Most women often experience pelvic pain or cramps right before and/or during their menstrual periods. This is a very common and normal symptom associated with menstruation, which generally subsides as menstrual bleeding tapers off.
The medical term for pelvic pain that occurs during menstruation is dysmenorrhea. However, physicians mainly use the term to refer to severe menstrual cramps that interfere with daily activities, which are caused by an underlying condition or disease.
In addition to the sharp pains in the lower abdomen, women often experience other symptoms associated with menstruation, including:
Swollen or sore breasts
Lower back or leg pain
Nausea and vomiting
Diarrhea or incontinence
PMS-related symptoms (e.g., bloating, weight gain, acne)
Menstrual cramps are caused by prolonged, intense uterine contractions that occur during menstruation. Prostaglandins (hormone-like substances) produced in the endometrium at the time of menses are a major cause of these often painful contractions.
Women are more likely to experience severe menstrual cramps (dysmenorrhea) if they have any of the following:
Early onset of puberty
A family history of painful menstrual periods
Prolonged menstrual periods
Obesity
Stress and anxiety
In addition, a number of conditions may cause a woman to experience dysmenorrhea, such as:
Endometriosis
Pelvic inflammatory disease
Uterine fibroids and/or polyps
For women experiencing dysmenorrhea due to any of these conditions, medical treatment for the underlying cause can help to alleviate the cramps. If a woman has an intrauterine device (IUD), removal of the birth control device may be necessary and she may need to consider another method of birth control.
For most menstrual cramps, over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or aspirin, can reduce pain and discomfort. There are also pain medications specifically designed for menstrual cramps and discomfort. If NSAIDs or other OTC medications are not successful in treating menstrual pain, a physician may prescribe low-dose birth control pills to prevent ovulation. This may reduce the production of prostaglandins and therefore the severity of the cramps.
Women can also soothe their cramps by soaking in a hot bath or using a heating pad on the abdomen. The heat helps to increase blood flow, which in turn will reduce muscle spasms. In addition, eating a healthy diet, exercising regularly, getting adequate rest and reducing and/or eliminating alcohol and cigarette smoking may help alleviate menstrual cramps.
About menstrual cramps
Menstrual cramps are among the symptoms that most often accompany menstruation. They are a type of pelvic pain characterized by sharp cramping or a dull aching sensation in the lower abdomen. Many women experience these symptoms just before and during their menstrual periods. The medical term for menstrual cramps is dysmenorrhea. However, physicians most often use the term when describing severe menstrual pain that interferes with daily life or that may require medical treatment for an underlying disorder.
To create a nourishing environment for a fertilized egg, the female sex hormone estrogen causes the uterine lining (endometrium) to thicken every month. Soon after, a follicle – a tiny sac in the ovary that contains a single egg (ovum) – ruptures and releases the egg during a process called ovulation. If the egg becomes fertilized by sperm on its way to the uterus, the egg implants in the lining of the uterus. However, if fertilization does not occur, the egg passes through the uterus and out of the body. Shortly thereafter, the uterus releases the lining and the menstrual flow begins.
To help expel its lining, the uterus contracts. These menstrual contractions or cramps can often be painful. For some, the pain or discomfort is minimal. For others, it can be very severe and interfere with everyday activities for a few days every month.
There are two types of menstrual cramps:
Primary dysmenorrhea. Lower abdominal pain that occurs during a woman’s menses and is not associated with any type of physical abnormality or disease. It usually begins within three years of the onset of menstruation (menarche).
In this type of dysmenorrhea, the pain characteristically begins at the start of menstruation and gradually diminishes over two to three days. Usually, the pain is strongest in the abdomen, although some women experience pain in their back or thighs.
Secondary dysmenorrhea. The occurrence of painful menstruation accompanying an underlying health condition such as endometriosis, uterine fibroids or pelvic inflammatory disease (PID).
Women with secondary dysmenorrhea often have symptoms and physical findings that alert the physician to the presence of an underlying pelvic disease. For example, women with severe menstrual cramps due to endometriosis often experience pain that begins mid-cycle and becomes progressively more severe the week before menstruation. It is sometimes accompanied by constipation.
Menstrual cramps are very common and often are not a cause of concern. However, if a woman experiences dysmenorrhea that interferes with daily life for several days a month, or if she is older and is just starting to experience severe menstrual cramps, it is important that she contact a physician, preferably a gynecologist, for an examination.
If left untreated, some of the pelvic conditions associated with secondary dysmenorrhea (e.g., endometriosis, PID) can chronically interfere with daily activities and compromise a woman’s reproductive health, possibly resulting in infertility. Identifying the underlying cause of dysmenorrhea is the first step for successful treatment.
Related symptoms to menstrual cramps
Menstrual cramps are characterized by sharp pains in the lower abdomen that vary in intensity and usually last up to three days after the onset of the menstrual flow.
Along with menstrual cramps, women often experience the following symptoms:
Breast tenderness or pain
Lower back or leg pain
Heavy or prolonged (lasting five days or more) menstrual bleeding
Some women experience more severe menstrual cramps (dysmenorrhea) and related symptoms that last for several days each menstrual cycle. Others experience only minimal discomfort that disappears soon after the onset of the menstrual flow. Some women do not experience any menstrual cramps or discomfort.
Sometimes the painful menstruation is due to an underlying pelvic condition (e.g., endometriosis, fibroids). In such cases, a woman will continue experiencing dysmenorrhea until the cause is treated.
Risk factors and causes of menstrual cramps
Factors that may contribute to severe menstrual cramps (dysmenorrhea) include:
Early onset of puberty (age 11 or younger).
Family history of painful menstrual periods.
Prolonged menstrual periods (lasting five days or longer).
Use of an intrauterine device (IUD). If the menstrual cramps continue after three months or become worse, a woman may need to consider having the IUD removed and choosing another birth control method.
Excessive weight or obesity.
Use of alcohol.
Cigarette smoking.
Stress and anxiety.
History of sexual or physical abuse.
No history of pregnancy.
Prostaglandins are hormone-like substances produced by the tissue that lines a woman’s uterus (endometrium). These chemicals cause many of the symptoms associated with menstrual discomfort.
Prostaglandins trigger the uterine muscle to contract, which helps the uterus expel its lining during the menstrual cycle. The hormones also reduce the blood supply to the uterus and increase the sensitivity of nerve endings to pain. Researchers believe that elevated levels of these substances cause dysmenorrhea.
Menstrual cramps are classified into primary and secondary dysmenorrhea. Primary dysmenorrhea is menstrual pain occurring in the absence of any physical or medical condition. Secondary dysmenorrhea is menstrual cramps caused by an underlying pelvic condition or abnormality.
A number of conditions can cause secondary dysmenorrhea. They include:
Endometriosis. A condition in which the type of tissue that lines a woman’s uterus becomes implanted outside the uterus, most commonly in the fallopian tubes, ovaries or the tissue lining the pelvis. This outside tissue becomes stimulated each month by the hormones and can spread resulting in adhesions and scarring. Though noncancerous, endometriosis can cause chronic pelvic pain and problems with fertility.
Pelvic inflammatory disease (PID). An infection of the female reproductive organs that is sometimes caused by sexually transmitted bacteria. Left untreated or treated too late, PID can damage the reproductive organs, which may make it difficult or impossible for a woman to conceive. PID can also increase the risk of pregnancy complications.
Uterine fibroids. Noncancerous tumors or growths within the lining of the uterus. They range in size from seedlings, undetectable by the human eye, to bulky masses that can distort and enlarge the uterus.
Adenomyosis. In this condition, glands that are normally found in the endometrium penetrate the muscular wall of the uterus. Pain results when displaced glandular tissue develops during a woman’s menstrual cycle and then attempts to slough off during menstruation.
Ovarian cysts. Fluid-filled sacs or pockets within or on the surface of an ovary. They typically occur as the result of ovulation (the release of an egg from the ovary) and are common in women of childbearing age. Most cysts are normal and shrink over time, usually within one to three months.
Abnormal pregnancy, such as an ectopic pregnancy (when a fertilized egg becomes implanted outside the uterus, usually in the fallopian tubes).
Narrow cervix (cervical stenosis). This abnormality may be present at birth or result from the removal of polyps or treatment of a precancerous condition (cervical dysplasia) or cancer of the cervix (cervical cancer).
Most women experience menstrual cramps at some time in their lives. The pelvic pain usually starts within three years of menarche. It may persist until a woman’s 20s or until she delivers a child and, for unknown reasons, may then decrease in intensity.
If the pelvic pain is severe, it may be caused by an underlying condition or abnormality and a woman will continue experiencing painful periods until the cause is treated. A physician, typically a gynecologist, should be consulted to diagnose the cause of the pain and determine appropriate treatment.
Diagnosis of menstrual cramps
Most healthy women experience menstrual cramps during menstruation. However, if the menstrual cramps disrupt daily life for several days a month, or if a woman is older and suddenly starts experiencing painful menstruation, it is important that she see a physician, preferably a gynecologist.
A physician will compile a patient’s medical and menstrual history and perform a physical examination, including a pelvic exam. During the pelvic exam, a physician checks for any abnormalities in the reproductive organs and looks for signs of infection.
To rule out other conditions or identify the underlying cause for the painful menstruation (dysmenorrhea), a physician may recommend diagnostic tests that include:
Blood tests. Laboratory analysis of blood to check for hormone levels or any condition that my affect normal body functions. In addition, if heavy menstrual periods are one of the symptoms, a physician may order a complete blood count (CBC) to determine if iron deficiency (anemia) is present.
Tissue sampling. A physician may perform an endometrial biopsy by removing a sample of cells from the lining of a woman’s uterus for laboratory analysis.
Imaging tests. Noninvasive tests that allow a physician to look for abnormalities inside a woman’s pelvic cavity, such as:
Ultrasounds. Tests that use sound waves to produce images of the shape and outline of various tissues and organs in the body. Ultrasounds can reveal ovarian cysts or abnormalities in a woman’s reproductive system. For a more thorough examination, a physician may order a transvaginal ultrasound.
Computed axial tomography (CAT scan). A test that uses x-rays and computerized technology to create images of organs and bones within the body. The CAT scan may be performed alone or with the use of a special injected contrast dye.
Magnetic resonance imaging (MRI). Noninvasive test that uses powerful magnets to produce images on a computer screen. MRI can help physicians diagnose diseases of numerous organs, tissues and structures.
Hysteroscopy. During this procedure, a physician inserts a viewing instrument through the vagina and cervical canal to examine the cervix and the inside of the uterus.
Hysterosalpingogram. During this procedure, a physician injects a contrast medium (special dye) through a woman’s cervix to highlight the uterine cavity and fallopian tubes for viewing on x-ray images.
Laparoscopy. During this surgical procedure, a physician makes tiny incisions in a woman’s abdomen and inserts a fiber-optic tube with a small camera lens to view the pelvic cavity.
In most cases, menstrual cramps are the result of a normal menstrual cycle and do not require extensive treatment. However, if an underlying condition is diagnosed (e.g., pelvic inflammatory disease or endometriosis), treatment of the condition can often result in the alleviation of the menstrual cramps.
Treatment for menstrual cramps
Over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen or naproxen, usually relieve and/or reduce menstrual pain effectively. In addition, there are a number of OTC products specifically designed for menstrual cramps and discomfort. NSAIDs may be more effective if taken one or two days before a menstrual period begins and continued for a couple of days after it begins. In addition, soaking in a hot bath or using a heating pad on the abdomen can help ease menstrual cramps.
For severe cramps that cannot be relieved with use of NSAIDs or OTC medications, prescription anti-inflammatories (e.g., diclofenac, indomethacin) may alleviate pelvic pain. In addition, birth control pills that contain estrogen in a low dose plus progestin may be prescribed to suppress the release of eggs from the ovaries (ovulation). Currently, there are special (extended-cycle) birth control pills available that reduce the number of menstrual periods to only four a year.
In addition, the Food and Drug Administration (FDA) is currently reviewing another form of oral contraceptive pills that eliminate menstrual cycles altogether. Initial clinical trials have found the new pills to be as effective in preventing pregnancy as other forms of oral contraception as well as helping alleviate symptoms such as severe menstrual cramps, menorrhagia and menstrual migraines. The new extended birth control pills may be available by prescription soon. Patients interested in the new pill should consult with their gynecologist. If these treatments are ineffective for relieving pain, the menstrual symptoms may be caused by an underlying condition or abnormality.
If the pelvic pain is severe (dysmenorrhea) and is caused by an underlying condition, treatment will depend on the cause. For example, treatment could include antibiotics to combat infection for pelvic inflammatory disease or surgery to remove endometriosis lesions, fibroids or polyps. A narrow cervix (cervical stenosis) can be widened surgically if needed. However, this operation usually relieves the pain only temporarily.
Prevention methods for menstrual cramps
Although menstrual cramps are part of a normal menstrual cycle, there are some lifestyle changes that may provide relief and make the pelvic pain and accompanying symptoms less severe. These changes include:
Incorporating a healthy diet and reducing intake of refined sugars, salt, nicotine, caffeine and alcohol, which can aggravate pelvic pain and PMS symptoms (e.g., bloating, acne, depression).
Taking vitamin B6, calcium and magnesium supplements may help alleviate PMS symptoms.
Exercising at least 20 to 30 minutes three times a week.
Getting adequate rest. This can be done by sleeping consistent hours and establishing a bedtime routine to help cue the body and mind for sleeping. In addition, the body is less vulnerable to pain when one is well rested.
Some women find that incorporating stress-relieving activities, such as regular massages, yoga or meditation, may help lessen menstrual pain. In addition, studies sponsored by the National Institutes of Health (NIH) indicate that acupuncture therapy (the ancient Chinese practice of puncturing the body with needles at specific points) may help relieve certain types of pain, including menstrual cramps. Also, there may be other forms of complementary and alternative medicine that may help women with menstruation discomfort.
Yearly check-ups with a gynecologist (GYN) are also recommended for all women to ensure good health and detect any underlying conditions that may be causing severe menstrual cramps (dysmenorrhea).
Questions for your doctor on menstrual cramps
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor or healthcare professional the following questions regarding menstrual pain:
Are menstrual cramps a problem I have to learn to live with every month?
What are the best ways to reduce my discomfort?
When should I begin to be concerned about my menstrual cramps?
How can I tell if there is another condition causing my pain?
Is there anything I can do to prevent dysmenorrhea?
Can my IUD be related to my cramps? If so, what can I use as an alternative method of birth control?
