Taming Menstrual Cramps

by Food and Drug Administration (FDA)

For many women "that time of the month" is one they'd rather forgo. More than half routinely experience some form of pain associated with menstruation, say doctors at the Mayo Clinic in Minnesota, and 1 in 10 suffers such severe dysmenorrhea — menstrual pain — she cannot function normally without taking medication.

Throughout history, women have tried to alleviate these menstrual discomforts themselves. But home remedies — teas, hot baths, heating pads, and such — offered only limited help. As recently as a decade ago, when there were far fewer products readily available for menstrual cramps than now, some doctors prescribed powerful prescription painkillers. Others, many women recall, told patients their problems would disappear as they grew older or after they had children. But today, the pain associated with menstruation is taken more seriously, and there are new, highly effective treatments for it.

"Nearly all women — I would say 99.9 percent — should be able to function quite well during their periods with the menstrual treatments available now," says Charles H. Debrovner, M.D., a gynecologist in private practice and on the faculty of the New York University School of Medicine in New York City. What's Causing the Pain?

There are two kinds of painful menses — primary and secondary dysmenorrhea — and it is very important to distinguish between them so both are treated properly, Debrovner stresses. Primary dysmenorrhea usually starts within three years of the onset of menstruation and lasts one or two days each month. While this type of menstrual pain may lessen for some women as they grow older or after the birth of children, it also can continue until menopause.

Secondary dysmenorrhea is menstrual pain caused by disease such as pelvic inflammatory disease, endometriosis (abnormalities in the lining of the uterus), or uterine fibroids (nonmalignant growths). Endometriosis is a major cause of secondary dysmenorrhea. Pain from it usually starts later in life and worsens with time, according to Debrovner. Another hint that disease might be the cause of menstrual pain is if pain also occurs during intercourse or during other parts of the cycle. Primary dysmenorrhea is a result of the normal production of prostaglandins — chemical substances that are made by cells in the lining of the uterus. (Prostaglandins are also produced elsewhere throughout the body.) The lining of the uterus — which has built up and thickened during the early stages of the menstrual cycle — breaks up and is sloughed off at the end of the cycle and releases prostaglandins, explains Lisa Rarick, M.D., medical officer in FDA's division of metabolism and endocrine drug products.

The prostaglandins, in turn, make the uterus contract more strongly than at any other time of the cycle. They can even cause it to contract so much that the blood supply is cut off temporarily, depriving the uterine muscle of oxygen and thus causing pain. Women who suffer painful contractions may be producing excessive amounts of prostaglandins. Or, it may be that some women are just more sensitive to them, says Rarick. The cramps themselves help push out the menstrual discharge. Because the cervical opening is often widened after childbirth or years of menstruation, cramps may lessen in severity later in life.

Most women describe their menstrual cramps as a dull aching or a pressure low in the abdomen. The pains may wax and wane, remain constant, or be so severe that they cause nausea, vomiting, diarrhea, backache, sweating, and an achiness that spreads to the hips, lower back, and thighs. Inhibiting Prostaglandins For many years, women had little help for these symptoms. Doctors recommended aspirin, heating pads, and hot baths. When those failed, they often prescribed painkillers such as Demerol or Tylenol with Codeine. These treatments were all aimed at the perception of pain rather than the cause of it. Even tranquilizers were sometimes used, according to Debrovner. But the advent of pain relievers that impede the production of prostaglandins has made it possible to directly treat the cause of the cramps. Called NSAIDs, for nonsteroidal anti-inflammatory drugs, these medications have proven remarkably effective for many women.

Because NSAIDS inhibit synthesis of prostaglandins, and thereby the contractions of the uterus, they may actually reduce menstrual flow. Many of Debrovner's patients report shorter periods when they take the drugs at the first sign of pain. He recommends taking them as early as possible after the menstrual flow starts. Waiting too long may mean they won't be as effective.

The prostaglandin inhibitors can cause gastrointestinal distress, so most doctors also recommend they be taken with milk and food. Labeling on the OTC products contains this information. While there are about a dozen prescription NSAIDs, three — ibuprofen (Motrin, Rufen, etc.), naproxen (Naprosyn), and mefenamic acid (Ponstel) — are now approved to treat menstrual cramps. OTC Products

FDA approved ibuprofen for over-the-counter use in 1984. It now can be found as the active ingredient in several OTC medications, such as Advil, Nuprin, and Motrin IB. The OTC dose per pill is 200 milligrams. The recommended dose is one tablet every four to six hours (or two, if one does not work), not to exceed six in a 24-hour period. Prescription formulations come in dosages of 400 to 800 milligrams.

Aspirin — long a standard over-the-counter treatment for cramps — works as a prostaglandin inhibitor, although probably not so powerfully as the specific inhibitors such as ibuprofen. While aspirin is known to thin the blood and increase bleeding, it does not appear to have this effect on menstrual flow, according to Rarick.

Researchers are not sure if acetaminophen, an analgesic found in drugs such as Tylenol and Datril, works to prevent prostaglandin production. If it does, its effect appears to be milder than that of aspirin or other NSAIDs. Doctors say, however, that it can successfully treat the headache and backache that often accompany menstrual cramps. Some over-the-counter menstrual pain medications, such as Midol and Pamprin, contain a mix of ingredients that include an analgesic such as acetaminophen, a diuretic such as pamabrom, and an antihistamine such as pyrilamine maleate. Some newer formulations now use ibuprofen in place of more classic analgesics such as aspirin or acetaminophen. Midol 200 Advanced Cramp Formula, for example, contains ibuprofen as its active ingredient. Maximum Strength Midol Multi-Symptom Formula, however, contains acetaminophen as an analgesic. With the variety of ingredients now available, it's wise to read the label to make sure the product is the best one to treat your symptoms. If in doubt, consult your doctor.

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