There is an article in Quartz about period pain (menstrual cramps or dysmenorrhea). While I agree many people, especially doctors, don’t take painful periods seriously enough I disagree with the assertion that we don’t know much about painful cramps. I’m also not a fan of comparing period pain to heart attacks.

Heart attacks are not that painful! Don’t sell period pain so short.

If you are waiting for terrible, excruciating chest pain to tell you that you are having a heart attack, well, you are going to miss the heart attack. Heart attacks often produce vague symptoms or mild pain, that is why many people ignore them. Many people think they are having indigestion. In addition, more than 40% of women have no pain with heart attacks. It would be dangerous for women to think that a heart attack should be at least as bad as their menstrual cramps.

I get that is hard to wrap your brain around the idea that cramps are usually worse than a heart attack. After all the heart muscle is literally dying during a heart attack and the uterus is not dying during a period (although it may feel like that). These facts simply underscore the complexity of visceral pain.

The only similarity between the pain of heart attacks and period cramps is that both the heart and the uterus are innervated by the sympathetic nervous system, which is why the pain is more vague in location or difficult to describe. With heart attacks people typically don’t point to a single spot right over their heart, often it is their arm or jaw or a larger area in their chest. Period cramps are also typically not confined to a single spot, they are usually generalized low back pain or lower abdominal cramps.

What do we know about cramps? It turns out we know a lot!

Primary dysmenorrhea is the term for painful menstrual cramps not due to another cause and so I’m going to limit this discussion to primary dysmenorrhea. About 40-50% of women have primary dysmenorrhea or painful periods; up to 50% of them have severe pain.

The pain of primary dysmenorrhea is mediated mostly by prostaglandins, which are substances involved in the body’s response to inflammation. Prostaglandins are released from the lining of the uterus during menstruation and they cause the uterus to contract. Prostaglandins are also algesic substances, meaning they prime the nervous system for pain (or heighten pain). So prostaglandins have a double whammy effect with period pain, causing painful uterine contractions and an increase in pain signaling. Prostaglandins also bring the joy of nausea, vomiting, and diarrhea that 60% of women get with their periods. Because pain and bleeding just isn’t enough, ya know?

I believe there is no word in any language to describe that unique experience of simultaneously running out of both pads (or tampons) and toilet paper when you are sitting on the toilet and in immediate need of both.

Recent studies tell us that most women with primary dysmenorrhea have increased secretion of menstrual prostaglandin F2 (PGF2) and that menstrual pain seems directly proportional to the amount of prostaglandin F2 that is released. A small percentage of women with severe primary dysmenorrhea do not have increased prostaglandins and so it is hypothesized that they are releasing other inflammatory mediators that cause excessive contractions. It is possible that some women release a normal amount of prostaglandins but have an overly responsive uterus.

Women with painful periods tend to have stronger and abnormal uterine contractions (confirmed by ultrasound in studies). This causes a greater reduction in oxygen delivery and thus more pain.

How strong and abnormal are these contractions?

Glad you asked!

When women have minimal or no cramps the baseline tone of the uterus during their period is less than 10mm Hg; typically there are 3–4 contractions per 10-minute interval and the pressure from a contraction can reach 120 mmHg. This is comparable to the pressure in the uterus during the second stage of labor (i.e. with pushing!). The contractions are regular and coordinated. The contractions help pinch off the blood vessels to reduce bleeding and assist in clotting.

menstrualcycle1_med

With primary dysmenorrhea several differences have been reported including an elevated basal tone, elevated pressures with contractions (as high as 150 –180 mmHg), an increased number of contractions, and poor coordination of the contractions. These differences result in reduced uterine blood flow with a drop in oxygen delivery increasing pain. When more than one contraction abnormality is present it is believed that they act synergistically to exponentially increase the pain.

There are also studies that suggest some women with severe primary dysmenorrhea may have different pain processing.

So if you need an analogy to describe period pain use labor or cutting your finger off without an anesthetic. A heart attack is often not painful or only mildly painful, especially for women, so for me that analogy just doesn’t cut it.

 

 

 

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27 Comments

  1. I would very much like to share this post, having shared the post that this is addressing. However, it is difficult to present a medical article as authoritative when it is full of spelling errors. We all make them. “Autocorrect” is usually an active enemy to accuracy.

    1. It’s a blog, not a medical article, unless I’m
      Mistaken. I think we can all assume that as a a doctor and mother, Jen Gunter has a busy like. I for one am extremely appreciative of the time she manages to carve out to provide us with top-notch medical info, deploying humour all the while.

  2. This was my life. When I had my daughter, I arrived at the hospital dilated 10 cm and ready to push, not because I wanted to, but because I thought labor pains would hurt more than cramps. They were pretty much exactly like my monthly cramps. Crowning was significantly worse, though, so part of L&D is worse than dysmenorrhea for me (only the last part though).

    1. Ha, I actually found crowning quite painless two out of three times. The third got stuck for a minute between one contraction and the next, which was very unpleasant (I imagine much more for him whose head was squeezed!) but also very short. I guess no two labors are the same.

  3. Such an important article. I will be sharing it with my after school girls’ group which will definitely lead to a lot of discussion. And knowing them, they’ll share it with many more girls. Thanks.

  4. Should a microperforate hymen that doctors have said can have surgery just be “popped” by inserting something? Will that “just” cause me pain or will actually damage me in there? I don’t want to waste the doctor’s time if it’s something I can solve myself but at the same time I have never been able to insert a tampon or have anything in there without burning pressure pain that hurts so much. Sorry for off topic question, u don’t have to answer. I really love how you validate female pain, it’s very feminist. I get annoyed by home birth feminists and ones that promote other crap because I believe it does more harm to women.

    I love this article because it helped me understand what heart attacks are like in plain language without numbers and stats (I have NVLD so I need words). I’ve seen ideas like this in articles but they listed a bunch of stuff so I wasn’t sure how common the smaller pain of a female heart attack is only that females have different signs than males. I like skeptic blogs like Orac, the Skeptical OB, your blog etc. that help people increase their medical and scientific literacy in ways people like me can understand. I failed a lot of courses in school especially maths and science and didn’t get anything out of it but when I read skeptical blogs I learned how to identify pseudoscience, that vaccines are safe, GMOs aren’t the end of the world etc. This helped my OCD as well because when I was a teen I believed in raw food diets, organic food and other quack stuff and it fed into my obsessions.

    Hope this comment is not too TMI or off topic or dumb but I love your work.

  5. I had a heart attack and it was not painful. I dismissed it as indigestion at first. Eventually my wife called the doctor and he had me shipped into hospital. I still believed I had some kind of indigestion. The pain eased and I felt fine and I checked myself out of hospital against medical advice (how stupid can you get?). But, I’m self employed and had customers calling me demanding attention. Later that day the ‘indigestion’ returned and my wife insisted I went back to the hospital. By then the blood tests I had during my earlier hospital confirmed a mild heart attack. The doctor told me two things. If I had been 10 years older and a smoker I probably would have died and, second, he gave me his diagnosis – I was fucking stupid! There is only one rule. Listen to the clinicians!

  6. Good morning! Very good article as always. On a separate note I find that receiving those in email form instead of social media improves the quality of reading! I make time for it… still shared it on Facebook though:-) Thank you for your work Hélène

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  7. Thanks
    Dr. G that was a good column. I like your rants too but the educational columns are good too

  8. I’ve sat with my wife in one of those pains, and she’s sat with me in the other. They are not the same. Every year the tech turns off my pacemaker to see if any native function is left (there isn’t), and every year doing that sends sharp pain into my head and I say, “so this is what it feels like when the pump is off.” As one of your respondents said, thank you for standing up for her – we don’t need this analogy to say that her pain is wicked.

  9. Slightly off-topic: I keep reading that menorrhagia tends to be associated with dysmenorrhea without any explanation as to why. It certainly seem to be true for me that the heaviest bleeding coincides with pain. Do we know the mechanism? If it’s the prostaglandins, the pill doesn’t seem to be helping.

  10. Great post! Again! I remember my pain being so bad that my upper legs would feel like someone worked them over with a baseball bat.

  11. Would like to hear from other women who have experienced both severe menstrual pain and heart attack or other heart pain (angina pectoris). I don’t clutch my chest in public any more than I ever grabbed my abdomen in public. We women have been taught not to be ‘hysterical’ about our ‘unmentionable’ pain. As a result, we tend not to physically react much to any pain, especially internal pain. Hence, no touching, groaning, or halting; very little grimacing, gasping, or panting; certainly no whining or complaining. And for the record, I am blessedly post menopausal. I agree with Dr.Gunter about the pain levels. Some of my menstrual pain was much worse than some of my heart pain has been. It is way too easy for a woman to say to herself, ‘Oh, this is tolerable pain, I’ve had worse cramps’, and as a result ignore a heart attack.

    1. I’ve had costochondritis, frequently said to be akin to the pain of a heart attack and possibly worse. Doctors treat it like one until they can prove otherwise, too, since the sensation is of one’s chest being crushed. I also have dysmenorrhoea and menorrhagia, and can barely crawl during the first few days of my period, even with heating pads and morphine in the mix. Honestly, I have to wonder whether I would ever even register a heart attack with how used I am to chest pain…

  12. THANK YOU SO MUCH for writing this. I had “normal,” if widely-spaced, periods as a teenager, but the cramps gradually got worse and worse until by age 24, I was bent double from the pain. (Fortunately, I was still living with my mother at the time. She made me an appointment with her very nice OB/GYN for the very next day. Dr L (now retired) put me on birth control, and it hasn’t been a problem since.)

    I don’t think a lot of men understand that because a period cramp is the uterus contracting, which is ALSO WHAT IT DOES DURING LABOR TO PUSH A BABY OUT, it hurts **way** more than muscle cramps in your arm or leg from overexertion during a workout. By age 21-22, mine had stopped responding to Midol, aspirin, or even the max-strength of OTC ibuprofin, because they hurt So Badly. In fact, one of the reasons I’m not looking forward to having kids (even though I want to have kids with my husband) is because I’ll have to go off the Pill in order to get pregnant.

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