Understanding
Primary Dysmenorrhoea

What is primary dysmenorrhoea?

Primary dysmenorrhoea is a cramping or throbbing pain in the lower abdomen area that typically occurs with the onset of menstruation and that lasts for about one to three days. With primary dysmenorrhoea, there is no identifiable underlying condition, and this distinguishes it from secondary dysmenorrhoea which is secondary (or due) to another condition.

Primary dysmenorrhoea is by far the most common gynaecological problem in menstruating women with a reported prevalence as high as 90%.  It is a recurrent problem, but the pain may become less severe with increasing age and may stop after having given birth.

How do you know you have primary dysmenorrhoea?

Primary dysmenorrhoea typically arises for the first time during the teenage years – mostly within three years of the first menstruation (which is known as the menarche). It is unusual for primary dysmenorrhoea to occur within the first six months after menarche.

The following characteristics describe the typical pain of primary dysmenorrhoea:

  • Sharp, throbbing, or intermittent spasms of pain usually centred in the lower stomach area above the pubic bone.
  • The pain may start one to three days before menstruation; usually peaks 24 hours after the onset of menstruation and subsides over the next two to three days.
  • Pain in the hips, lower back and inner thighs
  • The pain may spread to the hips, lower back and inner thighs.

 

Additional symptoms may include:

  • Nausea or vomiting
  • Loose stools (diarrhoea)
  • Fatigue
  • Fever
  • Headache
  • Light-headedness

Some women experience mild pain, while for others, the menstrual cramps or period pains are the leading cause of absenteeism in American women younger than 30 years of age.

Pain from secondary dysmenorrhoea (in other words pain due to an underlying condition or problem) usually starts earlier in the menstrual cycle and tend to last longer than pain from primary dysmenorrhoea.

When to see a doctor

Patients are advised to contact their doctor if:

  1. The pain is so bad that it disrupts life every month.
  2. The symptoms are progressively getting worse.
  3. Severe menstrual cramping only started after age 25.
  4. The pain is suddenly worse or different, or it lasts for more than usual.
  5. Bleeding is excessive (much more than usual).
  6. There are signs of infection, such as chills and fever, body aches.
  7. They suspect they might be pregnant.

 

The following symptoms are serious and require immediate medical attention:

  1. Fainting or dizziness when standing up
  2. A sudden, intense pain that causes doubling over
  3. Tissue (which may look silvery or grey) is present in the menstrual fluid
  4. Pain resembling menstrual cramping during pregnancy.

What causes primary dysmenorrhoea?

Prostaglandins in the womb (uterus), particularly prostaglandin F2α (PGF – pronounced prostaglandin F-two-alpha), have been identified as the causative or contributory agents. Prostaglandins are fatty compounds found in almost every tissue in the human body and they play an important role in inflammation. During menstruation, the disintegrating lining of the womb releases PGF. PGF then stimulates contractions of the muscle fibres in the wall of the womb (to help dispel the lining). Apart from causing these muscle contractions, PGF may also sensitise nerve endings.  Clinical research has shown that women with more severe dysmenorrhoea have higher levels of PGF in their menstrual fluid and that these levels peak during the first two days of menstruation. The theory behind prostaglandins being the causative agents is further supported by the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) in treating dysmenorrhoea. NSAIDs inhibit prostaglandin synthesis.

Risk factors

There is some evidence to link the following risk factors with more severe episodes of dysmenorrhoea:

  • Earlier age at first menstruation (menarche) – 11 years or younger
  • Long menstrual periods
  • Heavily bleeding during menstrual periods (known as menorrhagia)
  • Irregular menstrual bleeding (known as metrorrhagia)
  • A family history of primary dysmenorrhoea
  • Never having been pregnant
  • Smoking

How is the diagnosis made?

The diagnosis is mostly made by obtaining a thorough medical history and performing a physical examination. The physical examination will include a pelvic examination during which the reproductive organs are evaluated for signs of infection or other abnormalities.  In some instances, especially if it is suspected that there may be an underlying condition responsible for the symptoms, it may be necessary to do an ultrasound (or sonar), other imaging studies (such as scans) or a laparoscopy (key-hole surgery).

What treatment is available for primary dysmenorrhoea?

NSAIDs (such as diclofenac, ibuprofen, etoricoxib, and others) are the mainstay of treatment for primary dysmenorrhoea. The majority of women (between 64 and 100 %) will experience successful pain relief following use of one of these agents. These medicines inhibit prostaglandin synthesis and their release. Prostaglandins are responsible for the painful cramps of primary dysmenorrhoea but may also cause other symptoms such as nausea and diarrhoea.

For patients who do not adequately respond to treatment with NSAIDs, oral contraceptives can be prescribed, especially if birth control is also desired. Oral contraceptives provide relief from painful menstruation by reducing the volume of menstrual fluid and by suppressing ovulation. While oral contraceptives are effective in approximately 90% of women with primary dysmenorrhoea, it is important to note that they may take up to three cycles to provide the desired outcome. During this time, they can be successfully combined with NSAIDs.

For women who do not respond to the above treatment options, it becomes increasingly important to rule out secondary causes of painful menstruation, such as endometriosis or pelvic inflammatory disease. Although not properly understood, approximately 10% of women with primary dysmenorrhoea will not respond to treatment with NSAIDs or oral contraceptives and for them (as well as for those with contraindications to the use of these medicines) the following alternative options may provide relief:

  • TENS (transcutaneous electrical nerve stimulation) where electrodes on the skin deliver electrical current in varying levels to stimulate nerves and ease pain.
  • Laparoscopy (key-hole surgery) to the nerve plexus in the pelvis to prevent conduction of painful stimuli to the brain.
  • Acupuncture
  • Omega-3 fatty acids
  • Thiamine (vitamin B1)
  • Magnesium

These alternative treatment options provide varying degrees of relief from primary dysmenorrhoea.

 

Living and managing

When suffering from primary dysmenorrhoea, it is important to get enough sleep and to rest. Other recommendations include:

  • Regular exercise – some women experience relief from painful menstrual cramps with physical activity (including sexual intercourse)
  • Application of heat – a hot water bottle, heating pad or heat patch may also ease discomfort and pain
  • Dietary supplements – as mentioned above, omega-3 fatty acids, thiamine (vitamin B1), vitamin B6, and magnesium supplements may also prove beneficial
  • Reduce stress – psychological stress may increase the severity of menstrual cramps
  • Avoid caffeine, smoking, and alcohol
  • Massage the lower back and abdomen.

What to eat

It is always important to eat a healthy, balanced diet and to drink plenty of water. Ensuring that the body is well hydrated actually keeps it from retaining water and may thus help to reduce period-related bloating.

When suffering from painful menstrual periods, some foods may help to improve the condition, because they contain certain ingredients that have been shown to benefit people with primary dysmenorrhoea.

Examples of such foods include:

  1. Salmon or other cold-water fish (e.g., sardine, cod, herring or canned, light tuna) rich in omega-3 fatty acids as the latter may help to reduce inflammation linked to period pain.
  2. Red meat, or alternatively kale, spinach, or other leafy green vegetables that will help to offset iron lost in the menstrual fluid.
  3. Oats, dark chocolate, or other foods rich in magnesium (e.g., seeds, nuts, dry beans, whole grain) – magnesium relaxes blood vessels and may help to reduce painful menstrual cramps in this manner.
  4. Lettuce, celery, cucumbers, watermelon, berries, or other fruits and vegetables with a high water content to assist with adequate hydration.
  5. Foods rich in vitamin D and calcium (dairy products such as milk, cheese and yoghurt) since calcium may also alleviate period pain.
  6. Foods rich in vitamin B6 (such as bananas, poultry, peanuts, soya beans, or eggs), since vitamin B6 may help to reduce breast tenderness and irritability that may accompany period pain.
  7. Chamomile tea because of its calmative properties and ability to help reduce muscle cramps.

 

Best advice for women suffering from painful menstrual periods is to talk to their doctor about it.  Although it cannot be cured, it can be successfully treated and does not have to be endured.

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