Cramping and pelvic pain around the period time is also known as dysmenorrhea and it is one of the most common gynecological problems among women in their reproductive years. Dysmenorrhea is generally an acute type of pain with a sudden onset, a sharp rise and a short course. The rapid onset of the pain is generally consistent with perforation, either of the hollow viscus (uterus, intestine) or ischema. A severe type of cramping is commonly associated with muscular contraction or the obstruction of a hollow viscus. Pain perceived over the entire abdomen suggests a generalized reaction to an irritating fluid (Blood) within the peritoneal cavity. Since the viscera are relatively insensitive to pain, the first perception of the pain is often a vague, deep and poorly localized sensation associated with autonomic reflex response. Once the pain becomes localized, it is known as referred pain.
Acute types of pelvic pain can be due to ectopic pregnancy, leaking or ruptured ovarian cysts, functional cysts, hemorrhagic corpus luteum cysts, adnexal torsion, acute salpingo-oophritis, pelvic inflammatory disease, tubo-ovarian abscess, uterine leiomyoma, endometriosis, appendicitis, acute diverticulitis, intestinal obstruction, ureteral lithiasis, cycstits, or pyelonephritis.
Dysmenorrhea is not only acute, but also cyclical in that it occurs with a definite association to the menstrual cycle, this is compared to chronic pelvic pain where the pain occurs continually for more than six months. More specifically, cyclical pain usually appears within 1-2 years of menarche, when ovulatory cycles are established. The disorder tends to affect younger women but may persist into the 40’s. The cause of cyclical pain is an increase in endometrial prostaglandin production. These compounds are found in higher concentration in the secretory endometrium than in the proliferative endometrium. The decline of progesterone levels in the late luteal phase triggers lytic enzymatic action, resulting in a release of phospholipids with the generation of arachidonic acid and activation of the cyclooxygenase pathway. Women with primary dysmenorrhea have higher uterine tone with high-amplitude contractions resulting in decreased uterine blood flow. Vasopressin concentrations are also higher in women with dysmenorrhea.
Primary Dysmenorrhea: is pain without pelvic pathology. The pain of primary dysmenorrhea usually begins a few hours before or just after the onset of a menstrual period and may last up to 48 to 72 hours. The pain is similar to labor, with suprapubic cramping that may be tender to palpation, and may be accompanied by lumbosacral backache, pain radiating down the anterior thigh, nausea, vomiting, diarrhea, and rarely syncopal episodes. The pain of dysmenorrhea is colicky in nature and is improved with abdominal massage, counterpressure, or movement of the body, unlike abdominal pain due to chemical or infectious peritonitis. Bowel movements are generally normal and there is no upper abdominal or abdominal rebound tenderness, while there is generally uterine tenderness. Upon palpation and movement of the cervix, severe pain is absent and the pelvic organs are normal. With diagnosis, it is important to rule out any underlying pelvic pathologies and confirm the cyclical nature of the pelvic pain.
Western medicine treatment usually includes aspirin or ibuprofen. Up to 90% of women with primary dysmenorrhea find relief with oral contraceptives. Chinese medicine on the other hand differentiates different types of primary dysmenorrhea based on symptoms. Please consult your Doctor or Practitioner for diagnosis and treatment, a misdiagnosis may exacerbate symptoms.
- Qi Stagnation & Blood Stasis: pelvic pain starts a few hours before menses or on the first or second day of menstruation. There is lower abdominal pain refusing pressure, unsmooth flow of menses with clots, distending pain in the chest, ribside and breasts, a purplish tongue and a deep taut pulse. Use modified Ge Xia Zhu Yu Tang, modified Xue Fu Zhu Yu Tang, or modified Wu Yao Tang.
- Cold Wet Accumulation: pelvic pain starts a few hours before menses or during menstruation and is alleviated with the application of heat. Autonomic reflex response may occur, there is a small amount of menstrual flow that is dark red in colour. There can also be cold hands and feet, aversion to cold, loose stools, light purplish tongue with a white-moist or white-greasy coating and a deep-tense pulse. Use modified Shao Fu Zhu Yu Tang, modified Wen Jing Tang, or modified Ai Fu Nuan Gong Wan.
- Damp Heat Obstruction: pelvic pain starts before or during menstruation. It is in the lower abdomen and is stabbing, distending or burning in nature. Menses are dark red in colour and there can also be yellowish vaginal discharge. There may be a low fever, reddish tongue, yellow or yellow-greasy coating, and a stringy or slippery pulse. Use a modified Qing Re Tiao Jing Tang to treat.
- Qi & Blood Deficiency: in addition to pain during menstruation, pelvic pain usually lasts for longer. It is generally dull, continuous or bearing down in nature and alleviated with applied pressure. There is also a pale complexion, dizziness, palpitations, fatigue, a light red tongue and a weak pulse. Use modified Sheng Yu Tang or modified Bu Zhong Yi Qi Tang.
- Liver & Kidney Yin Deficiency: the pain is longer lasting and is dull in the lower abdomen and lower back. This is seen with dizziness, tinnitus, a light red tongue and a weak pulse. Use modifiend Tiao Gan Tang.
Specific herbs have specific functions in relation to dysmenorrhea. Shao Yao’s essential componenet is paeoniflorin which has analgesic, sedative, antispasmolytic (suppresses hypertonic uterine contraction), anti-inflammatory and ulcer relieving function in the nervous system, circulatory system and urogenital system. Chuan Xiong increases uterine smooth muscle contraction, and Dang Gui can suppress or increase uterine smooth muscle contraction. Pu Huang, Wu Ling Zhi, San Qi, Yu Hu SUo, Xiao Hui Xiang, and Mu Xiang also have analgesic functions due to their antispasmolytic properties. Common acupuncture points include: SP 6, SP 8, UB 32,LV3, LI 4, RN 3, RN 4, ST 27, ST 36.
Basically, in primary dysmenorrhea, the main causes are cold coagulation, Qi stagnation and deficiency, and obstruction. Most cases are due to cold syndrome, Blood stasis syndrome and syndrome of damp-heat and Blood accumulation. Treatment should focus on replenishing Qi and Blood and strengthening the Kidney as well as warming uterus, removing Blood stasis, and clear damp-heat.
Secondary Dysmenorrhea: usually occurs years after the onset of menarche. The pain of secondary dysmenorrhea often begins 1 to 2 weeks before menstrual flow and persists until a few days after the cessation of bleeding. The mechanisms underlying secondary dysmenorrhea are diverse and not fully elucidated, although most involve either excess prostaglandin production or hypertonic uterine contractions secondary to cervical obstruction (imperforate hymen, transverse vaginal septum, cervical stenosis), intrauterine mass (endometrial polyp, uterine leiomyoma, ademomyoma), the presence of a foreign body, or other various reasons (uterine anomalies, pelvic congestion syndrome, endometriosis). However, nonsteriodal anti-inflammatory agents and oral contraceptive pills are less likely to provide pain relief in women with secondary dysmenorrhea than in those with primary dysmenorrhea.
Dysmenorrhea associated with adenomyosis often begins up to a week before menses and may not resolve until after the cessation of menses. Associated dysparenia, constipation, and metrorrhagia increase the probability of the diagnosis. Whereas endometriosis is characterized by ectopic endometrium appearing within the peritoneal cavity, adenomyosis is defined as presence of endometrial tissue within the myometrium. Adenomyosis, endometriosis, and uterine leiomyomas frequently coexist.
Adenomyosis generally presents as excessively heavy or prolonged menstrual bleeding and dysmenorrhea, often beginning up to a week before the onset of a menstrual flow. The uterus is diffusely enlarged though usually less than 14 cm in size, and is often soft and tender, particularly at the time of menses. Mobility of the uterus is not restricted, and there is no associated adnexal pathology.
The management of adenomyosis depends on the patient’s age and desire for future fertility. Relief of secondary dysmenorrhea due to adenomyosis can be ensured after hysterectomy, but less invasive approaches can be tried initially. Nonsteriodal antiinflammatory agents, oral contraceptives, and menstrual suppression using progestins have all been found to be useful, though may not provide as much relief as for primary dysmenorrhea. Chinese Medicine differentiations include vary. Please consult your Doctor or Practitioner for diagnosis and treatment, a misdiagnosis may exacerbate symptoms.
- Cold Coagulation and Blood StasisC: pelvic pain is accompanied by a cold sensation and is aggravated by pressure. It starts up to a week before menses and may not resolve until after the cessation of menses. The menstrual flow is unsmooth and there are clots along with cold limbs, a purplish tongue with a white-slippery coating and a taut pulse. Treat with modified Shao Fu Zhu Yu Tang or modified Ai Fu Nuan Gong Wan.
- Qi Stagnation & Blood Stasis: the pain is in the lower abdomen with a distending sensation and starts up to a week before menses and may not resolve until after the cessation of menses. Menorrhagia may occur with deep red blood and clots – there may be slight alleviation of the pelvic pain after clots have passed. It may occur with PMS: irritability, susceptibility to rage, breast distention, and ribside pain before menstruation, dark tongue and a taut pulse. Treat with modified Ge Xia Zhu Yu Tang or modified Xue Fu Zhu Yu Tang.
- Qi Deficiency and Blood Stasis: lower abdominal pain with a sinking sensation begins up to a week before menses and may not resolve until after the cessation of menses. There may be heavy or long lasting menses, fatigue, anorexia, dark grayish tongue, and a deep-thready pulse. Treat with modified Ba Zhen Tang or modified Sheng Yu Tang
Dysmenorrhea, or cramping is a condition that affects many women in their child bearing or menstruating years. Chinese medicine can safely and effectively ease the symptoms of this disorder, effectively turning Aunt Flow into anything but a curse!
For more information about cramps and pelvic pain please contact us.
Caroline Prodoehl, R. TCMP
Wang, Yuxiang. (2010). Integrated Gynecology Course Notes. TorontoSchoolof Traditional Chinese Medicine.