Considerations

Many women have painful periods. Sometimes, the pain makes it difficult 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 20s.

Causes

Painful menstrual periods fall into two groups, depending on the cause:

• Primary dysmenorrhea
• Secondary dysmenorrhea

Primary dysmenorrhea is menstrual pain that occurs around the time that menstrual periods first begin in otherwise healthy young women. This pain is usually not related to a specific problem with the uterus or other pelvic organs. Increased activity of the hormone prostaglandin, which is produced in the uterus, is thought to play a role in this condition.
Secondary dysmenorrhea is menstrual pain that develops later in women who have had normal periods and is often related to problems in the uterus or other pelvic organs, such as:

Endometriosis

Causes

Every month, a woman's ovaries produce hormones that tell the cells lining the uterus (womb) to swell and get thicker. The body removes these extra cells from the womb lining (endometrium) when you get your period.
If these cells (called endometrial cells) implant and grow outside the uterus, endometriosis results. The growths are called endometrial tissue implants. Women with endometriosis typically have tissue implants on the ovaries, bowel, rectum, bladder, and on the lining of the pelvic area. They can occur in other areas of the body, too.
Unlike the endometrial cells found in the uterus, the tissue implants outside the uterus stay in place when you get your period. They sometimes bleed a little bit. They grow again when you get your next period. This ongoing process leads to pain and other symptoms of endometriosis.
The cause of endometriosis is unknown. One theory is that the endometrial cells shed when you get your period travel backwards through the fallopian tubes into the pelvis, where they implant and grow. This is called retrograde menstruation. This backward menstrual flow occurs in many women, but researchers think the immune system may be different in women with endometriosis.
Endometriosis is common. Sometimes, it may run in the family. Although endometriosis is typically diagnosed between ages 25 - 35, the condition probably begins about the time that regular menstruation begins.
A woman who has a mother or sister with endometriosis is much more likely to develop endometriosis than other women. You are more likely to develop endometriosis if you:

• Started your period at a young age
• Never had children
• Have frequent periods or they last 7 or more days
• Closed hymen, which blocks the flow of menstrual blood during the period

Symptoms

Pain is the main symptom of endometriosis. A woman with endometriosis may have:

• Painful periods
• Pain in the lower abdomen before and during menstruation
• Cramps for a week or two before menstruation and during menstruation; cramps may be steady and range from dull to severe)
• Pain during or following sexual intercourse
• Pain with bowel movements
• Pelvic or low back pain that may occur at any time during the menstrual cycle

Note: There may be no symptoms. Some women with a large number of tissue implants in their pelvis have no pain at all, while some women with milder disease have severe pain.

Exams and Tests

The health care provider will perform a physical exam, including a pelvic exam. Tests that are done to help diagnose endometriosis include:

• Pelvic exam
• Transvaginal ultrasound
• Pelvic laparoscopy

Treatment

Treatment depends on the following factors:

• Age
• Severity of symptoms
• Severity of disease
• Whether you want children in the future

If you have mild symptoms and do not ever want children, you may choose to have regular exams every 6 - 12 months so the doctor can make sure the disease isn't getting worse. You can manage your symptoms by using:

• Exercise and relaxation techniques
• Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil) and naproxen (Aleve), acetaminophen (Tylenol), or prescription painkillers to relieve cramping and pain.

For other women, treatment options include:

• Medications to control pain
• Hormone medications to stop the endometriosis from getting worse
• Surgery to remove the areas of endometriosis or the entire uterus and ovaries

Treatment to stop the endometriosis from getting worse often involves using birth control pills continuously for 6 - 9 months to stop you from having periods and create a pregnancy-like state. This is called pseudopregnancy. This therapy uses estrogen and progesterone birth control pills. It relieves most endometriosis symptoms. However, it does not prevent scarring or reverse physical changes that have already occurred as the result of the endometriosis.
Other hormonal treatments may include:

• Progesterone pills or injections. However, side effects can be bothersome and include weight gain and depression.
• Gonadotropin-agonist medications such as nafarelin acetate (Synarel) and Depo Lupron to stop the ovaries from producing estrogen and produce a menopause-like state. Side effects include hot flashes, vaginal dryness, and mood changes. Treatment is usually limited to 6 months because it can lead to bone density loss. It may be extended up to 1 year in some cases.

Surgery may be recommended if you have severe pain that does not get better with other treatments. Surgery may include:

• Pelvic laparoscopy or laparotomy to diagnose endometriosis and remove all endometrial implants and scar tissue (adhesions).
• Hysterectomy to remove the womb (uterus) if you have severe symptoms and do not want to have children in the future. One or both ovaries and fallopian tubes may also be removed. If you do not have both of ovaries removed at the time of hysterectomy, your symptoms may return.

Outlook (Prognosis)

Hormone therapy and laparoscopy cannot cure endometriosis. However, these treatments can help relieve some or all symptoms in many women for years.
Removal of the womb (uterus), fallopian tubes, and both ovaries (a hysterectomy) gives you the best chance for a cure. Rarely, the condition can return.

Possible Complications

Endometriosis can lead to problems getting pregnant (infertility). Not all women, especially those with mild endometriosis, will have infertility. Laparoscopy to remove scarring related to the condition may help improve your chances of becoming pregnant. If it does not, fertility treatments should be considered.
Other complications of endometriosis include:

• Long-term (chronic) pelvic pain that interferes with social and work activities
• Large cysts in the pelvis (called endometriomas) that may break open (rupture)

In a few cases, endometriosis implants may cause blockages of the gastrointestinal or urinary tracts. This is rare.
Very rarely, cancer may develop in the areas of endometriosis after menopause.

When to Contact a Medical Professional

Call for an appointment with your health care provider if:

• You have symptoms of endometriosis
• Back pain or other symptoms come back after endometriosis is treated

Consider getting screened for endometriosis if your mother or sister has been diagnosed with endometriosis, or if you are unable to become pregnant after trying for 1 year.

Prevention

 Birth control pills may help to prevent or slow down the development of the endometriosis.

Uterine fibroids

Causes

Uterine fibroids are common. As many as 1 in 5 women may have fibroids during their childbearing years (the time after starting menstruation for the first time and before menopause). Half of all women have fibroids by age 50.
Fibroids are rare in women under age 20. They are more common in African-Americans than Caucasians.
The cause of uterine fibroids is unknown. However, their growth has been linked to the hormone estrogen. As long as a woman with fibroids is menstruating, a fibroid will probably continue to grow, usually slowly.
Fibroids can be so tiny that you need a microscope to see them. However, they can grow very large. They may fill the entire uterus, and may weigh several pounds. Although it is possible for just one fibroid to develop, usually there are more than one.
Fibroids are often described by their location in the uterus:

• Myometrial -- in the muscle wall of the uterus
• Submucosal -- just under the surface of the uterine lining
• Subserosal -- just under the outside covering of the uterus
• Pendunculated -- occurring on a long stalk on the outside of the uterus or inside the cavity of the uterus

Symptoms

More common symptoms of uterine fibroids are:

• Bleeding between periods
• Heavy menstrual bleeding (menorrhagia), sometimes with the passage of blood clots
• Menstrual periods that may last longer than normal
• Need to urinate more often
• Pelvic cramping or pain with periods
• Sensation of fullness or pressure in lower abdomen
• Pain during intercourse

Note: There are often no symptoms. Your health care provider may find them during a physical exam or other test. Fibroids often shrink and cause no symptoms in women who have gone through menopause.

Exams and Tests

The health care provider will perform a pelvic exam. This may show that you have a change in the shape of your womb (uterus).
It can be difficult to diagnose fibroids, especially if you are extremely overweight.
An ultrasound may be done to confirm the diagnosis of fibroids. Sometimes, a pelvic MRI is done.
An endometrial biopsy (biopsy of the uterine lining) or laparoscopy may be needed to rule out cancer.

Treatment

Treatment depends on several things, including:

• Your age
• General health
• Severity of symptoms
• Type of fibroids
• Whether you are pregnant
• If you want children in the future

Some women may just need pelvic exams or ultrasounds every once in a while to monitor the fibroid's growth.
Treatment for the symptoms of fibroids may include:

• Birth control pills (oral contraceptives) to help control heavy periods
• Intrauterine devices (IUDs) that release the hormone progestin to help reduce heavy bleeding and pain
• Iron supplements to prevent or treat anemia due to heavy periods
• Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naprosyn for cramps or pain
• Short-term hormonal therapy injections to help shrink the fibroids

Surgery and procedures used to treat fibroids include:

• Hysteroscopic resection of fibroids: Women who have fibroids growing inside the uterine cavity may need this outpatient procedure to remove the fibroid tumors.
• Uterine artery embolization: This procedure stops the blood supply to the fibroid, causing it to die and shrink. Women who may want to become pregnant in the future should discuss this procedure with their health care provider.
• Myomectomy: This surgery removes the fibroids. It is often the chosen treatment for women who want to have children, because it usually can preserve fertility. More fibroids can develop after a myomectomy.
• Hysterectomy: This invasive surgery may be an option if medicines do not work and other surgeries and procedures are not an option.

Support Groups

National Uterine Fibroid Foundation - www.nuff.org.

Outlook (Prognosis)

Some women with fibroids have no symptoms and may not need treatment.
During a pregnancy, existing fibroids may grow due to the increased blood flow and estrogen levels. The fibroids usually return to their original size after the baby is delivered.

Possible Complications

Complications of fibroids include:

• Severe pain or excessively heavy bleeding that may require emergency surgery
• Twisting of the fibroid, which causes a blockage in nearby blood vessels feeding the tumor (surgery may be needed)
• Anemia (low red blood cell count) if the bleeding is very heavy
• Urinary tract infections, if pressure from the fibroid prevents the bladder from fully emptying
• Cancerous changes called leiomyosarcoma (rare)

In rare cases, fibroids may cause infertility. Fibroids may also cause complications if you become pregnant, although the risk is thought to be small:

• Some pregnant women with fibroids may deliver a premature baby because there is not enough room in the womb.
• A c-section may be needed if the fibroid blocks the birth canal or causes the baby to be in a dangerous position.
• Some pregnant women with fibroids have heavy bleeding immediately after giving birth. 

Pelvic inflammatory disease (PID)

Causes

Pelvic inflammatory disease (PID) occurs when bacteria move from the vagina or cervix into the uterus, fallopian tubes, ovaries, or pelvis.
Most cases of PID are due to the bacteria that cause chlamydia and gonorrhea. These are sexually transmitted infections (STIs). The most common way a woman develops PID is by having unprotected sex with someone who has a sexually transmitted infection.
However, bacteria may also enter the body during some surgical or office procedures, such as:

• Childbirth
• Endometrial biopsy
• Insertion of an intrauterine device (IUD)
• Miscarriage
• Therapeutic or elective abortion

In the United States, nearly 1 million women develop PID each year. About 1 in 8 sexually active adolescent girls will develop PID before age 20.
You are more likely to develop PID if you have:

• A male sexual partner with gonorrhea or chlamydia
• Multiple sexual partners
• Past history of any sexually transmitted infection
• Past history of PID
• Recent insertion of an IUD
• Sexual activity during adolescence

Symptoms

The most common symptoms of PID include:

• Fever (not always present; may come and go)
• Pain or tenderness in the pelvis, lower abdomen, or sometimes the lower back
• Vaginal discharge with abnormal color, texture, or smell

Other symptoms that may occur with PID:

• Bleeding after intercourse
• Chills
• Fatigue
• Frequent or painful urination
• Increased menstrual cramping
• Irregular menstrual bleeding or spotting
• Lack of appetite
• Nausea, with or without vomiting
• No menstruation
• Painful sexual intercourse

Note: There may be no symptoms. People who experience an ectopic pregnancy or infertility often have had silent PID, which is usually caused by chlamydia infection.

Exams and Tests

You may have a fever and abdominal tenderness. A pelvic examination may show:

• A cervix that bleeds easily
• Cervical discharge
• Pain with movement of the cervix
• Tenderness in the uterus or ovaries

Lab tests that look for signs of infection are:

• C-reactive protein (CRP)
• Erythrocyte sedimentation rate (ESR)
• WBC count

Other tests include:

• Culture of your vagina or cervix to look for gonorrhea, chlamydia, or other causes of PID
• Pelvic ultrasound or CT scan to look for other causes of your symptoms, such as appendicitis or pregnancy, and to look for abscesses or pockets of infection around the tubes and ovaries
• Serum HCG (pregnancy test)

Treatment

Your doctor will often start you on antibiotics while waiting for your test results.
If you are diagnosed with milder PID, you will usually be given an antibiotic injection or shot, and then sent home with antibiotic pills to take for up to 2 weeks. You will need to closely follow up with your health care provider.
More severe cases of PID may require you to stay in the hospital. Antibiotics are first given by IV, and then later by mouth. Which antibiotic is used depends on the type of infection.
A number of different antibiotics may be used for treating this type of infection. Some are safe in pregnant women. See gonorrhea or chlamydia for specific treatment recommendations.
Sexual partners must be treated to prevent passing the infection back and forth. You and your partner must finish all of the antibiotics. Use condoms until you both have finished taking your antibiotics.
Complicated cases that do not improve with antibiotics may need surgery.

Possible Complications

PID infections can cause scarring of the pelvic organs, possibly leading to:

• Chronic pelvic pain
• Ectopic pregnancy
• Infertility

When to Contact a Medical Professional

Call your health care provider if:

• You have symptoms of PID
• You think you have been exposed to a sexually transmitted infection (STI)
• Treatment for a current STI does not seem to be working

Prevention

Preventive measures include:

• Get prompt treatment for STIs.
• Practice safer sex behaviors. The only absolute way to prevent an STI is to not have sex (abstinence). Having a sexual relationship with only one person (monogamous) can reduce the risk. Use a condom every time you have sex. (See: Safe sex)

You can reduce the risk of PID by getting regular STI screening exams. Couples can be tested before starting to have sex. Testing can detect infections that are not yet causing symptoms.
All sexually active women ages 20 - 25 and younger should be screened each year for chlamydia and gonorrhea. All women with new sexual partners or multiple partners should also be screened.

Premenstrual syndrome

Causes

The exact cause of PMS has not been identified. Changes in brain hormone levels may play a role, but this has not been proven. Women with premenstrual syndrome may also respond differently to these hormones.
PMS may be related to social, cultural, biological, and psychological factors.
Up to 3 out of every 4 women experience PMS symptoms during their childbearing years. It occurs more often in women:

• Between their late 20s and late 40s
• Who have at least one child
• With a personal or family history of major depression
• With a history of postpartum depression or an affective mood disorder

The symptoms often get worse in a woman's late 30s and 40s as she approaches the transition to menopause.

Symptoms

PMS refers to a set of symptoms that tend to:

• Start during the second half of the menstrual cycle (14 days or more after the first day of your last menstrual period)
• Go away within 1 - 2 days after a menstrual period starts

The most common physical symptoms include:

• Bloating or feeling gaseous 
• Breast tenderness
• Clumsiness
• Constipation or diarrhea
• Food cravings
• Headache
• Less tolerance for noises and lights

Other symptoms include:

• Confusion, difficulty concentrating, or forgetfulness
• Fatigue and feeling slow or sluggish
• Feelings of sadness or hopelessness
• Feelings of tension, anxiety, or edginess
• Irritable, hostile, or aggressive behavior, with outbursts of anger toward self or others
• Loss of sex drive (may be increased in some women)
• Mood swings
• Poor judgment
• Poor self-image, feelings of guilt, or increased fears
• Sleep problems (sleeping too much or too little)

Exams and Tests

There are no specific signs or lab tests that can diagnose PMS. To rule out other possible causes of symptoms, it is important to have a:

• Complete medical history
• Physical exam (including pelvic exam).

Treatment

Keep a daily diary or log for at least 3 months. Record the type of symptoms you have, how severe they are, and how long they last. This symptom diary will help you and your health care provider find the best treatment.
A healthy lifestyle is the first step to managing PMS. For many women, lifestyle approaches are often enough to control symptoms.

• Drink plenty of fluids (water or juice, not soft drinks, alcohol, or other beverages with caffeine) to help reduce bloating, fluid retention, and other symptoms.
• Eat frequent, small meals. Leave no more than 3 hours between snacks, and avoid overeating.
• Eat a balanced diet with extra whole grains, vegetables, and fruit, and less or no salt and sugar.
• Your health care provider may recommend that you take nutritional supplements. Vitamin B6, calcium, and magnesium are commonly used. Tryptophan, which is found in dairy products, may also be helpful.
• Get regular aerobic exercise throughout the month to help reduce the severity of PMS symptoms.
• Try changing your nighttime sleep habits before taking drugs for insomnia.

Aspirin, ibuprofen, and other NSAIDs may be prescribed for headache, backache, menstrual cramping, and breast tenderness.
Birth control pills may decrease or increase PMS symptoms.
In severe cases, medicines to treat depression may be helpful. Antidepressants known as selective serotonin-reuptake inhibitors (SSRIs) are often tried first. You can reduce the need for medicines by using:

• Cognitive behavioral therapy
• Light therapy

Other medicines that may be used include:

• Anti-anxiety drugs for severe anxiety
• Diuretics (may help with severe fluid retention, which causes bloating, breast tenderness, and weight gain)
• Bromocriptine, danazol, and tamoxifen (rarely used for relieving breast pain)

Outlook (Prognosis)

Most women who are treated for PMS symptoms get significant relief.
PMS symptoms may become severe enough to prevent you from functioning normally.
The suicide rate in women with depression is much higher during the second half of the menstrual cycle.