Period-related pain, medically known as dysmenorrhea, colloquially often called “cramps,” should not prevent an adolescent from participating fully in school, in sports, in social life. If that’s happening on a regular basis, she needs evaluation and help and support — from her family, and from the medical profession.
“Painful periods can be very debilitating; I’ve seen adolescents who come in in wheelchairs from endometriosis or dysmenorrhea, completely wiped out,” said Dr. Monica Woll Rosen, an assistant professor of obstetrics and gynecology at the University of Michigan Medical School. “It’s real, but there is help out there. Don’t be discouraged.”
A couple of weeks ago, I wrote about heavy menstrual periods in adolescents, and in particular the risk of anemia from ongoing blood loss, and the importance of checking for bleeding disorders, which can become evident in adolescence when menstruation starts. One of the doctors I interviewed, Dr. Claudia Borzutzky, an adolescent medicine specialist at Children’s Hospital Los Angeles, said: “Someone’s menstrual period should not be impairing them from leading a normal life, because we have really good treatments for pain and for heavy bleeding.”
Many readers wrote in to ask about particular diagnoses and problems they felt should have been spotlighted, noting that adolescents with problematic menstrual symptoms often go a long time without getting the appropriate medical care — either because they don’t ask, or because they’re told that their pain, or their infrequent periods, or their heavy periods, are just normal variants of menstruation, maybe especially in the early years.
Menstrual problems don’t sort out neatly by symptom. Most of these problems can show up both as pain and as disordered cycles and abnormal periods that are irregular, heavy, or both. So let’s start with pain, and I’ll address infrequent periods in another column.
Menstrual pain — even bad menstrual pain — doesn’t always means that there is some underlying problem waiting to be diagnosed. What is called “primary dysmenorrhea,” that is, pain with periods with no underlying pathology, “can be incredibly impairing for young women, keep them out of school or work for one or two days a month,” said Dr. Andrea Bonny, an associate professor of pediatrics at The Ohio State University College of Medicine and chief of adolescent medicine at Nationwide Children’s Hospital.
Dysmenorrhea is common around the world, and it often affects school attendance and academic performance. The pain comes from prostaglandins, chemical compounds produced during the ovulation cycle, which can cause cramps as the muscle of the uterus — the myometrium — squeezes down to get the blood out. There’s a lot of variability in how the prostaglandins, along with the hormone shifts during the cycle, affect different bodies. Some people get GI distress — nausea, vomiting, diarrhea — reliably every month. And some people get bad cramps.
Dr. Jen Gunter, an OB/GYN in California, asks in her TED Talk, “Why can’t we talk about periods?” In an essay last fall, she described her own difficulties as an adolescent with cramps and period-related diarrhea.
The first line of treatment for pain with periods is often nonsteroidal anti-inflammatory drugs, like ibuprofen. It’s important to start taking them at the very first sign of discomfort and to take a sufficient dose around the clock during that part of the cycle — and used that way, they can be very effective for some adolescents with dysmenorrhea.
For many adolescents — and adults — with dysmenorrhea, the cornerstone of successful treatment is hormones. Oral contraceptive pills or other hormone based contraceptives (like implants or patches) will stop the production of prostaglandins and therefore mitigate the cramps, though some parents dislike the idea of adolescents taking hormones, or worry that having contraception may lead teenagers to be sexually active earlier. Again, it’s important for adolescents and their parents to feel comfortable talking this through with the doctor — and with one another.
Dr. Bonny said that she worries more about underlying problems when someone’s first menstrual period is marked by severe pain, because it may be a sign of some structural problem. And when there is progressively worsening pain and hormones don’t help, doctors worry about endometriosis.
The muscular uterine wall — the myometrium, where cramps take place — is lined with the endometrium, which thickens during the cycle and then is shed during menstruation. In endometriosis, cells such as the endometrial cells that normally line the uterus and slough off with every menstrual cycle, cued by the hormone shifts of ovulation, also grow on other organs, including the ovaries and the fallopian tubes.
[Read more: The website of the Endometriosis Foundation of America. | A 2019 review of endometriosis in adolescents.]
These tissues also respond to the hormonal signals, but the blood and tissue outside the uterus cannot leave the body and can cause inflammation, pain and, over time, give rise to scar tissue and adhesions. Pelvic pain — including pain with intercourse and pain with bowel movements or urination — is often seen as the hallmark of endometriosis, but it also causes heavy periods.
In order to make this diagnosis, doctors need to do a laparoscopy, inserting a camera through a tiny incision in the abdominal wall to look for the errant endometrial tissue and the damage it may have done; there’s no radiologic study that can substitute. Laparoscopy has risks, and doctors may be especially reluctant to take those risks in adolescents.
Dr. Rosen, who regularly performs such laparoscopies, said that often in teenagers, the trip to the operating room is a last resort, after numerous tries with medical therapy. “It’s very difficult to decide when to take someone to the operating room to look for endometriosis,” she said. But if the hormones don’t help, laparoscopy can also be an occasion for treatment, with surgical removal of the problem tissue. And since other medical treatments for refractory endometriosis carry other risks, that surgical diagnosis is important for confirming the cause of the pain before those other options are tried.
Endometriosis runs in families, so it may be worth moving more quickly to laparoscopy if there is a family history. It raises concerns about later fertility issues — endometriosis is very common in reproductive-age women, and often linked to difficulty conceiving. And these are, in turn, tricky questions to discuss with adolescents — all the more reason to find them doctors who are accustomed to having these conversations, and who understand the importance of addressing the anxieties and questions they may provoke.
An adolescent clinic should offer access to several different kinds of expertise — and may be more comfortable for kids as they age than a standard pediatric setting. Adolescent medicine specialists can be particularly helpful, and adolescent gynecologists will help with more complicated situations.
“You should have enough improvement in your symptoms — they don’t have to entirely go away, though we would love to do that — so they are not impacting your activities of daily living,” Dr. Bonny said. “If you can’t go to school because of your symptoms, we’re not treating you effectively. We need to be able to keep you in your life, in your sports, in your school.”
