Medically reviewed by Dr. Stacy Hengisman MD and Felice Ramallo MSRD.
For many women, periods are often accompanied by some level of discomfort or pain. But what happens when that discomfort turns into something more extreme or intense? When the pain becomes so severe that it interferes with daily activities or even leaves you bedridden?
Menstrual pain (aka dysmenorrhea) can have a variety of different causes, some of which are minor and easily treatable, while others are more serious and require medical attention. While it can be confusing and overwhelming to try to understand the difference between normal period pain and something more serious, finding relief for your symptoms is possible. Read on to learn more about the various things that could be contributing to your pain, and how to find the right treatment options, including the surprising treatment option (hint: pelvic physical therapy) that can help you find some serious relief.
What causes period pain
As annoying as they are, menstrual cramps are a reality for the majority of us. The pain can be classified into two types: primary dysmenorrhea, and secondary dysmenorrhea.
Primary dysmenorrhea describes the cramping pain that is associated with the process of menstruation, and typically appears in the years following menarche (your first period). It occurs around the time you start your period, and can last up to three days. Symptoms associated with primary dysmenorrhea include:
- Cramping/pain in the lower abdominal area which can radiate into the low back, and thighs
- Headaches
- Fatigue
- Swollen chest or breast tissues
- Varying gastrointestinal symptoms including bloating, nausea/vomiting, diarrhea, constipation
- Urinary frequency
- Mood and appetite changes
Primary dysmenorrhea is thought largely to be caused by the chemicals called prostaglandins. Prostaglandins are common chemicals involved in the body’s process of inflammation, prostaglandins are also produced in the uterus during menstruation, helping the smooth muscle in the uterus contract, and assisting in the shedding of the uterine lining (endometrium). It is also thought to contribute to dysmenorrhea by constricting the blood vessels in the uterus, which may reduce blood flow and irritate the nerves, causing pain. Research shows that the level of prostaglandins may be higher in those who experience dysmenorrhea.
When is it more than just period pain?
When pain becomes severe, changes over time, and/or impacts you beyond the confines of your period, it may be considered secondary dysmenorrhea which is menstrual related pain caused by disorders of the reproductive system.
With secondary dysmenorrhea, pain is typically longer lasting, and can become more severe as your menstrual cycle progresses. Symptoms of secondary dysmenorrhea may include:
- Later onset, usually beginning around the age of 25
- A change in the onset, duration and intensity of menstrual related pain
- Pelvic abnormalities on physical exam
- Painful sex (dyspareunia)
- Your period may last longer than 7 days (menorrhagia)
There are varying causes of secondary dysmenorrhea including:
- Endometriosis
- Uterine fibroids
- Adenomyosis
- Defects in the reproductive anatomy that can contribute to pain during menstruation
- Crohn's or some urinary disorders that may flare during menstruation, and contribute to pain.
- Pelvic infections/STI
- PCOS
Why getting relief from period pain is difficult (but it shouldn’t be)
For a long time, women’s pain has been minimized in the medical space. Fortunately, it looks like this might be changing for the better: While The Washington Post reported in 2022 that “several studies support the claim that gender bias in discrimination routinely leads to a denial of pain relief for female patients for a range of health conditions,” we all know that the first step toward solving a problem is acknowledging it exists in the first place. And for the first time in much of history, there is increasing recognition of how prevalent (and detrimental) medical gaslighting is.
Generally, the rule of thumb is that your menstrual cramps are “severe” when they:
- Don’t improve when you take over the counter pain medication
- Interfere with your daily activities
- Are also accompanied by heavy bleeding and/or clotting
That being said, if you are worried your cramps are too much, they are emotionally impacting you in a negative way, or you are worried about your level of pain: it is imperative that you make an appointment with your primary care doctor. Please do not worry about being perceived as ‘dramatic’ or ‘ridiculous’ - a good doctor will listen to your concerns and work with you to understand what is going on, so you can have peace of mind.
Why you shouldn’t delay getting help for your period pain
Like in the case of primary dysmenorrhea, period pain can be perfectly normal. However, sometimes it can be indicative that something more is going on. As mentioned above, really bad period pain is often associated with both PCOS and endometriosis — two reproductive health conditions that can be extremely disruptive to one’s well being, and have long-term health implications spanning from a higher risk of infertility, to increased risk of diabetes, and a bunch of physical symptoms that can be difficult to manage.
First, let’s talk about period pain in the context of PCOS. PCOS, or polycystic ovarian syndrome, is thought to be a result of androgen dominance and insulin resistance. With PCOS you may notice symptoms such as:
- Excess hair growth on the body
- Acne
- Alterations in your menstrual cycle including irregular or absent periods (as a result of a lack of ovulation), a heavy flow, clotting, and increased pain and cramping.
Endometriosis (aka endo) is another common cause of secondary dysmenorrhea, and excessively painful periods. Endometriosis is an inflammatory condition in which tissue that is similar to the lining of the uterus, grows outside of the uterus, leading to pain and dysfunction including:
- Systemic inflammation
- Adhesions that restrict the normal movement of organs and tissues
- Nerve sensitization
- Pressure of endometrial tissues on surrounding organs and tissues
- Central nervous system changes that amplify pain
- Pelvic floor muscle spasms
Treatments for period pain
When it comes to primary dysmenorrhea, there are several fairly effective treatment options to help you find relief.
- OTC Medication
Nonsteroidal anti-inflammatory drugs (otherwise known as NSAIDs) are the typical pain relief medication recommended, including ibuprofen and naproxen. NSAIDs block the production of prostaglandins to ease pain. Check in with your doctor to make sure this is good option for you.
- Superficial Heat
Applying a heating pad to your abdomen or taking a warm bath are good examples of how to use superficial heat to ease your pain. Heat can be both psychologically and physically soothing when experiencing period pain. One 2018 review of studies found that heat was as effective as NSAIDs at reducing pain, and while more research is needed in this area, heat pads can be a good addition to NSAIDs or alongside other tips to reduce menstrual cramps.
- Massage therapy
If you like massages, this could be a great recommendation for you - a review of studies found evidence to suggest that massage therapy and aromatherapy could be helpful in reducing period pain.
However, if you are still left with unmanageable period pain, or you feel that something is off, you should speak to your primary care doctor immediately. As we discussed before, because intense period pain can be a result of other medical conditions, measures that are often helpful for those with primary dysmenorrhea are not often enough. Finding the underlying cause of your pain is not only important for your health, it is often the key to relief from your pain.
Pelvic floor PT in managing period pain
After checking in with your physician to help you get some answers for your pain, pelvic physical therapy is another helpful treatment option. Pelvic floor physical therapy is proven to be very effective for those with chronic pelvic pain, including conditions known to exacerbate menstrual pain such as Endometriosis or PCOS. Pelvic floor physical therapy can not only help you to better manage your period pain, but it can help relieve the bowel, bladder, and sexual symptoms that commonly accompany secondary dysmenorrhea. For any period related pain it is common for physical therapy to include the following in your plan of care:
- Manual therapy techniques: Pelvic physical therapists are highly skilled in various manual therapy techniques to treat pain in the pelvic area helping to restore normal movement and function in the muscles and various tissues in the area.
- Posture and balance restoration: Education and exercise are used to help you move out of protective postures and restore balance in your body while you sit and stand.
- Lifestyle and behavioral strategy education: It is commonto develop a variety of behaviors meant to help you cope with pelvic pain, but unfortunately they often turn into habits that perpetuate pain. Pelvic floor physical therapy will help you target these habits, and work with you to develop healthier strategies to manage your symptoms.
- Exercise: Using a variety of movement based therapies and exercises physical therapy will help you move in ways that feels safe and painfree.
- Home Programs: Home programs help you take the relief found during physical therapy, home with you. These may consist of stretches, exercises, or self care techniques that will help to reinforce your physical therapy goals. Where appropriate, they may also include tools like pelvic wands or vaginal dilators to support manual therapy techniques used in the clinic.
Allara Health provides personalized treatment that takes the guesswork out of managing your hormonal imbalance, and offers a customized, holistic plan of attack that merges nutrition, medication. supplementation, and ongoing, expert support to begin healing your body.