Understanding Period Pain
Period pain is known medically as dysmenorrhea. It’s so common that we’ve been led to believe it’s simply normal, with it being rote to simply pop a couple of ibuprofen throughout those ‘period pain days,’ and keep on keeping on. It’s also ‘normal’ to have to call in a sick-day whether that be to school, work, or a sports or social event. While this may seem like no big deal, when we look at the data, it actually is; missed causes of period pain may not only have a health impact, but over our lives impacts women economically, socially, and career-wise.
Period pain is certainly common: as many as 50% to 90% of teens and young women experience it, and as many as 15% to 75% of us experience it as adults. Severe pain is experienced by 2–29% of women with dysmenorrhea.
But I want to emphasize something I consider extremely important: Common and normal aren’t exactly the same thing – and this is part of what I’ll cover here – along with just how much pain is actually normal, when to explore further, and what you can do for your teen – or yourself if you are a teen listening or reading. And if you are, I’m giving you a standing ovation for being here, learning about your body and cycle, and learning how to take care of yourself from an whole woman, integrative perspective.
Periods: Our Powerful 6th Vital Sign
In my book Hormone Intelligence, I discuss the importance of seeing our menstrual cycle as a 6th vital sign. Like the other five vital signs – temperature, blood pressure, heart rate, respiratory rate, and pain – it can give us important information about underlying health, and also the factors impacting our health.
In 2006, the American Academy of Pediatrics (AAP) and then a few years later, the American College of Obstetricians and Gynecologists (ACOG) published a report recognizing “Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign.” They noted that it was important for health care providers to be able to differentiate between normal and abnormal menstruation, because recognizing abnormal menstrual patterns during the teenage years could help improve early identification of potential health concerns. Unfortunately, this paper – an exceedingly important paper in acknowledgment of the importance of menstrual health – went largely unnoticed by pediatricians, gynecologists, and family physicians – the doctors who primarily take care of teens and young women.
Interestingly, they also didn’t mention pain at all in their discussion – which speaks to how normalized menstrual cramps are. When they refer to improving early identification of health concerns, they are referring to common underlying causes of period pain – which we’ll explore together – like PCOS and endometriosis – but they don’t ask the more penetrating and critical question: What are the underlying causes of these? We’ll explore that, also.
Primary vs. Secondary Dysmenorrhea
It’s true that some discomfort with menstruation is within the range of normal. Your uterus (if you aren’t familiar with female body parts, head over to my podcast, May I Introduce You to Your Lady Parts) has to do some work to expel the uterine lining that has built up since your last period – including breaking down that lining. Along with that comes some increased production of inflammatory chemicals, and contractions that rhythmically push that lining out.
The cramping, aching, and discomfort that results is called primary dysmenorrhea. Dysmenorrhea literally means “difficult monthly flow.” It usually begins in adolescence, once cycles start to involve ovulation, which is usually within 6 to 12 months of a young woman having her first period.
One of the hallmarks of primary dysmenorrhea is that the discomfort begins right around when your period starts – or sometimes the day before – and feels achy or crampy. It usually resolves after the first day or so of your period, though it may last for as long as three days.
By definition, primary dysmenorrhea is not caused by any underlying medical issues and is almost always due to the production of inflammatory chemicals called prostaglandins, and possibly also vasopressins. Our body naturally ramps up production of these chemicals premenstrually as part of the process of breaking down and shedding the uterine lining.
Primary dysmenorrhea may cause significant discomfort if you tend to overproduce these inflammatory chemicals, which can happen for a variety of reasons. We’ll get into some of the root causes that are under our control later on.
Notice that until now I’ve been saying discomfort, instead of pain, because that’s where I draw the line between normal primary dysmenorrhea and crossing the line into the realm of pain – which I consider to be an important differentiating point to begin to explore underlying causes.
It can be normal to have some wild cramping, but if you’re actually having painful periods, that may be increased inflammation or an underlying medical cause. When severe, period pain may be accompanied by nausea, vomiting, diarrhea, backache, headache, or dizziness. By medical definition, this is still considered normal primary dysmenorrhea, and while I don’t want to over pathologize a normal physiologic process, again, this is where I feel we cross the line from common being accepted as normal, and needing to rethink periods as a 6th vital sign. In short, we should never accept severe menstrual pain, or debilitating symptoms that accompany menstruation, as normal.
Conventional medicine does recognize a condition known as secondary dysmenorrhea. This is when menstrual pain is due to an underlying medical condition, most commonly endometriosis, adenomyosis, or heavy periods which may be due to high levels of estrogen production or long menstrual cycles (ie > 35 days) which can be due to a condition called PCOS.
The first step to helping address your daughter’s pain is figuring out if it’s primary or secondary dysmenorrhea. Unfortunately, there’s no pain score that says “this is when it’s primary dysmenorrhea” and “this is when it’s so bad that it’s not normal and you should look into possible underlying causes.” But my three main questions to help differentiate between the two are:
- Are you bent over in pain with your periods?
- Are you having to take medications to cope with the pain in your daily menstrual life (or at other times)?
- Are you having to change your regular activities due to the pain? While many of us may not particularly feel like doing everything we’d normally do on the first day of our bleed, it’s a different matter if you’re having to stop because you’re in so much discomfort.
If you are checking any of those boxes, it still may be primary dysmenorrhea , But it may also be a sign of increased inflammation. It’s also worth getting evaluated for other potential underlying causes including endometriosis, adenomyosis, and PCOS. Catching these early can prevent a whole lot of problems associated with these conditions down the road. In older teens, and particularly Black teens, it may also be appropriate to rule our uterine fibroids – which we now affect women earlier, with Black women in particular, being diagnosed with fibroids as early as in their 20s. These conditions can all be diagnosed in non-invasive ways with blood-work, ultrasound, and other imaging – in other words, non-surgically. Knowing the symptoms of these other conditions also allows you to do some sleuthing on your own.
Another sign that period pain could be due secondary dysmenorrhea is that pain pelvic or abdominal pain is occurring at other times of the month – not just around the start of your period. While secondary dysmenorrhea may occur only around your period, it also might occur throughout the month. And it might be accompanied by constipation or pain with bowel movements, urinary problems, or pain during sex. Secondary dysmenorrhea also tends to get worse, not better, with age.
One more clue to period pain possibly being something more, is if you – the mom – experienced moderate to severe period pain, and subsequently experienced additional gynecologic or obstetrics symptoms or conditions, for example, challenges with fertility or if you yourself were put on the Pill young for period symptoms. And if you’re a teen, this is a great time to talk with your mom about symptoms you’re having – and asking her whether she experienced these as well – as it might clue you into something potentially hereditary going on, like PCOS or endometriosis.
If your daughter’s menstrual pain doesn’t seem to be due to an underlying condition, that doesn’t mean it should just be accepted. Too often primary dysmenorrhea in teens is treated as normal and inevitable. It’s true that during the first two to five years after menstruation begins, it takes some time for hormones to settle into regular rhythms. And during that time, it’s normal to have irregular cycles, skipped periods, hormonal ups and downs, mild acne – and occasionally, more painful cramps. And yes, for some teens, primary dysmenorrhea improves over time.
Regardless, whether it’s primary or secondary, menstrual pain that interferes with your ability to live a full life should always be taken seriously and period pain should never be ‘dismissed.’
One of my young listeners brought to my attention just how often period pain is dismissed by classroom and gym teachers or sports coaches – and even by their own mothers! We need to believe in our girls starting at a young age – and also not simply let ‘the Pill’ be the solution. While it may sometimes be the answer, too often it is the automatic default prescription – and as I’ll share with you – is not necessarily the best one. Primary dysmenorrhea can often be successfully treated or reduced, while secondary causes can also be successfully treated with a variety of lifestyle, integrative, and pharmaceutical approaches as appropriate to your daughter’s level of symptoms and her preferences and goals.
Addressing the Root Causes of Period Pain in Teens
In addition to trying these treatments to relieve symptoms, you may want to try to get at the root causes of the chronic inflammation that often contributes to primary dysmenorrhea.
One of the major sources of inflammation that can wreak havoc on our periods is the processed foods, added sugars, and poor quality oils in many of our diets. Another source that deserves attention is endocrine-disrupting chemicals (EDCs), environmental toxins that, among other damaging effects, mimic our own estrogen: This makes the lining of your uterus thicker between periods than it’s supposed to be, and a thicker lining means a lot more cramping and pain when it sheds during your period every month.
Here are my key approaches to addressing both period pain, and the underlying inflammation that's often associated with it, particularly primary dysmenorrhea.
- Eat a low-inflammatory Mediterranean style diet. Higher intakes of fiber, fruits, and vegetables have been associated with reduced risk of primary dysmenorrhea. Aim for eight servings of a rainbow of veggies and fruits daily – which contain key phytonutrients that we need to protect our bodies from environmental toxins, keep our liver in excellent health which helps us detoxify our own naturally produced estrogens and those we’re exposed to environmentally, and get plenty of good quality fiber and fermented veggies to support healthy daily elimination and a healthy microbiome, also important to healthy hormone levels and reduced inflammation.
- It’s important to note that something teens often do – dieting to lose weight, as well as skipping meals and eating a low intake of antioxidants have been associated with a greater risk of menstrual cramps. Of course we want to help our teens love their bodies as they are, and we can also help them understand how to eat well to support their health – rather than fall into food and dietary habits that are ineffective, harmful, and usually counterproductive.
- Whenever possible, choose organic to reduce your exposure to herbicides and pesticides, which can be potent EDCs. If you’re on a tight food budget, check out the Environmental Working Group’s Dirty Dozen and Clean 15 to determine which produce are most important to eat organic.
- Teaching our teens to reduce their body burden of toxic ECD chemicals. Common everyday sources of EDCs include plastic food packaging, flame retardant-treated furnishings, household cleaners, paints, stains, etc. and importantly for our teens – cosmetics and body products including lotions, sunscreen, shampoo, conditioner, and much more. So work with them to browse online sources like Credo or The Detox Shop, and use the EWG Skin Deep easy-to-search database and rating system to search for the best skincare and cosmetic products. It doesn’t have to be expensive to use ‘cleaner’ body products – but it is a pay now or pay later situation. We can pay for the latest iPhone, or teach them to budget for better body products and spend wisely. We can also teach them to prioritize which products to invest more in – like lipstick which we ingest more of by licking it off our lips, or foundation, lotion, unscreen, soap, etc, which we apply to larger body surfaces, and daily.
Lifestyle Approaches to Reduce Period Pain in Teens
There are also some lifestyle measures that can offer some comfort, and that you can also do with your daughters as something you share, particularly if you too, struggle with menstrual symptoms. Some of these are both preventative and relieve symptoms, and some do one of the other. My go-to recommendations include:
- Yoga, including cat-and-cow pose and several others that are easy to learn – for prevention and pain relief.
- Low-level heat from a heating pad or hot water bottle applied to the lower belly or lower back.
- Switching from tampons to pads, which brings huge relief from menstrual cramps for many women; even if they want to wear tampons during the day for school, sports, etc., they can wear a pad at night instead.
Supplements and Herbs for Period Pain in Teens
There are also a number of herbs and supplements that can be highly effective for preventing and treating menstrual cramps.
While first-line conventional treatment for primary dysmenorrhea – and even the pain associated with secondary dysmenorrhea is NSAIDS, like Ibuprofen are effective in relieving period pain, as well as reducing heavy menstrual bleeding, they do have risks, including leaky gut, stomach bleeds, and even reduced fertility. I consider NSAIDs to be generally safe and effective when used for just a couple of days a month and are a great go-to when pain is getting in the way of a sports event, taking an exam, and so on. For best effects start at the first hint of cramps.
While birth control pills are also commonly prescribed, they’re not as effective for pain as NSAIDs and also carry more risks.
But as I’ve described in a previous podcast that dives deep into treating menstrual cramps, I recommend trying nutritional and botanical approaches first.
My core recommendation for period pain is a trio of vital nutrients: calcium, magnesium, Vitamin D, and I also often add fish oil, too, and I use these as a 3-month protocol, at least, to make an impact.
- Calcium: Two studies have explored the impact of calcium supplementation on PMS in general, and while one study showed just marginal improvement, the other showed more significant benefits. A typical dose is adding 600 mg/day of calcium citrate as a supplement either daily throughout the month, or just taking it in the 5 days prior to the onset of menstruation, and continuing for the first couple of days into the period.
- Vitamin E: Two small studies found that 500 IU of Vitamin E per day, or 200 units twice per day, beginning two days before menses and continuing through the first three days of bleeding helped to reduce period pain.
- Vitamin D: Several small studies have found that getting enough vitamin D can improve menstrual pain. This can usually be accomplished by adding 2000 iu of Vitamin D3 daily as a supplement, or have your daughter’s health care provider check your daughter’s 26(OH)D blood levels and help you supplement to hit the optimal blood level range of 50-70 ng/mL. Some women may need up to 4000 IU of Vitamin D3 daily for a few months to achieve those levels, and then dropping down to 2000 IU daily.
- Fish oil: Prevent inflammation by adding oil-rich salmon to your diet, about 4-6 ounces 2-3 times per week, or taking a daily supplement with Omega 3 fats (about 1000 mg EPA and 700 mg DHA) – most supplements will contain both and give you the dose and ratio on the package. A small number of studies have found that krill oil, specifically, may be helpful.
- Magnesium: Three studies have found that supplementing magnesium, a nutrient that most women in the US are low in, can reduce menstrual cramps, though it’s important to state that these were small trials, with inconsistent designs and a high rate of dropout from the studies. I recommend increasing up to about 600 mg/day of magnesium glycinate starting about 5 days before your period and continuing throughout the month at about 300 mg/day.
There are also a wide variety of herbs that have long been used for relieving menstrual cramps. My top two favorites that I use in my practice are ginger root and cramp bark.
Ginger root and cinnamon have the best studies, so I’ll talk about those first.
- Ginger is widely respected for its anti-inflammatory and pain-relieving effects, and several studies show impressive results for menstrual cramps and pain; it’s also helpful for relieving the nausea and vomiting that may accompany period pain. An effective dose is 2,000 mg/day, which can be taken in capsules, 500 mg 4x/day, or 1000 mg twice daily.
- Cinnamon has also been found to be effective for reducing pain, heavy menstrual bleeding, nausea, and vomiting with dysmenorrhea. The dose in the most impressive study was 420 mg of cinnamon bark in capsules with 2 capsules taken three times/day for the first 3 days of the period.
Cramp bark, and other herbs including black haw, motherwort, and black cohosh, can be taken in tinctures of capsules. Check out my previous podcast on menstrual pain for more information and dosage guidance and you can see my online formulary at Fullscript for products I use in my practice. I also talk about these herbs at length in my book Hormone Intelligence, and if you want to study herbal medicine for women with me, you can do that, too!.
Another herb that I’ve seen work well for period pain is cannabis. I have a whole podcast exploring the evidence on using cannabis for menstrual pain relief. So what do I think about using cannabis for teens? I’m not a fan of teenagers smoking it – sorry, girls! – for pain relief because I don’t believe the psychoactive effects are optimal for their still developing brains, and it may precipitate mental health problems in some teens, especially if you struggle with anxiety or depression. If you’re in a state where it’s legal, I do think it’s reasonable for teens to try a non-psychoactive CBD gummy or tincture that contains a low dose of THC-CBD taken before bed or on non-school or non-work days. You can inquire at a dispensary to ensure you get a product that isn’t psychoactive.
Rethinking Menstrual Health Starts Early
I want to emphasize that reframing menstrual health starts early. Menstrual symptoms don’t occur in a vacuum. The concept of our 6th vital sign emphasizes that our menstrual cycles are the result of our total hormonal ecosystem – which is also tied to our diet, inflammation levels, gut health, and more. I can’t overemphasize the power of learning to see our menstrual cycles not simply as a monthly nuisance or burden, and I’m not expecting us to sing kumbaya every time we have our periods – but we can teach our daughters that our monthly cycles are an indicator of our overall hormonal and systemic well-being – a report card of hormonal health, if you will, and that they can find more ease by learning to pay attention to the impact of lifestyle changes that are within our control on how our cycles feel, month after month. This is something I address completely in my book Hormone Intelligence, an important read for all women, and a wonderful gift for your teenaged or young adult daughter as a companion she can refer to over her life cycles.
Given that we have about 400 periods in our lifetime, learning how we can influence and support ourselves throughout our menstrual cycles at an early age can set us up for decades of greater ease and health – which I hope you now realize is within your hands. We shouldn’t simply accept period pain as normal anymore!