The main causes of primary dysmenorrhea are prostaglandins, produced by the uterine lining after ovulation toward the time of the menstrual period. These hormones stimulate the contraction of smooth muscle, including the muscular walls of the uterus. Some women produce more prostaglandins than others do, and this overproduction causes not only menstrual cramps but also the headaches, nausea, and other symptoms that sometimes accompany the abdominal pain.

Before the discovery of prostaglandins, researchers offered several theories to explain menstrual pain. One was that menstrual cramps were all in your mind. Another hypothesis suggested that dysmenorrhea was caused by narrowing of the cervix: because the menstrual flow could not easily escape through this constricted opening, the uterus contracted to help get rid of it. For that reason one of the early treatments for menstrual pain was a D&C, during which the cervix was mechanically dilated and the uterine lining scraped out.

Although physicians no longer believe that cramps are imaginary, menstrual cramps like any other pain can have a psychological component. If you expect something to be painful, it may well be so. If a girl sees her mother lying in bed two or three days a month, complaining of “the curse” and its “terrible pain,” the daughter may tend to repeat the pattern. Mothers can do their daughters a favor by encouraging a positive attitude toward this normal function.

A few teenagers have psychological issues surrounding menstruation. Counseling can help a young woman who has a phobia about bleeding, an aversion to her developing body, or problems with becoming a woman.

What can you do to relieve menstrual cramps?

The best drugs for menstrual cramps are prostaglandin synthetase inhibitors. As the name suggests, these drugs block the body’s production of prostaglandins. They are also called nonsteroidal anti-inflammatory drugs pronounced enseds and are used to treat arthritis, tendonitis, gout, and other inflammatory diseases. We know them in the drugstore as Advil, Aleve, Anaprox, Motrin, and Naprosyn, among others. Aspirin, the first common nonsteroidal anti-inflammatory drug, was used even before scientists knew why it worked, but the newer drugs are often more effective. When I was in medical school thirty years ago, Motrin was a relative newcomer, available only by prescription. We considered it a miracle drug, because it relieved menstrual pain so effectively.

The first rule with nonsteroidal anti-inflammatory drugs is, Take them early. Don’t be a John Wayne type, strong and silent, until you can’t stand the pain any longer. nonsteroidal anti-inflammatory drugs will stop the production of more prostaglandins, but they won’t do anything about the prostaglandins currently at work in your pelvis. Once your body produces prostaglandins, you have to wait until the normal metabolic processes break them down to get relief. If you have a regular cycle and can predict when your period will start, you can take prostaglandin inhibitors ahead of time, maybe a day before your period begins, and shut down prostaglandin production before the pain begins. The second important rule is, Take nonsteroidal anti-inflammatory drugs with food or milk. They are hard on the lining of your stomach and may cause nausea or stomach pain.

You are not harming yourself by depriving your body of prostaglandins for a couple of days a month. Their only real use is in starting the contractions of labor. And you need not worry that taking nonsteroidal anti-inflammatory drugs during your periods will keep you from having a normal pattern of labor when or if you start your family. Your body keeps on making prostaglandins, so they are always available when you need them (and sometimes when you do not).

A second line of attack on dysmenorrhea caused by prostaglandins is birth control pills. They suppress ovulation, and in menstrual cycles without ovulation, not much prostaglandin is produced.

Some mothers are concerned that when I prescribe birth control pills for their daughters’ cramps, I am giving license for intercourse. That is not my intention at all. The issue of when it is appropriate to become sexually active depends on moral, social, and religious factors as well as physical ones, and these factors are beyond the scope of my role as physician. I am simply treating a young woman for a medical condition, just as I would give her penicillin if she needed an antibiotic. So it is important that there be an open relationship between mother and daughter, or within the family, and a mutual understanding of shared values.

If you are taking birth control pills, remember that while they will prevent pregnancy they will do nothing to protect against sexually transmitted diseases, including herpes, the condyloma virus, and Acquired immunodeficiency syndrome. If you use birth control pills, you must also practice safe sex, which means using condoms, unless both you and your partner are monogamous.

You can stay on the pill as long as you wish. It is fine if you want to stop in six months or a year and see how you feel. If you then have no pain and do not feel like going back on the pill, that is fine. If you want to resume taking the pill, that is also fine. There is nothing wrong with going off and on the pill, as long as you use other forms of contraception when the pill is not protecting you from pregnancy.

Are nonsteroidal anti-inflammatory drugs safe?

Individuals who must take nonsteroidal anti-inflammatory drugs daily for long periods (for example, people with arthritis) can develop stomach ulcers or kidney problems. Some physicians are so concerned about these potential side effects that they discourage nonsteroidal anti-inflammatory drug use for menstrual cramps. But if you take nonsteroidal anti-inflammatory drugs in moderation — for only the first few days of your period — and with food, you should have no trouble. Do not take nonsteroidal anti-inflammatory drugs if aspirin or some other anti-inflammatory has given you asthma.

What is the standard dosage for anti-inflammatories?

Most over-the-counter ibuprofen tablets come as 200-mg tablets, though you can get them in dosages of 400-600 mg. The standard dosage for prescription Motrin is 600 mg (three 200-mg tablets) every six hours. If you are taking one Advil and it does not help, try two or three — but take them with food or milk and use them short term. Some anti-inflammatories, Advil and Naprosyn for example, come in liquid form for those who cannot swallow pills.

Anti-inflammatories come in a range of strengths, the stronger ones available only by prescription. Tylenol and aspirin are probably the mildest. Next in strength I would rate ibuprofen (Advil or Motrin); then come naproxen (Naprosyn, Aleve, and Anaprox), in-domethacin (Indocin), and finally ketoralac (Toradol), the most potent of all.

Is it all right to take both anti-inflammatory medications and birth control pills for menstrual pain?

If you get some relief from taking birth control pills but are still uncomfortable, you can try Motrin or some other nonsteroidal anti-inflammatory drug as well. The two medications are totally different and do not interfere with each other.

Does exercise help with menstrual cramps?

Exercise can be very beneficial for menstrual cramps and is in fact one of the most important things you can do to promote your own general physical and mental health. Research has shown that female athletes of whatever weight, not just lean long-distance runners, have less menstrual pain than women who do not exercise. You do not have to become a marathoner, as one of my patients did, to deal with menstrual discomforts, but you do need to get regular exercise — running, walking, aerobics, or whatever appeals to you.

Are there alternative treatments that help with menstrual pain?

Some women find that fish-oil supplements help. Fish oil has been shown to be effective in treating rheumatoid arthritis and seems to have anti-inflammatory properties. It does not seem to have adverse effects, and while you must take a great deal of it (eating salmon, mackerel, sardines, or other oily fish three times a week or swallowing 10-18 gm in fish-oil capsules), you are unlikely to overdose.

There are also herbal and folk remedies, most of which have not been tested scientifically. Raspberry tea is one traditional herbal remedy for cramps. While no clinical studies have discovered a chemical agent that relaxes the smooth muscles of the uterus, raspberry-leaf tea has long been considered useful for expectant mothers as well as menstruating women. When you buy raspberry tea, be sure you get the kind made from the leaves of the raspberry plant, not just tea infused with raspberry oil to give it a fragrant aroma. Herbalists sometimes recommend peppermint tea for menstrual cramps, though it is usually used to treat indigestion. Peppermint leaves seem to have an antispasmodic effect, at least in the upper digestive tract, which may account for the popularity of peppermint tea in treating cramps.

Herbal products, like prescriptions you buy at the drugstore, contain chemicals that may have significant side effects; they may cause interactions with other drugs or withdrawal symptoms. If you use these products, tell your doctor what you are taking. Because herbal medicines are not tested for safety by the FDA and are not offered in standard dosages, you may not know how much you are getting or even, in some cases, what you are getting.

Acupuncture, often used to control other kinds of pain, has been found to help women with menstrual cramps. It maybe effective in controlling pain through a connection with endorphins, natural narcotic-like substances produced by the brain.

Another home remedy is alcohol. When your grandmother had cramps, she perhaps took a shot of brandy and went to bed. Alcohol works because it is a smooth-muscle relaxant, so effective that in the old days doctors gave alcohol intravenously to stop premature labor. While a little alcohol at bedtime does relax you, you should not take alcohol in the morning if you have to go to work, and you should be sure not to overdo whenever you take it.

Are narcotic pain relievers useful for menstrual pain?

Occasionally I prescribe codeine for women who have prostaglandin-caused menstrual pain if they cannot tolerate ibuprofen or other nonsteroidal anti-inflammatory drugs. Some women take two or three codeine pills a month during the first days of their period so that they can sleep at night. Narcotics are very high risk drugs, and like other physicians I am aware of the possibility of addiction or abuse. I try to have the kind of relationships with my patients whereby I know who is vulnerable, and I prescribe them only to patients who are not.

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