Self-management of primary dysmenorrhea-related pain: cross-sectional study on non-pharmacological interventions

Abstract

Aim: Different nonpharmacological strategies are adopted to decrease primary dysmenorrhea (PD)-related pain. The present study aimed to verify women's use of nonpharmacological methods for pain and compare them with evidence from the literature.

Materials & methods: A two-step study was conducted, comprising an online survey with 9144 women to assess nonpharmacological strategies for relieving PD-related pain, and a literature review on PubMed of verify the evidence of nonpharmacological methods.

Results: Many women reported using heat therapy (61.5%), tea (42.4%) and massage (30.9%) to alleviate menstrual pain. However, the literature on these methods is limited.

Conclusion: Several nonpharmacological methods are used by women to relieve PD-related pain and studies with low bias risk are needed to prove their effectiveness.

Plain Language Summary

What is this article about

This article explores how women manage menstrual pain, known as primary dysmenorrhea (PD), using non-drug methods. The study investigates the common self-care techniques women employ to ease their pain and compares these practices with scientific evidence.

What were the results?

The study found that many women use non-drug methods such as heat therapy (61.5%), tea (42.4%) and massage (30.9%) to relieve menstrual pain. Despite their popularity, sometimes the scientific evidence supporting the effectiveness of these methods is limited.

What do these results mean?

These results indicate that while women frequently use various self-care methods to manage menstrual pain, there is a need for more high-quality scientific studies to confirm whether these methods are truly effective. This highlights a gap between common practices and scientific effectiveness.

Plain language summary

Article highlights.

• Prevalence and evidence of non-pharmacological methods: many women use non-drug methods to manage primary dysmenorrhea-related pain, but there is limited scientific evidence supporting their effectiveness.

• Implications for practice: understanding these methods can help inform healthcare providers about common self-management strategies used by women, highlighting the importance of further research to validate their effectiveness and provide evidence-based recommendations for pain management.

• Limited effectiveness of pharmacological methods: only 13.4% of women with PD achieved complete pain relief using pharmacological treatments.

• Sample size: findings from this study, while based on a large sample size, may not be fully generalizable across all regions due to Brazil's size and cultural diversity. However, the extensive sample size enabled a thorough exploration of various non-pharmacological interventions, offering valuable insights into the prevalence and effectiveness of these methods among Brazilian women.

• Cultural and societal influences: cultural and socioeconomic factors influence the choice of PD pain management methods. The diverse cultural landscape and socioeconomic disparities within Brazil can significantly impact women's access to and preference for certain pain management strategies. For example, traditional cultural beliefs and practices may influence the acceptance and utilization of non-pharmacological interventions, while economic constraints may limit access to certain treatments.

• Call for comprehensive research: there is a need for more high-quality research to evaluate the efficacy of non-pharmacological interventions for primary dysmenorrhea, which could lead to the development of better, evidence-based pain management strategies for women.

• Patient education: educating women about the variety of available pain management options, including non-pharmacological methods, can empower them to make informed decisions about their health and improve their overall management of primary dysmenorrhea.

• Impact on quality of life: the study highlights the significant impact of primary dysmenorrhea on women's quality of life, emphasizing the need for effective pain management strategies to improve daily functioning and overall well-being.

1. Background

Primary dysmenorrhea (PD) is the pain during the menstrual cycle not related to any pelvic diseases; it is the most common gynecologic condition in women of reproductive age [1]. Physiologically, PD is caused by the hypersecretion of prostaglandins with increased uterine contractility that restricts blood flow [2], leading to pain. PD may be associated with central sensitization symptoms [3] and has significant impact on quality of life, such as limited daily activities and psychological stress [2,4].

It is recognized that PD affects adolescent girls and women worldwide, with prevalence estimates ranging between 16 and 91% [5]. In Brazil, the prevalence of PD among women exhibits variability, indicating rates of 90.7% during the most recent menstrual cycle, 91.4% in the three previous cycles and 97.4% in the last 5 years, covering symptoms that range from mild to severe [6].

Untreated PD may result in absenteeism from school and work, with significant socioeconomic consequences [7]. In this context, pharmacological interventions (prescribed [8,9] or not [10,11]) are used to decrease pain in an attempt to improve function in this population. In most cases, non-steroidal anti-inflammatory drugs (NSAID) are used as first-line treatment for PD, and the use of combined oral contraceptives also is a treatment option for many women who are seeking contraception [8,9]. However, those medications can have side effects such as irregular bleeding, headaches, nausea [9], epigastric pain, edema, rash, the sensation of heaviness, drowsiness and increased risk for cardiovascular events, ulcers and thrombosis [12].

Many women avoid pharmacological methods for fear of possible side effects and the development of any kind of tolerance or dependence. As such, those women choose nonpharmacological management of PD-related pain [13], such as heat therapy [14], exercise [15], herbal medicine [16], transcutaneous electrical nerve stimulation (TENS) [17] or acupuncture [18]. However, some nonpharmacological methods used to relieve PD-related pain do not have enough scientific evidence to be used [14,18,19], while others lack systematic reviews with meta-analyses to assess the quality of evidence from the available clinical trials [20–23]. Furthermore, there is no previous research that quantifies the extent to which these approaches are used among women seeking relief from PD-related pain. Therefore, it is necessary to investigate which nonpharmacological strategies to relieve PD-related pain are most used by women and seek their evidence on the literature.

The hypothesis of this study suggests that there will be diversity in the utilization of nonpharmacological strategies among women seeking relief from PD-related pain. Another hypothesis of this study suggests that certain modalities will exhibit higher prevalence rates, despite limited scientific evidence supporting their effectiveness. Thus, this study aimed to verify women's use of nonpharmacological methods to relieve PD-related pain and compare them with available scientific evidence.

2. Materials & methods

2.1. Study design & ethical issues

This study was divided into two steps. For the first stage, secondary data from an online survey conducted by Google Forms was used [6] the data used in the present study refer to the use of different nonpharmacological methods to relieve PD-related pain for Brazilian women. In the second step, a literature search was performed in May 2022 and updated in June 2024 to compare available evidence with the nonpharmacological methods reported by women in the first step. For this study, we followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline [24]. This study was approved by the Ethics Committee on Human Research of Universidade Federal de São Carlos (protocol number 4.063.574). All participants agreed to participate by reading the Informed Consent Form and clicking on the “I agree to participate in this study” button.

2.2. First step: participants & procedures

The study was disclosed on social media (Facebook^®, Instagram^® and WhatsApp^®) and those women willing to participate accessed the link to the Google Forms Platform, agreed to take part in the study and completed the questionnaire. We included nulliparous women, aged between 18 and 45 years and with a self-report of menstrual pain in the last 3 months. We excluded women who were pregnant, postpartum (up to 12 months) or postmenopausal; women with a secondary dysmenorrhea disease (for example, polycystic ovary syndrome, endometriosis and adenomyosis) were also excluded from the study.

Participants’ characteristics were collected using a questionnaire with sociodemographic questions (age, education and geographic region) and gynecological information about the menstrual cycle and symptoms. This questionnaire was tested in a Delphi-method with fifteen health professionals with knowledge about dysmenorrhea and 35 women – not included in this study – during the menstruation period to verify the comprehensibility and response time.

We evaluated nonpharmacological methods to relieve PD-related pain with an open-ended question, “Which of these other methods do you use to relieve pain related to dysmenorrhea?”. Participants gave a total of 21 responses of categories of nonpharmacological methods: heat therapy, tea, massage, meditation, acupuncture/traditional Chinese medicine, reiki, homeopathy, phytotherapy, resting, physical activity, hypnosis, yoga, anthroposophical medicine, warm up the body, food, TENS, bath (cold or hot), cold compress, masturbation, non-medical cannabis and others.

2.3. Second step: procedures

Two independent reviewers (CBF, PCM) searched on PubMed database for systematic reviews of treatment for PD. The search strategy [Box 1] was performed using the terms used as nonpharmacological methods by the participants in step 1. We searched for clinical trials if no systematic review was found for any method. Results and quality of evidence from studies included in systematic reviews were extracted in Microsoft Excel to discuss the current study using nonpharmacological methods to relieve PD-related pain.

Box 1. PubMed search strategy for non-pharmacological methods to relieve PD-related pain.

(massage[Title/Abstract]) OR (manual therapy[Title/Abstract])) OR (Meditation[Title/Abstract])) OR (Mindfulness[Title/Abstract])) OR (Acupuncture[Title/Abstract])) OR (Reiki[Title/Abstract])) OR (Homeopathy[Title/Abstract])) OR (Herbal medicine[Title/Abstract])) OR (Phytotherapy[Title/Abstract])) OR (rest[Title/Abstract])) OR (Physical Activity[Title/Abstract])) OR (Exercise[Title/Abstract])) OR (Yoga[Title/Abstract])) OR (Hypnosis[Title/Abstract])) OR (Anthroposophic Medicine[Title/Abstract])) OR (Warm-up[Title/Abstract])) OR (Food[Title/Abstract])) OR (Diet[Title/Abstract])) OR (Nutrition[Title/Abstract])) OR (TENS[Title/Abstract])) OR (Transcutaneous electrical nerve stimulation[Title/Abstract])) OR (Bath[Title/Abstract])) OR (Compress[Title/Abstract])) OR (Cryotherapy[Title/Abstract])) OR (Cannabis[Title/Abstract])) AND ((Primary Dysmenorrhea[Title/Abstract]) OR (Menstrual Pain[Title/Abstract]))

PD: Primary dysmenorrhea; TENS: Transcutaneous Electrical Nerve Stimulation.

2.4. Data analysis

The collected data was exported from Google Docs to an Excel spreadsheet. The analysis was performed using the SPSS Software, version 21.0. Categorical data were described by frequency and percentage.

3. Results

A total of 9144 (25.1 ± 6.3 years) women with PD responded to the questionnaire. Most participants had over 11 years of study (87.7%), were from the southeastern region of Brazil (38.4%) and used medication to relieve PD-related pain (76.3%). Of those women, 65.2% also used one or more nonpharmacological interventions for PD-related pain. Table 1 shows the sociodemographic and clinical characteristics of participants.

Table 1.

Sociodemographic and clinical characteristics of the participants.

Characteristics	n (%)
Age group (n = 9130)
18–24 years	5452 (59.6)
25–39 years	3292 (36.0)
40–54 years	386 (4.2)
Education (n = 9136)
≤8 years	30 (0.3)
9–11 years	1084 (11.8)
≥12 years	8022 (87.7)
Brazilian geographic region (n = 7308)
Southeast	3513 (38.4)
South	1524 (16.6)
Northeast	1376 (15.0)
Midwest	540 (5.9)
North	355 (3.8)
Menarche age (n = 9030)
≤10 years	1109 (12.1)
11–12 years	5084 (55.5)
13–14 years	2512 (27.4)
≥15 years	325 (3.5)
Duration of menstrual period (n = 8990)
Irregular period	1583 (17.3)
<28 days	1493 (16.3)
28–29 days	4093 (44.7)
30–31 days	1339 (14.6)
≥32 days	527 (5.7)
Use of medication for menstrual pain (n = 9118)
Yes	6730 (73.6)
No	2384 (26.1)
Pain relief after use of medication (n = 6903)
Complete pain relief	1232 (13.4)
High pain improvement	3465 (37.8)
Light pain improvement	2111 (23.0)
Not changes	95 (1.0)
Use of non-pharmacological methods for menstrual pain (n = 9144)
Yes	5695 (65.2)
No	3449 (37.7)

Supplemental Table S1 shows the nonpharmacological methods used to relieve dysmenorrhea pain by the participants. The most preferred pain relief methods were heat therapy (61.5%), tea (42.4%), massage (30.9%), meditation (5.7%), acupuncture or traditional Chinese medicine (5.0%), reiki (2.3%), homeopathy (2.1%), phytotherapy (1.6%), physical activity (0.7%), yoga (0.2%), anthroposophical medicine (0.2%), food (0.1%), TENS (0.1%), cold compress (0.1%) and cannabis (0.08%). Rest, hypnosis, warming, bath and masturbation methods was also used to relieve dysmenorrhea pain by the participants, but no evidence was found to evaluate the effects of these methods on the pain intensity of women with PD. On the ‘others’ category, we included nonpharmacological methods with less than eight responses each: beverage (cold or hot), crystals, object in the belly region, prayer, pompoarism (strengthening exercises for the pelvic floor muscles) and pressure over the pain site. Supplemental Table S1 also summarizes the available evidence for each of the reported nonpharmacological methods used by the participants.

4. Discussion

The results of our study show that, to optimize the management of menstrual pain, most women use pharmacological methods. Although the goal of pharmacological treatment is to provide adequate relief of pain, only 13.4% women with PD achieved complete relief of pain with pharmacological methods, leading women to seek for alternative methods to relieve their menstrual pain.

Heat therapy was the most used strategy to relieve PD-related pain in the present study. According to Jo et al. [14], heat therapy increases blood flow and promotes relaxation of the uterine musculature. This method can be used in many ways, such as hot water bags, towels or bottles. Studies cite that application of heat to the lower abdomen was effective for relief of menstrual cramps [25,26]. Compared with pharmacological methods, heat therapy had similar efficacy than ibuprofen, and was more effective than acetaminophen [25,26] in relieving menstrual pain. Heat therapy is a cheap easy-to-access method with very few contraindications for its use, which turns this method an interesting alternative to be used.

Rose tea can also be considered an alternative method for PD relief, with evidence of symptom improvement 1 month after starting treatment. The study by Tseng et al. [27] randomized adolescents with PD into a control group and an intervention group. Participants were instructed to drink two cups of rose tea a day. In this study, rose tea was used one week before the menstrual period until the fifth menstrual day. However, the mechanism behind rose tea's effectiveness for dysmenorrhea is still unclear. There are theories about improving blood circulation in the uterus, but more studies are still needed to clarify its effect [27].

Unlike conventional massage, rhythmic massage has a softer touch and can act as a body therapy in which some patients report feeling emotional relief through gentle touch [28]. In the rhythmic massage, the applied movements had varied speed and depth, several sliding and kneading maneuvers with circular movements were applied [28]. Vagedes et al. [29] showed that rhythmic massage significantly improves menstrual pain in 12 sessions, once a week, lasting 30 to 45 min and for 3 months. It is possible that rhythmic massage has effects on tissues and muscles, affecting the autonomic nervous system [30], and leading to a more relaxed state, which would contribute to the pain relief perceived.

Although massage has positive results, there is still limited knowledge about its effects on PD [29]. Anthroposophical medicine also consists of rhythmic massage. However, the anthroposophical approach adds a holistic element, with the search for self-healing through individual and mental aspects. One study demonstrated a significant reduction in pain intensity after 12 weeks of therapy, improvement in quality of life and reduction in analgesic consumption in women with dysmenorrhea. Despite this, the study had some limitations, such as the low number of participants and lack of details of how anthroposophical medicine was used [29].

No studies were found that exclusively evaluated the practice of meditation on pain intensity of women with PD, but we found the use of yoga Nidra. This type of yoga is a specific set of steps aimed at promoting a deep state of relaxation, bringing awareness of different parts of the body, breathing and sensations and feelings [31]. In a study [32], participants with PD performed 1-h sessions, once a week, for 12 weeks, with the final 30 min of the session with yoga Nidra. After treatment, menstrual pain intensity showed significant improvement compared with the control group [32]. Although the study had some limitations, such as the lack of treatment for the control group [32], yoga exercises also showed a reduction in the intensity of menstrual pain in women with PD in a systematic review with meta-analysis [33]. However, all included studies showed heterogeneity between protocols and two studies were not double-blind to minimize the risk of bias [33].

In a systematic review with meta-analysis, acupuncture was effective and safe for the improvement of PD pain [34]. However, acupuncture has a moderate degree of evidence [35] as most studies on this technique for PD pain relief have a low or uncertain risk of bias due to the difficulty of blinding the volunteers, evaluators and applicators of the technique. In studies that assess pain, blinding participants is critical to reduce the risk of bias. In addition, there is a lack of homogeneity in the studies that use acupuncture as the methods vary in terms of frequency, session time, selection of acupuncture points and comparison groups. These variations may influence the results of future clinical trials [34].

In a review, Reiki could be considered a safe non-pharmacologic method in management of chronic health conditions [36]. In adolescents with PD, Reiki showed no statistically significant difference when compared with placebo group in VAS score medians after the application. More studies about reiki are needed to check for its effectiveness on PD-related pain [23]. Regarding homeopathy, there are controversies about the use of this method to relieve PD-related pain. The inconsistencies of the results of these studies may be related to the small sample sizes [37].

In a systematic review that included 9 studies with 647 women with PD, the use of medicinal herbs such as cinnamon, fennel and ginger effectively reduced the intensity of PD pain [38]. Compared with the other herbs, cinnamon has been shown to shorten the duration of menstrual pain as the extract of this plant has an antispasmodic effect that inhibits uterine contractility [39]. Fennel also has antispasmodic actions and can be compared with mefenamic acid in relieving PD pain [40,41]. Ginger contains a variety of substances reported to have analgesic and anti-inflammatory effects, such as gingerols, free fatty acids, carbohydrates and proteins [42]. So, like fennel, ginger has also been shown to be as effective as mefenamic acid for menstrual pain relief [43]. However, further studies with a larger sample sizes are needed to confirm these results [38].

Physical activity is a nonpharmacological method which can be effective to treat PD [44], as it has shown its effects on promoting analgesia to several chronic pain conditions [45]. However, only 1.1% of participants in this current study perform exercises to relieve menstrual cramps. Matthewman et al. reported reduced menstrual pain intensity and duration for exercise versus any non-exercise comparator [44]. Physical activity has several benefits without presenting risks, and is one option to reduce PD-related pain [46,47].

TENS also is a nonpharmacological method well-tolerated which has evidence to treat PD [17,48]. The effect of TENS is to increase the threshold for pain signals from uterine hypoxia and hypercontractility, resulting in lower perception of painful uterine signals. TENS is also a non-pharmacologic method that can be used with other alternatives including heat therapy [49]. High-frequency TENS is more effective in reducing pain than placebo TENS [50]. Even though the evidence points to several benefits of TENS use for this purpose, the home-based TENS use is not very common in Brazil as it is in other countries such as the USA. This may explain why, despite the evidence, not many women have access to this resource.

Cold compress can be considered a low-cost resource for reducing pain caused by dysmenorrhea, as the cooling leads to a decrease in the nerve conduction velocity, which would result in analgesia. Regarding this method, a study compared the use of cold compresses with the use of hot compresses and observed a reduction in pain immediately after application and 30 min after the end of the intervention in both groups. However, the group that used the cold compress showed greater reduction in pain when compared with the group that used the hot compress [42]. Another study that compared the use of cold compresses with performing abdominal stretching exercises found a significant reduction in pain in both interventions, but exercise was much more effective in reducing menstrual pain when compared with cold compresses [43]. However, despite the possible positive results that cryotherapy may have on PD-related pain, several women prefer hot packs due to cold intolerance.

No studies were found on the use of cannabis to improve PD pain intensity. However, Armour et al. [51] who analyzed pain relief strategies in 484 women with endometriosis and observed that 13% of women used cannabis as a method of pain relief. In the present study, only 0.1% reported its use for this purpose. The analgesic and anti-inflammatory pharmacological properties of cannabidiol are known, as well as the reduction in the consumption of pharmacological drugs used to control pain. Of all the methods presented in the study by Armour et al. [51], cannabis was the most effective in relieving pain. However, there are many barriers to its use, such as stigma and prohibition in some countries, even for medical cannabis [52].

A systematic review found a relationship between nutritional factors and PD. It is possible that a good diet with consumption of foods rich in vitamins and minerals, such as fruits and vegetables, is associated with a lower occurrence of pain during menstruation. On the other hand, restrictive diets for weight loss or skipping a meal negatively influence PD. Due to the lack of conclusive results in the systematic review, further studies are needed to assess the effects of food on PD-related pain relief [53].

For the Rest, Hypnosis, Warming, Bath and Masturbation methods, we did not find evidence that evaluated the effects of these methods on the pain intensity of women with PD. These are specific methods and women from other countries may choose to use methods other than those mentioned in the present study. This also depends on cultural aspects of each population and can be influenced by social, cultural, and economic factors for the management of PD-related pain [51]. In addition, in some countries, menstruation is still treated as a taboo and the population most affected by this aspect are adolescents. During menstruation, many students miss classes due to pain and fear of possible leakage [54]. The number of adolescents or young women who seek help or professional guidance is also very low, which makes the practice of self-medication even more common [54,55]. It is also interesting to mention that, in the study by Ortiz et al. [55], which evaluated 1152 students, it was observed that only 28% had a medical consultation to seek information or treatment about dysmenorrhea. Thus, adolescents tend to seek help or guidance first from their mother and then from their peers [54].

4.1. Strengths & limitations

This is the first study that performed a great literature review based on Brazilian women's preferences on nonpharmacological interventions for PD-related pain. The large sample size and the possibility that participants could indicate more than one method enlarged the number of possible interventions, which in turn lead to a more complete literature research. The results of this study are useful to know self-care strategies for managing PD and trace a profile for management of PD-related pain by Brazilian women. Despite the large sample size, an online survey limits women of low socioeconomic or educational status to access digital platforms. Furthermore, the information about PD was obtained by self-report, so there is a risk of bias on PD diagnosis. Given Brazil's continental size, these findings may not be generalizable to the Brazilian population with regional cultural differences.

5. Conclusion

Several nonpharmacological methods are used by women to relieve PD-related pain. Among them, heat therapy was the method most used by the women in this study. Although there are studies for most methods, studies with high methodological quality are still needed to prove the effectiveness of heat therapy, tea, massage, meditation, acupuncture or Traditional Chinese Medicine, Reiki, homeopathy, herbal medicine, yoga, anthroposophical medicine, food and others for the relief of PD-related pain.

Funding Statement

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001 and by São Paulo Research Foundation (FAPESP), grants 2019/14672-7 (JCR) and 2021/11871-9 (GTA).

Supplemental material

Supplemental data for this article can be accessed at https://doi.org/10.1080/17581869.2024.2376519

Author contributions

JC Rodrigues: Acquisition, analysis and data interpretation, manuscript draft and revision, final approval of the present manuscript version, agreement to be accountable for all aspects of the present work.

GT De Arruda: Acquisition, analysis and data interpretation, manuscript draft and revision, final approval of the present manuscript version, agreement to be accountable for all aspects of the present work.

PC de Moraes: Acquisition, analysis and data interpretation, manuscript draft and revision, final approval of the present manuscript version, agreement to be accountable for all aspects of the present work.

CB Firão: Acquisition, analysis and data interpretation, manuscript draft and revision, final approval of the present manuscript version, agreement to be accountable for all aspects of the present work.

MA Avila: Conception, design, acquisition, analysis and data interpretation, manuscript draft and revision, final approval of the present manuscript version, agreement to be accountable for all aspects of the present work.

P Driusso: Conception, design, acquisition, analysis and data interpretation, manuscript draft and revision, final approval of the present manuscript version, agreement to be accountable for all aspects of the present work.

Financial disclosure

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001 and by São Paulo Research Foundation (FAPESP), grants 2019/14672-7 (JCR) and 2021/11871-9 (GTA). The funders had no role in study design, data collection, analysis, decision to publish, or preparation of the manuscript.

Ethical conduct of research

The authors state that they have obtained appropriate institutional review board approval (protocol number 4.063.574, Ethics Committee of Universidade Federal de São Carlos), following the principles outlined in the Declaration of Helsinki. In addition, for investigations involving human subjects, informed consent has been obtained from the participants involved.

Data availability statement

This study reports original cross-sectional trial, and data will be made available by the authors at request.