Primary Dysmenorrhea — Menstrual “Cramps” — Matters!

Taken from the May/June 2017 issue of the Women's Health Activist Newsletter.

I went out and asked if she was in pain, was she OK? She said, "I'll be OK," and went inside my neighbor’s house where, through the patio door, I could see her leaning on something and rocking back and forth for hours.

Later, I learned from our new neighbor that the woman was experiencing profound pain from her menstrual period. We all know that if this were a sudden pain, not menstrual pain, she would have been taken to the emergency room—but if it's "just" period pain, that's supposed to be “OK.” Period pain, no matter how unbearable, is accepted as normal. In fact, my new neighbor was incensed that the woman hadn't hidden her period pain, a requirement that sociologist Kate Seear calls "menstrual etiquette:" the pressure to hide menstruation and everything associated with it.1

This normalization of period pain and related symptoms (the medical term is “primary dysmenorrhea”) implies that women are defective by design—how can female biology be respected when it doesn't work right for a large number of women and girls? Estimates range widely, with the best studies indicating that the majority of women experience some dysmenorrhea at some point, with lower percentages in developing countries. The prevalence of severe pain in a World Health Organization review was 12-14 percent.2

In recent decades, science has shown that dysmenorrhea results from an imbalance in prostaglandins, which are substances produced throughout the body that control contraction and relaxation of smooth muscles (such as the uterus, the strongest muscle in the body) and many other functions. When the prostaglandin causing the uterus to contract (part of the process to expel menstrual blood and tissue) is out of balance with the prostaglandin that relaxes the uterus, pain results.3

There are many reasons why the contracting and relaxing prostaglandins can be out of balance, including the food we eat and the chemicals in our environments. First, prostaglandins are made by essential fatty acid precursors in the diet. Today's typical diet has an overabundance of the essential fatty acid precursors that produce the contracting prostaglandin. To make matters worse, the typical diet severely lacks the counterbalancing precursors for the relaxing prostaglandin. Secondly, our pesticides, plastics, household cleaners, cosmetics, and fragrances often contain chemicals called xenobiotics, which act like artificial hormones in our bodies, and create havoc. (If you’d like to learn more about this research, a good place to jumpstart your reading is the classic Our Stolen Future.4) Given the prevalence of poor nutrition and toxic chemicals, it's amazing that every woman doesn't have menstrual pain!

The Endometriosis Association's own discovery that byproducts in pesticides and herbicides called dioxins can be a major causative factor in endometriosis, especially with prenatal exposure, are covered in our books.5,6 

Exactly the same prostaglandin imbalance is seen in endometriosis, and there's evidence that primary dysmenorrhea may occur on a continuum with endometriosis.7,8,9  Endometriosis is a systemic immune and hormonal disease linked to uterine-type tissue growing outside of the uterus, chronic inflammation, seven autoimmune diseases,7 and an increased risk for cancer10 and heart disease.11 In the medical world, the pain due to endometriosis and other diseases is called "secondary" dysmenorrhea because it is related to the pathology of the diseases; in primary dysmenorrhea, the medical community assumes that no pathology exists (although a prostaglandin imbalance itself seems pathological, since it is not normal or healthy).

Because primary dysmenorrhea has become so common—keeping girls out of school and diminishing the productivity of some women—there's a tendency to regard it as normal, a view that’s been reinforced by centuries of taboo and shame around menstruation (think menstrual huts, etc.).12 Yet, other common health problems—enlarged prostates, for instance, which affect many older men, or heart disease, affecting more than a third of men13—are not accepted as normal.

Even the American College of Obstetricians and Gynecologists (ACOG) seems to regard primary dysmenorrhea as normal. In ACOG’s Committee Opinion on Adolescent Health Care, "Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign," the word "pain" does not even appear (nor, for that matter, does "primary dysmenorrhea" or "cramps.").14 Rather, the document focuses on recommending that clinicians ask girls the timing and length of their cycles, probably reinforcing again for the girl the idea that menstrual pain is normal. Official Opinions like this, which are typically used as guides for clinical practice, also miss the opportunity to inform clinicians about adolescent menstrual pain, which is especially prevalent in this age group and leads to significant school absenteeism.

Perhaps this failure to educate clinicians explains the experience, frequently reported by young women with primary dysmenorrhea, of being dismissed by their health care providers, who make "it’s all in her head," "she’s psychosomatic" statements. In research based on the Association’s large research registry, 61 percent of women and girls who eventually were diagnosed with endometriosis had been told by health care providers that nothing was wrong with them, most frequently (69%) by gynecologists!15

Primary dysmenorrhea is diagnosed in a rather unscientific way—essentially via a pelvic exam that identifies no ovarian cysts or other abnormalities that could indicate endometriosis or another problem. The most common treatments for primary dysmenorrhea in conventional medicine are non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen, which inhibit the formation of prostaglandins; oral contraceptives, and intrauterine devices (IUDs), which thin the endometrial lining and reduce the amount of prostaglandins being produced.16

Holistic approaches that may be helpful or even preventive for primary dysmenorrhea are:17

  • Omega-3 essential fatty acids in the form of purified fish oils or "safe" fish (fish that are not loaded with mercury and dioxins or overfished)
  • Flax oil and walnuts (which may not be as effectively utilized by the body as fish oils)
  • Vitamins B, E, D, calcium, and magnesium
  • Heat therapy (which has been found to be as effective as NSAIDs for pain relief)18
  • Exercise (scientific evidence is limited, but some studies find it can reduce dysmenorrhea)
  • Acupuncture and traditional Chinese medicine, and
  • Herbs (including dong quai, chasteberry, and pasque flower)19

Menstruation is an amazing process—the endometrial lining of the uterus is the only adult tissue that routinely regenerates itself, like a developmental process—typical to that seen in embryonic development, and scientists who study the process are in awe of it.20 But menstruation has been shrouded in mystery, negativity, and shame, rather than revered as being part of the process by which we bring new life into the world. The view of menstruation as something shameful was not lost on women when presidential candidate Donald Trump responded to CNN reporter Megyn Kelly's question about his sexist comments by saying, "You could see there was blood coming out of her eyes. Blood coming out of her wherever."21

The taboo and supposedly shameful nature of menstruation is also seen in, as just one example, the reaction to Rupi Kaur, an Indian-Canadian poet and artist, who posted a tasteful picture of herself lying on a bed with blood stains at the crotch of her sweatpants and on the sheets. She received death threats and pornographic images, some from males she knew, and Instagram took the photo down.22 Why? Years back, a male artist said one of the most profound things I've ever heard about menstruation. He said girls grow up emotionally faster than boys—because they menstruate, girls learn we're not here just for ourselves; boys have no similar easy biological message. Menstruation may tell girls their bodies are here for the possibility of the next generation. Does that threaten some males because it clearly says women's bodies don't exist just for them?

Finally, one reason given for the limited research on primary dysmenorrhea is that women don't complain—the menstrual stigma in many cultures stymies that. So let's all convey the message to the girls of the next generation that period pain is not normal, and push science and medicine to help us better understand how to help all women and girls have the health we deserve!

Mary Lou Ballweg is the founder, President, and Executive Director of the Endometriosis Association, which provides support for those affected by endometriosis, educates the public and medical community, and promotes and conducts research. Learn more at:

The continued availability of external resources is outside of the NWHN’s control. If the link you are looking for is broken, contact us at [email protected] to request more current citation information.


1. Seear K, “The etiquette of endometriosis: stigmatisation, menstrual concealment and the diagnostic delay,” Social Science & Medicine 2009; 69(8):1220-1227.

2. Latthe P, Latthe M, Say L, et al., “WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity,” BMC Public Health 2006; 6: 177.

3. Coco AS, “Primary dysmenorrhea,” Am Fam Physician 1999; 60(2):489-496.

4. Colborn T, Dumanoski D, Myers JP, Our stolen future: are we threatening our fertility, intelligence, and survival?—a scientific detective story, New York City: Plume, 1997.

5. Ballweg ML, The Endometriosis Association: The Endometriosis Sourcebook, Chicago: Contemporary Books, 1995.

6. Ballweg ML, The Endometriosis Association. Endometriosis: The Complete Reference for Taking Charge of Your Health, Chicago: Contemporary Books, 2003.

7. Sinaii N, Cleary SD, Ballweg ML, et al., “High rates of autoimmune and endocrine disorders, fibromyalgia, chronic fatigue syndrome and atopic diseases among women with endometriosis: a survey analysis.” Hum Reprod 2002; 17 (10):2715-2724.

8. Yates J. “Endometriosis: expert answers to 7 crucial questions on diagnosis.” Clinician Reviews 2015; 25(11):20-23, 26-29.

9. Chapron C, Borghese B, Streuli I, et al., “Markers of adult endometriosis detectable in adolescence.” J Pediatr Adolesc Gynecol 2011; 24(5): S7-S12.

10. Melin A, Sparen P, Bergqvist A, “The risk of cancer and the role of parity among women with endometriosis,” Hum Reprod 2007; 22(11):3021-3026.

11. Mu F, Rich-Edwards J, Rimm EB, et al., “Endometriosis and risk of coronary heart disease,” Circulation Cardiovascular Quality and Outcomes 2016; 10(3):1-8.

12. Kaur G, “Banished for menstruating: the Indian women isolated while they bleed,” The Guardian, December 22, 2015.

13. Go AS, Mozaffarian D, Roger VL, et. al. on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee, “Heart disease and stroke statistics—2013 update: a report from the American Heart Association,” Circulation 2013; 127: E6-E245.

14. The American College of Obstetricians and Gynecologists’ Committee on Adolescent Health Care, Menstruation in girls and adolescents: using the menstrual cycle as a vital sign, Washington, DC: The American College of Obstetricians and Gynecologists Committee Opinion, December 2015.

15. Ballweg ML. “Impact of endometriosis on women's health: comparative historical data show that the earlier the onset, the more severe the disease,” Best Practice & Research Clinical Obstetrics and Gynaecology 2004; 18(2):201-218.

16. Osayande AS, Mehulic S, “Diagnosis and initial management of dysmenorrhea,” Am Fam Physician 2014; 89(5):341-346.

17. Dipasquale R, “Dysmenorrhea – it isn't normal,” Naturopathic Doctor News & Review 2014; 10(7):20-22.

18. Smith RP, “Managing dysmenorrhea,” Contemporary OB/GYN 2015; available online at:,2.

19. Perry M, “How to relieve dysmenorrhea,” HealthGuidance, no date; available online at:

20. Maybin JA, Critchley HOD, “Menstrual physiology: implications for endometrial pathology and beyond,” Hum Reprod Update 2015; 21(6):748-761.

21. Barrow B, Bustos S, “Trump's rivals criticize comments,” The Associated Press, August 9, 2015.

22. Rao M, “About that period photo that broke the Internet,” Huffington Post, May 6, 2015.