Open Source Apothecary At Home / Urinary and reproductive

Painful periods (dysmenorrhoea)

NSAIDs and heat have the best evidence. Ginger has small trials and is a reasonable second line.

remedy

Primary dysmenorrhoea — period pain without an underlying condition — is caused by prostaglandins from the endometrium causing intense uterine contraction and ischaemia, and the treatment follows from that.

NSAIDs are the treatment. They inhibit prostaglandin synthesis directly, and they are more effective than paracetamol for period pain. Take them before the pain peaks, at the onset of bleeding or at the first sign, and take them regularly for the first 2-3 days rather than waiting for severe pain — this is the difference between an effective and an ineffective trial of an NSAID.

Continuous heat — a heat patch on the lower abdomen — has randomised evidence comparable to ibuprofen in some trials, which makes it unusually good for a non-drug measure.

Ginger has small randomised trials showing pain reduction in primary dysmenorrhoea, comparable to an NSAID in one trial. It is safe and cheap, and reasonable as an adjunct or where an NSAID cannot be taken.

Combined hormonal contraception reduces period pain substantially and is a common treatment for it. This is a clinical decision.

Other measures with evidence. Regular aerobic exercise, and transcutaneous electrical nerve stimulation (TENS).

The distinction that matters. Primary dysmenorrhoea starts with the periods and improves with age or after childbirth. Secondary dysmenorrhoea — pain that starts later in life, worsens over time, or is associated with heavy or irregular bleeding, pain during sex, or infertility — suggests endometriosis, adenomyosis or fibroids and needs assessment. Endometriosis affects roughly one in ten women, takes an average of years to diagnose, and the delay is a known and serious problem. Someone whose period pain does not respond to NSAIDs should be assessed, not given a different herb.

What the studies found

Preparation

NSAIDs — the treatment

• Ibuprofen 400 mg or naproxen 500 mg at the first sign, then regularly for 2-3 days
• Start early and take it regularly. Waiting for severe pain makes it less effective.
• Take with food
• Not in pregnancy, not with a history of GI bleeding or kidney disease, and check interactions

Heat

• A heat patch or hot water bottle on the lower abdomen, continuously
• Randomised evidence comparable to ibuprofen in some trials
• Cheap, safe, effective

Ginger

• 750-2000 mg of ginger powder daily, starting 1-3 days before the period
• Small trials show pain reduction
• Safe; can be taken with or instead of an NSAID if an NSAID is contraindicated

Fennel

• Small trials of fennel extract in dysmenorrhoea; 1-2 g of crushed seed as an infusion

What else has evidence

• Regular aerobic exercise
• TENS
• Combined hormonal contraception — a substantial reduction in pain; a clinical decision
• Magnesium: small trials, weak evidence

When it is not primary dysmenorrhoea

• Pain that starts later in life, worsens over time, or is not relieved by NSAIDs
• Heavy or irregular bleeding; pain during sex; infertility; bowel or urinary symptoms with the period
• These suggest endometriosis, adenomyosis or fibroids. Ask for assessment.

Cautions and interactions

• NSAIDs are not for use in pregnancy, or with a history of stomach bleeding, kidney disease or heart failure.
• Pain not relieved by an NSAID taken properly is a reason for assessment, not a different herb.
• Endometriosis is common and takes years to diagnose. Push for assessment if the pattern fits.
• Do not use herbal emmenagogues (pennyroyal, rue, tansy) — they are abortifacients and toxic.

When this is not a self-care problem — get help

• Pain that is severe, new, worsening, or with heavy bleeding — assessment.
• Sudden severe one-sided pelvic pain with a missed period — possible ectopic pregnancy; emergency care.
• Fever with pelvic pain and abnormal discharge — possible pelvic inflammatory disease; urgent assessment.
• Soaking a pad an hour, or bleeding with dizziness or fainting — emergency care.

Related

• Endometriosis
• Heavy periods
• PMS and PMDD
• Menopause: hot flushes and the honest evidence

Sources

1. Ginger for Pain Management in Primary Dysmenorrhea: A Systematic Review and Meta-Analysis. Journal of integrative and complementary medicine 2024; doi:10.1089/jicm.2023.0799 PubMed 38770631
2. Efficacy of herbal medicine (cinnamon/fennel/ginger) for primary dysmenorrhea: a systematic review and meta-analysis of randomized controlled trials. The Journal of international medical research 2020; doi:10.1177/0300060520936179 PubMed 32603204
3. Dangguijagyag-san for primary dysmenorrhea: A PRISMA-compliant systematic review and meta-analysis of randomized-controlled trials. Medicine 2020; doi:10.1097/MD.0000000000022761 PubMed 33080743
4. Herbal medicine (Hyeolbuchukeo-tang or Xuefu Zhuyu decoction) for treating primary dysmenorrhea: A systematic review and meta-analysis of randomized controlled trials. Medicine 2019; doi:10.1097/MD.0000000000014170 PubMed 30702569
5. Wenjing decoction (herbal medicine) for the treatment of primary dysmenorrhea: a systematic review and meta-analysis. Archives of gynecology and obstetrics 2017; doi:10.1007/s00404-017-4485-7 PubMed 28791471