I feel grateful every day just to be above ground and be reasonably physically and mentally healthy. I have a great family. I have rebuilt bridges. I have strengthened old relationships and built new ones. I am attempting to take even better care of myself and make myself a priority. I have made myself a mission of positivity that I attempt to fulfill at least once a day, no matter how small the triumph.
Wow! It seems like a lot of work doesn’t it? Frankly, it is, but so Worth IT! There are days when I get tired and don’t feel like putting in an effort. That’s when I have to stop and remember where I was even a year or two ago: somewhat depressed, frustrated, lonely despite people surrounding me, full of cancer trying to take my life, not able to work like I wanted to help support my family, mentally swirling with guilt and self-induced feelings of failure.
I have come a long way since then, but in order to keep my current path intact, I need to keep in mind where I came from and the lessons it taught me. I learned that no one can fully heal all of me but me. No one can really help assure my future without my help and driving force. I need to be mindful and grateful of the “good days” even if thrybaten’t as frequent as I would like. I learned that there isn’t always a tommorow, so I better make damn sure that today is the best I can muster. Nobody can do that for me. I’ve got to care enough to do it myself.
The last couple of years have been really hard. My children were sick. We have all been “living” with a pandemic raging around us. I battled cancer. My husband tried to die from a heart attack. The list goes on. I know I know. You all know this already. Despite all this, I have continued to make it my mission to be a beacon of positivity unlike the planet has ever known. I am constantly in search of the bright side or the retrieval of the positive, no matter how small a portion it is. I get signs from the universe all the time that this is what I am supposed to do. I have had complete strangers reach out to me for help and guidance, which I love and I am happy to give. That is truly me in my element: helping people. I wouldn’t trade it for the world.
So, I have spent all this time being tough and positive…still am. However, I find myself struggling a bit lately. It’s all fun and games when everything is going my way, so to speak. But, I have noticed sometimes, that when something doesn’t, it kind of crushes me for a hot minute before I can get a hold of myself. I start resenting and complaining, or freaking out all together. This kind of reaction is somewhat foreign to me and I find myself saying “Whoa Katz. Get a grip why don’t ya? You have been through way worse shit than this for chrissake!” ” You are alive! Does anything else really matter?” Most of the time that works, but I find myself having to do it more and more often lately and that bothers me.
Part of me realizes that there is an element of PTSD circulating around my brain with my serotonin, trying to convince me that there is only a matter of time before another shoe drops. It insidiously permeates my life still, forcing unreasonable reactions and fears. It is pretty par for the course after what I have been through. I think that my goal for now is to stop trying to push it away and acknowledge it and deal with it. I think that by trying to suppress it, I am actually giving the PTSD more power than it already has. I assure you that I have been taking all the outward steps: showing up to counselling, reading about it, talking to myself like I said, nodding when my therapist explains it to me. But, I really haven’t been doing the internal work. I have been so busy pushing forward toward my happiness mission that I haven’t really allowed myself time to recover or react.
This really smacked me in the face last Friday. I went for my routine mammogram. Some of the same techs were there that were with me last year when all my cancer stuff was ramping up. I got my mammogram done and those 45 angle views really pulled at my lymphedema on the side of my neck and it started to throb and hurt. Everybody did everything right..and I should have expected this to happen and prepared, but I didn’t. Instead, I laughed it off at the moment and went upstairs to my office, only to start bawling my head off in a flood of cancer memories the moment my MA asked me if I was alright. I just couldn’t stop. One memory/flashback after another started just flooding me over and over. I actually had to leave the office and felt really guilty doing it on top of it. I knew I just couldn’t be my best self for patients though. I literally cried half the day as I reexperienced everything from the whole last year all over again. Sheesh.
My point is, that I really have missed the boat on recovery and reaction somewhat. The strategy I thought was helping me “not to wallow” was actually preventing me from processing what was going on with me. I pushed it down and just kept pushing forward instead. By not allowing myself the time to really go through things…..while I was going through things…..I didn’t really do myself any good. Sure, I got through my cancer experience and survived. That is definitely a win. But, I bottled so much stuff up that now it bubbles over when I don’t expect it. That’s no good either.
The bottom line is that I am very grateful to be a survivor and I love helping others survive whatever they are going through, life-threatening or not. But, in order to truly survive and thrive on top of that, I have to allow myself to process and react to experiences when I have them. I need to not punish myself or second guess reactions and just….have them. I have to realize that, no matter how tough I am, I am still human. I need to give myself the same consideration and time that I give to everyone else. I promise that I’ll work on it.
So, what the heck is primary dysmenorrhea? Primary dysmenorrhea is defined as significant pain during your menstrual cycle without a specific or identifiable cause. To me, this is a bit misleading because there is a cause for the pain, and we will explain that in a bit. I think it should say without a specific anatomical or additional pathologic cause outside of the normal biochemical reactions in our bodies.
Dysmenorrhea can interfere with our quality of life and our daily activities and performance. You know what I mean. We all know women who have to miss work or school because of their severe cramps, pain and bleeding. Dysmenorrhea is the most common gynecologic condition affecting women. The percent is reported anywhere from 17% to 90% depending on what you read. Sometimes the pain is minimal but sometimes it literally stops the woman from being able to function. Current statistics state that up to 15% of women that have dysmenorrhea actually miss work or school or functioning in general with regularity. Even for those women that do not miss work or school, the pain is often enough to reduce focus and productivity. In the United States, it is estimated that there are about 600 million hours of productivity lost to dysmenorrhea. This translates to about 2 billion dollars annually. I think that deserves our attention. Just keep it in mind the next time a work or school colleague has to stay home because they are in pain with their period. This stuff is real folks!
So, what causes this pain? What is primary dysmenorrhea? Primary dysmenorrhea is pain with menses that has no underlying pathology. Dysmenorrhea is called secondary if it caused by another condition like endometriosis, fibroids, pelvic inflammatory disease, or interstitial cystitis. For the purposes of this blog, we are going to focus on primary dysmenorrhea.
Primary dysmenorrhea usually starts at the onset of ovulatory menstrual cycles. Usually women do not ovulate for about 6 to 12 months after menarche( the onset of menses for the first time). Sometimes ovulation does not start for up to 2 years. The pain is usually crampy, comes and goes, and increases in intensity. It starts just before the bleeding starts and lasts up to 72 hours. There can also be nausea, bloating, diarrhea and vomiting.
Who is at risk for primary dysmenorrhea? There are multiple factors: 1) body mass index less than 20, 2) smoking, 3) longer menstrual cycles, 4) irregular or heavy flow, 5) history of sexual assault, 6) menarche younger than 12, 7) age younger than 30, and a family history of dysmenorrhea. Usually it gets better with age and after child bearing
Here is the pathophysiology of primary dysmenorrhea. The pain is probably due to the increased prostanoid secretion. So, what the heck is a prostanoid? Prostanoids are prostaglandins, thoromboxanes, and prostacyclins. And what are those things? Basically, all we need to know is that these are chemicals that cause cramps. So, the process goes something like this. When we ovulate, our progesterone stabilizes something called lysosomes, which are like storage containers full of inflammatory chemicals. At the end of the luteal phase of our cycle, our progesterone levels go down and the lysosomes break down and release something called phopholipase A2. Well this phopholipase starts the cyclooxygenase pathway, which then causes production of the prostanoids that I mentioned before. Then voila! Cramps! The main prostanoids that concern us in dysmenorrhea are the prostaglandins. They are the compounds that cause uterine contractions that restrict blood flow in the uterus. Because blood flow is restricted, there is less oxygen. Because there is less oxygen, metabolites are produced that stimulate pain receptors. In addition to that, some of the prostaglandins lower pain threshold because they actually sensitize the nerve receptors. And, if that weren’t enough, the prostaglandins are also responsible for all the gi symptoms we know and hate. There are other compunds that are involved in this process as well but since the prostaglandins are the main culprit, we are going to focus on those for the purposes of this blog.
As if the prostaglandins weren’t enough of an issue, it has also been documented that women who suffer from primary dysmenorrhea actually have an altered pain sensitivity in the first place. Altered pain perception in dysmenorrhea has been studied all the way back to the 1940s. This altered perception is part of central sensitization syndromes. These syndromes are all associated with pain hypersensitivity without documented tissue injury, inflammation or an actual nervous system lesion. This include several disorders such as low back pain, tension headaches and irritable bowel syndrome. All of these conditions lead to amplified sensory input. These result in the patient having more pain with less stimuli.
I think we have now effectively established that primary dysmenorrhea sucks. So, what can we do about it? There are multiple options. Right now we are going to focus on the non-surgical ones. The goal of each option is to interfere with the prostaglandin production, decrease muscle tone in the uterus, or inhibit pain perception with analgesia. Before we go into these options, it is important to remember that the real key to success and compliance with any regimen is SHARED DECISION MAKING between the patient and the doctor. Have the patient be an active part of deciding on treatment, after discussing side-effects, efficacy, etc and this will help greatly. If the patient is invested in the option, it is much more likely to be helpful.
The first category of options is hormonal. Combined( both estrogen and progesterone) birth control pills are number one in this category. They are effective in about 70-80% of patients. They inhibit ovulation and prevent multiplying of endometrial cells, which decreases prostaglandins, progesterone and vasopressin. This applies to the pill, ring and the patch. Extended use( skipping the placebos) seems to be the most affective. There is a possible risk of blood clots with this method, although this risk is very small in low risk, non-smoking patients.
Progesterone only contraception like Depo Provera or the Mirena Iud. They also inhibit ovulation and eliminate menstrual cycles. Sometimes these methods can cause irregular bleeding. Since this bleeding is still anovulatory, it is not associated with dysmenorrhea. The risk of blood clots is lower with this method. Sometimes there is weight gain reported, but this can usually be avoided with proper nutrition monitoring. Depo Provera itself has been associated with decreased bone density, which seems to be completely reversible after stopping it. While this sounds concerning, it has not been deemed enough of a reason to discourage patient from using it.
There are non hormonal options as well for primary dysmenorrhea. NSAIDS( non steroidal anti inflammatory drugs) are a first line treatment and are effective for the vast majority of patients. They work by inhibiting the cyclooxygenase enzyme we were talking about earlier, which then suppresses prostaglandin production. It’s like stopping the cramps before they can even be created! They also have a direct analgesic effect at the central nervous system level. There is not a lot of evidence to say that one is better than the others. Usually medications like Motrin, ibuprofen, Alleve, and Anaprox are among the first choice options. More expensive medications like Celebrex are reserved for second options. Ideally, these are taken as needed only. One suggested regimen is to start the medication 2 days prior to the onset of menses and continue for the first 72 hours of the menstrua cycle. The key is not to wait until the pain has already gotten started and try to catch up to it, but to act proactively.
Another possible non hormonal option is Magnesium. Magnesium appears to reduce the amount of prostaglandins in menstrual fluid. It is also a muscle relaxant and causes blood vessel dilation. This sounds logical but there is not a lot of data just yet.
Calcium channel blockers like Nifedipine can cause muscle relaxation and decrease prostaglandin production and possibly reduce uterine contractions. More data is needed here as well. I personally would feel hesitant to prescribe a blood pressure medicine for cramping.
Vitamin E, in some small studies has been shown to reduce dysmenorrhea. It has been shown to increase oxygen delivery to uterine cells, decrease prostaglandins production, and inhibit cyclooxygenase. This should result in reduction in pain and cramping. Unfortunately, so far the majority of this data is in the mice population.
Ginger also inhibits cyclooxygenase activity and decreases menstrual pain. The added bonus to ginger is that it is also an antiemetic( anti nausea) so it may help with the gi effects as well. Thus far the doses studied have ranged from 750 to 2000 mg a day with the same efficacy as NSAIDS. Go Ginger!
There are some other proposed non hormonal options for dysmenorrhea as well. All of these require further study but they are interesting prospects. The first is transcutaneous electrical nerve stimulation(TENS). This is hypothesized to work in three ways. 1) it sends electrical impulses to the nerve root, elevates the pain threshold, and the pain sensation is not felt. 2) It stimulates the release of endorphins which reduce pain. 3) It increases dilation of blood vessels in the uterine muscle and reduces hypoxia which also reduces pain.
Acupuncture( needles) and acupressure( firm pressure) stimulate designated locations to relieve pain. There are specific sites on the body on the auricle of the ear, the medial calf muscle, and near the medial malleolus of the ankle that have been identified as possible beneficial treatment areas for dysmenorrhea. There are no specific regimens that have been backed up by studies to recommend with confidence at this point. So far, the range varies from a once a menstrual cycle treatment to daily for 7 days during the menstrual cycle. More to follow later here.
Let’s not forget the good old heating pad applied directly to the suprapubic region. Local heat improves tissue oxygenation, dilutes the levels of prostaglandins and increases blood flow. All of these effects can lead to decreased pain as well. A lot more evidence is needed, but it makes sense.
Apparently exercise and yoga play a role here as well by increasing endorphin release, lowering stress and anxiety, and increasing blood flow. I am here to tell you that as good as that sounds, the thought of jumping on the exercise bike or doing some aerobics in the middle of a crazy period sounds a little daunting to me. I get that there is some moderate quality evidence that this helps over the long term, plus the other health benefits of exercise, but I still think I would have a hard time putting it into practice. I am going to opt to continue to follow how that plays out.
There are a number of herbal and complimentary remedies that have been suggested as well. Rose tea, fish oil, krill oil, sweet fennel seed, low fat vegetarian diet and decreased dairy intake. So far, there is no high quality evidence for any specific dietary supplement. Still, the side effects are minimal so they may be worth trying.
The bottom line is, dysmenorrhea is a real thing that affects millions of women and costs billions of dollars in lost productivity. Beyond that, it can really affect quality of life and daily function both mentally and physically. It deserves our careful attention with a thoughtful plan tailored to the patient’s specific needs and risk factors.
I had no idea just how much guilt comes with chronic disease. This may not be true for everyone, but it is definitely true for me. I just can’t seem to balance the whole “just concentrate on getting better” side of me with the side that is worried about everybody else, my business, other people’s schedules, my patients, and just generally letting people down with all of my limitations. Sometimes I think it takes me more time and energy to process all the guilt and worrying than it would just to be sick. I get it. That sounds ridiculous, but it is the truth for me. It is just a tough balance for me.
You know what I think would be a good idea? We should sit patient’s down, after they have had a chance to digest the news of their new diagnosis, and hook them up with a mentor or counsellor to sit them down and help them start to wade through and plan for all the other complications and stuff that comes with any chronic illness. It might make it less overwhelming than just having everything smack you in the face as it comes, while you are busy trying to “just concentrate on getting better.” I get that some cancer patients have patient navigators, but the main role of these individuals is to keep the patient on track in terms of appointments, tests, and treatments. This is useful to be sure, but the real trick is managing all the outside life stuff that is on top of the tests, etc. I say we start offering life navigators too because, in most cases, the damage that is done with all the life fails, failed relationships, missed work, and unpaid bills far exceeds whatever damage the cancer inflicted.
OK, now that I have your attention. What the hell is slogging? The word slog is a verb meaning to work hard over a period of time. It also means to hit forcefully and typically wildly, especially in boxing. For the purposes of this blog, we are going to stick with the first definition. Personally, I also find the word imbued with a trace of difficulty or struggle as well, as if the work being done is innately more challenging than usual and that more effort is required. I also think that it implies a certain lack of joy in the task to be completed. Even the word itself has a heaviness to it, at least mentally and emotionally. I don’t find myself using it unless I am referring to a state in which I am struggling to get the basic requirements completed day to day. One final potentially positive component of the word slog is the implication of a necessary process, like slogging to get somewhere.
I think that this word perfectly describes the world at large today with all of the changes in restrictions, work environments, and day to day life. The level of unpredictability and the lack of control has brought out the worst in some and brought out the best and most altruistic in others. I even find myself struggling to get up, get dressed, and get psyched up to face the day, not knowing if I am going to be at the hospital for 25 hours or 4 hours, or if anyone is even going to show up. It is a conscious, sometimes burdensome mental effort to go to work and strive each day. This is by no means a reflection of how much I love my job. I LOVE MY JOB. I always will. I LOVE MY PATIENTS. I am grateful to even have a job. I have always embraced the role of the uplifting, caring, compassionate superhero to women. It’s my favorite thing in the whole world to help save someones life, make it better or bring new life into the world. It’s just that the positive level of variety that first attracted me is not the same. The variety I now encounter has more to do wondering who if anyone is going to show up on a given day. On top of that, my hands are tied with regard to what services I am ALLOWED to provide for patients. Some of the best aspects of my job in terms of preventative care and early diagnosis are severely limited right now because I do not have a crystal ball to predict what a patient needs without a procedure, exam or surgery. It is very frustrating to go to work every day knowing that I am not able to give patients everything they need. I worry every day about what I am potentially missing because of these limitations. Last, but not least, let’s not forget the mental burden of economic insecurity. There is no unemployment for bosses and business owners. There are some loans with a mountain of paperwork and extensive stipulations, but even those have no guarantee of ensuring the survival of your business of 20+ years. There you go, slogging at it’s best. I am getting through every day and working hard, but it is a struggle and the joy factor is more limited, not because I don’t love what I do, but because I am not allowed to completely do what I do. And yet, I keep slogging away in order to be able to eventually get back to running my practice as I see fit.
I get the same kind of feeling at home too. Most days, I manage to get myself motivated to at least attempt a project that has been hanging over my head( sometimes for years) and then other times I feel like I would rather scream than clean one more thing and I just don’t feel like doing anything. The difficulty rating of just going to the store has now been elevated to a ten out of ten between masking, gloving, making lists and figuring out a strategy to get the most with the least trips, knowing that I might not leave the house for an errand for another few weeks at best. Then there is the daily feeling hanging over your head that leaves you wondering if this truly is the new normal? On top of that is the constant barrage of input from all directions of conspiracy and control theories that only serve to add to the overall panic and disrupt any logical progression of thought. You cannot get away from them. You turn off the news and they appear on you social media instead. You turn away from social media and just listening to music and your broadcast is interrupted with another update. Whew! It’s a bit much. Again, slogging at it’s best. But, right now, there is no other choice. I have to keep slogging through on my way back to the way things used to be. It’s part of the process right now. It’s part of the process of doing my part in order to flatten the pandemic curve. If I quit or rebel, I am not making anything go any faster. Maybe if we all slog together, we may just get to the end of this thing a little faster. Let me leave you with this quote from Walter Annenberg, philanthropist, businessman, and ambassador:
” I want to remind you that success in life is based on hard slogging. There will be periods when discouragement is great and upsetting, and the antidote for this is calmness and fortitude and a modest yet firm belief in your competence. Be sure that your priorities are in order so that you can proceed in a logical manner, and be ever mindful that nothing will take the place of persistence.”