Menstrual cramps are something nearly every menstruating person has experienced at some point. For many, they come and go as part of their monthly cycle, but for others, they can become severe enough to disrupt daily life.
According to one epidemiological review, up to 91% of women of reproductive age experience menstrual cramps, 29% of which suffer from severe pain. If your cramps are particularly intense, persistent, and accompanied by other gynecological symptoms, they may be a signal of an underlying medical condition that requires attention.
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The Physiology of Menstrual Cramps
Dysmenorrhea is the medical term used to describe painful periods or menstrual cramps.
What Are Menstrual Cramps?
Menstrual cramps are a type of pelvic pain that occurs during menstruation. They can range from mild discomfort to severe, debilitating pain.
There are two types of dysmenorrhea:
- Primary dysmenorrhea is the most common form, often affecting adolescents and young adults, and is not linked to any other underlying conditions.
- Secondary dysmenorrhea is caused by an underlying medical condition and tends to occur in individuals over the age of 25.
Why Do They Happen?
The pain of menstrual cramps stems from the contraction of the uterine muscles, triggered by the release of chemicals called prostaglandins, particularly prostaglandin F2α (PGF2α) and prostaglandin E2 (PGE2). These prostaglandins are responsible for making the uterus contract to help expel the lining that builds up each month. The higher the level of prostaglandins, the stronger the contractions and the more pain you feel.
Hormonal imbalances in estrogen and progesterone are often implicated in dysmenorrhea.
Estrogen dominance, characterized by elevated levels of estrogen relative to progesterone, can exacerbate underlying gynecological pathologies, such as endometriosis and adenomyosis.
These conditions are estrogen-dependent and involve chronic inflammation. Estrogen promotes the growth of endometrial tissue (the tissue that lines the inside of the uterus) and increases the production of pro-inflammatory mediators, which can heighten pain perception and contribute to the severity of dysmenorrhea.
Low progesterone levels further compound this issue. Progesterone has anti-inflammatory properties and helps regulate the menstrual cycle by balancing the effects of estrogen. When progesterone levels are low, there is a decrease in the metabolism of and increased synthesis of prostaglandins, leading to their accumulation.
Common Causes of Severe Menstrual Cramps
While menstrual cramps are often just a part of life, there are certain factors and medical conditions that can make them more severe.
Lifestyle and Stress Factors
Let's look at some of the modifiable factors that increase the risk of developing painful periods:
Diet
In a study that looked at the relationship between dietary habits and menstrual disorders in women, researchers found that women with a lower dietary intake of protein were more likely to experience dysmenorrhea. Additionally, nutrient deficiencies were linked to the presence of menstrual disorders, specifically:
- Fiber
- B vitamins
- Vitamin C
- Vitamin D
- Vitamin E
- Potassium
- Calcium
- Magnesium
- Iron
Cigarette Smoke
Smoking is a risk factor for dysmenorrhea because it restricts blood flow and is toxic to the ovaries. Being a former or current smoker increases your risk of dysmenorrhea by as much as 1.5 times.
Alcohol
Studies have identified alcohol consumption as a factor associated with the severity of dysmenorrhea. Alcohol can influence reproductive hormone levels, specifically having estrogen-like effects in the body, potentially exacerbating menstrual pain.
Stress
Women with high stress may be at more than twice the risk of dysmenorrhea compared to those with low stress. Stress can trigger hormonal imbalances by increasing the production of cortisol, a stress hormone that can disrupt the balance of reproductive hormones like estrogen and progesterone. Chronic cortisol elevations can also activate pro-inflammatory pathways, amplifying uterine contractions and pain perception.
Medical Conditions Linked to Severe Cramps
The list of possible causes of secondary dysmenorrhea includes, but is not limited to:
Endometriosis
Endometriosis is a gynecologic condition that affects 1 in 10 women of reproductive age. It is characterized by the growth of endometrial tissue outside the uterus, which behaves as the normal lining would, thickening and shedding each cycle but without an easy exit. This leads to inflammation and scar tissue formation.
Endometriosis is the most common cause of secondary dysmenorrhea, affecting up to 75% of adolescents with dysmenorrhea. In addition to painful menstrual cramping, endometriosis also causes:
- Chronic pelvic pain
- Heavy menstrual bleeding (menorrhagia)
- Infertility
Adenomyosis
Adenomyosis is a uterine condition that occurs when endometrial tissue grows into the muscular wall of the uterus (myometrium). An estimated 15-30% of patients with adenomyosis present with dysmenorrhea, believed to be caused by increased prostaglandin levels. It is most commonly diagnosed in women 41-45 years old.
Uterine Fibroids
Fibroids, or leiomyomas, are benign tumors that grow in or on the walls of the uterus. Although they aren't cancerous, they can cause heavy bleeding, painful cramps, and pressure in the pelvic region. According to one study, 61% of women with fibroids reported having mild-to-severe dysmenorrhea.
Pelvic Inflammatory Disease (PID)
PID is an infection of the female reproductive organs, often caused by untreated sexually transmitted infections (STIs) like chlamydia and gonorrhea.
Left untreated, PID can cause permanent scarring within the female reproductive tract, resulting in complications like:
- Chronic pelvic pain
- Infertility
- Ectopic pregnancy (implantation of a fertilized egg outside of the uterus)
Genetics and Family History
Having a family history of dysmenorrhea increases the risk of an individual developing it by as much as 20 times. Genome-wide association studies (GWAS) have identified several genetic loci associated with dysmenorrhea. Specific genetic variants that have been implicated in conferring risk for dysmenorrhea include:
Recognizing Symptoms and When to Seek Help
Despite being so prevalent, research suggests up to 86% of women with dysmenorrhea don't seek help from their doctor. It's important to know when menstrual cramps are more than just a normal part of your cycle.
Identifying Severe vs. Normal Cramps
Normal menstrual cramps usually begin at the start of menstruation and last for a few hours to a day. They tend to be mild in intensity, feeling like a dull ache or pressure in the lower abdomen, and do not interfere with daily activities.
Severe cramps, on the other hand, may last for several days and are often accompanied by other symptoms like:
- Nausea
- Vomiting
- Diarrhea
- Bloating
- Dizziness
- Headache
- Low back pain
- Pain that radiates down the backs of the legs
- Full-body pain
Severe dysmenorrhea is also a leading cause of absenteeism from school or work and lost productivity.
Warning Signs of Underlying Conditions
If cramps are accompanied by the following symptoms, it may indicate a more serious issue:
- Pain that interferes with daily activities, such as work, school, social activities, or sleep
- Pelvic pain that occurs independently of the menstrual cycle
- Pain that doesn't respond to over-the-counter pain relievers
- Pain during intercourse
- Excessively heavy bleeding (soaking through at least one pad or tampon every hour for several hours in a row; needing to double up on pads to manage menstrual flow; needing to change pads and tampons during the night; bleeding for longer than one week)
- Abnormal vaginal discharge
- Infertility
These symptoms could indicate gynecologic conditions that require medical intervention. It's important to talk to a doctor who can perform a physical exam, order imaging tests like ultrasounds, and even recommend a laparoscopy to diagnose conditions like endometriosis.
Management and Treatment Options
Fortunately, there are many options to manage and treat severe menstrual cramps.
Safe and effective treatment options will vary depending on the type and root cause of painful periods. Before starting treatment, you should always talk with a doctor for an accurate diagnosis and personalized recommendations tailored to your specific condition.
Home Remedies and Lifestyle Changes
- Anti-Inflammatory Diet: Studies suggest that making dietary changes away from a pro-inflammatory, standard American diet and towards more anti-inflammatory food choices – such as increasing the intake of vegetables, fruits, whole grains, and legumes (like in a vegetarian diet) – can help reduce menstrual pain.
- Exercise: The American College of Obstetricians and Gynecologists (ACOG) recommends that women exercise most days of the week to reduce menstrual pain to make natural pain-relieving chemicals called endorphins. This recommendation is supported by evidence that suggests women who exercise regularly (at least three times per week) may experience less severe menstrual cramps.
- Relaxation Techniques: Relaxation and stress reduction may be better than no treatment for reducing pain. Studies have indicated that techniques that foster a healthy stress response, such as yoga, progressive muscle relaxation, and biofeedback, may help alleviate acute symptoms of menstrual cramping.
- Heat Therapy: Topical heat (about 102°F) may be as effective as ibuprofen and more effective than acetaminophen at reducing pain.
Over-the-Counter Medications
- Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs are a first-line treatment for primary dysmenorrhea because evidence supports they are superior to placebo and acetaminophen for reducing pain. They reduce pain and inflammation by blocking prostaglandin production. Ibuprofen and naproxen are over-the-counter NSAIDs that can be purchased without a prescription. Medical guidelines recommend that these medications be taken regularly, starting 1-2 days before the onset of a period and continuing through the first 2-3 days of bleeding.
Medical Interventions
- Oral Contraceptive Pills (OCPs): Combined estrogen-progestin OCPs are an alternative first-line treatment to NSAIDs for those with contraindications or desire contraception. Additionally, they can be used in combination with NSAIDs. They work by thinning the endometrium and reducing prostaglandin production.
- Intrauterine Device (IUD): Hormonal IUDs are an alternative contraceptive option to OCPs that can be used to treat dysmenorrhea. A systematic review concluded that the levonorgestrel-releasing IUD is as effective as, if not better than, OCPs in treating primary dysmenorrhea and secondary dysmenorrhea caused by endometriosis.
- Physical Therapy (PT): Pelvic floor physical therapy is a subset of PT focused on strengthening and stabilizing the pelvic muscles. An 8-week kegel exercise program, in particular, has been shown to effectively reduce menstrual pain.
- Surgical Options: In cases of secondary dysmenorrhea or chronic pelvic pain that don't respond to conservative first-line therapies, surgery may be recommended. Depending on the circumstances, these could include laparoscopy, uterine nerve ablation (UNA), and presacral neurectomy (PSN).
Alternative Therapies
- Acupuncture: According to one systematic review and meta-analysis, acupuncture might reduce menstrual pain and other dysmenorrhea-associated symptoms as well as or better than placebo or NSAIDs.
- Supplements: There is a relatively extensive pool of data supporting the use of various dietary and herbal supplements as natural remedies for reducing menstrual pain, including ginger, chasteberry (Vitex agnus-castus), thiamine (vitamin B1), fish oil (omega-3 fatty acids), and calcium-magnesium complex.
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Key Takeaways
- Severe menstrual cramps are not part of a healthy menstrual cycle and are more than just an uncomfortable inconvenience – they can be a sign of a deeper health issue.
- Endometriosis, adenomyosis, uterine fibroids, and pelvic inflammatory disease are examples of underlying medical conditions that can cause painful periods and need to be treated appropriately by a doctor.
- Lifestyle factors and genetics can also increase the risk of developing dysmenorrhea by promoting inflammation and hormonal imbalances.
- If your cramps are severe, disrupt your daily life, or are accompanied by other gynecological symptoms, it's important to consult a healthcare provider to determine the best course of action.
- There are many effective solutions, both medical and natural, that can help resolve the pain and improve your quality of life. A doctor can help you figure out the root cause of your severe menstrual cramps and the best combination of treatment options that will safely and effectively get rid of pain.
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