Period pain

Do you have the impression that women's pain is still being neglected in gynaecology?

I don't "have an impression", I know it is. When listening to my patients, I am convinced that painful menstruation is being underestimated all the time, despite the growing knowledge on the subject. Some gynaecologists still tell women that this is their beauty and they have to accept it. There is also social consent to this kind of suffering. Teenagers rarely come to the doctor with painful periods because their mothers and grandmothers tell them: "I experienced it like that too, you'll get over it after childbirth", "Don't go there, it's a family trait". So it has to be said over and over again: this pain is not normal, suffering is not normal.

Women who have painful periods often also hear questions like: "Does it really hurt you that much?", "Are you not exaggerating?". If you, as a gynaecologist, were to explain to these doubters how severe this pain can be, what would you say?

I'd say, "Imagine the strongest pain you've ever experienced – for example, when you broke your leg or passed a kidney stone – and then consider that a period can hurt like that too." My patients often rate this pain as 10 on a 10-point scale, they compare it to labour, and sometimes they lose consciousness because of it.

I have also read about women who are brought in on a wheelchair because they cannot walk because of the pain.

It happens, but rarely. Numbness, tingling and pain in the extremities are more common. Pain causes myofascial tension, which in turn puts pressure on nerves and vessels, which can impair nerve conduction and lead to ischemia of some parts of the body.

How many women suffer from painful periods?

There are different statistics depending on what pain intensity was considered borderline – whether it was, for example, at least 5/10 or 8/10. Most often, however, these ailments are considered to affect more than half of women under the age of 20. Among older women, especially those who have given birth, this problem is a little less common. This is mainly due to the postpartum enlargement of the cervical canal. As a result, blood drainage is easier and uterine contractions – and therefore pain – are less strong. But this is not a rule. Therefore, a patient cannot be reassured with, "Everything will go away after childbirth," but a detailed diagnosis needs to be carried out when menstrual pain reduces the comfort of a woman's life.

What should this diagnostics look like? From the materials for doctors that I read while preparing for our interview, I understood that, simply put, if a woman has primary dysmenorrhea, I wouldn't count on an in-depth diagnosis. You are "eligible" for it only in the case of secondary dysmenorrhea. Who, when and on what basis declares this pain as primary or secondary?

This division is artificial and imperfect. Primary dysmenorrhea is assumed to be one that is not caused by any known pathology. In this case, the pain is caused by the secretion of prostanoids, such as prostaglandins and thromboxanes – e.g. pro-inflammatory substances that intensify contractions of the muscles and vessels of the uterus. They begin to secrete around the menstrual period in women who already have ovulatory cycles, usually a few months after the first menstruation. However, one would have to wonder why these substances are secreted in a particular patient in such amounts that they cause severe pain. Perhaps in a few years we will find that there is a specific disease behind it.

Perhaps in a few years we will find that there is a specific disease behind it. It is also risky to assume that a young girl could not have developed a disease manifested by painful periods. Until recently, for example, we thought that endometriosis mainly affects women over 20 years of age. In recent years, the frequency of reported cases of this disease among adolescents has increased and it is increasingly being discussed at scientific conferences. We have teenage patients with a very severe form of this disease, which means that it began to develop shortly after the first menstruation. Perhaps at some point their gynaecologist mistakenly assumed they were dealing with primary dysmenorrhea. Or maybe at the beginning the diagnosis was good and the problem was that subsequent doctors, relying on it, did not start an in-depth diagnosis, and the disease could have developed in the meantime. It is worth knowing that endometriosis in the initial stage can be very difficult, and sometimes even impossible to detect in imaging tests. This "primary dysmenorrhea" patch may lull specialists into a false sense of security.

Does this mean that if a woman complains of painful menstruation, she should be well examined regardless of her age, so that possible diseases are excluded?

Yes. A thorough interview is very important here. Sometimes it can do much more than the subsequent gynaecological examination.

Should a woman prepare for it?

Before the visit, it is worth analysing your ailments. The important things are: the location of the pain, in which direction the pain radiates, the moment it occurs, how long it lasts, whether it changes, and whether the bleeding is profuse. It is also important whether there are any additional symptoms, such as nausea, vomiting, diarrhoea, flatulence or constipation. Some patients complain of headaches, fatigue and depressive moods. Sometimes symptoms unrelated to the menstruation itself are decisive, such as painful intercourse, pain when passing stools or urine, as well as comorbidities and a negative family history. All of this can lead us to a different diagnosis.

It's good when all this is written down, because the visit is often accompanied by such intense stress that the patient forgets when she had her last period, even though she checked it in the waiting room in the phone app. It is not uncommon for me to hear in response to the question, "How can I help you?" the woman is only able to answer, "I have painful periods," and she starts crying.

Why?

I specialise, among others, in the treatment of endometriosis, so I am often not the first doctor to whom the patient addresses her complaint. She doesn't know if I will take her ailments seriously. Patients often say that gynaecologists do not believe them or do not take them seriously, so they overlook many symptoms, especially the more embarrassing ones. They also do not mention health problems that are not directly associated with gynaecological problems, such as fever, haemoptysis or pneumothorax. All this makes it difficult to make a correct diagnosis.

What does pneumothorax have to do with painful menstruation?

Like painful periods, it can lead to a suspicion of endometriosis. Importantly, in the initial stages of the disease, symptoms appear mainly at the beginning of the cycle, but as the disease progresses, they become more frequent and can occur at any time.

What is this disease about?

We talk about it when the endometrium, the mucosa lining the uterine cavity, also appears in other places, such as the ovary, intestine, bladder, liver and diaphragm – in the latter case, the symptom may be pneumothorax. No matter where it is located, it undergoes the same cyclical changes as if it were in the womb – it secretes certain pro-inflammatory substances during certain phases of the cycle.

Is there also bleeding from the endometrium outside the uterus during menstruation?

Usually single blood cells are released, but it's not the blood that is the main problem, but the pro-inflammatory substances. They lead to the local inflammation, causing changes in the tissue on which they are located – making it fibrous and tense. They also pull the surrounding tissue, causing pain. So far, the causes of this disease have not been discovered.

Is it true that as much as 10 percent of women can suffer from it?

These are the statistics, but I believe that there are actually more sick women. Endometriosis is not always symptomatic. We are also not always able to see its outbreaks, although we have made great progress in diagnostics anyway – today we are able to detect endometrial changes using ultrasound, which we were once able to find only laparoscopically.

Should a patient with painful menstruation have an ultrasound?

In my opinion, yes. Today, ultrasound is so accessible and informative that in this case it should be performed. Sometimes other imaging tests are also necessary, such as an MRI and hormonal tests or consultation with other specialists.

What diseases, apart from endometriosis, can painful periods indicate?

Congenital abnormalities of the uterus and vagina that may impede blood outflow, uterine fibroids and polyps, pelvic congestion syndrome, diseases of the urinary and digestive systems.

Under what circumstances would you tell a woman who has heard that her period pains were not caused by a disease, "I would continue trying to get to the bottom of it"?

When a woman notices some of the other disturbing symptoms that I mentioned earlier. If it turns out that a woman who has painful periods is healthy, then of course I would not consider the problem solved. Chronic, recurrent menstrual pain generates a lot of problems: it contributes to the formation of myofascial changes, causes frustration and a feeling of being misunderstood by relatives, conflicts with them, causes absenteeism from work and school.

So how should a woman who has been declared healthy deal with this pain?

We have different methods to address pain and its perception at different stages. To inhibit its formation, we use contraceptive pills and an intrauterine hormonal insert – contrary to the myths, it can also be used by women who have not given birth yet. In the case of some contraindications to hormonal treatment, we choose drugs containing only gestagens as they carry a lower risk of thromboembolic episodes. The mechanism of this method is such that, due to the action of endometrial hormones, throughout the cycle it remains the same as in its first phase, so there is no secretion of prostaglandins and no pain. We use other methods when the pain has already appeared.

They say that before the pain is in full swing, it is a good idea to take a non-steroidal anti-inflammatory drug, such as ibuprofen, and a diastolic pill.

It's a good idea. Instead of a reliever drug, you can also put a hot water bottle on your lower abdomen or take a hot shower.

Is it safe for your stomach to take these drugs every month during your period?

If a woman has no contraindications to such therapy and does not exceed the standard dose specified in the leaflet, treatment can be based on this. However, if this is not enough, I would urge you to consult your doctor.

What do you think about the TENS machine?

It is used for transcutaneous electrical nerve stimulation and modulation of the nerve conduction pathway – it does not eliminate the cause of pain, but reduces its perception. It is a safe and quite an effective method. You can also improve your comfort by influencing the interpretation of pain by participating in psychotherapy addressing it.

What do you usually propose to patients?

I often combine different methods, but I start with proposing a lifestyle change, especially to women saying "I won't take any pills", because I also make the choice of treatment dependent on the patient's approach to it.

What is this lifestyle change about?

I propose, among others, switching to a diet that is devoid of pro-inflammatory substances, mainly those of animal origin, sugar and wheat gluten. We have observed that this, in combination with physical activity, improves the condition in a lot of patients. Some are also happy with the effects of acupuncture, herbs and ginger.

Is the effectiveness of these methods confirmed by scientific research?

There is some research going on, and some looks promising. However, to answer yes to your question, more extensive and better-structured studies would be needed, such as those carried out with birth control pills and non-steroidal anti-inflammatory drugs. However, since the risk of side effects is small in the case of changing the diet or introducing physical activity, I can recommend that the patient try them.

How do you rate the effectiveness of urogynaecological physiotherapy? It is often associated with rectal and vaginal examination – a certain barrier of intimacy is crossed, so women may be less willing to test this method.

It is a kind of physiotherapy that deals with the elimination of myofascial tensions in the lesser pelvis, which build up over the years of endometriosis and painful menstruation. The manual techniques used in this case relate to different parts of the body, not only the vagina or anus. I work with a lot of good physiotherapists and osteopaths who can sometimes significantly reduce pain experienced during intercourse, menstruation or movement within one or two visits. In such cases, pills and even surgeries are often unable to help as effectively as this physical therapy. This is one of the basic elements of complementary treatment that I propose and that I am definitely convinced of.

Ewa Pągowska talks to Tomasz Songin, MD, PhD

Graphics: Marta Frej

• Tomasz Songin, MD, PhD - is a gynaecologist-obstetrician. He works i.a. at the Międzylesie Specialist Hospital in Warsaw and the Miracolo Clinic dealing with the treatment of endometriosis.

Interview published in "Wysokie Obcasy" of "Gazeta Wyborcza" from 16 January 2021.