Painful menstruation affects approximately 40% of menstruating women, and 10% are incapacitated for up to 3 days. Painful menstruation is the leading cause of lost time from school and work among women of childbearing age. This pain may precede menstruation by several days or may accompany it, and it usually subsides as menstruation tapers off.

Although some pain during menstruation is normal, excessive pain is not. Dysmenorrhea refers to menstrual pain severe enough to limit normal activities or require medication.

There are two general types of dysmenorrhea:

• Primary dysmenorrhea refers to menstrual pain that occurs in otherwise healthy women. This type of pain is not related to any specific problems with the uterus or other pelvic organs.
• Secondary dysmenorrhea is menstrual pain that is attributed to some underlying disease process or structural abnormality either within or outside the uterus (for example, pelvic inflammatory disease, fibroids, endometriosis, adhesions, or uterine displacement). Endometriosis is the most common cause of dysmenorrhea associated with a disease process and is frequently misdiagnosed.

Activity of the hormone prostaglandin is thought to be a factor in primary dysmenorrhea. Prostaglandin levels have been found to be much higher in women with severe menstrual pain than in women who experience mild or no menstrual pain.

The presence of an IUD (intrauterine device) for contraception may be a potential cause of menstrual pain, although they usually lead to pelvic pain only around the time of insertion. Some women also find that use of tampons exacerbates menstrual cramps and pain.

Psychological distress, often accompanied by physical pain and bloating, is commonly known as premenstrual syndrome (PMS). Symptoms include stress, anxiety, depression, irritability, mood swings, and crying jags. If these symptoms are severe enough to interfere with work or relationships, the condition is known as premenstrual dysphoric disorder (PMDD), and medications such as antidepressants may be helpful for treatment.

The incidence of menstrual pain is greatest in women in their late teens and 20s, then declines with age. It does not appear to be affected by childbearing. An estimated 10% to 15% of women experience monthly menstrual pain severe enough to prevent normal daily function at school, work, or home.

The majority of women will suffer this degree of disability at least once during their reproductive years. Increased risk is associated with younger age, multiple sexual partners, and past medical history of any of the conditions associated with secondary dysmenorrhea.

• Premenstrual syndrome (PMS)
• Stress and anxiety
• Pelvic inflammatory disease
• Multiple sexual partners
• History of sexual or physical abuse
• Fibroids
• Ovarian cysts
• Endometriosis

Medical treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) has a success rate as high as 80%. Ibuprofen (such as Advil) is the most commonly used of these drugs and may relieve mild menstrual pain. Antiprostaglandins like Diclofenac (Cataflam) are also quite effective in the management of moderate to more severe pain.

A recently developed category of drugs are COX-2 inhibitors. COX-2 inhibitors include celecoxib (Celebrex), rofecoxib (Vioxx), and valdecoxib (Bextra). COX-2 inhibitors may show a decreased rate of gastrintestinal side effects. To work effectively, these medications must be taken at the first appearance of symptoms. Some women experience several days of severe pain, which may require the use of narcotic pain relievers such as codeine.

Some relief can also be provided by applying a heating pad to the abdomen, effleurage (a light circular massage with the fingertips), drinking warm beverages, taking a warm shower, performing waist-bending and pelvic-rocking exercises, and walking.

Emotional support, psychological counseling, or antidepressants may be helpful for those women who have inadequate relief of chronic pain or whose emotional symptoms are more painful than the physical ones.

You should contact your health care provider if any of the following occur:

• The pain is severe.
• Your menstrual periods always hurt.
• If other unexplained symptoms accompany the pain.

Your health care provider will obtain your medical history and will perform a physical examination.

Medical history questions documenting your symptoms may include the following:

• Menstrual history
  • How old were you when your periods started?
  • Have they always been painful? If not, when did pain start?
  • Are you sexually active?
  • Do you use birth control? What type?
• Quality
  • Was the previous menstrual period a normal amount?
  • Do you use tampons with menstruation?
  • Do you normally have regular periods?
  • Do you have heavy menstrual bleeding (menorrhagia)? With passage of blood clots?
  • Do you have prolonged menstrual bleeding (more than five days per menstrual period)?
  • Describe the pain (sharp, dull, intermittent, constant, aching, cramping).
• Time pattern
  • When was your last menstrual period?
  • How long have you had the same menses pattern?
  • When did you begin to have painful menstruation?
  • Is it getting worse or better?
  • When in your menstrual cycle do you experience the pain?
• Relieving factors
  • What have you done to try to relieve the discomfort? How effective was it?
  • What has been effective in the past for you?
• What other symptoms are also present?

The physical examination may include a pelvic examination with ultrasound.

Diagnostic tests that may be performed include:

• Dilation of the cervix
• Laparoscopy
• Cultures (may be taken to rule out sexually transmitted diseases such as gonorrhea, primary syphilis, or chlamydia infections)
• CBC
• Sed rate
• RPR

Oral contraceptives may be prescribed to alleviate menstrual pain. If not needed for contraception, they may be discontinued after 6 to 12 months. Many women note continued freedom from symptoms despite stopping the medication.

Surgery may be necessary for women who are unable to obtain adequate pain relief or pain control. Procedures may range from removal of cysts, polyps, adhesions, or fibroids to complete hysterectomy in cases of extreme endometriosis.

Prescription medications may be used for endometriosis. For pain caused by IUD, removal of the IUD and alternative birth control methods may be needed.

Antibiotics may be necessary for pelvic inflammatory disease.