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.

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