| | | | Other Names | | | Dysmenorrhea, Menstrual Cramping, Menstrual Cramps.
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| | | Also known as: Menstrual Cramps, Painful
Menstruation.
Dysmenorrhea, or painful menstruation, is classified
as either primary or secondary. Primary dysmenorrhea generally occurs
within a couple of years of the first menstrual period. The pain tends to
decrease with age and very often resolves after childbirth. Secondary
dysmenorrhea is menstrual pain caused by another condition, commonly
endometriosis. It starts later in life and tends to increase in intensity
over time.
As many as half of menstruating women are affected by
dysmenorrhea, and of these, about 10% have severe dysmenorrhea, which
greatly limits activities for one to three days each month.1
What
are the symptoms of dysmenorrhea? Dysmenorrhea includes symptoms of
abdominal bloating, frequent and intense cramps, pain below the waistline,
or a dull ache that may radiate to the lower back or legs. There may also
be symptoms of headache, nausea, diarrhea or constipation, frequent
urination, and, occasionally, vomiting. The symptoms usually occur just
before or during the menstrual period.
Conventional treatment
options: Conventional treatment includes pain medications, such as
ibuprofen (Advilr, Motrinr, Midol PMSr), mefenamic acid (Ponstelr), and
acetaminophen (Tylenolr). Oral contraceptives may also be used to suppress
ovulation. Danazol (Danocriner), an anti-estrogen drug, and progestins are
also used. In cases of severe nausea and vomiting, antinausea medicines
may be recommended.
Dietary changes that may be helpful: Some
physicians advise that alcohol should be avoided by women experiencing
menstrual pain, because it depletes stores of certain nutrients and alters
the metabolism of carbohydrates-which in turn might worsen muscle spasms.
Alcohol can also interfere with the liver's ability to metabolize
hormones. In theory, this might result in elevated estrogen levels,
increased fluid and salt retention, and heavier menstrual
flow.
Lifestyle changes that may be helpful: Many women feel the
need to lie still while experiencing menstrual cramps, while others find
that exercise helps relieve the pain of dysmenorrhea. This variation from
woman to woman may explain why some researchers report that exercise makes
symptoms worse,2 though most studies report that exercise appears
helpful.3
Nutritional supplements that may be helpful: The niacin
form of vitamin B3 has been reported to be effective in relieving
menstrual cramps in 87% of a group of women taking 200 mg of niacin per
day throughout the menstrual cycle. They then took 100 mg every two or
three hours while experiencing menstrual cramps.4 In a follow-up study,
this protocol was combined with 300 mg of vitamin C and 60 mg of the
flavonoid rutin per day, which resulted in a 90% effectiveness for
relieving menstrual cramps.5 Since these two preliminary studies were
published many years ago, no further research has explored the
relationship between niacin and dysmenorrhea. Niacin may not be effective
unless taken for seven to ten days before the onset of menstrual
flow.
In theory, calcium may help prevent menstrual cramps by
maintaining normal muscle tone. Muscles that are calcium-deficient tend to
be hyperactive and therefore might be more likely to cramp. Calcium
supplementation was reported to reduce pain during menses in one
double-blind trial,6 though another such study found that it relieved only
premenstrual cramping, not pain during menses.7 Some doctors recommend
calcium supplementation for dysmenorrhea, suggesting 1,000 mg per day
throughout the month and 250-500 mg every four hours for pain relief,
during acute cramping (up to a maximum of 2,000 mg per day).
Like
calcium, magnesium plays a role in controlling muscle tone and could be
important in preventing menstrual cramps.8 9 Magnesium supplements have
been reported in preliminary10 and double-blind11 12 European research to
reduce symptoms of dysmenorrhea. In one of these double-blind trials,
women took 360 mg per day of magnesium for three days beginning on the day
before menses began.13
Diets low in omega-3 fatty acids (EPA and
DHA) have been associated with menstrual pain.14 In one double-blind
trial, supplementation with fish oil, a good source of omega-3 fatty
acids, led to a statistically significant 37% drop in menstrual symptoms.
In that report, adolescent girls with dysmenorrhea took an unspecified
amount of fish oil that provided 1,080 mg of EPA and 720 mg of DHA per day
for two months to achieve this result.15 A double-blind trial found that
the same amount of EPA and DHA plus 7.5 mcg per day of vitamin B12 led to
a greater than 50% decrease in menstrual symptoms, but a group taking only
fish oil did not obtain as much relief.16 Six grams of fish oil per day
provides the approximate levels of EPA and DHA used in these
trials.
In a double-blind trial, adolescents living in India who
were suffering from dysmenorrhea took 100 mg of vitamin B1 (thiamine) per
day for three months. Eighty-seven percent of those treated experienced
marked relief of dysmenorrhea symptoms.17 However, vitamin B1 deficiency
is relatively common in India, whereas it is rare in the Western world,
except among alcoholics. It is not known whether vitamin B1
supplementation would relieve dysmenorrhea in women who are not B1
deficient.
Some practitioners report success using topical
progesterone cream for dysmenorrhea.18 To date, this approach lacks
sufficient research.
Are there any side effects or interactions?
Refer to the individual supplement for information about any side effects
or interactions.
Herbs that may be helpful: Corydalis contains
several alkaloids, and one called tetrahydropalmatine (THP) is considered
to be the most potent. In laboratory research, THP has been shown to
exhibit a wide number of pharmacological actions on the central nervous
system, including pain-relieving and sedative effects.19 According to a
secondary reference, painful menstruation responded favorably to the
administration of THP.20 For a pain-relieving effect, the recommended
amount for the crude dried rhizome is 5-10 grams per day. Alternatively,
one can take 10-20 ml per day of a 1:2 extract.
Cramp bark
(Viburnum opulus) has been a favorite traditional herb for menstrual
cramps, thus its signature name. Cramp bark may help ease severe cramps
that are associated with nausea, vomiting, and sweaty chills. Research
from animal studies shows that cramp bark blocks spasms of smooth
muscle.21 Cramp bark is traditionally prepared by placing two teaspoons of
the dried bark into a cup of water and bringing it to a boil; it is then
simmered gently for 10 to 15 minutes. The tea may be drunk three times per
day.22 Alternatively, 4-8 ml of tincture may be used three times per
day.
Black cohosh has a history as a folk medicine for relieving
menstrual cramps. Black cohosh can be taken in several forms, including
crude plant, dried root, or rhizome (300-2,000 mg per day), or as a solid,
dry powdered extract (250 mg three times per day). Standardized extracts
of the herb are available, though they have primarily been researched for
use with menopausal women suffering from hot flashes. The recommended
amount is 20-40 mg twice per day.23 The best researched form provides 1 mg
of deoxyactein per 20 mg of extract. Tinctures can are also used (2-4 ml
three times per day).24 The Commission E Monograph recommends black cohosh
be taken for up to six months, and then discontinued.25
Blue
cohosh, although unrelated to black cohosh, has also been used
traditionally for easing painful menstrual periods. Blue cohosh, which is
generally taken as a tincture, should be limited to no more than 1-2 ml
taken three times per day. The average single application of the whole
herb is 300-1,000 mg. Blue cohosh is generally used in combination with
other herbs. Women of childbearing age using this herb should cease using
it as soon as they become pregnant-the herb was shown to cause heart
problems in an infant born following maternal use of blue
cohosh.26
False unicorn was used in the Native American tradition
for a large number of women's health conditions, including painful
menstruation. Generally, false unicorn root is taken as a tincture (2-5 ml
three times per day). The dried root may also be used (1-2 grams three
times daily). It is typically taken in combination with other herbs
supportive of the female reproductive organs.
Dong quai has been
used either alone or in combination with other Traditional Chinese
Medicine herbs to help relieve painful menstrual cramps. Many women take
3-4 grams per day. A Japanese herbal formulation known as
toki-shakuyaku-san combines peony root (Paeonia spp.) with dong quai and
four other herbs and has been found to effectively reduce symptoms of
cramping and pain associated with dysmenorrhea.27
Vervain is a
traditional herb for dysmenorrhea, however there is no research to
validate this use. Tincture has been recommended at an amount of 5-10 ml
three times per day.
Clinical reports from Germany have suggested
that vitex may help relieve different menstrual abnormalities associated
with premenstrual syndrome, including dysmenorrhea.28 These studies used
40 drops of a liquid preparation that delivers the equivalent of 40 mg of
the dried berries of the plant.
Are there any side effects or
interactions? Refer to the individual herb for information about any side
effects or interactions.
Other integrative approaches that may be
helpful: Relaxation techniques have been used with some success to
alleviate dysmenorrhea in some young women. According to one preliminary
study, the symptoms of menstrual cramps, nausea, irritability, and poor
concentration greatly improved after 20-minute relaxation sessions twice
per week.29
Acupuncture may be a useful therapy in the treatment of
dysmenorrhea. A preliminary trial reported that 86% of women treated with
acupuncture for dysmenorrhea had complete cessation of pain for three
consecutive menstrual periods.30 Other preliminary trials have
demonstrated similar results. 31 32 33 A controlled clinical trial
reported 91% efficacy with acupuncture compared to 36.4% efficacy with
sham acupuncture (using fake acupuncture points) and 18% efficacy in an
untreated control group.34 A small trial compared a 30-minute TENS
(transcutaneous electrical nerve stimulation) treatment to stimulate
acupuncture points with a placebo pill for dysmenorrhea. There was a large
placebo effect in this study, and pain relief over the next several hours
was not significantly better in the treatment group compared to placebo.35
More controlled trials are needed to determine whether acupuncture is a
useful treatment for dysmenorrhea.
Spinal manipulation has been
investigated as a treatment for dysmenorrhea. One small preliminary study
reported improvement in symptoms measured by a questionnaire.36 A
controlled clinical trial compared a single treatment of spinal
manipulation to the low back and pelvis to a sham manipulation that was
designed to be ineffective. Women receiving real manipulation reported
twice as much relief as those receiving sham treatment.37 A recent, larger
trial repeated the above study, testing a series of treatments over two
months. Women reported less pain from both real and sham treatment, but
there was no difference between the groups.38 Whether there is a real
benefit from spinal manipulation for women with dysmenorrhea remains
unclear at this time.
References:
1. Galeao R. La
dysmenorrhee, syndrome multiforme. Gynecologie 1974;25:125 [in
French].
2. Metheny WP, Smith RP. The relationship among exercise,
stress, and primary dysmenorrhea. J Behav Med 1989;12:569-86.
3.
Bolomb LM, Solidmum AA, Warren MP. Primary dysmenorrhea and physical
activity. Med Sci Sports Exerc 1998;30:906-9 [review].
4. Hudgins
AP. Am Practice Digest Treat 1952;3:892-3.
5. Hudgins AP. Vitamins
P, C and niacin for dysmenorrhea therapy. West J Surg
1954;Dec:610-1.
6. Penland J, Johnson P. Dietary calcium and
manganese effects on menstrual cycle symptoms. Am J Obstet Gynecol
1993;168:1417-23.
7. Thys-Jacobs S, Starkey P, Bernstein D, et al.
Calcium carbonate and the premenstrual syndrome: effects on premenstrual
and menstrual symptoms. Am J Obstet Gyencol 1998;179:444-52.
8.
Durlach J. Neuromuscular and phlebothrombotic clinical aspects of primary
magnesium deficiency. Z Ernahrungswiss 1975;14:75-83 [in
French].
9. Martignoni E, Nappi G, Facchinetti F, Gennazzani AR.
Magnesium in gynecological disorders. Gyn Endocrinol 1988;2(Suppl 2):26
[abstract].
10. Benassi L, Barletta FP, Baroncini L, et al.
Effectiveness of magnesium pidolate in the prophylactic treatment of
primary dysmenorrhea. Clin Exp Obstet Gynecol 1992;19:176-9.
11.
Fontana-Klaiber H, Hogg B. Therapeutic effects of magnesium in
dysmenorrhea. Schweiz Rundsch Med Prax 1990;79:491-4 [in
German].
12. Seifert B, Wagler P, Dartsch S, et al. Magnesium-a new
therapeutic alternative in primary dysmenorrhea. Zentralbl Gynakol
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13. Fontana-Klaiber H, Hogg B.
Therapeutic effects of magnesium in dysmenorrhea. Schweiz Rundsch Med Prax
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14. Deutch B. Menstrual pain in Danish
women correlated with low n-3 polyunsaturated fatty acid intake. Eur J
Clin Nutr 1995;49:508-16.
15. Harel Z, Biro FM, Kottenhahn RK,
Rosenthal SL. Supplementation with omega-3 polyunsaturated fatty acids in
the management of dysmenorrhea in adolescents. Am J Obstet Gynecol
1996;174:1335-8.
16. Deutch B, Jorgensen EB, Hansen JC. Menstrual
discomfort in Danish women reduced by dietary supplements of omega-3 PUFA
and B12 (fish oil or seal oil capsules). Nutr Res
2000;20:621-31.
17. Gokhale LB. Curative treatment of primary
(spasmodic) dysmenorrhoea. Indian J Med Res 1996;103:227-31.
18.
Hudson T. Natural progesterone: Clinical indications in women's health.
Townsend Letter for Doctors and Patients 1999;Dec:140-3.
19. Zhu
YP. Chinese Materia Media: Chemistry, Pharmacology, and Applications.
Australia: Harwood Academic Publishers, 1998, 445-8.
20. Zhu YP.
Chinese Materia Medica: Chemistry, Pharmacology, and Applications.
Australia: Harwood Academic Publishers, 1998, 445-8
21. Nicholson
JA, Darby TD, Jarobe CH. Viopudial, a hypotensive and smooth muscle
antispasmotic from Viburnum opulus. Proc Soc Exp Biol Med
1972;40:457-61.
22. Hoffmann D. The Holistic Herbal. Forres,
Scotland: The Findhorn Press, 1986, 88.
23. Murray MT. The Healing
Power of Herbs. Rocklin, CA: Prima Publishing, 1995, 376.
24.
Bradley PR, ed. British Herbal Compendium, vol 1. Bournemouth, Dorset, UK:
British Herbal Medicine Association, 1992, 34-6.
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Therapeutic Guide to Herbal Medicines. Boston, MA: Integrative Medicine
Communications, 1998, 90.
26. Jones TK, Lawson BM. Profound
neonatal congestive heart failure caused by maternal consumption of blue
cohosh herbal medication. J Pediatr 1998;132:550-2.
27. Kotani N,
Oyama T, Hashimoto H, et al. Analgesic effect of a herbal medicine for
treatment of primary dysmenorrhea-a double-blind study. Am J Chinese Med
1997;25:205-12.
28. Loch E, B”hnert KJ, Peeters M, et al. The
treatment of menstrual disorders with Vitex agnus-castus tincture. Der
Frauenarzt 1991;32:867-70 [in German].
29. Ben-Menachem M.
Treatment of dysmenorrhea: A relaxation therapy program. Int J Gynaecol
Obstet 1980;17:340-2.
30. Yuqin Z. A report of 49 cases of
dysmenorrhea treated by acupuncture. J Tradit Chin Med
1984;4:101-2.
31. Xiaoma W. Observations of the therapeutic effects
of acupuncture and moxibustion in 100 cases of dysmenorrhea. J Tradit Chin
Med 1987;7:15-7.
32. Chuang Z. Treatment of 32 cases of
dysmenorrhea by puncturing hegu and sanyinjiao acupoints. J Tradit Chin
Med 1990;10:33-5.
33. Lin L. Literature research on point injection
with Chinese Angelica liquor. J Tradit Chin Med 1998;18:308-12.
34.
Helms JM. Acupuncture for the management of primary dysmenorrhea. Obstet
Gynecol 1987;69:51-6.
35. Lewers D, Clelland JA, Jackson JR, et al.
Transcutaneous electrical nerve stimulation in the relief of primary
dysmenorrhea. Phys Ther 1989;69:17-23.
36. Thomason PR, Fisher BL,
Carpenter PA, Fike GL. Effectiveness of spinal manipulative therapy in
treatment of primary dysmenorrhea: a pilot study. J Manip Physiol Ther
1979;2:140-5.
37. Kokjohn K, Schmid D, Triano J, Brennan P. The
effect of spinal manipulation on pain and prostaglandin levels in women
with primary dysmenorrhea. J Manip Physiol Ther 1992;15:279-85.
38.
Hondras MA, Long CR, Brennan PC. Spinal manipulative therapy versus a low
force mimic maneuver for women with primary dysmenorrhea: a randomized,
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