Puberty is the time when your body changes because of hormones produced by your ovaries. Puberty usually starts between age 8 and 13 and includes growth of your breasts, the appearance of hair in your genital and underarm areas, and a growth spurt in your height. You may also notice that you have body odor and some discharge in your vaginal area from the effect of the hormones. Usually your menstrual periods will start about 2 to 3 years after you notice the first signs of breast development. The age when you start puberty may be earlier or later than others your age because late or early puberty may run in your family. Puberty may start earlier in girls who are overweight and later in girls who are underweight or involved in sports or activities such as dance, gymnastics or track.

Puberty begins when the pituitary gland in your brain begins to release chemical messengers called gonadotropins, Follicle-Stimulating Hormone (FSH) and Luteinizing Hormone (LH), which in turn stimulate your ovaries inside your belly to make hormones, especially estrogen. The estrogen causes breast development and menstrual periods. The two small, grape-shaped ovaries are also filled with hundreds of thousands of eggs. Menstrual periods occur because the lining of the uterus (called the endometrium) thickens because of rising levels of estrogen and when the levels fall, the lining is not supported and passes out of your body through the vagina as a “period.” As your system matures, the gonadotropins send different levels of hormones that “tell” your ovaries to release an egg once a month and to make progesterone in addition to estrogen. The egg then travels towards the uterus. If the egg is not fertilized by a sperm, then two weeks later, the levels of estrogen and progesterone fall and the blood filled lining of the uterus that becomes thicker between periods passes out of your body through your vagina. This flow, which comes out as blood, is your menstrual period. The whole process is called menstruation. Menstrual periods can occur when you are releasing eggs each month or they can occur when you are just making estrogen. When you are not ovulating, the periods may be lighter or heavier than normal and more irregular.

What will having my period feel like?

Some girls may experience premenstrual syndrome “PMS.” Symptoms of PMS usually start about a week before your period and disappear about 1-2 days into your period. Signs and symptoms of PMS may include mood swings, acne, bloating, food cravings, increased breast tenderness, fatigue, and increased hunger and thirst. When your period begins, it’s normal to experience mild pain with your periods a couple of days each month. However, if your pain is not relieved with over-the-counter pain medicine, and you miss school or doing things with your friends because of it, you may have “dysmenorrhea” (pronounced: dis–men–o–ree–a). When your period begins, it will feel like liquid flowing slowly with start and stops, out of your vagina. Although it may seem like a lot of blood, only a small amount is released at a time and should not be painful. It’s also normal to see small clots of blood from your vagina on the toilet paper after you urinate (pee). However, if you see clots larger than a quarter, you should call your health care provider (HCP) and schedule an appointment.

What if I haven’t had my period yet?

It’s normal to get your period as early as 9 years old or as late as 15 years old. This is a big time range, and it’s hard to be one of the first or one of the last. Children who are active in sports or are very thin may not get their period until a later age. Losing weight while you are in your growth spurt can also delay your periods. A late start to puberty and menstrual periods may run in your family. Talk to your parent or your healthcare provider about your worries and concerns. If you haven’t gotten your period by the time you have turned 15 or if you haven’t had your period or breast development by age 13, get a check-up with your health care provider (HCP) just to make sure everything is okay. Your HCP sees many children who develop late, so don’t be embarrassed to ask. Your HCP may do a genital exam and check to see if your hymen (a thin piece of tissue that covers part of the entrance to your vagina) is open. Some children are born with an “imperforate hymen,” which means that the hymen does not have an opening, and blood cannot leave the vagina. Rarely, children are born with a condition called Mayer Rokitansky Kuster Hauser syndrome (MRKH), which is an incomplete vagina and/or small or absent uterus, so they don’t get their period for this reason. It’s a good idea to get regular check-ups during puberty just to make sure that everything is okay.

How often will I get my period?

You will likely get your period about once every month. A typical menstrual cycle is about 28 days. This means that there will be about 28 days from the first day of your period to the first day of your next period. 28 days is an average number, but anywhere between 21 and 35 days is normal. In the first year of having periods, most girls have at least 4 periods; the second year, at least 6 periods; and for the 3rd to 5th year, at least 8 periods each year. Most adults have 9 to 12 periods a year. Your period will usually last between 3 and 7 days. The amount of blood flow you have will probably be different each day. You will usually have the most blood in the beginning of your period and the least towards the end. When you are first getting your period, you may have a very heavy period one cycle and very light one the next.

What if my periods don’t come regularly?

You may be in the first or second year of having periods or you may be one of those adolescents whose periods may be affected by changes in body weight or diet, increased stress, eating disorders, hormone imbalance, exercise, illness, or going away to camp or college. While it is common for a child just starting their period to have irregular periods for a year or two, make sure to keep track of your periods and share your Period Calendar or apps with your HCP when you go for your yearly check-up.

Periods too far apart. If you are having your periods less than 6 times a year in your second year of periods or less than 8 times a year after that, this may be because of stress, intense exercise, weight loss, or diet. Too few periods could also be caused by a hormone imbalance called Polycystic Ovary Syndrome (PCOS). Children with PCOS often have acne, excess hair growth, or weight problems in addition to irregular periods. You should check with your HCP if there are more than 35 days between your periods (from the first day of your period to the first day of your next period).

Periods too close together.

You may get your period every two or three weeks. This can be because of stress, some types of exercise, or other changes in your life. If your periods are less than 21 days apart (from the first day of one period to the first day of the next period), or if your period seems to be very heavy or lasts longer than 7 days, your HCP may want to check your blood count to see if you are anemic. If you are anemic, you may have too few red blood cells or too little hemoglobin (oxygen-carrying protein in your red blood cells). People who are anemic (because of heavy periods) need to eat foods that have iron and take an iron supplement. Your HCP will tell you the dose (how much) to take and when you will need to have a follow-up blood test.

Make sure you talk with your HCP if you are having sexual intercourse, because irregular periods could be a sign of pregnancy.

Why should I track of my period?

Keeping track of when your period starts and stops is a good way to see if there is a pattern to your menstrual cycle. It is also important to write down how many days you have your period and the amount of flow you have. Bring your Period Trackers with you when you see your HCP so that he or she can evaluate your cycle.

My Monthly Period & Symptom Tracker

Print out our My Monthly Period & Symptom Tracker use it as an easy way to keep track of your menstrual flow, and it’s also a way to keep track of cramps, and/or PMS and period symptoms (if you have them) each month.

• Review the Sample Monthly Period & Symptom Tracker
• Print copies of My Monthly Period & Symptom Tracker
• Simply make a check mark in the appropriate box (or boxes) for each day of the month. If you don’t have any flow or any symptoms on any given day, leave the box empty. Refer to the Blood Flow Key at the bottom for “Flow” definitions.
• The dates at the top are the same as the dates in one month. Some months have 28 days, others have 30 or 31.
• Remember to bring My Monthly Period & Symptom Tracker with you to your medical appointments.

My Yearly Period Tracker

• My Yearly Period Tracker is a simple and convenient way to track your period throughout the year.
• Review the sample Yearly Period Tracker.
• Print a copy of My Yearly Period Tracker.
• Refer to the Key at the bottom to learn how to fill in the box with the appropriate letter(s). Place a “T” in the box for the hormone pill taken and place an “R” for reminder (placebo) pills.
• Be sure to indicate if you’ve taken a pill during your period by putting a B/T or B/R in the box.
• Remember to bring My Yearly Period Tracker with you to your medical appointments.
• Talk to your HCP about whether you should use the monthly and/or yearly tracker to track your period.

What if I skip a period?

If you miss your period, it could be because of a change in your body or in your life. If you are under stress, you’ve been sick, you are exercising a lot, or you’ve lost weight, you may skip a period. It is common to skip a period every once in a while, especially during the first year that you are getting it. However, if you are having unprotected sexual intercourse or close sexual contact, or if your birth control method has failed, it could also mean that you are pregnant. If you think you may be pregnant, it is very important to see your HCP. If you skip many periods, you should talk to your healthcare provider and see why this is happening.

What if I have big clots of blood during my period?

Small, dark, chunky clots of blood can be normal. Some women get them during their period when they have days of heavy cramping and heavy bleeding. Your body usually makes things called “anti-coagulants” that keep your blood from clotting as it moves to your vagina and out of your body. But during days of heavy bleeding and cramping, the blood may be leaving the uterus so quickly there isn’t time to release these anti-coagulants. The blood then clots. If you have clots that are bigger than the size of a quarter, talk with your HCP.

What if I get spots of blood on my underwear between my periods?

Bleeding in the middle of your cycle could mean different things. Some individuals bleed a little bit during the middle of their cycle, when they ovulate (when a mature egg is released from your ovaries, the hormone levels may decrease a little). This is nothing to worry about. Other times, “spotting” occurs because of an infection such as a sexually transmitted infection. Very rarely, “spotting” can be because of a polyp or fibroid, but this is not very common. You should talk to your HCP if you have bleeding when you don’t have your period.

PMS stands for Premenstrual Syndrome; “pre” means “before” and “menstrual” refers to the menstrual cycle or periods. Not all girls will get PMS. Most girls and women with PMS have symptoms during the week before their period that lessen or disappear within 1-2 days after their period starts. Symptoms can usually be treated with lifestyle changes such as exercise and relaxation therapy and over-the-counter medicine. If these aren’t effective, prescription medicines are sometimes prescribed.

PMDD stands for Premenstrual Dysphoric Disorder. This diagnosis is reserved for young and adult women who have: five or more of the most common PMS symptoms during the week before their period, for at least two menstrual cycles in a row, and symptoms are not due to a medical condition such as thyroid disease. Symptoms such as mood swings, irritability, depression and fatigue are usually so severe that the young/adult woman misses school, work and/or avoids her regular social activities.

How do I know if I have PMS symptoms?

PMS symptoms usually occur 5-7 days before a girl/woman’s menstrual period. There are actually a total of 150 known symptoms of PMS. The most common symptoms include: mood swings, breast soreness, bloating, acne, cravings for certain foods, increased hunger and thirst, and fatigue. Other symptoms may include constipation or diarrhea, irritability, and feeling blue or down in the dumps. If you have any of these symptoms and they happen during the week before your period starts and go away when your period arrives or a few days later, you may have PMS. If you feel blue or down in the dumps and these feelings last longer than the week before your period, it’s probably not related to PMS. In this situation, it’s particularly important to ask your primary care provider if you should talk to a counselor or therapist.

Since there are so many possible symptoms of PMS, it’s a good idea to keep track of them. Remember to note if the symptoms are mild, moderate, or severe. Use a period and symptom tracker for 2-3 months and then bring it to your next medical appointment. A record of your symptoms can help your health care provider figure out the best treatment choices for you.

My Monthly Period & Symptom Tracker

My Monthly Period & Symptom Tracker is an easy way to keep track of your menstrual flow, and it’s also a way to keep track of cramps, and/or PMS and period symptoms (if you have them) each month There are other ways of tracking your periods and symptoms including apps available for iPhones and Android phones – talk to your HCP to determine what method will best work for you.

• Review the sample Monthly Period & Symptom Tracker.
• Print out copies of My Monthly Period & Symptom Tracker.
• Put a check mark in the appropriate box (or boxes) for each day of the month. If you don’t have any flow or any symptoms on any given day, leave the box empty. Refer to the Blood Flow Key at the bottom for “Flow” definitions.
• The dates at the top are the same as the dates in one month. Each month has 30 or 31 days (except for February which has 28 or 29 depending unless it is a leap year).
• Remember to bring My Monthly Period & Symptom Tracker with you to your medical appointments.

Sample Monthly Period and Symptom Tracker

My Monthly Period and Symptom Tracker

What causes PMS?

Scientists are still trying to figure out what causes PMS. We know that during the second half of the menstrual cycle, progesterone (female hormone) levels increase. Then, just before the period comes, progesterone and estrogen (another female hormone) levels drop. It is believed that changes in hormone levels result in PMS symptoms. Other factors may have an effect on PMS symptoms; for example, you may notice that your symptoms are better if you get plenty of sleep and exercise regularly. Although PMS can be frustrating, there are things you can do that may help relieve your symptoms.

Are there any tests to check for PMS?

There are no specific tests such as a blood test to diagnose PMS. The diagnosis is based on specific symptoms. Your health care provider (HCP)will likely ask you a lot of questions. Some questions will be about your period and when you have symptoms, how long they last, etc. and if your symptoms get better or disappear when your period starts. Your HCP will also ask about what medicines you take including any over-the-counter medicine, vitamins and dietary supplements. They  may order tests to make sure your symptoms are not caused by another condition such as a problem with your thyroid gland. Also, your HCP may ask you if you have ever been treated for a mood or anxiety disorder, substance abuse, headaches, chronic fatigue or other medical conditions that can sometimes get worse a few days before a  menstrual period.

Is there anything I can do to treat my PMS symptoms?

Nutrition and lifestyle changes are a first step. The following suggestions are healthy recommendations for everyone and are particularly helpful for young women with PMS symptoms, according to research.

Nutrition Changes:

• Eat whole grains that are high in fiber (such as whole grain breads, whole wheat pasta, and high fiber cereals instead of white bread, white pasta, and sugary cereals). Whole grains help to keep blood sugar levels more stable compared to refined grains such as white bread, which could keep cravings under control and prevent mood changes associated with PMS.
• Cut back on sugar and fat. Even though your body may be craving sweets or fast foods that are high in fat, try to limit these foods since they may add to your PMS symptoms such as bloating.
• Limit foods high in salt (sodium) for the few days before your period. For example, avoid: canned soups, Chinese food, hotdogs, chips, and pizza which are very high in sodium. Cutting down on sodium may help to control bloating by lowering the amount of fluid your body retains.
• Keep hydrated. Drink plenty of water to reduce bloating and help with digestion.
• Cut back on caffeine. Reducing the amount of caffeine you eat and drink (soda, coffee drinks, and chocolate) may help you feel less tense and may also ease irritability and breast soreness.
• Try eating up to 6 small meals a day instead of 3 large ones and include a balance of foods and nutrients (lean protein, whole grain carbohydrates, fruits/veggies, and healthy fats such as olive oil or avocado) at each small meal. This will help keep your blood sugar levels even, which will give you energy that lasts.
• Don’t forget calcium! Research studies have shown that getting 1300 mg of calcium per day may help with PMS symptoms such as mood swings, headaches, and irritability. This means you should eat or drink three to four servings of high calcium foods (such as milk, Calcium fortified OJ, or soy milk) each day or take calcium supplements.

Lifestyle Changes:

• Fit in exercise. Do aerobic exercise (such as running, dancing, or jump roping) for 30-60 minutes a day, 4 to 6 times a week.
• Catch your ZZZ’s. If you’re a teen, you need about 9 hours of sleep each night.
• Try to maintain a regular schedule. This includes meals, exercise, and bedtime.
• Keep stress to a minimum. If possible, try to schedule events that you think could be stressful during the week after your period.
• Avoid alcohol. Drinking alcohol before your period can make you feel more depressed.

Are there medications that might help?

If your symptoms don’t improve with a few nutrition and lifestyle changes, talk with your health care provider (HCP). They may be able to prescribe medicine that will help lessen or get rid of your discomforts. There are many different medicines that are currently used to treat PMS symptoms. The most commonly prescribed are oral contraceptives (birth control pills) which prevent ovulation and keep hormone levels even. Most pills (particularly those that are low in progestin or contain drospirenone) can improve symptoms. Sometimes symptoms can improve even more if the pill is taken continuously (one active pill every day and no placebo pills). Other medications such as ibuprofen or naproxen sodium  can help to relieve lower back discomfort and headaches.  A mild diuretic such as Spironolactone can lessen bloating and mood changes. If depression is a significant issue, your health care provider may prescribe antidepressants such as Fluoxetine, Sertraline, or other SSRI medicines either for the 7 days before your period or daily.

Are there vitamins or minerals that will improve my symptoms?

Although more research studies are needed, there are certain vitamins and minerals that may help PMS symptoms. Several research studies show that calcium can significantly decrease many of the symptoms associated with PMS. Make sure that you are getting the recommended 1300 mg/day from calcium-rich foods or drinks or from supplements. Other supplements that could help with PMS symptoms are magnesium (400 mg/day), vitamin B6 (100 mg/day), and vitamin E (400 IU/day), but more research is needed. Check with your health care provider about whether you should try them and how much you should take because taking high doses of supplements can have unpleasant or dangerous side effects. For example, high doses of magnesium may cause diarrhea in some people.

Menstrual periods can be light and easy for some teens and young women, but for others, they can be heavy and/or accompanied by painful cramps. Cramps can be a big reason why girls are absent from school, why they miss sport practices, and why they may avoid social events with their friends.

What is Dysmenorrhea?

Dysmenorrhea (pronounced: dis-men-o-ree-a) is a medical term that means “difficult or painful periods.” There are two types of dysmenorrhea, primary and secondary.

Primary dysmenorrhea is the most common kind of dysmenorrhea. Cramps (pain in the lower abdomen (belly) area and/or lower back) can start 1-2 days before your period comes and can last 2-4 days.

Secondary dysmenorrhea is when cramps and, for some, lower back pain are a result of a medical problem such as endometriosis or pelvic inflammatory disease.

What causes menstrual cramps?

Menstrual cramps are caused by uterine contractions (when your uterus tightens and relaxes allowing blood to leave your uterus). The lining of your uterus releases special chemicals called “prostaglandins.” These substances can increase the intensity of the contractions, especially if the levels rise. High levels of prostaglandins may also cause nausea and lightheadedness.

*Some or all of these problems may start a day or two before your period and can last for part or all of your period. These signs could be caused by other medical conditions and therefore it is important to talk with your health care provider about your symptoms.

Is it normal to have some mild cramps during your period?

Yes, it is normal to have mild cramps during your period because of uterine contractions. The uterus is a muscle that tightens and relaxes which can cause jabbing or cramp-like pain. However, if the discomfort is not relieved with over-the-counter medications and causes you to miss school or other daily activities, it could mean that there is another reason for your symptoms.

It is common for young women to have irregular periods when they first begin to menstruate. This means that ovulation (when a woman’s body makes eggs) may not happen for a few months or even for a few years. So, you may not have menstrual cramps when you first begin your period. Menstrual cramps may be more likely in cycles in which you ovulate, and prostaglandin levels are higher. After one, two, or three years, when your hormonal system is more mature, you might have more painful menstrual cramps.  But you can have menstrual cramps from your first periods even when you are not ovulating.

If your cramps are severe and interfere with your daily activities, don’t ignore what your body is telling you. Make an appointment with your healthcare provider because there may be other reasons for your pain.

What other symptoms do girls have during their periods?

Girls may have other symptoms, such as:

• Nausea (feeling like you want to throw up)
• Vomiting (throwing up)
• Loose bowel movements/diarrhea
• Constipation
• Bloating in your belly area
• Headaches
• Lightheadedness (feeling faint)

Are menstrual cramps the same as PMS (Pre-Menstrual Syndrome)?

Menstrual cramps are not the same as PMS. Symptoms of PMS such as bloating, weight gain, and moodiness happen before a woman’s period begins, and get a lot better when her period starts. On the other hand, menstrual cramps usually get worse the first day or two of a period and have a different cause and treatment.

What medicine can I take for my menstrual cramps?

If you are having menstrual cramps, talk with your parents or health care provider about your options. If your menstrual cramps are painful, you may think about taking some type of over-the-counter medication for one to two days. These medications are “anti-prostaglandins.” They help relieve the discomfort, make your flow lighter, and cause your uterus to cramp less. Look for over-the-counter medications such as ibuprofen or naproxen sodium. Take this medicine when you first start to feel uncomfortable and continue taking it every 4-6 hours or as recommended by your health care provider. Since this kind of medicine can upset your stomach, you should take it with food. Make sure you read the label to see how much and how often you should take the medication. You should not take these products if you are allergic to aspirin-like medicine or have stomach problems. It is important not to take more medicine than is recommended or prescribed.

Is there anything else I can do to help my menstrual cramps?

Natural remedies such as a microwavable warm pack or a heating pad placed on your abdomen (lower belly) may help. Soaking in a warm bath may also relieve uncomfortable cramps. Some teens find that increasing their physical activity helps; others find that resting quietly for short periods of time helps.

Acupuncture is an alternative treatment that is sometimes recommended to treat menstrual cramps. A TENS unit is another form of alternative treatment that is often recommended for managing menstrual cramps. You should also eat healthy foods, drink lots of fluids, and get plenty of rest. Check with your health care provider about different treatments that work best for you.

Is it okay to exercise when I have my period?

Exercising is a good way to stay fit and healthy. Some girls like to exercise when they have their period because it helps lessen their cramps. Other girls are uncomfortable exercising when they have their period. You should find what works best for you. Talk to your coach or gym teacher if exercising is uncomfortable during your period.

What if nothing helps my menstrual cramps?

If your menstrual cramps are not relieved by over-the-counter medicine, make an appointment to see your health care provider. Use a period and symptom tracker for 2-3 months and then bring it to your next medical appointment. A record of your symptoms can help your health care provider figure out the best treatment choices for you.

My Monthly Period & Symptom Tracker

My Monthly Period & Symptom Tracker is an easy way to keep track of your menstrual flow, and it’s also a way to keep track of cramps, and/or PMS and period symptoms (if you have them) each month.

• Review the sample Monthly Period & Symptom Tracker.
• Print out copies of My Monthly Period & Symptom Tracker.
• Simply make a check mark in the appropriate box (or boxes) for each day of the month. If you don’t have any flow or any symptoms on any given day, leave the box empty. Refer to the Blood Flow Key at the bottom for “Flow” definitions.
• The dates at the top are the same as the dates in one month. Some months have 28 days, others have 30 or 31.
• Remember to bring My Monthly Period & Symptom Tracker or your smartphone app with you to your medical appointments.

Sample Monthly Period and Symptom Tracker

My Monthly Period and Symptom Tracker

It’s common for many girls to have mild pain with their periods a couple of days each month. However, if your pain is not relieved with over-the-counter pain medicine, and you miss school or doing things with your friends because of it, you may have “dysmenorrhea” (pronounced: dis–men–o–ree–a).

What is dysmenorrhea?

Dysmenorrhea is a medical term that means “difficult or painful periods”. There are two types of dysmenorrhea; primary and secondary.

• Primary dysmenorrhea is the most common kind of dysmenorrhea. Cramping pain in the lower abdomen (belly) can start from 1–2 days before your period begins and can last 2–4 days. The pain is typically similar from one period to the next.
• Secondary dysmenorrhea is when cramps are a result of a medical problem such as endometriosis. Endometriosis is a condition that occurs when tissue similar to the lining of the uterus is found outside its normal location. This usually causes pain before and/or during a young woman’s menstrual period.

What causes dysmenorrhea?

The cramps you feel as a result of dysmenorrhea are caused by uterine contractions (when your uterus tightens and relaxes, allowing blood to leave your uterus). The lining of your uterus releases special chemicals called “prostaglandins” (pronounced: pross–ta–glan–dins). These chemicals are released from the lining of the uterus and increase the strength of the contractions, especially during the first couple of days of a woman’s menstrual cycle (when levels are high). High levels of prostaglandins may also cause nausea, diarrhea, and lightheadedness.

What are the symptoms of dysmenorrhea?

Most young women who have dysmenorrhea experience lower back pain and cramping in the lower area of the abdomen during their periods. This pain can range from dull to throbbing. Some girls may have other symptoms during their period such as nausea, vomiting, loose bowel movements/diarrhea, constipation, bloating in the belly area, headaches, and/or lightheadedness, all of which can be mild to severe.

Is it normal to have cramps during your period?

Yes, it’s normal to have mild cramps during your period, because of uterine contractions. The uterus is a muscle that tightens and relaxes. This can cause jabbing, or cramp–like pain. However, if the discomfort is not relieved with over-the-counter medications (such as ibuprofen) or causes you to miss school or other daily activities, it could mean that there is another reason for your symptoms.

Some or all of these problems may start a day or two before your menstrual period and can last for part or all of your menstrual period. These signs could be caused by other medical conditions and therefore it’s important to tell your health care provider about all of your symptoms. If your pain interferes with your daily life activities, you should see a health care provider to evaluate further.

Is it okay to exercise when I have my period?

It is safe to exercise when you have your period, and it’s a great way to stay healthy. Exercise can be very beneficial in managing period symptoms, especially cramps. Some girls enjoy high intensity exercise such as running, cycling, or kick boxing. While others enjoy low intensity work outs such as yoga, walking, or weight training. Whether it’s high or low intensity, exercise is may be beneficial in managing period symptoms, give it a try!

Are menstrual cramps the same as PMS (Pre–Menstrual Syndrome)?

Menstrual cramps are not the same as PMS. Symptoms of PMS such as mood swings, breast soreness, and bloating happen before a woman’s period begins and get better when it starts. On the other hand, with dysmenorrhea, cramps are usually worse the first few days of a woman’s period and have a different cause and treatment.

How is dysmenorrhea treated?

• Anti-inflammatory medication– If your menstrual cramps are painful, you may want to take an over–the–counter nonsteroidal ant-inflammatory (NSAID) medication for 1–2 days of your period. If your pain is severe, you may want to begin taking an NSAID 1-2 days before your period starts. These medications are “anti–prostaglandins” (pronounced: an–tee–pross–ta–glan–dins), meaning that they work to stop the cramping effects of prostaglandins. They help to relieve discomfort, make your flow lighter, and cause your uterus to cramp less. Try over–the–counter medicine with ibuprofen (Motrin) or naproxen sodium (Aleve) in it. Make sure you read the label so you know how much and how often to take it. You should not take these medications if you are allergic to aspirin–like medications or if you have stomach problems (such as ulcers). Remember to always take these medications with food.
• Additional pain reliever medication- If your menstrual cramps are still painful or you cannot take over-the-counter NSAID medications, you may want to take Acetaminophen (Tylenol). You can take acetaminophen 1-2 days of your period. If your pain is severe, you may want to begin taking an NSAID 1-2 days before your period starts. Make sure you read the label, so you know how much and how often to take it. It is OK to take acetaminophen with NSAID medication together at the same time. You may also alternate when you take each medication to help relieve your pain. However, you should not take acetaminophen if you have kidney or liver disease.
• Hormonal treatment – Oral contraceptive pills (OCPs), also called birth control pills, as well as other hormonal treatments (patch, vaginal hormonal ring, Depo-provera, IUD and hormonal implants) are often prescribed because the hormones thin out the lining of the uterus which lessens the blood flow and cramping. These medications are sometimes prescribed continuously so you don’t get a period.

Is there anything else I can do to help my dysmenorrhea?

• Heat – Natural remedies such as a microwavable heating pack or a heating pad placed on your lower abdomen may help. Be sure to check that the heating pad is not too hot, as it can burn your skin.
• TENS Unit are very helpful in relieving the pain caused by menstrual cramps. The pads can be place on the lower abdomen, lower back, or anywhere there is pain. The unit sends soothing pulse via the pads to relax the skin, muscles, and nerve endings.
• Soaking in a warm bath may also help to relieve cramps.
• Acupuncture is a complementary therapy that may be recommended to treat dysmenorrhea.
• Yoga is a type of exercise that has shown to help lessen menstrual cramps for some girls/women.
• Regular exercise has been known to lower pain.
• Pelvic Floor Physical Therapy is known to help relax the muscles of the pelvic floor to help lower pain.
• Track your menstrual cycle with our period and pain tracker to see if there is a pattern to your pain–when it begins and ends.

What is a Period and Pain Tracker?

This is a tool to help you keep track of your menstrual cycle and any pain you may have; when it comes, where it hurts, how long it lasts, and what relieves it. It’s a good idea to keep track of your pain for about 3 cycles. Be sure to bring your completed Period and Pain Tracker with you when you have appointments with your health care provider or gynecologist.

Do I need to have any tests?

If comfort measures such as using a heating pad, TENS unit, exercising, and taking over-the-counter medicine and/or hormonal treatment are not helpful, or the pain gets worse, make an appointment to see your health care provider (HCP) or gynecologist. Your HCP will decide if you need to have any tests such as a pelvic ultrasound. If you are sexually active, your HCP may test you for sexually transmitted infections (STIs). If you still have pain after 2-3 months of taking OCPs and mild pain medication, your HCP may talk to you about seeing a gynecologist. Your gynecologist may discuss another procedure called laparoscopy to find out the cause of your pain.

Most girls who play sports have regular menstrual periods, and girls who are very active may skip a few periods. However, some girls who train really hard and don’t get enough nutrition may skip many menstrual periods, or they may get their period at a later age than usual, especially if they’ve lost weight, are not taking in adequate nutrition, or if they’ve developed an eating disorder.

Who is at risk for the Relative Energy Deficiency in Sports (RED-S)?

Athletes who do a lot of physical activity are at risk for low energy availability due to under eating, over exercising or both. Athletes who are very competitive or focus a large part of their lives on their sport are considered to be at a higher risk. Certain activities that involve a lot of endurance (such as long distance running) may put you at more risk for RED-S. There is also a higher risk among girls involved in activities that demand a thin physical appearance, such as gymnastics or dancing. Being aware of these demands or pressures on your body is a good first step towards keeping yourself healthy. It’s important to remember to balance your sports activities and nutrition. The right balance will keep you healthy.

What is the Relative Energy Deficiency in Sports and what causes it?

Relative Energy Deficiency in Sports (RED-S) is a syndrome (collection of signs and symptoms) that links health problems including: low energy availability with or without disordered eating, menstrual dysfunction, low bone density, cardiovascular and psychological health. The definition was recently expanded to include all athletes, not just those who have periods, though you may still hear the term “Female Athlete Triad” describing this syndrome. However, girls may begin to skip periods if they are not getting adequate nutrition for the amount of exercise they do (energy availability). Periods also may be irregular. Stress lowers estrogen levels, which may cause skipped periods. Low estrogen levels and a lack of menstrual periods can lead to low bone mass (low bone mineral density) and stress fractures (small cracks) in their bones.

Health care providers, athletes, and coaches may continue to use the term “Female Athlete Triad” (triad means three) or the more recent “Relative Energy Deficiency” to refer to athletic girls who have the following:

1. Insufficient nutrition for the level of activity, termed “Low energy availability” (with or without disordered eating):Healthy female athletes get enough calories through the food they eat to provide their body with energy. Unhealthy female athletes do not get enough nutrition (calories/energy). The result can lead to low body weight, irregular menstrual cycles and low bone density that may or may not happen all at the same time. Even eating regular amounts of food may not be enough for a very active person to maintain a normal weight. Healthy nutrition is needed to have regular periods and normal estrogen levels. If you lose weight, you are especially likely to skip periods. Some girls also have an eating disorder such as anorexia nervosa or bulimia. When a young woman with anorexia nervosa or bulimia exercises too much, she is putting an extreme strain on her body.
2. Menstrual Dysfunction: This is defined as the irregular, infrequent, or amenorrhea (no menstrual periods) for longer than 90 days. This lack of menstrual periods can happen when there is significant weight loss, disordered eating, or intense training or exercise. A certain percentage of body fat is needed to maintain a healthy weight and strong bones. Girls will stop having their periods if their weight drops to an unhealthy level for their body, or their nutrition is not balanced. Having your period every 2 to 3 months or very light periods may be a sign that you are not taking in enough nutrients, particularly if you are very active. A healthy weight is especially important for your body to make enough of the female hormone, “estrogen.” Normal levels of estrogen are important for your body to absorb calcium (a mineral your body needs to build strong bones). Low levels of estrogen can cause low bone mass.
3. Low Bone Density: This is when your bones are weaker than they should be. Although physical activity helps to build a healthy skeleton and strong bones, too much exercise can cause problems if you don’t have regular periods and normal estrogen levels. Everyone (teen girls especially) needs the right balance of adequate nutrition, exercise, body weight, calcium intake, vitamin D, and estrogen levels to have healthy bones.

What health problems can RED-S cause in the future?

Each of the above conditions (low energy availability, menstrual dysfunction, and low bone density) are serious conditions that can cause health problems in the future and the need for special medical care. Even if you only have one or two of the conditions, it’s important to talk about them with your health care provider. For example, athletes may eat a healthy diet yet still skip menstrual periods and be at risk of low bone mass.

Disordered eating can cause heart problems such as an irregular heartbeat, muscle weakness or fatigue, fainting, and loss of concentration with school work and athletics.

Menstrual Dysfunction- Irregular/infrequent or no periods are signs that your body is not functioning properly. The biggest concern is that low estrogen levels may result in low bone mass.

The teen years are the most important time in a girl’s life for developing healthy and strong bones for the future.  Most healthy young women will gain most of their bone mass (bone strength) by the time they are 18 years old; however, the peak time for developing healthy bones is between 11 and 14 years of age. This means that by the time you are 20 years old, your bones will likely be the strongest they will be.

During your teen years, low bone mass and intense exercise can make it easier for you to get stress fractures. A stress fracture is a very small crack that can occur in bones when you do the same activity over and over for too long. For example, a runner may get a stress fracture in her lower leg or foot, and a gymnast may get a stress fracture in her spine. If you continue to do the activity in spite of the pain, the bone may break.

How will I know if I have low bone mass?

If you are skipping periods and your health care provider is worried about low bone mass, he/she may suggest that you have a test that can tell whether your bones have lost thickness or strength. One of these tests is called a DXA (Dual Energy X-Ray Absorptiometry) scan. It’s a painless test that uses low radiation waves (multiple x-rays) to take a picture of your bones. The test results allow your health care provider to assess whether you have more or less bone mass compared to other girls your age.

What should I do if I’m a female athlete?

• Give your body enough energy to fuel your performance. During sports seasons, make sure you eat a healthy diet with enough calories to make up for all of your training. Ask your health care provider: What is a healthy weight for you? Try not to lose weight if you are already at a healthy weight. Eat a balance of fats, protein, and carbohydrates. Make sure you get 1300 mg of calcium and at least 600 international units of vitamin D every day (through eating a healthy diet and taking vitamins) to keep your bones strong. Over-the-counter multi-vitamin tablets contain different amounts of vitamin D.
• Keep a menstrual calendar. Use a calendar or phone app to keep track of when your periods start and how long they last. If you’re skipping periods, see your health care provider. It may be a sign that your body is under too much stress, or that you’re not taking in enough nutrients (calories).
• Don’t ignore injuries. If you develop the same pain in your leg or foot every time you run, the same pain in your back whenever you do gymnastics, or the same pain in any part of your body whenever you do the same activity, you may have a stress fracture. Be sure to get it checked out.
• Talk with your health care provider. If you are bingeing, purging, not letting yourself eat, avoiding fats in your meals, or worried about your weight a lot of the time, get help from coaches, trainers, and health care providers. While some problems may be hard to talk about, the earlier they are treated, the better.