Period Pain (Dysmenorrhoea)

Who gets painful periods?

Most women have some pain during periods. The pain is often mild, but in about 1 in 10 women the pain is severe enough to affect day-to-day activities. The pain can be so severe that they are unable to go to school or work. In medical terms, period pain is called dysmenorrhoea.

Primary dysmenorrhoea is the most common type of painful periods. This is where there is no underlying problem of the uterus (womb) or pelvis. It often occurs in teenagers and women in their 20s.

Secondary dysmenorrhoea means that the pain is caused by a problem of the uterus or pelvis. This is less common, and is more likely to occur in women in their 30s and 40s.

Primary dysmenorrhoea - the common type of painful periods

What causes the pain of primary dysmenorrhoea?

The cause is not clear. The uterus is normal. What is thought to happen is that normal body chemicals called prostaglandins build up in the lining of the uterus. Prostaglandins help the uterus to squeeze (contract) and shed the lining of the uterus during a period. In women with period pain there seems to be a build-up of too much prostaglandins, or the uterus may be extra sensitive to the prostaglandins. This may cause the uterus to contract too hard, which reduces the blood supply to the uterus. This can lead to pain.

What are the symptoms of primary dysmenorrhoea?

The main symptom is crampy pain in your lower abdomen. Often, the first few periods that you have are painless. Period pains may only develop 6-12 months after you have started your periods. The pain:

• May spread to your lower back, or to the top of your legs.
• Usually starts as the bleeding starts, but it may start up to a day before.
• Usually lasts 12-24 hours, but lasts 2-3 days in some cases.
• Can vary with each period. Some periods are worse than others.
• Tends to become less severe as you get older or after having a baby.

In some women, other symptoms occur during a period in addition to pain. For example: headaches, tiredness, faintness, breast tenderness, feeling sick, bloating, diarrhoea and feeling emotional or tearful.

Note: the following are not symptoms of primary dysmenorrhoea: fever, vaginal discharge, sudden severe abdominal (tummy) pain, pain when you have sex, vaginal bleeding between periods, vaginal bleeding after having sex. You should see your doctor if any of these symptoms develop.

How is primary dysmenorrhoea diagnosed?

In many cases, particularly in teenagers, the symptoms are so typical that primary dysmenorrhoea can be confidently diagnosed by your doctor by asking you about your symptoms. Your doctor will probably also examine the front of your abdomen just to check that it is normal (which it is in primary dysmenorrhoea).

Tests and an internal (pelvic) examination are not normally needed unless symptoms are unusual or not typical and the diagnosis of primary dysmenorrhoea is not certain. That is, if secondary dysmenorrhoea is suspected (see below).

What are the treatment options for primary dysmenorrhoea?

Most women with painful periods have mild pain that they can treat themselves at home. However, if your pain becomes more severe and is interfering with your usual activities, you should see your doctor.

There are a number of treatments that may help if you have primary dysmenorrhoea.

• Warmth: you may find it soothing to hold a hot water bottle against your lower abdomen, or to have a hot bath. The pain often does not last long, and this may be all that you need. (Be careful not to burn yourself with a hot water bottle which is too hot.) A warm bath or shower may also help.
  
  
• Non-steroidal anti-inflammatory painkillers: these can greatly ease the pain in about 8 in 10 cases. They work by blocking the effect of the prostaglandin chemicals that are thought to cause the pain. Also, non-steroidal anti-inflammatories usually reduce the amount of bleeding. There are several types and brands, and most need a prescription. However, you can buy one type (ibuprofen) at pharmacies. Some tips when using an anti-inflammatory include the following:
  • Take the first dose as soon as your pain begins, or as soon as the bleeding starts, whichever comes first. Some doctors advise to start taking the tablets the day before your period is due. This may prevent the pain from building up.
  • Take the tablets regularly, for 2-3 days each period, rather than 'now and then' when pain builds up.
  • Take a strong enough dose. If your pains are not eased, ask your doctor or pharmacist if the dose that you are taking is the maximum allowed. An increase in dose may be all that you need.
  • Some people cannot take non-steroidal anti-inflammatory painkillers. For example, people with a duodenal ulcer, and some people with asthma.
  • Side-effects are uncommon if you take a non-steroidal anti-inflammatory for just a few days at a time, during each period. Read the leaflet that comes with the tablets for a full list of possible side-effects and cautions.
• Paracetamol: this is an alternative painkiller that you can try if you cannot take non-steroidal anti-inflammatory painkillers. Also, paracetamol can be used in combination with a non-steroidal anti-inflammatory painkiller if the anti-inflammatory alone is not enough. Sometimes painkillers containing a combination of codeine and paracetamol may be helpful if paracetamol alone is not enough. Always read the details on the packet so that you do not exceed the maximum daily dose of either painkiller.
  
  
• The combined oral contraceptive pill ('the pill'): this is an option if you also need contraception. Painful or heavy periods are much less likely if you take 'the pill'. This is because the pill causes the lining of the uterus to become thin, and the amount of prostaglandin is much reduced. See separate leaflet called 'Combined Oral Contraceptive Pill' for more detail.
  
  
• The intra-uterine system (IUS): a special intra-uterine contraceptive device called the IUS is an option if you also need long-term contraception. This device slowly releases a progestogen hormone called levonorgestrel. This 'thins' the lining of the uterus. It is a good contraceptive, but also reduces the amount of pain and bleeding during periods. See separate leaflet called 'Intrauterine System' which describes the IUS in more detail.
  
  
• Other progestogen contraceptives: another option if you also need contraception is to try another type of contraception that contains progestogen. Options include Cerazette® contraceptive pill or an injectable progestogen contraceptive such as Depo-Provera®. See separate leaflets called 'Progestogen Only Pill' and 'Contraceptive Injection' which describe these options in more detail.
  
  
• A transcutaneous electrical nerve stimulation (TENS) machine: this can be an option for women who prefer not to use medication. These machines give out a small electrical current. They seem to work by interfering with pain signals which are sent to the brain from the nerves. However, you would normally have to buy a TENS machine, as they are not usually available on the NHS for the treatment of period pain.
  
  
• Other medicines: if all other treatments have failed, then various other medicines are sometimes tried. For example, medicines that prevent ovulation are sometimes used. These are not routine treatments as side-effects can be a problem, and the research evidence to support their use is limited.
  
  
• Alternative medicine treatments: there is not enough evidence so far to support the use of other treatments for painful periods. For example, herbal and dietary supplements, acupuncture, exercise and spinal manipulation. Some small studies have shown that some of these treatments may help but overall, the effectiveness of these treatments is not clear. More studies are needed to help decide if these treatments are helpful or not for painful periods.

Secondary dysmenorrhoea - period pain due to an underlying cause

What causes secondary dysmenorrhoea?

A problem of the uterus (womb) or pelvis sometimes causes painful periods. For example: endometriosis, fibroids, or infection of the uterus and Fallopian tubes (pelvic inflammatory disease). Some types of intrauterine device (IUD; also known as the 'coil') also make painful periods worse in some women.

What are the symptoms of secondary dysmenorrhoea?

Again, the main symptom is crampy lower abdominal pain during your periods. With secondary dysmenorrhoea, your periods tend to become more painful after several years of 'normal' periods (that is, periods with normal, mild, period pains).

The following may indicate secondary dysmenorrhoea:

• If you have a change in your usual pattern of pain. For example, if your periods become more painful than they used to be, or the pain lasts longer than it used to. In some women with secondary dysmenorrhoea the pain starts several days before the period begins, and lasts all the way through the period. (This is uncommon with primary dysmenorrhoea.)
• If you have other symptoms. For example:
  • Irregular periods
  • Bleeding in between periods
  • Pains between periods
  • The bleeding becomes heavier than previously
  • Vaginal discharge
  • Pain during sex

You should see your doctor if you develop any of these problems.

How is secondary dysmenorrhoea diagnosed?

Your doctor will usually examine you if they suspect that you have secondary dysmenorrhoea. This may involve an examination of your abdomen (tummy) as well as an internal examination to check your uterus (womb) and pelvis. The idea is to look for possible causes of your painful periods, such as fibroids in your uterus. Your doctor may also suggest that they take some swabs during the examination to look for any signs of infection.

If your doctor feels that you have secondary dysmenorrhoea, they may suggest that they refer you to a specialist (usually a gynaecologist) for further investigations. The investigations that are carried out depend on the likely underlying problem. They may include an ultrasound scan of your uterus (womb) and pelvis, a hysteroscopy (a telescope examination of the inside of your womb) or a laparoscopy (a telescope examination of the internal organs of your pelvis). See separate leaflet called 'Laparoscopy and Laparoscopic Surgery' for more detail.

What are the treatment options for secondary dysmenorrhoea?

The treatment of secondary dysmenorrhoea depends on the underlying cause. See separate leaflets called 'Endometriosis', 'Fibroids' and 'Pelvic Inflammatory Disease', which describe some of the problems that can cause secondary dysmenorrhoea in more detail. These leaflets also discuss treatment.

If you have an IUD and have painful periods, the treatments for primary dysmenorrhoea (described above) often help. However, some women prefer to have their IUD removed if symptoms do not improve.