“Periods are supposed to be painful,” a patient’s mom recently said to me. “She misses school for the first few days of each period. I did too, that’s normal.”
This is an all too common sentiment shared by many parents, guardians, and patients — and even some healthcare professionals. Yes, period cramping is very common, affecting between 50% to 90% of people who have periods, but that doesn’t make it necessary. Sometimes, it can also mean something more dangerous.
What Is Dysmenorrhea?
Most cramping associated with periods is called primary dysmenorrhea, meaning painful periods (menstrual pain) without pathology. Sometimes there are anatomic or other reasons that periods are especially painful — this is called secondary dysmenorrhea, affecting about 10% of young people with dysmenorrhea. The most common cause of secondary dysmenorrhea is endometriosis, which can also lead to chronic pelvic pain even outside of periods. Adenomyosis and uterine fibroids can also cause periods to be especially heavy and painful. In rare cases, obstructive mullerian anomalies also lead to cyclic abdominal pain due to a blockage preventing complete evacuation of menstrual blood.
But in cases of primary dysmenorrhea, where there isn’t any pathology, doesn’t that make the pain normal?
While it means that nothing dangerous is causing the pain, it doesn’t mean doctors shouldn’t treat it if we have the medical knowledge and resources to do so. About one in eight adolescents and young adults report missing school or work due to dysmenorrhea. If someone has a headache and it’s preventing normal daily activities, it makes sense to treat the headache.
Approaches to Treatment
Good news: there is a plethora of options. I find it most helpful to discuss all the available options with patients so they can decide the best plan for themselves. The first line treatment of primary dysmenorrhea is non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen. Dysmenorrhea is often caused by increased inflammatory markers, which help the uterus contract and push out menstrual blood, so it’s logical that anti-inflammatory medications would be helpful. Most of the time, families aren’t using adequate dosages of these medications; they are most helpful when started 1 to 2 days before each period and taken around the clock (e.g., every 4-6 hours depending on the dosage) to suppress the pain.
Most of the other options are hormonal medications. Periods occur due to the cyclicity of hormonal changes each month, so it makes sense that a period issue would be treated with hormones. However, due to societal stigma, many families, patients, and even providers stop listening at the mention of medications containing hormones. Add on the fact that most of these medications are also more commonly known as types of birth control, and the walls definitely go up. I prefer to call them hormonal suppression or menstrual management, which helps patients keep an open mind so we can at least discuss the options, especially when facing anxious parents and teenagers. I generally mention these medications work to maintain a thin endometrial lining so that periods are lighter and less painful, or don’t occur at all.
Discussing the usage, benefits, and potential side effects of each of the options can often leave the patient feeling overwhelmed. There is not one best option for everyone, and I let them know that the best option for them is whichever one they choose. That choice is also allowed to change over time; most of these methods are very easy to start and stop.
In some cases, patients will feel like they’ve tried everything and nothing is helping. It is usually reasonable to treat dysmenorrhea with NSAIDs and hormonal medications for 3 to 6 months, and then pursue other evaluation for secondary dysmenorrhea if symptoms have not improved significantly. This can sometimes mean an ultrasound evaluation of the pelvis and/or pelvic exam. A diagnostic laparoscopy (minimally invasive surgery to look at the pelvis) can sometimes also be necessary. The most important thing is to consider other etiologies and refer to other specialists if needed. For example, endometriosis can be a debilitating and life-long condition, especially if not treated early. Studies have shown a delay of 4 to 11 years from symptom onset to diagnosis of endometriosis. In situations like these, listening to and following up with the patient is critical.
Healthcare professionals, patients, and parents alike need to move away from normalizing all menstrual cramps. Painful periods are common, but they don’t have to be tolerated.
Y. Frances Fei, MD, is a pediatric and adolescent gynecologist at Nationwide Children’s Hospital, and an obstetrician-gynecologist at The Ohio State University Wexner Medical Center.