Why Period Pain Hurts So Much: A Look Into Prostaglandins

By Dr. Thansiya A K, MBBS

According to studies, 45–95% of women experience period pain during their lifetime. This can negatively impact the quality of life (QOL) of young females and is the main reason behind their absenteeism from school or work.

An Overview of Menstruation

Menstruation is the monthly shedding of the lining of your uterus. It is also known as menses, menstrual period, menstrual cycle, or period. Menstruation is a hormonally regulated, cyclical process.

The menstrual cycle is divided into four phases:

• Follicular phase: This phase begins when you get your period and ends at ovulation. Estrogen secretion rises while other hormone levels are low during this phase.
  

• Ovulation: This phase occurs roughly on day 14 in a 28-day menstrual cycle. A sudden increase in luteinizing hormone (LH) causes your ovary to release its egg.
  

• Luteal phase: This phase lasts from about day 15 to day 28. Secretions of progesterone and estrogen are characteristic of the luteal phase, which ends with menstruation.
  

• Menses phase: This phase begins on the first day of your period. It's when the lining of your uterus sheds through your vagina if pregnancy hasn’t occurred.

A rise in basal body temperature is the most reliable clinical indicator of ovulation. Progesterone withdrawal is the main trigger for both menstruation and endometrial repair.

What Is Period Pain

Dysmenorrhoea, also known as period pain, refers to painful menstrual cramps of uterine origin and is considered one of the most common gynaecological disorders among females of childbearing age.

Primary dysmenorrhea (PD) is spasmodic and painful cramps in the lower abdomen that begin shortly before or at the onset of menses and may last for up to 3 days.

Studies show that:

• 45% to 95% of females of childbearing age suffer from PD

• 2% to 29% experience severe pain

• 70% to 90% of the females afflicted are under 24 years old

Secondary dysmenorrhea (SD) usually originates from a pathological disorder, may not necessarily occur during menstruation, and is usually detected in older females (over 24 years).

The Real Culprit: Prostaglandin

Increased levels of uterine PGF2α and PGE2 during endometrial sloughing are the main causes of period pain. Prostaglandins are involved in increasing myometrial contractions and vasoconstriction, leading to uterine ischemia and the production of anaerobic metabolites.

Treatment

First-line therapies recommended for treating PD are NSAIDs (nonsteroidal anti-inflammatory drugs) and hormonal contraceptives.

Hormonal contraceptives include:

• Combined oral contraceptive (COC) pills

• Contraceptive transdermal patches or vaginal rings

• A levonorgestrel intrauterine system

• Subcutaneous depot medroxyprogesterone acetate

Emerging research has found that non-pharmacological treatments help reduce menstrual pain through several mechanisms, including increasing pelvic blood supply, inhibiting uterine contractions, and stimulating the release of endorphins and serotonin.

• Applying heat to your abdomen and lower back may relieve pain

• Massaging with essential oils for about 20 minutes

• Avoiding certain foods that cause bloating and water retention can help. Some of the biggest culprits include fatty foods, alcohol, carbonated beverages, caffeine, and salty foods

• Papaya is rich in vitamins

• Brown rice contains vitamin B6, which may reduce bloating

• Walnuts, almonds, and pumpkin seeds are rich in manganese, which eases cramps

• Olive oil and broccoli contain vitamin E

• Chicken, fish, and leafy green vegetables contain iron, which is lost during menstruation

• Flaxseed contains omega-3s with antioxidant properties, which reduce swelling and inflammation

• Exercise immediately before or during your period

• Transcutaneous electrical nerve stimulation (TENS) is a non-invasive treatment modality

Surgical Interventions

Laparoscopic uterosacral nerve ablation (LUNA), presacral neurectomy (PSN), and hysterectomy may be needed in rare cases.

Need for Awareness

Despite being highly prevalent, affecting up to 90% of adolescent girls, menstrual pain is often brushed aside. But intense pain affecting quality of life is not “normal.”

Painful periods have a biochemical basis, not an imaginary one. Recognising the role of prostaglandins helps validate the patient experience and tailor better interventions.

References:

1. Dawood, M. Y. “Primary Dysmenorrhea: Advances in Pathogenesis and Management.” Obstetrics and Gynecology 108, no. 2 (2006): 428–441. https://doi.org/10.1097/01.AOG.0000225920.61894.8d.
   

2. Wiley Online Library. “Chapter 3: Dysmenorrhea and Menstrual Health.” Accessed June 19, 2025. https://onlinelibrary.wiley.com/doi/10.1002/9781119426080.ch3.

3. ScienceDirect. “Clinical Management of Dysmenorrhea.” Accessed June 19, 2025. https://www.sciencedirect.com/science/article/abs/pii/S0002916523337304.

4. National Center for Biotechnology Information. “Pathophysiology of Dysmenorrhea.” Accessed June 19, 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC8943241.

_MSM/SE