A Public Cervix Announcement

In 2018, the ovulating woman is bombarded with a constant stream of unsolicited opinions about her body. Perhaps one of the most confusing topics is how we should handle our periods. According to the “Embarrassing Moments” column in YM that I religiously read as a tween, periods were a monthly joykill whose sole purpose was to ruin white jeans and public swimming pool outings. Your period was just this mortifying thing that happened to you, not in you; some sort of biological curse that was in no way connected to your physical or emotional self. For many of us who grew up watching maxipad commercials with Windex blue liquid as a sterile stand-in for menstrual blood, the message was clear: the less we honestly and openly discussed our periods, the better.

Has anything really changed since then? Our President publicly shamed a journalist for daring to question him in an interview, citing that her “bleeding” must have been the reason for her...doing her job? A woman’s natural bodily function is treated like a dirty secret, yet at the same time, she’s required to pay a hefty “luxury tax” for feminine hygiene products. In a culture that couches menstruation in shame, it’s no wonder there aren’t many places to openly and safely discuss our periods and the physical and emotional issues that arise during “that time of the month”.

In the midst of all this noise, something important gets lost: for many women menstruation equals crippling, cyclical pain. It’s bad enough we bleed for seven days and don’t die, dare we complain about being in pain as well? It’s time to change the way we talk about the pain associated with periods, so we turned to Dr. Laura Payne, a clinical a Clinical Psychologist and Assistant Adjunct Professor of Pediatrics at the David Geffen School of Medicine at UCLA. Dr. Laura has devoted much of her professional research to examining central pain mechanisms in adolescent girls and young adult women, so basically she’s Ovary Yoda.

How much physical discomfort is “typical” with a period?

Dr.Laura: There really is no "typical" amount of pain or discomfort that is associated with periods.  Pain is a totally subjective experience, and the best indicator that menstrual pain is a "problem" is the degree to which it interferes in a person's life.  If someone is missing school or work regularly due to pain, can't function in her daily role, or is so preoccupied by the discomfort that she has trouble concentrating, that could indicate that the pain is problematic.  But, the bottom line is that if a person believes it is causing a problem, then it's causing a problem.

Concerns that would definitely warrant a visit to a good Ob/Gyn would be pain in the pelvic region that happens when a person is NOT menstruating, recurrent pain or discomfort during sexual intercourse, very irregular menstrual cycles, or very short (less than 22 days) or long (more than 35 days) menstrual cycles.  These symptoms are certainly not diagnostic, but a good physician will be able to use this information and possibly do additional diagnostic procedures to determine the best course of treatment (this is often a procedure called a laparoscopy, which is a surgery to see inside the uterus). Some conditions associated with these symptoms are endometriosis (an overgrowth of the uterine lining outside the uterus and can cause very painful periods and fertility issues). Pelvic inflammatory disease, uterine fibroids, and other less common conditions can also be a cause.

Menstrual pain often isn’t something women are allowed to publicly discuss. Many of us still feel like we’re in 7th grade trying to get out of swim class. Are there any misconceptions about menstrual pain you’d like to dispel?

Dr. Laura: It is unfortunate that we are still at a point where it is difficult for many women to discuss menstrual pain, and understandably so.  Until recently, much of the medical community has either dismissed or just not really recognized menstrual pain as a significant, often life-impairing condition.  Common misconceptions of menstrual pain are that "it's not that bad" or that because one woman doesn't experience severe pain, then other women don't either. Pain is a completely subjective, individual experience that is determined by all sorts of information that is processed in the brain.  Some of this information has to do with specific nerve signals from uterine cramping; other things that affect the pain experience are mood, anxiety, anxiety about pain, past experiences with pain (positive or negative), and genetic/biological factors. I would hope that we would be able to get to the point that when a person says that she is experiencing pain that is severe and debilitating, we can just accept that at face value, instead of questioning her perception.

I feel like that last statement applies to SO MANY situations. What are some methods to cope with the physical pain?

Dr. Laura: For many women, NSAIDs (non-steroidal anti-inflammatory drugs - ibuprofen, aspirin, naproxen) are very effective.  These drugs work by inhibiting the buildup and release of prostaglandins (which are chemicals that, when released, trigger uterine cramping) in the uterine wall.  NSAIDs seem to work best when taken before the menstrual pain is at its worst point, although research suggests they are probably just about as effective when taken after the pain has already peaked.  

What are your thoughts on using menstrual tracking apps or devices like Livia? Are there any technological advancements that can help us handle menstrual pain?

Dr. Laura: I think these apps can be super helpful and very empowering for women. I've never looked at Livia, but I have used Clue for some of my research studies. Clue collects anonymous data from its users and is very involved in research, so it's a great way to support research in this area.

That’s the app I use! Glad to know it’s got the Dr. Laura seal of approval! Do other lifestyle factors play into the severity of the pain at all (diet, exercise, mental health, stress, etc.)?

Dr. Laura: There are not a lot of consistent data in this area - many articles do talk about diet and exercise but I don't think there is anything conclusive in the relationship to pain.  Mental health and stress can definitely be factors in how we experience pain, not only because stress and anxiety or depression may heighten our awareness and focus on potential threats (i.e., pain), but also because psychological symptoms and pain share similar neurobiological pathways so if one is "activated" that can also trigger the other.

What is the effect on the brain and nervous system from chronic menstrual pain? How can early diagnosis and intervention help long term? Can this chronic pain lead to other serious issues like depression and anxiety?

Dr. Laura: These are the million dollar questions!  (Thanks!) At this point, we cannot say that menstrual pain "causes" any changes in the brain or nervous system or other issues, or vice versa.  Almost all studies so far have been correlational, which means we look at data in a single point of time. Even if menstrual pain is related to alterations in various neural pathways or changes in the nervous system, we can't say what "causes" what.  To better answer this question, we need longitudinal studies (following people over time) so that we can look at what factors predict changes in pain. There is a hypothesis that menstrual pain is a risk factor for future chronic pain problems, but that could be through one or more mechanisms.  For example, we don't know if having repeated episodes of pain (i.e., menstrual pain) changes how the brain processes pain, which then leads to other pain problems, or if how the brain processes pain is a "pre-existing" factor that leads to menstrual pain as well as other pain problems. This is a very important area of pain research in general.

Can CBT (Cognitive Behavioral Therapy) help address these physical symptoms?

Dr. Laura: CBT approaches have been shown to be very effective for pain.  For menstrual pain specifically, I developed and tested a 4-session, CBT group intervention for young adult women with moderate to severe menstrual pain.  In the group, participants were taught skills of "decatastrophizing" (learning to recognize and modify anxious/catastrophic thoughts about pain), mindfulness (staying in the present moment), and coping skills (having a big "toolbox" of various things that will help them cope with pain).  Data from this study show that the girls reported significantly less menstrual pain even after one year from when treatment ended.

What support system should you try to create if you suffer from recurring menstrual pain?

Dr. Laura: Try to surround yourself with people who understand and are supportive in the ways that you want to deal with pain - for some, that means resting in bed with a hot water bottle; for others, that means exercise and stretching.  Also, talk to your friends and family members if you can. Many more people suffer from menstrual pain than we might realize and it can be helpful knowing others' experiences.

Is there any hope on the horizon? What new developments can we look forward to?

Dr. Laura: Yes! There is hope.  I think where treatment is going right now is trying to identify different "sub-groups" of people with menstrual pain to personalize treatment approaches.  Menstrual pain may be triggered by different factors in different people and it probably has not been accurate to just group everyone together. So, there is ongoing research looking at whether certain women may respond better to NSAIDs, while others may need different interventions - medication or otherwise.  I hope that this new exciting research will finally allow us to really individualize treatments, therefore making them more effective.

Dr. Laura, our ovaries thank you for the work you’re doing. We need all the advocates we can get to bring awareness to female health issues like this. It’s a relief to know we’re not ovary-acting (sorry, couldn’t help it)!

Laura Payne, PhD is a Clinical Psychologist and Assistant Adjunct Professor of Pediatrics at the David Geffen School of Medicine at UCLA. She is Research Director of the UCLA Pediatric Pain Program and her research focuses on understanding central mechanisms (including neurobiological and psychological factors, such as depression, anxiety, and emotion regulation) related to pain. Dr. Payne received her Ph.D. in 2007 from Boston University and completed her postdoctoral fellowship with the UCLA Pediatric Pain Program from 2007 to 2013. During that time, Dr. Payne was awarded an NIH National Research Service Award to explore the relationship of emotion regulation to chronic pain (NIH/NIMH F32MH084424). She received the UCLA Chancellor's Award for Outstanding Postdoctoral Research in 2010, has published her research in scholarly journals, and has presented at numerous national and international meetings and conferences. In 2013, Dr. Payne was awarded a Bridge Award from the UCLA Clinical and Translational Science Institute (NIH/NCATS KL2TR000122) to support her research examining central pain mechanisms in adolescent girls and young adult women with primary dysmenorrhea (menstrual pain). In 2014, Dr. Payne was awarded a career development grant from the National Institute of Child Health and Human Development to continue this area of research (NIH/NICHD K23HD077042). She also received a UCLA Children's Discovery and Innovation Institute Seed Grant to explore the feasibility and acceptability of a cognitive-behavioral intervention for girls with moderate to severe menstrual pain.

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