Menstrual Cramps and PMS (Premenstrual Syndrome) Treatment

Severe menstrual cramps can be so painful that they interfere with a woman's regular activities for several days.

Menstrual cramps are abdominal and pelvic pains experienced by a woman around the time of her menstrual period. Menstrual cramps usually start shortly before the menstrual period, peak within 24 hours after their onset, and subside after a day or two.

Menstrual cramps can range from mild to severe. Mild menstrual cramps may be barely noticeable, short-lived, and are sometimes felt only as a sense of mild pressure in the abdomen and pelvis. Severe menstrual cramps can be so painful that they interfere with a woman's regular activities for several days. The discomfort can extend to the lower back or legs. Menstrual cramps are not the same as the symptoms experienced due to premenstrual syndrome (PMS), although the symptoms of both disorders can sometimes be experienced together. Many women suffer from both PMS and menstrual cramps.

Medical research of menstrual cramps has shown that they are often worse in women who began menstruating early and who have long menstrual periods associated with heavy menstrual flow. Smoking and a family history of severe menstrual cramps are also associated with severe dysmenorrhea.

Treatment options vary and each woman needs to find the treatment that works best for her. Non-drug measures that may help include adequate rest and sleep, regular exercise (especially walking), and smoking cessation. Some women find that abdominal massage, yoga, or orgasmic sexual activity can help. A heating pad applied to the abdominal area may also relieve the pain.

For mild menstrual cramps, over-the-counter (OTC) aspirin and acetaminophen, or acetaminophen plus a diuretic may help. However, aspirin has a limited effect in curbing the production of prostaglandin and is only useful for mild cramps. For moderate menstrual cramps, the nonsteroidal anti-inflammatory drugs (NSAIDs) can be helpful. The NSAIDs are more effective than aspirin in inhibiting the production and action of the prostaglandins. NSAIDs that are available OTC are:

• ibuprofen;
• naproxen sodium; and
• ketoprofen.

For optimal control of menstrual cramps, a woman should start taking a NSAID before the onset of her pain becomes difficult to control. This might mean starting medication 1 to 2 days before the onset of her period and continuing the medication for the first 1 to 2 days of her period. The best results are obtained by taking one of the NSAIDs on a regular schedule rather than on an as needed basis. Therefore, ibuprofen should be taken every 4-6 hours, ketoprofen every 4-8 hours, and naproxen every 8-12 hours for the first few days of the menstrual flow.

Prescription NSAIDs available for the treatment of menstrual cramps include mefenamic acid.

PMS remains a puzzle because of the wide-ranging symptoms and the difficulty in making a firm diagnosis.

Premenstrual syndrome (PMS) is a combination of emotional, physical, psychological, and mood disturbances that occur after a woman's ovulation and normally end with the onset of her menstrual flow.

PMS remains a puzzle because of the wide-ranging symptoms and the difficulty in making a firm diagnosis. Several theories have been advanced to explain the cause of PMS. None of these theories has been proven and specific treatments for PMS largely lack a solid scientific basis. Most evidence suggests that PMS results from alterations in or interactions among the levels of sex hormones and brain chemical messengers known as neurotransmitters.

The treatment of PMS can sometimes be as challenging as diagnosing the condition. Some measures lack a solid scientific basis but seem to help some women. Other treatments with a sound scientific basis may not help all patients. General measures include:

• Exercise: Aerobic exercise for 30 minutes 3-5 times a week improves general health and helps relieve nervous tension and anxiety. Exercise also improves cardiovascular fitness and muscle tone, decreases weight and fluid retention, and improves self-esteem.
• Emotional support from family and friends.
• Stress reduction and stress management: Learning relaxation techniques, and developing coping mechanisms to reduce stress.
• Dietary changes: Reduce salt and refined sugar intake (too much salt and refined sugar exacerbates fluid retention).
• Avoid caffeine, as this may increase irritability
• Decrease the intake of animal fats.
• Avoid cigarettes and alcohol.

Research studies have linked a deficiency of calcium and magnesium to PMS; therefore, it may be beneficial for woman to try supplements of these nutrients at recommended dosages. Some women have reported relief of symptoms with these supplements. It is always important to follow recommended guidelines when taking vitamin supplements, since taking excess doses of some supplements may be harmful.

Medications used to treat the different symptoms of PMS include taking:

• Diuretics, which are medications that increase urine production, thereby eliminating excess fluid and relieving weight gain, bloating, and swelling. Ammonium chloride, caffeine, and pamabrom are mild diuretics that are ingredients in nonprescription OTC products such as Diurex PMS, Lurline PMS, Midol PMS, Pamprin Multisymptom, and Premesyn PMS. Spironolactone is a prescription diuretic that has been used to treat premenstrual swelling of the hands, feet, and/or face.
• Nonsteroidal anti-inflammatory medications (NSAIDs) that are commonly used for menstrual cramps, headaches, and pelvic discomfort. NSAIDs are available as both prescription and non-prescription products. Examples of NSAIDs include ibuprofen, naproxen, ketoprofen, and mefenamic acid.
• Oral contraceptive pills (OCPs) that are sometimes prescribed by doctors to decrease fluctuations in ovarian hormone levels. While older studies failed to provide evidence that OCPs can consistently provide relief for symptoms of PMS, the newer low-dose birth control pills, with their improved hormonal formulations, seem to be more beneficial.
• Ovarian suppressors such as danazol have been prescribed by doctors to suppress ovarian hormone production. Danocrine cannot be used over long periods because of side effects.
• Gonadotropin-releasing hormone (GnRH) analogs, which cause the complete suppression of ovarian function, and have been found to be helpful in treating some women with PMS. These GnRH analogs are not prescribed long term (more than 6 months) because of their adverse effects on bone density and an increased risk of bone thinning (osteoporosis).
• Antidepressants which are prescribed by doctors to treat the mood disturbances related to PMS. Antidepressants appear to work by increasing brain chemical (serotonin and others) levels that are affected by the ovarian hormones.
• Fluoxetine and paroxetine. These are examples of antidepressant medications that have been found to be effective in treating the mood changes associated with PMS.

1. Always read the labels and know the ingredients in the products. Never take more than the recommended doses without first checking with your doctor.
2. Most healthy adults tolerate aspirin and NSAIDs well, but some may develop side effects such as headaches, dizziness, upset stomach, heartburn, porr appetite, constipation, or diarrhea. Taking these drugs with food can decrease the stomach upset and heartburn. 
3. Aspirin and NSAIDs can cause ulcers and should be avoided by patients with known peptic ulcer disease or reflux esophagitis. They can also increase the risk of bleeding and should be avoided by women with certain blood diseases. Women who are scheduled for elective surgery should inform their doctors that they are taking aspirin or NSAIDs. The doctor may ask them to withhold these medications for a period of time prior to the procedure.
4. True aspirin allergy is rare. However, it may lead to hives, difficulty breathing, and/or shock within three hours of ingestion. Aspirin allergy is most common among individuals who have asthma, hives, or nasal polyps. Individuals with true aspirin allergy should also avoid NSAIDs because they are chemically similar to aspirin.
5. Aspirin (and many other medications and some vitamins) can increase the anti-coagulant effect of the blood-thinning medication warfarin resulting in an increased risk of bleeding. Patients taking warfarin to prevent strokes and other thrombocytic diseases should not use prescription or OTC medications for menstrual cramps or PMS without first checking with the doctor supervising their warfarin dosages.
6. Ammonium chloride, an OTC diuretic, is an acid that can cause stomach upset in high doses. It can also cause an excess accumulation of acid (acidosis) in the blood of patients with kidney and liver disease.
7. Caffeine is a diuretic and a stimulant. It can cause restlessness, anxiety, and insomnia. Nervousness, irritability, and nausea can occur if caffeine-containing foods and beverages are consumed concurrently. Women taking certain asthma medications such as aminophylline or theophylline should also avoid caffeine.