Hope for menstrual cramps (dysmenorrhea) with breathing

Posted: April 22, 2023 | Author: erikpeper | Filed under: behavior, biofeedback, Breathing/respiration, healing, health, meditation, Pain/discomfort, posture, relaxation, self-healing, stress management, Uncategorized | Tags: dysmenorrhea, Imagery, menstrual cramps, stroking, visualization | 1 Comment

Adapted from: Peper, E., Chen, S., Heinz, N., & Harvey, R. (2023). Hope for menstrual cramps (dysmenorrhea) with breathing. Biofeedback, 51(2), 44–51. https://doi.org/10.5298/1081-5937-51.2.04

“I have always had extremely painful periods. They would get so painful that I would have to call in sick and take some time off from school. I have been to many doctors and medical professionals, and they told me there is nothing I could do. I am currently on birth control, and I still get some relief from the menstrual pain, but it would mess up my moods. I tried to do the diaphragmatic breathing so that I would be able to continue my life as a normal woman. And to my surprise it worked. I was simply blown away with how well it works. I have almost no menstrual pain, and I wouldn’t bloat so much after the diaphragmatic breathing.” -22 year old student

Each semester numerous students report that their cramps and dysmenorrhea symptoms decrease or disappear during the semester when they implement the relaxation and breathing practices that are taught in the semester long Holistic Health class.  Given that so many young women suffer from dysmenorrhea, many young women could benefit by using this integrated approach as the first self-care intervention before relying on pain reducing medications or hormones to reduce pain or inhibit menstruation. Another 28-year-old student reported:

“Historically, my menstrual cramps have always required ibuprofen to avoid becoming distracting. After this class, I started using diaphragmatic breath after pain started for some relief. True benefit came when I started breathing at the first sign of discomfort. I have not had to use any pain medication since incorporating diaphragmatic breath work.” 

This report describes students practicing self-regulation and effortless breathing to reduce stress symptoms, explores possible mechanisms of action, and suggests a protocol for reducing symptoms of menstrual cramps. Watch the short video how diaphragmatic breathing eliminated recurrent severe dysmenorrhea (pain and discomfort associated with menstruation).  

Background: What is dysmenorrhea?

Dysmenorrhea is one of the most common conditions experienced by women during menstruation and affects more than half of all women who menstruate (Armour et al., 2019).  Most commonly dysmenorrhea is defined by painful cramps in the lower abdomen often accompanied by pelvic pain that starts either a couple days before or at the start of menses. Symptoms also increase with stress (Wang et al., 2003) with pain symptoms usually decreasing in severity as women get older and, after pregnancy.

Economic cost of dysmenorrhea

Dysmenorrhea can significantly interfere with a women’s ability to be productive in their occupation and/or their education. It is “one of the leading causes of absenteeism from school or work, translating to a loss of 600 million hours per year, with an annual loss of $2 billion in the United States” (Itani et al, 2022).  For students, dysmenorrhea has a substantial detrimental influence on academic achievement in high school and college (Thakur & Pathania, 2022). Despite the frequent occurrence and negative impact in women’s lives, many young women struggle without seeking or having access to medical advice or, without exploring non-pharmacological self-care approaches (Itani et al, 2022).

Treatment

The most common pharmacological treatments for dysmenorrhea are nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., Ibuprofen, Aspirin, and Naproxen Sodium) along with hormonal contraceptives. NSAIDs act by preventing the action of cyclooxygenase which prevents the production of prostaglandins.  Itani et al (2022) suggested that prostaglandin production mechanisms may be responsible for the disorder. Hormonal contraceptives also prevent the production of prostaglandins by suppressing ovulation and endometrial proliferation.

The pharmacological approach is predominantly based upon the model that increased discomfort appears to be due to an increase in intrauterine secretion of prostaglandins F2α and E2 that may be responsible for the pain that defines this condition (Itani et al, 2022). Pharmaceuticals which influence the presence of prostaglandins do not cure the cause but mainly treat the symptoms. 

Treatment with medications has drawbacks.  For example, NSAIDs are associated with adverse gastrointestinal and neurological effects and also are not effective in preventing pain in everyone (Vonkeman & van de Laar, 2010). Hormonal contraceptives also have the possibility of adverse side effects (ASPH, 2023). Acetaminophen is another commonly used treatment; however, it is less effective than other NSAID treatments.

Self-regulation strategies to reduce stress and influence dysmenorrhea

Common non-pharmacological treatments include topical heat application and exercise. Both non-medication approaches can be effective in reducing the severity of pain. According to Itani et al. (2022), the success of integrative holistic health treatments can be attributed to “several mechanisms, including increasing pelvic blood supply, inhibiting uterine contractions, stimulating the release of endorphins and serotonin, and altering the ability to receive and perceive pain signals.”

Although less commonly used, self-regulation strategies can significantly reduce stress levels associated menstrual discomfort as well as reduce symptoms. More importantly, they do not have adverse side effects, but the effectiveness of the intervention varies depending on the individual.

• Autogenic Training (AT), is a hundred year old treatment approach developed by the German psychiatrist Johannes Heinrich Schultz that involves three 15 minute daily practice of sessions, resulted in a 40 to 70 percent decrease of symptoms in patient suffering from primary and secondary dysmenorrhea (Luthe & Schultz, 1969). In a well- controlled PhD dissertation, Heczey (1978) compared autogenic training taught individually, autogenic training taught in a group, autogenic training plus vaginal temperature training and a no treatment control in a randomized controlled study.   All treatment groups except the control group reported a decrease in symptoms and the most success was with the combined autogenic training and vaginal temperature training in which the subjects’ vaginal temperature increased by .27 F degrees.
• Progressive muscle relaxation developed by Edmund Jacobson in the 1920s and imagery are effective treatments for dysmenorrhea (Aldinda et al., 2022; Chesney & Tasto, 1975; Çelik, 2021; Jacobson, 1938; Proctor et al., 2007).
• Rhythmic abdominal massage as compared to non-treatment reduces dysmenorrhea symptoms (Suryantini, 2022; Vagedes et al., 2019):
• Biofeedback strategies such as frontalis electromyography feedback (EMG) and peripheral temperature training (Hart, Mathisen, & Prater, 1981); trapezius EMG training (Balick et al, 1982); lower abdominal EMG feedback training and relaxation (Bennink, Hulst, & Benthem, 1982); and integrated temperature feedback and autogenic training (Dietvorts & Osborne, 1978) all successfully reduced the symptoms of dysmenorrhea.
• Breathing relaxation for 5 to 30 minutes resulted in a decrease in pain or the pain totally disappeared in adolescents (Hidayatunnafiah et al., 2022). While slow deep breathing in combination with abdominal massage is more effective than applying hot compresses (Ariani et al., 2020). Slow pranayama (Nadi Shodhan) breathing the quality of life and pain scores improved as  compared to fast pranayama (Kapalbhati) breathing and improved  quality of life and reduces absenteeism and stress levels (Ganesh et al. 2015). When students are taught slow diaphragmatic breathing, many report a reduction in symptoms compared to the controls (Bier et al., 2005). 

Observations from Integrated stress management  program

This study reports on changes in dysmenorrhea symptoms by students enrolled in a University Holistic Health class that included homework assignment for practicing stress awareness, dynamic relaxation, and breathing with imagery.

Respondents: 32 college women, average age 24.0 years (S.D. 4.5 years)

Procedure: Students were enrolled in a three-unit class in which they were assigned daily home practices which changed each week as described in the book, Make Health Happen (Peper, Gibney & Holt, 2002).  The first five weeks consisted of the following sequence: Week 1 focused on monitoring one’s reactions to stressor; week 2 consisted of daily practice for 30 minutes of a modified progressive relaxation and becoming aware of bracing and reducing the bracing during the day; Week 3 consisted of practicing slow diaphragmatic breathing for 30 minutes a day and during the day becoming aware of either breath holding or shallow chest breath and then use that awareness as cue to shift to lower slower diaphragmatic breathing; week 4 focused on evoking a memory of wholeness and relaxing; and week 5 focused on learning peripheral hand warming.

During the class, students observed lectures about stress and holistic health and met in small groups to discuss their self-regulation experiences. During the class discussion, some women discussed postures and practices that were beneficial when experiencing menstrual discomfort, such as breathing slowly while lying on their back, focusing on slow abdominal awareness in which their abdomen expanded during inhalation and contracted during exhalation.  While exhaling they focused on imagining a flow of air initially going through their arms and then through their abdomen, down their legs and out their feet. This kinesthetic feeling was enhanced by first massaging down the arm while exhaling and then massaging down their abdomen and down their thighs when exhaling. In most cases, the women also experienced that their hands and feet warmed.  In addition, they were asked to shift to slower diaphragmatic breathing whenever they observed themselves gasping, shallow breathing or holding their breath.  After five weeks, the students filled out a short assessment questionnaire in which they rated the change in dysmenorrhea symptoms since the beginning of the class.

Results.

About two-thirds of all respondents reported a decrease in overall discomfort symptoms.  In addition to any ‘treatment as usual’ (TAU) strategies already being used (e.g. medications or other treatments such as NSAIDs or birth control pills), 91% (20 out 22 women) who reported experiencing dysmenorrhea reported a decrease in symptoms when they practiced the self-regulation and diaphragmatic breathing techniques as shown in Figure 1.

Figure 1. Self-report in dysmenorrhea symptoms after 5 weeks.

Discussion

Many students reported that their symptoms were significantly reduced and they could be more productive.  Generally, the more they practiced the relaxation and breathing self-regulation skills, the more they experienced a decrease in symptoms. The limitation of this report is that it is an observational study; however, the findings are similar to those reported by earlier self-care and biofeedback approaches. This suggests that women should be taught the following simple self-regulation strategies as the first intervention to prevent and when they experience dysmenorrhea symptoms.

Why would breathing reduce dysmenorrhea?

Many women respond by ‘curling up’ a natural protective defense response when they experience symptoms. This protective posture increases abdominal and pelvic muscle tension, inhibits lymph and blood flow circulation, increases shallow breathing rate, and decreases heart rate variability.  Intentionally relaxing the abdomen with slow lower breathing when lying down with the legs extended is often the first step in reducing discomfort.

By focusing on diaphragmatic breathing with relaxing imagery, it is possible to restore abdominal expansion during inhalation and slight constriction during exhalation. This dynamic breathing while lying supine would enhance abdominal blood and lymph circulation as well as muscle relaxation (Peper et al., 2016).  While practicing, participants were asked to wear looser clothing that did not constrict the waist to allow their abdomen to expand during inhalation; since, waist constriction by clothing (designer jean syndrome) interferes with abdominal expansion.  Allowing the abdomen to fully extend also increased acceptance of self, that it was okay to let the abdomen expand instead of holding it in protectively. The symptoms were reduced most likley by a combination of the following factors.

• Abdominal movement is facilitated during the breathing cycle. This means reducing the factors that prevent the abdomen expanding during inhalation or constricting during exhalation (Peper et al., 2016).
  • Eliminate‘Designer jean syndrome’ (the modern girdle). Increase the expansion of your abdomen by loosening the waist belt, tight pants or slimming underwear (MacHose & Peper, 1991).
  • Accept yourself as you are. Allow your stomach to expand without pulling it in.
  • Free up learned disuse:  Allow the abdomen to expand and constrict instead of inhibiting movement to avoid pain that occurred following a prior abdominal injury/surgery (e.g., hernia surgery, appendectomy, or cesarean operation), abdominal pain (e.g., irritable bowel syndrome, recurrent abdominal pain, ulcers, or acid reflux), pelvic floor pain (e.g., pelvic floor pain, pelvic girdle pain, vulvodynia, or sexual abuse).

• The ‘defense response’ is reduced. Many students described that they often would curl up in a protective defense posture when experiencing menstrual cramps.  This protective defense posture would maintain pelvic floor muscle contractions and inhibit blood and lymph flow in the abdomen, increase shallow rapid thoracic breathing and decrease pCO2 which would increase vasoconstriction and muscle constriction (Peper et al., 2015; Peper et al., 2016). By having the participant lie relaxed in a supine position with their legs extended while practicing slow abdominal breathing, the pelvic floor and abdominal wall muscles can relax and thereby  increase abdominal blood and lymph circulation and  parasympathetic activity. The posture of lying down implies feeling safe which is a state that facilitates healing.
• The pain/fear cycle is interrupted.  The dysmenorrhea symptoms may trigger more symptoms because the person anticipates and reacts to the discomfort. The breathing and especially the kinesthetic imagery where the attention goes from the abdomen and area of discomfort to down the legs and out the feet acts as a distraction technique (not focusing on the discomfort).  
• Support sympathetic-parasympathetic balance.  The slow breathing and kinesthetic imagery usually increases heart rate variability and hand and feet temperature and supports sympathetic parasympathetic balance.
• Interrupt the classical conditioned response of the defense reaction.  For some young girls, the first menstruation occurred unexpectedly.  All of a sudden, they bled from down below without any understanding of what is going on which could be traumatic.  For some this could be a defense reaction and a single trial condition response (somatic cues of the beginning of menstruation triggers the defense reaction).  Thus, when the girl later experiences the initial sensations of menstruation, the automatic conditioned response causes her to tense and curl up which would amplify the discomfort. Informal interviews with women suggests that those who experienced their first menstruation experience as shameful, unexpected, or traumatic (“I thought I was dying”) thereafter framed their menstruation negatively. They also tended to report significantly more symptoms than those women who reported experiencing their first menstruation positively as a conformation that they have now entered womanhood.

How to integrate self-care to reduce dysmenorrhea     

Be sure to consult your healthcare provider to rule out treatable underlying conditions before implementing learning effortless diaphragmatic breathing.

• Allow the abdomen to expand during inhalation and become smaller during exhalation. This often means, loosen belt and waist constriction, acceptance of allowing the stomach to be larger and reversing learned disuse and protective response caused by stress.
• Master diaphragmatic breathing (see: Peper & Tibbetts, 1994 and the blogs listed at the end of the article).
• Practice slow effortless diaphragmatic breathing lying down with warm water bottle on stomach in a place that feels safe.
• Include kinesthetic imagery as you breathe at about 6 breaths per minute (e.g. slowly inhale for 4 or 5 seconds and then exhale for 5 or 6 seconds, exhaling slightly longer than inhaling). Imaging that when you exhale you can sense healing energy flow through your abdomen, down the legs and out the feet.
• If possible, integrate actual touch with the exhalation can provide added benefit.  Have a partner first stroke or massage down the arms from the shoulder to your fingertips as you exhale and, then on during next exhalation stroke gently from your abdomen down your legs and feet. Stroke in rhythm the exhalation.
• Exhale slowly and shift to slow and soft diaphragmatic breathing each time you become aware of neck and shoulder tension, breath holding, shallow breathing, or anticipating stressful situations. At the same time imagine /sense when exhaling a streaming going through the abdomen and out the feet when exhaling.   Do this many times during the day.

• Practice and apply general stress reduction skills into daily life since stress can increase symptoms. Anticipate when stressful event could occur and implement stress reducing strategies.   
• Be respectful of the biological changes that are part of the menstrual cycle. In some cases adjust your pace and slow down a bit during the week of the menstrual cycle; since, the body needs time to rest and regenerate. Be sure to get adequate amount of rest, hydration, and nutrition to optimize health. 
• Use self-healing imagery and language to transform negative association with menstruation to positive associations (e.g., “curse” to confirmation “I am healthy”).

Conclusion

There are many ways to alleviate dysmenorrhea.  Women can find ways to anticipate and empower themselves by practicing stress reduction, wearing more comfortable clothing, using heat compression, practicing daily diaphragmatic breathing techniques, visualizing relaxed muscles, and positive perception towards menstrual cycles to reduce the symptoms of dysmenorrhea. These self-regulation methods should be taught as a first level intervention to all young women starting in middle and junior high school so that they are better prepared for the changes that occur as they age. 

“I have been practicing the breathing techniques for two weeks prior and I also noticed my muscles, in general, are more relaxed.  Of course, I also avoided the skinny jeans that I like to wear and it definitely helped.   

I have experienced a 90% improvement from my normal discomfort.  I was still tired  – and needed more rest and sleep but haven’t experienced any “terrible” physical discomfort.  Still occasionally had some sharp pains or bloating but minor discomfort, unlike some days when I am bedridden and unable to move for half a day. –  and this was a very positive experience for me “ — Singing Chen (Chen, 2023)

Useful blogs to learn diaphragmatic breathing

Healing irritable bowel syndrome with diaphragmatic breathing*

Breathing reduces acid reflux and dysmenorrhea discomfort

Enjoy sex: Breathe away the pain*

References

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