Patient education: Painful menstrual periods (dysmenorrhea) (Beyond the Basics)

INTRODUCTION — Painful menstruation, also known as dysmenorrhea, is a common problem. For most people who are affected, dysmenorrhea begins during adolescence, usually within four to five years of the first menstrual period. Painful periods become less common over time, as a person gets older.

This topic review discusses the causes, symptoms diagnosis, and treatment of dysmenorrhea in people who do not have an underlying cause for their pain (eg, endometriosis, uterine fibroids, uterine adenomyosis, bowel or bladder disease, etc). Information about these problems is available separately. (See "Patient education: Endometriosis (Beyond the Basics)" and "Patient education: Uterine fibroids (Beyond the Basics)" and "Patient education: Chronic pelvic pain in females (Beyond the Basics)".)

CAUSE OF DYSMENORRHEA — During menstruation, chemicals called "prostaglandins" form in the lining of the uterus. They cause muscle contractions in the uterus, which can trigger pain and decrease blood flow and oxygen to the uterus. Similar to labor pains, these contractions can cause significant pain and discomfort.

Prostaglandins may also contribute to other menstrual symptoms such as nausea and diarrhea.

DYSMENORRHEA SYMPTOMS — The pain of dysmenorrhea is crampy and usually located in lower abdomen; some people also have severe pain in the back or thighs. The pain usually begins just before or as menstrual bleeding begins, and gradually improves over one to three days. Pain usually occurs intermittently, and can range from mild to disabling.

Other symptoms that may accompany cramping include nausea, diarrhea, dizziness, fatigue, headache, or a flu-like feeling.

DYSMENORRHEA DIAGNOSIS — To diagnose dysmenorrhea, your health care provider will review your medical history and do a physical examination.

Physical examination — This involves a complete abdominal and pelvic examination. During the examination, your provider will observe and feel the size and shape of your vagina, cervix, and uterus; they will also attempt to feel the ovaries.

An internal pelvic examination may not be necessary in adolescents.

Other tests — Depending on your situation, your provider may also do a pelvic ultrasound (performed vaginally if possible). This can be useful in determining if you have another condition that can cause pain, such as uterine fibroids, uterine adenomyosis, or endometriosis.

INITIAL TREATMENT — There are a number of treatments available for dysmenorrhea.

Nonsteroidal anti-inflammatory drugs (NSAIDs) — NSAIDs are a group of medications that are very effective in reducing pain associated with dysmenorrhea. Some NSAIDs are available without a prescription, such as ibuprofen (sample brand names: Advil, Motrin) and naproxen (sample brand name: Aleve); others require a prescription. Prescription NSAIDs are probably no more effective than nonprescription NSAIDs as long as an adequate dose is used.

NSAIDs are most effective if they are started as soon as bleeding or other menstrual symptoms begins, and then taken on a regular schedule for two to three days. Your health care provider can talk to you about the best dose and schedule for you.

Birth control — For people who do not wish to get pregnant, birth control pills and other forms of hormonal birth control can also be used to treat dysmenorrhea. In addition to the pill, these include the patch, vaginal ring, injection, hormone-releasing intrauterine device (IUD), and implant. Using hormonal birth control usually relieves dysmenorrhea within several months of starting it.

These methods work by thinning the lining of the uterus, where prostaglandins are formed, thereby decreasing the uterine contractions and menstrual bleeding that contribute to pain and cramping. Some people choose to use hormonal birth control along with NSAIDs to manage pain.

If you are interested in hormonal birth control, talk with your health care provider. Each method has benefits and downsides, and the right choice for you will depend on these factors and your preferences. (See "Patient education: Hormonal methods of birth control (Beyond the Basics)" and "Patient education: Long-acting methods of birth control (Beyond the Basics)".)

Continuous dosing — Traditionally, hormonal birth control treatments such as the pill, patch, or ring are taken on a schedule that will trigger bleeding about once a month. However, it is possible to take your birth control continuously in order to avoid bleeding and minimize period-related pain. This is known as "continuous dosing."

Continuous dosing means the following:

●Pill – If you use birth control pills, you would take one "active" pill per day for 21 or 24 days (depending upon the brand of pill), and then start a new pack of pills immediately. This can be done indefinitely, although many people stop taking their pill for several days every 9 to 12 weeks; many people will have some bleeding during this time.

●Patch – If you use the patch (sample brand names: Xulane, Twirla), you would apply a new patch once per week for 9 to 12 weeks, and then use no patch for several days. Most people will have some bleeding during this time.

●Ring – If you use the vaginal ring (sample brand names: Nuvaring, EluRyng, Annovera), you would insert a new ring every three to four weeks for 9 to 12 weeks, and then use no ring for several days. Most people will have some bleeding during this time.

●Injections – If you get injections of medroxyprogesterone acetate (brand name Depo-Provera), you would get one injection every 12 weeks. Most people have some intermittent spotting or bleeding for the first few months; this usually decreases with time. However, after receiving four or more injections (one year or more of use), most people have little to no bleeding.

People who use continuous dosing of a hormonal birth control method often have intermittent light bleeding or spotting, especially during the first two to three months; this usually declines with time. When bleeding occurs, it is usually lighter and associated with less severe cramping compared with before the treatment.

Nondrug treatments — Treatments that do not require the use of a medication can also help to reduce the pain of dysmenorrhea. In some cases, these treatments are not as effective as medications, although they can be combined with a medication to increase the pain-relief benefit.

Heat — Applying heat to the lower abdomen with a heating pad, hot water bottle, or self-heating patch can significantly reduce pain, often as well as treatment with an NSAID. It is important to avoid burning the skin with a heating pad or hot water bottle that is too hot; a temperature of approximately 104°F (40°C) is recommended. A risk of burns is generally not a concern if a self-heating patch is used. You can use heat as often as desired. Using heat in addition to an NSAID medication may speed the relief of pain [1].

Dietary, vitamin, and herbal treatments — A variety of dietary and vitamin therapies have been studied for the relief of dysmenorrhea [2]. However, these studies involved a small number of people and do not provide sufficient information regarding safety or efficacy. Based on limited evidence, most experts do not recommend dietary, vitamin, or herbal remedies for treating dysmenorrhea.

Physical activity — Exercise seems to reduce menstrual symptoms, including pain, in some studies [3]. Exercise has a number of benefits, so it is reasonable to try exercising to relieve period-related pain. Exercise does not have to be strenuous to be helpful. Even gentle forms of activity, like walking, are good for your health and can improve your mood. (See "Patient education: Exercise (Beyond the Basics)".)

Complementary or alternative medicine — There is some evidence that complementary medicine practices such as yoga or acupuncture are effective in reducing painful periods [4]. However, further study is needed to confirm the safety and efficacy of these treatments. Further information about complementary and alternative medicine is available from the National Center for Complementary and Integrative Health (https://nccih.nih.gov/).

Transcutaneous electrical nerve stimulation — Transcutaneous electrical nerve stimulation (TENS) is a treatment that involves the use of electrode patches, which are applied to the skin near the area of pain. TENS has been used to treat pain caused by many conditions, and may help to reduce dysmenorrhea in some patients.

This treatment involves wearing a small battery pack on a belt, which generates a mild electrical current that passes to the electrodes. The electrical current is believed to stimulate the release of chemicals that block or reduce painful nerve impulses.

An analysis of several studies showed that TENS does not relieve pain as well as medications; however, it may be a useful alternative for people who cannot or prefer not to take pain-relieving medications [5].

IF INITIAL TREATMENT IS NOT SUCCESSFUL — As discussed above, the most effective treatments for dysmenorrhea include NSAIDs and/or hormonal birth control methods. If you try one of these treatments but it does not sufficiently relieve pain within two to three months, your health care provider might recommend switching treatments or combining approaches (for example, adding birth control if you already use NSAIDs, or vice versa).

Typical next steps — If neither NSAIDs nor hormonal birth control adequately improve pain, your provider can recommend next steps based on your age, symptoms, and other medical conditions. Options include:

●Surgery to identify a cause – Diagnostic laparoscopy may be recommended to determine if endometriosis, or another condition, could be causing the pain. Usually performed in an operating room under general anesthesia, laparoscopy is a minimally invasive surgery that uses small incisions and a thin telescope with a camera to determine if there are signs of endometriosis or other abnormalities on or near the uterus, ovaries, or other areas inside the pelvis. Most people having laparoscopy can go home on the day of surgery.

●Medication to suppress periods completely – If your provider thinks your pain is related to endometriosis, they might recommend treatment with a gonadotropin-releasing hormone (GnRH) agonist, such as nafarelin (brand name: Synarel) or leuprolide (brand name: Lupron), or a GnRH antagonist, such as elagolix (brand name: Orilissa) or relugolix (brand name: Myfembree). If dysmenorrhea improves within two to three months of starting treatment, this suggests that endometriosis probably was the cause.

These options are discussed in full detail in a separate topic review. (See "Patient education: Endometriosis (Beyond the Basics)".)

Nerve cutting surgery — At least two surgical procedures have been developed to treat dysmenorrhea. Both of these surgeries involve cutting or destroying the uterine nerves, which prevents the transmission of pain signals. However, these procedures have not been shown to provide long-term relief of pain. Furthermore, surgery may be associated with complications. These may be related to regrowth of nerves or pain signals being transferred by alternate routes [6]. As a result, surgical treatments for dysmenorrhea are generally not recommended.

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Endometriosis (The Basics)
Patient education: Uterine adenomyosis (The Basics)
Patient education: Menstruation (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Endometriosis (Beyond the Basics)
Patient education: Uterine fibroids (Beyond the Basics)
Patient education: Chronic pelvic pain in females (Beyond the Basics)
Patient education: Hormonal methods of birth control (Beyond the Basics)
Patient education: Long-acting methods of birth control (Beyond the Basics)
Patient education: Exercise (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Dysmenorrhea in adult females: Clinical features and diagnosis
Primary dysmenorrhea in adolescents
Dysmenorrhea in adult females: Treatment
Uterine adenomyosis

The following organizations also provide reliable health information.

●National Library of Medicine

(www.nlm.nih.gov/medlineplus/ency/article/003150.htm)

●The American College of Obstetricians and Gynecologists

(www.acog.org/Patients)