Painful periods are very common, and yet it is extraordinary how women are blatantly told to “bear the pain” and often even shamed for taking medication for period pain!
Period pain or dysmenorrhea, to call it by its technical term, would have afflicted a great percentage of women at various times in their lives. The degree would vary and so may the incapacitance it causes. Some women have just a vague discomfort while others may need medication to relieve the pain. In some, the pain may be so intense as to cause absenteeism from school, work or social obligations, due to restriction of movement and activity.
The prevalence of dysmenorrhea in studies varies from 45% to 95%, according to the different definitions and threshold of pain itself. However, it remains one of the most common gynecological problems accounting for absenteeism from work and school. As high as 13-51% of women have been absent at least once and 5-14% are often absent, depending on the severity of symptoms.
Can pain ever be normal? But since time immemorial, mothers, sisters, teachers and even doctors have assured women that “it is normal” to have discomfort and even pain during periods. Worse still, girls and women are often discouraged to “resort” to painkillers or medications.
A stoicism towards pain is ingrained from menarche itself.
What causes period pain? As most of us would know, menstruation is the regular shedding of the lining of the uterus when pregnancy does not occur. During this process the body produces a chemical substance called prostaglandin (PG) which causes the uterus to contract or spasm. The higher the levels of PGs in the blood, the more intense these contractions. These contractions decrease and cut blood flow to the lining of the uterus enough to destroy it and allow it to be shed.
But sometimes the reduced blood flow during these contractions causes pain because of the oxygen being cut off and toxins building up – what doctors call ischemic pain (which in the heart is also called a heart attack), so we can think of dysmenorrhea (painful periods) as a mild ‘uterine attack’!
Why does the pain occur?
Period pain may be primary, without any organic cause, or secondary, due to a pathological cause.
The most common causes of secondary dysmenorrhea are
which are conditions that require active treatment. Not diagnosing or giving treatment on time can affect the woman’s fertility, other than a continuation of the pain every month. So especially if the pain is a fairly recent problem, art needs to be shown to a gynaecologist, and treated.
What are the underlying risk factors?
Several risk factors like
have been seen associated with increasing severity of dysmenorrhea.
What medication is available to women?
Self-care or medication suggested by family and friends is usually the norm. Very often this is in the form of the ubiquitous hot water bottle, yoga, or Paracetamol. Whereas these measures may provide partial allayment of symptoms, they are in no way the perfect solution.
As mentioned earlier, the cause of pain is Prostaglandins and so the first line of treatment are medications that decrease the effect of these, in which commonly used ones like Ibuprofen fall. These are given as symptomatic treatment, only when pain occurs.
The second line of treatment is the use of Oral Contraceptive (OC) pills to suppress ovulation – this results in decreased pain during periods. This is useful medication in several causes of secondary dysmenorrhea as well, especially Endometriosis.
There are of course more advanced methods of treatment which include surgery, depending on the cause of dysmenorrhea – your gynaecologist is the best person to decide on this.
Some ‘alternative therapies’ which might work for some women
Though these therapies have no large-scale studies done to validate their efficacy, they can be self-administered, thereby affording a modicum of privacy. In addition, they are useful in patients where the pain medications or oral contraceptive pills cannot be given for some medical reasons. Hence the interest in them has piqued as an alternative to drug therapy.
Among these are herbal products, Vitamin B-1 and B-6, Magnesium, and fish oil capsules (Omega-3 Fatty Acids). While there is no dosage specified anywhere, there certainly are small studies that show that they work better compared to women given a placebo.
Other methods are exercise, yoga, heat patches, TENS (Transcutaneous Electrical Nerve Stimulation) low fat Vegan diet, and acupuncture.
There is also some research underway currently, on the effect of medication like Vitamin K, TENS, medication to decrease the spasmodic pain, low dose oral contraceptives (to minimise side-effects), etc.
Given the armamentarium of drug therapy and alternative therapies available, why is women not encouraged to seek these or even not prescribed more of these, when they can so easily make life better for them during periods?
Pain part of being a woman?
Many young girls “suffer in silence” simply because they do not know who or how to approach for relief from the monthly cyclic pain. This is rooted in the taboos and myths surrounding menstruation itself, and especially so for India. From not allowing menstruating women into the kitchen and temples to not talking about it in public, young girls are conditioned into taking the pain as “part of being a woman”.
Taking pills a sign of ‘weakness’?
I often encounter mothers / women who seem to harbor the view that taking medication for period pain is harmful and even a sign of “weakness”. It is taken as a mark of tolerance and endurance to be able to avoid medication during periods.
“Hawww… young unmarried girl, going to a gynaecologist?”
Besides, even approaching a Gynecologist OPD is associated with a certain amount of hesitation on the part of parents and often, young girls are routed through other departments and specialists to us for common gynecological problems. After all, “log kya kahenge?”
A stigma about oral contraceptives as “promiscuous girls use them”
Another common resistance is when we prescribe OC (Oral Contraceptive) pills for adolescents or unmarried girls. The mothers in the case of younger girls and the patients themselves are reluctant to take them, as there appears to be a stigma of being promiscuous attached to buying or using OCs regularly. A myth that I make it a point to bust.
Women’s health care has been marginalised
At the risk of sounding gender biased, I also feel that this aspect of care has been ignored or neglected because the treatment plans and other literature had been dominated by male authors and caregivers for a long time and dysmenorrhea was looked upon as an insignificant problem not meriting research.
It would be pertinent to note that in rural India, use of disposable pads is limited, and the alternative cloth which is used as an absorbent also contributes to unsatisfactory management of irregular and heavy menstruation, and also contributes to the pain and discomfort.
In about 20% of cases of dysmenorrhea, it is the only symptom of the conditions alluded to earlier. These are conditions that need attention and treatment instituted early, to prevent serious sequelae. Quite often the patient seeks advice only after enduring the pain and discomfort for years, by when the damage can be serious, especially in cases of endometriosis which can result in infertility or sub-fertility.
Education about periods – the most important!
The attempt to educate women (and the men in their families / communities) should start when they are girls, and so an effective school /college-based program for adolescents and young adults is the need of the hour. They should be taught that not only is it unnecessary to “just bear it” but may also not taking treatment on time can have serious consequences affecting the quality of life, resulting in restriction of movement and absenteeism, and even their ability to have a child later in life.
There should be no shame
It should be emphasized it is neither a sign of weakness to seek help for period pain nor a cause for shame.
Mothers need to made aware
India being a country where mothers are the first caregivers for this symptom, it is essential to increase public awareness about dysmenorrhea and the simple ways and drugs available to help them tide over these days.
Encourage visiting a gynaecologist
In cases which do not respond to simple measures, they should be encouraged to seek professional help to rule out the more sinister causes of dysmenorrhea.
Dysmenorrhea is a very common, but quite a treatable condition, which is an under-appreciated fact. First line treatment remains the pain medication or some easily available alternative therapies. If these fail, investigation by specialists is a must.
It is imperative to educate young women about the modalities of treatment available as well as the potential danger of having the cause of severe period pain diagnosed too late. Health education targeting mothers and teachers about the safety of medications, as well as potential danger in ignoring it, would also go a long way in achieving painless periods in young women.
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