Menstrual cramps, or dysmenorrhea (as physicians call it), are one of the most common healthcare problems that women suffer during their reproductive years. It has been estimated that as many as 30 to 50 percent of all women suffer from pain during their menstrual period, with the incidence being highest in younger women, from teenagers to women in their thirties.
In fact, at least 10 percent of younger women have symptoms so severe that they are unable to handle their normal range of activities. Many women have to miss days of work and important social functions because any movement or activity is too painful. For the first day or two of menstruation, only bed rest or curling up on the floor in the fetal position is tolerable until the symptoms finally pass. This often happened to me during my teens and twenties.
Besides the lower abdominal pain, cramp sufferers can also experience backache, pinching and pain sensations in their inner thighs, bloating, nausea, vomiting, diarrhea, constipation, faintness, dizziness, fatigue, and headaches. For those women who must curtail their activities because of cramps, these problems translate into billions of dollars of lost wages and productivity on the job, as well as a significant decrease in the quality of life for several days each month.
In fact, the gynecology textbook that I used during my medical training estimated that menstrual cramps caused the loss of 140 million work hours annually. It is no wonder that women with moderate to severe cramps regard their monthly period with apprehension and even dread.
Despite the many symptoms and the millions of sufferers, menstrual cramps have been traditionally considered by the medical community to be a “minor” female ailment. Doctors treated women as if the problem were “all in their heads.” The problem was either ignored or else treated with powerful painkilling drugs and tranquilizers. Often these drugs had significant side effects and did nothing to alleviate or help prevent the problem on a long term basis. Luckily, the medical community’s interest in menstrual cramps has increased during the past two decades. Researchers understand much more about what causes menstrual cramps on a physiological basis. This has led to newer, much more effective drug treatments, as well as nutritional and other lifestyle related therapies.
The Normal Menstrual Cycle
It is important to look at the normal menstrual cycle and see how it functions. This background will make it easier for you to understand why painful menstruation occurs.
First, understand why we menstruate. Menstruation refers to the shedding of the uterine lining, or endometrium. Each month the uterus prepares a thick, blood-rich cushion to nourish and house a fertilized egg. If pregnancy doesn’t occur and the egg doesn’t implant in the uterus, then the body doesn’t need this extra buildup of the uterine lining. The uterus cleanses itself by releasing the extra blood and tissue so that a fresh buildup can occur all over again the following month, in preparation for a possible pregnancy.
The mechanism that regulates the buildup and shedding of the uterine lining is controlled by fluctuations in your hormonal levels. It begins each month when follicle stimulating hormones (FSH) and luteinizing hormones (LH) are released from the pituitary, a gland located at the base of the brain. Once FSH and LH are released into the bloodstream, their destination is the ovaries. The ovaries hold all the eggs a woman will ever have, in an inactive form called follicles. During each cycle, the FSH and LH from the pituitary gland cause one follicle to ripen, and normally one egg is released for possible fertilization. As part of this pro-cess, the follicles begin to produce the hormones estrogen and progesterone. Estrogen reaches its peak during the first half of the cycle as the newly released egg is maturing. Progesterone output occurs after midcycle when ovulation has occurred. Ovulation refers to the production of a mature egg cell.
Besides preparing the egg for fertilization, estrogen and progesterone stimulate the lining of the uterus. During the first two weeks following menstruation, estrogen causes the uterine lining to gradually rebuild itself. The inner mucous layer of glands of the endometrium begin to grow long, and the lining thickens through an increase in the number of blood vessels as well as the production of a mesh of fibers that interconnect throughout the lining. By midcycle, the lining of the uterus has increased three times in thickness and has a greatly increased blood supply.
After midcycle, usually around day 14, ovulation occurs; the egg is picked up by the fallopian tube and continues on to the uterus. The follicle that has produced the egg for that month (graafian follicle) is further stimulated after midcycle by LH and changes into a yellow body, or corpus luteum. It is the corpus luteum that secretes progesterone. Progesterone has further effects on the uterine lining. It causes a coiling of the blood vessels of the lining, which becomes swollen and tortuous and secretes a thick mucous.
If the egg is fertilized, it will implant on the uterine wall and the corpus luteum will continue to secrete progesterone. If no fertilization occurs, the corpus luteum begins to deteriorate and the progesterone levels decrease. The lining of the uterus starts to break down and menstruation begins.
Types and Causes of Menstrual Cramps
There are two types of menstrual cramps: primary dysmenorrhea, in which the pain itself is the main problem; and secondary dysmenorrhea, in which the pain is a consequence of another underlying health problem.
By far the most women suffer from the primary type of dysmenorrhea. This classification breaks down into two subtypes: primary spasmodic or congestive. Primary spasmodic dysmenorrhea is the type most commonly found in young women in their early teens to late twenties. It is more common in women who have never borne children. In fact, childbearing seems to mark the end of the primary spasmodic type of cramps in many women. It is characterized by sharp, viselike pains that are caused by a constriction and tightening of the uterine muscle. Some women also feel these sharp pains in the inner thighs and low abdominal muscles, and some additionally experience feelings of hot and cold, faintness to the point of passing out, nausea, vomiting, and bowel changes varying from constipation to diarrhea. The immediate cause of the cramping is that the uterine muscle and the blood vessels that supply the uterus are tight and contracted. Blood circulation and oxygenation to this area are diminished, so the metabolism of the uterus and pelvic muscles is decreased. Waste products of metabolism, such as carbon dioxide and lactic acid, build up, intensifying the pain and discomfort.
Primary spasmodic dysmenorrhea has been linked to imbalances in the intricate hormonal system that operates throughout the menstrual cycle. First, medical researchers observed that women who don’t ovulate, and consequently undergo only the estrogenic effects on the lining of the uterus, do not experience cramps. Therefore, progesterone needs to be present for menstrual cramps to occur. When cramps occur, the changes seen in the lining of the uterus are typical of those occurring during an ovulatory cycle when progesterone is present. Pain-free menses without ovulation are typically seen in women at both the beginning and end of their reproductive years, that is, in young teenagers who have just started to menstruate and in women who are transitioning into menopause. There is no evidence, however, that women with cramps actually have low levels of estrogen, or conversely, high levels of progesterone. It may be the interplay between the two hormones that influences the tension and constriction in the uter-ine muscle and blood vessels.
In addition to the hormones estrogen and progesterone, hormonelike chemicals called prostaglandins also affect menstrual cramps. These chemicals are found in many tissues in the body, including the uterus, gastrointestinal tract, and blood vessels. There are many different types of prostaglandins, all of which affect muscle tension. However, not all prostaglandins affect muscles in the same way. Some, such as the series two prostaglandins (specifically the E2 and F2 Alpha), trigger powerful smooth muscle contractions. Because of this physiological effect, an overabundance of series two prostaglandins is strongly linked to menstrual cramps and pain. These prostaglandins have also been linked to high blood pressure because they act to narrow the diameter of blood vessels. They can also trigger irritable bowel syndrome since they cause cramping of the intestinal muscles. Not all prostaglandins, however, cause muscle contraction. Others, such as the series-one and series three, actually promote muscle relaxation and can help relieve menstrual cramps.
Prostaglandins are derived from fatty acids in the diet. The series two prostaglandins that trigger muscle contractions are derived from animal fat meat, dairy products, and eggs. The beneficial muscle relaxant series one and series three prostaglandins are derived from vegetable and fish sources of fatty acids. These fatty acids, called linoleic acid and linolenic acid, are found predominately in raw seeds and nuts, such as flax seed or pumpkin seed, and in certain fish, such as trout, mackerel, and salmon. Thus, how we eat can actually determine which hormonal pathway we travel, leading to either muscle tension or muscle relaxation. This is a very good example of how our food selection can determine our state of health. Like progesterone, excessive prostaglandin production is seen only during ovulatory menstrual cycles. Prostaglandin production increases during the second half of the cycle, peaking toward the end of the cycle with the onset of menstruation.
The pain that characterizes primary congestive dysmenorrhea is different from that of spasmodic cramping. Congestive symptoms produce a dull aching in the low back and pelvic region, often accompanied by bloating, weight gain, breast tenderness, head-aches, and irritability. Unlike spasmodic cramping, these symptoms don’t improve with age and, in some women, can worsen with age. Some of the worst symptoms are seen in women in their thirties and forties.
Women with congestive symptoms tend to retain excessive amounts of fluid and salt. Bloat accumulates in the pelvic region as well as breasts; it can cause an uncomfortable, dull aching sensation that makes these parts of the body tender to the touch. Excessive amounts of estrogen can worsen these symptoms, since estrogen increases fluid and salt retention in the body.
An excess secretion of the pituitary hormone ACTH can also worsen congestive symptoms. ACTH stimulates the production of adrenal hormones, which are then sent to the kidneys and cause the kidneys to retain fluid. As a result, women urinate less frequently in the time leading up to menstruation. Once the menstrual period starts, this excess fluid is released. Nutritional factors also influence bloating. High salt foods should be avoided, since they increase fluid retention.
Food allergies can also contribute to congestive symptoms. Women who are sensitive to both wheat and dairy products (two of the most allergenic foods) can have a premature increase in their congestive symptoms. I have observed this in many of my patients. Other high stress foods include alcohol, which is toxic to the liver. The liver is responsible for the breakdown of estrogen so that it can be excreted from the body. Excessive alcohol intake can increase the levels of estrogen in the body, increasing pelvic congestion. Sugar causes constriction of blood vessels, which can worsen cramps; both sugar and alcohol should be avoided in a cramp relief program. When I put women on a salt-free, dairy-free, and wheat-free diet, the tendency to accumulate bloat decreases, as does the dull, aching abdominal discomfort and low back pain. Other risk factors can also contribute to both spasmodic and congestive menstrual cramps. These include the following variables:
- Use of tampons may contribute to menstrual cramping in some women. Women who find that tampon use worsens their cramps should switch to sanitary napkins.
- Use of an IUD may significantly worsen the spasmodic type of cramping, and the device may need to be removed if symptoms are too severe.
- Bladder infections can cause symptoms of dull, aching pain in the lower abdominal region. Frequent bladder infections near or during menstrual periods can be a problem for some women.
- Vaginal yeast infections can occur during menstrual periods because of changes in the vaginal pH.
- Childlessness is a risk factor for spasmodic cramping; congestive symptoms may actually be worse in women who have had several pregnancies.
- Lack of exercise and poor posture increases the tendencies toward both types of cramps, since blood circulation and oxygenation is decreased.
- Stress can worsen cramps by causing women to tense their pelvic and low back muscles unconsciously.
The result of underlying health problems that can cause uterine and low back pain, secondary dysmenorrhea occurs most frequently in older women, typically in their forties and early fifties. Often, periods will suddenly become painful after years of pain-free menstruation. Secondary dysmenorrhea is much less common than the primary types. Some common causes of secondary dysmenorrhea include the following conditions.
Fibroid Tumors of the Uterus. Fibroid tumors occur when the muscular tissue of the uterus grows excessively. Fibroids can grow very large in some women, enlarging the uterus to sizes seen in pregnancy. If they grow large enough to impinge on the bowel and bladder, or if their growth outstrips their blood supply, they can worsen menstrual cramps. These growths occur most often in women during their reproductive years.
Fibroid tumors are stimulated by estrogen. They may expand in size with the use of estrogen dominated birth control pills, during pregnancy, or in women who secrete high levels of estrogen naturally. Besides causing menstrual cramps, large fibroids can put pressure on the bladder or bowels, causing urinary frequency or bowel changes. Fibroids can also cause excessive menstrual bleeding and pelvic discomfort to the point of necessitating a hysterectomy. In fact, fibroids are one of the most common reasons for the 650,000 hysterectomies performed each year in the United States. Usually such tumors shrink after menopause because of the decrease in estrogen.
Pelvic Inflammatory Disease (PID). This refers to an infection of a woman’s uterus, fallopian tubes, or ovaries. This serious infec-tion must be diagnosed and treated immediately in order to pre-vent scarring of the reproductive organs and infertility. Symptoms of PID include fever, chills, back pain, a puslike vaginal discharge, pain during or after sexual intercourse, and spotting. When chronic, a low-grade smoldering infection can also cause lower abdominal cramps during menstruation. If untreated, the chronic menstrual pain can necessitate a hysterectomy.
Endometriosis. In this condition, pieces of the uterine lining, or endometrium, implant and grow outside the uterus in other parts of the pelvic cavity. Implants can be found on any pelvic structure, including the fallopian tubes, ovaries, and outer wall of the uterus. They can even become embedded in the intestinal and bladder walls. These tissues, like the normal lining of the uterus, are responsive to hormonal changes and can bleed with the onset of the menstrual period. Although the bleeding from the uterine lining can leave the body vaginally through menstruation, bleeding from endometrial implants in the pelvis is retained by the body and can cause scarring and inflammation over time. Pain is the most common symptom that arises from this structural damage. Women with endometriosis suffer from pain during menstruation as well as during sexual intercourse.
Treatments for endometriosis vary depending on the woman’s age, severity of symptoms, and her childbearing status. Supportive therapy often includes antiprostaglandin medication such as Motrin and Ponstel. Stronger painkilling medication may be used if symptoms are severe. Pregnancy is actually a treatment for endometriosis, since it relieves monthly menstruation. In fact, doctors have traditionally recommended that women with endometriosis consider pregnancy to alleviate the problem. Unfortunately, women with endometriosis suffer from a higher level of infertility than the general population because of the scarring and other structural damage that endometriosis creates in the reproductive tract. In some cases, physicians recommend treatments including the use of birth control pills and other hormonal therapies that inhibit normal menstruation and reverse the stimulation of the endometrial implants. These therapies can be quite effective in reversing the process, but their use requires care because of the many possible side effects that can occur. In advanced cases, endometriosis may culminate in a hysterectomy.
In summary, this chapter has given you information on the dif-ferent types, causes, and symptoms of menstrual cramps. As you can see, menstrual cramps can arise from a variety of conditions. To identify your specific type of menstrual cramp pattern, go on to the next chapter. Chapter 2 contains a self evaluation workbook that will help you pinpoint the risk factors and lifestyle habits that contribute to your symptoms.
Types of Menstrual Cramps
Primary Spasmodic Dysmenorrhea
Severe viselike pain, backache, tightening and pain sensations in the inner thighs, nausea, vomiting, diarrhea, constipation, faintness,
dizziness, fatigue, headaches
Primary Congestive Dysmenorrhea
Dull aching in low back and pelvis, bloating, weight gain, breast tender-
ness, headaches, irritability
Pelvic and back pain, spotting, pain during or after sexual intercourse,
fever, chills, puslike vaginal discharge, urinary frequency, bowel changes
Risk Factors for Menstrual Cramps
- Use of tampons
- Use of IUD
- Bladder infections
- Yeast infections
- Childlessness (primary spasmodic dysmenorrhea)
- Multiple pregnancies (primary congestive dysmenorrhea)
- Lack of exercise
- Poor posture
- Emotional stress