Dysmenorrhea – Naturopathic Approaches

Zeynep Uraz, ND

General Overview

Background reading and videos

1. Diagnosis and Initial Management of Dysmenorrhea – 2014 (AAFP) – most up-to-
date http://www.aafp.org/afp/2014/0301/p341.pdf
2. Primary Dysmenorrhea – Consensus Guidelines SOGC – 2017
http://www.jogc.com/article/S1701-2163(16)39930-3/pdf
3. Clinical Key- First consult topic “Dysmenorrhea”

Please become familiar with the following background topics (found in the
SOGC and AAFP guidelines):
 Primary vs. Secondary Dysmenorrhea
 Symptoms of Dysmenorrhea
 Diagnosis and differential diagnosis (AAFP has a great chart for this)
 Conventional treatment options (what are MDs doing?)
 Is a pelvic exam required to initiate therapy for dysmenorrhea?
 What is the treatment algorithm for primary dysmenorrhea?

Dysmenorrhea impacts 45-95% of menstruating individuals. However, despite its

prevalence, very few individuals with dysmenorrhea seek care. This is likely due to
several reasons (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5746430/).

The Pathophysiology of primary dysmenorrhea: high-pressure contractions of

the myometrium (pressure is higher with higher pain), decrease in endometrial
blood flow during contractions, causing uterine ischemia and pain. Higher
contractions are usually correlated with lower blood flow. During the sloughing of
the endometrium, prostaglandins are released by the disintegrating endometrial
cells. These prostaglandins stimulate myometrial contractions, ischemia and
sensitization of the nerve endings.

Characteristics of Primary Dysmenorrhea:

From the SOGC guidelines (2017):
Risk factors:

AAFP – 2014

Assessment of individuals with dysmenorrhea

Specific assessments are required in the workup of dysmenorrhea.

1. Differentiation between primary and secondary dysmenorrhea

2. Menstrual history
a. Age at menarche
b. Length and regularity of cycles
 c. Amount of bleeding
d. History of dysmenorrhea (how long after first period did
dysmenorrhea begin), progression over time, degree of impact on ADL
e. Characteristics of pain: intensity, type, location, radiation, associated
symptoms, relation to onset of full menstrual flow

SOGC:

Physical exam:
Abdominal exam is useful.
Pelvic exam: Does not need to be conducted at the outset of assessment, especially
in non-sexually active individuals.

Additional laboratory testing and imaging:

In the workup of primary dysmenorrhea, not required. May be useful in cases that
do not respond to treatment, or if there is suspicion of secondary causes.

SOGC GUIDELINE FOR TREATMENT OF PRIMARY DYSMENORREA:

NATUROPATHIC APPROACHES

Treatment goals
We should be the experts on dietary and lifestyle measures that are therapeutic for
dysmenorrhea. And provide evidence-based coaching to help patients adhere to the
recommendations.

Lifestyle Counseling
Exercise – lower incidence of dysmenorrhea (effects on hormones and stress) 1 - see
more below.
Smoking – smokers have a higher risk of developing dysmenorrhea. Smoking aggravates
pain, and pain is even associated with passive exposure.
Alcohol – excessive consumption may be associated with pain; however, moderate
consumption may help relax smooth muscle.

First-Line Therapy
Regular exercise, heat, NSAIDS

Exercise for Dysmenorrhea

A Cochrane review – looking at exercise and its potential impact on dysmenorrhea.

Physical Therapies
Heat:
- applied to lower abdomen (approx. 4 good studies on this)

Sarris, J and Wardle J. Clinical Naturopathy. 2010.

1
 - Hot bath, heating pad, hot water bottle
- Primary dysmenorrhea
- One RCT found topical heat treatment at approximately 39ºC (102ºF) to be as
effective as ibuprofen and significantly more effective than placebo 2
- Another RCT found that a heated wrap significantly reduced pain after 8 hours of
treatment compared with paracetamol in women with primary dysmenorrhea 3

Transcutaneous Electrical Nerve Stimulation (TENS):

- TENS – non-invasive, clinically significant intervention for dysmenorrhea
- A systematic review found that high-frequency TENS was more effective than
placebo for the treatment of dysmenorrhea. The review found no evidence
supporting low-frequency TENS4
- High frequency TENS involves placing electrodes on the skin. An electric
current applied at different pulse rates and intensities to stimulate these
areas in efforts to provide pain relief. High frequency TENS (also referred to
as conventional TENS) usually consists of pulses delivered at 50-120 Hz at a
low intensity. Low-frequency TENS (also referred to as acupuncture-like
TENS), on the other hand, usually consists of pulses delivered at 1-4 Hz at
high intensity and with long pulse width.
- Applied locally, intensity – to tolerability. Duration as needed.
- May be especially useful in those who cannot tolerate NSAIDs
- Adverse outcomes: muscle tightness, headaches, nausea, redness, burning of
the skin
- Low frequency TENS not superior to placebo

2
Akin MD, Weingand KW, Hengehold DA, Goodale MB, Hinkle RT, Smith RP. Continuous
low-level topical heat in the treatment of dysmenorrhea. Obstet Gynecol. 2001;97:343-9
3
Akin M, Price W, Rodriguez G Jr, Erasala G, Hurley G, Smith RP. Continuous, low-level,
topical heat wrap therapy as compared to acetaminophen for primary dysmenorrhea. J
Reprod Med. 2004;49:739-45
4
Proctor ML, Smith CA, Farquhar CM, Stones RW. Transcutaneous electrical nerve
stimulation and acupuncture for primary dysmenorrhoea. Cochrane Database Syst Rev.
2002:CD002123
Spinal Manipulation 5
- Results from the four trials of high velocity, low
amplitude manipulation suggest that the technique was no more effective
than sham manipulation for the treatment of dysmenorrhoea, although it
was possibly more effective than no treatment. Three of the smaller trials
indicated a difference in favour of HVLA, however the one trial with an
adequate sample size found no difference between HVLA and sham
treatment. There was no difference in adverse effects experienced by
participants in the HVLA or sham treatment.
- Low risk
- May be worth trying in receptive patients

Uterine massage
- Maya uterine massage (the arvigo technique) or other non-commercial pelvic
organ massage techniques
- Massage – regular intervals may help water retention and pain

5
Proctor ML, Hing W, Johnson TC, Murphy PA. Spinal manipulation for dysmenorrhoea.
Cochrane Database Syst Rev. 2006:CD002119
 - Looking at the big picture – musculoskeletal dysfunction, pelvic floor muscles,
interaction between muscles of back, abdomen, digestive system, urinary system
and reproductive system
- No evidence to support its use

Nutritional Supplementation6, 7

There is one Cochrane review on Dietary Supplements for Dysmenorrhea.

6
Proctor ML, Murphy PA. Herbal and dietary therapies for primary and secondary
dysmenorrhoea. Cochrane Database Syst Rev. 2001:CD002124
7
Hudson, T. Women’s Encyclopedia of Natural Medicine. 2008.
Individual Studies (dietary supplements):

**Thiamine – 100 mg/day helped alleviate dysmenorrhea completely in 87% of study

subjects.
- To prove the efficacy of oral vitamin B1 administration for the treatment of
primary dysmenorrhoea, a randomised, double-blind, placebo-controlled study was
carried out on 556 girls aged 12-21 yr, having moderate to very severe
spasmodic dysmenorrhoea. Thiamine hydrochloride (vitamin B1) was given in a
dose of 100 mg orally, daily for 90 days. The combined final results of both the
'active treatment first' group and the 'placebo first' group, after 90 days of
vitamin B1 administration, were 87 per cent completely cured, 8 per cent relieved
(pain almost nil to reduced) and 5 per cent showed no effect whatsoever. The results
remained the same two months later as well when no drug was administered. Unlike
all the current treatments which are suppression-oriented, this curative treatment
directly treats the cause, is free from side effects, is inexpensive and easy to
administer8.
- Although this RCT was fairly large, there is only a single study on vitamin B1.
- These findings are consistent with those of open trials which found thiamine to have
an analgesic effect, although those studies employed much higher dosages.
However, thiamine deficiency is fairly common in India, so it is possible that the
nutrient is only effective when repleting a deficiency.

Magnesium – a Cochrane systematic review found that Mg was more effective than
placebo for pain relief and resulted in less medication being required. Three small trials
were included that compared magnesium and placebo. Overall magnesium was more
effective than placebo and the need for medication was less in the Mg group. There
was no difference in adverse effects in magnesium group. Dosage of 250-500 mg/day.
Watch for diarrhea. Magnesium may impair the effectiveness of thyroid hormone
supplements, captopril, and tetracycline if given concomitantly. A 4-hour lapse should
occur between dosing these drugs and magnesium.
8
Gokhale LB. Curative treatment of primary (spasmodic) dysmenorrhoea. Indian J Med
Res. 1996 Apr;103:227-31.
Since magnesium is part of chlorophyll, the green pigment in plants, green leafy
vegetables are rich in magnesium. Unrefined grains (whole grains) and nuts also have
high magnesium content. Meats and milk have an intermediate content of magnesium,
while refined foods generally have the lowest. Water is a variable source of intake;
harder water usually has a higher concentration of magnesium salts.

EFAs – Specifically fish oil with approx. 2000 mg EPA and DHA combined. Reduce pain
scores in dysmenorrhea. A systematic review included one randomized, controlled trial
(RCT) that found that fish oil (omega-3 fatty acids) was more effective than placebo for
pain relief in the treatment of primary and secondary dysmenorrhea9.
- An RCT found no significant difference in pain between fish oil and placebo when
four interventions for dysmenorrhea were compared for a minimum of 3 months:
fish oil; fish oil plus vitamin B12; seal oil; and placebo. This RCT did find, however,
that there was a significant decrease in pain in the group taking fish oil plus vitamin
B1210.

Niacin – 100 mg bid and q 2-3 hrs during cramps. Flushing will occur- but is probably
necessary to help the pain. There is one small study that was conducted in 1954. In
this trial niacin supplementation provided relief for up to 90% of women whose cramps
were severe enough to impair activities of daily living (require bed rest, or time off from
work). Hudgins prescribed 100 mg of the nutrient twice daily and at least 100 mg every
2 to 3 hours during cramps. He believed that the dosage should produce flushing—
although he found in a preliminary trial that niacinamide (which does not produce
flushing) seemed to work as well. He also believed that the efficacy of niacin was
enhanced by the addition of ascorbic acid 300 mg daily and rutin 60 mg daily, and
suggested that, by improving capillary permeability, they enhanced the vaso-dilating
effect of the niacin.

Unfortunately, his work was never confirmed by randomized trials, although his
extremely high success rate makes it likely that the response was more than a placebo
effect 11. Given the. Burden of taking niacin with flushing, it may be worthwhile to
consider the many other effective options out there.

9
Harel Z, Brio FM, Kottenhahn RK, Rosenthal SL. Supplementation with omega-3 polyunsaturated fatty
acids in the management of dysmenorrhea in adolescents. Am J Obstet Gynecol. 1996;174:1335-8
Proctor ML, Murphy PA. Herbal and dietary therapies for primary and secondary dysmenorrhoea.
Cochrane Database Syst Rev. 2001:CD002124
10
Deutch B, Jorgensen EB, Hansen JC. Menstrual discomfort in Danish women reduced by dietary
supplements of omega-3 PUFA and B12 (fish oil or seal oil capsules). Nutr Res. 2000;20:621-31

11
Hudgins AP. Vitamins P, C and niacin for dysmenorrhea therapy. West J Surg Gynecol 62:610–11, 1954
Vitamin E – In 1955, a placebo-controlled study in which 100 young women with
spasmodic dysmenorrhea received either alpha-tocopherol 50 mg 3 times daily or
placebo for 10 days pre-menstrually and for the next 4 days. After 2 cycles, 68% of
women in the supplemented group improved compared to only 18% of the
controls.12 These results were confirmed recently in a similar study.13

Calcium – Low intake associated with water retention. 1000-1200 mg/day total so
supplement accordingly. Also helps prevent cramping.

Iron- Iron deficiency, as marked by low ferritin levels or low transferrin saturation, may
be associated with an increased risk of dysmenorrhea.14

In 1965, Nathaniel Shafer of the department of medicine, New York Medical College,
learned from 2 patients receiving iron supplementation for iron deficiency anemia that
their severe symptoms of dysmenorrhea had disappeared. He proceeded to question
another 4 patients whom he had treated for iron-deficiency anemia, and to treat
another 6 patients complaining of dysmenorrhea (several of whom also had iron
deficiency anemia) with iron, without informing them that the treatment may relieve
their pain. (None of these patients had endometriosis or other organic pelvic disease to
account for the dysmenorrhea.)

All reported a reduction or complete disappearance of menstrual pain following iron

supplementation. 15 Unfortunately, there are no RCTs published to date to support this
data.

Vitamin D -
Two trials.
1. A loading dose of 300,000 IU of vitamin D3 in women with serum levels in the
lowest quartile. 40 women ages 18-40 with dysmenorrhea (unspecified if
primary or secondary). Reduced pain scores from baseline. No NSAID use in
vitamin D group vs. 40% of women in control group did use NSAIDs 16.

12
Butler EB, McKnight E. Vitamin E in the treatment of primary dysmenorrhoea.Lancet i:844–7, 1955
13
Ziaei S et al. A randomised placebo-controlled trial to determine the effect of vitamin E in treatment of
primary dysmenorrhoea. BJOG 108(11):1181–3, 2001
14
Penland J, Hunt J. Nutritional status and menstrual-related symptomology.
Abstract. FASEB J 7:A379, 1993
15
Shafer N. Iron in the treatment of dysmenorrhea: A preliminary report. Curr Ther
Res 7(6):365–6, 1965
16
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1108739
 2. A similar study of 60 women with low serum levels of 25(OH) vit D. Randomized
to receive 50000IU/week of vitamin D or placebo. Pain severity and intensity
decreased in the treatment group compared to placebo. Duration of treatment
was 8 weeks.

Botanical Medicine

***Zingiber officianale – has been shown to be equally effective as ibuprofen and

mefenemanic acid in treatment of pain. Has an inhibitory effect on inflammatory and
spasmodic PGs.
- N=150 reproductive aged women with primary dysmenorrheal were divided into
three groups, in a double-blind clinical trial. Group 1)ginger rhizome capsules,
250 mg four times a day for three days starting day one of their menses. Group
2)250 mg mefenamic acid capsules, four times daily days one through three.
Group 3) 400 mg ibuprofen capsules four times daily again, days one through
three of the menses.
- Severity of dysmenorrhea decreased in all groups and no differences were found
between the groups in pain severity, pain relief or satisfaction.
- More women in the ginger group became completely pain free, vs the
mefenamic acid and ibuprofen groups. The rate of satisfaction from the
treatments was 20/50 women in the mefenamic acid group,22/50 women in the
ibuprofen group and 21/50 women in the ginger group. 17

- 105 Iranian women; moderate-to-severe primary dysmenorrhea

- Ginger capsules were given in one of two methods: 1) 500 mg ginger capsules or
placebo 3x/daily starting 2 days before the beginning of menses and continued
through day 3 of menses. 2) 500 mg ginger capsules or placebo 3x/daily on days
1,2 and 3 of menses.
- The severity of pain was significantly reduced in the ginger group compared to
the placebo group for both dosing methods with better results in the first dosing
method.
- A 1.4 to 2.0 point reduction in severity was seen with ginger and with the first
dosing method, ginger significantly reduced the duration of pain compared with
placebo. There was a 4.6 ± 10.6 hour decrease in the duration of pain versus a
2.3 ± 18.2 hour increase in duration in the placebo group. The second ginger
dosing method was not significant in pain duration between ginger and placebo
18
.

Vitex agnus castus

Use of VAC compared to Yasmin in women experiencing primary dysmenorrhea.
The study does not mention the dose of vitex that was used.
17
J Alternative and Complementary Med 2009; 15(2):129-132.
18
BMC Complement Altern Med. July 10, 2012;12(1):92
 Results: Vitex equally reduced visual analog scores of pain and improved uterine
artery blood flow to the same degree as ethinyl estradiol. 19
Commentary: not a great study, but due to the relative lack of harm in using this
herb, it could be warranted on a trial basis.

Herbs that work generally on the HPO axis have been used traditionally in treating
dysmenorrhea – Vitex agnus castus, Paeonia lactiflora, Cimicifuga racemosa all act as
“hormone regulators” 20
- Uterine tonic herbs: Angelica sinensis, Chamaelirium luteum, Aletris farinse,
Caulophyllum thalictroides, Tribulus terrestris.

Diet
Overall principles of a healthy diet also apply to Dysmenorrhea.

There is not a lot of good quality evidence here.

****Skipping breakfast: associated with higher rates of dysmenorrhea, consistently

across several studies.
Engaging in weight loss strategies through diet is consistently associated with higher
rates of dysmenorrhea.

The rest of the data on diet is very mixed. For every positive study, you can usually
find one saying the opposite. It is important that we not cherry pick.

This is the most comprehensive study, and worth a look:

https://www.karger.com/Article/FullText/495408

What are the clear takeaway points from this study?

19
https://www.ncbi.nlm.nih.gov/pubmed/24245554
20
Sarris, J and Wardle J. Clinical Naturopathy. 2010.
TCM and acupuncture

The data on acupuncture are mixed. There is enough convincing evidence that benefit
may exist, to try using acupuncture in individuals who are open to it and are good
candidates.

There are several approaches to acupuncture in the application of dysmenorrhea.

Western approach involves using points that are local, and stimulate blood flow.

Diagnose TCM picture and address with acupuncture and herbal formulas
Etiology: Emotional strain, cold and dampness, Overwork, chronic illness, excessive
sexual activity, childbirth
Full types:
› Stagnation of qi, stasis of blood, stagnation of cold, damp-heat, stagnant
liver qi turning into fire
Empty types:
- Qi and blood deficiency, yang and blood deficiency, kidney and liver yin
deficiency
When to Refer?
 Suspect underlying cause/secondary dysmenorrhea (refer for workup, not
necessarily treatment)
 Refractory to treatment after 4-6 months
› In most of these cases, the cause is secondary dysmenorrhea