant subset, ranging from 5% to 29%, report severe pain that interferes with their daily activities. It is particularly prevalent among adolescents, with rates often cited between 70% and 91%. Dysmenorrhoea is a leading cause of missed school or work days among young women.

Dysmenorrhoea is primarily categorised into two main types:

Primary Dysmenorrhoea 

This is the more common type of painful periods and occurs in the absence of any underlying pelvic pathology. It typically begins within 6-12 months of the first menstrual period (menarche), once ovulatory cycles are established. The pain is thought to be caused by an overproduction of prostaglandins, hormone-like substances that cause the uterus to contract. These contractions help to shed the uterine lining, but in excessive amounts, they can lead to intense pain. Primary dysmenorrhoea often improves with age or after childbirth.
 

Secondary Dysmenorrhoea

This type of dysmenorrhoea is caused by an identifiable underlying medical condition affecting the reproductive organs. Unlike primary dysmenorrhoea, it often begins later in life, typically in a person's 20s or 30s, and the pain may worsen over time. The pain associated with secondary dysmenorrhoea can also start earlier in the cycle and last longer than typical menstrual cramps.

The causes of dysmenorrhoea differ depending on whether it's primary or secondary.

Causes of Primary Dysmenorrhoea

The primary cause of primary dysmenorrhoea is the overproduction of prostaglandins by the uterine lining (endometrium). These powerful hormone-like chemicals play a crucial role in regulating inflammation and pain. During menstruation, the uterine lining produces prostaglandins to help the uterus contract and expel its contents. However, if too many prostaglandins are produced, or if an individual is particularly sensitive to them, the uterine contractions can become excessively strong and painful, leading to reduced blood flow (ischaemia) to the uterine muscle.

Causes of Secondary Dysmenorrhoea

Secondary dysmenorrhoea is caused by various underlying gynaecological conditions, including:

• Endometriosis: A condition where tissue similar to the lining of the uterus (endometrium) grows outside the uterus, such as on the ovaries, fallopian tubes, or other pelvic organs. This ectopic tissue responds to hormonal changes during the menstrual cycle, bleeding and causing inflammation, pain, and sometimes scar tissue (adhesions).
• Adenomyosis: A condition where the endometrial tissue grows into the muscular wall of the uterus (myometrium). This can cause the uterus to enlarge and lead to heavy and painful periods.
• Uterine Fibroids: Non-cancerous growths that develop in or on the wall of the uterus. Depending on their size and location, fibroids can cause heavy bleeding, pelvic pressure, and painful periods.
• Pelvic Inflammatory Disease (PID): An infection of the female reproductive organs, often caused by sexually transmitted infections.PID can lead to inflammation, scarring, and chronic pelvic pain, including painful periods.
• Cervical Stenosis: A narrowing of the opening of the cervix, which can impede the flow of menstrual blood, leading to increased pressure and pain within the uterus.
• Intrauterine Devices (IUDs): While copper IUDs can sometimes cause increased menstrual pain or heavier bleeding in some individuals, hormonal IUDs often reduce period pain.
• Polycystic Ovary Syndrome (PCOS): Although not a direct cause, the hormonal imbalances and irregular periods associated with PCOS can sometimes contribute to more painful or unpredictable menstrual cycles.

The hallmark symptom of dysmenorrhoea is cramping pain in the lower abdomen. However, other symptoms often accompany this pain and can vary in intensity. These include:

• Dull, aching, or throbbing pain in the lower abdomen.
• Pain radiating to the lower back and inner thighs.
• Nausea and vomiting.
• Diarrhoea or constipation.
• Headaches or migraines.
• Fatigue or low energy levels.
• Dizziness or light-headedness.
• Bloating.
• Breast tenderness.
• Mood changes, such as irritability or depression.

Diagnosing dysmenorrhoea usually begins with a detailed medical history and a physical examination. Your doctor will ask about your menstrual cycle, the nature and severity of your pain, and any other associated symptoms. They will also want to know if the pain interferes with your daily activities.

Diagnostic steps may include:

• Pelvic Examination: A physical examination to check for any abnormalities in the reproductive organs, such as fibroids, tenderness, or unusual growths.
• Ultrasound Scan: This non-invasive imaging technique uses sound waves to create images of the uterus, ovaries, and fallopian tubes. It can help identify conditions like fibroids, ovarian cysts, or adenomyosis.
• Blood Tests: May be performed to rule out other conditions, such as infection or hormonal imbalances.
• Tests for Sexually Transmitted Infections (STIs): If PID is suspected, tests for STIs may be conducted.
• Laparoscopy: In some cases, especially when secondary dysmenorrhoea is suspected and other tests are inconclusive, a laparoscopy may be performed. This is a minimally invasive surgical procedure where a small incision is made in the abdomen, and a thin, lighted tube with a camera (laparoscope) is inserted to visualise the pelvic organs directly and identify conditions like endometriosis.
• Hysteroscopy: A procedure where a thin, lighted scope is inserted through the cervix to view the inside of the uterus. This can help identify polyps or other abnormalities within the uterine cavity.

The treatment for dysmenorrhoea depends on its type, severity, and the underlying cause (if any). The goal is to reduce pain and improve quality of life.

For Primary Dysmenorrhoea

• Pain Relievers (Analgesics):
  • Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Medications like ibuprofen and naproxen are often the first line of treatment. They work by reducing the production of prostaglandins, thereby decreasing uterine contractions and pain. They are most effective when taken at the first sign of pain or just before your period starts.
  • Paracetamol: Can be used for milder pain, though generally less effective than NSAIDs for menstrual cramps. Sometimes, a combination of tranexamic acid and mefenamic acid (Brands available: Pause-MF, Etosys MF) is prescribed to relieve pain and control heavy bleeding. 
• Hormonal Contraceptives: Combined oral contraceptive pills, contraceptive patches, vaginal rings, and hormonal IUDs can significantly reduce menstrual pain by thinning the uterine lining and reducing prostaglandin production, or by preventing ovulation altogether.
• Heat Therapy: Applying a heating pad or hot water bottle to the lower abdomen can help relax uterine muscles and alleviate pain.
• Lifestyle Modifications: Regular exercise, a healthy diet, and stress reduction techniques can also help manage symptoms.

For Secondary Dysmenorrhoea

Treatment focuses on addressing the underlying condition:

• Endometriosis: Treatment may include pain relievers, hormonal therapy (e.g., GnRH agonists, progestins, combined oral contraceptives), and surgical removal of endometrial implants.
• Adenomyosis: Hormonal therapies, uterine artery embolisation, or in severe cases, hysterectomy (surgical removal of the uterus) may be considered.
• Uterine Fibroids: Treatment options range from medication (e.g., NSAIDs, hormonal therapy) to minimally invasive procedures (e.g., uterine fibroid embolisation) or surgery (e.g., myomectomy to remove fibroids, or hysterectomy).
• Pelvic Inflammatory Disease (PID): Treated with antibiotics. Sexual partners may also need treatment.
• Cervical Stenosis: May require a procedure to dilate the cervix.

Many individuals explore alternative therapies to manage dysmenorrhoea, often alongside conventional treatments. Some popular options include:

• Transcutaneous Electrical Nerve Stimulation (TENS): A device that delivers low-voltage electrical currents to the skin, which may help block pain signals.
• Herbal Remedies: Certain herbs like ginger, chamomile, cinnamon, and evening primrose oil are traditionally used for menstrual pain relief, though scientific evidence varies. Always consult a healthcare professional before taking herbal supplements, especially if you are on other medications.
• Dietary Changes: Some individuals find that a diet rich in anti-inflammatory foods (fruits, vegetables, omega-3 fatty acids) and low in processed foods, caffeine, and alcohol can help.
• Yoga and Pilates: Gentle exercise and stretching can help relax muscles and improve blood flow, potentially easing cramps.
• Magnesium and Vitamin B1 (Thiamine): Some research suggests that these supplements may help reduce the severity of menstrual cramps.

• Early age at first period (menarche).
• Heavy menstrual bleeding (menorrhagia).
• Longer duration of menstrual periods.
• Smoking.
• Family history of dysmenorrhoea.
• Stress and anxiety.
• Obesity (though some studies are inconclusive).
• Nulliparity (never having given birth).

• Significant impact on quality of life and daily activities.
• Increased absenteeism from school or work.
• Anxiety and depression due to chronic pain.
• Sleep disturbances.
• Infertility (if caused by underlying conditions like endometriosis).
• Development of chronic pelvic pain (in some cases of secondary dysmenorrhoea).

• Track Your Cycle and Symptoms: Keep a menstrual diary to note when your pain starts, how severe it is, and what helps. This can help you anticipate pain and plan your pain management strategies.
• Use Heat Therapy Regularly: Apply a heating pad, hot water bottle, or take a warm bath/shower to relax your abdominal muscles and ease cramps.
• Over-the-Counter Pain Relief: Don't wait for the pain to become unbearable. Take NSAIDs (like ibuprofen or naproxen) at the first sign of discomfort or as recommended by your doctor.
• Prioritise Rest: Listen to your body. If you're experiencing significant pain and fatigue, allow yourself to rest and reduce your usual activities.
• Explore Gentle Movement: While intense exercise might be challenging, gentle activities like walking, light yoga, or stretching can sometimes help alleviate discomfort and improve mood.

"Painful periods are normal; just deal with it." 

While some mild discomfort is common, debilitating pain that interferes with daily life is not normal and indicates dysmenorrhoea, a condition that warrants medical attention and treatment.

"It's all in your head." 

The pain of dysmenorrhoea is very real and has physiological causes, whether it's primary dysmenorrhoea due to prostaglandin overproduction or secondary dysmenorrhoea due to an underlying condition like endometriosis.

"Having a baby will cure it." 

While primary dysmenorrhoea often improves after childbirth for some individuals, it does not guarantee a cure, especially for secondary dysmenorrhoea caused by conditions that may persist or worsen after pregnancy.

It's important to consult a doctor if:

• Your period pain is severe and interferes with your daily life.
• Your pain suddenly worsens or changes in character.
• You experience new symptoms, such as pain during sex, abnormal bleeding between periods, or unusual discharge.
• Over-the-counter pain relievers aren't effective in managing your pain.
• Your period pain starts later in life (e.g., after your mid-20s).
• You are concerned about your symptoms or suspect an underlying condition.

• What could be causing my painful periods?
• Are there any underlying conditions I should be tested for?
• What are the best treatment options for my type of dysmenorrhoea?
• Are there any side effects to the recommended medications or treatments?
• What lifestyle changes can I make to help manage my pain?
• When should I expect to see an improvement in my symptoms with treatment?
• What are the long-term implications of dysmenorrhoea if left untreated?

• Acknowledge their pain and validate their experience. Avoid dismissive comments like "it's just period pain."
• Offer to help with chores, errands, or childcare if their pain is debilitating.
• Offer a hot water bottle, a comfortable space to rest, or make them a warm drink.
• Learn about dysmenorrhoea to better understand what they are going through and how you can be a more informed source of support.

Dysmenorrhoea, or painful periods, is a prevalent health condition that can significantly impact an individual's quality of life. It's crucial to recognise that severe period pain is not something that should be endured silently. By understanding the different types, causes, and available treatments, individuals can work with healthcare professionals to find effective strategies for managing their symptoms and improving their well-being. Whether it's through simple lifestyle adjustments, over-the-counter medications, hormonal therapies, or addressing underlying conditions, relief is often within reach. Open communication with doctors and a supportive environment are key to navigating the challenges of dysmenorrhoea and living a more comfortable life.