Painful menstrual periods are periods in which a woman experiences crampy lower abdominal pain, sharp pain that comes and goes, aching pain, or possibly back pain.

Menstruation - painful; Dysmenorrhea; Periods - painful; Cramps - menstrual; Menstrual cramps

Painful menstruation affects many women. For a small number of women, the discomfort makes it difficult to perform normal household, job, or school-related activities for a few days during each menstrual cycle. Painful menstruation is the leading cause of lost time from school and work among women in their teens and 20s.

The pain may begin several days before, or just at the start of your period. It generally lessens as menstrual bleeding tapers off.

Although some pain during menstruation is normal, excessive pain is not. The medical term for excessively painful periods is dysmenorrhea.

Primary dysmenorrhea refers to menstrual pain that occurs around the time that menstrual periods first begin in otherwise healthy young women. This type of pain is usually not related to any specific problems with the uterus or other pelvic organs. Increased activity of the hormone prostaglandin, which is produced in the uterus, is thought to be a factor in primary dysmenorrhea.

Secondary dysmenorrhea is menstrual pain that develops later, after periods have been more normal, and is often related to problems in the uterus or other pelvic organs, such as:

• Endometriosis
• Fibroids
• Intrauterine device (IUD) made of copper
• Ovarian cysts
• Pelvic inflammatory disease
• Premenstrual syndrome (PMS)
• Sexually transmitted diseases
• Stress and anxiety

The following steps may allow you to avoid prescription medications:

• Apply a heating pad to your lower abdomen (below your belly button). Be careful NOT to fall asleep with the heating pad on.
• Do light circular massage with your fingertips around your lower abdomen.
• Drink warm beverages.
• Eat light but frequent meals.
• Follow a diet rich in complex carbohydrates such as whole grains, fruits, and vegetables, but low in salt, sugar, alcohol, and caffeine.
• Keep your legs elevated while lying down, or lie on your side with your knees bent.
• Practice relaxation techniques such as meditation or yoga.
• Try over-the-counter anti-inflammatory medicine, such as ibuprofen. Start taking it the day before your period is expected to start, and continue taking it regularly for the first few days of your period.
• Try vitamin B6, calcium, and magnesium supplements, especially if your pain is from PMS.
• Take warm showers or baths.
• Walk or exercise regularly, including pelvic rocking exercises.
• Lose weight if you are overweight.

If these self-care measures do not work, your doctor may prescribe medications such as:

• Antibiotics
• Antidepressants
• Birth control pills
• Prescription anti-inflammatory medicines such as meclofenamate (Meclomen)
• Prescription pain relievers (including narcotics such as codeine, for brief periods)

Call your doctor right away if:

• Vaginal discharge is increased in amount or is foul-smelling.
• You have a fever.
• Your pain is significant, your period is more than one week late, and you have been sexually active.

Also call your doctor if:

• Self-care measures don't relieve your pain after 3 months.
• You have an IUD that was placed more than 3 months ago.
• You pass blood clots or have other symptoms with the pain.
• Your pain is severe or sudden.
• Your pain occurs at times other than menstruation, begins more than 5 days before your period, or continues after your period is over.

Your doctor will examine you, paying close attention to your pelvis and abdomen, and ask questions about your medical history and current symptoms, such as:

• How old were you when your periods started?
• Have they always been painful? If not, when did the pain begin?
• When in your menstrual cycle do you experience the pain?
• Is the pain sharp, dull, intermittent, constant, aching, or cramping?
• Are you sexually active?
• Do you use birth control? What type?
• When was your last menstrual period?
• Was the flow of your last menstrual period a normal amount for you?
• Do your periods tend to be heavy or prolonged (lasting longer than 5 days)?
• Have you passed blood clots?
• Are your periods generally regular and predictable?
• Do you use tampons with menstruation?
• What have you done to try to relieve the discomfort? How effective was it?
• Does anything make the pain worse?
• Do you have any other symptoms?

Diagnostic tests that may be performed include:

• Blood tests including CBC
• Cultures (may be taken to rule out sexually transmitted diseases such as gonorrhea, primary syphilis, or chlamydia infections)
• Laparoscopy
• Ultrasound

Your health care provider may prescribe birth control pills to relieve menstrual pain. If you don't need them for birth control, you can stop using the pills after 6 to 12 months. Many women continue to have symptom relief even after stopping the medication.

Surgery may be necessary for women who are unable to get enough pain relief or pain control. Procedures may range from removal of cysts, polyps, adhesions, endometriosis, or fibroids to a complete hysterectomy.

Prescription medications may be used for endometriosis.

For pain caused by an IUD, your doctor may recommend:

• Waiting until the end of the first year of use. Painful periods go away in many women during this time.
• Have the IUD removed and use alternative birth control methods.
• Change to an IUD that contains progesterone, which usually makes the periods lighter and less painful.

French L. Dysmenorrhea. Am Fam Physician. 2005;71(2):285-291.

Harel Z. Dysmenorrhea in adolescents and young adults: etiology and management. J Pediatr Adolesc Gynecol. 2006;19:363-371.

Lentz GM. Primary and secondary dysmenorrhea, premenstrual syndrome, and premenstrual dysphoric disorder: Etiology, diagnosis, management. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier;2007:chap 36.