Painful Periods

Almost all women have some degree of cramping during their periods. Mild cramping which occasionally requires an over-the-counter pain reliever is generally normal. Severe monthly cramps which are not relieved by medication and which interfere with work or social activities are not normal, however, and require evaluation. Severe cramps may be a symptom of an underlying condition (for example, endometriosis) which can cause infertility and serious harm if not treated. Severe cramps ought to be evaluated by a gynecologist.

The medical term for menstrual cramps is dysmenorrhea. Dysmenorrhea is a surprisingly common problem in women, particularly young women: About two-thirds of adolescents report menstrual cramps which are severe enough to interfere with daily activities. Generally speaking, period cramps decline as women get older, though some women notice worsening of their cramps as they approach menopause. Dysmenorrhea can present as low abdominal pain, low back pain, or pain in the upper thighs; it may occur mainly before your period or during your heavy flow. Sometimes, women with dysmenorrhea also suffer from nausea, vomiting, diarrhea or other symptoms.

Medical Conditions That Cause Period Cramps

There are many potential causes of period cramps. A condition called endometriosis frequently causes dysmenorrhea, especially in association with dyspareunia, or painful intercourse. In women with endometriosis, the inner lining of the womb (the endometrium) flows backwards through the fallopian tubes to deposit in the pelvis. Once these deposits implant in the pelvis they can cause pelvic pain, period cramps, and fertility problems. Women with endometriosis typically report cramps which are worst before their period flow begins, and pain with deep penetration during intercourse. Sometimes they will also have pain during bowel movements.

Closely related to endometriosis is a condition called adenomyosis. In women with adenomyosis, the inner lining of the womb grows into the muscular wall of the organ. This causes enlargement of the uterus, heavy menstrual bleeding, and often incapacitating cramps. While endometriosis is common in young women, adenomyosis usually occurs in women in their 30s and 40s, after childbearing.

Fibroids often cause period cramps, sometimes occurring with heavy menstrual bleeding. Many women are unaware that they have fibroids—even huge fibroids—until they are properly evaluated by a gynecologist. Likewise, polyps in the uterus can cause menstrual cramps in association with heavy flow, and require professional evaluation to detect.

Certain sexually-transmitted infections can cause pelvic pain and period cramps. In particular, chlamydia is notorious for causing pelvic adhesions (scar tissue) which can lead to chronic pelvic pain.

Sometimes, period cramps are caused by congenital abnormalities—problems in the structure of the female genital organs which are present at birth. In some young women, for example, the flow of menstrual blood to the outside world may be obstructed; they may have no period flow at all or only a light flow every month, together with disabling menstrual cramps. Because flow through the vagina is obstructed, blood and tissue from the uterine lining tend to flow backwards through the tubes, and can cause endometriosis.

Diagnosing the Cause of Period Pain

Evaluation of dysmenorrhea begins with a thorough medical history and gynecologic examination. We are particularly interested in the timing of your pain in relation to your period, its severity, and whether over-the-counter medication successfully treats the pain. We are also interested in the results of any prior testing or treatment performed to evaluate your cramps. We usually perform an ultrasound exam to search for causes of pain. Screening for sexually transmitted conditions is also usually performed.

Treatments for Painful Periods

Treatment of dysmenorrhea typically begins with appropriate pain medication. We often use prescription-strength ibuprofen or naproxen, both of which do a remarkable job of relieving menstrual cramps. (Cramps are caused mainly by release of prostaglandins in the lining of the uterus; medications like ibuprofen and naproxen block the production of prostaglandins.) Both ibuprofen and naproxen are available over-the-counter (e.g., as Advil or Aleve, respectively), and both are good choices for initial relief of menstrual cramps. Importantly, these medications are much more effective for menstrual cramps than medications containing acetaminophen (e.g., Tylenol).

If appropriate medication fails to relieve cramps, birth control pills are an attractive option for many women. Birth control pills cause thinning of the endometrium, the inner lining of the uterus where prostaglandins are formed. Women on birth control pills will typically have less bleeding during their period and significantly less cramps. Other forms of contraception (for example, the vaginal ring, the contraceptive patch, and the Mirena IUD) can also be useful for relief of period cramps.

Women who have cramps in association with heavy bleeding may be candidates for an endometrial ablation procedure. During this procedure, an instrument is used to destroy the inner lining of the uterus under light anesthesia. While primarily used to lessen menstrual flow, there is good evidence that endometrial ablation reduces menstrual cramps significantly in properly selected women.

If initial treatment fails, further evaluation is indicated. Often, women may be offered diagnostic laparoscopy, a procedure during which a telescope is inserted through the navel to examine the pelvic organs directly. In many women, diagnostic laparoscopy will reveal a cause of pain which would not otherwise be diagnosed. In these cases, treatment can be directed towards the underlying condition. An accurate diagnosis is important, since some causes of pain can lead to further medical issues as well as infertility if not treated.

At The Woman’s Health Pavilion, we have extensive experience in the evaluation and treatment of menstrual cramps. If you use over-the-counter medications and still have cramps which interfere with your lifestyle, we invite you to make an appointment for consultation.