Menstrual Cramps
Understanding Period Pain & Effective Menstrual Pain Relief

Menstrual cramps are dull cramping lower abdominal pain occurring in a throbbing wave pattern along the bikini line area a day to two before the onset of menstruation in a woman, continuing, in many cases, till the end of that menstrual period. They pain gets better though, towards the last few days of the period.

The pain could be moderate or very severe, and could spread to the lower back and even down the thighs. Menstrual or period cramps, is also known as dysmenorrhoea (the medical term for menstrual pain).

About three out of every four women would suffer with varying degree of menstrual cramp. In as much as one in ten women, menstrual pain or cramp could be so disabling, that they are unable to carry on with their normal activities during their menstrual periods. Times off school or work or reduced productivity from the effect of such pain every month from severe menstrual cramps are not uncommon.

Menstrual pain or cramp usually starts within the first six to twelve months of the onset of menarche. Period pain tends to get better as a woman gets older. Many women report that they stop having severe period pain after the birth of their first child.

This type of menstrual or period pain commencing within a few months or years from the very first menses, is called primary dysmenorrhoea and signifies that the woman has started ovulating. It is not due to any underlying problems. Many women who have period pain in their early teens to 20's have primary dysmenorrhoea.

In some women, they develop menstrual pain only later in life (starting from late twenties to forties). Such cases are due to some underlying causes, and are thus referred to as secondary dysmenorrhoea. If you develop new onset menstrual pain after your teenage years, it is almost certain that something is not right, and it is important that you see your doctor. The commonest causes of this type of menstrual pain starting later in life are discussed below.

Symptoms of Menstrual Cramps

Painful period or menstrual pain is usually benign and not a cause to worry. However, for those starting their periods newly, it is important to be sure that the lower abdominal pain they are having is due to menstrual pain. So what are the symptoms of menstrual cramps or period pain?

The timing of the pain and it's nature are the important factors to help identifying the symptoms of menstrual pain.

• Lower abdominal pain occurring below the level of your belly button and may spread to your lower back or to the top of your leg or legs around the time of your menses

• It is often cramping in nature

• This pain usually starts a day or two before the expected time of menstruation and tends to ease off before the end of the menstrual period, or sometimes continues all through to a few days after the menses have ceased flowing.

• There may associated vomiting, loose stools, bloating and headache

• Dizziness and sweating has been reported in some women

• A few women actually faint or "pass out" every month, during the height of their pain

• Increased emotional irritability may be associated symptom.

Except the doctor is very sure from the history, all patient who presents with lower abdominal pain around the time of menstruation need to be examined like any other patient, just to exclude other possible causes of lower abdominal pain, or to indeed exclude causes of secondary dysmenorrhoea.

Some women have reported the presence of pain in the rectum or anus during their menses or even passage of blood from the anus during their menses. Such complaint points to the likely presence of rectal endometriosis and would need further investigations.

Causes of Menstrual Cramps

Primary dysmenorrhoea which is the most common form of menstrual cramps is said to occur only in women who are ovulating.

Ovulation is the scientific word used to described the release of eggs from the ovary in readiness for fertilization. So it is true to say that a woman who experiences menstrual pain is fertile woman, from the point of egg production and release.

Ovulation leads to the release of chemicals known as prostaglandins, which causes the blood vessels in the wall of the uterus or womb to contract, as well as contraction of the muscle of the womb. This in turn causes reduction in the blood flow to the womb muscles, bringing about the annoying dull cramping pain.

The release of other chemical agents like vasopressin as well as an interplay of psychological input has been blamed for triggering primary dysmenorrhoea.

It is not uncommon for women who suffer significantly from menstrual pain to have very close relatives like their own mother or sister who also suffer with severe period pain. This obviously point to genetic link in determining who suffers from severe menstrual pain.

Secondary dysmenorrhoea is menstrual pain or cramping occurring due to the presence of an underlying medical problem in the woman. This tends to be more common in older women who have had a relatively uneventful period of menstruation in their life previously, but who now develops disturbing menstrual pain. It could also be seen (rarely), in younger women who recently started their periods.

The most common reason for secondary dysmenorrhoea in a young woman who recently started seeing her menses is the presence of an intact hymen in the vagina, trapping her menstrual flow, leading to distension of her vagina by trapped menstrual blood causing pain around the time of menstruation. That is why it is important to examine all women who presents with painful period for the first time.

Other causes of menstrual cramps in women who have had normal periods in the past include:

• Endometriosis
• Pelvic Inflammatory Disease
• Imperforate hymen - as mentioned above
• Fibroids
• Adenomyosis
• Adhesions
• Narrowing of the neck of the womb (cervical stenosis), e.g following a traumatic delivery or injury to the cervix

Each of these potential causes of menstrual pain can be excluded by taking a thorough history from the woman, examination and pelvic scan or endoscopy, if required.

Diagnosis of Menstrual Cramps

There is no blood test or scan required to make a diagnosis of menstrual cramps per se. A good story or description of pain around the time of your period and examination if need is often enough for a doctor to be 100 percent sure that the cause of your pain is due to period pain. This is true in case of primary dysmenorrhoea.

In secondary dysmenorrhoea, the history and examination also enough to make a diagnosis of menstrual pain, but more tests may be required to help find out what may be causing the pain. Such test could include:

• High Vaginal Swab or Endocervical swab
  This is a test to ascertain if a pelvic infection is to be blamed. It involves an internal examination. You will be required to lay on a couch on your back, with your knees bend backwards while your ankles are joined together and your thighs opened as wide apart as possible. A gel or water is used to smear a plastic or metallic speculum, and tend introduced into the vagina gently to expose the cervix or mouth of the womb. A small swab - cotton rolled on a stick, is then used to collect secretions from your cervix. It is not a painful procedure. It is easier than doing the smear test, though similar. The sample is sent off to the lab and results are often available in about three to ten days, depending on the capabilities of the lab.
  
• Pelvic Ultrasound Scan
  This is a routine scan to see if there are causes like fibroids, womb adhesions, adenomyosis, endometriosis, or even polyps as the cause of secondary dysmenorrhoea. Some women with a coil (IUCD) inside their womb may find out that removing the devise may cure them of their dysmenorrhoea.
  
• Laparoscopy
  This is the use of pin hole camera to look inside the abdomen to see if the cause of a new onset menstrual pain can be identified. Ultrasound scan might not be able to detect conditions like endometriosis and looking directly inside the abdomen might be the only solution.

• Hysteroscopy
  This is a test where a pin-hole camera is used to look directly inside the womb through the vagina. This is important in cases where ultrasound and laparoscopy has not shown anything, and if the doctor still thinks that there might be something inside the womb causing the problem.
  

Treatment of Menstrual Cramps

If your menstrual pain is proving disruptive to your life, then you will need some form of treatment for pain relief. The following are useful treatment options:

• Use of Thermal Wraps or Hot Water Bottles
  Applying warm materials to the lower abdomen help soothe the pain of menstrual cramps. This might be enough on it's own. Hot water bottles were popular in the past, but these days, the ThermaCare Menstrual Relief Patches because they are less likely to cause burns and injuries to the skin.
  
• Pain Killers
  Not all types of pain killers are particular good for menstrual cramps. You could start with simple pain killer like paracetamol also called acetaminophen, marketed as panadol , Tylenol in the USA or Acamol in Israel. Taking two tablets of 500mg strength paracetamol up to four times a day in combination with thermal wraps will relief pain in many women. You can get this over the counter. Should the pain not go away, you could take, as well as the above, stronger pain killers known as NSAIDs (Non-Steroidal Anti-inflammatory Drugs ). A good example of this medication is Mefenamic acid . It is marketed in the USA as Ponstel and in the United Kingdom as Ponstan. In the UK, this is a prescription only medication. When taken at a dose of 500mg three times a day, it is found to be very effective. As said earlier, you can take this as well as paracetamol, but on its own, it should be okay. Some persons develop diarrhoea, rash or even jaundice when taking this medication. If that happens while you taking it, please stop taking it and see your doctor for advice.

  All pain killers for period pain are best taken starting a day or two from when the period is expected and continue till the period goes away or pain is bearable.

  Other types of NSAIDs medications that can be effective for period pain include Naproxen (marketed as Feminax, Naprogesic, Aleve, Anaprox, or Feminax Ultra e.t.c.), Ibuprofen (marketed as Nurofen, Brufen, Motrin, Nuprin and Advil), and Diclofenac (marketed as voltarol. The first two are often available as over the counter medications and anyone can get them from a chemist without a doctor's prescription. Diclofenac, to be taken at a dose of 50mg three times a day with food can only be used on a doctor's prescription, though preparations with lesser strengths are available in some countries as over the counter medication. There NSAIDs are not suitable for everyone. If you suffer with asthma, it could trigger an attack in such persons. If could also cause an upper abdominal pain in some others, especially if it is taken on an empty stomach.

  See your doctor for advice.
  

• Use of Contraceptive Pills
  About 1 in 10 women who suffer with period pain find the pain so disabling that even the use of pain killers and warm wraps fail to control their pain. This could lead to their taking time off school and work from month to month. Is that the case with you? The use of the combined oral contraceptive pill (containing the two female hormones - oestrogen and progesterone) helps in controlling ovulation in these women and thus stop menstrual pain.

  Provided there is no contraindication to taking such pills (like history of blood clots, focal migraine with aura, family history of breast cancer, severely overweight and smoking), taking the pill monthly will control the pain in most cases
  

• Nutritional Therapy
  Some women find that taking supplements like Omega-3 fatty acids, or Calcium & Magnesium combination, or vitamin E or Niacin. While there are growing body of evidence that some of these supplement provide relief from menstrual pain, it is not known whether this is as a result of placebo effect. You can get such supplements from reputable online stores like Holland & Barrett. If you try any of these supplements for menstrual pain and find them useful, then feel free to discuss its continue use with your doctor.
  
• Yoga
  Yoga for menstrual cramps is increasingly becoming a popular form of menstrual pain relief exercise. Adopting certain posture that stretches the abdomen by arching the lower back and remaining still in that position for severe minutes has been reported to help soothe the pain of period cramps in some women.
  

Other remedies that have been use for menstrual cramps include the use of TENS machine, acupuncture, homeopathy, hypnosis and relaxation and guided imagery techniques.