Menstrual cramps: Could it be fibroids or endometriosis?

Dear Doc,

I had my first period when I was 14. During my teenagehood, it was a painful experience due to stomach cramps and other ailments that come with it. This somehow became better when I was in my twenties. Right now I am in my mid-thirties and the painful periods have come back. What could be causing this and how do I get rid of the problem?

Dear reader,

Menstrual cramps are referred to as dysmenorrhea. If the cramps started soon after you started receiving your periods, meaning that the pain is purely from the monthly cycle, then this is called primary dysmenorrhea. The menstrual cramps are due to contraction of the walls of the uterus. These contractions increase during menstruation because of a rise in chemicals called prostaglandins, to help in shedding of the uterine lining (which is what comes out as period bleeding). The prostaglandin levels rise two days or so before the periods and continue to be high for two or three days during the periods, which is why the symptoms tend to begin either just before or when the periods start and then reduce after two or three days of the menses.

There may be pain in the lower abdominal, back or inner thighs. There may also be nausea, vomiting, diarrhoea or constipation, change in appetite, breast pain, headache, dizziness, fatigue, sleep disturbances, frequent urination and mood changes. There may be reduction and increase in the symptoms over time and for some, primary dysmenorrhea may decrease as the individual grows older and/or after giving birth, though this is not the case for everyone.

Some people develop secondary dysmenorrhea, which refers to painful periods that develop as a result of other conditions like:

uterine fibroids and uterine polyps: non-cancerous growths in the uterus

pelvic inflammatory disease: inflammation of the pelvis and pelvic organs, usually due to infection that spreads up from the vagina into the uterus, the fallopian tubes and pelvis

endometriosis: where the endometrium (the tissue lining the uterus) grows anywhere else outside the uterus such as on the ovaries, on the lining of the pelvis or in the large intestines

adenomyosis: where the lining of the uterus (endometrium) grows into the uterine muscle.

Cervical stenosis: narrowing of the cervix as a result of surgery, radiotherapy

Abnormalities of the reproductive tract such as differently shaped uterus or fallopian tubes

For some, use of an intra-uterine contraceptive device

Large caesarean scar niche

Interstitial cystitis – painful bladder syndrome

For most people, secondary dysmenorrhea begins later in life. Someone with primary dysmenorrhea can also develop secondary dysmenorrhea later if they develop an underlying condition. With secondary dysmenorrhea, the pain may begin several days before the periods and last throughout the periods. There may also be heavy bleeding, bleeding in between periods, pain and/or bleeding associated with sexual intercourse.

It is advisable for you to be reviewed by a gynaecologist for evaluation, which may include physical examination, taking of a vaginal swab and pap smear, or an ultrasound scan. If an underlying condition is identified, then it will be treated, which would help reduce the cramping. Primary dysmenorrhea cannot be cured but can be managed using medication such as non-steroidal anti-inflammatory drugs like ibuprofen and mefenamic acid, other painkillers like paracetamol, anti-spasmodic medication like buscopan and anti-nausea medication. For severe cramps, hormonal medication may be prescribed. Other measures to manage the cramps are the use of heating pads, massage, rest and exercise, and avoiding smoking, alcohol use and caffeine intake.

Dear doctor,

What is the meaning of having a prolapsed disc? My father was diagnosed with the same and he has pain in the lower back and weakness in his left leg.

Dear reader,

The spine is a structure along the back that is made up of bones (called vertebrae), ligaments, muscles, and discs. There are 33 bones or vertebrae, which are aligned, one on top of the other. In between the bones, there is an inter-vertebral disc, which acts as a cushion between one bone and the next one.

In addition, there is the spinal cord, which is a group of nerves that is carried from the brain. Each of the vertebral bones has a space in the middle and when they are aligned on top of each other, they form the spinal canal, where the spinal cord passes through. In the space between one vertebral bone and the next, a pair of nerves exit the spinal cord and goes on to the organs/tissues at that level.

A prolapsed disc (also called a herniated disc or slipped disc) means that the inter-vertebral disc is bulging out of its normal position. This prolapse may happen at any level, from the neck to the lower back, and one or more discs may be affected. It can happen as a result of wear and tear with age.

It may also be due to twisting and turning movements of the spine while lifting, or as a result of injury. Sometimes there is no identifiable cause of a prolapsed disc. The bulging of the disc may press on the nerves that are exiting the spine at the same level and sometimes it may lead to narrowing of the spinal canal, called spinal stenosis, causing pressure on the spinal cord.

A prolapsed disc may have no symptoms or there may be symptoms at the affected area. The symptoms may include pain, numbness and tingling or weakness. For your father, since the prolapsed disc is at the lower back, there may be back pain and weakness of the lower limb because of the effect on the nerves exiting the spinal cord at that level.

Most of the time the symptoms of a prolapsed disc improve with rest, physical therapy and guided exercise. Medication to manage the pain can also be used. Surgery may be done when there are severe symptoms that do not improve with conservative management. In addition, your father should maintain good posture and avoid strenuous activities. Lifting should not be done with a bent back, even for small loads. It is preferable to squat and lift slowly with the back straight.

Send your questions to [email protected]