Dysmenorrhea

Also indexed as: Menstrual Cramps, Painful Menstruation

Dysmenorrhea, or painful menstruation, is classified as either primary or secondary. Primary dysmenorrhea generally occurs within a couple of years of the first menstrual period. The pain tends to decrease with age and very often resolves after childbirth. Secondary dysmenorrhea is menstrual pain caused by another condition, commonly endometriosis. It starts later in life and tends to increase in intensity over time.

As many as half of menstruating women are affected by dysmenorrhea, and of these, about 10% have severe dysmenorrhea, which greatly limits activities for one to three days each month.1

Checklist for Dysmenorrhea

Rating Nutritional Supplements Herbs
2Stars Vitamin B3 (niacin)
Vitamin B3 (niacin) (plus vitamin C and rutin)
Vitamin E		  
1Star Calcium
Fish oil (EPA/DHA)
Magnesium
Progesterone (topical cream)
Vitamin B1		 Black cohosh
Blue cohosh
Corydalis
Cramp bark
Dong quai
False unicorn
Peony
Vervain
Vitex
See also:  Homeopathic Remedies for Dysmenorrhea
3Stars Reliable and relatively consistent scientific data showing a substantial health benefit.
2Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.
1Star An herb is primarily supported by traditional use, or the herb or supplement has little scientific support and/or minimal health benefit.

What are the symptoms of dysmenorrhea? Dysmenorrhea includes symptoms of abdominal bloating, frequent and intense cramps, pain below the waistline, or a dull ache that may radiate to the lower back or legs. There may also be symptoms of headache, nausea, diarrhea or constipation, frequent urination, and, occasionally, vomiting. The symptoms usually occur just before or during the menstrual period.

How is it treated? Conventional treatment includes pain medications, such as ibuprofen (Advil®, Motrin®, Midol PMS®), mefenamic acid (Ponstel®), and acetaminophen (Tylenol®). Oral contraceptives may also be used to suppress ovulation. Danazol (Danocrine®), an anti-estrogen drug, and progestins are also used. In cases of severe nausea and vomiting, antinausea medicines may be recommended.

Dietary changes that may be helpful: Some physicians advise that alcohol should be avoided by women experiencing menstrual pain, because it depletes stores of certain nutrients and alters the metabolism of carbohydrates—which in turn might worsen muscle spasms. Alcohol can also interfere with the liver’s ability to metabolize hormones. In theory, this might result in elevated estrogen levels, increased fluid and salt retention, and heavier menstrual flow.

Lifestyle changes that may be helpful: Many women feel the need to lie still while experiencing menstrual cramps, while others find that exercise helps relieve the pain of dysmenorrhea. This variation from woman to woman may explain why some researchers report that exercise makes symptoms worse,2 though most studies report that exercise appears helpful.3

Nutritional supplements that may be helpful: The niacin form of vitamin B3 has been reported to be effective in relieving menstrual cramps in 87% of a group of women taking 200 mg of niacin per day throughout the menstrual cycle. They then took 100 mg every two or three hours while experiencing menstrual cramps.4 In a follow-up study, this protocol was combined with 300 mg of vitamin C and 60 mg of the flavonoid rutin per day, which resulted in a 90% effectiveness for relieving menstrual cramps.5 Since these two preliminary studies were published many years ago, no further research has explored the relationship between niacin and dysmenorrhea. Niacin may not be effective unless taken for seven to ten days before the onset of menstrual flow.

In theory, calcium may help prevent menstrual cramps by maintaining normal muscle tone. Muscles that are calcium-deficient tend to be hyperactive and therefore might be more likely to cramp. Calcium supplementation was reported to reduce pain during menses in one double-blind trial,6 though another such study found that it relieved only premenstrual cramping, not pain during menses.7 Some doctors recommend calcium supplementation for dysmenorrhea, suggesting 1,000 mg per day throughout the month and 250–500 mg every four hours for pain relief, during acute cramping (up to a maximum of 2,000 mg per day).

Like calcium, magnesium plays a role in controlling muscle tone and could be important in preventing menstrual cramps.8 9 Magnesium supplements have been reported in preliminary10 and double-blind11 12 European research to reduce symptoms of dysmenorrhea. In one of these double-blind trials, women took 360 mg per day of magnesium for three days beginning on the day before menses began.13

Diets low in omega-3 fatty acids (EPA and DHA) have been associated with menstrual pain.14 In one double-blind trial, supplementation with fish oil, a good source of omega-3 fatty acids, led to a statistically significant 37% drop in menstrual symptoms. In that report, adolescent girls with dysmenorrhea took an unspecified amount of fish oil that provided 1,080 mg of EPA and 720 mg of DHA per day for two months to achieve this result.15 A double-blind trial found that the same amount of EPA and DHA plus 7.5 mcg per day of vitamin B12 led to a greater than 50% decrease in menstrual symptoms, but a group taking only fish oil did not obtain as much relief.16 Six grams of fish oil per day provides the approximate levels of EPA and DHA used in these trials.

In a double-blind trial, adolescents living in India who were suffering from dysmenorrhea took 100 mg of vitamin B1 (thiamine) per day for three months. Eighty-seven percent of those treated experienced marked relief of dysmenorrhea symptoms.17 However, vitamin B1 deficiency is relatively common in India, whereas it is rare in the Western world, except among alcoholics. It is not known whether vitamin B1 supplementation would relieve dysmenorrhea in women who are not B1 deficient.

In a double-blind trial, supplementation with 500 IU of vitamin E per day for two months, beginning two days before menstruation and continuing for three days after the onset of menstruation, was significantly more effective than a placebo at relieving menstrual pain.18

Some practitioners report success using topical progesterone cream for dysmenorrhea.19 To date, this approach lacks sufficient research.

Are there any side effects or interactions? Refer to the individual supplement for information about any side effects or interactions.

Herbs that may be helpful: Corydalis contains several alkaloids, and one called tetrahydropalmatine (THP) is considered to be the most potent. In laboratory research, THP has been shown to exhibit a wide number of pharmacological actions on the central nervous system, including pain-relieving and sedative effects.20 According to a secondary reference, painful menstruation responded favorably to the administration of THP.21 For a pain-relieving effect, the recommended amount for the crude dried rhizome is 5–10 grams per day. Alternatively, one can take 10–20 ml per day of a 1:2 extract.

Cramp bark (Viburnum opulus) has been a favorite traditional herb for menstrual cramps, thus its signature name. Cramp bark may help ease severe cramps that are associated with nausea, vomiting, and sweaty chills. Research from animal studies shows that cramp bark blocks spasms of smooth muscle.22 Cramp bark is traditionally prepared by placing two teaspoons of the dried bark into a cup of water and bringing it to a boil; it is then simmered gently for 10 to 15 minutes. The tea may be drunk three times per day.23 Alternatively, 4–8 ml of tincture may be used three times per day.

Black cohosh has a history as a folk medicine for relieving menstrual cramps. Black cohosh can be taken in several forms, including crude plant, dried root, or rhizome (300–2,000 mg per day), or as a solid, dry powdered extract (250 mg three times per day). Standardized extracts of the herb are available, though they have primarily been researched for use with menopausal women suffering from hot flashes. The recommended amount is 20–40 mg twice per day.24 The best researched form provides 1 mg of deoxyactein per 20 mg of extract. Tinctures can are also used (2–4 ml three times per day).25 The Commission E Monograph recommends black cohosh be taken for up to six months, and then discontinued.26

Blue cohosh, although unrelated to black cohosh, has also been used traditionally for easing painful menstrual periods. Blue cohosh, which is generally taken as a tincture, should be limited to no more than 1–2 ml taken three times per day. The average single application of the whole herb is 300–1,000 mg. Blue cohosh is generally used in combination with other herbs. Women of childbearing age using this herb should cease using it as soon as they become pregnant—the herb was shown to cause heart problems in an infant born following maternal use of blue cohosh.27

False unicorn was used in the Native American tradition for a large number of women’s health conditions, including painful menstruation. Generally, false unicorn root is taken as a tincture (2–5 ml three times per day). The dried root may also be used (1–2 grams three times daily). It is typically taken in combination with other herbs supportive of the female reproductive organs.

Dong quai has been used either alone or in combination with other Traditional Chinese Medicine herbs to help relieve painful menstrual cramps. Many women take 3–4 grams per day. A Japanese herbal formulation known as toki-shakuyaku-san combines peony root (Paeonia spp.) with dong quai and four other herbs and has been found to effectively reduce symptoms of cramping and pain associated with dysmenorrhea.28

Vervain is a traditional herb for dysmenorrhea, however there is no research to validate this use. Tincture has been recommended at an amount of 5–10 ml three times per day.

Clinical reports from Germany have suggested that vitex may help relieve different menstrual abnormalities associated with premenstrual syndrome, including dysmenorrhea.29 These studies used 40 drops of a liquid preparation that delivers the equivalent of 40 mg of the dried berries of the plant.

Are there any side effects or interactions? Refer to the individual herb for information about any side effects or interactions.

Other integrative approaches that may be helpful: Relaxation techniques have been used with some success to alleviate dysmenorrhea in some young women. According to one preliminary study, the symptoms of menstrual cramps, nausea, irritability, and poor concentration greatly improved after 20-minute relaxation sessions twice per week.30

Acupuncture may be a useful therapy in the treatment of dysmenorrhea. A preliminary trial reported that 86% of women treated with acupuncture for dysmenorrhea had complete cessation of pain for three consecutive menstrual periods.31 Other preliminary trials have demonstrated similar results.32 33 34 A controlled clinical trial reported 91% efficacy with acupuncture compared to 36.4% efficacy with sham acupuncture (using fake acupuncture points) and 18% efficacy in an untreated control group.35 A small trial compared a 30-minute TENS (transcutaneous electrical nerve stimulation) treatment to stimulate acupuncture points with a placebo pill for dysmenorrhea. There was a large placebo effect in this study, and pain relief over the next several hours was not significantly better in the treatment group compared to placebo.36 More controlled trials are needed to determine whether acupuncture is a useful treatment for dysmenorrhea.

Spinal manipulation has been investigated as a treatment for dysmenorrhea. One small preliminary study reported improvement in symptoms measured by a questionnaire.37 A controlled clinical trial compared a single treatment of spinal manipulation to the low back and pelvis to a sham manipulation that was designed to be ineffective. Women receiving real manipulation reported twice as much relief as those receiving sham treatment.38 A recent, larger trial repeated the above study, testing a series of treatments over two months. Women reported less pain from both real and sham treatment, but there was no difference between the groups.39 Whether there is a real benefit from spinal manipulation for women with dysmenorrhea remains unclear at this time.

References:

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2. Metheny WP, Smith RP. The relationship among exercise, stress, and primary dysmenorrhea. J Behav Med 1989;12:569–86.

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5. Hudgins AP. Vitamins P, C and niacin for dysmenorrhea therapy. West J Surg 1954;Dec:610–1.

6. Penland J, Johnson P. Dietary calcium and manganese effects on menstrual cycle symptoms. Am J Obstet Gynecol 1993;168:1417–23.

7. Thys-Jacobs S, Starkey P, Bernstein D, et al. Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. Am J Obstet Gyencol 1998;179:444–52.

8. Durlach J. Neuromuscular and phlebothrombotic clinical aspects of primary magnesium deficiency. Z Ernahrungswiss 1975;14:75–83 [in French].

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16. Deutch B, Jørgensen EB, Hansen JC. Menstrual discomfort in Danish women reduced by dietary supplements of omega-3 PUFA and B12 (fish oil or seal oil capsules). Nutr Res 2000;20:621–31.

17. Gokhale LB. Curative treatment of primary (spasmodic) dysmenorrhoea. Indian J Med Res 1996;103:227–31.

18. Ziaei S, Faghihzadeh S, Sohrabvand F, et al. A randomised placebo-controlled trial to determine the effect of vitamin E in treatment of primary dysmenorrhoea. Br J Obstet Gynaecol 2001;108:1181–3.

19. Hudson T. Natural progesterone: Clinical indications in women’s health. Townsend Letter for Doctors and Patients 1999;Dec:140–3.

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21. Zhu YP. Chinese Materia Medica: Chemistry, Pharmacology, and Applications. Australia: Harwood Academic Publishers, 1998, 445–8

22. Nicholson JA, Darby TD, Jarobe CH. Viopudial, a hypotensive and smooth muscle antispasmotic from Viburnum opulus. Proc Soc Exp Biol Med 1972;40:457–61.

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24. Murray MT. The Healing Power of Herbs. Rocklin, CA: Prima Publishing, 1995, 376.

25. Bradley PR, ed. British Herbal Compendium, vol 1. Bournemouth, Dorset, UK: British Herbal Medicine Association, 1992, 34–6.

26. Blumenthal M, Busse WR, Goldberg A, et al. (eds). The Complete Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, MA: Integrative Medicine Communications, 1998, 90.

27. Jones TK, Lawson BM. Profound neonatal congestive heart failure caused by maternal consumption of blue cohosh herbal medication. J Pediatr 1998;132:550–2.

28. Kotani N, Oyama T, Hashimoto H, et al. Analgesic effect of a herbal medicine for treatment of primary dysmenorrhea—a double-blind study. Am J Chinese Med 1997;25:205–12.

29. Loch E, Böhnert KJ, Peeters M, et al. The treatment of menstrual disorders with Vitex agnus-castus tincture. Der Frauenarzt 1991;32:867–70 [in German].

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32. Xiaoma W. Observations of the therapeutic effects of acupuncture and moxibustion in 100 cases of dysmenorrhea. J Tradit Chin Med 1987;7:15–7.

33. Chuang Z. Treatment of 32 cases of dysmenorrhea by puncturing hegu and sanyinjiao acupoints. J Tradit Chin Med 1990;10:33–5.

34. Lin L. Literature research on point injection with Chinese Angelica liquor. J Tradit Chin Med 1998;18:308–12.

35. Helms JM. Acupuncture for the management of primary dysmenorrhea. Obstet Gynecol 1987;69:51–6.

36. Lewers D, Clelland JA, Jackson JR, et al. Transcutaneous electrical nerve stimulation in the relief of primary dysmenorrhea. Phys Ther 1989;69:17–23.

37. Thomason PR, Fisher BL, Carpenter PA, Fike GL. Effectiveness of spinal manipulative therapy in treatment of primary dysmenorrhea: a pilot study. J Manip Physiol Ther 1979;2:140–5.

38. Kokjohn K, Schmid D, Triano J, Brennan P. The effect of spinal manipulation on pain and prostaglandin levels in women with primary dysmenorrhea. J Manip Physiol Ther 1992;15:279–85.

39. Hondras MA, Long CR, Brennan PC. Spinal manipulative therapy versus a low force mimic maneuver for women with primary dysmenorrhea: a randomized, observer-blinded, clinical trial. Pain 1999;81:105–14.