Painful Periods

Normal?
Mother nature intends animals to get pregnant every time they ovulate. In humans, a menstrual period is a failure for the woman to conceive.
Any period could therefore be considered to be abnormal. 

Need treatment?
The severity of menstrual pain, called dysmenorrhoea, varies markedly in different women and from time to time.

Some women feel no pain or only very mild pain. But, some are incapacitated by severe pain, often accompanied by heavy bleeding. Given that humans have frequent periods, is this acceptable? And, at any age?

No woman of any age should have to put up with very painful periods. They should not have to stay home causing loss of education and disruption of work. They should not be told to put up with it. This includes young women having their first few periods. They should not be told that they should wait to grow out of it.

Painful periods can be a sign of pathologic disease such as endometriosis or adenomyosis. Not treating such diseases early can have life-long adverse effects such as infertility and requiring extensive surgery. Young women can be developing endometriosis from their first period.

How to manage dysmenorrhoea
Simple measures may help sufficiently. These include massage, heat packs, exercise or paracetamol. If over only a couple of cycles of no relief, move to the next step without delay.

The next step is to try NSAIs such as Nurofen, Naprosyn and Voltarin.. Some work better for different patients than others. But if relief is not substantial over a couple of cycles, move to the next step without delay.

The next step is hormone control of the cycle. The cheapest and most convenient hormone treatment is a contraceptive pill. Chose a cheap median dose monophasic pill such as Microgynon 30 or one of its generics. If acne is a problem, a pill such as Brenda containing cyproterone may also help that. Low dose pills with 20mcg ethinyloestradiol are less likely to work well. If after a couple only of cycles, dysmenorrhoea is still a problem, add a NSAI during the expected time that pain is felt. If then after a couple more cycles, the pain is still severe, move to the next step without delay.

At this stage, any physiological pain caused by prostaglandin release from the shedding endometrium should have been adequately treated. If the pain persists, it strongly suggests a pathological cause. This diagnosis can be made within 8 cycles. Some of the steps to get here can be bypassed in an effort to improve the quality of life of the person with severe or disabling dysmenorrhoea.

So, we are now at the stage or diagnosing a pathological condition. This could be caused by a rare congenital abnormality such as a rudimentary horn of one side of the uterus. But, almost certainly, it suggests endometriosis or adenomyosis.

Managing possible endometriosis or adenomyosis
These are progressive diseases. Only early diagnosis and treatment will stop progression and preserve fertility.

The “gold standard” is to do a laparoscopy to see endometriosis is present and to treat it at the same time. No visible abnormality leads to a diagnosis of adenomyosis although this may also be suggested by the uterine appearance.

Any treatment must attempt to preserve fertility if the woman desires that option.

Unfortunately, endometriosis frequently re-occurs no matter how well and completely the surgery is performed.

Taking a contraceptive pill continuously to avoid periods does not stop the progression of endometriosis.

For adenomyosis, the management is more clear cut. The only way to stop the pain is to stop the periods. An oral contraceptive pill is frequently prescribed but even if it given continuously does not prevent progression of the disease. Breakthrough bleeding is common and will always be accompanied by the severe pain previously felt.

There only two pathways that I have found successful in managing adenomyosis. The obvious one is a hysterectomy. However, this not an option if fertility is desired or even if there is ambivalence about wanting to preserve fertility. The other option is continuous high dose progestogen therapy.

Continuous progesterone therapy can usually be achieved with oral Provera. Unfortunately, its generic Ralovera does not seem to be particularly bioactive and should not be used. Depot Provera seems to be too small a dose to adequately control many women’s cycle with breakthrough bleeding causing more pain which is difficult to control. Long term use of oral Provera over many years has the theoretical risk of causing osteoporosis but bone mineral density studies do not support this. “High dose” Provera using 30 – 100mg daily in two doses is well tolerated by 80% of patients and cannot be taken by about 10%. Provera also comes in 500mg tablets and several of these daily do not cause any more side effects, but is only used after treating some cancers.

Because of the high chance of endometriosis recurring after treatment, I recommend immediate suppressive treatment with continuous Provera as above, unless fertility is wanted at that time.

In a young woman, it may be reasonable to prescribe continuous Provera without doing a laparoscopy. The progress of any endometriosis will be arrested. When conception is desired, the Provera can be stopped. If conception does not occur within a few cycles, a laparoscopy could be done then with the same success expected as for one performed before the suppressive treatment.

The half-life of Provera is short and when stopped, its bioactivity should have ceased within 48 hours.