Period 35: Reckoning with menstrual pain – and a note on “biological sex”
As a young person, when my periods became intensely painful, my mother introduced me to prescription strength doses of ibuprofen. I would take 800-1000 milligrams every four to six hours to get through the school day. Many days it was enough, but sometimes it only took the edge off.
When I lived away from home in college, and then grad school, I was less prepared and would occasionally find myself with my period but no ibuprofen in the house. Sometimes, also, I just wouldn’t want to have to take so much medicine to feel better. So I’d curl up in bed and cry, or watch television on the couch, willing away the pain.
It wasn’t until my own child began getting painful periods that I realized how unacceptable this all was. Watching your child cry, and be angry at the unfairness of it, and be unable to function… it does something to you. I was helpless to offer anything except… ibuprofen. To be fair, it is the best over the counter medicine for cramps because ibuprofen is an anti-inflammatory pain medicine that addresses the prostaglandins wreaking havoc on one’s abdomen during menses. But it is often not enough.
This all came up for me again recently for two reasons. One, over the last year I’ve interviewed a number of people who have had miscarriages at home. There are effectively two types of home miscarriages, one is “wait and see” which is exactly how it sounds, the other is medically managed using misoprostol or mifepristone/misoprostol. Medically managed miscarriage tends to occur faster and with fewer side effects, but it can also be more painful. Exactly zero of the people I’ve spoken to with either type of home miscarriage were offered anything except acetaminophen (paracetamol for you Europeans) or ibuprofen.
Two, I was talking to someone knowledgeable about abortion care recently, who told me there are also no particular pain management recommendations or prescriptions offered for people who choose medical management (the exact same medicines as home miscarriage) for their abortion. While there are many benefits to home abortion, like home miscarriage it can be painful.
When people have miscarriages or abortions at home, they are experiencing contractions and often some cervical dilation. It is emotionally fraught as well as physically painful. They are often alone with this experience, suffering for days (and then continuing sometimes to bleed for weeks after). And we tell them to take a little Advil?
Pain management in medical abortion (and thus also miscarriage – remember, the methods are the same) is barely studied. A systematic review that came out in 2022 was only able to find a handful of studies, and most were of different dosing levels of – you guessed it – ibuprofen or acetaminophen. (If you find yourself in this situation: the most effective was to take 1600mg ibuprofen prophylactically and then continue to take as needed.)[1]
Pain seems to be part of the punishment implicit in having a uterus. Menstruation, miscarriage, abortion, they are all of a piece: a failed chance at a baby. At a moment when we should be thinking of ways to reduce suffering, we leave people without any way to manage their pain. And the best we have to offer is an incredibly high dose of ibuprofen, which carries its own set of risks.
Which brings me back to period pain, because for most it’s the first uterine pain we experience, and the one that is most often belittled. A qualitative study of nursing students with dysmenorrhea (menstrual pain) found that what they often sought out was a safe environment where their pain was understood. Unsafe environments were where they were belittled, where they were confronted by those who had never experienced dysmenorrhea, or those whose periods stopped long ago, or places that were unfamiliar to them so they were unsure if they could trust the people around them with their pain.[2]
This feeling of unsafety comes from the fact that people in pain are assumed to be more sensitive, more likely to catastrophize their pain, maybe milking it a little.[3,4] We gaslight people with menstrual pain that their bodies are somehow different, or weaker, or more susceptible to pain. But is this true?
A paper came out a few weeks ago that looks to be the first of several on the EMPATHY (Early Menstrual Pain Impact on Multisensory Hypersensitivity) project. This project started following young girls before they got their first periods, through at least their fourth menstrual cycle (and I think beyond, but this paper only looked at first and fourth period). By their fourth the vast majority of participants were experiencing significant levels of menstrual pain. The individuals reporting greater pain were not different in any major way to those who did not have pain. There were no significant differences in these individuals’ psychosocial health or pain sensitivity.[5]
So one, people with adolescent dysmenorrhea are not weak nor more susceptible, suggesting no inherent failure in their bodies that predicts why they are in so much pain. Two, periods just really fucking hurt when you’re a kid. Part of it may really be the newness of the physiology – that the massive inflammatory process of menstrual repair is an assault on the system. And ibuprofen therefore should help. But it seems like for many it just isn’t enough and we need to consider other ways to mitigate the pain from all this inflammation.
So we don’t know why menstrual pain varies (or miscarriage or abortion pain for that matter), we’ve barely studied pain management techniques or treatments that may help, and people in pain have little recourse in public settings to manage their pain because they don’t know who they can trust. No wonder so many withdraw from public life, take days off work or school, or otherwise stay silent about the experience.
A few links
First – I co-authored a piece for American Scientist with Agustín Fuentes, Caroline VanSickle, and Catherine Clune-Taylor titled “Biology is Not Binary.” I have a thread on Bluesky summarizing the piece (I am no longer active on Twitter and do most of my text-based social media on Bluesky now). It’s behind a paywall so if you don’t subscribe or aren’t a Sigma Xi member, hit me up for a copy.
Next, I was happy to see this paper by Kelly McNulty and colleagues (including co-author Alyssa Olenick, who full disclosure is the coach I get my barbell programming from) reviewing the lack of exercise physiology research on mid-life women (AKA on me). It’s open access!
I was annoyed to see RED-S described as “mysterious” given the decades of research on it, but still glad, I guess, that CNN covered it.
ProPublica followed a family for a year after not being able to get an abortion. A mother that the state had already decided was unfit to be a parent and had had several children taken from her, was forced to carry a dangerous pregnancy conceived three months after an emergency C-section. As you might imagine, this had significant health complications for her and her baby, and massive repercussions on her family’s ability to get by. Read her family’s story here.
Finally, mainstream media has continued to minimize the death and suffering and starvation of tens of thousands of people in Gaza. This week I don’t have particular pieces to recommend but I keep my Instagram stories pretty updated. There are many emergency protests happening this weekend after the airstrikes on Rafah; look to your local activist organizations to find out when yours might be.
References
1. Reynolds-Wright, J. J., Woldetsadik, M. A., Morroni, C. & Cameron, S. T. Pain management for medical abortion before 14 weeks’ gestation: A systematic review. Contraception 116, 4–13 (2022).
2. Fernández-Martínez, E. et al. Living with Pain and Looking for a Safe Environment: A Qualitative Study among Nursing Students with Dysmenorrhea. International Journal of Environmental Research and Public Health 17, 6670 (2020).
3. Merone, L., Tsey, K., Russell, D. & Nagle, C. “I Just Want to Feel Safe Going to a Doctor”: Experiences of Female Patients with Chronic Conditions in Australia. Womens Health Rep (New Rochelle) 3, 1016–1028 (2022).
4. Sebring, J. C. Towards a sociological understanding of medical gaslighting in western health care. Sociology of health & illness 43, 1951–1964 (2021).
5. Tu, F. F. et al. A multidimensional appraisal of early menstrual pain experience. American Journal of Obstetrics and Gynecology (2024) doi:10.1016/j.ajog.2024.01.017.