Dysmenorrhea: Period Pain

by Patricia “Mickey” Stuart, MPH, MS, CDCES

It is estimated that 67 – 90% of women between 17 to 24 years of age report symptoms of dysmenorrhea or period pain. The discomfort has been described as mild to unbearable. It’s associated with increased work absenteeism and frequent disruption to normal daily activities.

Period pain has also been identified as the number one reason school-age females report for school absenteeism. Losing a week of normal activities every 4 – 6 weeks can be problematic and unacceptable. Rather than suffering through pain, finding a better option is preferred.

Is “period pain” real?

During the menstrual period, decreasing reproduction hormones (estrogen and progesterone) trigger the menstrual process. The shedding uterus lining triggers the release of prostaglandins. Prostaglandins trigger the uterus to begin contracting for the purpose of expelling the lining tissue. Is the discomfort or pain real? Yes, it can be very real.

Sometimes the intensity of the dysmenorrhea or “period pain” is mild, and sometimes it can be very uncomfortable with symptoms including back pain, low abdominal or pelvic pain, and, sometimes, nausea, headaches, dizziness, or diarrhea.

Because women experience the menstrual period differently, it can often be difficult to know if the symptoms experienced are more intense or difficult than they should be. Additionally, symptoms may occur prior to menstrual flow and/or continue until the old uterine lining is expelled and hormones and prostaglandin levels return to a non-menstrual state.

Is period pain treatable?

With the potential of affecting so many women, why don’t we have a “fix” for this? There’s a whole industry out there marketing dysmenorrhea solutions. Walk into a pharmacy and prepare to be amazed by the over-the-counter options available to make this time of the month “better” by reducing fluid retention and that bloated feeling, reducing the emotional fluctuations associated with pre-menstrual syndrome (aka, PMS), and even some herbs and/or pain relievers.

Healthcare providers may prescribe various medications, birth control pills, and/or pain relievers. Additionally, there are physiotherapy treatments and devices for general pain which can include period pain, e.g., heated abdominal compress pads and patches, special devices that emit a mild electrical current (TENS units) to disrupt the pain pathway, acupuncture, acupressure, and more.

The challenge is that there’s no guarantee that any of these measures will produce satisfactory results. So, for many women, that special time of the month is an unwelcomed visitor that disrupts their lives for a few days and leaves them flummoxed that they will probably have this experience again in about a month.

What’s a girl to do? Stop “settling” and let’s get real.

Reality check: “One-size-fits-all” is not real. Some of those over-the-counter products do work for some people. Sometimes a pain reliever is all that necessary. Sometimes birth control pills help — but what if you don’t want to take them? Then there’s the physiotherapy options. Access could be an issue — my nearest acupuncturist is closer than I expected (and after 3 years in Japan I do respect acupuncture and acupressure as options). Yet, with all this, a lot of women are still very uncomfortable.

Here’s another reality check: Research supports certain types of exercise has a significant effect on period pain, quality of life and daily function in the majority of women reporting period pain symptoms. Physical activity can relieve period pain by improving blood flow; lowering prostaglandin levels; increasing serotonin levels (“happy” hormone); increasing the body’s natural pain relievers called beta-endorphins; and relaxing muscle tension in the abdomen, back and pelvis. Full disclosure: I’m an exercise physiologist and support using exercise as medicine. What do you have to lose?

Start with exercise

If you’re new to exercise, start with only 5 – 10 minutes of increased activity 2 – 5 times a day. Work toward longer activity periods by increasing physical activity duration in 5-minute increments every 3 – 5 days of activity. It is interesting to note that women that have well established physical activity patterns have reported perceiving a greater rate of exertion when menstruating. So, lowering the intensity and duration may be preferable for them also.

The activity should be low intensity vs high intensity. High intensity activity has actually been associated with increasing period pain. The types of exercise or physical activity recommended includes:

Walking

Light walking keeps blood flowing without over stressing the body. The focus is to keep the intensity low, the movement comfortable, and the mindset relaxed.

The toughest part of this is to keep the intensity low and not brisk. The best indicator of intensity is to use a modified talk test. In moderate or brisk walking, you should be able to talk but not sing. For a light walk, you should be relaxed enough to comfortably sing a song without gasping for breath. On a 10-point perceived exertion scale, a light walk should be less than a 5. If you’re doing this on a treadmill, keep the incline 0 and the speed 2.5 mph or less. At this intensity, this activity only requires comfortable clothes and shoes.

Keeping the movement comfortable is simply “walking tall” allowing the normal relaxed shoulders and normal swaying movement of the arms. This is not “power walking” with 90 degrees bent elbows. The walking is gentle with a comfortable heel-to-toe roll.

The mindset should be relaxed. Listen to a book on tape, music, or just enjoy the sounds of life. This is important since if you’re mentally stressed, it tends to spread from head to toe.

Yoga, tai chi, Pilates, and/or stretching

Yoga and tai chi may be among the most misunderstood activities in the US. While they are often confused with each other, too many people ignore the traditions of the activities and make them just part of gym workouts or stretching routines. These activities appear slow and deliberate. The goal for these activities is focused and controlled breathing with controlled movement and stretching.

Tai chi has been widely recommended for older adults as it has proven to support balance. Interesting enough, at its core tai chi is actually a Chinese martial art. It relies on continuous circular movements while in an upright position. While small fragments of tai chi are often taught in exercise classes, the full depth of tai chi includes mindfulness and builds strength while fostering a relaxed state.

Yoga’s popularity seems to rest primarily as a “stretching flexibility” trend. This understanding misses the Indian philosophy and mental discipline goal. Yoga is not intense. It includes deliberate movement with gentle static poses. The participant may be standing or on a floor mat. Like tai chi, it is often included in small fragments as part of an exercise class warm-up or cool-down.

Pilates focuses more on strengthening deep core muscles. It improves posture and stability more by strength than flexibility. Just like tai chi and yoga, Pilates is also frequently included in fragments as part of exercise programs.

Low impact cardio and/or strength training

The emphasis here is on “low impact” and “low intensity” activity, stretch bands, and/or weights. For way too long the phrase “no pain, no gain” has echoed exercise facilities drowning out the benefits of low intensity activities – but research has proven the benefits are legitimate.

Let’s begin by making sure we’re all talking about the same thing: Low impact means one foot stays on the ground during exercise. There is no jumping, hops, wide side-steps, high knee marching, or quick toe taps.

If using weights, upper body recommendations are 5-pound weights or less; lower body recommendations are 10-pound weights or less. If you are accustomed to exercising at a greater intensity, then use 30 – 50% of your one-repetition maximum or select a weight you can lift easily for 15 – 20 repetitions.

Remember that tempo can impact intensity also. If there’s music, keep the beats per minute (BPM) to approximately 120 BPM or less. If you’re wondering the best way to determine 120 BPM, consider one of these options:

Metronome: A mechanical metronome is a spring loaded pendulum that controls the tempo by adjusting a weight. When activated, it produces a constant clicking sound as the pendulum rocks back-and-forth allowing a visual and audible cue to the selected rhythm.
Digital metronome: This may be a phone app designed to replace the mechanical metronome. Android and Apple offer free apps to download these devices.
Spotify 120 BPM playlist: (admittedly, this could be the most fun) Spotify is an online audio streaming service available for all platforms (computer users or cell phones). Spotify can be free with ads or without ads with a subscription. It actually has an established 120 BPM playlist of songs with a 120 beats per minute criteria. NOTE: Apple’s iTunes does not currently have this option, but you can always create your own iTunes playlist of 120 BPM songs.

While I have repeatedly used the term mindfulness or mindset, I should probably define what this means. Mindfulness in physical activity means focusing on the process of the activity vs getting the pose correct or counting down the reps. It is a higher awareness and focus on the step-by-step process and bodily sensations associated with the activity and how this experience makes you feel. Any mental wanderings are examined with curiosity and kindness vs criticism.

For those truly new to mindfulness this focus does not come easily; it does take practice. Breathing can become an anchor to help “center” the user when distracted by discomfort. This changes thoughts toward more positive thinking or positive mindset. It is through repeating the practice that you learn how to find this “center” during life’s more stressful moments and/or more bodily aches and pains. Because the brain selectively chooses where to guide its focus, finding this “center” moves the brain’s focus away from the signals of pain and thereby lessens its perception of that pain.

In summary . . .

Reality: there is no one-size-fits-all. Find the activity that interests you or “fits” you. The goal is to increase the body’s natural relaxation response — low and slow is preferred. It does take practice. The benefits will not happen overnight. Remember, this is all 100% for you and that you deserve a less stressful lifestyle. These activities have been shown to relax tight muscles and lower the volume of stress hormones that amplify body discomforts.

It’s been said, “if physical activity could be bottled, it would be the most widely prescribed product on earth” (Robert N Butler, MD). Remember that period pain can be a unique experience, and response to physical activity is unique. As such, a medical provider should confirm what the source of your discomfort may be and remove the concern that it’s something else that could be more urgent.

Don’t settle for the usual. Take charge. Live better.