Dysmenorrhea, or painful menstruation, is one of the most common problems women face, affecting over half of people who menstruate. Dysmenorrhea is associated with significant impairment of life in up to 29% of women it affects. Additionally, 12% of monthly school and work-related activities are lost due to absenteeism because of painful periods. (18)

Conventional approaches to treating dysmenorrhea focus on short-term pain relief but don't address the underlying causes to provide patients with long-term relief of monthly symptoms. This article will discuss a functional medicine approach to treating dysmenorrhea that emphasizes a holistic evaluation of overall health to balance hormones and achieve pain-free periods. 

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What Is Dysmenorrhea?

Menstrual pain or cramping is called dysmenorrhea. 45-95% of people who menstruate will experience dysmenorrhea. Dysmenorrhea is classified as primary or secondary. Painful menstruation that occurs without physical abnormalities or identifiable pelvic disease is primary dysmenorrhea. In contrast, secondary dysmenorrhea is due to a pelvic or systemic condition. (12) 

What Causes Dysmenorrhea?

Primary dysmenorrhea is caused by natural chemicals called prostaglandins. Prostaglandins are lipid molecules with hormone-like actions that, among other actions, are responsible for uterine muscle and vascular contractions during menstruation. The intensity of menstrual cramps is proportionate to the number of prostaglandins released by the uterine lining. (12, 18) 

Various factors are associated with an increased risk of primary dysmenorrhea, including high stress, smoking, heavy menstrual bleeding (menorrhagia), and premenstrual syndrome (PMS). These risk factors and dysmenorrhea can be attributed to an estrogen-dominant state. Elevated estradiol levels accelerate prostaglandin release, while progesterone antagonizes this reaction.

Dietary patterns that include skipping breakfast and high consumption of salt snacks, fruit juices, refined sugars, unhealthy fats, and ultra-processed foods are also associated with an increased risk of moderate-to-severe dysmenorrhea. Inflammatory, standard American diets increase the risk of micronutrient deficiencies; vitamins B1, D, and E, magnesium, omega-3, and zinc deficiencies may play a role in the cause and severity of dysmenorrhea. (16)

There are many potential causes of secondary dysmenorrhea, including endometriosis, fibroids, adenomyosis, endometrial polyps, pelvic inflammatory disease (PID), and the use of a contraceptive intrauterine device (IUD) (18). Similar to primary dysmenorrhea, imbalances between the ratio of estrogen and progesterone are often associated with causing many of these female reproductive health concerns (16). 

Dysmenorrhea Symptoms

For most women, menstrual pain is mild lasting for the first one or two days of their period. However, dysmenorrhea can be so severe for some that it keeps them from doing their normal activities for the duration of their period. Secondary dysmenorrhea is generally associated with more severe menstrual pain; the pain may begin before a period starts, worsens as the period continues, and may not resolve after the period ends. (12) 

Other symptoms associated with dysmenorrhea include (18): 

• Gastrointestinal symptoms: indigestion, nausea, vomiting, bloating, diarrhea, and constipation
• Irritability
• Headache
• Low back pain
• Fatigue

Functional Medicine Labs to Test for Root Cause of Dysmenorrhea

A comprehensive medical history and physical exam are important for diagnosing dysmenorrhea. With clinical suspicion of secondary dysmenorrhea, your doctor will likely order additional tests and imaging, such as tests to rule out sexually transmitted infections and pelvic ultrasound, to rule out secondary causes for menstrual pain. 

Functional medicine practitioners often order specialty tests to help identify underlying imbalances associated with painful periods. Some of the most common functional medicine labs ordered during the diagnostic evaluation of dysmenorrhea are discussed below.

Hormone Panel

The DUTCH Complete comprehensively assesses sex hormones, adrenal hormones, and organic acids. The biomarkers measured on this panel assess the endogenous/exogenous pools of reproductive hormones and how the body metabolizes them. This allows doctors to understand the intricacies behind estrogen-to-progesterone ratios and guides hormone-balancing treatment recommendations. Additionally, these test results help assess the patient's stress response, B vitamin nutrient status, and oxidative stress levels.

Nutritional Assessment

Vitamin and mineral imbalances can contribute to poor hormonal balance, increased prostaglandin production, and increased severity of dysmenorrhea. A micronutrient panel measures various essential nutrients to assess the patient's whole-body nutritional status on a cellular level to help create an individualized and targeted treatment plan.

Comprehensive Stool Test

Addressing gut health is critical to any successful treatment plan to address menstrual health. The gut is responsible for eliminating excess estrogen. Slowed intestinal motility, dysbiosis, and elevations in a bacterial enzyme called beta-glucuronidase can prevent efficient and effective elimination of estrogen from the body, contributing to hormonal imbalances and estrogen dominance. A comprehensive stool analysis can provide important information regarding gut health and function as it pertains to hormonal health. (8) 

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Conventional Treatment for Dysmenorrhea

Conventional guidelines recommend using nonsteroidal anti-inflammatory drugs (NSAIDs), which reduce prostaglandin synthesis, and/or hormonal contraceptives as first-line treatment options for dysmenorrhea.

Functional Medicine Treatment Protocol for Dysmenorrhea

While conventional treatments may be effective in reducing the severity of pain, they do not address the underlying cause(s) of dysmenorrhea. Therefore, discontinuation of either medication typically results in the return of symptoms. Alternatively, a functional medicine approach involves targeted therapies to correct underlying imbalances known to contribute to menstrual pain. A holistic approach should include healthy lifestyle modifications, targeted dietary and botanical supplements, and other complementary modalities to support hormonal and reproductive health.

Therapeutic Diet and Nutrition Considerations for Dysmenorrhea

All women should implement an anti-inflammatory, nutrient-dense diet to support a healthy menstrual cycle. A healthy diet both decreases the intake of foods contributing to pain and increases the intake of foods that provide essential nutrients for pelvic and menstrual health. Incorporating a variety of fruits, vegetables, whole grains, and lean protein into the diet daily encourages meeting daily nutrient requirements for vitamins, minerals, healthy fats, and fiber. Foods to try to incorporate into the diet to support healthy menstruation include olives, avocado, cruciferous vegetables, herbs and spices, berries, and probiotic foods. (9)

A low-fat, vegan diet has been shown to reduce dysmenorrhea. Diets that are low in fat and high in fiber have reduced circulating estradiol levels in women by up to 25%. Fiber's ability to reduce plasma estrogen is explained by its ability to bind estrogens in the gut so that they cannot be reabsorbed into circulation. Additionally, fiber helps to feed the microbiota in the colon, fostering a healthy intestinal microbiome and encouraging gut health. (9, 11)   

Diet also plays a role in suppressing painful menstruation by suppressing the inflammation that contributes to pain perception. Arachidonic acid is a precursory building block for synthesizing prostaglandins. Replacing arachidonic acid-rich foods, such as red meat and poultry, with foods rich in anti-inflammatory omega-3 fatty acids, such as fatty fish, flaxseed, and hemp seeds, can reduce dysmenorrhea by reducing pro-inflammatory prostaglandin formation. (11) 

Supplements Protocol for Dysmenorrhea

Many studies support the use of various natural supplements as alternative treatment options to conventional medications for treating dysmenorrhea. Supplements can be used in addition to modifying diet, regularly exercising, and healthfully managing stress to alleviate pain, balance hormones, and support gut health. The following are supplements that can be incorporated into a dysmenorrhea treatment protocol.

Ginger

Ginger's anti-inflammatory constituents, shagaol and gingerol, have an inhibitory effect on inflammatory and spasmodic prostaglandins. Studies show that ginger is as effective as NSAIDs in reducing the severity and duration of dysmenorrhea.

Dose: 750-2,000 mg dried herb powder 1-2 times daily 

Duration: as needed during menses

B Complex

B vitamins play a crucial role in women's health. They are involved in energy production, red blood cell formation, mood regulation, hormone metabolism, and nervous system function. Vitamins B1, B3, and B6, in particular, have been extensively studied for their use in treating menstrual-related health complaints. Vitamin B1 (thiamine) dosed at 100 mg daily effectively treated moderate-to-severe dysmenorrhea in a double-blind, randomized control trial of over 500 East Indian women aged 12-21 years (20). Vitamin B3 (niacin), given at 100 mg twice daily throughout the month and then every 2-3 hours during episodes of menstrual cramps, is effective in 87% of women with dysmenorrhea. Vitamin B6, typically dosed between 50-100 mg daily, effectively reduces period pain.

Dose: dose per label instructions, typically one capsule daily

Duration: at least three months

Magnesium

Magnesium is important in regulating muscular contractions and relaxation; magnesium deficiency can result in increased muscle cramps and pain. A review of three small trials concluded that magnesium is more effective than placebo for dysmenorrhea-associated pain relief. Additionally, patients experienced a reduced need for pain medication when supplementing with magnesium. (22) 

Dose: 150-300 mg daily (28) 

Duration: at least three months

Vitamin D

Vitamin D metabolites reduce the levels of inflammatory prostaglandins. Studies have suggested that vitamin D deficiency is associated with increased severity of menstrual pain and that serum levels of vitamin D reduce in the luteal phase of the menstrual cycle. Additionally, studies have shown that supplementing women deficient in vitamin D reduces pain intensity and duration and the need for pain-relieving medications. (24) 

Dose: 2,000-5,000 IU daily

Duration: at least 8-12 weeks

Fish Oil

Fish oil, rich in omega-3 fatty acids, can positively reduces menstrual cramps (22). One study found that supplemental fish oil was more effective than ibuprofen for treating severe dysmenorrhea. 

Dose: 2 grams daily

Dose: at least three months

When to Retest Labs

Observing beneficial changes in menstrual cycles can take up to three full menstrual cycles. While clinical observation for symptom improvement is encouraged during this time, postponing repeat labs until at least three months after initiating a dysmenorrhea treatment protocol is recommended.

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Summary

Dysmenorrhea, commonly known as painful menstrual cramps, can significantly impact the quality of life for many individuals. While traditional treatments focus on symptom management, a growing body of evidence supports a functional medicine approach that addresses the root causes of dysmenorrhea. Working with a functional doctor, you can explore strategies such as dietary modifications, stress management techniques, hormone balancing, and targeted supplementation to find comprehensive and lasting relief from menstrual pain.