- Mild menstrual cramps are “normal.” Severe cramps are not.
- There are ways to treat symptoms and attempt to control pain.
- Learn when should you see a doctor about severe menstrual cramps.
What periods are and what they do
Every month during a healthy woman’s reproductive years if no fertilized egg is present, the lining of the uterus (endometrium) breaks down, sloughs or sheds, and exits the body through the vagina, resulting in menstruation.
What are “normal” menses or periods?
Eleanor Friele, MD, a gynecologist at Swedish First Hill in Seattle, says, “We see ‘normal’ menstrual cycles that occur every 21 to 35 days, and last from two to seven days. Throughout a woman’s life, and as she ages or experiences other life occurrences like sickness or even stress, the frequency and duration can change.”
Your menstrual cycle might be regular — lasting about the same length every month and occur with the same general frequency. Or, your period may be somewhat irregular, both in length and between cycles, and your period might be light or heavy, painful or pain-free, long or short, and still be considered “normal.” Just because your period is normal for you, if you are having significant problems like heavy or prolonged bleeding, severe pain, or issues of missing more than one month several times a year, you should see a doctor to discuss this. It is okay to start with your primary care provider, but you can also go right to an OB-GYN for this.
How do you know your pain is abnormal?
Some women experience painful periods, and some do not. There are two types of painful periods or dysmenorrhea.
- Primary – painful regular menstrual cycles that start soon after your first period. These are commonly due to a narrow cervical canal causing strong uterine contractions to push out the menstrual tissue.
- Secondary – painful periods that start several years after starting menstruation, usually in your 20’s-30’s. These can be due to fibroids, endometriosis, or adenomyosis.
When periods are painful (“doubling-over” painful, making you unable to perform your regular daily activities), it is time to look further. Another pain “meter” might be that over-the-counter drugs such as ibuprofen and acetaminophen are not effective in alleviating the pain. This secondary type of pain also bears investigation.
When and why you should see a doctor
Dr. Friele says, “Many of the symptoms of menstrual complaints, bowel issues and urinary changes, bloating and migraines are related to the breakdown products released from the endometrium. The more endometrial tissue present, the worse the symptoms tend to be.”
As described above, for some women it is the shape and dilation of the cervical canal that causes the pain. Those women usually do not have heavy periods; the pain starts just prior to bleeding and usually is better within a day of starting the period.
Fibroids can also cause pain. These are balls of muscle cells, non-cancerous uterine tumors, that can cause a heavier period due to altering the uterine canal, or when they outgrow their blood supply. They may cause pain due to the muscle trying to contract around them during your period.
In endometriosis, which is a major cause of infertility in women, tissue that is similar to the uterine lining grows on the pelvic organs. We do not know how this tissue gets there, but during the menstrual cycle it will grow and bleed just like the lining of the uterus. Surrounding tissue becomes inflamed. There is often scarring. Other indicators of possible endometriosis are:
- Pelvic pain associated with sex
- Pain that occurs in between your periods
- Blood in your urine or stools at the time of your period
- Painful bowel movements or urination during your period
Heavy and painful menses may also be caused by adenomyosis. This is a circumstance where the uterine lining has grown into the muscle wall. When the period comes, there are a lot more endometrial cells to bleed, so the periods are often heavier. It is likely that some of the pain comes from the amount of blood that is coming out of the uterus, and some comes from the blood building up in the uterine muscle wall. This can also lead to pain with intercourse.
Seeking care for severe painful menses
See your doctor as soon as you suspect there’s more going on than “normal” painful periods.
There are ways to treat the symptoms and attempt to control pain.
The first step is to see a gynecologist who will review your symptoms and medical history to see if something else might be going on. The doctor will then perform a pelvic exam and an ultrasound to look for other causes of pain like fibroids, adenomyosis or ovarian implants of endometrium called endometriomas. For most women, the first step is suppression of the periods with estrogen and progesterone-containing birth control pills. Another way to suppress the uterine lining growth is with a progesterone IUD.
If these measures fail, the doctor will usually do a trial of an anti-hormone which will decrease endometriosis. This can be taken for up to 6 months’ of courses and then can be suppressed with either of the hormonal issues above.
Patients who fail the above treatment will usually get a minimally invasive procedure called a laparoscopy, as this is the only way to formally diagnose endometriosis, which is not easily seen on ultrasound.
Treatment options depend on the severity of symptoms; the size, number and locations of growths; extent of the disease and scarring; and your age and whether you want a baby in the future, although there is no concrete evidence that operating on endometriosis improves fertility. Pain medications can help with symptoms, and while hormonal therapy frequently alleviates discomfort, there are cases where surgery may be recommended.
Robot-assisted surgeries for endometriosis using the da Vinci system have been expertly performed at Swedish for more than a decade. They are minimally invasive, and they require less time in the hospital and have reduced risk of complications than traditional surgery.
“Every woman is different, and our goal is to make sure women experiencing abnormal menstrual pain get checked, both to relieve symptoms and help you,” Dr. Friele concludes.
Visit the Swedish Robotic Surgery Program for more information on the multidisciplinary robot-assisted surgical program at Swedish.
This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.
