Are Period Pains Normal?

A couple of weeks ago, Nigerian Twitter was awash with women tweeting their experiences with period pain. At the time, I did a Twitter thread here that got a lot of engagements over several days, but I always meant to write a more comprehensive post on the topic, as part of a new series I hope to launch on sexual and Reproductive health education.

So, let’s begin-

What is Dysmenorrhea?

Dysmenorrhea, or period pain (PP for the rest of this post) is defined as painful cramps that occur with menstruation. It is the most common reported gynecologic problem in women of all ages and races, and one of the most common causes of pelvic pain. Between 16 to 90% of women have reported having period pain, reported prevalence varying widely due to individual thresholds for symptom severity before seeking help.

In addition to the medical implication, PP causes women and girls several hours to days of lifestyle disruption every month that can affect their academics, career and relationships. It can also limit their participation in sports and other leisure or recreational activities.

Symptoms of Dysmenorrhea

Some of the complaints of women presenting with dysmenorrhea include

• lower abdominal / pelvic pain, which may radiate to the back / legs
• low back pain
• Headache
• Diarrhea
• Fatigue
• Nausea
• vomiting
• Pain on bowel movement

Types of Dysmenorrhea

Primary Dysmenorrhea — refers to PP that occur in the absence of underlying problems in the reproductive system. It is thought to be related to the hormones and chemical messengers related to menstruation. Such pain typically lasts eight to 72 hours, usually beginning at the onset of menstrual blood flow. Primary dysmenorrhea typically starts six to twelve months after the first period, and often peaks in the late teens or early twenties.

Secondary Dysmenorrhea — arises from a specific pelvic pathology. It is suspected in older women with no prior history of dysmenorrhea. It is often accompanied by other symptoms like excessive blood loss during menses, vaginal bleeding in between the menses, pain and / or bleeding during or after sex/ during urination/ bowel movement, and infertility. Secondary dysmenorrhea tends to precede the menstrual flow.

Risk Factors and Protective Factors

Some of the risk factors that have been identified for higher possibility of having PP include (in decreasing order of severity) — Heavy menstrual loss

• Premenstrual syndrome
• Irregular menstrual cycles
• Age less than 30 years
• Pelvic Inflammatory diseases (often sexually transmitted)
• Sexual abuse
• First period at age < 12 years
• Low Body Mass Index
• Sterilization

Factors that appear to have protective effects against PP include — regular exercise, oral contraceptive use, and early childbirth.

What to expect when you seek help for Dysmenorrhea?

1. Emergency Pain Relief — if you are presenting with acute period pain, your health practitioner may offer you pain relief as first line management, after initial assessment. This is to reduce your distress before other parts of the consultation can continue.
2. History Taking — If you are not actively in pain/ once your pain is manageable, your HP will ask a series of questions to differentiate primary from secondary dysmenorrhea (and possible causes of the latter.) These questions will cover details of your periods, the onset and severity of the pain, other symptoms associated with the pain, your recent sexual history, previous experience of and future plans for pregnancy, relevant personal and family medical history, especially of other female family members among others. It can seem intrusive but a detailed history will guide the next steps of the consultation.
3. Examination — In addition to a general examination, and except in cases of adolescent women who are as yet sexually inactive, a pelvic exam is usually carried out for women complaining of dysmenorrhea. Findings may point to presence of sexually transmitted infections or indicate the possibility of secondary dysmenorrhea.
4. Tests — While most young women without indication of secondary causes will be offered treatment for primary dysmenorrhea, initial tests for dysmenorrhea may include:

• Blood panels (PCV, hematocrit, red cell indices) if anemia appears significant
• Ultrasound, usually transvaginal
• Laparoscopy, only if there’s strong indication of pelvic pathology like endometriosis.

5. Treatment — Whether primary or secondary cause is suspected, most women are offered a pain management regimen, usually consisting of NSAIDs, a group of non-addictive painkillers that have shown varying effectiveness for management of period pain. The most common side effects of NSAIDs are gastrointestinal so it is important to discuss with your doctor and follow the pharmacist’s advice on administration. If oral route is unfavorable, rectal suppositories may be offered.

Second line treatment option offered to women with dysmenorrhea, especially those without plans for current fertility, is the use of combined hormonal contraceptive (oral has more robust evidence of efficacy than other routes of application- IUD, cervical etc)

Women with confirmed cases of secondary dysmenorrhea will have their treatment tailored to the specific causes identified.

In conclusion, while it is normal to feel some cramping and pain during your period, pain that disrupts your day or is associated with other symptoms should not be dismissed. Please see your reproductive health service provider.

PS: do you have any questions on this (or other reproductive health) topics? Ask, and I will try to respond in the comments or in another post. Don’t forget to follow this page to recieve updates on new posts.