Menstrual Pain

STUDIES

Teenage girls and women of child-bearing age have menstrual periods. These are brought on when the thick functional mucosal lining of the uterus (endometrium) detaches and passesing out through the vagina with blood as part of the normal ovarian cycle. Some teenage girls and women have cramps and abdominal pain during their periods, which can be so severe that it is difficult for them to attend studies or go to work foras many as one, two or three days.

The usual medical treatments for painful periods (dysmenorrhoea) are painkillers (analgesics), generally nonsteroidal anti-inflammatory drugs (NSAIDs like ibuprofen), or the oral contraceptive pill. Not everyone wants to take NSAIDs as they can cause adverse effects such as gastrointestinal discomfort and bleeding; they also do not effectively alleviate the pain for everyone. Complementary therapies may effectively reduce the need for medical treatment.

We present some of the evidence from Cochrane systematic reviews about complementary and alternative treatments related to painful periods. This evidence comes from carefully researched reviews of information about clinical trials done to evaluate medical treatments. Studies are only included in these reviews if they meet pre-defined criteria.

Some teenage girls and women have cramps and pain in their abdomens during their menstrual periods. These can be so severe that it is difficult to attend studies or go to work for one, two or three days.

Complementary therapies may effectively reduce the need for medical treatment. There are Cochrane reviews available for a number of possible therapies.  

HERBAL AND DIETARY SUPPLEMENTS FOR PAINFUL MENSTRUAL PERIODS

Herbal therapies (plant or botanical phytomedicines) and dietary supplements (including vitamins, minerals, amino acids) are among the more popular complementary medicines.

Herbal and dietary therapies are suitable as treatment for disorders such as period pain as they can be self-administered and are often easily available from health shops, chemists and supermarkets. This ease of administration, while in some ways beneficial, can in itself create problems with the control of dosage, quality of the product, safety and drug interactions.

Herbal therapies are considered innocuous by a large number of consumers. Reviews of the literature, however, have shown that a large number of allergic reactions, toxic reactions, drug interactions and contamination can occur (Ernst 1998). The majority of countries in Western Europe, under European Union (EU) directives, regard phytomedicines as drugs and as such a large number of herbal remedies are integrated into conventional medicine and pharmacy (Blumenthal 1998).

What the synthesised research says

Vitamin B1 is an effective treatment for painful periods. This conclusion is based on one well conducted trial in which women on active treatment took vitamin B1 100 mg daily.

In this trial, daily vitamin B1 over two months was more effective than non-active treatment (placebo) in reducing pain. The trial was of good quality, although it was in a specific group, 556 school age adolescents in India.

Magnesium was more effective than placebo at reducing period pain in two trials. Magnesium was taken daily in one of the trials and during periods (menses) in the second.

A third trial found magnesium to be no different from taking placebo. This trial measured a combination of pain scores and use of additional medication, which was not done in the other trials.

Looking separately at absence from work and use of additional medication, one small trial found magnesium treatment to be more effective than placebo.

In two of the three included trials (a total of 98 women) around a third of women did not complete the trial. Women might have withdrawn because of a lack of benefit from treatment or adverse effects so this reduces the strength of the results.

Vitamin B6 was more effective at reducing period pain than a placebo. Vitamin B6 alone also reduced pain more than a combination of magnesium and vitamin B6. Vitamin B6 was given at a dose of 200 mg daily and magnesium at a dose of 500 mg daily (10 to 13 women in each treatment group).

Vitamin E was tested in only one small trial (50 women) over one month and had no benefit. This one small trial compared women taking vitamin E once daily plus ibuprofen during a period, compared with just ibuprofen during a period. No difference in pain relief was evident between the two groups (50 women). Any benefit of a dietary supplement may, however, require longer than one month cycle to take effect.

Taking fish oil (omega-3 fatty acids) for two months gave effective pain relief.

This conclusion is from one small trial (42 women) comparing fish oil (omega-3 fatty acids) to placebo.

Women were also able to take less additional medication when they supplemented their diet with fish oil.

Four women reported side effects with fish oil (difficulty swallowing capsules, nausea, acne exacerbation) and stopped treatment.

The Japanese herbal remedy Toki-shakuyaku-san taken for two months effectively reduced period pain. Women on the herbal remedy needed fewer painkillers (the NSAID, diclofenac). These benefits were maintained during a two month follow-up period in which women received no treatment.

The conclusions are from one trial comparing the herbal remedy to placebo (in 40 women). For this trial, the women had been randomly assigned to take the herbal remedy or a placebo. Neither the women, nor their doctors knew who was taking the active treatment. What’s more, there was careful monitoring of adherence to treatment during the trial and no participants withdrew prematurely.

A limitation of this trial is that women were diagnosed from a complex set of symptoms according to traditional Chinese medicine, as well as having the typical diagnosis of primary dysmenorrhoea.

How it was tested

The researchers made a thorough search of the medical literature and identified seven authoritative controlled trials.

The overall age range was 12 to 45 years; three of the trials focused on adolescents (age 12 to 21 years). The duration of treatment varied from two to six months.

Trials were performed in a variety of countries: USA (2), Switzerland, India, Japan, Venezuela, and Germany.

A number of different herbal and dietary interventions were considered by the seven trials. Magnesium was investigated in three trials (98 women), Vitamin B6 in one trial (46 women in total but in groups of 10 to 13 receiving different treatments: vitamin B6, magnesium, vitamin B6 plus magnesium or a non-active tablet), Vitamin B1 in one trial (556 women), Vitamin E in one trial (50 women), fish oil or omega-3 fatty acids in one trial (42 women), and a Japanese herb combination in one trial (40 women). The Japanese herb combination contained six herbs: Angelicae radix, Paeoniae radix, Hoelen, Atractylodis lanceae rhizoha, Alismatis rhizoma, and Cnidii rhizoma.

Side effects and general cautions

Minimal adverse effects were experienced in both magnesium and placebo groups. One trial reported no adverse effects in either treatment group. Another trial, which involved only 21 women, reported adverse effects in four women in each of the active and inactive treatment groups. The magnesium group complained of diarrhoea, stomach acid problems, and excessive thirst; the placebo group complained of diarrhoea, stomach acid problems, and tiredness. Women who were on oral contraceptives, had an intrauterine device inserted, or on additional medication did not participate in the trial.

Sources

Proctor ML, Murphy PA. Herbal and dietary therapies for primary and secondary dysmenorrhoea. The Cochrane Database of Systematic Reviews 2001, Issue 2. Art. No.: CD002124. DOI: 10.1002/14651858.CD002124.

Blumenthal M. Introduction. In: M Blumethal, WR Busse, A Goldberg, J Guenwald, T Hall, S Klein, C Riggins, R Rister editor(s). The complete German Commission E monographs: therapeutic guide to herbal medicines. Austin, Texas: American Botanical Council, 1998:5-70.

Ernst E. Harmless herbs? A review of the recent literature. American Journal of Medicine 1998;104(2):170-8.

BEHAVIOURAL INTERVENTIONS FOR PERIOD PAIN

Behavioural therapies work on both physical and coping strategies for controlling symptoms rather than focusing on medical solutions for any underlying causes of the symptoms. They are effective in managing pain in many health conditions including osteoarthritis and cancer.

Behavioural therapies assume that the mind (psychological) and environmental factors interact with, and influence, physical processes and behaviours.

Behavioural interventions set out to modify an individual's behaviour and can also be aimed at modifying thoughts and beliefs (cognitions). These include biofeedback (training that develops an individual's ability to control their autonomic nervous system, for example heart rate), electromyographic (EMG) training (use of a graphic representation of muscle contractions to learn to control them), Lamaze breathing exercises, desensitization, hypnotherapy, imaging and relaxation training.

What the synthesised research says

Behavioural interventions may effectively reduce period pain and symptoms when comparing women receiving a behavioural intervention with a control group of women not receiving the intervention.

One trial of pain management training reported reduction in pain and reduced discomfort.

Three trials of relaxation reported varied results, two trials showed no difference in symptom severity scores; one trial reported relaxation was effective for reducing the severity of menstrual cramp symptoms.

Two trials reported less restriction in daily activities following treatment with either relaxation or pain management training. One trial also reported less time absent from school following treatment with pain management training compared to a control.

One trial found that pain management training resulted in less time absent from school or work compared to a control by some five hours (range couple of hours to nearly 8 hours).

How it was tested

The researchers made a thorough search of the medical literature and identified five controlled trials that could be included. These were carried out in the USA between 1975 and 1987 and involved a total of 213 women aged 16 to 44 years.

Different behavioural interventions were considered by the five trials. Relaxation by itself or in combination with other treatments (imagery, biofeedback) was investigated by three trials; biofeedback (with EMG or skin temperature training), pain management, and coping skills each in one trial. The duration of treatment varied from one to six months. Level of pain and severity of symptoms was typically measured for the menstruation following treatment.

Side effects and general cautions

None of the trials reported data on adverse effects of treatment.
The results could not be combined and are inconclusive because of different ways of defining dysmenorrhoea, interventions and ways of measuring their effects. Women with different levels of severity of dysmenorrhoea were included.

Common exclusion criteria were use of oral contraceptives or intrauterine devices and use of additional medication such as nonsteroidal anti-inflammatories.

Treatment providers vary in how they give behavioural therapies and may be tailored for an individual. In the trials included in this review, many treatments were scheduled during menses, however other trials carried out interventions anytime in the menstrual cycle.

Source

Proctor ML, Murphy PA, Pattison HM, Suckling J, Farquhar CM. Behavioural interventions for primary and secondary dysmenorrhoea. The Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD002248. DOI: 10.1002/14651858.CD002248.pub3.

SPINAL MANIPULATION FOR PAINFUL MENSTRUAL PERIODS

Spinal manipulation involves a therapist using hands to put pressure on certain parts of the back bone. This is a service which can be offered by physiotherapists, osteopaths and chiropractors. Manipulating the lower spine can improve blood flow to the pelvic area of the body and so help with painful periods caused by restricted blood flow. Manipulation may also resolve pain coming from problems in the spine itself or referred pain arising from musculoskeletal structures in the pelvis and hips.

Manipulation of the lower spine, the area that would commonly be targeted in dysmenorrhoea, has low risks of fractures and nerve compression.

Spinal manipulation can, however, cause severe adverse reactions including death and paralysis but these adverse events are usually related to manipulation of the neck and happen in one in one million manipulations.

What the synthesised research says

Both spinal manipulation and going through the process without manipulation (a sham procedure) reduced the level of pain experienced with a period. A technique of high-speed manipulation of the lower (lumbar) spine while lying on one side may be no more effective than a sham procedure.

These conclusions were taken from four gold standard type trials where 206 participants were randomly assigned to high velocity, low amplitude rotation manipulation or a sham procedure. The largest of these trials (137 women) with the best reported methodology found no clear benefit with actual manipulation. The other three trials were small and did favour manipulation. Manipulation was more effective than no treatment in a single trial (19 women).

Some therapists use a hand-held pressure applicator that means they can monitor the force used for manipulation (Toftness technique). In one small trial with 30 participants regular manipulation was more effective than sham treatment in reducing period pain at six months but not when measured after the shorter time of three months of treatment.

How it was tested

The researchers made a thorough search of the medical literature and were able to identify five controlled trials. Spinal manipulation was being used for the treatment of painful periods that had no known cause or was associated with a medical problem like endometriosis or ovarian cysts.

Results from the four trials (206 participants) of high velocity, low amplitude rotation manipulation suggest that the technique was no more effective than sham manipulation. The only difference between sham and active manipulation was posture and the force applied. The two procedures may have been too similar to see a clear difference and the sham manipulation may have given some benefit.

Side effects and general cautions

Most trials did not report on adverse events. In trials where they were, there was no difference in adverse effects experienced by participants in the active or sham treatment groups.

All the trials took place in chiropractic and osteopathic clinics in the United States. Women were generally not entered into the trial if they had existing back trauma or pain, pelvic medical problems, infrequent or irregular periods and the use of an intra-uterine device (IUD) or oral contraceptives.

Spinal manipulation treatments varied greatly, including the timing and number of treatments (only once on day 1 of their menstrual cycle in one trial), length of follow up and consistency of treatments (within and between women).

Therapists perform physical therapies with their own variations. Treatment may also be individually tailored. Even if this is not so, therapists often vary the duration of treatment, the exact placement of attention/manipulation along the spine, the force of manipulation, the types of manoeuvres, the frequency of treatments, timing of treatments in the cycle and the number of treatments performed. There may also be accompanying treatments like massage or use of pressure points, laser acupuncture, and exercises.

Source

Proctor ML, Hing W, Johnson TC, Murphy PA. Spinal manipulation for primary and secondary dysmenorrhoea. The Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No.: CD002119.pub2. DOI: 10.1002/14651858.CD002119.pub2. This review was updated for Issue 3, 2006; no new trials were found.

TENS (TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION) AND ACUPUNCTURE FOR PAINFUL MENSTRUAL PERIODS

TENS uses small electrodes on the skin to apply an electric current. The pulse rates (frequencies) and intensities of stimulation are adjusted by the therapist to get the best pain relief.

Where TENS is self-administered, a person has a portable unit and places the electrodes on the painful areas, and carries on her daily activities. Physician or therapist-administered treatments are more likely to be applied on meridian points (specific trigger points accessed on the body surface), generally using high frequencies. In high frequency TENS a woman may feel a comfortable tingling sensation.

The idea is that the electric current alters the body's ability to receive and process pain signals.

Low-frequency TENS (acupuncture-like TENS) triggers visible rhythmic muscle contractions which make it more difficult to continue carrying on daily activities.

Acupuncture involves fine, solid metallic needles which penetrate the skin and are manipulated manually or by electrical stimulation. The needles are inserted into the skin along meridian points. These are thought to cause excitation that blocks pain impulses.

What the synthesised research says

High-frequency TENS effectively relieved painful periods in small trials in which women treated with TENS were compared with those randomly assigned to be given a sham, or inactive, therapy. (This is a randomised controlled trial). Three of 4 such controlled trials reported more effective pain relief with high-frequency TENS than with sham therapy.

Only 2 of these trials looked at the effects of TENS on the use of painkillers and there was no difference when women had active or sham TENS. In one of the trials, there was no difference in absence from work or school between the two treatment groups.

Low-frequency TENS was no more effective in reducing pain than the comparison treatment, either sham TENS (4 trials) or an inactive placebo pill (2 trials). This was the overall conclusion although one trial in each of sham and placebo pill trials had a positive effect for active TENS. The need for painkillers was reduced in one trial.

Three trials directly compared high-frequency TENS with low-frequency TENS to see if one was better than the other. No conclusions can be made because results were conflicting.

Acupuncture was clearly more effective than both sham acupuncture and no treatment for pain relief (from one small, quality trial).

From two trials: one showed that TENS and painkillers gave similarly pain relief; in the other trial ibuprofen was better.

How it was tested

The researchers made a thorough search of the medical literature and identified 9 randomised controlled trials that altogether included 213 women.

Seven trials investigated TENS, one investigated acupuncture, and one investigated both TENS and acupuncture.

Six of the trials were performed in the USA, and three in Sweden.

Women were on average 25 (range 15 to 38) years of age.

Side effects and general cautions

For high-frequency TENS, only one trial reported adverse effects associated with treatment, in 4 out of 32 women. These included muscle vibrations, tightness, headaches after use, and slight redness or burning of the skin.

Low-frequency TENS, one trial reported that there were no adverse effects.

Different treatment schedules were used in the trials. Many women received TENS treatments during their periods. In other trials, especially those using acupuncture, women received treatment anytime in the menstrual cycle.

Women were excluded from some of the included trials if they used oral contraceptives or had an intrauterine contraceptive device (IUD).

Source

Proctor ML, Smith CA, Farquhar CM, Stones RW. Transcutaneous electrical nerve stimulation and acupuncture for primary dysmenorrhoea. The Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD002123. DOI: 10.1002/14651858.CD002123.