The menstruating endometrium is a physiological example of an injured or "wounded" surface that is required to rapidly repair each month. The physiological events of menstruation and endometrial repair provide an accessible in vivo human model of inflammation and tissue repair.
How about that? The uterus, more specifically the endometrium, is so cool researchers are studying it to help understand inflammation and tissue repair. About once a month a whole lot of women, non binary, and trans people shed an entire layer of their uterus. For some, it is no big deal for others it hurts. A lot. In many cases this pain is due to primary dysmenorrhea (period pain). However, doctors do have form for dismissing women’s complaints and it could actually be due to endometriosis, ovarian cysts, or a range of gynaecological complaints. If your pain is stopping you from working or going to school then please see a health professional.
Let's start with physiology
Before we explore period pain management we first need to learn some physiology. The uterus is made up of three layers of muscle each oriented in a different way so as to enable the flexibility and strength to hold and birth a baby. It then has two non muscular layers that make up the endometrium. The basal layer has stem cells which regenerate the functional layer - which is the layer that sheds. This is the layer that is fresh each month so as to provide a healthy place for an egg to implant and a placenta to grow.
When progesterone levels drop the NFκB (nuclear factor kappa-light-chain-enhancer of activated B cells) system, the inflammasome and matrix metalloproteinases are activated. These systems drive the process of desquamation (shedding) and re-epithelisation (repair).
Shedding
The release of NFκB triggers the expression of prostaglandins and their precursor enzymes cyclooxygenase-2 (COX2). While COX2 plays a role in endometrial breakdown, prostaglandin F2α, along with other vasoconstrictors, constricts endometrial blood vessels. This hypoxic environment leads to tissue breakdown and bleeding.
Repair
At sites where shedding is complete the presence of prostaglandins triggers the activation of anti-inflammatory pathways. The repair process begins. Chemicals such as glucocorticoids, endometrial cortisol, reparative macrophages, lipid mediators and hypoxia inducible factor (HIF) ensure timely repair and cessation of menstrual bleeding. The process of re-epithelisation takes four to six days.
Menstruation is inflammatory, prostaglandin-y, and muscle crampy
That overview shows us that menstruation is an inflammatory process; it involves prostaglandins; and engages one of the strongest muscles in the body. Knowing these things helps us to take a three pronged approach to period pain management.
1. Prostaglandins
Studies show that dysmenorrheic females (people who get period pain) have higher levels of prostaglandins than eumenorrheic females (people who don’t).
Prostaglandins are the compounds that increase contractions and vasoconstriction. They also create inflammation and pain. Here is a video I made earlier to explain how non steroidal anti inflammatory medication works to prevent prostaglandin production.
I would recommend taking anti inflammatories the day before your period - with food. And regularly. If you are an adult - aspirin stays in the system for longer so might be worth trying. Teenagers aren’t allowed to use aspirin because of the chance of it messing up your liver and brain with a super rare disorder called Reye’s syndrome.
Other pain relief options that are backed by research are heat, TENS (Transcutaneous electrical nerve stimulation) and acetic acid.
By heat I mean a hot water bottle, a heat pad or even adhesive heat patches.
TENS machines are small portable devices that deliver small electrical currents to the pelvic area. They are thought to override or interfere with pain signals and reduce the perception of pain.
Pickle juice (or anything with acetic acid in it) doesn’t have strong research to back it up, but athletes have used it to reduce cramps for decades - so give it a try and see for yourself.
2. Inflammation
Thirty three university students recruited because of their period pain were asked to eat a (healthy) vegan diet for two months followed by their regular diet for two months. However, the vegan diet reduced their pain intensity so effectively that many of the subjects decided to not comply with the study requirements and stuck to their new high vegetable, beans and pulses diet. The researchers concluded that the positive results might have been “mediated by dietary influences on oestrogen activity.”
Oestrogen is normally pulled from the bloodstream by the liver, which sends it to the intestines. There, fibre soaks it up like a sponge and carries it out with other waste. A vegan diet is high in fibre and low in foods that aren’t good for the bowel. This is backed up by other studies showing that dietary fibre reduces period pain. The microbiome is also an area of interest for those studying endometriosis.
Good gut health is also linked to lower inflammatory markers. This article by the Guardian has great tips for increasing dietary fibre. This British heart foundation article has great advice about improving gut health generally.
Supplements that have evidence for reducing period pain are: omega 3, magnesium, zinc, and B vitamins. So does ginger, cinnamon and turmeric which all happen to taste great in tea.
And. Exercise is anti inflammatory too. Cytokines are cell signalling molecules. They are small proteins that trigger the growth and activity of immune cells. They spread the word that we’re under threat. Exercise decreases the number of inflammatory cytokines (inflammation messengers) released and increases the number of anti-inflammatory cytokines - these are the messengers that calm the immune response down.
3. Exercise your uterus muscle.
The muscular design of the uterus is very clever. The fibres of each layer are orientated differently. This enables them to stretch and contract in all planes of movement. If you sit a whole lot then your uterus might actually be quite sedentary. The muscle fibres may not be used to moving regularly and so feel quite shocked when pushed by prostaglandins to mobilise. I encourage you to try mobilising and strengthening your uterus (and the surrounding structures) for a month.
See, if squats, leg raises, bridges and pelvic circles make a difference. It’s worth a try right? Below are some videos explaining each movement. I’m holding a sponge to represent the orientation of the uterus as I move. Yes. I do realise that my uterus is not that big.
Let’s start with a squat
On the inhale bend your knees and imagine the uterus being lengthened under load by the other pelvic organs. On the exhale, imagine the uterus is a strong muscle engaging and lifting.
Single leg raises are next
When the right leg bends upwards the right side of the uterus rolls back while the left side rolls forwards. Imagine the uterus being wrung like a damp tea towel. Alternate your leg raises and feel the strength deep in your pelvis.
On to Pelvic bridges to sit up
When lifting and tucking the pelvis imagine the uterus stretching and tilting back. When rolling up and over imagine the uterus being compressed and tilting forward.
Pelvic circles
Imagine initiating the movement from the uterus as you circle your pelvis. Either visualise it moving in one plane from one side, to the front, to the other side, to the back - or tipping as you do this.
And that’s my approach to helping people with period pain. I’d love you to try it for a few months and get back to me. Until then I leave you with Maisie Hill’s battle cry:
xx
P
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