Invisible pain

From 'wait-and-watch' to 'have babies': Women with period pain get more advice than treatment

There is little clarity on how much menstrual pain is considered clinically normal.

Until recently, Kamakshi Kumar (name changed) had reason to dread the onset of her period. The 34-year-old media professional would routinely spend the first day of her period wracked with cramps that were often severe enough to cause nausea and vomiting. On more than one occasion, Kumar’s pain was so acute that it caused fainting spells.

Like several other women who are accustomed to varying degrees of discomfort before or during their period, Kumar tried to deal with the pain by using hot water bags and anti-spasmodic medication to relieve the cramps. It did not help matters that many of the gynaecologists she met advocated childbirth as a solution. “When I finally mustered up the courage to see a doctor, she gave me a moral lecture and insisted I got married,” she said. “She said this pain was because I don’t have a child. She scared me, and I bore the pain.”

In effect, pregnancy and childbirth are the only long-term solutions many gynaecologists offer for this immediate problem.

Although extreme, Kumar’s experience is far from an isolated one. Period pain – or dysmenorrhea, as it is referred to in medical terms – is an exceedingly common affliction among women of reproductive age. According to a paper published in the journal Epidemiologic Reviews, an analysis of 15 primary studies on dysmenorrhea showed that, “The prevalence of dysmenorrhea varies between 16% and 91% in women of reproductive age, with severe pain in 2%-29% of the women studied.” Despite its widespread prevalence, however, dysmenorrhea remains an invisible condition, often borne silently by those who suffer from it.

Most commonly, dysmenorrhea is caused by chemical changes that take place in the body as part of the menstrual process. At the onset of menstruation and sometimes even a couple of days before, the muscular wall of the uterus contracts to shed its blood-rich endometrial lining. The trigger for these contractions to begin is provided by hormone-like chemicals known as prostaglandins, which are also associated with pain and inflammation.

Together, these two factors cause a constellation of symptoms – such as cramps, bloating and water retention – that are together known as primary dysmenorrhea. Dysmenorrhea can also be caused by underlying disorders in the reproductive organs such as fibroids or endometriosis, a painful condition in which endometrial tissue that normally lines the inside of the uterus grows outside it. This is known as secondary dysmenorrhea and usually occurs among women older than 30.

Debilitating pain is not normal

One of the challenges in treating primary dysmenorrhea is that despite being widespread, it continues to remain a bit of a mystery. There is little clarity on what is considered “normal” – and why some women suffer more than others. In general, gynaecologists say that acute period pain is most common among teenagers who have just started menstruating. “Many youngsters have spasmodic dysmenorrhea [or painful cramps],” said Dr Akhila Sangeetha Bhat, a consultant gynaecologist based in Chennai. “It is pretty normal [at this age].”

However, the understanding of normal period discomfort is hazy. Individual experiences can vary widely, depending on pain thresholds, level of activity and other factors. Gynaecologists are quick to clarify that any kind of severe pain should not be dismissed as routine. “If the pain is debilitating or makes you miss activities like school or work, it definitely merits investigation,” said Dr Suruchi Desai, consultant gynaecologist at Nanavati Hospital and Sujay Hospital in Mumbai.

“It will get better with time”

Since it takes a few years after menarche, or the onset of menstruation, for the cycle to stabilise and fall into a regular rhythm, teenagers and young adults are often told that their pain will improve with time. But this may not be the case for everyone. Often, the wait-and-watch approach is a frustratingly inadequate solution.

Lata Murugan, 49, a film teacher based in Chennai, has seen her teenaged daughter Sanjana experience this first hand. Ever since she started menstruating a couple of years ago, her daughter has had excruciatingly painful cramps, for which she has had to be admitted in hospital once. She got a brief reprieve from the pain after her gynaecologist put her on a six-month course of birth control pills. But a year later, the pain returned. Now back on a course of the pill, Sanjana has also been recommended back-strengthening yoga exercises. “[The doctor] hopes that in three months, the back will be stronger and be able to handle the cramps,” said Murugan. “We have to wait and see.”

Murugan says she is frustrated by the lack of more tangible solutions. “What I’ve seen her go through is terrible,” she said. “I really feel more research is required to tackle this problem.”

One size does not fit all

Currently, the two mainstays of treatment for primary dysmenorrhea include oral contraceptives and non-steroidal inflammatory drugs or painkillers such as ibuprofen. While the former help to relieve pain by reducing the menstrual flow or preventing periods altogether, the latter block pain-causing prostaglandins. However, women with certain underlying conditions such as cardiovascular disease, liver disease or gastric ulcers may not be able to use one or the other of these methods, which further limits their treatment options.

It is clear that there is no single solution to period pain, especially since the triggers may vary from person to person and also change with age. “When you have period pain in the 30-40 age group, there is definitely an organic cause,” said Desai. These could include problems such as fibroids, which develop over time.

Stress, lack of exercise and poor eating habits also have a significant bearing on the problem, according to Desai. Even though some women are handed a worse deal than others when it comes to dysmenorrhea, they can control some aspects of the pain.

“When you exercise and have a healthy lifestyle, it has the same impact on your period as exercise has on any other part of the body,” said Desai. “It helps to disseminate the prostaglandins that cause the cramping.”

In addition, avoiding processed foods that are high in sugar, salt and fat, can relieve some of the discomfort associated with periods. “High sodium foods such as pickles, processed cheese, colas, chips and instant noodles aggravate bloating and water retention,” she said. “Even if you crave them, stay away from them.”

Additionally, several studies have found that women with severe dysmenorrhea produce larger quantities of prostaglandins. None of this additional knowledge has translated to specialised or targeted treatments. A significant study conducted in 2013 found that sildenafil, more commonly known by its brand name Viagra, may be used to treat dysmenorrhea. But more research is required before it is approved as a form of treatment. As this article points out, period pain is largely ignored by the medical community, and there is little funding available for research on the subject.

Marriage is not the answer

The medical approach to period pain is often problematic because it becomes intertwined with moral righteousness. Some studies conducted over the years have shown that dysmenorrhea could significantly reduce or even disappear after childbirth in some women, prompting many gynaecologists pressure women to marry and have children. This is another factor that prevents women from seeking the help they need.

For instance, Kumar put off finding a solution for her worsening period pain because of previous experiences. “My main problem with the doctors I consulted over the years was that they lectured me mostly on the pitfalls of premarital sex and advocated marriage,” she said. “Finally, last year, I went to a renowned doctor who made me do a whole barrage of blood tests and an ultrasound, so that he could fully understand my situation.” After finding nothing seriously amiss, he prescribed birth control pills and vitamins for a deficiency.

Kumar said that this relatively simple solution has changed her life. “I am like a new person now,” she said. “I had a pitch to make on the first day of my period recently. Earlier, it would have been death but this time, I rocked it.”

This is the second part of a series on forms of pain that are not understood well or are ignored or dismissed as minor health issues. Read the series here.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

Relying on the power of habits to solve India’s mammoth sanitation problem

Adopting three simple habits can help maximise the benefits of existing sanitation infrastructure.

India’s sanitation problem is well documented – the country was recently declared as having the highest number of people living without basic sanitation facilities. Sanitation encompasses all conditions relating to public health - especially sewage disposal and access to clean drinking water. Due to associated losses in productivity caused by sickness, increased healthcare costs and increased mortality, India recorded a loss of 5.2% of its GDP to poor sanitation in 2015. As tremendous as the economic losses are, the on-ground, human consequences of poor sanitation are grim - about one in 10 deaths, according to the World Bank.

Poor sanitation contributes to about 10% of the world’s disease burden and is linked to even those diseases that may not present any correlation at first. For example, while lack of nutrition is a direct cause of anaemia, poor sanitation can contribute to the problem by causing intestinal diseases which prevent people from absorbing nutrition from their food. In fact, a study found a correlation between improved sanitation and reduced prevalence of anaemia in 14 Indian states. Diarrhoeal diseases, the most well-known consequence of poor sanitation, are the third largest cause of child mortality in India. They are also linked to undernutrition and stunting in children - 38% of Indian children exhibit stunted growth. Improved sanitation can also help reduce prevalence of neglected tropical diseases (NTDs). Though not a cause of high mortality rate, NTDs impair physical and cognitive development, contribute to mother and child illness and death and affect overall productivity. NTDs caused by parasitic worms - such as hookworms, whipworms etc. - infect millions every year and spread through open defecation. Improving toilet access and access to clean drinking water can significantly boost disease control programmes for diarrhoea, NTDs and other correlated conditions.

Unfortunately, with about 732 million people who have no access to toilets, India currently accounts for more than half of the world population that defecates in the open. India also accounts for the largest rural population living without access to clean water. Only 16% of India’s rural population is currently served by piped water.

However, there is cause for optimism. In the three years of Swachh Bharat Abhiyan, the country’s sanitation coverage has risen from 39% to 65% and eight states and Union Territories have been declared open defecation free. But lasting change cannot be ensured by the proliferation of sanitation infrastructure alone. Ensuring the usage of toilets is as important as building them, more so due to the cultural preference for open defecation in rural India.

According to the World Bank, hygiene promotion is essential to realise the potential of infrastructure investments in sanitation. Behavioural intervention is most successful when it targets few behaviours with the most potential for impact. An area of public health where behavioural training has made an impact is WASH - water, sanitation and hygiene - a key issue of UN Sustainable Development Goal 6. Compliance to WASH practices has the potential to reduce illness and death, poverty and improve overall socio-economic development. The UN has even marked observance days for each - World Water Day for water (22 March), World Toilet Day for sanitation (19 November) and Global Handwashing Day for hygiene (15 October).

At its simplest, the benefits of WASH can be availed through three simple habits that safeguard against disease - washing hands before eating, drinking clean water and using a clean toilet. Handwashing and use of toilets are some of the most important behavioural interventions that keep diarrhoeal diseases from spreading, while clean drinking water is essential to prevent water-borne diseases and adverse health effects of toxic contaminants. In India, Hindustan Unilever Limited launched the Swachh Aadat Swachh Bharat initiative, a WASH behaviour change programme, to complement the Swachh Bharat Abhiyan. Through its on-ground behaviour change model, SASB seeks to promote the three basic WASH habits to create long-lasting personal hygiene compliance among the populations it serves.

This touching film made as a part of SASB’s awareness campaign shows how lack of knowledge of basic hygiene practices means children miss out on developmental milestones due to preventable diseases.

Play

SASB created the Swachhata curriculum, a textbook to encourage adoption of personal hygiene among school going children. It makes use of conceptual learning to teach primary school students about cleanliness, germs and clean habits in an engaging manner. Swachh Basti is an extensive urban outreach programme for sensitising urban slum residents about WASH habits through demos, skits and etc. in partnership with key local stakeholders such as doctors, anganwadi workers and support groups. In Ghatkopar, Mumbai, HUL built the first-of-its-kind Suvidha Centre - an urban water, hygiene and sanitation community centre. It provides toilets, handwashing and shower facilities, safe drinking water and state-of-the-art laundry operations at an affordable cost to about 1,500 residents of the area.

HUL’s factory workers also act as Swachhata Doots, or messengers of change who teach the three habits of WASH in their own villages. This mobile-led rural behaviour change communication model also provides a volunteering opportunity to those who are busy but wish to make a difference. A toolkit especially designed for this purpose helps volunteers approach, explain and teach people in their immediate vicinity - their drivers, cooks, domestic helps etc. - about the three simple habits for better hygiene. This helps cast the net of awareness wider as regular interaction is conducive to habit formation. To learn more about their volunteering programme, click here. To learn more about the Swachh Aadat Swachh Bharat initiative, click here.

This article was produced by the Scroll marketing team on behalf of Hindustan Unilever and not by the Scroll editorial team.