Menstrual Pain

What is Menstrual Pain?

Menstrual pain, or dysmenorrhea, is recurring lower abdominal pain that occurs during the menstrual cycle. It is called primary dysmenorrhea when it is not caused by another disease, which accounts for about 90% of cases, and secondary dysmenorrhea when an underlying condition is responsible.^[1]

Common symptoms

Primary dysmenorrhea usually begins within a few hours of the start of bleeding and settles within about 72 hours. The pain is felt in the middle of the lower abdomen and may spread to the lower back or upper legs. It tends to feel crampy and is similar from one cycle to the next.^[1]

Nausea, vomiting, headache, dizziness, fatigue and sleep trouble can come with it.^[1]

Causes and risk factors

Primary dysmenorrhea typically begins within about two years of the first period, or once ovulation is regular, and is often diagnosed in teens and young adults.^[1] It is commonly linked to prostaglandins, chemicals released by the uterine lining that make the uterus contract.

Secondary dysmenorrhea is tied to a condition of the pelvis. Endometriosis is the most common cause, and adenomyosis is another.^[2] Fibroids and pelvic infection can also be involved.

How it is diagnosed and treated conventionally

A history and physical exam often reveal the cause. Heavy or abnormal bleeding, pain during sex, pain outside the period, a change in how the pain feels, or an abnormal pelvic exam point toward a secondary cause and call for further tests such as an ultrasound.^[2]

Treatment for primary dysmenorrhea includes anti-inflammatory pain relievers (NSAIDs) and hormonal contraceptives. Hormonal contraceptives are also first-line for pain from endometriosis. Heat, exercise and some supplements may help.^[2]

Why Menstrual Pain calls for a whole-person approach

Period pain involves more than the uterus. It can affect sleep, mood and daily function, and the cause matters, so the first step is finding out whether pain is primary or secondary.^[1] Care that also addresses muscle tension, stress, sleep and movement is a reasonable addition to medical treatment.

Uterine contractions and prostaglandins

Higher prostaglandin levels increase uterine contractions and pain, which is why NSAIDs, which reduce prostaglandins, are a standard treatment.^[2]

Underlying conditions

Endometriosis, adenomyosis and fibroids can cause secondary dysmenorrhea. These are medical conditions that need their own evaluation.^[2]

Movement, exercise and muscle tension

A network meta-analysis of 33 trials found that exercise and topical heat were among the non-drug approaches linked to lower pain scores.^[3] A meta-analysis of 4 small trials of yoga found lower menstrual pain compared with no yoga.^[4]

Stress, sleep and daily impact

Dysmenorrhea is linked to negative emotional, psychological and functional effects and can come with sleep difficulties.^[1]

Acupuncture for Menstrual Pain

What the research shows

Studies are encouraging but of low quality, and the best-designed trial found no benefit over sham. A Cochrane review of 42 trials with 4,640 women found the evidence insufficient to say whether acupuncture or acupressure works for primary dysmenorrhea. Results against sham acupuncture were inconsistent, and the only trial at low risk of bias in every area found no difference. Compared with NSAIDs, pain scores were lower with acupuncture in all seven trials that reported them, but the evidence was low quality.^[5]

A network meta-analysis of 33 trials of non-drug treatments for primary dysmenorrhea found that acupuncture, along with exercise and topical heat, probably reduced pain in the short term, and called for larger, better-designed studies.^[3] A meta-analysis of 13 trials with 675 women found acupuncture and moxibustion more effective for pain than control treatments, with fewer adverse events.^[6] A small trial of 60 young women found less pain with acupuncture than with no acupuncture, but it had no sham group.^[7]

For secondary dysmenorrhea, a meta-analysis of 14 trials of acupuncture for endometriosis-related pain found reductions in pain severity, but the authors cautioned that the studies were limited by design and quality problems.^[8] A family medicine review concluded there was not enough evidence to support acupuncture for dysmenorrhea.^[2]

How acupuncture may work

How acupuncture eases period pain, if it does, is not established. A systematic review that included acupressure studies suggested that acupressure, a related needle-free technique, may suppress pain by lowering prostaglandin levels, raising beta-endorphin levels and improving blood flow through the uterus.^[9] These are proposed explanations, not settled facts, and they have not been confirmed for acupuncture.

What treatment involves

Treatment uses fine, sterile, single-use needles, usually left in place for about 20 to 40 minutes. In one small trial, sessions lasted 20 minutes.^[7] A course of several visits is usual, often timed around the cycle, and we reassess after a short course.

Serious problems from acupuncture are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[10] Tell the practitioner first if you are or may be pregnant, have a bleeding disorder, take blood thinners, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine for Menstrual Pain

The Ayurvedic view

Ayurveda describes painful periods under names such as Kashtartava and links the pain to aggravated Vata, the principle of movement, which is said to obstruct the downward flow of menstrual blood. This is a traditional framework used to choose care, not a biomedical diagnosis.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Warm, cooked meals and regular routines, with less cold and dry food
• Warm oil massage of the lower abdomen and back, and local heat
• Gentle yoga and breathing practices
• Herbs such as ginger and turmeric, which are used in Ayurveda and have also been studied on their own, prescribed individually

Panchakarma procedures are not appropriate during pregnancy, acute illness or frailty, during menstrual bleeding, or before the cause of pain has been medically assessed.

What the research shows

The research on Ayurveda as a system for menstrual pain is very limited. We found no systematic review or randomized trial of a full Ayurvedic treatment plan for dysmenorrhea.

Some individual elements have been studied. A trial of 124 women with premenstrual syndrome and dysmenorrhea found that curcumin lowered pain scores, but placebo lowered them by almost as much, so the difference between them was not significant.^[11] For yoga, a meta-analysis of 4 small trials with 230 women reported lower pain.^[4] Ginger is covered in the herbal section below.

Herbal medicine for Menstrual Pain

Herbs and formulas that have been studied

Studied herbs include ginger, cinnamon and fennel, and Chinese formulas such as Xuefu Zhuyu decoction and Wenjing decoction.^{[12, 13, 14]}

What the research shows

The evidence is limited and of low quality. A meta-analysis of 12 trials found ginger reduced pain intensity and duration more than placebo and similar to NSAIDs, but the authors noted risk of bias and unclear safety data.^[15] A meta-analysis of 9 studies with 647 patients found cinnamon, fennel and ginger each reduced pain more than placebo.^[12]

A Cochrane review of 27 trials of dietary supplements, mostly in students in Iran, rated all the evidence low or very low quality and said there is no high-quality evidence for any supplement.^[16]

For Chinese herbs, a Cochrane review of 39 trials with 3,475 women found promising results compared with drugs, but the trials were small and of poor methodological quality.^[17] A meta-analysis of 18 studies found Wenjing decoction better than NSAIDs, with low-quality evidence, and a meta-analysis of 8 trials found Xuefu Zhuyu decoction favorable, alone or added to Western medication, compared with Western medication only, but with a small number of studies and high risk of bias.^{[13, 14]}

Safety and herb-drug interactions

Herbs can interact with medicines, including blood thinners, antidepressants and immunosuppressants.^[18] Ginger is among the foods and herbs linked to a higher bleeding risk with warfarin.^[19] Because many women use NSAIDs or hormonal birth control, tell us about every medicine and supplement you take.

In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[20] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant, trying to conceive, or have liver or kidney disease.

Translating traditional medicine into modern biological language

This is interpretation, not equivalence. Chinese medicine often describes period pain as stagnation of qi and blood, or cold in the uterus, in which flow of blood is obstructed. Researchers measure related ideas such as prostaglandin levels, uterine contraction and uterine blood flow.^[9]

Ayurveda's aggravated Vata describes spasmodic, cramping pain. Reviews of medicinal plants and acupressure propose that they ease pain through prostaglandin reduction, nitric oxide, beta-endorphins and calcium channel blocking.^[9] No study has shown that a dosha or a TCM pattern corresponds to a specific biological process.

How this care fits with your medical care

Complementary care sits beside your medical care. Keep your gynecologist or primary care doctor, and do not stop or change pain medicines or hormonal contraception without your prescriber. We do not diagnose the cause of period pain, so pain that is new, worsening or not relieved by usual treatment should be medically evaluated.^[2]

Please bring any diagnosis such as endometriosis, ultrasound or imaging reports, a pain and cycle diary, and a list of all medicines and supplements.

When to seek urgent medical care

Most period pain is not dangerous, but some features suggest a secondary cause or an emergency.^[2]

• Sudden, severe pelvic pain, especially with fever, vomiting or fainting
• Very heavy bleeding, such as soaking a pad or tampon every hour
• Pain with a missed period or possible pregnancy
• Fever with pelvic pain or unusual vaginal discharge
• Pain that is steadily worsening or no longer relieved by usual treatment

If any of these occur, call 911 or go to the nearest emergency department.