TEEN DOC: Menstrual Cramps Got You Down?

by Dr. Ann L. Engelland

(January 7, 2004) Menstrual cramps or dysmenorrhea is the leading cause of absenteeism among American teenage high school girls. As many as 30% of teens miss at least one day of school or work each month. Acceptable? Something we just have to live with? I think not. This brief article will explain what dysmenorrhea is and describe current thinking about its management.

Dysmenorrhea is a whole constellation or syndrome of symptoms that includes pelvic cramping but also gastrointestinal symptoms (nausea, vomiting, loss of appetite, diarrhea) and aches elsewhere (head, back, legs, stomach or just plain all over) irritability, dizziness and sleep disturbances.

But I’ve had my period for two years and never felt any cramps?

At the outset of a girl’s menstruation she usually does not have accompanying cramps or significant symptoms because she will not begin ovulating until one to three years after the first period (menarche). Ovulation causes the body to produce progesterone and it is this hormone which in turn makes the body produce prostaglandins which stimulate cramping and contraction of the uterine muscles.

So what happens once a girl starts ovulating?

Once ovulation begins, periods become more predictable and regular but they also may be accompanied by any or all (or none) of the symptoms of dysmenorrhea. 90% of dysmenorrheal is “functional” and part of normal physiology. Severe cramping from the outset of menarche warrants an evaluation to rule out “secondary” or more complicated causes of pain.

Don’t most girls know what to do for cramps?

Research shows that most girls do not seek medical advice for their cramps. Most try heat, rest, exercise or “distraction” but only 40% of them say this works.

What about taking over the counter pain medication?

Many of the “OTC” medications work, but most girls do not take them often enough or in strong enough doses to get the maximal benefit.

So what is the trick with OTC medications like Ibuprofen?

The trick is to take the medication at the FIRST HINT that the period is coming and then every 4-6 hours afterwards. Some may need up to 600mg at each dose. A medical caregiver should be consulted if you think you need doses this big.

Are there other medications?

Yes, there are prescription NSAID’s (non-steroidal anti-inflammatory drugs) such as Naproxen sodium, mefenamic acid, and a new class of NSAID’s which work differently. Vioxx and Bextra are brand names which are new and approved for girls and women over 18.

What else can a woman try?

Regular exercise plus specific pelvic exercises are often helpful in managing cramps.

What about nutrition?

There is some interesting recent evidence from Denmark showing that a diet high in omega 3 fatty acids (from fish or from fish oil supplements) may reduce the production of prostaglandins in the uterine tissue and lead to less cramping and the need for less medication.

I’ve heard that birth control pills help cramps?

For many girls, oral contraceptive pills reduce cramping because they stop ovulation (remember that’s why they work as a contraceptive) and progesterone production. Most clinicians don’t start girls on pills until they have tried correct doses of the other medications. Unless of course they need the contraception or the other benefits of hormone pills (say, for acne treatment).

What is Tricycling?

Tricycling means taking hormone pills continuously for three months before having a period. Effectively, girls get a period four times a year on this regimen. The problem in using pills this way for adolescents is that we do not have a lot of experience with it yet and there can be a lot of unpredictable “break-through” bleeding when you least expect or want it.

Overall, the outlook is good for girls and women with dysmenorrhea or menstrual syndrome. It is my philosophy that teens, their mothers and their clinicians should strive for minimal discomfort and absence from school, work or social life. There are a number of tools available to us now, and by working together we can make adjustments in lifestyle, exercise and medication that can really make a difference.

Dr. Ann L. Engelland has a practice in Mamaroneck devoted to
Adolescent Primary Care. 914 698-5544

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