PMS and Dysmenorrhea

Let us start with the most obvious statement: I am a man and I will never understand having a menstrual cycle, nor will I understand the physical or psychological effects it has on women experience before, during, and after their period.

This might even fall on deaf ears for a male gynecologist to say, “I understand the challenges you are experiencing,” because, honestly, I won’t. The reality is, I can with my knowledge guide my patients with the best course of action.

With today’s blog, I worked with my colleague Dr. Jasmine Talei, a naturopathic doctor, to explore the causes of painful periods (dysmenorrhea) and premenstrual syndrome (PMS). We jumped into how:

  1. health practitioners can best evaluate these issues
  2. Discuss a combined approach for both medical and naturopathic remedies
  3. Break down stigmas that are associated with both conditions.

It is a tragedy that Dysmenorrhea and Premenstrual Syndrome (commonly known as PMS), have received such negative connotations. I have seen it used by both men and women to create a sense of shame among women when they have their menstrual cycles. It’s hard enough for most women to experience their menses monthly, but added symptoms of:

  • bloating
  • fatigue
  • mood changes
  • hopelessness
  • difficulty concentrating
  • headaches
  • breast tenderness
  • difficulty sleeping
  • Appetite changes

Demonizing this natural physiological and psychological situation is in itself terrible. Unfortunately, I have many family members and friends who have experienced insensitive remarks, such as “Oh she’s just having her period!” “Oh she is just PMS-ing” “oh she’s always just a bitch and its worse with her periods.” It’s mind-boggling that such sensitive times in any woman’s life is vilified, rather than supported or explored or understood, both by men and other women.

So! Let us explore both:

Pre Menstrual Syndrome is a collection of bodily symptoms and mood changes that usually occur 1-2 weeks before start of the menstrual cycle. Not all women experience these symptoms when they first have their period as teenagers (also known as menarche). Many women may be symptom-free until later in their reproductive lives, such as after pregnancy, or in their 30s.

Dysmenorrhea or painful periods occur from either unknown causes (primary type) or from known issues (secondary) such as endometriosis, fibroids, pelvic infections, or adenomyosis. Painful periods affect 50-90% of young women.


Why though? Whats the reason?

Your body naturally creates a product called Prostaglandins which are involved in a variety of activities in our bodies: “contraction and relaxation of smooth muscle, the dilation and constriction of blood vessels, control of blood pressure, and modulation of inflammation.”

Your uterus is a remarkable organ. It is comprised of smooth muscles and blood vessels that respond to hormonal changes each month. If after ovulating you don’t get pregnant, the body recognizes this and responds by dropping the amount of progesterone it needs, causing menstruation to occur. With that bleeding, prostaglandins are released which stimulate the uterus to contract (i.e. cramping) and blood vessels to constrict, also releasing inflammatory markers. These changes cause the pain that is often associated with menstruation. Some women do not experience these symptoms, but those who do vary in the intensity of pain.

Diagnosis of painful periods and PMS is usually clinically based. Good doctors should get a good history from their patients, to better understand:

  • how often they are having their menses
  • how many days it lasts
  • what symptoms are associated with the menses
  • the character and severity of the pain
  • What is your past medical and surgical history
  • What medications you are taking, etc.

Doctors should be well equipped to ask the right questions, but it also helps if you know your medical history as well. It’s a two-way street after all. Express your concerns!

A physical exam is always the next step for a physician to assess where the pain is, how it is characterized with an exam. Some doctors may do a transvaginal ultrasound to see if there are secondary causes to your painful periods.

So, what remedies or medical treatments are there?

In this next part, I don’t want to push just medical management. In recent years, naturopathic medicine has slowly taken center stage in patient care. While there was much skepticism to the effects of herbal remedies, and many doctors argued that there is not enough research or double-blind studies to ensure the safety or quality of these treatments, new studies have appeared showing success in natural-based treatments.

So I decided to work closely with my colleague, Dr. Jasmine Talei who is a naturopathic doctor, to explore what remedies and alternative based medicines are available to combat menstrual pains and PMS.

Complimentary Medical Methods:

  • Regular exercise
  • Journaling and Understanding your cycles and associated symptoms
  • Meditation and Yoga
  • Acupuncture
  • Diet (see below)
  • Toxin Exposures
  • Avoiding salty food or large meals that cause or worsen bloating
  • Stop smoking
  • Naturopathic supplements
  • calcium
  • Omega 3
  • Vitamin D
  • vitamin B6
  • Magnesium citrate/ magnesium glycinate

Medical Management:

These can be started while taking several of these nutritional supplements.

    • NSAIDs like Ibuprofen or aspirin block the chemical reactions that stimulate pain during menstrual cycles
    • I often advise my patients to take NSAIDS 24 hours prior to their menstrual cycle starting to minimize the effects
    • Hormonal Contraception (i.e. birth control pills)
      • Minimize the presence of prostaglandins
      • Reduce period flow
      • Also a great method of contraception
    • The estrogen and progesterone suppress ovulation and cause the lining of the uterus (endometrium) to thin

*It is important to note that a lot of these studies that evaluated these methods of management are limited due to small sample size, but the overall incidence of dysmenorrhea seems to be reduced.

Additional management For PMS:
For some women experiencing PMS, mood changes are the primary aggravating factor. Many women’s symptoms are so severe that it is difficult to get out of bed, unable to focus or experience significant depressive symptoms. If you are one of these women, you are not alone!

Much like the syndrome, there is a lot of misjudgment about the medical management of PMS with anti-depressants called SSRIs. While they are commonly used to treat anxiety and depression, medications like Zoloft, Prozac have been known to reduce the symptoms of PMS

There are two ways to take an SSRI for PMS

  • The first is to simply take it every day throughout your cycle
  • Another way is to take it only after ovulation (which usually occurs about 14 days before your period) and to stop when menstruation starts
  • They are designed to target symptoms of depression, anxiety, irritability, anger, headaches and mood swings associated with PMS
  • Some side effects of SSRIs: nausea, headache, difficulty sleeping, lack of sexual desire or arousal or orgasm, dizziness, dry mouth

Per Dr. Talei, these are Naturopathic ways to boost your mood:

So! Dr. Talei and I have shared a lot of information. And this is not a definitive primer on how to manage menstrual pain or PMS. Rather it was an opportunity to share different perspectives, and how multidisciplinary practices can help alleviate dysmenorrhea and PMS.
As always, consult your physician or me or my colleague Dr. Talei for any additional questions or concerns.

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Daniel Niku, MD, MS

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