Menstrual Cramps Are Common, But Not Normal
According to a study by the National Institutes of Health (NIH), 30% of women of childbearing age (18-44) and 44% of women with endometriosis experience chronic and cyclic pain. Women with endometriosis are more likely to experience pain during intercourse, menstrual cramping, pain with bowel elimination, vaginal pain and pelvic-abdominal pain. The researchers suggest that physicians and providers ask about pelvic pain during routine office visits.
I have had pelvic pain and although endometriosis was ruled out with two separate exploratory laparascopies in my teens and twenties, I continued to suffer until receiving attention to adhesions in my abdominal wall. My experience linking adhesions with menstrual cramps came after attending a visceral mobilization class, taught by a physical therapist who worked directly with Jean-Pierre Barral, a French osteopath. As physical therapists, we spent two full days practicing techniques on each other before using the techniques clinically. Several participants had adhesions and scars that have never been addressed, including me. After receiving treatment, my menstrual cycle came early without spotting or a sign of a cramp, which was VERY unusual for me. I felt "normal" for the first time in years! My hips were loose, my back was not restricted and I could activate my deep core with ease! The effects lasted for months, until I walked into my daughter's room and slipped on the hard wood floor and landed hard on my hip. It was like a scene from a movie, only I wasn't a stunt actor and I thought I truly broke something. When I finally was able to get up, I was unable to walk without a limp and my pelvis was out of alignment. I did some self correction and treatment techniques in order to go to work that day, but still felt stiff and locked up. I managed to return to function but my body in its healing process already began to make adjustments including collagen remodeling and my next menstrual cycle was horrific! I had cramps and spotting that lasted about a week. I was not able to get relief from my cramps and hip pain until I called upon the help of one of my therapists. Prior to this, I had not made the connection of trauma such as falling to adhesions and menstrual cramps. It is a question I ask of all my patients since then, as falling is a risk factor for developing adhesions.
My experience is not unique. Many women with painful menstruation, or dysmenorrhea, report that cramps diminish and in some cases, resolve completely after receiving myofascial release of the deep fascia in the abdominal wall, known as visceral mobilization. My clinical and personal conclusion is that adhesions are responsible for the majority of menstrual cramps and painful periods. Can you imagine if women could have treatment instead of suffering through unproductive and canceled days off work and school? This is a public health issue and treatment other than surgery, which leads to more adhesions, is not likely to be recommended. Although common, women have learned to live with cramps and pain as if normal. The good news is that adhesions are getting more attention as studies confirm the negative impact of fascia restrictions and how visceral mobilization can help!
My other significant finding is that adhesions contribute to hip and pelvic pain and dysfunction. Many individuals who come into our clinic are hoping to resolve one issue and after being evaluated, it is discovered there are underlying issues contributing to the symptoms and disruption of the core. The majority of individuals have adhesions with RIGHT hip pain or a range of motion deficit, in addition to an asymmetrical pull on the pelvis and spine, causing back pain or sacroiliac (SI) dysfunction. We have learned from osteopaths who developed visceral mobilization techniques, that there is more fascia on the right side of the abdomen with larger organs such as the liver and therefore, more adhesions on the right side. The abdominal fascia is continuous with the hip capsule and can lock up or restrict the hip. I can usually predict that a patient will have a right hip issue, whether they are aware of it or not. If there is a surgical history, it is obvious. I am astonished at the number of women and girls who have adhesions despite not a single cut or scar. If I dig deeper into their medical history, it usually comes out that they have had digestive issues or irritable bowel or a history of constipation or heavy menstrual cycles or they fell on their tailbone as a child. All of these contribute to adhesions that are silent and without obvious symptoms, or so it appears. Nearly every person I treat has adhesions to some degree that need to be addressed.
Common complaints related to adhesions include:
coccydynia (tailbone pain)
sacroiliac (SI) dysfunction
abdominal or pelvic pain
dysmenorrhea (painful menstruation)
dyspareunia (painful penetration)
frequency, urgency, incontinence of urine or nocturia (night time voiding)
When our 12 year old daughter had a laparoscopic appendectomy, the surgeon assured us she would be back to “normal” the following week and could resume all activity. I knew better from my experience; I didn’t like that she had a surgical history that increased her risk of developing adhesions. I was shocked by the fascial restrictions limiting her right hip range of motion so extensively. She presented exactly like my pelvic pain patients, but I did not expect it in with someone so young! She had right hip flexor tightness producing clunking of her hip and severe restrictions in her organ mobility. I knew if I didn’t mobilize the adhesions, she would not only be unable to exercise comfortably, but when she started menstruating, would most likely have severe menstrual cramps.
Falling is a risk factor for adhesions, as also identified in a competitive ice skater I am treating. She came in initially with severe right hip pain after falling off a horse to the point she stopped skating and was about to give up on her dream. She had traditional physical therapy, but when the issues went unresolved for over six months, she decided to seek the help of a pelvic floor therapist (me)! When I probed further into her past, she reported having debilitating menstrual cramps even before falling off the horse. Unexpectedly, her fascia was more restricted than some of my postsurgical patients who have had a C-section! (surgery is an obvious risk factor for adhesions). I have determined her adhesions and right hip dysfunction to be related to the frequent falls on the ice since she was a child. I am happy to report she went back to full competition and her menstrual cramps subsided significantly. She continues to see me for maintenance, since she continues to fall during intense daily practices, putting her at risk for hip tightness and adhesions.
You might be asking yourself, what is wrong with scar tissue and why can’t I just have it surgically removed? The problem with surgery is that adhesions or collagen cross-links develop in the normal process of healing from surgery. Fascia has nociceptors or pain fibers so pain can be experienced when the fascia is under stretch or tension. The only way to truly mobilize fascia is to physically load the tissue in all three fascial planes, either through visceral mobilization or specific deep stretching. It is important to note that scar tissue will not go away on its own! If it is not restored to normal mobility, the core muscles will not be able to function as they were designed to. The fascia around the organs is continuous with the fascia that envelopes the muscles in the lumpopelvic region, including the thighs. A muscle contraction can actually reproduce the symptoms or tug on the fascia more, perpetuating the problem, hence the “catch 22” that so many individuals are in.
Visceral mobilization is laborious and time consuming, requiring one-on-one attention and can only be performed by a highly skilled provider who has experience. It can be performed on the abdomen, thighs and even internally (vaginally or rectally) to address restrictions around the tailbone, urethra or pelvic floor. Currently, physical therapists are one of the only providers that can perform internal treatment, although this varies from state to state. Do your research and ask questions before scheduling an appointment to ensure you will be in good hands (pun intended).
*Source: "Pelvic pain may be common among reproductive-age females", nih.gov.news, August 2015.
Written by: Janine Laughlin, PT