When period pain strikes again
We caught up with Dr Kent Kuswanto, Epworth obstetrician and gynaecologist to talk all things periods.
Would you like to tell us a bit about you and what you do, Kent?
KK: I’m Kent Kuswanto, obstetrician and gynaecologist here at Epworth Freemasons Hospital, and I specialise in minimally invasive gyno surgery, and mainly laparoscopy surgery to remove fibroids, endometriosis. I also perform hysterectomies. I therefore see a wide variety of problems in women with periods; heavy periods, irregular periods, period pains, or even up to having annual pap smears checks. I also look after women in their pregnancy and deliver babies, so it’s a very fulfilling job.
What causes period pain and why do some unlucky women suffer more than others?
KK: Period pain is actually a very very common problem, especially for younger women. The commonest cause of this is something called primary dysmenorrhea, where the body releases a hormone called prostaglandin when the uterus sheds the period every month. Prostaglandin causes uterus cramps, it can also cause symptoms like headache, nausea, vomiting, and even diarrhoea. When the prostaglandins release every month you have period pain. Some women have more painful periods than others maybe because they have underlying issues such as endometriosis or fibroids. Endometriosis occurs when the cells that are usually in the lining of the uterus are found isolated outside of the uterus. This can cause inflammation and irritation every time you have a period, and that can cause pain. Fibroids are benign tumours of the uterus, as they grow bigger and bigger they make the period heavier, and when your periods are heavier then you produce more prostaglandin, the same hormone that causes the uterus to cramp and cause pain.
How can you relieve period pain?
KK: There are many ways to relieve period pain. There are some easy ways such a using a heat pack around your belly or on your back to relax the muscle, or some relaxation techniques such as doing yoga, meditation or having a warm bath. Then there are medications that you can try to start with; simple medication like over the counter analgesia, such as non-steroidals. Things like voltaran, brufen, ponstan. These medication have anti-prostaglandin properties. These are the properties that you want to cancel out, those prostaglandin that release at the time of the period, therefore reducing inflammation, reduce cramping and pain. If you can use it together with other simple medication like paracetamol or Panadol they work even better together. Then, there are hormonal medication that you can use to reduce period pain. This will be the oral contraceptive pill, or the progesterone-containing IUD intrauterine device, which is a Mirena. If you see your local GP they will probably recommend this as a first line and they can reduce the period pain by reducing the flow of the period, but also being able to skip your period altogether with the pill. If these simple measures don’t work, then that’s probably when you should investigate for other underlying things such as endometriosis and fibroids.
What is normal period pain & what’s not? When should you go & see your doctor?
KK: It’s hard to judge because every woman perceives pain differently and most women have some sort of pain or discomfort during this time of their period. But, if your period is so painful that you’re always at sick bay at school, you’re unable to go to school, you’re unable to go to work, you’re bed-bound, then something’s not quite right. Then it’s a problem that needs to be addressed. Far too often women present to the doctor and are told that their periods are normal periods, that they feel like they’ve been dismissed, if that’s the case then I would suggest you go again until the period pain is resolved, or you go for a second opinion. Even if, in cases where you’ve done a lot of investigation and ultrasounds and it shows that your ovaries are normal, your uterus is normal, but you’re still in pain, then it’s still an issue that needs to be addressed.
What’s PMS & what is premenstrual dysphoric disorder?
KK: PMS is a consolation of emotional and physical symptoms that occurs around the time of the period. It usually occurs between the time of ovulation until the period arrives then lasts two weeks of the cycle. Physical symptoms such as bloating, breast tenderness, constipation, and food cravings for example, and emotional symptoms such as moody, cranky, angry, irritable, are a part of pms. If they’re severe, then (the woman) has pms, which is premenstrual syndrome, and/or pmdd, which is premenstrual dysphoric disorder, which is a very severe form of pms.
How common are pms & pmdd?
KK: They’re very very common. 80% of women will have one or two of these symptoms around the time of their period and they don’t usually cause any disruption to their daily activities. But if you have a series of symptoms as mentioned before, and this is affecting your work, affecting your relationship at home, then you have pms. About 10% of women have pms and a very small minority of these have pmdd, which is 2%,
What are the causes of pms and pmdd?
KK: It’s thought that the hormonal changes at the time of ovulation, between ovulation your period, and its effect on serotonin receptor in the brain cause pms. So, serotonin, as you know, is the happy hormone, it’s the hormone that controls the mood in the brain. So this hormone/hormonal effect on the brain affects your mood, but the effect of the estrogen and progesterone in the body cause the physical symptoms like bloating, breast tenderness, nausea and vomiting.
Do you have any tips on managing pms symptoms?
KK: For the vast majority of women simple things like, again, relaxation techniques and exercise will help. Exercise is good for general well-being anyway. Doing exercise increases your endorphins, which is your feel-good hormone, that might help pms. Relaxation techniques such as doing yoga, mediating and doing mindfulness might help that too. If you know how to do these techniques then do it, but if not you might engage a psychologist or counsellor to help you initially. Then there are supplements that may help with pms, things like magnesium, calcium, primrose, evening primrose oil, or vitamin B-6. Having said that, large studies haven’t showed that these supplements are any better than any placebo.
Is there any medical treatment for pms or pmdd?
KK: Before we start anyone on medication we need to confirm that it’s pms, that it’s regular, that the symptoms get relief within one or two days after the period arrives, and that there’s no underlying depression or any other hormonal problems that are the problem. Once we’re certain that a woman has pms there are a couple of medications that we’d normally use. One is an SSRI, which is the commonest anti-depressant used in the community, it’s a selective serotonin receptor inhibitor. A second treatment would be the contraceptive pill, and this is because it’ll reduce the pits and troughs of the hormone when you ovulate.
How do you know if your bleeding during your period is too heavy?
KK: As with period pain it’s really hard to judge whether your flow is normal or too heavy. A good indication are symptoms of overflowing, or if you change your pads every one to two hours during your period, if you have large clots, if you have accidents and if because of this you’re stressed you can’t go out during the time of your period, you can’t go to work or you’re embarrassed then it’s a problem that needs to be addressed. Having heavy periods also leads to being low in iron and being anemic. So some signs of that would include being really fatigued, low concentration, dizzy, tired, if you have any of these symptoms you should probably see your doctor. It’s a very common problem.
What causes these heavy periods?
KK: There are many causes of heavy menstrual bleeding. The commonest cause is a hormonal imbalance, called dysfunctional uterine bleeding, this occurs very frequently in young women when they first start getting their period, and in women in their forties just before they go through menopause. If you’re not ovulating regularly, then your periods become irregular and heavy. Then there are other causes of heavy periods such as fibroids, adenomyosis, which is the where the lining of the uterus is in the muscle of the uterus, polyps of the uterus, infections, bleeding disorders, and in less commonly, abnormal, overgrowth of cells in the lining of the uterus or uterine cancer. Obviously these are really uncommon causes of heavy uterine bleeding but really important to look for and rule out.
Why might a period become irregular or stop altogether?
KK: The commonest cause of not having a period is pregnancy. Once you rule that out then we go to look for other things that might stop your period. Regular periods is a sign of regular ovulation. The best way to look at causes would be to look at why and how would a women get a period. A period occurs when the brains sends hormonal signals to the ovaries and the ovaries send hormonal signals to the uterus every month; this leads to monthly periods. Any disruption of the signals from the brain or from the ovaries will lead to having irregular or no periods at all. So in fact, the commonest cause of having no period is the brain not sending the signal to the ovary, this usually happens in elite athletes who exercise a lot. Or in someone who is extremely underweight, or in fact these days more likely being overweight stops your period. Or if you’re stressed in your work life or at home. Or if you’ve travelled from one time zone to another time zone that just stops the brain from sending the signals to the ovaries. Then there are ovarian causes of not having your period, so therefore your ovaries are not ovulating. The commonest cause of this would be polycystic ovarian syndrome, or premature menopause. If your ovaries have run out of eggs unexpectedly early then you might not get a period.
Are there ways to improve the regularity of your period?
KK: As the commonest cause are from the brain not sending signals to the ovaries then you would try, if you’re overweight (for example) to lose some weight. (In this case) increase your exercise to get your weight to a healthy range, then your periods should start again. If you’re underweight then the converse, you increase your calorie intake and reduce your exercise. Having said that it’s easier said than done for an elite athlete to stop exercising. Once they stop training and stop exercising their period will come back naturally. Then there are medication that we can use to regulate periods, this medication would normally be in the form of the contraceptive pill, and that’s because the contraceptive pill has estrogen and progesterone in it. In someone with polycystic ovary for example it’s quite useful to use the pill because we want the progesterone in the pill to help lighten the period and make it more regular. The progesterone in the pill might help with acne and excess hair in polycystic women anyway. In women who are not ovulating because they’re pre-menopausal who are using the pill, we want the estrogen effect of the pill to give them bone strength. The pill is good for contraception either way.
Do tampons cause toxic shock syndrome?
KK: Yes they do. More than half of toxic shock syndrome are caused by tampon use. Having said that it’s very rare, only about 1 in 100 000 women will get toxic shock syndrome when they use tampons. This is because women are now becoming more aware that toxic syndrome occurs and because tampons are now made from less absorbent material. It’s more likely to occur if you wear tampons for more consecutive days of your period, or if you leave a single tampon for a longer period of time, usually more than 8 hours.
What are the symptoms of toxic shock syndrome?
KK: You get really really unwell really quickly. Usually around day two or three of your period. The classic signs are high fever, low blood pressure and skin rash. But women can also feel like they’re really sick, so they can have vomiting, abdominal pain, diarrhoea, abnormal discharge. So if you have any of these symptoms during your period and you’re really worried and you’re using a tampon then you need to see a doctor immediately.
We’ve had a question come through over Facebook, it’s “I’m nearly 47, with six children, my periods are always heavy and lately a bit irregular. I had hormone tests for pre-menopause which showed no sign of it. Do you have any suggestions?”
KK: It sounds like you’re not ovulating if you have these problems because, as I mentioned earlier, it’s a very very common problem in women in their forties not to have regular ovulation anymore. So as you get closer and closer to menopause your ovaries will not release eggs regularly every month anymore and when this happens the lining of the uterus gets thicker and thicker because ovulation actually releases progesterone as the lining of the uterus thins. So without that progesterone the lining of the uterus gets thicker and thicker up until a point where you bleed, and (then) you bleed really heavily. My suggestion is for you to see a doctor to check to make sure you’re not anaemic or low in iron, given that you’ve got heavy bleeding. Do an ultrasound to check that there’s no underlying cause of heavy bleeding like polyps or fibroids or adenomyosis as mentioned before. If these are all normal then you probably have dysfunctional uterine bleeding and in these women the hormone level are normal because you’re not menopausal yet. The treatment for this will be simple things, such as iron supplementation, increase your iron, eating more green leafy vegetables and red meat. Then there are medications that we can use, non-hormonal medication can be used to reduce the bleeding and to make your blood clot easier so therefore you’d bleed less. Or either hormonal medication. The hormonal medication we’d be using is progesterone which is the hormone that’s lacking when you’re not ovulating regularly from the ovary. This may be in the form of an IUD, such as Mirena. Then there are things like operations if there is an underlying problem. But, I think we should check your blood count and do an ultrasound first and talk to your GP.
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