Period Pain and Heavy Periods: Causes, Home Relief, Medicines and When to Worry

Many women experience some discomfort during their periods. For most, it is mild and short-lived. But for some, period pain (dysmenorrhoea) and heavy menstrual bleeding (menorrhagia) interfere with work, school, sleep and social life. These problems are common, treatable and often undertreated. Knowing what is normal helps you decide when to seek help.

Why periods hurt

Before and during the period, the womb lining releases hormone-like chemicals called prostaglandins, which make the womb muscle contract to shed the lining. Higher levels cause stronger cramps, and can also cause headache, nausea, loose stools and back pain.

• Primary dysmenorrhoea: period pain without an underlying disease. It usually begins within a few years of the first period, starts just before or with bleeding, lasts 1-3 days, and tends to improve with age and after childbirth.
• Secondary dysmenorrhoea: pain caused by a condition in the pelvis, and often begins later in life, becomes worse over time, or lasts longer. Causes include:
• Endometriosis: womb-lining-like tissue growing outside the womb
• Adenomyosis: lining tissue within the womb muscle
• Fibroids: benign muscle growths in the womb
• Pelvic inflammatory disease (infection)
• Ovarian cysts
• Intrauterine device (copper IUD)
• Cervical stenosis or other structural problems

Home relief for period pain

• Heat: a hot water bottle or heating pad on the lower abdomen or back is as effective as some painkillers.
• Gentle exercise: walking, stretching, yoga and swimming can reduce pain.
• Painkillers: take early, at the first sign of pain or just before the period, and continue regularly for 2-3 days.
• NSAIDs such as ibuprofen or mefenamic acid reduce prostaglandins and are often the most effective. Take with food. Do not use if you have a stomach ulcer, kidney disease, certain asthma, or are pregnant. Avoid NSAIDs if you have fever that could be dengue. See dengue warning signs.
• Paracetamol is a safer alternative if NSAIDs are unsuitable.
• Rest, hydration and sleep.
• Limit caffeine, alcohol and smoking around your period, as they can worsen cramps.
• Eat well: balanced meals, with iron-rich foods, and magnesium or omega-3 sources such as nuts and fish.
• TENS machines and massage help some women.

Medical treatments

• Hormonal contraception: the combined pill, progestogen-only pill, implant, injection or hormonal IUD (levonorgestrel IUS) can reduce pain and bleeding.
• Tranexamic acid during the period reduces heavy bleeding and is non-hormonal.
• Treatment of underlying causes: hormonal medicines or surgery for endometriosis, procedures for fibroids or polyps.
• Iron supplements for anaemia.

What counts as heavy bleeding?

• Needing to change a pad or tampon every 1-2 hours, or double protection
• Bleeding for more than 7 days
• Passing large clots
• Flooding or soaking through clothes or bedding
• Disturbed sleep because of changing protection
• Bleeding that affects daily activities
• Signs of anaemia: fatigue, pallor, dizziness, breathlessness, palpitations, hair loss

Causes of heavy bleeding

• Hormonal imbalance, such as in puberty, PCOS and perimenopause
• Fibroids and polyps
• Adenomyosis and endometriosis
• Thyroid disease
• Bleeding disorders (such as von Willebrand disease), especially if heavy since the first period
• Copper IUD
• Blood-thinning medicines
• Rarely, cancer of the womb lining or cervix

See irregular periods and PCOS for related information.

Tests

• Blood count and iron studies (ferritin) for anaemia
• Thyroid function, and clotting tests if indicated
• Pelvic ultrasound (abdominal or vaginal)
• Hysteroscopy, endometrial biopsy or MRI where needed
• Cervical screening and swabs for infection

Iron-rich foods for women with heavy periods

Eat dhal, green leafy vegetables (gotukola, mukunuwenna, spinach), chickpeas, eggs, fish, liver and meat, with vitamin C foods such as lime, orange or guava to improve absorption. Avoid tea or coffee with meals. Many women need an iron tablet for at least 3 months, as directed by a doctor.

When to see a doctor

See a doctor if:

• Pain is severe, stops you doing normal things, or is not helped by simple painkillers
• Pain is getting worse, or starts later in life or lasts more than a few days
• You have pain during sex, or while passing urine or stool during your period
• You bleed heavily, or have signs of anaemia
• You have bleeding between periods, after sex or after menopause
• You have fever, foul discharge or pelvic pain suggesting infection
• You are trying to conceive and have painful periods (possible endometriosis)

Seek urgent care for sudden severe pelvic pain, fainting, or bleeding that soaks a pad every hour for several hours, or if there is any chance you are pregnant. See early pregnancy symptoms.

Do not suffer in silence

Many women are told that painful or heavy periods are "normal." Endometriosis takes on average several years to diagnose. If your periods hurt enough to disrupt your life, you deserve assessment and effective treatment.

References

• NICE guideline NG88: heavy menstrual bleeding, assessment and management
• American College of Obstetricians and Gynecologists: dysmenorrhea and heavy menstrual bleeding
• Royal College of Obstetricians and Gynaecologists: heavy periods and endometriosis guidance
• World Health Organization: endometriosis fact sheet