When Abby Norman, author of Ask Me About My Uterus, got her first period on Thanksgiving at 12, she spent the day in the bathroom with unbearable cramps, diarrhea, and thigh pain. “I felt so sick to my stomach that I couldn’t have any Thanksgiving dinner, which was very disappointing,” she remembers.
She thought her periods would get better over time, but they didn’t. “I always felt sick and had a lot of pain. But I thought that was normal and I never knew anything different,” she recalls. “Pretty much every conversation I had with an older woman, or any book I read, said that cramps were normal and that I just had to put up with it.”
From Zooey Deschanel complaining that “it feels like a fat man is sitting on my uterus” in New Girl to a Natalie Portman and her friends couch-ridden in No Strings Attached, movies and TV depict period pain as an inevitable part of womanhood. But is suffering every month actually necessary? And why do we find it acceptable?
The Science Behind Painful Periods
The American College of Obstetricians and Gynecologists divides period pain, also known as dysmenorrhea, into two categories: secondary (tied to an underlying condition) and primary (standing on its own). But many apparent cases of primary dysmenorrhea are likely undiagnosed secondary dysmenorrhea, says Maya Dusenbery, author of Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed. For her book, Dusenbery interviewed countless women who were told their pain was normal only to be diagnosed with conditions that had gone untreated for years.
That’s what happened to Norman. It wasn’t until after she’d dropped out of college due to her debilitating pelvic pain that she learned she had endometriosis, a condition where tissue similar to the uterine lining grows in other parts of the body. Even though it impacts one in 10 women of reproductive age, endometriosis goes undiagnosed for 10 years on average due to doctors’ unwillingness to take menstrual pain seriously.
Endometriosis is not the only routinely overlooked cause of secondary dysmenorrhea. Others include adenomyosis (when tissue similar to the uterine lining grows in the uterine muscles), fibroids (tumors on the uterus that seven percent of American women have reported), and ruptured ovarian cysts, says Iris Kerin Orbuch, MD, Director of the Advanced Gynecologic Laparoscopy Center in Los Angeles. Another common source is polycystic ovary syndrome (PCOS), a condition characterized by excess male hormones, irregular periods, and ovarian growths that affects 8-20 percent of reproductive age women, says reproductive endocrinologist Aimee Eyvazzadeh, MD.
Since so many women with these conditions believe they’re suffering from primary dysmenorrhea, its prevalence — which some studies have found to be as high as 91 percent, according to a meta-analysis in Epidemiologic Reviews — may be exaggerated, says Dusenbery. In addition, severe menstrual pain is not as common as people tend to believe. A World Health Organization study found that if affected 12-14 percent of women worldwide — too many, but hardly enough to call it normal.
Painful Periods Are Not Normal
Even if primary dysmenorrhea is very common, that doesn’t make it normal either. There’s some debate over exactly how much discomfort is normal. Eyvazzadeh says mild menstrual cramps simply result from uterine contractions that get the blood out. But OB/GYN Eden G. Fromberg, DO believes that any discomfort stemming from these contractions — or menstruation in general — indicates a problem, albeit not necessarily a serious one.
“The uterus is comprised of specialized smooth muscle tissue and has more in common with your heart than your bicep,” says Fromberg. “Uterine pain, like cardiac pain, is not a normal response to muscular contraction.” Often, uterine pain indicates ischemia, or inadequate blood flow to the uterus, which can stem from many problems including ligament pressure, stress, poor posture, a sedentary lifestyle, dysfunctional breathing patterns, and uncomfortable clothing (including high heels, which can cause pelvic floor spasms and uterus displacement), Fromberg adds. These issues can often be treated with natural remedies like massage, movement therapy, and acupuncture.
“Uterine pain, like cardiac pain, is not a normal response to muscular contraction.”
Mary Lou Ballweg, president and executive director of the Endometriosis Association, doesn’t buy that uterine contractions are naturally painful either. Rather, she points toward research showing that an excess of chemical compounds called prostaglandins, which influence the strength and frequency of uterine contractions, is what causes menstrual cramps.
A study in Prostaglandins, for example, found that one woman with dysmenorrhea had nearly twice the menstrual prostaglandin activity as two women without it. Another study in Prostaglandins, Leukotrienes and Essential Fatty Acids identified more prostaglandins in tissue affected by endometriosis than normal uterus and ovary tissue. Yet another 16-woman study in the American Journal of Medicine found that both oral contraceptives and Ibuprofen reduced prostaglandin release and, consequently, menstrual pain compared to a placebo. “We conclude that primary dysmenorrhea is related to a high level of menstrual prostaglandin release,” the authors wrote. This is not a fringe idea. The American College of Obstetricians and Gynecologists acknowledges prostaglandins as the usual cause of primary dysmenorrhea.
Diet Is A Factor In Painful Periods
Many fatty acids in our modern diet are precursors to prostaglandins, Ballweg explains. In addition, excess estrogen leads to excess prostaglandins, so diet impacts prostaglandin production through its effect on estrogen activity, says Fromberg. Functional nutritionist Alisa Vitti, author of WomanCode and creator of the MyFLO period app and FLOliving.com, teaches women to get enough omega 3 fatty acids (which can be found in nuts, seeds, and certain fish) and reduce omega-6 acids (like that found in canola oil, red meat, and dairy products) so they’ll produce fewer pain-inducing prostaglandins. Her clients’ menstrual pain tends to go away within two to three cycles.
“When women are given a proper education on how their hormones actually work, then the powerful menstrual mythology that keeps them in pain needlessly is brought to light/”
One 33-woman study in Obstetrics & Gynecology found that women experienced less menstrual pain and PMS after following a diet centered on vegetables, fruits, and legumes (which are low in fat but relatively high in Omega-3) and excluding Omega-6-rich animal fats and oils than after following their usual diet and taking a placebo pill.
“When women are given a proper education on how their hormones actually work, then the powerful menstrual mythology that keeps them in pain needlessly is brought to light, and a woman can do what she needs to do with food to make her period easier,” says Vitti. “What better opportunity for women to see how false all the negative propaganda about menstruation is.”
Modern Life Could Cause Women Pain
On top of diet, many chemicals in the products we use and the air we breathe interfere with hormones. In fact, some pads and tampons contain highly toxic byproducts of paper bleaching called dioxins and Polychlorinated Biphenyls (PCBs), says Fromberg. One study in Seminars in Reproductive Medicine found that exposure to dioxins can block progesterone receptors that are necessary for healthy menstruation. Another study in Fundamental and Applied Toxicology found that dioxin can lead to endometriosis.
Another likely culprit in our environment is xenoestrogens — natural and synthetic hormones that imitate estrogen activity, says Fromberg. They’re in pesticides, plastics, cosmetics, and bleaching agents used in pads and tampons, and they can lead to estrogen dominance, or an excess of estrogen, which has been linked to many health issues including high blood pressure and fibroids. “Estrogen dominance is a tremendous public health issue, underlying numerous gynecological illnesses ranging from fibroids to endometriosis to PMS, menopausal symptoms, and dysmenorrhea,” says Fromberg.
“Pain is nature’s way of telling us something is wrong, so it’s hard for me to accept that menstrual pain would be normal.”
Given this evidence, Fromberg and Ballweg both believe it’s not nature but environmental toxins, unhealthy diets and lifestyles, and other health issues that cause primary dysmenorrhea. Dusenbery agrees: “Calling primary dysmenorrhea ‘normal’ doesn’t make sense given that it is recognized to be due to an imbalance — one that isn’t inevitable.”
Yet primary dysmenorrhea’s causes are rarely discussed by doctors, let alone researched, which Ballweg views as yet another example of our society’s dismissal of women’s pain. “Pain is nature’s way of telling us something is wrong, so it’s hard for me to accept that menstrual pain would be normal,” she says. “It is a routine monthly function. If a routine function such as bowel movements were to be consistently painful, it would not be considered normal. It’s only because of the taboo and stigma and shame that has surrounded menstruation that people have allowed this myth to develop. Many other types of health problems are common (obesity, ED, enlarged prostate in older men) but not considered normal.”
Doctors Agree: Period Pain Is Preventable
Regardless of how common or normal period pain is, doctors agree that it’s preventable, and leaving it untreated is inexcusable. “Society has created this notion that women should suffer because we are women,” says Eyvazzadeh.
If your period pain interferes with your life in any way or is not alleviated by over-the-counter painkillers, Eyvazzadeh recommends asking a doctor for a pelvic ultrasound to investigate underlying causes. “When a doctor talks to a patient about her symptoms then does a pelvic exam and says, ‘See, I didn’t feel anything,’ that’s dismissive and not appropriate,” she says. “If a woman is complaining about pelvic pain, the right approach is an imaging study to further characterize her organs so that she can have all the information she needs in order to make appropriate treatment decisions for herself.”
“If you don’t get help from the first person you ask, ask someone else… Women put up with too much. They don’t have to live with it.”
Consultant gynecologist Gabrielle Downey doesn’t believe in any universal rule of thumb for how much discomfort warrants a doctor’s visit or treatment. This is totally up to the patient, she says. If the patient doesn’t want her discomfort to continue — no matter how minor it may seem to someone else — then it should not. “If you don’t get help from the first person you ask, ask someone else,” Downey says. “Women put up with too much. They don’t have to live with it.”
The consequences of living with painful periods, after all, are more than just physical. They can range from missing work and social activities to experiencing low self-esteem, compromised mental health, and feeling unlucky to be female, says Orbuch. Norman says she became depressed and anxious after years of being told the pain was “all in her head.” This kind of gaslighting can even make women doubt their own sanity. One colleague of Ballweg’s told her, “I lost my voice at a young age because I could not talk about my pain.”
“The anger and resentment builds, and these women who find out that they have been misdiagnosed for years — it’s palpable,” says Eyvazzadeh. “But I think once they’re finally diagnosed, it’s incredibly empowering. It’s the ultimate ‘I told you so’ dance. And I do the dance with them. And I say, ‘See? It wasn’t in your head. You aren’t crazy.’”
No Woman Should Accept Living In Pain
The belief that women are unwell for several days every month harms all women—even those without painful periods. “The assumption that pain is just ‘part of being female’ can lead to the false notion that women cannot function competently or that women are physically inferior,” says Orbuch. Hence, Donald Trump’s “blood coming out of her wherever” insult toward Megyn Kelly and men tracking female coworkers’ cycles so they can avoid them around their periods.
“I remember one doctor at a medical conference I attended stating that menstruation was proof that God’s not a woman,” says Ballweg. “There is almost an impression that people believe women are defective by design.”
“Periods connect us to the cycle of life, to all biological and metaphorical cycles of release and renewal.”
Rather than view period pain as evidence of women’s supposedly inferior build, Fromberg views it as their body’s way of speaking to them. “Your menstrual cycle is your barometer of where you are flowing in the cycle of life,” she says.
In fact, a health menstrual cycle can lead to lots of amazing things, from the energy surge and high libido some experience during ovulation to the opportunity for self-care and reflection during menstruation. “Periods connect us to the cycle of life, to all biological and metaphorical cycles of release and renewal, and to the source of life itself, which is within us,” says Fromberg. And there’s nothing inferior or unlucky about that.