Ending the neglect of menstrual pain in adolescents is the key to improving outcomes for people with persistent pelvic pain

Although menstruation is a normal physiological event, it causes significant problems for many people. Period pain differs considerably between individuals, and concerns are often dismissed or ignored without acknowledging its impact or the possibility of long term risks. In this issue of the MJA, Cameron and colleagues1 report on the frequency of dysmenorrhoea, severe pain, and missed activities in a cohort of Australian adolescents. The authors discuss the importance of early identification and treatment of dysmenorrhoea for improving quality of life and minimising absence from school and work.

It has been reported that 90% of adolescents who menstruate experience period pain, and that for 21% this pain is severe.2,3 Their quality of life and participation in school, sport, and social activities are all affected. Cameron and colleagues1 quantified these effects using data collected from 1600 adolescent participants in the Longitudinal Study of Australian Children. Schools rarely specifically register recurrent monthly absenteeism, presenteeism, or attendance at the sick bay. Cameron and colleagues found that adolescents with dysmenorrhoea were up to five times as likely to miss school and three times as likely to miss sporting or exercise for reasons related to their periods as female participants without dysmenorrhoea. Highlighting the high prevalence of dysmenorrhoea is needed to overcome the stigma attached to female pain, indicated by the many adolescents and young adults who report that their period pain is regarded as normal or dismissed by health care providers.3

Like other chronic pain conditions, persistent pelvic pain, including dysmenorrhoea, results from a complex interplay of social, psychological, and biological factors.4 Endometrial shedding is an inflammatory process that involves substances that activate nociceptors.5 Persistent pelvic pain can have a negative effect on mood and mental health, and stressful life events conversely influence pain perception and health risk behaviours.6,7,8 However, these factors and their effects on pain are seldom explored by clinicians and researchers, nor do we routinely explore diet, exercise habits, sleep, or environmental factors in people with period pain.

An emphasis on diagnosis can delay prompt management of pain and symptoms. Further, delaying the treatment of recurrent period pain may lead to central sensitisation, a state in which the central nervous system has an abnormal or amplified response to sensory input.9 The analogy with headache is clear: lesions are not sought before someone with headache is receives treatment. While recognising that a cure for headache is often not possible, we nevertheless act to reduce pain and suffering.

Continuous use of the combined oral contraceptive pill to suppress menses (“skipping periods”) is a simple method for managing dysmenorrhoea.10,11 It mimics the stable hormonal states of pregnancy and breastfeeding, but is underused by primary care clinicians. Cameron and colleagues1 found no evidence that the oral contraceptive pill reduced the severity of dysmenorrhoea, but they noted that the Longitudinal Study of Australian Children collected data on oral contraceptive use for birth control purposes by sexually active adolescents, but not its use for pain management. Further, whether the oral contraceptive pill was used cyclically or continuously was not asked.

Persistent pelvic pain is often neglected as the “pain problem without a home”.12 Media discussion of women's health and pain is focused on endometriosis, and federal and state government interest and funding has increased dramatically since publication of the National Action Plan for Endometriosis.13 However, the broader question of persistent pelvic pain receives less attention, despite the fact that it is a greater public health problem: an estimated one in ten women have endometriosis, whereas persistent pelvic pain is reported by about 25% of women.14 Indeed, if we restrict our attention to those with endometriosis, we fail to adequately recognise the pain of the 50% of women with period pain for whom no evidence of endometriosis is identified by laparoscopic investigation.15 It also disregards the fact that 20–45% of women without specific symptoms have some degree of endometriosis.16

The study by Cameron and colleagues1 makes clear that period and pelvic pain must be recognised and evidence‐based interventions provided to adolescents with persistent dysmenorrhoea if we are to improve their quality of life as adults. Understanding the trajectories of menstrual health throughout life is critical for developing effective public health interventions for optimising women's health.