Menstrual Pain

Premenstrual syndrome (PMS) and related menstrual disorders are common sources of misery among menstruating women. Symptoms interfere with family activities, social outings, and work. A normal menstrual cycle is characterized by the regular rise and fall of sex hormones, most importantly estrogen and progesterone, culminating in menstruation. The cycle is usually divided into four phases:

Follicular phase: During this phase, a rise in follicle stimulating hormone (FSH) causes several follicles (each containing an egg) to grow on the surface of the ovary. Under the influence of luteinizing hormone (LH), these follicles secrete estradiol, a form of estrogen, causing a slowdown in growth of the follicles. The estrogen also encourages uterine lining tissue to build up in preparation for a fertilized egg. Eventually, one follicle emerges as the dominant follicle.

Ovulation: A boost in the production of LH causes the dominant follicle to burst, releasing an egg into the fallopian tube. Timing varies individually, but ovulation usually occurs around day 14 of the cycle. Once the egg is in the fallopian tube, it is available for fertilization.

Luteal phase: After the egg has been released, the remaining follicle tissue is known as the corpus luteum. During the next two weeks of the menstrual cycle, the corpus luteum secretes an increasing amount of progesterone to prepare the body for early pregnancy and reception of a fertilized egg. If the egg is not fertilized, progesterone levels decline. Women typically suffer from PMS during the luteal phase of their menstrual cycle.

Menstruation: Menstruation is characterized by low levels of progesterone and estrogen when the egg has not been fertilized. The built-up portion of the uterine wall sloughs off and passes through the vagina as blood, mucus, and tissue remnants. This sloughing off is caused by contraction of the arterioles that supply the thickened uterine lining with blood, as well as the contractions of the smooth muscular wall. These contractions cause muscle cramping and are under the control of cyclooxygenase (COX) enzymes, which are often inhibited by over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs).

Symptoms & Diagnosis

Since PMS covers such a wide range of symptoms, identifying PMS can be difficult. Until the clinical diagnosis of PMS was established, there was significant disagreement as to whether it was a legitimate medical condition. It is now estimated to affect up to 50% of menstruating women, and symptoms can begin as early as 16 to 18 years of age, peaking in the 20s and 30s. Symptoms decrease with age and eventually cease with menopause.

PMS can affect various systems of the body:

• Psychological: tension, phobia, panic, depression, irritability, fatigue
• Nervous system: migraine headaches, fainting, seizures, dizziness
• Skin: acne, boils, hives
• Musculoskeletal: backache, joint pain, edema
• Respiratory: asthma, allergies
• Head and neck: sinusitis, sore throat, hoarseness
• Urinary: bladder infections
• Gastrointestinal: bloating, gas, food cravings
• Breasts: tenderness, swelling

Among women with PMS, some form of hormonal dysfunction occurs during the luteal phase. In many cases, symptoms associated with severe menstrual disorders are caused by a derangement of serotonin, an important neurotransmitter that regulates mood and behavior.

Evidence also suggests effects from decreased sensitivity of GABA (a neurotransmitter associated with relaxation and a decrease in anxiety) receptors in the brain, increased sensitivity of brain motor cells, and disturbances of the hypothalamic-pituitary-adrenal (HPA) axis, which controls stress hormone levels.

Statistically, women with PMS sometimes have a personal or family history of alcohol abuse and mood-related psychiatric disorders. Also, women with a history of sexual abuse were found to be more likely to suffer from severe PMS. Up to 95% of women who experienced sexual abuse, often at early ages, are likely to suffer from PMS.

Medical Treatment

Traditional medicine is not well equipped to treat PMS. There are no unique physical findings or lab tests to diagnose PMS, and few drugs achieve consistent results without significant side effects. If symptoms are mild, most women are told to use over-the-counter painkillers (NSAIDs) such as ibuprofen (Motrin) and naproxen sodium (Aleve) to ease uterine cramping and breast tenderness. These drugs inhibit prostaglandin synthesis and exhibit negative effects on the brain, kidneys, and other organs.

Hormone-based birth control pills are frequently recommended to cease ovulation, allowing women to bypass hormonal fluctuations that occur during this time. Unfortunately, evidence of their effectiveness is mixed, and long-term contraceptive use carries undeniable and often unforeseeable risks.

Antidepressants are commonly used for depression associated with PMS. Selective serotonin reuptake inhibitors (SSRIs) that are commonly used to treat PMS include Prozac and Zoloft. These drugs typically require a 2-3 week phase-in period before reaching maximum effectiveness, and side effects include nausea, diarrhea, tremor, weight loss, and headache. Benzodiazepines induce sedative, muscle-relaxant, and anticonvulsant effects. Xanax is a commonly prescribed benzodiazepine and has a serious risk of addiction and abuse.