The menstrual cycle is a rite of passage for young women, though it can be an often inconvenient and uncomfortable one. For some women, this discomfort and inconvenience can be quite disabling. Is this normal?
First, let’s take a quick look at the menstrual cycle. This cycle ranges from 28-35 days, and has distinct phases based on hormone levels. The first phase (follicular phase) starts day 1. Estrogen and progesterone levels are low, which causes the pituitary gland to release follicle-stimulating hormone (FSH) to produce a follicle inside the ovary, inside which the egg will mature. This follicle produces estrogen, which helps mature the egg. Around day 12-14, estrogen levels rise enough to begin the second phase (leutenizing phase). Leutenizing hormone released from the pituitary gland ruptures the follicle and causes the egg to be released; estrogen levels, which initially sharply decrease, then slowly increase to grow the uterine lining in anticipation of fertilization. Progesterone increases to act as a check on estrogen. If fertilization does not occur, estrogen and progesterone levels decrease near the end of this phase. Around day 28, the uterine lining is sloughed off during menstruation.
So what causes the symptoms often felt during this time? According to Heba Shaheed, pelvic floor PT and creator of The Pelvic Expert, low back pain is often caused by the uterus itself; heavy with blood, it pulls on its supporting ligaments, which connect to the spine. If the uterus is tilted, this pulling can occur in other areas, contributing to pelvic pain. Cramps are the result of uterine contractions to help push the blood out, which cause constriction in the blood vessels to the uterine tissue, but can also be caused by spasming pelvic floor muscles.
So, then, how can periods differ among women?
Amount of bleeding: 1/3 of all women experience heavy menstrual bleeding at some point. Menstrual bleeding is typically heavy when ovulation does not occur, which happens most often when the menstrual cycle first begins at puberty, and ends at menopause. During both of these times, hormone levels often fluctuate. Progesterone is often insufficient, which results in increased growth of the uterine lining. Insuffcient estrogen can also be a factor, as it does not trigger LH to release the egg. Anovulation can also occur in response to stress, or significant body weight changes.
Abnormal uterine bleeding is classified as more than 80mL of blood loss per cycle, and is classically defined as “excessive menstrual blood loss which interferes with a woman’s physical, social, emotional, and/or material quality of life” (NICE, cited in Munro & Hogqvist Tabor, 2016) for the majority of periods in the past 6 months. This can manifest as fully soaking 6 tampons in 1 day, needing to change protection overnight, and fully soaking a tampon in an hour for several hours in a row.
The PALM-COEIN system classifies likely causes of heavy bleeding; these are:
Polyp: growth on uterine lining
Adenomyosis: abnormal uterine lining growth into muscular uterine wall
Leiomyoma: uterine fibroid (smooth muscle tumor)
Malignancy
Coagulopathy: clotting disorder
Ovulatory dysfunction: absent or irregular ovulation resulting from hormone imbalance (inadequate progesterone or estrogen)
Endometrial: uterine lining abnormality, or growth of endometrial tissue outside the uterus
Iatrogenic: caused by other medical treatments
Not yet classified
It is therefore important for women to seek medical advice for heavy periods. Treatments vary according to the cause; if hormonal fluctuations are the cause, hormonal birth control is often prescribed.
Pain: Painful menstruation is called dysmenorrhea, and has 2 classifications.
1. Primary dysmenorrhea: cramping pain caused by overproduction of prostaglandins in the uterus, resulting in increased uterine contractions and blood vessel constriction, without a medical cause. Can affect from 45-95% of all women. It is often accompanied by nausea, fatigue, and diarrrhea. Cramps often reduce in severity as a woman ages. This is often treated with NSAIDs and hormonal supplementation.
2. Secondary dysmenorrhea: pain due to an underlying abnormality or medical condition, such as uterine fibroids, adenomyosis, endometriosis. It can even be caused by an IUD (more likely with copper-containing IUDs). Pain often begins earlier in the menstrual cycle and lasts longer. Cramps often increase in severity over time.
Period pain can be significantly disabling, but when is it abnormal? If your pain negatively impacts your quality of life, it is not normal. If NSAIDs or other palliative remedies like heat do not adequately control your pain, or if you notice an increase in pain duration during your cycle or an overall increase in pain severity over the years, you should seek medical advice to determine the underlying cause.
Recent research indicates that women with primary dysmenorrhea demonstrate higher sensitivity to pain overall; questions remain regarding whether these women may be at increased risk for other pain disorders like fibromyalgia.
In conclusion, menstruation is normal, and the accompanying cramping and discomfort can also be normal. Very heavy bleeding, and/or significant pain, both of which negatively impact your quality of life, are NOT normal and require evaluation by a medical professional.
So, can physical therapy help? Absolutely! As mentioned earlier, pelvic pain during menstruation can be caused by spasming pelvic floor muscles. Over time, these muscles can remain in a shortened state, and become unable to lengthen appropriately. This can lead to other issues, such as pain with intercourse, or bowel and bladder dysfunction. Chronically tight muscles can also put more pressure on the nerves, resulting in persistent pain. Pelvic physical therapists are trained in the assessment and treatment of pelvic floor muscles; in conjunction with medical treatment addressing the underlying cause of pain, physical therapy can help improve muscle length and function in order to reduce pain and improve overall quality of life.
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References:
Behera, MA, and Price, TM (October 17, 2017). Abnormal (Dysfunctional) Uterine Bleeding Treatment and Management [website article]. Retrieved from https://emedicine.medscape.com/article/257007-treatment#d8
Dawood, MY (2006). Primary dysmenorrhea: advances in pathogenesis and management. Obstetrics and Gynecology, 108(2), 428-441.
Hurskainen, R, Grenman, S, Komi, I, Kujansuu, E, Luoto, R, Orrainen, M, Patja, K, Penttinen, J, Silventoinen, S, Tapanainen, J, Toivonen, J (2007). Diagnosis and treatment of menorrhagia. Acta Obstetricia et Gynecologica Scandinavica, 86(6), 749-757.
Iacovides, S, Avidon, I, Baker, F (2015). What we know about primary dysmenorrhea today: a critical review. Human Reproduction Update, 21(6), 762-778.
Munro, MG, and Hoqgqvist Tabor, V. (March 6, 2016). Heavy Periods: How to tell if your heavy periods are “normal.” [blog post]. Retrieved from https://medium.com/clued-in/how-to-determine-if-you-suffer-from-heavy-menstrual-bleeding-hmb-70840b0c595c
Shaheed, H (March 12, 2017). From Endometriosis & Chronic Pelvic Pain to Empowerment & Vitality [blog post]. Retrieved from https://thepelvicexpert.com/blog/from-endometriosis-chronic-pelvic-pain-to-empowerment-vitality/
https://my.clevelandclinic.org/health/diseases/4148-dysmenorrhea