A Functional Medicine Dysmenorrhea Protocol: Comprehensive Testing, Nutrition, and Supplements

Dysmenorrhea, or painful menstruation, affects up to 91% of menstruating individuals, making it one of the most common gynecological concerns. Perhaps because of its frequency, dysmenorrhea has been normalized in society to the extent that suffering is often seen as an inevitable part of the reproductive years. This normalization minimizes the severity of the condition and makes it less likely for affected individuals to seek out help. It's time to recognize dysmenorrhea for what it is: a medical condition that warrants medical attention.

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What Is Dysmenorrhea?

Menstrual pain or cramping is called dysmenorrhea. There are two types of dysmenorrhea: primary and secondary.

Primary Dysmenorrhea

Primary dysmenorrhea refers to common menstrual cramps that are not associated with any other medical condition. The initial onset of primary dysmenorrhea typically occurs during adolescence, and it often gets less painful with age. These cramps usually start on the day your period begins or shortly before and can persist for up to three days.

Secondary Dysmenorrhea

Less common than primary dysmenorrhea, secondary dysmenorrhea is menstrual pain that is linked to an underlying reproductive system disorder. Secondary dysmenorrhea can occur anytime after menarche (the first onset of menstruation). The pain associated with secondary dysmenorrhea often begins earlier in the menstrual cycle and can be more intense and persistent than typical menstrual cramps.

Dysmenorrhea Signs & Symptoms

Dysmenorrhea is described as lower abdominal pain and cramping that occurs during menstruation. Sometimes, the pain radiates to the thighs or lower spine. Some patients may also report that the pain is accompanied by other symptoms, such as:

• Nausea and vomiting
• Headache
• Diarrhea
• Fatigue
• Sleep disturbances
• Dizziness

Root Causes of Dysmenorrhea

Primary dysmenorrhea is caused by natural chemicals called prostaglandins. Prostaglandins are lipid molecules with hormone-like actions that, among other actions, are responsible for uterine muscle and vascular contractions during menstruation. The intensity of menstrual cramps is proportionate to the number of prostaglandins released by the uterine lining. (18, 28) 

Various factors are associated with an increased risk of primary dysmenorrhea, including high stress, smoking, heavy menstrual bleeding (menorrhagia), and premenstrual syndrome (PMS).

Dietary patterns that include skipping breakfast and high consumption of salt snacks, fruit juices, refined sugars, unhealthy fats, and ultra-processed foods are also associated with an increased risk of moderate-to-severe dysmenorrhea. These patterns are typical of the standard American diet, which also increases the risk of nutrient deficiencies (such as vitamins B1, D, and E, magnesium, zinc, and omega-3 fatty acids) that may play a role in the development and severity of menstrual cramping. (27)

There are many potential causes of secondary dysmenorrhea, including endometriosis, fibroids, adenomyosis, endometrial polyps, interstitial cystitis, pelvic inflammatory disease (PID), and the use of a contraceptive intrauterine device (IUD) (28). 

Estrogen dominance, a hormonal state in which estrogen levels are elevated in relation to progesterone, can underlie both types of dysmenorrhea (19, 42).  

How to Diagnose Dysmenorrhea

Patients with menstrual cramping are encouraged to speak with a doctor, who will thoroughly evaluate their symptoms and medical history to make an accurate diagnosis.  

Step 1: Clinical Diagnosis

Primary dysmenorrhea is a clinical diagnosis, meaning that a diagnosis can be made based on clinical findings without ordering specific tests. If your doctor suspects primary dysmenorrhea, a detailed history and physical examination may be the extent of their evaluation process. 

Step 2: Labs to Diagnose Secondary Dysmenorrhea

Abnormal uterine bleeding, painful intercourse, noncyclic pain, and a family history of endometriosis are findings that suggest secondary dysmenorrhea (30). 

To rule out organic causes of secondary dysmenorrhea, the following labs are recommended:

• Complete blood count with differential (CBC w/ Diff) to look for signs of infection
• Gonococcal and chlamydial cultures to rule out sexually transmitted infections (STIs) and PID
• Quantitative human chorionic gonadotropin (hCG) to rule out ectopic pregnancy
• Erythrocyte sedimentation rate (ESR) to screen for active inflammation
• Urinalysis to rule out urinary tract infection

Abdominal and transvaginal ultrasound should also be performed to screen for pelvic pathology, including endometriosis, ectopic pregnancy, ovarian cysts, fibroids, other pelvic masses, and malpositioned IUDs.

Step 3: Digging Deeper with Testing to Understand the Root Cause of Dysmenorrhea

The following labs can help pinpoint the root causes of dysmenorrhea: 

Comprehensive Hormonal Assessment

Healthy hormonal patterns typically involve a balanced interplay between estrogen and progesterone throughout the menstrual cycle. In the follicular phase, estrogen levels rise, peaking just before ovulation. After ovulation, during the luteal phase, progesterone levels increase significantly. These hormones should follow a predictable rhythm, promoting regular ovulation and a healthy endometrial lining.

Typical findings on urine, salivary, and blood hormone panels that suggest hormonal imbalances causing dysmenorrhea include elevated estrogen levels relative to progesterone and insufficient progesterone production in the luteal phase. 

Any one of these panels provides a thorough hormonal evaluation:

• Female Hormone Panel by Precision Point
• DUTCH Plus  by Precision Analytical (DUTCH)
• Saliva Female Hormones by Ayumetrix
• Rhythm by Genova Diagnostics

Micronutrient Assessment

Vitamins, minerals, and other nutrients play a role in maintaining hormonal balance and ensuring the proper functioning of the reproductive system. These nutrients are essential for hormone synthesis/metabolism and regulating systemic inflammation levels. Certain nutrients, such as B vitamins, magnesium, omega-3 fatty acids, vitamin E, zinc, and calcium, are particularly important.

Micronutrient tests can identify deficiencies or imbalances in these and other nutrients. By addressing these deficiencies through diet, supplementation, or lifestyle changes, functional medicine practitioners can support hormone synthesis and metabolism, reduce the production of pain-inducing prostaglandins, and promote normal uterine contractions. 

• Micronutrient Test by SpectraCell
• Cellular Micronutrient Assay by Cell Science Systems 
• NutrEva FMV by Genova Diagnostics

Comprehensive Stool Test

The estrobolome is the subset of the gut microbiome capable of metabolizing and influencing the enterohepatic circulation of estrogens in the body. Imbalances in the estrobolome can lead to elevations of an enzyme called beta-glucuronidase, which allows estrogens to be reabsorbed into the bloodstream rather than excreted. 

A comprehensive stool analysis can provide important information regarding gut health and dysbiosis as it pertains to hormonal balance and estrogen metabolism:

• GI-MAP + Zonulin by Diagnostic Solutions
• GI360 by Doctor's Data
• GI Effects Comprehensive Profile - 3 day by Genova Diagnostics

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Treatment Plan for Dysmenorrhea

Here is a step-by-step protocol that can be implemented to treat dysmenorrhea:

Step 1: Reduce Inflammation

Here's Why This Is Important:

Inflammation, specifically elevated levels of prostaglandins, plays a central role in the pathophysiology of menstrual pain.

How Do You Do This?

Medical guidelines recommend using non-steroidal anti-inflammatory drugs (NSAIDs) as a first-line treatment for reducing prostaglandin synthesis. Patients should be instructed to begin taking an NSAID 1-2 days before the anticipated onset of menses and continue for 2-3 days. (30) 

Chronic use of NSAIDs, however, does increase the risk of peptic ulcer disease (PUD), gastrointestinal bleeding, and kidney toxicity. Given these side effects, alternative anti-inflammatory solutions can be considered. 

Evidence shows that the following supplements have anti-inflammatory properties and can reduce menstrual cramping, in some cases as effectively as NSAIDs:

• Ginger 750-2,000 mg of ginger powder daily for the first 3-4 days of a menstrual cycle
• Vitamin D 50,000 IU weekly for eight weeks
• Fish oil 1,000 mg daily

Treating inflammation should always involve dietary modifications, including anti-inflammatory foods, such as those rich in omega-3 fatty acids and antioxidants, and eliminating pro-inflammatory foods like processed sugars, trans fats, and alcohol.

Lifestyle factors like chronic stress, poor sleep, and physical inactivity are linked to higher levels of systemic inflammation. Therefore, patients should be encouraged to healthfully manage stress, prioritize sleep, and exercise regularly to modulate inflammation levels.  

Step 2: Correct Estrogen Dominance

Why Is This Important?

Estrogen dominance fuels prostaglandin formation and more severe cramping but also underlies many of the medical conditions known to cause secondary dysmenorrhea. 

How Do You Do This?

Because the greatest reports of pain symptoms occur at times of falling estrogen levels during the menstrual cycle, medical guidelines recommend the use of combined oral contraceptive pills (OCPs) to prevent cyclical hormonal fluctuations and improve pain symptoms. It's important to note, however, that many patients will experience a return of symptoms when they discontinue these medications because they fail to restore the optimal hormonal balance desired for painless periods.

Estrogens are metabolized in the liver and eliminated from the body through the intestines. Patients with "sluggish" liver function and slow bowels are likely to have estrogen dominance due to these impaired estrogen detoxification pathways. Therefore, a natural approach to supporting a healthy estrogen-to-progesterone ratio must include liver and gut support. 

• Increase high-fiber, prebiotic, and probiotic foods to support a healthy gut microbiome and promote regular, daily bowel movements. These include beans, garlic, onion, kefir, and sauerkraut.
• Include cruciferous vegetables, such as broccoli, cauliflower, Brussels sprouts, kale, and cabbage, in the diet. These vegetables are rich in indole-3-carbinol, which supports estrogen detox pathways in the liver.
• Milk thistle, dandelion root, artichoke, and turmeric can reduce inflammation and support liver function.
• B vitamins support methylation pathways involved in estrogen liver metabolism and ensure estrogen metabolites are neutralized into less inflammatory forms that can be safely eliminated from the body. Research supports using vitamin B1 (100 mg daily), vitamin B3 (100 mg twice daily), and vitamin B6 (50-100 mg daily) to reduce menstrual pain. 

As you are working on supporting liver and bowel function, certain herbs and dietary supplements can support healthy hormonal cycling and metabolism of estrogen into less potent forms:

• Diindolylmethane (DIM) is a metabolite of indole-3-carbinole. DIM aids the healthy metabolism of estrogen in the liver. 
• Calcium-d-glucarate (1,500-3,000 mg daily) inhibits beta-glucuronidase, encouraging the elimination of excess estrogen through stool.
• Chasteberry acts on the pituitary gland to raise progesterone levels and improve the estrogen-to-progesterone ratio.

The Risks of Untreated Dysmenorrhea

Up to 29% of patients with dysmenorrhea report significant impairment in their quality of life. Menstrual pain is a leading cause of absenteeism from school or work among menstruating patients. Over time, the physical toll of chronic pain manifests emotionally, with patients having an increased risk of anxiety and depression. (25) 

Hyperalgesic priming refers to a condition where the nervous system becomes more sensitive to pain over time. Repeated episodes of dysmenorrhea can lead to changes in the nervous system, making it more responsive to pain stimuli. This means that individuals with untreated dysmenorrhea may experience heightened sensitivity to pain and are at an increased risk of chronic pelvic pain. (25) 

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Key Takeaways:

• Too many women endure monthly menstrual pain and are often left with unsatisfactory solutions that fail to address the root causes of their discomfort. 
• To move beyond merely coping with symptoms, comprehensive strategies that target the underlying inflammation and hormonal imbalances associated with dysmenorrhea should be implemented. These include dietary modifications, supporting liver function and gut health, and using hormone-balancing herbs.
• By focusing on these holistic interventions, we can transition from symptomatic-based treatments to approaches that reestablish healthy, pain-free menstrual cycles.