For a paper published in Pain Medicine, my colleagues and I developed a mind-body intervention, based on principles of cognitive-behavioral therapy (CBT), for young women with moderate-to-severe primary dysmenorrhea (PD; menstrual pain without an identified medical cause). As the most common gynecological complaint and leading cause of school and work absences in reproductive-age girls and women, menstrual pain is an important public health issue. First-line treatment approaches for PD include NSAIDs and hormonal contraceptives. However, these approaches have limitations. A recent study found as many as 18% of women with menstrual pain did not experience sufficient relief with NSAIDs. Additionally, NSAIDs and hormonal contraceptives come with the risk of significant side effects and may be intolerable for many. Because CBT is a widely used, evidence-based approach for treating chronic pain, we believe that patients with menstrual pain may benefit from learning similar skills. We utilized CBT principles in the development of a five-session, group treatment for menstrual pain.
Investigating the Feasibility & Acceptance of CBT
The goals of this study were to determine whether the intervention was both feasible and acceptable to girls with menstrual pain and to evaluate the efficacy of the intervention on menstrual pain and other psychological variables. Feasibility was defined as at least 75% of participants attending at least three of five sessions, and acceptability was measured by a questionnaire administered at the end of the first session following an explanation of the rationale for the study. Efficacy was assessed by comparing pre-treatment self-reported menstrual pain ratings on a 0-10 scale to ratings made at post-treatment and follow-up. Additional self-report measures of somatization, depression, anxiety, and pain catastrophizing were also included at all assessments. All enrollees received the treatment in one of four group cohorts during the approximately 1-year study.
CBT Is Viable & Effective
The group intervention was both feasible and acceptable to participants. Most importantly, participants reported significantly lower menstrual pain ratings at 3- and 12-month follow-up compared with pre-treatment, despite no changes in self-reported medication use. Only pain catastrophizing significantly improved over follow-up, while somatization, depression, and anxiety remained unchanged from pre-treatment. These findings suggest that a cognitive-behavioral approach to pain management is a viable and effective non-drug alternative to traditional pharmaceutical treatments for girls and women with menstrual pain. The improvement in pain catastrophizing suggests that this construct may be a potential mechanism of pain reduction. Because pain catastrophizing is often associated with chronic pain conditions and is a cognitive risk factor for future pain problems, teaching participants skills to modify catastrophic thoughts about pain may be a critical target of treatment.
Physicians, including pain specialists, should specifically ask patients about their experiences with menstrual pain to assess the degree to which it is problematic. It may be worth considering referring patients for CBT for menstrual pain (or even CBT for non-specific pain), particularly for those who do not tolerate or find sufficient relief from pharmaceutical approaches. Most importantly, it is crucial to have an open dialogue with patients about menstrual pain to help find effective treatment approaches and challenge the antiquated belief that girls and women just have to “live with it.”
Continuing Menstrual Pain Research
While menstrual pain research is of great importance, there remains much to learn. Standard treatment approaches may work for the majority of girls and women, but a significant number will remain impaired and in pain. Future research should continue to evaluate non-drug treatments for PD in randomized controlled trials and improve the rigor and quality of trials testing alternative therapies (eg, acupuncture, herbs, supplements). Additionally, exploring mechanisms of symptom improvement may lead to a better understanding of the various factors contributing to girls’ and women’s experiences of menstrual pain, so that personalized medicine approaches can be developed. When we are able to move away from a “one size fits all approach,” we will be able to reduce suffering and improve the lives of patients with this common and disabling pain condition.