Last updated by Dr Sarah Brewer on
Painful periods and other period symptoms such as heavy, irregular or absent periods, are among the most common reasons for a woman to consult her doctor and it’s not surprising that menstruation is often referred to as the ‘curse’.
- The normal menstrual cycle
- What is dysmenorrhea?
- Symptoms of dysmenorrhea
- What causes dysmenorrhea?
- Treatment of dysmenorrhoea
- Fish oil helps dysmenorrhea
- Magnesium for painful periods
- Cannabidiol CBD oil for painful periods
- CBD supplements
- Pycnogenol for dysmenorrhea
- Heat patches reduce period pain
- Magnetic clips reduce dysmenorrhea
- Livia the Off Switch for dysmenorrhea
- Endometriosis and painful periods
- Heavy periods
- Irregular periods
- Keep a menstrual diary
- Period calendar and PMS symptom tracker
- Premenstrual syndrome
- Bleeding between periods
- Absent periods
- Post-menopausal bleeding
The normal menstrual cycle
The average age at which periods start (menarche) is around 12 years 5 months in the U.S. and 12 years 11 months in Britain, while and the average age when periods stop at the menopause is 51 years. From puberty until the menopause, women experience an average of 13 menstrual bleeds per year.
Allowing for the lack of periods occurring during pregnancy, the average modern woman therefore experiences between 400 and 500 periods during her life. Each period usually lasts from 1 to 8 days, with 3 – 5 days being most common.
During a normal period, you lose between 30ml and 75ml fluid, so during your fertile time of life you lose between 13.5 and 33.75 litres (22.5 – 56.25 pints) menstrual fluid, which is an astonishing amount. It’s not always easy to make up the iron lost every month. Women, on average, have iron intakes below the recommended daily amount, and 27% fall below the intake needed to prevent iron deficiency anaemia. If you feel tired, exhausted, lack in energy, or look pale, see your doctor – you could well have iron deficiency anaemia or another health issue that needs investigation.
What is dysmenorrhea?
Dysmenorrhea (also spelled dysmenorrhoea or simply referred to as dysmen) is the medical term for painful periods.
Painful periods affect as many as 9 out of 10 women at some time during their life. One in 10 women experience symptoms severe enough to interfere with normal activities, and some need time off work or studies when cramping pains are severe. Painful periods typically occur within two or three years of starting to menstruate (primary dysmenorrhea).
Dysmenorrhoea that comes on later during your reproductive life is known as secondary dysmenorrhoea and is usually due to an underlying gynaecological condition, such as endometriosis or fibroids, or is related to an approaching menopause.
Symptoms of dysmenorrhea
The pain of dysmenorrhea is often described as aching or cramping and comes and goes in waves, causing a dragging sensation in your lower abdomen (pelvis) that may spread down your legs or into your lower back.
In primary dysmenorrhoea, which affects teenagers and young women, pain usually starts just before a period and typically lasts for less than 12 hours, although for some it may persist for two or three days or longer.
In secondary dysmenorrhoea, which comes on later in life, pain can start several days before a period and may last until bleeding stops.
Other symptoms that can accompany dysmenorrhea include nausea, backache, headache, bowel problems such as looseness, and generally feeling under the weather. Often, all you want to do is lie down and cuddle up to a hot water bottle. I recommend using a long hot water bottle that you can wrap around your back and abdomen for best results eg YuYu long hot water bottles in the UK, or the Peter Pan long hot water bottle in the US.
What causes dysmenorrhea?
Each month, the outer layer of your womb lining (endometrium) builds up to form a thick, nourishing cushion in which a fertilised egg can implant and grow. If pregnancy does not occur, the outer two-thirds of this thick lining is shed so that a fresh one can develop. The lining is shed by rhythmic contractions of powerful muscles in the uterine wall, which squeeze out the unwanted endometrium as a normal menstrual bleed.
During menstruation, the womb lining produces hormone-like chemicals (prostaglandins) that constrict blood vessels to reduce blood losses. Excessive cramping pain, or dysmenorrhea, is thought to occur when you make more prostaglandins than usual, or become more sensitive to their effects. This causes unusually strong contractions and muscles in the womb wall may go into severe spasms or cramps. This temporarily reduces the normal flow of blood to the uterus causing a shortage of oxygen and nutrients which is felt as pain.
As your bowel is also sensitive to prostaglandins, painful periods may be accompanied by diarrhoea, nausea and even vomiting.
Other factors linked with primary dysmenorrhoea include having an unusually narrow or tight cervical canal which may trigger excessive cramping. This usually resolves naturally by the age of 25 and is rare after having a baby.
Other anatomical facts associated with painful periods including having a womb that naturally tilts backwards instead of forwards (retroverted), or having a gynecological condition such as endometriosis, fibroids, pelvic inflammatory disease, polyps or, very rarely, a uterine cancer.
Heavy, painful periods can also occur if a contraceptive coil stimulates strong period cramps.
From a nutritional point of view, lack of omega-3 fatty acids and/or magnesium deficiency can contribute to dysmenorrhea:
- Omega-3s act as building blocks to produce substances that reduce inflammation, and to create a more beneficial type of prostaglandin (series 3) that is less likely to trigger cramping.
- Magnesium has a relaxing effect on muscles to reduce cramping.
Treatment of dysmenorrhoea
Usual medical advice is to take a simple painkiller (eg paracetamol/acetominophen), a drug that reduces muscle spasms (eg hyoscine) or a non-steroidal anti-inflammatory drug which reduces the production of prostaglandins (eg ibuprofen, mefenamic acid). Sometimes hormone treatments (eg the contraceptive Pill) may be suggested to reduce painful periods especially if you also need contraception. Click here to read my review of the best painkillers.
Fish oil helps dysmenorrhea
Period pains seem to be significantly worse in women with a low intake of fish, and taking omega-3 fish oil supplements has been shown to significantly improve painful periods. This is because they contain essential fatty acids that have a beneficial effect on the types of prostaglandins produced.
In fact, the results from 46 studies show that omega-3 fish oil significantly reduced chronic pain – especially dysmenorrhea – and more than halved the degree of discomfort. Omega-3 fish oil supplements are especially helpful for improving painful periods in teenage girls.
If you are vegetarian, then flaxseed oil is a good alternative source of omega-3.
Magnesium for painful periods
Magnesium has a relaxing effect on muscles and is highly effective for relieving dysmenorrhea. Taking magnesium supplements can also reduce back pain and lower abdominal pain associated with menstruation – especially on the second and third days – due to its muscle relaxant effect.
Magnesium deficiency is widespread. The latest National Diet and Nutrition Survey (NDNS) in the UK showing that average (median) magnesium intake for women aged 19 to 65 years was just 229mg per day – significantly below the EU recommended intake of 375mg per day. If you have dysmenorrhea, then increasing your magnesium intake is highly recommended. Magnesium rich foods include: whole grains, nuts (especially Brazil nuts), seeds, beans, dark green leaves, seafood and dark chocolate (hooray!).
If you have loose bowels during a period, you may find it better to absorb magnesium through the skin as magnesium supplement can have a laxative effect (not always a bad thing). Here are 3 of the best ways to get extra magnesium in the form of magnesium skin oil, magnesium skin cream and magnesium bath flakes.
Cannabidiol CBD oil for painful periods
Medical marijuana has been proposed to treat severe dysmenorrhea for women living in New York, while tampons infused with cannabis are said to cure menstrual cramps within 20 minutes. I don’t recommend using either of these! Instead, I suggest you try cannabidiol CBD oil capsules which, taken by mouth, have a direct effect on the brain to relieve pain perception, relax muscles and, as a bonus, improve sleep quality. Cannabidiol is not psychoactive, so will not give you a high, but will relax painful crams.
It’s important to select a quality CBD product that has been independently tested to ensure it contains a known amount of CBD to ensure it’s effective and free from psychoactive THC (so it is legal for general use). Select a CBD product that’s cold extracted using carbon dioxide (CO2) which preserves the activity of a full spectrum of cannabinoids.
Many people find CBD oil capsules or gummies are more pleasant to take than natural cannabidiol oil which has an earthy taste.
NB If you have a medical condition, always talk to your doctor before taking CBD. Check for drug supplement interactions if you are taking any prescribed or over-the-counter drugs. CBD interacts with liver enzymes that breakdown many drugs and can lead to higher or lower than expected levels of the prescribed medication. A useful drugs-supplement interaction checker is available at Drugs.com which includes cannabidiol.
Pycnogenol for dysmenorrhea
Pycnogenol is an extract obtained from the bark of French maritime pine trees. Pycnogenol contains a rich blend of natural fruit acids and antioxidants that have an anti-inflammatory and pain-relieving effect. Pycnogenol also has beneficial effects on the circulation and is widely used to reduce cramps.
A study in Japan involving 47 women with severe menstrual pain – in some cases due to endometriosis – found that taking Pycnogenol pine bark extracts significantly improved menstrual cramping and abdominal pain when started at least two weeks before menstruation. Sixty four percent of women in the trial described the pain relief as good or very good, while another 9% described pain relief as moderate. The dose used for dysmenorrhea was 30mg twice a day during menstruation, but higher doses of 100mg per day are often used.
Another larger study, involving 116 women with dysmenorrhea, found those taking Pycnogenol had a significantly lower pain score and needed significantly less analgesic medication than those taking placebo. The pain relieving effect lasted even when Pycnogenol supplements were stopped.
Heat patches reduce period pain
Heat reduces dysmenorrhea by relaxing cramped muscles and by stimulating heat receptors that send messages to the brain – this helps to block the transmission and perception of pain messages.
A survey of 2,400 students found that 35% of those who responded used heat (hot water bottle or heat patches) to treat dysmenorrhoea, and 92% of these were highly satisfied with the outcome.
Heat patches are applied over the lower abdomen to release heat for up to 12 hours. While you can stick them to your skin, you can also stick them over your underwear, or to the underside of a t-shirt, for example, making them ideal for use during normal daily activities, or if you have sensitive skin. Heat patch contain natural substances that give off heat when they interact with the air, to supply a constant temperature of around 38.9 degrees C (102 degrees F).
A study involving 193 female students with dysmenorrhea compared the effects of using a heat patch against oral painkillers and a control group who did not use any treatments, for two menstrual cycles. Those using the heat patches had significantly reduce pain compared with control and self-medication groups. Pain intensity scores reduced from 8.08 down to 4.76 after 4 hours of heat therapy, and further reduced down to 1.99 after 8 hours of wearing the heat patch. For those taking pain killing medication, pain reduced from 8.09 down to 4.19 at 8 hours, making the heat treatment significantly more effective.
Magnetic clips reduce dysmenorrhea
I am a great fan of magnetic therapy which helps to improve blood flow, reduce cramping and ease pain. A magnetic device called MN8 clips onto underwear and improves period pains in 9 out of 10 women.
A study involving 23 student nurses with dysmenorrhea compared the effects of wearing a therapeutic magnet (800-1299 gauss) above the pubic bone against a control device that was not magnetic. Within 3 hours of applying the true magnet there was a significant difference in dysmenorrhea pain compared with placebo.
Another study involving 35 women with dysmenorrhea compared the effects of wearing a static magnet device (2700 gauss) or an identical, much weaker magnetic device (140 gauss) which acted as a placebo. In those using the full-strength magnet, there was a significant reduction in period pain scores of -17 pain units, compared with a reduction of -5.0 with the weaker placebo.
Both I and my daughter have also found wearing a magnetic device helpful for reducing pain.
Livia the Off Switch for dysmenorrhea
Livia is a drug-free way to relieve painful periods using the power of transcutaneous electrical nerve stimulation (T.E.N.S.). Electrical pulses flood your nerve endings with low-grade tingles that stop pain messages from being transmitted to the brain. The brain tends to shut down monitoring of pathways that send constant low-grade stimuli, so it is not distracted from other more important sensory input. By down-grading the messages sent from the TENS machine, the perception of other signals using the same nerve pathways – such as from muscles experiencing period cramps – are also reduced. The pain signals get blocked and the discomfort is temporarily numbed in a similar way to acupuncture.
Choose your Livia colour, stick the two adhesive pads over the area that hurts, and switch it on for instant pain relief. You can adjust the settings to find a level of pain relief that works best for you. While Livia is not cheap, the concept is highly effective – I used TENS when having my first-born, and later when having twins, so can definitely vouch that it works!
Although painful periods are no laughing matter, if you fancy a chuckle, watch this clip.
Endometriosis and painful periods
Around one in ten women suffer from a condition known as endometriosis in which womb lining cells are found elsewhere in the body – most usually in the abdominal cavity. Because these cells remain sensitive to your monthly hormone cycle, they swell up and bleed into surrounding tissues once a month to produce pain, inflammation and scarring. Period pains can be severe in endometriosis and may be linked with nausea, vomiting and diarrhoea.
If you experience severe period pains with related symptoms, ask your doctor if you could have endometriosis, as the diagnosis is often delayed for as long as seven years after symptoms first start.
A review of ten studies in which acupuncture was used to treat endometriosis found it was more effective than placebo for treatment dysmenorrhea, nausea and vomiting.
Livia, mentioned above, works in a similar way but uses electrical tingles rather than acupuncture needles to block pain messages.
Researchers who were willing to weigh tampons and sanitary pads before and after use have determined that, during a normal menstrual period, you lose between 30ml and 75ml blood – anything greater than this is classed as a heavy period and is known medically as menorrhagia.
Menorrhagia affects around one in ten women at some time during their life. It is most common soon after menstruation has first started, due to failure to release an egg (ovulation) in some cycles. As a result, the womb lining grows thicker than normal so that, when the outer two-thirds is shed, the blood loss is correspondingly greater. This is known as dysfunctional uterine bleeding, and can also affect women approaching the menopause as they start to run out of eggs.
Assessing menstrual losses is no easy matter, but the following warning signs suggest you need to see your doctor to discuss treatment for menorrhagia:
- You need to change your sanitary protection several times during the night
- You need to change your sanitary protection every hour over several consecutive hours
- You need to use both tampons and towels (or even nappies) to cope with flooding
- You pass clots of blood
- You feel tired, exhausted or look pale and washed out with a rapid pulse which suggest you could be anaemic
- Your menstrual bleeding lasts 10 days or longer.
Few women are blessed with a normal menstrual cycle. Textbooks suggest periods appear like clockwork, every 28 days and last for five days. In real life, however, things are often different.
The length of the menstrual cycle varies, with anything between 21 and 35 days considered normal. For some women however, the interval between periods may be 15 days or less, and in others 50 days or more – especially as the menopause approaches. The 28-day cycle usually quoted as the average only occurs in around 12% of women, and in those using the combined oral contraceptive pill which triggers a regular withdrawal bleed.
Having irregular periods means there is a wide variation in the interval between periods, the duration of bleeding and the amount of blood that is lost. As a result, periods:
- Are unpredictable
- May occur more or less frequently than normal
- May be more or less heavy than normal
- May be more painful than normal.
As with other period problems, irregular periods are most common in the early teens, when periods have just started, and again as the menopause approaches. They are often due to having menstrual cycles in which you do not always release an egg (ovulation). As a result, hormone imbalances occur that affect the way the womb lining (endometrium) plumps up and is shed. Periods may also be irregular temporarily after just having had a baby or stopping breast-feeding.
Periods can also become irregular as a result of:
- physical stress (eg excessive exercise, jetlag)
- emotional stress (eg bereavement, depression)
- significant loss of weight
- having an over-active or underactive thyroid gland
- polycystic ovary syndrome (PCOS)
- gynaecological problems such as an ovarian tumour
- approaching menopause.
An irregular, heavy period that is also late may be due to a miscarriage, although a normal period that is late may also be heavier than usual, so it is difficult to tell. If you think you may have had a miscarriage, always seek medical advice.
Keep a menstrual diary
It is important to keep a record of when your bleeding occurs if your periods are irregular. This can help to tell true irregular periods from regular periods with irregular non-menstrual bleeding in-between. Irregular bleeding that is non-cyclical (ie not due to normal menstruation) is known as metrorrhagia and always needs investigating to find out the cause.
Period calendar and PMS symptom tracker
Download my 90-day Period Calendar and PMS symptom tracker as an Excel spreadsheet which you can edit yourself: period calendar
NB Always tell your doctor immediately if you develop bleeding between periods, bleeding after sexual intercourse, or bleeding after you thought your periods had stopped at the menopause.
In some women, dysmenorrhoea is accompanied by symptoms of premenstrual syndrome (PMS) such as bloating, irritability and tender breasts. The symptoms of PMS start in the two weeks before a period is due and stop quickly once bleeding occurs.
PMS is thought to result from a relative imbalance between the two female hormones, oestrogen and progesterone. More than 150 symptoms have been described as forming part of the PMS complex which can be divided into four main sub-groups. These are:
- PMS-A with main symptoms of Anxiety, irritability and insomnia
- PMS-C with sugar Cravings, increased appetite, headache and fatigue
- PMS-D with Depression, forgetfulness and confusion
- PMS-H (for Hyper-hydration) with fluid retention, weight gain, bloating and breast tenderness.
PMS-A and PMS-H are the most common and subtypes and can co-exist. PMS has been linked with nutritional factors such as lack of dietary magnesium, zinc, defects of essential fatty acid metabolism, excess sugar, caffeine or alcohol.
Bleeding between periods
Bleeding between periods (intermenstrual bleeding) can take the form of spotting or a heavier loss, and may occur spontaneously or after making love. It should always be investigated to rule out potentially serious conditions, including the possibility of a miscarriage or ectopic pregnancy, although in many cases no obvious cause is found.
If you using an hormonal method of contraception (eg oral contraceptive pill, mini pill, Depot injection, Mirena intra-uterine system) these can cause a form of bleeding between periods that’s known as breakthrough bleeding. Your doctor can advise whether or not you need to use an additional method of contraception to prevent an unplanned pregnancy until other causes have been ruled out.
One of the most common causes of bleeding between periods is a cervical erosion (more properly known as an ectropion). This develops the when delicate cells lining the cervical canal spread to cover an area on the outer cervix. These forms a red, velvety area that bleeds easily when touched. A cervical erosion can occur as a normal result of oestrogen stimulation and is common in women on the Pill and during pregnancy.
A cervical polyp is another cause of bleeding between periods, especially when bleeding occurs after sex. A polyp is a fragile, fleshy growth that can protrude through the cervical opening on a stalk.
Infection and inflammation can also trigger vaginal bleeding and Chlamydia infection and pelvic inflammatory disease need to be ruled out.
Another possible cause of bleeding between periods is a hormone imbalance. Occasionally, bleeding between periods or after sex is an early sign of a cancer of the cervix, womb or ovaries although this is uncommon it still needs to be investigated.
If you notice any bleeding between periods, even if it is only slight spotting, always seek prompt medical advice.
A lack of menstrual periods is known as amenorrhea (or amenorrhoea). If periods have not started by the age of 16 years, this is known as primary amenorrhea, but if previously normal periods stop for more than six months, in a woman who is not pregnant, breastfeeding or nearing the menopause, it is referred to as secondary amenorrhea.
Periods that come and go irregularly are common in the first few years after menstruation due to hormone imbalances as the part of the brain (hypothalamus) that regulates the menstrual cycle finds its normal rhythm. Menstruation can also become irregular as the menopause approaches when oestrogen levels fall.
Pregnancy is the commonest cause of secondary amenorrhoea and always needs to be ruled out.
Another common cause is stopping the oral contraceptive Pill as it can take a while for the normal hormonal cycle to restart. This is not usually harmful and periods tend to restart on their own within 8 weeks, although occasionally they take up to a year to recur.
Over 50% of women using the contraceptive injection (which contains a slow-release store of a synthetic progestogen hormone) experience absence of periods by the end of their first year of use. As the injection is a slow-release preparation, it does not stop acting immediately as soon as the method is stopped, and periods can take a year or longer to return to normal.
Other hormonal conditions that can cause secondary amenorrhoea include having an over-active or underactive thyroid gland, polycystic ovaries (in which the ovaries produce too many male hormones) and increased production of prolactin hormone in the pituitary gland.
Prolactin hormone stimulates milk production during breastfeeding and also inhibits ovulation so that menstruation ceases. Prolactin levels can increase other than when breast-feeding due to a benign (non-cancerous) pituitary tumour.
Emotional problems such as intense stress can also cause periods to stop, although this is unusual. Other causes of infrequent or absent periods include being very overweight or significantly underweight (eg in anorexia nervosa), taking excessive exercise (eg some elite athletes ballet dancers, models) and the emotional and physical stress of a serious illness, all of which can affect hormone balance in the body.
Prolonged amenorrhoea for any cause except pregnancy reduces the beneficial effects of oestrogen hormone on bone and increases the future risk of developing osteoporosis – especially in smokers. The risk of bone demineralisation and osteoporosis as a result of long-term amenorrhoea with the contraceptive injection (depot progestogen) remains uncertain, but some clinics measure oestrogen levels after a woman has used depot progestogen for a certain period of time and offer added oestrogen replacement if levels are low.
Most women breathe a sigh of relief when their periods stop at the menopause. Any vaginal bleeding appearing more than six months after you thought your periods had stopped should not be dismissed as a return of a period, or one of those things, but should always be reported to your doctor – even if it’s only a little spotting.
One of the commonest causes of post menopausal bleeding is a doctor prescribing HRT and forgetting to warn the woman that her monthly period may return. Other causes include:
- general thinning of vaginal tissues due to lack of oestrogen
- trauma during intercourse – especially after a time of sexual abstinence
- a polyp (benign fleshy growth) of the cervix or endometrium
- fibroids – benign tumours of uterine muscle
- over-stimulation of the endometrium (cystic hyperplasia) due to excessive doses of oestrogen (eg where oestrogen HRT but no progestogen is taken by a woman who has not had a hysterectomy)
Post menopausal bleeding should always be investigated although, in 9 out of ten cases, nothing abnormal is found, so try not to panic. However, one percent of single episodes of post menopausal bleeding and 10% of recurrent episodes of post menopausal bleeding may be due to a gynaecological cancer. If diagnosed early your chance of successful treatment is greatly improved.
I hope you’ve found this information on dysmenorrhea and other period problems useful. If you have any outstanding questions, please use the comments box below.