Menstrual cramps or period pain (dysmenorrhoea) has been seen in approximately 25% of women though some studies quote figures as high as 60%. The symptoms are more in young women and may reduce with age. Its severity may differ from mild discomfort to severely incapacitating pain involving the use of pain killers and absence from work.
As menstruation involves the shedding of the endometrium which lines the uterus (womb) there are always some uterine contractions involved. This is due to the release of prostaglandins, substances that cause the uterus to contract. If there is heavy bleeding, more than the ability of the body to maintain it in liquid form, there may be clots passed and this causes further pain due to uterine contractions and dilatation of the cervix (mouth of the uterus) to push them out.
The important issue to check in these cases is if there is any pathology or disease-causing this pain or is it just psychological or natural in that patient. Especially if the cramps are of recently onset, they need to be investigated.
Pelvic sonography is a simple test that gives information about the presence of conditions like fibroids, endometriosis, adenomyosis, endometrial hyperplasia, polyps, etc which can cause excessive menstrual cramps and period pain, and sometimes heavy bleeding. Depending on the pathology, treatment can be planned. Fibroids can be removed by key-hole or laparoscopic or Hysteroscopic surgery depending on their location.
Endometrioma on a collection of thick dark blood in the ovaries can be removed laparoscopically. The thickness of the lining of the uterus needs to be checked by hysteroscopy and biopsy to rule out any major disease like cancer. Polyps can be removed hysteroscopically.
Adenomyosis, which is the collection of tiny pools of blood, in the walls of the uterus, is a progressive disease and is difficult to treat except by temporarily stopping the menses with hormonal medication for a few months or years. Sometimes when there is an extensive mass of adenomyosis, it can be removed laparoscopically. In a woman who does not wish to reproduce any further, a hormonal intrauterine device can be put inside. This will reduce or stop menstrual bleeding for 5 years and hence the pain associated with it. Unfortunately, all of these conditions can reoccur and may require repeat surgery. Hence in older women, removal of the uterus may sometimes be a good permanent solution.
If there is no obvious problem seen on examination or sonography, the patient can be given some safe and effective pain killers, which are often anti-prostaglandins, and also drugs to reduce menstrual bleeding such as Tranexamic acid. These can keep reducing pain and bleeding by 50%. In some resistant cases, hormone pills may be necessary, cyclically or continuously for long periods of time. Acupressure, behavioral interventions, thiamine, vitamin E and topical heat have been tried with some benefits.
In some patients, none of these treatments work, then laparoscopy is advised. Here a thin telescope is put into the abdomen and the pelvis is examined for problems. Often one can diagnose mild endometriosis, pelvic adhesions, pelvic congestion, tuberculosis, or some infection and appropriate therapy can be started.
If there is intractable pain, then during the laparoscopy, some pain relief procedures can be done such as LUNA (Laser uterine nerve ablation) or presacral neurectomy, where the pain-causing nerves are excised.
Though considered normal, menstrual cramps can become a life-altering problem and have to be treated with care and sensitivity.
dr. Rishma Dhillon Pai, Consultant Gynecologist
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