Menstrual Cramps Explained: Causes, Symptoms, And Treatments

If you've got a uterus, chances are it gives you some grief in one form or another roughly once a month. Even completely "normal" periods can come with a slew of annoying or unpleasant symptoms, including mood swings, breast tenderness, out-of-control cravings, and difficulty sleeping (via the Cleveland Clinic). But menstrual cramps are perhaps the most common period-related complaint women report.

In a 2012 study published in the Journal of Pain Research, researchers surveyed 408 young women to learn more about their experience with menstrual cramps. They found that 43.1% reported pain with every period, while another 41% experienced pain during some periods. Of those who sometimes or always get cramps, a little more than 67% had experienced them ever since they first began menstruating (menarche), while another 21% started experiencing them in the first year after periods began. In terms of timing, 18.7% begin cramping two days before bleeding starts, 22.2% begin the day before, 50.7% experience cramps when bleeding starts, and 8.4% get cramps later in their period. A little less than 50% of respondents who experienced cramps only had to endure them for a day, while 38.5% had them for two days, 9.6% for three days, and an unlucky 2.1% had them for their entire period. Nearly 38% of respondents had missed work or school because of painful cramps and 44.6% felt their social performance was reduced. Yet only 65.6% took medication to lessen their menstrual cramps.

Causes of menstrual cramps

The uterus is a muscle, and like any other muscle, it can experience cramps when it contracts too strongly. As WebMD explains, "If [the uterus] contracts too strongly during your menstrual cycle, it can press against nearby blood vessels. This briefly cuts off oxygen to the uterus. It's this lack of oxygen that causes your pain and cramping."

But you can't consciously flex your uterus in the same way that you can flex your calf or your biceps, so what triggers these contractions in the first place? A group of hormones known as prostaglandins are to blame. According to You and Your Hormones, prostaglandins can be produced by every cell in the body and have a variety of important functions. They trigger the inflammation that begins the healing process after an injury, and also help control the relaxing and tightening of the muscles of the airways and digestive tract. Prostaglandins also play a role in ovulation, the shedding of the uterine lining during menstruation, and the onset of labor. NSAIDs, which are often used to manage menstrual cramps, work by blocking an enzyme needed for the formation of prostaglandins.

While prostaglandins are important, sometimes you can have too much of a good thing. During your period, higher levels of prostaglandins are associated with more severe menstrual cramps (via the Mayo Clinic).

Who gets menstrual cramps?

Anyone who gets a period can experience menstrual cramps, but certain factors put you at increased risk. According to the Mayo Clinic, cramps are more common in those under 30, as well as those who were 11 or younger when they first began menstruating. Irregular menstrual cycles, heavy bleeding, and a family history of menstrual cramps also increase the likelihood that you'll have menstrual cramps.

Unfortunately, these risk factors aren't ones we can control. But there is one lifestyle choice that can up your odds of having painful periods: smoking. In a 2016 study published in Tobacco Control, researchers found that ex-smokers were 33% more likely to have chronic menstrual pain than nonsmokers, while current smokers were 41% more likely. Drilling down deeper into those increased odds, the researchers found that the younger someone was when they began smoking, the more likely they were to have chronic menstrual cramps. Compared to nonsmokers, those who began smoking at 13 or younger were 59% more likely to have painful periods, those who began between 14 and 15 were 50% more likely, and those who began smoking at age 16 or older were only 26% more likely.

While it's not clear exactly why smoking makes it so much more likely to have menstrual cramps, Dr. Jennifer Leighdon Wu told Reuters that cigarette smoke may reduce the amount of oxygen reaching the uterus. She also noted that "taking up smoking before the age of 13 may affect [the] hormonal axis."

Menstrual cramp symptoms

According to Norton Children's Hospital, menstrual cramps can feel like everything from a dull, consistent ache to a sharp and stabbing pain. They tend be felt in the lower abdomen, but the pain can radiate to the legs or back as well. The institution notes that "for some, the cramping pain is accompanied by nausea, fatigue, headache, vomiting, loose stool or diarrhea." It can be difficult to quantify pain, and the severity of period cramps varies from one person to another, but the pain should be manageable with NSAIDs like ibuprofen and heat. If the pain can't be controlled, or if a person with normally mild cramps starts having much more intense pain, it's a good idea to see a doctor to make sure there aren't any underlying medical conditions that need to be addressed.

In addition to differences in prostaglandin production, anatomy may play a role in why some women experience excruciating cramps while others have none at all. According to a 2016 study published in the Journal of Physical Therapy Science, there's a connection between the amount of tension in the ligaments connecting the uterus to the sacrum (back of the pelvis) and the amount of menstrual pain a woman will have. The researchers hypothesized that an imbalance in the alignment of the pelvis or an abnormal rotation of the pelvis caused by tight ligaments could worsen menstrual cramps by causing a buildup of fluid in the pelvis or triggering increased prostaglandin production.

Primary dysmenorrhea

Although the vast majority of women will have an occasional episode of menstrual cramps now and again, many women experience them as a regular part of their periods each month. Dysmenorrhea is the medical term for recurrent menstrual cramps. There are two types of dysmenorrhea: primary and secondary. In the case of primary dysmenorrhea, there's no underlying medical condition causing the painful periods (via the Cleveland Clinic).

Primary dysmenorrhea is extremely common. According to Med Broadcast, it affects 50% of menstruating women. Of those, approximately 10% have severe pain. The condition is most common during the late teen years and early 20s and often improves on its own as a woman ages. Primary dysmenorrhea may also improve after giving birth.

Just because primary dysmenorrhea is common doesn't mean individuals have to suffer in silence. As Health Partners explains, if your cramps cause extreme pain that interferes with daily life, you should see a doctor. You should also consult with a doctor if cramping lasts longer than two days, you get no or very limited relief from OTC pain relievers, your cramps feel different than they usually do, or you have cramping in your uterus at other points in your menstrual cycle besides your period. In addition to being able to suggest additional treatment options, your doctor can screen for underlying medical conditions that may be causing the extreme period pain (secondary dysmenorrhea).

Endometriosis can cause painful menstrual cramps

Although there's usually no underlying medical cause for regularly painful periods, this isn't always the case. According to the Cleveland Clinic, secondary dysmenorrhea is menstrual pain caused by a problem with the reproductive organs. There are a number of conditions that can lead to painful period cramps, including adenomyosis (a condition in which the uterine lining grows deeper into the uterus), cervical stenosis (a narrowing of the cervix), pelvic inflammatory disease (a bacterial infection of the reproductive organs), and uterine fibroids (benign growths in the uterus). But endometriosis — when the tissue that lines the uterus and is shed each month grows outside the uterus — is perhaps the most common cause of secondary dysmenorrhea. Endometriosis affects approximately 10% of reproductive-age women around the globe (via the World Health Organization).

As the Mayo Clinic explained, when endometrial tissue grows outside the uterus, it acts in the same way it does inside the uterus. During each menstrual cycle, it thickens and then breaks down, but because it's not where it's supposed to be, the blood and broken-down tissue has no way to leave the body. This can lead to extremely painful periods, as well as pain during sex and bowel movements. The exact cause of endometriosis is unknown, but it usually develops several years after periods first begin. Fortunately, a variety of medication and surgical treatments are available for endometriosis.

Uterine fibroids can cause dysmenorrhea

Uterine fibroids are another very common cause of secondary dysmenorrhea. According to Johns Hopkins Medicine, as many as 70% of women will develop fibroids at some point in their life. Per the Mayo Clinic, many women with fibroids never have symptoms, but for those who do, pelvic pain and pressure is a common complaint. Other symptoms include periods that last longer than a week, heavy menstrual bleeding, frequent urination and difficulty fully emptying the bladder, and pain in the back or legs. Although they don't usually cause complications, fibroids may cause fertility issues or pregnancy complications. Fibroids can range in size, and an individual may have one or many.

The Mayo Clinic noted that although the exact cause of uterine fibroids is unknown, certain genetic changes, the influence of estrogen and progesterone, and other growth factors may play a role. Although any woman of reproductive age can get fibroids, those who began their period at a young age are at greater risk, as are Black women and those who have a close family member who also has fibroids. In many cases, doctors take a "watchful waiting" approach to see if or how quickly the fibroids grow. Some fibroids may shrink on their own. If fibroids are causing painful menstrual cramps or other symptoms, treatment options include medication and a variety of surgical procedures.

Diagnosing dysmenorrhea

In most cases, menstrual cramps are self-diagnosed: Your period just started and it feels like someone is tying your uterus into a knot, so clearly those are period cramps. But if your menstrual pain is recurrent and severe or accompanied by other worrisome symptoms, it's a good idea to see a doctor who can determine if there's an underlying medical condition behind your painful cramps (secondary dysmenorrhea). If no other medical condition is found, you'll be diagnosed with primary dysmenorrhea.

According to the Mayo Clinic, diagnosis begins with questions about your symptoms and medical history, followed by a pelvic exam. Imaging tests allow doctors to visualize the uterus, cervix, ovaries, and other surrounding structures to check for evidence of fibroids, endometriosis, pelvic inflammatory disease, and other conditions. Ultrasound, which uses sound waves, is most commonly used, although CT scans (which use x-rays) and MRIs (which use radio waves and magnetic fields) can also be used when a more detailed image is needed. In some cases, laparoscopy is used to diagnose a condition that's causing secondary dysmenorrhea. In this procedure, a doctor makes tiny incisions in the abdomen and inserts a flexible tube with a camera that allows them to see the reproductive organs.

Cramps can change over your lifespan

According to a 2012 study published in the Journal of Pain Research, the vast majority of women who have regular menstrual cramps begin experiencing them at or within a year of their first period. But the appearance and severity of menstrual cramps can change as you age and your body goes through various changes. According to Health, menstrual cramps are very common for women in their 20s. Many conditions that cause extremely painful cramps, including uterine fibroids and endometriosis, tend to be diagnosed when a woman is in her 30s. Pregnancy of course puts a temporary stop to menstruation (and thus menstrual cramps), but having a baby can actually cause a permanent decrease in period cramps once menstruation returns. When a woman hits her 40s, menstruation and the symptoms that go along with it, including cramps, can become erratic as the body enters perimenopause.

Unfortunately, menopause (which happens for most women between the ages of 45 and 55) doesn't necessarily mean an end to pelvic pain. Many conditions that can cause painful menstrual cramps during a woman's childbearing years can continue to cause cramping after menstruation stops. Uterine fibroids usually stop growing or even shrink after menopause, but for some women, they can continue to cause cramps and other symptoms. For menopausal women with endometriosis, hormone replacement therapy to address some of the symptoms of menopause (such as hot flashes) may make their condition worse and worsen pain (via Medical News Today).

Home remedies for menstrual cramps

When menstrual cramps strike, there are a number of options for dealing with them, many of which don't involve medication. According to the Mayo Clinic, psychological stress can make period cramps worse, so activities like meditation that help reduce stress may reduce menstrual cramp symptoms. Heat can also lessen the pain of cramps, so consider using a hot bath, heating pad or adhesive patch, or a hot water bottle.

And while breaking a sweat may be the last thing you feel like doing when you're bloated and crampy, experts agree that exercise can be beneficial for menstrual cramps. As the Ogden Clinic explained, "exercise relieves cramps because it helps release beta-endorphins, sometimes called 'human morphine.'" These beta-endorphins are natural pain relievers and help the body clear out cramp-inducing prostaglandins faster. Exercise also helps reduce stress and get rid of water retention, both of which may indirectly reduce pain. But not all exercise has the same beneficial effects. According to WebMD, aerobic exercise is the most choice because the release of pain-relieving endorphins is triggered by an elevated heart rate. Good options include brisk walking, jogging, biking, or swimming. Aim for at least 30 minutes three times a week.

OTC medications to treat menstrual cramps

When heat and exercise and trying to remain zen just aren't cutting it, there are over-the-counter (OTC) medications that can help relieve period cramps. According to the Library of Medicine (LoM), non-steroidal anti-inflammatory drugs (NSAIDs) are the pain relievers of choice because these medications block the production of the prostaglandins that cause cramps. OTC NSAIDs include ibuprofen (Advil) and naproxen (Aleve), although others, such as diclofenac, are available via prescription in stronger doses (via drugs.com). Per the LoM, acetaminophen (Tylenol) can also relieve menstrual cramps, but appears to be less effective than NSAIDs. But even NSAIDs have limitations. Research suggests that they only work in about 31% of cases, and some women may experience side effects such as GI upset.

There are a number of pain relievers, including Midol, marketed specifically to women grappling with menstrual cramps. But as USA Rx explains, Midol doesn't contain any secret-weapon ingredients. It simply contains a pain reliever — either ibuprofen, naproxen, or acetaminophen. But thanks to the so-called "pink tax," Midol is a pricier option than plain ol' Advil. As The Balance states, "the pink tax refers to the general tendency for products marketed specifically toward women to be more expensive than those marketed toward men." So when cruising the pharmacy aisles, you can save yourself some money by opting for a pain reliever that isn't specifically marketed as being for menstrual cramps.

Birth control for menstrual cramps

Birth control methods that use synthetic hormones can lessen the severity of menstrual cramps while simultaneously preventing unwanted pregnancy. According to Verywell Health, combination birth control pills (which contain both estrogen and progestin), Mirena IUD, NovaRing (vaginal ring), Nexplanon (contraceptive implant), and contraceptive patches all appear to reduce the incidence and severity of menstrual cramps. Birth control pills and other hormonal contraception methods reduce menstrual cramps by blocking the production of prostaglandins. Some forms of birth control, including the Mirena IUD, may cause periods to stop altogether, which eliminates menstrual cramps. In other cases, you can intentionally choose to skip your period to avoid menstrual cramps. This can be done by skipping the placebo birth control pills or by keeping the vaginal ring or contraceptive patch in place on the days it would normally be removed.

But as the University of Colorado points out, controlling cramps with hormonal birth control isn't an overnight fix; it usually takes six months to one year to see results. Additionally, birth control won't solve potential underlying causes of severe cramps such as fibroids or pelvic inflammatory disease. If you've opted for a hormone-free copper IUD as your preferred method of contraception, it's important to note that copper IUDs, while excellent at preventing unwanted pregnancy, may actually lead to more severe menstrual cramps and heavier bleeding during your period (via Planned Parenthood).

Alternative medicine treatments for menstrual cramps

If you're looking for a way to relieve menstrual cramp pain but want to stay away from pharmaceuticals and synthetic hormones, there are a number of complementary and alternative medical treatments that may be helpful. The Mayo Clinic notes, however, that these therapies haven't been scientifically proven to help, and more research is needed. 

Acupuncture involves the insertion of thin needles at certain points in the body to manipulate an individual's energy, or chi. Acupressure follows the same principles but utilizes pressure on the surface of the skin rather than needles. Transcutaneous electrical nerve stimulation (TENS) is another treatment option. A TENS device has electrodes that you attach to your skin and which deliver an electrical current to stimulate your nerves. While TENS appears to be more effective than a placebo at treating menstrual cramps, exactly how it works is unclear. It may increase a person's pain threshold, or it may stimulate the release of prostaglandin-destroying endorphins.

Certain herbal remedies may also be able to soothe menstrual cramps. According to Verywell Health, ginger may ease cramps by reducing inflammation and the production of prostaglandins, but research on ginger's efficacy has been mixed. Fennel contains a compound called anethole that may have antispasmodic properties. Maritime pine bark may also be effective at relieving menstrual cramp pain. A variety of herbs commonly used in traditional Chinese medicine to treat menstrual cramps include red and white peony, angelica root, licorice root, and gardenia.

Surgical treatments for secondary dysmenorrhea

If your menstrual cramps are caused by an underlying medical condition such as endometriosis or uterine fibroids and more conservative treatments to manage pain and other symptoms haven't worked, your doctor may recommend surgery.

For endometriosis, laparoscopy and laparotomy are two procedures that allow surgeons to visualize and remove endometrial tissue growing outside the uterus. The tissue can either be cut out (excision) or destroyed with heat (cauterization or vaporization). During these procedures, doctors can also sever pelvic nerves to prevent pain signals from reaching the brain. It's important to note that these procedures may only be effective in the short-term, as the endometrial tissue may regrow. These surgeries may also negatively impact a woman's fertility (via the Eunice Kennedy Shriver National Institute of Child Health and Human Development).

For uterine fibroids, the Mayo Clinic outlines a variety of surgical approaches that range from noninvasive to traditional surgeries. MRI-guided focused ultrasound surgery is a noninvasive procedure that uses targeted ultrasound waves to break up fibroids. There are a variety of minimally invasive procedures to shrink or destroy fibroids, including uterine artery embolization, radiofrequency ablation, and laparoscopic myomectomy. If fibroids are particularly large or you have a large number of them, they may need to be removed through an abdominal myomectomy, which is a major surgical procedure. As a last resort, some women may choose to have their uterus removed (hysterectomy). With the exception of hysterectomy, all procedures carry a risk that fibroids will eventually return.

Things that can make menstrual cramps worse

While there are a number of options for curtailing the pain associated with menstrual cramps, there are also a few things that can make cramps more likely or more painful that you should avoid. As mentioned above, smoking can increase the risk of painful cramps (via the Mayo Clinic), so add that to the already long list of reasons to quit.

What you drink and eat can also negatively impact cramps. In an interview with Insider, Dr. Kecia Gaither, MPH, FACOG, noted that drinking excessive amounts of alcohol can worsen cramps because it lowers magnesium levels and increases production of cramp-inducing prostaglandins. In the same interview, Dr. Terry Dunn highlighted the potential risks of consuming too much caffeine. Caffeine can raise estrogen levels, which may exacerbate cramps and other period-related symptoms. Dunn also cautioned that eating a lot of salty foods can worsen bloating and water retention, which could make menstrual cramps more unpleasant. And while you may want nothing more than to dull the pain with a pint of ice cream, too much sugar can also worsen cramps. According to an interview with Dr. Gandhali Deorukhkar Pillai published in Healthshots, sugar is pro-inflammatory and can cause levels of estrogen and progesterone to fluctuate in response to the insulin spike sugar causes, which in turn worsens cramps.