Dysmenorrhea, pain associated with menses, is either Primary (Functional) or Secondary (Acquired). It is most common during adolescence and tends to decrease over time and after pregnancy. Pain results from myometrial uterine contractions stimulated by increased prostaglandin production in secretory endometrium. Treatment involves suppressing prostaglandin secretion and/or ovulation and addressing underlying disorders.

Primary dysmenorrhea is cyclical pain associated with menses during ovulatory cycles without demonstrable lesions affecting the reproductive structures. Secondary dysmenorrhea is pain with menses that is caused by demonstrable pathology. Dysmenorrhea causes more absenteeism from school and work than any other single factor. Up to 40% of female adults have some degree of menstrual pain.

Primary:

• Contractions due to increased prostaglandin secretion
• Uterine ischemia
• Anxiety and stress
• Narrow cervical os
• Tissue expulsion through narrow cervix
• Displaced uterus

Secondary:

• Endometriosis
• Adenomyosis
• Narrow cervical os, cervical stemosis, other anatomic abnormalities
• Tissue expulsion through narrow cervix
• Extrauterine pregnancy
• Congenital abnormalities
• Endometrial polyp/submucosal fibroid expulsion
• Fibroids
• Uterine infections
• Chronic/acute pelvic inflammatory disease (PID)
• Intrauterine device (IUD)

• Ovulatory cycles
• IUD
• Stressful events
• Pelvic infection
• Abdominal surgery/ectopic pregnancy
• Sexually transmitted diseases

Symptoms and degree of pain vary from person to person.

Primary:

• Low abdominal cramping/dull ache
• Ache radiating to lower back, groin, legs
• Pain may begin before or at start of menses, usually peaks after 24 hours, and decreases after 48 hours
• Heavy menstrual flow
• Headache
• Nausea
• Constipation or diarrhea
• Frequent urination
• Vomiting (infrequently)
• Premenstrual syndrome

Secondary:

• Often vague, often continuous low abdominal pain/cramping
• Increased pain with menses
• Associated gastrointestinal upset, thigh pain

• PMS Syndrome
• Gastrointestinal disorders
• Irritable bowel syndrome
• Sexually transmitted disease
• Chronic tubal inflammation
• Adhesions from previous abdominal surgery/ectopic pregnancy
• Enlarged uterus
• Urinary tract infection
• Endometriosis

• Abdominal exam: Rule out any palpable mass; check for abnormal bowel sounds and tender or distended bladder.
• Pelvic exam: Uterine or ovarian pressure may result in extreme tenderness—suggestive of pelvic inflammatory disease.

To exclude infection:

• White blood cell count/differential
• Elevated erythrocyte sedimentation rate (ESR)
• Urinalysis
• Cervical/vaginal cultures to rule out localized infection

• Enlarged uterus
• Adhesions
• Fibrous/ovarian tumors
• Abdominal surgery/ectopic pregnancy adhesions
• Uterine displacement/ prolapse

• Pelvic ultrasound; pelvic CT may be necessary

• Pain occurrence in relation to menstrual cycle (pain two to three days prior to and/or lasting two to three days following commencement of blood flow may indicate pathology, or relationship to bowel movements or urination)
• Presence and/or condition of intrauterine devices
• Psychological assessment (major life events, level of physical/emotional functioning, history of physical abuse)
• Laparoscopy, cervical mucus/endometrium analysis

Prior to invasive diagnosis, trial therapeutic medical management is recommended. Exercise/relaxation can also be done. Studies indicate relief in 25% to 85% of patients without pathological disorders.

• Antiprostaglandins, anti-inflammatory (ibuprofen 800 mg to start; 400 to 600 mg every six hours) for primary disorder without pathological complications
• Gonadotropin-releasing hormone (GnRH) analogs/oral contraceptives to suppress ovarian function (consider age/risk factors)
• Antibiotics for PID
• Estrogen/oral progestins for endometriosis (e.g., norethindrone for 12 months). Prognosis: 80% relief, 50% return of fertility.
• Diuretics, if edema present

Dysmenorrhea may be effectively treated with alternative therapies and mind-body techniques such as meditation, yoga, tai chi, and gentle exercise. Begin with nutritional support, magnesium, B6, vitamin E, and red raspberry. A minimum of three months may be required to accurately assess the effects of treatment.

Increase intake of essential fatty acids. These are anti-inflammatory and needed for hormone synthesis. Essential fatty acids are found in cold-water fish, nuts, and seeds. Reduce intake of saturated fats (meat products and dairy products) which are pro-inflammatory. Eliminate refined foods, sugar, dairy products, and methylxanthines (coffee and chocolate) which are pro-inflammatory and deplete the body of essential nutrients. Increase fresh fruits and vegetables, proteins, and whole grains.

• Magnesium (400 mg/day) with B6 (100 mg/day) throughout cycle to promote hormone production and induce relaxation. Can be used at higher doses during menses (magnesium up to 600 mg/day, and B6 up to 300 mg/day) for acute relief.
• Vitamin E (400 to 800 IU/day) to improve blood supply to muscles and promote oxygen utilization
• B-complex (50 to 100 mg/day) for reducing the effects of stress
• Flaxseed, evening primrose, or borage oil (1,000 to 1,500 mg one to two times/day), to reduce inflammation and support hormone production
• Niacinamide (50 mg bid) to reduce pain and inflammation. Begin seven days before menses and continue until the end of flow. Adding rutin (60 mg/day) and vitamin C (300 mg/day) will potentiate effects.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

• Chaste tree (Vitex agnus-cactus) and black cohosh (Cimicifuga racemosa), 30 drops each, bid, influence the pituitary to balance the estrogen:progesterone ratio and reduce dysmenorrhea.
• Red raspberry (Rubus idaeus) tea has tonifying properties and strengthens uterine tissue.
• Tea of chamomile (Matricaria recutita) and ginger root (Zingiber officinale) can help reduce ovarian cyst pain.
• Tinctures of cramp bark (Viburnum opulus), black cohosh, Jamaica dogwood (Piscidia piscipula), and wild yam (Dioscorea villosa) can be used together in equal parts to relieve pain and cramping. Use 20 drops every half hour for four doses, then as needed up to eight doses/day for seven days.

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency.

The following methods help to increase circulation and relieve pelvic congestion. Do one or both for maximum therapeutic effects.

• Castor oil pack: Used externally, castor oil is a powerful anti-inflammatory. Apply oil directly to skin, cover with a clean soft cloth (e.g., flannel) and plastic wrap. Place a heat source (hot water bottle or heating pad) over the pack and let sit for 30 to 60 minutes. For best results use three consecutive days in one week.
• Contrast sitz baths: Use two basins that can be comfortably sat in. Fill one with hot water, and one with cold water. Sit in hot water for three minutes, then in cold for one minute. Repeat this three times to complete one set. Do one to two sets per day three to four days per week.

Dysmenorrhea may respond to acupuncture treatment, for pain relief and resolving deficiencies/excesses that may contribute to symptoms.

Therapeutic massage is helpful in reducing the effects of the stress which may exacerbate dysmenorrhea.

• Regular evaluation to determine effectiveness of treatments
• Patient to report additional symptoms/complaints or if treatment offers no relief

• Patient's desire for pregnancy when determining treatment
• Allergies/adverse interactions to traditional/nontraditional medications

• Avoid stress and caffeine, alcohol, and sugar prior to onset of menses.
• Regular exercise increases blood circulation.
• Relaxation reduces stress.
• Reduce risk of acquiring sexually transmitted diseases.

Infection from underlying pathology

• Most women experience dysmenorrhea at some time in their lives.
• Pregnancy often relieves primary dysmenorrhea.
• Prognosis is good when underlying causes are accurately diagnosed and treated.

• Certain drugs/underlying pathologies may interfere with pregnancy.

Batchelder HJ, Scalzo R. Allopathic specific condition review: dysmenorrhea. Protocol J Botan Med. 1995;1(1).

Berkow R, ed. The Merck Manual of Diagnosis and Therapy. 16th ed. Rahway, NJ: Merck Research Laboratories; 1992.

Branch WT Jr. Office Practice of Medicine. 3rd ed. Philadelphia, Pa: WB Saunders Co; 1994.

Penland JG, Johnson PE. Dietary calcium and manganese effects on menstrual cycle symptoms. Am J Obstet Gynecol. 1993;168:1417-1423.

Werbach MR. Nutritional Influences on Illness. New Canaan, Conn: Keats Publishing Inc; 1987.