In 2003, a paper was published by the University of Maryland called ‘The Girl Who Cried Pain: A Bias Against Women in the Treatment of Chronic Pain’, which found that while women experience “more frequent and greater pain” than men, they are likely to “be less well treated than men for their painful symptoms” [1].
This is certainly true in the case of period pain. Why? Let’s examine.
Menstruation, in medical terms, is the regular shedding of the uterine lining (endometrium) and resulting discharge of blood and mucosal tissue that occur monthly to women during fertile years. For some, menstruation comes and goes with little or no pain. For others, menstruation can be accompanied by severe and often crippling abdominal pain and cramping; a condition known as dysmenorrhea.
Dysmenorrhea is a common gynecological problem currently estimated to affect between 17% and 81% of women of reproductive age [2]. Around 90% of this group suffer from primary dysmenorrhea, meaning pain occurs despite there being no underlying medical problem [3]. This pain is caused by the production of prostaglandin during ovulation, which triggers uterine contractions that reduce blood flow and cause ischemia, and the associated pain.
Others suffer from secondary dysmenorrhea, which describes menstrual pain caused by an underlying medical problem, such as endometriosis, fibroids, adenomyosis, endometrial polyps, ectopic pregnancy and chronic pelvic inflammatory disease.
Between 10% to 15% of women suffer severely enough from period pain that it interferes with their normal daily activities and causes absenteeism from school or work [2]. In the US alone, dysmenorrhea is estimated to cause annual losses of nearly 600 million working hours, costing $2 billion per year [4]. Still, many cases of dysmenorrhea remain undiagnosed and unreported, with many women simply choosing to suffer in silence and not seek medical treatment.
WHY ARE WOMEN SUFFERING IN SILENCE?
Medicine has long been a field biased towards men. The Girl Who Cried Pain study is not the only one that provides evidence that women are less likely than men to receive more advanced diagnostic and therapeutic interventions [5-10]. Additionally, the disproportionate representation of women in clinical trials has skewed the production of medical and scientific knowledge against women [11].
It is therefore not surprising that, for many women, viable treatment options for period pain simply do not exist. This fact, along with the resulting lack of awareness that period pain is not merely ‘a fact of life’, but rather a medical condition that warrants treatment, have led to the unnecessary suffering of millions of women across the globe, and this needs to change.
In order to raise awareness of the current treatment options available for dysmenorrhea, as well as highlight why further scientific exploration is needed into treatment for this hugely prevalent condition, we’ve evaluated the pros and cons of each below.
DRUG TREATMENTS
Painkillers
A large number of women are able to manage their pain using painkillers which work to block prostaglandin production. These non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen, naproxen sodium, and more, have proven clinical efficacy, however a subset of patients do exist, around 20-25% of people, that show resistance to NSAIDs [12]. Even for those who are not resistant, adverse side effects like gastrointestinal reflux [12] and peptic ulcers [13] are also a worry.
Oral contraceptive pills (OCPs)
The combined OCP provides pain relief through a combination of ovulation suppression and thinning of the uterine lining which decreases prostaglandin production. The combined OCP does have proven clinical efficacy in reducing the severity of dysmenorrhea [14], however concerns over its long-term safety have been raised, with adverse side effects such as venous thromboembolism, weight gain and cardiovascular events being well reported [15]. Another aspect is the fact that it provides contraception, which may be an advantage or a problem depending on the patient.
Hormone depot systems i.e. IUD/the coil
Hormone depot systems include intrauterine devices that release hormone directly into the uterine cavity, devices that are implanted under the skin in the upper arm impregnated with hormone and long-lasting, injectable hormones. They are widely used as contraceptive implants but, despite clinical evidence existing for their efficacy in treating dysmenorrhea [16-18], they are not currently routinely used in the treatment of dysmenorrhea. Some safety concerns do exist around the effect of certain systems on bone mineral density [19].
SURGICAL INTERVENTIONS
For those that are unresponsive to available drug treatments, surgical options may be explored.
Nerve interruption
There are two nerve interruption techniques, uterosacral nerve ablation (LUNA) and presacral neurectomy (PSN), both of which can be carried out laparoscopically, i.e. via keyhole surgery. LUNA involves the destruction of the uterine nerve fibres that exit the uterus through the uterosacral ligament, and PSN refers to the removal of the presacral plexus, the group of nerves that conducts the pain signal from the uterus to the brain. While some studies suggest their efficacy [12,20,21], the procedures are invasive and irreversible, with possible adverse side effects ranging from constipation, urge incontinence, uterine prolapse and bladder dysfunction [12].
Hysterectomy
For individuals who do not wish to bear children, a hysterectomy may be considered. A total hysterectomy involves removal of the womb and the cervix, while a subtotal hysterectomy removes only the womb. Both procedures can be performed laparoscopically and are clinically proven to relieve dysmenorrhea pain, however the procedures are invasive, irreversible, and permanently prevent childbirth [22].
NEUROMODULATION APPROACHES
Transcutaneous electrical nerve stimulation (TENS)
TENS devices have been shown to be effective in treating pain in a wide variety of conditions, including dysmenorrhea. They deliver an electric current at set frequencies through the skin to the desired site using self-adhering electrodes. There are a few different theories on how TENS provides period pain relief, ranging from blocking pain signal transmission to stimulating endorphin release, yet while TENS is an anecdotally accepted treatment for some, there isn’t enough good-quality scientific evidence to say for sure whether it is a reliable method of pain relief [23]. It is also often reported to provide short-term relief only [23]. One thing is for sure, though; it’s drug-free with very minimal side effects.
ALTERNATIVE THERAPIES
Finally, many alternative therapies have been investigated in the treatment of dysmenorrhea, including acupuncture, herbal and dietary supplements, behavioural therapies, various forms of exercise, and topical heat. No substantial evidence currently exists to prove the efficacy of these alternative therapies in relieving period pain, however there is more and more evidence suggesting a relationship between topical heat (i.e. hot water bottles and heat pads) and pain relief [24,25].
WE DESERVE BETTER
It’s obvious, then, that no single treatment for dysmenorrhea exists that is not without its disadvantages. This is not to say no treatment can exist. Considering the huge numbers of people negatively affected by it, dysmenorrhea is an underserved condition. Further exploration into treatments are needed to establish drug-free, clinically proven methods of pain relief that do not have adverse side effects, long-term consequences or substantial barriers to access.
REFERENCES
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