Painful periods are common in teenagers and young adults. Periods tend to become less painful as you get older. An anti-inflammatory painkiller often eases the pain. In most cases, the cause of the pain during periods is not clear. In some cases, usually in women in their 30s or 40s, a problem in the pelvis causes the pain.
Who has painful periods?
Most women have some pain during periods. The pain is often mild but, in about 1 in 10 women, the pain is severe enough to affect day-to-day activities. The pain can be so severe that they are unable to go to school or work. Doctors may call period pain 'dysmenorrhoea'. Period pain is one type of pelvic pain.
Primary dysmenorrhoea is the most common type of painful periods. This occurs where there is no underlying problem of the womb (uterus) or pelvis. It often occurs in teenagers and women in their 20s.
Secondary dysmenorrhoea is pain caused by a problem of the womb or pelvis. This is less common, and is more likely to occur in women in their 30s and 40s.
What causes the pain of primary dysmenorrhoea?
The cause is not clear. The womb (uterus) is normal. It is thought that normal body chemicals (called prostaglandins) build up in the lining of the womb. Prostaglandins help the womb to contract and remove the lining of the womb during a period. In women with period pain there seems to be a build-up of too much prostaglandin, or the womb may be extra sensitive to the prostaglandins. This may cause the womb to contract too hard. This reduces the blood supply to the womb and leads to pain.
What are the symptoms of primary dysmenorrhoea?
The main symptom is crampy pain in your lower tummy (abdomen). Often, the first few periods that you have are painless. Period pains may only begin 6-12 months after you have started your periods. The pain:
- May spread to your lower back, or to the top of your legs.
- Usually starts as the bleeding starts, but it may start up to a day before.
- Usually lasts 12-24 hours, but lasts 2-3 days in some cases.
- Can vary with each period. Some periods are worse than others.
- Tends to become less severe as you get older, or after having a baby.
In some women, other symptoms occur as well as pain - for example:
- Breast tenderness.
- Feeling sick (nausea).
- Feeling emotional or tearful.
Note: the following are not symptoms of primary dysmenorrhoea:
- High temperature (fever).
- Vaginal discharge.
- Sudden severe abdominal pain.
- Pain when you have sex.
- Vaginal bleeding between periods.
- Vaginal bleeding after having sex.
You should see your doctor if any of these symptoms develop.
How is primary dysmenorrhoea diagnosed?
In many cases (particularly in teenagers) the symptoms are so typical that it can be confidently diagnosed by your doctor just by asking about your symptoms. Your doctor will probably also examine the front of your abdomen just to check that it is normal (which it is in primary dysmenorrhoea).
Tests and an internal (pelvic) examination are not normally needed unless symptoms are unusual. In that case the diagnosis of primary dysmenorrhoea is not certain and secondary dysmenorrhoea may be suspected (see below).
What are the treatment options for primary dysmenorrhoea?
Most women with painful periods have mild pain that they can treat themselves at home. However, if your pain becomes more severe and is interfering with your usual activities, you should see your doctor.
There are a number of treatments that may help if you have primary dysmenorrhoea:
- Warmth: you may find it soothing to hold a hot water bottle against your lower abdomen, or to have a hot bath. The pain often does not last long, and this may be all that you need. (Be careful not to burn yourself with a hot water bottle which is too hot.)
- Non-steroidal anti-inflammatory painkillers: these can greatly ease the pain in about 7 out of 10 cases. They work by blocking the effect of the prostaglandin chemicals that are thought to cause the pain. Also, non-steroidal anti-inflammatory painkillers usually reduce the amount of bleeding. There are several types and brands, and most need a prescription. However, you can buy one type (ibuprofen) at pharmacies. Some tips when using an anti-inflammatory include the following:
- Take the first dose as soon as your pain begins, or as soon as the bleeding starts, whichever comes first. Some doctors advise to start taking the tablets the day before your period is due. This may prevent the pain from building up.
- Take the tablets regularly, for 2-3 days each period, rather than 'now and then' when pain builds up.
- Take a strong enough dose. If your pains are not eased, ask your doctor or pharmacist if the dose that you are taking is the maximum allowed. An increase in dose may be all that you need.
- Some people cannot take non-steroidal anti-inflammatory painkillers. For example, people with a stomach ulcer, and some people with asthma.
- Side-effects are uncommon if you take a non-steroidal anti-inflammatory painkiller for just a few days at a time, during each period. Read the leaflet that comes with the tablets for a full list of possible side-effects and cautions.
- Paracetamol: this is an alternative painkiller that you can try if you cannot take non-steroidal anti-inflammatory painkillers. Also, paracetamol can be used in combination with a non-steroidal anti-inflammatory painkiller if the anti-inflammatory alone is not enough. Always read the details on the packet so that you do not exceed the maximum daily dose of either painkiller.
- Combined hormonal contraceptive (CHC) in the form of 'the pill', the patch or the ring: one of these is an option if you also need contraception. Heavy periods are much less likely if you take CHC. You can also take them in a way so that you have fewer periods in a year. This will reduce the number of times you have pain. See separate leaflet called Combined Oral Contraceptive Pill for more detail.
- The intrauterine system (IUS): a special intrauterine contraceptive called the IUS is an option if you also need long-term contraception. The IUS slowly releases a progestogen hormone called levonorgestrel. This 'thins' the lining of the womb. It is a good contraceptive, but also reduces the amount of pain and bleeding during periods. See separate leaflet called Intrauterine System (IUS) which describes the IUS in more detail.
- Other progestogen contraceptives: another option if you also need contraception is to try another type of contraception that contains progestogen. Options include Cerazette® contraceptive pill or an injectable progestogen contraceptive such as Depo-Provera®. See separate leaflets called Progestogen-only Contraceptive Pill and Contraceptive Injection which describe these options in more detail.
- A transcutaneous electrical nerve stimulation (TENS) machine: this can be an option for women who prefer not to use medication. These machines give out a small electrical current. They seem to work by interfering with pain signals which are sent to the brain from the nerves. However, you would normally have to buy a TENS machine, as they are not available on the NHS for the treatment of period pain. See separate leaflet called TENS Machines for more details.
- Other medicines: if all other treatments have failed, various other medicines are sometimes tried. For example, medicines that interfere with your cycle are sometimes used. These are not routine treatments, as side-effects can be a problem and the research evidence to support their use is limited.
- Alternative medicine treatments: there is not enough evidence so far to support the use of other treatments for painful periods. For example, herbal and dietary supplements, acupuncture, exercise and spinal manipulation. Some small studies have shown that some of these treatments may help but, overall, the effectiveness of these treatments is not clear. More studies are needed to help decide if these treatments are helpful or not for painful periods. Be aware that they may interfere with other medicines that you take.
Secondary dysmenorrhoea - period pain due to an underlying cause
What causes secondary dysmenorrhoea?
A problem of the womb (uterus) or pelvis sometimes causes painful periods. For example: endometriosis, fibroids, or infection of the womb and Fallopian tubes (pelvic inflammatory disease).
What are the symptoms of secondary dysmenorrhoea?
Again, the main symptom is crampy lower tummy (abdominal) pain during your periods. With secondary dysmenorrhoea, your periods tend to become more painful after several years of 'normal' periods (that is, periods with normal, mild, period pains).
The following may indicate secondary dysmenorrhoea:
- If you have a change in your usual pattern of pain. For example, if your periods become more painful than they used to be, or the pain lasts longer than it used to. In some women with secondary dysmenorrhoea the pain starts several days before the period begins, and lasts all the way through the period. (This is uncommon with primary dysmenorrhoea.)
- If you have other symptoms - for example:
You should see your doctor if you develop any of these problems.
How is secondary dysmenorrhoea diagnosed?
Your doctor will usually examine you if they suspect that you have secondary dysmenorrhoea. This may involve an internal examination to check your womb and pelvis as well as an examination of your abdomen. The idea is to look for possible causes of your painful periods, such as fibroids in your womb. Your doctor may also suggest that they take some samples (swabs) during the examination to look for any signs of infection.
If your doctor feels that you have secondary dysmenorrhoea, they may suggest that they refer you to a specialist (usually a gynaecologist) for further investigations. The investigations that are carried out depend on the likely underlying problem. They may include:
- An ultrasound scan of your womb and pelvis.
- Using a telescope to examine the inside of your womb (a hysteroscopy).
- Using a telescope to examine the internal organs of your pelvis (a laparoscopy). See separate leaflet called Laparoscopy and Laparoscopic Surgery for more detail.
What are the treatment options for secondary dysmenorrhoea?
The treatment of secondary dysmenorrhoea depends on the underlying cause. See separate leaflets called Endometriosis, Fibroids and Pelvic Inflammatory Disease, which describe some of the problems that can cause secondary dysmenorrhoea in more detail. These leaflets also discuss treatment.
If you have an intrauterine contraceptive device (IUCD - also known as 'the coil') and have painful periods, the treatments for primary dysmenorrhoea (described above) often help. However, some women prefer to have their IUCD removed if symptoms do not improve.
Dr Michelle Wright
Dr Jacqueline Payne
Prof Cathy Jackson