Menstrual
cramps are a very common problem for adolescent girls and
women. They may be mild, moderate, or very severe. In fact,
they are the single most common cause of days missed from
school and work. About ten percent of girls are incapacitated
for up to three days each month.
What
are cramps? About
80 percent of the time, cramps are part of the primary dysmenorrhea
syndrome. Cramps are caused by hormones called prostaglandins,
which cause painful cramping of the uterus during menstruation.
The production of prostaglandins in the uterus is stimulated
by the hormone progesterone, which is made by the ovary
after ovulation has occurred. These prostaglandins can affect
other organs as well. Frequently, back pain, headaches,
nausea and vomiting, dizziness, and/or diarrhea accompany
menstrual cramps. These symptoms may begin a day or so before
the menstrual flow begins; they usually peak by the second
day of flow. Medications
are the single best treatment for cramps. Other remedies
are helpful also. I’ll discuss both in the following
sections.
Medications
for Treating Cramps
Many teens and women do not realize that there are very
effective medications that can relieve not only menstrual
cramps, but also the other symptoms that may accompany them.
Generally these medications fall in the category of nonsteroidal
anti-inflammatory drugs (NSAIDs), such as ibuprofen. Some
NSAIDs are available in both non-prescription strength (over-the-counter,
or OTC) and in larger doses by prescription only. Other
NSAIDs are only available by prescription.For some girls,
cramps begin a day or so before their period starts; girls
may also notice signs that their period is coming, such
as abdominal bloating or constipation. In this case, it
can be very helpful to begin taking the medication before
the period actually begins.
For
mild cramps, I recommend starting with acetaminophen
or ibuprofen at the lower dose, at the lower number of daily
doses. Acetaminophen is not an NSAID but is a pain reliever.
It works well for some women. Increase as needed to the
maximum dosage and frequency indicated in Table I (and on
the bottle); if relief is not achieved, switch to a different
medication at the higher dosage and frequency.
For
moderate to severe cramps, I recommend starting
with ibuprofen 200 milligrams four times daily or naproxen
sodium 220 milligrams twice daily. Again, increase as needed
to the maximum dosage and frequency. If cramps are moderate
or severe, it is also important to continue taking the pain
reliever regularly, even if there is no pain when the dosage
is due. The regimen should be continued until the day when
symptoms would subside, which is usually by the third day
of the menstrual period. If ibuprofen or naproxen sodium
at the maximum daily dose does not relieve symptoms adequately,
it’s time to contact your health care provider. Also,
there are prescription-only medications that are especially
effective against the other problems such as nausea, vomiting,
and diarrhea. Don’t give up hope. Under medical supervision,
higher doses and other medications are safe and effective
Practical
Suggestions for Medications: Since
many schools restrict access to medications and because
it is simply more often recommend that patients select medications
that can be administered three times a day or less. Take
the first dose in the morning, the second right after school,
and the third about eight hours later. I
recommend taking any of these medications with a meal or
small snack and a glass of milk, juice, or other liquid.
Rarely, a large tablet or capsule may have trouble making
its way all the way down the esophagus; the liquid helps
wash it down. Review the package directions and warnings
carefully, and heed them. Do not take one of the listed
drugs together with another one on the list, or with any
other NSAID. A girl taking any medication on a daily basis
should check with her doctor before starting any of these
medications. Sometimes, though, more help is needed for
primary dysmenorrhea than just NSAIDs. Of the prescription-only
NSAIDs, I find mefenamic acid (Ponstel ®) to be especially
useful. It not only works to eliminate cramps, but it can
really help with diarrhea, nausea, and vomiting.
What
if Pain Medications Don’t Work?
I
generally work with patients to adjust NSAID treatment regimens
for three to six months. Occasionally, we find that even
the highest-strength prescription regimens still don’t
help. Before changing to other medications, I schedule a
pelvic examination to evaluate for other, far less common
causes of menstrual cramps. If one of these causes exists,
the dysmenorrhea is referred to as secondary dysmenorrhea.
Causes of secondary dysmenorrhea include infection in the
genital tract, a narrow passageway connecting the inside
of the uterus to the vagina (the cervical canal), and endometriosis.Endometriosis
is a condition in which nodules (bumps) of tissue just like
the lining of the uterus are found on internal organs in
the lower abdomen. It can cause very severe, debilitating
pain that is not necessarily limited to the menstrual period.
Sometimes the tissue nodules can be found during careful
pelvic examination. Under these circumstances, I also need
to insert a gloved finger into the patient's rectum during
the examination.
Hormonal
Treatment for Period Cramps:
Assuming the pelvic examination is normal and I don't suspect
endometriosis or another condition, I recommend adding hormonal
treatment for girls with severe dysmenorrhea that has not
responded to NSAIDs alone. The hormones prevent ovulation,
and thus prevent the ovary from causing the production of
the pain-causing prostaglandins. As you probably know, the
oral contraceptive pill (OCP) prevents ovulation. And this
is the easiest, least expensive way to use hormones to treat
severe primary dysmenorrhea. OCPs are 80 percent to 90 percent
effective when used for this purpose.
The
Pill -- Once
in a while, a parent asks me, “Won’t Ashley think
that if she's taking the pill, it's license to have sex?”
In one sense, the answer might be yes. Not knowing how to
get the pill does indeed prevent some careful teenagers
from having sexual intercourse. Therefore, I suppose that
occasionally a girl who has not had sex because of this
concern might start having sex if she were put on the pill
for medical reasons. However, most teenagers know that condoms
alone are very effective in preventing pregnancy and many
sexually transmitted infections. In other words, any concern
over the absence of the added protection provided by the
pill will not discourage most teens from engaging in sex
if they so desire.
Natural
Remedies for Cramps
- Menstrual cramps have been around for thousands of years,
and so have many non-medical treatments. I recommend that
nonmedical remedies be used in addition to the pain medications
described above. Rest and stress reduction Like many other
conditions, cramps may be made worse by fatigue from too
many late nights and by anxiety. So, getting enough rest
before a period is due can actually help prevent bad cramps.
Heat,
in the form of a warm bath or a heating pad applied to the
lower abdomen, can be very helpful (and comforting).
Exercise
-- A
girl who exercises regularly, and who feels up to it despite
having cramps, may find that continued participation in
her usual activities helps relieve the cramps. I encourage
my patients to continue their daily routine during their
period as much as possible.
Bed
rest is not a documented remedy for cramps; some
doctors believe instead that walking about helps expel the
menstrual products, and the prostaglandins they contain,
from the uterus. Additionally, anxiety generally increases
as a girl worries about making up missed school assignments.
On the other hand, cramps are occasionally truly incapacitating,
and trying to force a “stiff upper lip” won’t
help.
Self-Massage is often useful
with Dysmenorrhea, see the abdomen section of that article.
For more on PMS, go there...
See Abdominal Pain, if you
think it is not menstrual pain, or call your health care
provider.
You may want to try aromatherapy too, it works for many people.
Many
teens don't suffer from dysmenorrhea, as their uterus is still
growing, and yet they may get it several years after their first
period begins. Symptoms may begin one to two days before menses,
peak on the first day of flow, and subside during that day or
over several days.The
pain is typically described as dull, aching, cramping and often
radiates to the lower back. The pain from your period that is
severe enough to be given this name by your health care provider
is thought to be the result of uterine contractions, caused
by prostaglandins (a hormone-like substance, normally found
in your body). Prostaglandins are known to stimulate uterine
contractions. In addition to pain other symptoms may include,
There
are many over-the-counter drugs NSAIDs -- (ibupofen and naproxen),
and acetaminophen that may provide relief. A heating pad works
well for cramps when used OTC pain meds. Some women benefit
from exercise, some from rest. There are also prescription
drugs to help alleviate this painful disorder. Talk to your
health care provider about them. Before you diagnose yourself,
see your health care provider to be sure the pain you are
having is not associated with another condition like