Painful menstruation affects many women. For a small number of women, such discomfort makes it next to impossible to perform normal household, job, or school-related activities for a few days during each menstrual cycle. Painful menstruation is the leading cause of lost time from school and work among women in their teens and 20's.

The pain may begin several days before or just at the start of your period. It generally subsides as menstrual bleeding tapers off.

Although some pain during menstruation is normal, excessive pain is not. Dysmenorrhea refers to menstrual pain severe enough to limit normal activities or require medication.

There are two general types of dysmenorrhea:

• Primary dysmenorrhea refers to menstrual pain that occurs in otherwise healthy women. This type of pain is not related to any specific problems with the uterus or other pelvic organs.
• Secondary dysmenorrhea is menstrual pain that is attributed to some underlying disease process or structural abnormality either within or outside the uterus.

Activity of the hormone prostaglandin, produced in the uterus, is thought to be a factor in primary dysmenorrhea. This hormone causes contraction of the uterus and levels tend to be much higher in women with severe menstrual pain than in women who experience mild or no menstrual pain.

• Premenstrual syndrome (PMS)
• Stress and anxiety
• Endometriosis
• Pelvic inflammatory disease
• Multiple sexual partners
• History of sexual or physical abuse
• Fibroids
• Ovarian cysts
• Intrauterine Device (IUD), but usually only for the first three months after insertion
• Tampons can aggravate menstrual pain in some women

The following steps may allow you to avoid prescription medications:

• Apply a heating pad to your lower abdomen (below your navel). Be careful NOT to fall asleep with it on.
• Take warm showers or baths.
• Drink warm beverages.
• Do light circular massage with your fingertips around your lower abdomen.
• Walk or exercise regularly, including pelvic rocking exercises.
• Follow a diet rich in complex carbohydrates, like whole grains, fruits, and vegetables, but low in salt, sugar, alcohol, and caffeine.
• Eat light but frequent meals.
• Try over-the-counter anti-inflammatory medicine, such as ibuprofen.
• Practice relaxation techniques like meditation or yoga.
• Try vitamin B6, calcium, and magnesium supplements, especially if your pain is from PMS.
• Keep your legs elevated while lying down. Or lie on your side with knees bent.

If these self-care measures do not work, your doctor may prescribe medications like:

• Cox-2 inhibitors such as celecoxib (Celebrex) and valdecoxib (Bextra)
• Stronger anti-inflammatories like diclofenac (Cataflam)
• Antidepressants
• Birth control pills
• Antibiotics
• Stronger pain relievers (even narcotics like codeine, for brief periods)

Call your doctor right away if:

• You have a fever.
• Vaginal discharge is increased in amount or foul-smelling.
• Your pain is significant, your period is over one week late, and you have been sexually active.

Also call your doctor if:

• Your pain is severe or sudden.
• Self-care measures don't relieve your pain after 3 months.
• You pass blood clots or have other symptoms with the pain.
• Your pain occurs at times other than menstruation, begins more than 5 days prior to your period, or continues after your period is over.
• You have an IUD that was placed more than 3 months ago.

Your health care provider will obtain your medical history and perform a physical examination, paying close attention to your pelvis and abdomen.

Your doctor will ask questions about your symptoms, such as the following:

• How old were you when your periods started?
• Have they always been painful? If not, when did the pain begin?
• When in your menstrual cycle do you experience the pain?
• Is the pain sharp, dull, intermittent, constant, aching, or cramping?
• Are you sexually active?
• Do you use birth control? What type?
• When was your last menstrual period?
• Was the flow of your last menstrual period a normal amount for you?
• Do your periods tend to be heavy or prolonged (lasting longer than 5 days)?
• Have you passed blood clots?
• Are your periods generally regular and predictable?
• Do you use tampons with menstruation?
• What have you done to try to relieve the discomfort? How effective was it?
• Does anything make the pain worse?
• Do you have any other symptoms?

Diagnostic tests that may be performed include:

• Blood tests including CBC
• Ultrasound
• Dilation of the cervix
• Laparoscopy
• Cultures (may be taken to rule out sexually transmitted diseases such as gonorrhea, primary syphilis, or chlamydia infections)

Birth control pills may be prescribed to alleviate menstrual pain. If not needed for birth control, they may be discontinued after 6 to 12 months. Many women note continued freedom from symptoms despite stopping the medication.

Surgery may be necessary for women who are unable to obtain adequate pain relief or pain control. Procedures may range from removal of cysts, polyps, adhesions, or fibroids to complete hysterectomy in cases of extreme endometriosis.

Prescription medications may be used for endometriosis. For pain caused by an IUD, removal of the IUD and alternative birth control methods may be needed.

Antibiotics are necessary for pelvic inflammatory disease.