Pain: Chief complaint during heavy periods

Results of a new survey indicate that in women experiencing heavy periods, pain is the most commonly reported problem.1 What are some clinical strategies to help ease these symptoms?

Before suggesting treatments, it is important to understand the etiology of excessive uterine bleeding. Consider the causes, suggest authors of Contraceptive Technology:

  • Obstetrical: pregnancy or pregnancy complications;
  • Medication: phenytoin, anticoagulants, digitalis, unopposed estrogen, or copper intrauterine device;
  • Systemic: coagulation disorders, endocrino-pathies such as thyroid or adrenal disorders, hepatic or renal failure, or trauma;
  • Cervical abnormalities: infection, polyp, cancer, or trauma;
  • Abnormalities: fibroids, infections, hyperplasia, polyp, cancer, or adenomyosis;
  • Dysfunctional uterine bleeding: diagnosis of exclusion.2

Women experiencing heavy periods with pain warrant vaginal ultrasonography, which may reveal the presence of such conditions as adenomyosis or uterine fibroids, says Andrew Kaunitz, MD, professor and assistant chair in the Obstetrics and Gynecology Department at the University of Florida College of Medicine — Jacksonville.

Another diagnostic possibility in this setting is endometriosis.

Cyclical, but particularly extended or continuous use of oral contraceptives, may reduce flow and pain, says Kaunitz. Use of depot medroxy-progesterone acetate (DMPA; Depo Provera, Pfizer, New York City) as well as the levonorgestrel intrauterine system (Mirena LNG IUS, Bayer HealthCare Pharmaceuticals; Wayne, NJ) represent two effective and underutilized options in women with heavy flow and cramps, Kaunitz observes. In his practice, these medical, office-based therapeutic strategies are proactively offered to patients with heavy flow/pain before considering surgical management, he states.

What's the problem?

For the current survey, researchers performed a cross-sectional postal survey along with qualitative interviews of Scottish women. Of the 2,833 women who were surveyed, 906 women ages 25 to 44 reported heavy or very heavy periods. Further analysis was performed on this subset, with a portion of the women participating in qualitative interviews.

The new research was spurred by previous work regarding referrals to hospital clinics for menstrual problems,3 says Miriam Santer, MD, a research fellow in the University of Edinburgh Medical School's Division of Community Health Sciences and lead author of the current paper. As a family practitioner, Santer says she has seen several women with heavy menstrual bleeding, many of whom seemed frustrated with their symptoms and care.

When asked what bothered them the most about their periods, the women who indicated a history of heavy bleeding reported pain most frequently, followed by heaviness, moodiness or tiredness, irregularity, and other timing problems, such as unpredictable duration and spotting. The type of work women did played a major role in how problematic heavy menstruation was for them, researchers note.

"I think one of the main implications of this paper is how important it is for women experiencing heavy menstrual bleeding to fully understand the range of treatments available," observes Santer. "Because other menstrual symptoms, such as pain, influence the impact of heavy menstrual bleeding, women need to discuss their symptom profile with their health care provider and come to a decision about the best treatment for them."

To evaluate excessive uterine bleeding, take a complete menstrual history, with a focus on the last several months, advise Contraceptive Technology authors. The age of the patient and the pattern of her bleeding guide the evaluation.2

For women with acute, prolonged but less significant bleeding, women who are hemodynamically stable with no other identified problems may benefit from use of oral contraceptives.2 Women who opt not to take contraceptive may look at use of nonsteroidal anti-inflammatory drugs (NSAIDs), which may help to alleviate pain, Santer notes.

Options for NSAID doses and schedules for menorrhagia treatment include:

  • ibuprofen, 800 mg three times daily;
  • naproxen sodium, 550 mg three times daily;
  • mefenamic acid 500 mg three times daily; or
  • meclofenamate sodium, 100 mg three times daily.

Initiate therapy immediately prior to or on the first day of menses, with recommended dose maintained for three to five days.4

An individual approach is important in addressing patients' needs when it comes to treatment, Santer says. "For instance, although the LNG-IUS is a very effective treatment for many women, especially those requiring contraception, this might be less helpful for someone whose main concern is irregularity of bleeding," Santer notes.

References

  1. Santer M, Wyke S, Warner P. What aspects of periods are most bothersome for women reporting heavy menstrual bleeding? Community survey and qualitative study. BMC Womens Health 2007; 27:8.
  2. Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 19th revised edition. New York City: Ardent Media; 2007.
  3. Warner P, Critchley HOD, Lumsden M-A, et al. Referral for menstrual problems: cross sectional survey of symptoms, reasons for referral, and management. BMJ 2001; 323:24-28.
  4. Shulman LP. Abnormal uterine bleeding: Treatment and management options. Presented at the 2007 Contraceptive Technology conference. Washington DC; March 2007.