Originally published: 6 August, 2020
Sylvia* had been a normal child with a normal childhood, by all accounts. She hardly had any physical ailments and had never been hospitalised. She spent a few days in bed in a dark room, with measles, and that had been the extent of her experience with illness.
After her thirteenth birthday, her life changed, profoundly. It took a turn for the worse with the onset of puberty, a precursor for a life marked by severe and debilitating pain, every month. The pain was so severe, her legs and hands trembled, her jaw clenched, her hands balled into fists, her appetite disappeared, dark circles framed her eyes, she suffered nausea, vomited, had diarrhea, lower back pain, could not concentrate at school, at work, on anything, but the pain. Without pain medication, she would lie on her bed, on her stomach, and groan tonelessly, like a wounded animal, for hours on end. It consumed her being, entirely, and affected her outlook on life.
Dysmenorrhea* is the medical term for “pain with menstruation” and is classified as a menstrual disorder. There are two types of dysmenorrhea: primary dysmenorrhea refers to pain (mild to severe) experienced before or at the beginning of monthly menses without the presence of underlying medical problems and, secondary dysmenorrhea is pain caused by underlying reproductive problems such as endometriosis and / or uterine fibroids. Secondary dysmenorrhea occurs earlier during the menstrual cycle and lasts longer than actual menstruation. It is, as yet, unknown exactly how many women suffer painful menstruation but it is estimated that between 20% to 80% of women of reproductive age are afflicted by the condition.
Not much research has to date been conducted into dysmenorrhea with the unfortunate result that medical professionals are unclear about the causes of primary dysmenorrhea. Secondary dysmenorrhea is treatable with hormones, medication and surgery, but scanty bits of information seem to suggest that prostaglandins could be to blame for primary dysmenorrhea.
The female body undergoes changes in hormone levels during ovulation, and in preparation for menstruation, prostaglandins are secreted into the bloodstream. Prostaglandins play an important role in clot formation (blood-clotting), regulating the contraction of smooth tissue, such as uterine walls, and inflammation. During menstruation, prostaglandins cause contractions in the uterus to expel the uterine lining which in turn, causes pain and inflammation in women suffering primary dysmenorrhea.
Women at higher risk of experiencing painful menstruation are, typically, under 20 years of age, have a family history of painful menstruation, smoke cigarettes, bleed heavily during menstruation, or may have irregular periods, never had children, or reached puberty before the age of 11.
Sylvia was a smoker, experienced heavy bleeding during menstruation and never had children. While reviewing her risk factors, she noted that heavy bleeding and severe pain during menstruation were standard for her before she smoked.
Various treatments are recommended to relieve pain associated with primary dysmenorrhea. Everything and anything to the truly bizarre, it seems. Many treatments claim, of course, to be effective but, as Sylvia had discovered over the course of a three-decade long desperate search for some semblance of relief, that very, bitterly few treatments effectively alleviate severe menstrual pain.
She became obsessed with it: avoiding pain. And, she detested menstruation because of its association with pain. It was a curse, a blight on her existence.
In her quest to manage the pain, she swallowed ibuprofen capsules until her stomach lining ulcerated, and her doctor prescribed medication, without treating the cause, namely, menstruation pain. She placed burning-hot water-bottles on her abdomen and lower back, and sat in hot, steaming baths of water until the skin on her thighs and lower back turned bright pink. She sucked on a homeopath's grains until her molars ached. She rubbed her legs, back and feet for hours with muscle-pain relief gels such as Voltaren. She stuck adhesive pain-relief patches (designed for male athletes, actually) on to her lower back and abdomen. She ground her teeth. Exhausted by the pain, she fell asleep until another stab of pain woke her up again, not long after. Her sleep was interrupted, her daily activities, her appetite, her normal routine...her life.
She lost count of the many times she had wished for death. And, every single time, she could not imagine having to endure another menstrual cycle and yet, at the time this post was written, Sylvia had already endured thirty-three such years, and three-hundred-and-ninety-six such painful periods.
Recommended treatments* to alleviate primary dysmenorrhea include placing hot water-bottles on the pelvic area or lower back, massaging the abdomen, taking warm baths, doing regular exercises, eating light but nutritious meals, practicing relaxation techniques or yoga, taking anti-inflammatory medication shortly before and during menstruation, taking vitamin supplements such as calcium, magnesium, vitamins B-6, B-1, E, and omega 3 fatty acids, raising the legs higher than the hips when sitting or sleeping, and reducing the intake of alcohol, caffeine, sugar and salt to prevent bloating. Contrary to recommended treatment, Sylvia discovered, quite accidentally, that drinking red wine somewhat relieved her pain but also caused heavier than usual bleeding.
In her 45th year of life, Sylvia broached the subject with her doctor. Years of amateur research had suggested that menstrual pain gradually diminishes with age. She wanted help, anything. After listening to her for less than a minute, her doctor waved a hand in the air and dismissed the subject as ''irrelevant''. Sylvia was disturbed by his reaction. To date, he had been the fourth medical professional she had approached without getting help. A few years before, a female doctor had put her on a contraceptive pill that had elevated her blood pressure, caused melasma on her nose and forehead, and worsened her pre-menstrual bloating. It appeared that she just could not win against biology, nor conquer her own body, or the painful hell of her existence.
Up to that point, since the age of thirteen, her life had regularly been disrupted by severe menstruation pain. In high school, she gave up swimming because heavy bleeding and severe pain required her to use heavy-duty sanitary pads. She also gave up playing tennis because of the same. She had lost count of the many days she had been absent or took sick-leave because she had been incapable of focusing on anything at work, except the pain. The many, many family and social events she had not attended. Her biggest regret was not being able to deliver a speech at her brother's wedding.
She could not sit for long because the pressure on her pelvic area and lower back worsened the pain. She could not stand upright for long because the downward-pushing pressure of her organs on her uterus worsened the pain. She had to be near a toilet, always, because vomiting and diarrhea were breaths away.
According to international medical practitioners, women should contact a gynaecologist when menstrual pain is so severe that:
* it affects their ability to perform basic tasks every month;
* after experiencing at least three consecutive painful periods;
* if they're passing blood clots during menstruation;
* when menstrual pain is accompanied by nausea and diarrhea; or,
* if they experience pelvic pain when not menstruating.
The gynaecologist should first conduct a pelvic examination to detect any abnormalities in the reproductive system. If none are apparent, medical treatment for pain relief is usually prescribed.
Sylvia coped with the first two to three days of menstruation by lying down, eating very little, heavily sedated by the strongest pain pills she could buy at the pharmacy, without prescription.
Why had Sylvia never seen a gynaecologist?
Firstly, in Namibia, medical doctors (general practitioners) refer patients to specialists; in other words, patients cannot approach specialists, directly. Second, none of the doctors Sylvia had approached for help regarded her complaint as sufficiently serious for referral to a gynaecologist, even though she had clearly outlined a menstrual disorder. Most had dismissed her complaints. One had even quipped that it was “normal.”
Was it ignorance? Or, was it due to a pervasive sexist, prejudicial perception that women's pain is falsely constructed and therefore, exaggerated?
Across the globe, thousands of female patients, if not more, have reported that medical professionals “downplay” and dismiss their complaints of pain. The frequency and number of such reports, including Sylvia's case, prove that a gender bias exists in the clinical management of pain.
In 2018, the BBC (British Broadcasting Corporation) published an article* about “pain bias” and reported that women in pain wait longer for treatment and are “less likely to be given effective painkillers than men.” The article also stated that the medical industry had a long and ugly history of dismissing women's pain. In addition to not taking women seriously when they report pain, most medical professionals are convinced that women's pain is psychological, not physical, and indicative of underlying anxiety disorders.
In 2009, it emerged* that oestrogen affects both the perception of pain and the effect of painkillers in women. A study had been commissioned after women reported that they experienced ''greater clinical pain'' and suffered “greater pain-related distress.” The study showed, conclusively, that women and men experience pain, differently.
Sylvia currently finds relief for severe menstruation pain with the help of NSAIDs (non-steroidal anti-inflammatory drugs), mefenamic acid, in particular. Her local pharmacist, a woman, suggested she give mefenamic acid capsules a try after Sylvia broke down and cried in the pharmacy, situated along Independence Avenue, in Windhoek.
After ingesting the first capsules, in desperation, the pain in Sylvia's lower abdomen, back and legs gradually subsided until she experienced painless menstruation, for the very first time in her life. She was filled with wonder that such a thing was even possible.
The side-effects of high doses of mefenamic acid are lethargy, drowsiness and sleep. Sylvia struggles to stay awake for longer than fifteen minutes after taking the medication and realised, just recently, that her quality of life, although relatively pain-free at the moment, was still lower than that of women without painful menses because of the side-effects of the medication. Whereas she had previously experienced debilitating pain, nausea and diarrhea, she now had painless menstruation, without nausea and diarrhea, but spent several, potentially productive hours, asleep.
The lives of women afflicted by primary dysmenorrhea are unenviable. According to Dr. Perry G. Fine*, the long-term effects of persistent or chronic pain include diminished qualify of life with adverse indications for mood and mental health. Studies indicate that long-term exposure to pain are associated with an increase in major depressive disorders, suicidal ideation, and suicide attempts. People affected by recurring pain experience impaired sleep, sexual dysfunction, clinical hypertension and cognitive disruptions in concentration and memory. Their quality of life declines significantly when the frequencies of interruption to or interference with their social lives, work and daily activities, increase.
At 46, Sylvia doesn't believe medical professionals in Namibia will change their perceptions and treatment of women in pain, specifically, primary dysmenorrhea. She read too many reports in local newspapers about women mistreated, neglected or dying in hospitals, the deaths of newborns and children (the most vulnerable), women in pain, often pregnant, waiting for hours under trees for medical assistance, in rural areas.
Sylvia is grateful for a small thing. She is grateful that a female pharmacist had believed and provided her with relief from severe menstrual pain, for the first time in her life. Even though she spends the first two to three days of her menstruation mostly asleep, and experiences vivid dreams, she no longer fears the onset of menstruation, every month, and her hatred for it, has lessened, considerably.
References for further reading:
- Not her real name*
- Dysmenorrhea: https://my.clevelandclinic.org/health/diseases/4148-dysmenorrhea
- Pain Bias: The Health Inequality Rarely Discussed: https://www.bbc.com/future/article/20180518-the-inequality-in-how-women-are-treated-for-pain
- Sex-based Differences in Pain Perception and Treatment: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2745644//
- Chronic Pain: Long-term Effects on the Brain and Body Explained: https://www.pathways.health/chronic-pain-long-term-effects-on-the-brain-and-body-explained/
- Long-term Consequences of Chronic Pain: https://academic.oup.com/painmedicine/article/12/7/996/1840819
- The image, for illustrative purposes only, was downloaded from Office of Women's Health.
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