There comes that dreadful moment again when everyone around you asks whether you are okay, for your face tells it all. Something is wrong but you want to maintain your composure as much as possible.
Left alone, you may lie on the floor, wobble and cry, for “auntie” has come and did not come in peace. If you haven’t figured it out yet then I am talking about menstrual cramps. Let’s get a better understanding of what actually goes on during this inevitable ‘period’ in most women.
In this post, you will get to understand what causes menstrual cramps, how to treat menstrual cramps and even how to prevent or reduce the pain associated with menstruation.
What are menstrual cramps?
Menstruation is a natural phenomenon and it is an indication of female hormonal and reproductive health. Menstrual cramps, also termed dysmenorrhea, is of Greek origin: dys means painful, meno means monthly and rhoe means flow.
It is experienced as lower abdominal pain or uterine cramps that occur during the few days prior to and/or during menstruation, and usually subsides at the end of menstruation. The pain may radiate to the lower back and thighs and is also associated with nausea, vomiting, insomnia, migraine, dizziness, and rarely, fainting and high fever.
What causes menstrual cramps?
Before we talk about what causes menstrual cramps/dysmenorrhea let’s talk about the types. We have two of them: primary dysmenorrhea and secondary dysmenorrhea.
Is when investigations done (usually ultrasound scan of the abdominopelvic region) reveals the normal structure and function of the reproductive organs. It is thought that the underlying mechanism of this type of dysmenorrhea is the prostaglandin-stimulated contraction of uterine (womb) muscles, which leads to decreased blood flow resulting in low oxygen levels (hypoxia) in the uterus.
The hypoxia then triggers the spasmodic pain described by affected women. Further effects of prostaglandins on smooth muscle may manifest as Gastro-Intestinal symptoms (e.g., nausea, vomiting, diarrhea), which frequently coexist in women with primary dysmenorrhea.
This on the other hand is directly linked to pelvic pathology: loss of structure or function of the organs. Nevertheless, the cause may overlap with that of primary dysmenorrhea. Some common causes of secondary dysmenorrhea are:
i. Endometriosis: presents as pelvic pain or discomfort that gets worse before and during menstruation.
ii. Pelvic Inflammatory Disease: infection of organs in the pelvic region which occurs following untreated sexually transmitted infections or the use of instruments during pelvic examinations. If left unmanaged it may affect fertility.
iii. Adenomyosis: in simple terms, the lining of the uterus grows into the muscles of the same organ. It’s associated with an increase in size of the uterus and heavy vaginal bleeding.
iv. Fibroids: benign overgrowth of the lining of the uterus which was associated with heavy and prolonged bleeding.
Other less common ones are: ovarian torsion and cervical stenosis.
Can menstrual cramps be prevented?
Per the very mechanism by which the pain occurs, you cannot entirely prevent menstrual cramps. However, you can minimize the pain during periods or reduce the frequency of pain episodes. Unless measures or conditions that prevent menstruation altogether such as menopause or removal of the uterus are in place or ongoing.
What activities can help relieve menstrual cramps?
Exercise is the first on the list here. A 45 to 60 minutes session three times a week is recommended especially for women less than 30 years of age as it has been found, as a general benefit, exercise reduces pain and discomfort of dysmenorrhea.
Next is dietary changes. Fruits and vegetables together with a low-fat diet allows reduced production of arachidonic acids: a precursor of prostaglandins.
Smoke cessation and low alcohol consumption has also been found to alleviate the symptoms of dysmenorrhea.
Topical application of heat to the supra pubic area is an effective and natural way of reducing symptoms of dysmenorrhea.
Acupressure and acupuncture, though enough evidence does not exist to recommend, can be an option for those who do not want pharmacotherapy.
How to treat menstrual cramps?
Some medications have been to manage menstrual cramps which include paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), contraceptives and some minerals/supplements.
Paracetamol remains the most used pain medication probably due to its safety profile at therapeutic doses in addition to its affordability. For NSAIDs, there is little evidence as to which is the best, but the most commonly used globally is ibuprofen, naproxen, mefenamic acid and ketoprofen. Pain medications are the first line medicines for managing dysmenorrhea. By inhibiting the enzyme (cyclo-oxygenase) that converts arachidonic acid to prostaglandins, they subsequently decrease uterine contractility and menstrual volume. They are well tolerated but come with GI disorders, nausea and vomiting as side effects.
Hormonal contraceptives suppress ovulation and growth of endometrium thereby reducing menstrual volume and prostaglandin secretion. This leads to reduced uterine contractions and hence reduced cramps. Continuous use of oral combined contraceptives reduces how frequent a woman menstruates thus reduces episodes of dysmenorrhea within a given time.
Progestin-only pills, though not well studied as the combined ones, remain as alternatives with fewer side effects. Long-acting medroxyprogesterone acetate totally suppresses menstruation in most women but has not been used because of its profound effects on the bone (reduces bone density).
Vitamin E reduces the activity of phospholipase A2 and cyclo-oxygenase enzymes with a resultant decrease in prostaglandins levels. This leads to the relaxation of the uterine muscles. Vitamin B1 (thiamine) deficiency causes muscle spasms, reduced pain tolerance, and fatigue, thus thiamine supplements can help reduce dysmenorrhea symptoms as its deficiency may heighten cramps during menstruation.
Low levels of omega 3 fatty acids have been found to be associated with dysmenorrhea. Omega 3 in fish oils, when incorporated into cellular membranes is linked to reduced production of prostaglandins and leukotrienes. Nausea and worsening of acne are common side effects.
Can menstrual cramps lead to infertility?
No it cannot. Primary dysmenorrhea has no effect on fertility. However, the underlying conditions of secondary dysmenorrhea may by itself or as a complication lead to infertility.
For example, pelvic inflammatory disease if left untreated can cause strictures in the fallopian tubes thus a fertilised egg may not reach the womb for normal growth. So, menstrual cramps have no direct way of causing infertility in women.
Do menstrual cramps happen to everyone and why?
We have learnt that menstruation is a natural phenomenon exclusive to women. However, about 50% have dysmenorrhea and 10% out of them have severe symptoms such that their daily routines get interrupted.
Like most conditions, there are factors that increase the risk of having menstrual cramps. Some are;
ii. Drinking during menstruation (alcohol increases duration of cramps)
iv. Having first menses (menarche) before 11 years old
v. Women who have never been pregnant (Cramps reduces in severity after 1st conception and delivery)
Menstrual cramps are common, and almost every woman would have at least an episode in a lifetime during the reproductive age. If it is severe and does not respond to therapy or interrupts daily activities, see your doctor to rule any underlying cause as soon as possible.
- Mayo Clinic (2021). Dysmenorrhea. Available at https://www.mayoclinic.org/diseases-conditions/menstrual-cramps/symptoms-causes/syc-20374938 (Accessed: 21/4/21)
- Johns Hopkins Medicine (2021). Dysmenorrhea. Available at https://www.google.com/amp/s/www.hopkinsmedicine.org/health/conditions-and-diseases/dysmenorrhea%3famp=true (Accessed: 21/4/21)
- Alsaleem, M. A. Dysmenorrhea, associated symptoms, and management among students at King Khalid University, Saudi Arabia: An exploratory study. J Family Med Primary Care. 2018 Jul-Aug 7(4): 769-774
- Iacovides S, Avidon I, Baker FC. What we know about primary dysmenorrhea today: a critical review. Hum Reprod Update. 2015;21(06):762-778.
- Morrow C, Naumburg EH. Dysmenorrhea. Prim Care. 2009;36 (01):19-32
- Gumaraes, I. and Povoa, A. M (2020) Dysmenorrhea: Assessment and Treatment. Available at https://doi.org/10.1055/s-0040-1712131
- American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 110: noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010;115:206-218.
- Marjoribanks J, Ayeleke RO, Farquhar C, et al. Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. Cochrane Database Syst Rev. 2015 Jul 30;(7):CD001751