Period cramps: An annoying but treatable pain

Abstract

Female health issues such as period cramps are great opportunities for pharmacists to improve the care and quality of life for those with self-treatable conditions. Primary dysmenorrhea, a very common menstrual problem for young people, is defined as cramping pain in the lower abdomen at the onset of menstruation in the absence of any identifiable pelvic disease. Pain usually develops within hours of the start of menstruation and peaks as the flow becomes heaviest during the first day or two of the cycle. It is distinguished from secondary dysmenorrhea, painful menses resulting from pelvic pathology such as endometriosis, and is one condition most people assigned female at birth can manage with a combination of self-care options including nonpharmacologic and pharmacologic options. The primary goal of treatment for primary dysmenorrhea is pain relief, though other symptoms such as nausea, vomiting, fatigue, and diarrhea may also occur. Patients may complain not only of pain in the abdomen (severe at times) but also in the hips, lower back, or inner thighs and pressure in the abdomen. Menstrual cramps occur when prostaglandin causes the uterus to contract and press against nearby blood vessels, cutting off the supply of oxygen to the muscle tissue and causing pain. Pharmacotherapy has been shown to be the most reliable and effective treatment for relieving dysmenorrhea. Because the pain results from uterine vasoconstriction, anoxia, and contractions mediated by prostaglandins, symptoms can often be relieved using agents that inhibit prostaglandin synthesis and possess anti-inflammatory and analgesic properties. NSAIDs provide the best relief for mild cramps because they reduce prostaglandin production. FDA has approved diclofenac, ibuprofen, ketoprofen, meclofenamate, mefenamic acid, and naproxen for treatment of primary dysmenorrhea. Research has shown that aspirin may not be as effective as other NSAIDs. For patients who can't take NSAIDs, other pain relievers such as acetaminophen may help relieve cramping pain. Oral hormonal contraceptives have also been shown to provide dysmenorrhea relief by inhibiting ovulation and preventing prostaglandin production. In some patients, oral contraceptives can prevent dysmenorrhea altogether, though these agents are not approved by FDA for this indication. Some states now allow dispensing of oral hormonal contraceptives by pharmacists without a prescription, so this may be an option for patients choosing voluntary childlessness. Other therapies for dysmenorrhea—including a low-fat vegetarian diet and supplements containing pyridoxine (vitamin B6), magnesium, and vitamin E—have been proposed, but most are not well studied. Acupuncture, acupressure, aromatherapy, various herbal medicines, and physiotherapy have also been suggested to relieve menstrual pain, as have yoga, massage, and relaxation or breathing exercises. Remind patients that most supplements are not regulated by FDA and should be taken with caution. More common ways to relieve abdominal pain include placing a heating pad or hot water bottle on the lower back or abdomen, avoiding foods that contain caffeine, avoiding smoking and drinking alcohol, and massaging the lower back and abdomen. Heat therapy is thought to relieve menstrual pain through vasodilation, which increases blood flow to the area and relaxes smooth muscles. Also, advise patients to exercise regularly as exercise can lessen symptoms through stress reduction and decreased prostaglandin levels. More serious pain may be due to secondary dysmenorrhea, which can be caused by endometriosis, adenomyosis, pelvic inflammatory disease, cervical stenosis, or fibroids. Circumstances that may indicate secondary dysmenorrhea include dysmenorrhea occurring during the first one or two cycles after menarche (congenital outflow obstruction), dysmenorrhea beginning after age 25 years, dysmenorrhea in patients with no history of previous painful menstruation, heavy menstrual flow or irregular cycles, and little or no pain relief after NSAID therapy or beginning oral contraceptives. Because secondary dysmenorrhea is caused by conditions that should be treated by a physician, it's important to advise patients with these symptoms or with pain that begins earlier in the menstrual cycle and lasts longer than common menstrual cramps without nausea, vomiting, fatigue, or diarrhea to consult their physician rather than attempting self care. Also advise patients complaining of menstrual cramps about the signs of toxic shock syndrome—a fever of over 102 °F, vomiting, diarrhea, dizziness, and a rash that looks like a sunburn. Toxic shock can be life-threatening and affected patients should get medical help right away. Primary dysmenorrhea is extremely common and treatable with NSAIDs and/or oral contraceptives, heat, massage, exercise, or diet. Patients with symptoms of secondary dysmenorrhea should be referred to their physician for diagnosis and treatment.