Lack of Awareness and the Normalization of Dysmenorrhea

According to the Spanish Society of Gynecology and Obstetrics (SEGO), dysmenorrhea may affect at least one third of females of reproductive age. However, coming up with an exact figure is difficult, “especially because pain has come to be considered as just part of having your period, and so many girls and women bear this pain for years and years before seeking medical attention,” said Miriam Al Adib, MD. “They’re told that this pain is normal, so they put up with it.” Al Adib is an Ob/Gyn and expert in endometriosis in Madrid, Spain.

“From healthcare workers to society at large, everyone just thinks that it’s normal. So, girls and women end up not going to the doctor,” agreed Francisco Carmona, MD, head of gynecology at Clínic Hospital of Barcelona and scientific and surgery director at the Women’s CD Gynecology Clinic, Barcelona, Spain.

What Is Dysmenorrhea?

Primary dysmenorrhea is caused by myometrial contractions mediated by prostaglandins (mainly prostaglandin F_2alpha). The chemical also causes decreased blood flow to the endometrium and myometrium, uterine ischemia, and sensitivity of the nerve endings. “Although the inflammation originates in the pelvis or lower abdomen, it can radiate to the perirenal spaces, producing the kind of lower back pain that so many girls and women experience as well,” explained Al Adib.

The condition may arise as a symptom of a disease, in which case it is called secondary dysmenorrhea. When there is nothing in the patient’s history to explain the condition, it is referred to as primary dysmenorrhea. According to Carmona, “it’s quite likely that many of the girls and women who seem to present with primary dysmenorrhea — they actually have endometriosis or possibly adenomyosis, which is when endometrial tissue grows into the muscular wall of the uterus. So, many of these patients who have this pain are being underdiagnosed when they very well could be suffering from one of these disorders.” And being an expert in these disorders, he has seen such cases in his gynecology practice.

Pain associated with dysmenorrhea can be mild, moderate, or severe. And it may or may not be accompanied by other complaints — from leg cramps, headache, nausea, dizziness, vomiting, and fainting to fatigue, anxiety, irritability, and even depression. According to SEGO, primary dysmenorrhea usually presents in the months following menarche (the first menstrual period) and in females between ages 17 and 25. Although the pain is known to lessen with age and after giving birth, the condition tends to persist throughout a female’s life.

For some females, the pain can be disabling, so much so that some countries have come to approve leave policies for workers who suffer from incapacitating menstrual pain. Currently, no EU country has a law that provides for menstrual leave. However, there are a couple of exceptions in Spain. The city council of Girona approved a policy last June, and 3 months later, Castelló de la Plana’s city council followed suit. The policies have since become rights protected by labor law. “For those who have severe dysmenorrhea, it’s great to have the option to take menstrual leave,” said Al Adib.

Genetic and Environmental Factors

Although there are genetic factors at play in this condition, “there’s also an environmental aspect; bad habits, stress, eating processed foods, insomnia all can intensify this kind of pain,” Al Adib said. SEGO points out that females who smoke or who are overweight are more likely to develop this painful disorder.

Dysmenorrhea is caused by a prostaglandin imbalance. High levels of prostaglandins lead to inflammation. “For example, processed foods, a sedentary lifestyle, and insomnia can stimulate the production of prostaglandins. Losing weight or gaining weight also alters the balance of hormones in such a way as to favor inflammatory processes. It’s the same with stress, which is regulated by cortisol,” said Al Adib, who has explored the issue in-depth in her books Hablemos de nosotras: reflexiones de una ginecóloga rebelde [Let’s Talk About Us: Reflections of a Rebellious Gynecologist] and Hablemos de vaginas: salud sexual femenina desde una perspectiva global [Let’s Talk About Vaginas: A Comprehensive Look at Female Sexual Health].

The drugs that are used to treat this type of pain are anti-inflammatory painkillers and contraceptives. “Combined oral contraceptives, ‘the pill,’ contain synthetic hormones that inhibit the hypothalamic-pituitary-ovarian axis. This creates an artificial menstrual cycle in which ovulation does not occur,” Al Adib explained. The following behaviors help reduce symptoms: exercising regularly; cutting down on cigarettes, alcohol, and caffeine; following a diet low in saturated fats; drinking more fluids; and getting better sleep. “If dysmenorrhea is the result of bad habits, the first step of any treatment plan would ideally be to advise the patient to replace those habits with good ones. And if things don’t improve, we can start the patient on supplements and come up with a custom nutrition plan to address the high levels of estrogen and inflammation. There are also some other options, such as pelvic floor physical therapy,” she noted. When it comes to dysmenorrhea, Al Adib believes that one of the biggest challenges is the lack of patient information, especially for young females.

A survey of 1000 female high school students in France found that even though a vast majority suffered from dysmenorrhea, half had not consulted a doctor about it. Instead, most took medication on their own — and often not enough to adequately relieve the pain. What was alarming was the percentage of respondents who greatly downplayed their pain symptoms: 55.1% believed that intense pain was a normal part of menstruation.

As for Carmona, he believes that “we need to educate young people about this problem, one that has the potential to greatly affect the lives of girls and women; we need more campaigns to raise awareness, explaining to adolescents that period pain is not normal: having your period doesn’t have to mean pain. Because there’s a genetic component, girls will look at their relatives’ experiences. Their grandmother, their mother, their aunt — when they were young, they experienced the same kind of pains; then, as they got older, things improved. So, based on this, the girls come to the conclusion that this is just how it goes, that they’ve got to hang in there and bear the pain.”

“In biology classes, students learn things that are much more complicated than the menstrual cycle and the causes of period pain. The basic facts of these two topics should be taught as part of the regular curriculum,” said Al Adib. “That knowledge will prove to be so very helpful.”

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