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Painful Periods

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Many women suffer from painful periods, called "dysmenorrhea" in medical language. Although this is a common problem for many women, there is a considerable amount of misinformation about this condition. An understanding of the reasons why some women have painful periods will help patients evaluate different treatment options.

The uterus, sometimes called the "womb," is a muscular organ about the size of a pear or an avocado that is located at the top of the vagina. It is located directly underneath the pubic hair and is attached to surrounding tissue by a number of strong ligaments. The main job of the uterus is to help protect a developing baby, and assist with the baby's birth by roducing strong, muscular contractions. (The uterus can contract at other times, and this is one of the reasons women experience painful periods). When a woman is not pregnant the uterus responds to levels of hormones in the body and produces a thick lining called the endometrium.

The endometrium lines the inside of the uterus and shrinks and grows during a woman's menstrual cycle. During her period this lining is shed, producing varying amounts of blood. Chemicals called "prostaglandins" are released from the uterine lining, perhaps to cause the uterus to contract so it can expel the blood. Unfortunately, these chemicals also cause considerable pain.

Some women, for reasons not completely understood, simply have a larger uterine (endometrial) lining, and make more prostaglandins. They have more cramps, more bleeding, and more pain. Other women have slightly "out of whack" hormone production or development, which causes the uterine lining to grow more than normal. When they finally have bleeding it is often heavy and painful. Some medical conditions, like decreased thyroid production (hypothyroidism), can produce rregular and heavy periods. Finally, onditions within the uterus itself, for example fibroids (non-cancerous tumors within the muscle of the uterus), polyps (non-cancerous growths, similar to skin tags, within the uterine cavity), and, in unusual situations, pre-cancer or even cancer can cause heavy and painful bleeding. In almost all cases, however, it is simply a little too much endometrium that causes this common problem.

Your health care provider can usually diagnose this condition by taking your medical history and performing a standard genital examination. If the uterus in otherwise normal and there are no signs of other medical problems, treatment is usually very straightforward and very rewarding for both the patient and her health care provider.

In most cases a simple combination of oral contraceptives ("the pill") and a class of medication called NSAIDS (pronounced N-sades) will alleviate the pain and excess bleeding. The pill works because it decreases the size of the endometrial lining, and the NSAID medications work by both decreasing the lining size, and blocking the prostaglandin chemicals that cause so much pain. There are a number of NSAIDs available. These medications are in the same class as ibuprofen (i.e. Advil, Motrin, Anaprox, Cataflam) but must be taken in the appropriate dose to be effective. One trick commonly used is to start NSAIDs at the first sign of your period, and take them as directed throughout the time that you are bleeding. By getting them in your system as early as possible there is an excellent chance that they will work.

Both the oral contraceptive pill and NSAIDs used together can produce dramatic resolution of pain and heavy bleeding. In the rare situation where these are not effective, stronger medications, called GnRH agonists, may be helpful. However, these expensive medications can cause significant side effects so most women are better served with the oral contraceptive/NSAID combination. As with all medical problems, see your doctor or other health care provider for a face-to-face discussion of your medical issues.

D. Ashley Hill, M.D.

Associate Director

Department of Obstetrics and Gynecology

Florida Hospital Family Practice Residency

Orlando, Florida