Menstrual pain- causes, classifications and treatment

Article

20. 09. 2022 Gynecology

Menstruation, or period, is normal vaginal bleeding that occurs as part of a woman's monthly cycle. Unfortunately, many women suffer from pain and other symptoms of varying intensities, which mean that the recurring monthly period is an unpleasant and possibly debilitating experience. What causes the menstrual cycle, what are the causes of menstrual pain, why do some women experience more severe symptoms, and what are the treatment options and medication for menstrual symptoms, and should you seek out medical attention?

What is menstruation?

Menstruation is a periodic recurrent bleeding from the genitals that occurs during a woman’s fertile life stage, i.e. between puberty and menopause. Its importance lies in the monthly renewal of the uterine lining so that it is ready to receive a fertilized egg.

"Menstrual bleeding occurs as a result of cyclical changes in the endometrium (the lining of the uterus), which we call the menstrual cycle. It usually takes place regularly in intervals of about 25 to 32 days and lasts about 3 to 5 days - but this can vary from woman to woman. The bleeding occurs specifically as a result of the endometrium shedding and leaving the uterus through the cervix and the vagina along with the uterine blood vessels" explains Tereza Čeledová, MD, gynaecologist at Canadian Medical. 

At the beginning of the menstrual cycle (right after menstruation occurs), the endometrium starts to gradually grow again. Under the influence of FSH (follicle-stimulating hormone), a follicle grows in the ovary, and starts producing oestrogen in its wall. About halfway through the menstrual cycle, the ovum is released (ovulation) and the egg sheath turns into a progesterone-producing corpus luteum. The hormone progesterone acts on the endometrium, which is then ready to receive the fertilised egg. If fertilisation does not occur, the progesterone production in the corpus luteum is released from the endometrium and menstruation occurs.

 

Why does menstruation hurt?

Menstruation is often accompanied by pain in the lower abdomen, but it should never be unbearable or significantly bothersome. The pain is caused by contractions in the uterus which is trying to expel the shedding uterine lining. But women should not be suffering from unbearable pain during a normal and healthy menstruation. Physiologically normal menstruation should not be accompanied by painful, unbearable cramps or excruciating back or headaches.

There can be a number of causes of menstrual pain. Often, the primary cause is abnormally strong uterine contractions. These are associated with higher levels of prostaglandins, which help with the shedding of the uterine lining and act on the smooth muscle. At higher concentrations, they can also affect the muscles of the intestinal wall (resulting in diarrhoea) and play a central role in the development of pain. Prostaglandins are often overproduced in women who have  dysmenorrhoea, i.e. very painful menstruation (more details below). They cause more uterine contractions, or low blood flow to the uterus caused by the contractions, and therefore more severe pain.

The cause of cramping and pain is often a disbalance of hormones oestrogen and progesterod, which are produced by the ovaries. 

Often overlooked are also abnormalities in the pelvic floor, such as spasms or muscle imbalance. 

Generally speaking, if the problems persist even towards the end of he period, or there is irregular spotting or irregular bleeding throughout the cycle, the cause of the symptoms may be other health issues. In this case, its necessary to consult a gynaecologist. The cause may be:

  • uterine fibroids (benign nodules of the uterine musculature),
  • polyps (growths on the uterine lining),
  • endometriosis,
  • hormonal disorders,
  • urological inflammations,
  • ovarian/uterine inflammation,
  • cervical stenosis,
  • uterine malformations,

 

PMS- Premenstrual syndrome

“One in ten women experience premenstrual pains or mood fluctuations in the 7 days prior to the onset of their period. This is referred to as premenstrual syndrome, otherwise known as PMS, which can manifest very differently in women. According ot some studies, the cause may be a misbalance in oestrogen and progesterone which starts to fluctuate during the second half of the menstrual cycle,” adds Dr Čeledová. Towards the end of the cycle, the levels of progesterone dip significantly, which causes an overpowering of oestrogen. This fluctuation may be the reason for the intensity of the pre-menstrual symptoms. 

PMS is diagnosed when the patient has repeated symptoms for at least 5 days before menses, which subside with the onset of bleeding: 

  • anxiety and general irritability,
  • outbursts of anger,
  • mood swings,
  • depression,
  • water retention and a feeling of bloating, swelling of the limbs,
  • breast pain,
  • headaches, joint pain,
  • weight gain,
  • decreased libido.

 

If this is accompanied by other symptoms such as reduced interest in normal activities, lethargy, depression, severe changes in appetite (overeating, lack of appetite) and insomnia, this is referred to as premenstrual dysphoric disorder. The cooperation with a psychologist or psychiatrist is necessary in the treatment/therapy process..

 

Menstrual pain

Initial symptoms usually appear 1 to 2 days prior to the start of the period and they typically last for several days (very dependent on the individual). Menstrual pains are typically felt in the  lower abdomen, sometimes also shooting to the back or groin. The strongest discomfort usually occurs on the 1st and 2nd day of menstruation.  

Menstrual pain usually comes on in waves and in varying intensities, and can be accompanied by a pain in the lumbar region. Additionally, short bouts of nausea or breast pain may also occur. 

Other symptoms, such as vomiting, migraines, diarrhoea, fainting or loss of consciousness, are symptoms of dysmenorrhoea, an abnormal course of menstruation.

Difficulties during menses are therefore a very individual matter. In addition to bleeding and pain in the lower abdomen, menstruation can have an effect on the psyche, causing hypersensitivity and irritability in many women.

 

Pain during ovulation

Sometimes, menstrual-like pain occurs during or shortly after ovulation. In most cases, it isnt’ an indicator of a more severe medical complication; the cause may be the presence of a follicle with an egg that stretches the membrane of the ovary, or a ruptured follicle. If the problems persist, medical attention should be sought out.  

 

Menstrual pain without bleeding 

Pain in the lower abdomen similar to menstrual pain can have a number of causes. It can also be an indicator of the early stage of pregnancy. If these problems are associated with delayed menstruation or atypical menstruation, it is definitely advisable to take a pregnancy test and see a gynaecologist.

If pregnancy is not proven, it is necessary to invesatigate the problem further with a doctor for a possible diagnosis of another health problem.

 

Dysmenorrhoea

Dysmenorrhoea, or excessively painful menstruation, can vary in severity (from crampy abdominal pain to brief periods of unconsciousness). It particularly affects young girls, and after pregnancy it usually subsides. A certain role is genetics and hereditary psychogenic factors. 

  • Primary dysmenorea- typically occurs in adolescent girls and is closely linked to the ovulatory cycle- the pain appears when the girl begins to ovulate regularly. Psychology also plays a major role - in some cases, when the young girl isn’t sufficiently prepared for or informed about her menstruation, it can contribute negatively to her symptoms. 

 

EXPERT ADVICE: Taking off days from school or taking sick-days for dysmenorrhoea is only recommended if there are other symptoms present other than pain. Taking the load off excessively, especially in young girls, can lead to fixation of the psychosomatic component of dysmenorrhoea.

 

How to reduce menstrual

As a general rule of thumb warmth, rest and relaxation are the best treatment for pain. Warm compresses (the Thermofor heating bottle is handy) or a light massage of the abdomen and back to relax the muscles can help relieve menstrual pain.

Mental well-being also has a powerful effect on the menstrual cycle. Stress and relationship problems can significantly disrupt mental balance and trigger menstrual pain even without hormonal causes. Therefore, it is important to manage your stress levels and have time to yourself during menstruation.

The principles of a healthy lifestyle and a good diet apply during menstruation more than ever- a good drinking regime, lots of vegetables, fruits and whole-grain foods with lots of fibre. Supplements and a diet rich in calcium, magnesium and vitamins B, C and E are advised. 

On the contrary, it is recommended to reduce the consumption of sugars, white flour, animal fats, caffeine, alcohol, tobacco and salt.

 

Prescription medication

In obstetrics & gynaecology, non-steroidal anti-inflammtaory drugs (NSAIDs) are often used to reduce the tension of the uterine musculature, which leads to the pain relief and the easing of other symptoms. This is because NSAIDs inhibit the over-production of prostaglandins and thus excessive uterine contractions. Moreover, NSAIDs have a very quick onset, so they are often advised for the treatment of primary dysmenorrhea. The most effective compounds of this group include nimesulid, which in our country is contained in Aulin, Coxtral, Mesulid, Nimed, Nimesil (only on prescription), as well as very effective suppository Indomethacin.

Combined hormonal contraception is also sometimes recommended as a medication method to relieve intense menstrual symptoms. The hormones in the contraceptive pill balance the hormonal imbalance in the body and as a result of their influence, menstruation is less painful, regular and usually weaker. However, possible contraindications should always be consulted with a gynaecologist. 

Over-the-counter medication

  • Ibalgin 400 - contains the medicinal substance ibuprofen, which prevents the formation of prostaglandins. Its effect is satisfactory when taken before the onset of menstruation.
  • Ataralgin - the main active substance is paracetamol, then guaifenesin and caffeine.
  • Valetol - contains a combination of active ingredients propyphenazone, paracetamol and caffeine. Saridon has a very similar composition.
  • Mastodynon drops - are suitable for the treatment of menstrual problems and are recommended to be taken before and during menstruation.
  • Gynex drops - are suitable for longer term use and are good for adjusting the menstrual cycle, PMS and menstrual pain. 

EXPERTS ADVISE: There is also a lot of good evidence surrounding the use of CBD and other cannabinoids, which are substances found in hemp.

 

Natural remedies, herbs and exercises for menstrual pain

Herbal teas and herbal remedies are recommended as natural remedies - yarrow, St. John's wort, stinging nettle, evening primrose, seaweed, kelp or calendula can have a positive impact on the severity of the menstrual cycle.

 

Exercises

Some sports, such as yoga, swimming or aerobic exercises are very suitable during menstruation.  Overall, movement that provides relaxation and improves circulation is recommended. On the other hand, sports that are too strenuous are not recommended.

Special exercises that help to relax and relieve tension in the lower abdomen, especially pelvic floor strengthening exercises, are quite affective at relieving menstrual pain.

One way to help with menstrual pain is the Ludmila Mojžíšová method. In practice, these are exercises that are performed during the day and serve to strengthen the pelvic floor as well as consciously relax it. To practice and explain these techniques, we always recommend a consultation with an experienced physiotherapist.

 

When to consult with a doctor

Up to 75% of women suffer from menstrual pain. In case of severe or chronic difficulties that limit a woman in her normal activities, it is important to visit a gynaecologist. Sometimes it is appropriate to rule out another cause of the pain, or a sudden abdominal episode, so it is always necessary to see a gynaecologist for acute, severe or unusual symptoms, regardless of the woman's age.

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