Most women report some painful or discomfort with their period. However, some women have killer cramps (the medical term is severe dysmenorrhea) and for many of them life goes on a 3 to 5-day hold once a month.

Period pain is due to release of a substance called prostaglandins from the lining of the uterus during menstruation. Prostaglandins help the uterus contract (cramp), which is one of the mechanisms used to clot the blood and eventually end the period.  Why do some women have more painful periods? Studies tell us some women make more prostaglandins, and most prostaglandins mean more pain. Medical conditions, such as endometriosis, muscle spasm in the pelvis, and bladder pain syndrome, can all get worse during the period as hormones have a very complex effect on pain. In addition, prostaglandins make all pain worse (if you cut your hand and poured prostaglandins into the wound it would hurt a lot more). So, if you have a pain condition in the pelvis and your body starts churning out prostaglandins the pain condition may flare.

While many women find period pain improves over time, waiting until your 30s or 40s isn’t exactly a treatment option. So what can be done to help period pain before then?

Birth control pills are definitely a treatment option (they reduce the amount of prostaglandins released during menstruation) and about 2/3 of women report they improve period pain. However, they don’t work for everyone, and some women can’t take them or simply don’t want to take a daily medication for pain that happens 3 to 7 days a month. Medications like ibuprofen or acetaminophen are also very effective for many women (they block production of prostaglandins).

For a variety of reasons many women ask about natural, which I take to mean non-pharmaceutical, options. Some because that fits in with their personal approach to health care, others because of medication side effects, and some because it is something they can try at home before seeking medical care. (Non-pharmaceutical doesn’t necessarily mean safer or better.  Simply non-pharmaceutical.)

The problem is studies on these non-pharmaceutical approaches are far from robust. If this is something you want to try understand that many of the studies have what one might call quality issues (some with serious methodological flaws), so drawing a conclusion is challenging. Retrieving all the studies was a challenge as they were quite old or in obscure journals or in German or all three so I had to rely on the abstracts and summaries from other reviewers (who I really hope read them). Placebo effect is also a big factor, and many of the studies didn’t adequately control for the placebo effect (and keep in mind 60 percent of people can experience a placebo effect). By the way, placebo effect doesn’t mean the response isn’t real it’s just with pain expectation is everything. If you expect/believe you will have pain relief then your brain churns out pain killers.

I’ve left two big ones off the list even though they are really #1 and #2: quitting smoking and maintaining an ideal body weight. They don’t apply to everyone and if they do apply, well, they require a longer term strategy tan everything on the list below. Smoking is a risk factor for painful periods (basically smoking makes everything worse) and fatty tissue increases estrogen (one possible mechanism of painful periods) and increases inflammation (and pain at a cellular level is inflammation).

1. Exercise. The original natural therapy, although the evidence for painful periods is low quality (mostly because there are so few studies). However, exercise typically helps most pain syndromes and improves blood flow to the pelvis, and stimulates the release of endorphins (natural pain killers). Anecdotally I have many patients who say exercise really helps. I know it’s hard when you feel crampy and crummy to get motivated (especially if your flow is heavy), also exercising with a pad is a real drag, but the potential benefits are huge. Personally I find after 2 to 3 minutes of running that I forget about my cramps altogether.

2. Ginger capsules for five days a month starting 2 to 3 days before the onset of the period (either 250 mg four times a day or 500 to 1000 mg twice a day). Ginger may impact inflammation.

3. Magnesium, which may work by reducing prostaglandins. A Cochrane review suggests it is more effective than placebo, but the studies are small and old and in German. The dose is typically 360-400 mg a day for three days starting one day before the onset of bleeding. Magnesium can cause diarrhea, so it is important to be mindful of that side effect.

4. A TENS unit (transcutaneous electrical stimulation) on the high-frequency setting. A TENS unit is a small device worn against the skin that deliver an electrical current to the area with pain (not a painful current). The mechanism of action is still not well understood. A TENS doesn’t affect how the uterus contracts but may affect uterine blood flow,  stimulate endorphin release, or affect the pain signal going from the uterus to the brain.  There are several small studies, but keep in mind it is hard to do sham TENS (you either know it’s on or not) so placebo control is an issue. Understanding these limitations it is possible 40 to 60 percent of women may get some benefit. In my experience, it’s best to have the sitting determined by an experienced physical therapist. The advantage of a TENS unit is that they are relatively inexpensive and have no risk of side effects and the evidence suggesting they can help is of moderate quality.

5. Thiamine supplements (vitamin B1), which may affect prostaglandin production. There is only one study from 1996 using 100 mg a day for three months. The author claims an 87 percent “cure” and another 5 percent significantly improved. However, one study reporting astronomical cure rates is a condition that is unlikely “curable” in an obscure journal from 1996 does leave some questions unanswered. The upside is the there is probably little harm in trying three months to see how it works.

6. Vitamin E either 500 units a day for five days (2 days before onset of bleeding and continuing for three days into the menses) or 200 units twice a day for 5 days. Vitamin E is an antioxidant, impacts the immune system and is important for the formation of blood cells, but how this affects period pain is unknown. The studies are slightly better quality than some of the others but still small and with issues. There is controversy over the safety of vitamin E supplements and taking more that 400 units a day is not recommended. There are a lot of potential safety issues emerging about vitamin E, so it’s important to keep in mind these two small studies offered no long-term data on safety.

7. Fish oil capsules, 6 g (containing 1,080 mg EPA and 720 DHA) divided into two doses a day or two grams of Krill oil a day. The recommendations are based on three small studies two from 1996 and one from 2003. Again, the general mechanism of action is believed to be anti-inflammatory/reduction in prostaglandins. People say the marine burps from krill oil are less offensive than from fish oil.

8. French maritime bark extract (Pycnogenol) 60 mg once or twice a day. There are two studies with just over 150 patients, although only one study used a placebo control. Pycnogenol is also supposed to have anti-inflammatory properties.

9. Dill capsules 250 mg twice a day for five days (starting two days before the onset of bleeding. The placebo was a traditional medication for painful periods, mefanamic acid. Like several of the studies listed above this one was conducted on a university students in Iran, so how generalizable the results are to other populations is unknown.

10. Chocolate chip cookies. OK, so this isn’t a period pain study (I couldn’t find any studies using chocolate for menstrual pain), it’s a general pain study that found eating a sweet and palatable food (they used chocolate chip cookies) improved pain tolerance for women versus a non sweet food (black olives) and a neutral food (rice cakes). Chocolate chip cookies did not improve pain tolerance for men. Obviously sweeping generalizations about menstrual cramps are not possible with a study of 40 women looking at laboratory induced pain, but it does make one wonder if there is something to those chocolate cravings?

Keep in mind this is all information from lower quality studies and vitamins or herbs are not necessarily safe, especially in mega doses. Even chocolate chip cookies should be ingested in a responsible dosage. All of the non-cookie studies claim effect within 2-3 months, so if trying one of the above therapies is up your alley give it three months maximum and if you are not any better move on to something else. Except exercise, keep that up even if it doesn’t help your cramps.

Jennifer Gunter is an obstetrician-gynecologist and author of The Preemie Primer. She blogs at her self-titled site, Dr. Jen Gunter.

Image credit: Shutterstock.com