You don't have to take to your bed once a month if you know how to beat the pain.

Dr Fong Yang
Obstetrician/Gynaecologist

One in every four to five women here suffers from some degree of menstrual pain. Painful periods, or dysmenorrhoea, can affect any woman who has menstrual cycles, be it regular or irregular. You can get painful periods whether you are a teenager, a working woman or as a mother. It helps to understand the reasons why.

The Teenager
Some girls experience menstrual pain from their very first menstrual period at the age of 12 or so. Though uncommon, this may be caused by an absence of an opening in the hymen (a membrane at the outlet of the vagina), which prevents the menstrual blood from flowing out of the vagina. This "imperforate hymen" causes retention of menstrual blood and stretching of the vagina, resulting in severe cramps. Fortunately, this can be easily treated by a gynaecologist who makes an incision or cut in the hymen to let the blood flow out; cure is usually permanent.

The Young Woman
A commonly heard complaint is that of pre-menstrual abdominal bloating and discomfort. Better known as pre-menstrual tension, this results from the retention of fluid in your body due to hormonal changes before menstruation, and is usually relieved with the onset of your period. This condition has no known long-term consequences, and usually resolves after the birth of your first child.

From the ages of 20 to the late 30s, two important causes of menstrual pain come into play. A small but significant portion of women in this age group experience irregular menstrual cycles.

Instead of the usual 28- to 30-day cycles, you may have periods only once every two to three months or even longer. And when you do get your period, it is almost always very heavy and is associated with the passage of blood clots. These clots are formed from the pooling of blood in the womb (uterus) from the heavy flow, and they irritate the womb muscles. The womb muscles then contract to force the clots out, much like the contractions felt in labour, but of a lesser intensity.

This "uterine colic" is described as cramps in the lower abdomen and lower back, and is episodic. After a piece of clot is expelled, the pain would go away for a couple of hours, only to return with the passage of the next clot, until the menstrual flow is over or until the flow is less heavy. Occasionally, women with regular cycles would also experience similar colicky pain. These women commonly have heavy menstrual flows, either from the presence of fibroids in their womb, or from an imbalance of hormones that regulate the cycle.

The other significant cause of pain is endometriosis. This is a condition of unknown origin, but presents with varying degrees of pain that come on only with the onset of menses.

It may last throughout the entire duration of the menstrual flow, followed by a pain-free period of three weeks or so, only to return with the next cycle. The pain is commonly described as a constant ache in the lower abdomen, with occasional pain in the lower back, painful sensation in the rectum/anus during bowel movements, and in some women painful sexual intercourse.

A large number of women with endometriosis find their menstrual pains getting progressively worse with each passing month, and they are also usually infertile.

The Older Woman
If you are above 40, menstrual pain may be due to a condition called adenomyosis. This is a variant of endometriosis, which results in fairly severe menstrual pain, and an enlargement of the womb. There may occasionally be pressure symptoms resulting from the womb pressing against the urinary bladder; these women will find that they have to go to the bathroom very frequently because of urinary urge.

In rare instances, cancers of the reproductive organs may cause pain and heavy periods. These are more common in this age group, and medical attention should be sought earlier.

How To Beat The Pain
The first step in managing menstrual pain is to consult your doctor for a preliminary check-up and assessment. Your family doctor will be able to discuss with you the reason behind your pain, and in most situations offer you medical treatment.

Some of the most common medications prescribed are painkillers, such as mefanamic acid or indomethacin. These medications also reduce menstrual flow by 20 to 30 percent, thereby easing the pain of uterine colic. Other medications like tranexamic acid help reduce menstrual flow by up to 60 percent, and are very helpful if your pain is due to the passage of blood clots.

If you suffer from an irregular period or a hormonal imbalance, your doctor may prescribe hormonal pills to regulate your cycle. These are taken for a period of three to six months, and should not be confused with hormonal pills taken by menopausal women.

If your doctor suspects endometriosis or fibroids, he may refer you to a gynaecologist for further assessment. This may include an internal examination, ultrasound scans, and sometimes laparoscopy (a surgical procedure to look inside your tummy for endometriosis). Treatment may include both medication and/or surgery, depending on the extent of the condition, your age and your plans for starting a family. Similar considerations apply if you are diagnosed with adenomyosis.

Break The Cycle
Conditions like imperforate hymen and fibroids are unavoidable. However, early medical consultation and treatment will reduce the discomfort and prevent other consequences from occurring.

Endometriosis, adenomyosis and fibroids are less often seen in women who have children before the age of 30. The conditions are less severe and are more easily treated even if they do affect you subsequently.

In about 10 to 15 percent of women with pre-menstrual tension, the use of evening primrose oil (EPO) has been shown to reduce or resolve the symptoms. How exactly it works is not known, but it is believed that EPO contains certain substances lacking in our bodies which caused the bloating in the first place. The usual dose is 1,000 milligrams of EPO daily, and you will notice that it provides relief after four to six weeks of its use.

The important thing to remember about menstrual pains is that although they are common, you do not have to suffer in silence.

There are now a whole host of treatment options that your doctor can offer you. He will also be able to discuss with you the advantages and disadvantages of the various options, the side effects of treatment, as well as the long-term benefits of each treatment. Remember to be candid, and to tell him how you feel about treatment, and what your expectations are (be reasonable).

Menstrual pain is usually more of an inconvenience than a medical emergency. By participating actively in your treatment through dialogue with your doctor, you stand to benefit from understanding your condition and could resume your normal lifestyle sooner and with minimum inconvenience.

Date reviewed: 13 April 2000