Editor’s note: This article is a slightly revised excerpt from Dr. Jen Gunter’s new book, Blood: The Science, Medicine, and Mythology of Menstruation. While this excerpt focuses on alternative therapies, the rest of the book highlights evidence-based information. Thank you to Dr. Gunter and Citadel Press for granting permission.
Pain, as defined by the International Association for the Study of Pain, is an “unpleasant sensory and emotional experience” and “a personal experience that is influenced to varying degrees by biological, psychological, and social factors.” It’s the only sense that includes an emotional component. That doesn’t mean it’s in your head; rather, this definition encompasses the mind-body connection. As such, pain is not just the electrical signal the brain receives and interprets; many other factors, such as anxiety, depression, adverse childhood experiences, other pain conditions, sleep, stress, belief systems, and cultural factors, can all modify the pain experience in complex ways. Because of these complexities (and inadequate funding for studies), medicine doesn’t always have answers, or the answers have side effects. Sometimes a well-studied therapy doesn’t fit with an individual’s belief systems. And many people have had their pain dismissed by medicine. So, there are several reasons people wish to try alternative approaches.
Treating a medical condition is in many ways like taking a trip. You are at point A, meaning in pain, and want to get to point B, less pain. Therapies are the routes between points A and B. Some routes have better maps than others, and some appear physically impossible—for example, going through a mountain where no tunnel exists. With medical care that has been studied, we can make statements such as “Sixty-five percent of the time, if someone takes Highway 1, they can get from A to B, and we know this because several hundred people took that route and there was someone waiting at point B, counting how many made it through.” Alternate routes are riskier. We can say, “Well, 50 percent of people said this route worked, but we don’t have good evidence to show they made it to point B.” Or perhaps, “That route looks like a shortcut that can’t possibly work because that road doesn’t exist.” Alternative medical therapies are like these alternate routes. Some inhabit a medical gray zone, meaning the hypothesis is biologically plausible and hence intriguing, but the studies aren’t good enough to make a recommendation for the therapy. Others have less plausible hypotheses and/or terrible data.
People sometimes think, “Well, if the hypothesis sounds good, why not?” The trouble is, lots of seemingly brilliant medical hypotheses turned out to be not just duds but harmful. One example is not eating peanuts until age one to reduce peanut allergies. That sounds like it makes sense, right? We should wait until a baby’s immune system can handle peanuts. So, for years, that was the recommendation. As it turns out, that strategy increases the risk of peanut allergies. Another example is taking vitamin E to prevent heart disease. Researchers thought it was a good idea to test this hypothesis because people with diets higher in vitamin E seemed to be less likely to develop heart disease. And hey, vitamin E is an antioxidant, and vitamins must be safe; after all, they are natural and in food. That study came to an abrupt end because of worse outcomes for those who took vitamin E.
For doctors, alternative therapies are a difficult line to walk. Some are low cost and low-risk, but some are expensive and time-consuming, and some, like vitamin E, have hidden risks. If the data were good, these therapies would be standard of care. Although many functional medicine providers and naturopaths do so with confidence, I couldn’t look someone in the eye and recommend an untested and expensive “period repair” supplement. Alternative therapies are often promoted as “natural,” which ties into the health halo of that word (natural being equated to effective and safe). However, there are no supplement trees or farms, so be wary of false advertising.
It’s not wrong to try an alternative therapy. It’s your body and your decision. What is wrong is for a medical provider to misrepresent the therapies. You can make an informed choice only if you are given accurate information. Consider two ways a healthcare provider might discuss turmeric for period pain:
- “Turmeric is a good option for painful periods. It’s an ancient therapy long used in traditional medicine, and it contains the powerful chemical curcumin.”
- “There are a few studies on turmeric for painful periods, but overall, they are low-quality, so it isn’t possible to draw conclusions. The people who propose turmeric typically do so based on a substance it contains: curcumin. Some people recommend turmeric supplements, and others curcumin. It’s debatable whether curcumin is biologically active (whether it does anything meaningful in the body), but even if it is, less than 1 percent of curcumin that is ingested enters the circulation. In addition, curcumin is removed from the bloodstream within minutes (it’s metabolized very quickly), so even if it manages to be absorbed, it’s not likely to hang around long enough to do anything. In higher-quality studies, curcumin has never been shown to be effective for any medical condition, and there are cases of liver failure associated with turmeric supplements.”
If you were to decide to take turmeric for painful periods based on the first advice, you would be making an uninformed choice. But you wouldn’t realize that, because you wouldn’t know your medical provider didn’t give you all the details. On the other hand, deciding to take turmeric after hearing the second description would be an informed choice. You’d have heard about the biological constraints, what research has shown and not shown, and potential downsides. It’s easy to see why many people are attracted to the much shorter, more optimistic but much less informative and ultimately unethical presentation.
With all of that in mind, here are some alternative options you might hear about and can consider for painful periods or endometriosis-related pain. For the record, I discuss some of them in the office, but I do so with the principles of informed consent that I just used for turmeric, which I suppose can be summed up as a “warts and all” approach.
Diet
Can diet affect painful periods? Maybe. And that’s really a maaaaaaybe. Studies have linked a variety of diets and/or foods with less period pain: low-fat vegetarian, higher in fruit, lower in legumes, lower in omega-6 fatty acids, lower in alcohol, lower in meat, higher in dairy. Some of these recommendations are contradictory, which is problematic. For example, vegetarians often eat legumes and omega-6s, so if a vegetarian diet is helpful, how is a diet higher in legumes and omega-6s harmful?
Diet data largely comes from observational studies, meaning people told researchers whether they had period pain and what they typically ate. Observational studies have a lot of issues. First, people’s recall isn’t always accurate. Second, we may not know who has endometriosis and who has painful periods. But even more importantly, what we eat is associated with a variety of factors that might affect pain and are unrelated to the actual food. For example, living in poverty can decrease the availability and affordability of fresh fruits and vegetables and can reduce access to health care, which can increase the risk of having untreated causes of pain. People with period pain may be more likely to choose ready-made meals because they are in too much pain to grocery shop and/or prepare food, but ready-made meals tend to be lower in fiber and contain seed oils, which have omega-6s. Or people with pain may feel comforted when they eat certain foods. Basically, diet can be linked with period pain in myriad ways, but not as a cause-and-effect kind of relationship. Finally, people have been eating very different diets around the world for millennia, and no culture seems immune from period pain.
To answer the question about diet and menstrual-related pain, we need randomized studies, meaning one group is randomly assigned to one diet and another almost identical group is assigned to a different diet, and then these two groups are followed to see if, over time, they report different levels of period pain. We just don’t have this data.
Omega-6 fatty acids have been getting the villain treatment lately—being blamed for everything from type 2 diabetes to heart disease to brain fog and, yes, painful periods—and it’s not uncommon to see period coaches and naturopaths vilifying seed oils because they are high in omega-6s. Omega-6 and omega-3 fatty acids are polyunsaturated fats that are essential for our bodies. Omega-6s are found in vegetable oils, nuts, and seeds; omega-3s are found in fish, vegetable oils, some nuts, flax seeds, flaxseed oil, and leafy vegetables. Some people believe omega-6s are inflammatory, and from a period standpoint, one theory is that the linoleic acid in omega-6s increases arachidonic acid, a necessary step in making prostaglandins, substances that cause painful periods. However, less than 1 percent of the linoleic acid in our food is converted into arachidonic acid, and arachidonic acid itself can be anti-inflammatory. Basically, it’s complicated. But there are quality studies that don’t link omega-6s with inflammation. In fact, they’re associated with lower rates of heart disease, which suggests they aren’t inflammatory.
It’s important to remember that seed oils, the oils high in omega-6s, tend to be used in ultra-processed foods and fried foods in restaurants, which are linked with inflammatory health conditions. However, the omega-6s aren’t the culprit; these foods also tend to have a lower nutritional value and are calorie-dense.
What about people who say they feel better, cramp-wise, after changing their diet? It’s definitely possible to feel better within a few cycles after a dietary change. For example, if you increase your fiber intake, you are less likely to have constipation, and most people feel better when they aren’t constipated (that’s the understatement of the year). Improving diet quality may reduce bloating or heartburn and, again, that might make you feel better. Moreover, just the idea of self-care (and changing diet can be self-care) can make people feel better. It is also possible that changing diet affects pain in a way we have yet to understand.
The best we can say is that a traditional Western diet—one that is higher in calorie-dense, nutritionally poor foods, lower in fiber, and higher in saturated fat—is the least healthy diet overall. Trans fats are inflammatory and should be avoided for many health reasons. (They are banned in the United States and Canada but are still available in many countries.) Aiming for healthier diet choices is beneficial for many reasons, and if you are healthier overall, that may well be better for period pain. Given how many awful messages girls and women receive about their bodies, and the state of food policing, in the absence of high-quality data, my default is to simply consider these basics:
- Aim for at least 25 g of fiber a day. I really like this approach, as it adds something rather than taking something away. Foods high in fiber are associated with a low risk of breast cancer, colon cancer, and heart disease.
- Increase your intake of fruits and vegetables (this helps in the fiber department too).
- Try to eat two servings of fish a week (assuming you aren’t vegetarian or vegan).
- Reduce animal fats. Swap in cooking oils for butter, introduce two to three vegan meals per week, choose leaner cuts of beef or eat less beef, and switch out whole milk for 2% milk, skim milk, or even plant-based milks.
- Consult a registered dietician for good advice on dietary changes that are healthier overall. Personally, I’d take a hard pass on anyone who vilifies seed oils or sells supplements. Also avoid people who call themselves “functional nutritionists,” as that isn’t a recognized branch of health care.
- Reduce alcohol intake. Not many people want to hear this, but overall, less is better.
Exercise
The data here are not the greatest, but overall, it seems that exercise may reduce the intensity of painful periods. Because of the low quality of the studies, we can’t specify what type of exercise—whether aerobic, weightlifting, or some of both—or how many minutes is optimal. One theory is that exercise may reduce inflammatory mediators that are part of painful periods, but there is a lot of “maybe” and “possibly” here. However, we know exercise is beneficial for overall health, so it may be indirectly helpful for menstrual pain.
When I was a teen with painful cramps, if someone had said, “Well, you could treat your pain by exercising,” I would have rolled my eyes. When my cramps were at their worst, any movement was painful. I’ve explained how pain can spread to other body parts, and for some that can be the abdominal wall. For me, it was often physically painful to stand up straight. In addition, given my menstrual diarrhea, there were times when I simply couldn’t be far from a bathroom. I didn’t exercise regularly, so telling me to start would have been as helpful as telling me to fly to the moon. However, when I began to get into running in my thirties, I did find that exercise was helpful when my cramps were uncomfortable but not excruciating. I don’t know whether it was because exercise helped my mood and made me feel better that way, or because it provided a distraction (a valid therapy for pain), or because it lowered inflammatory mediators and directly reduced my pain. Over the years, the better I got at exercising, the more I could do it when I had cramps.
This is all anecdotal, and there are many other potential explanations, but if you suffer with bad cramps and don’t exercise regularly, consider starting an exercise regimen on the days you don’t have pain. Ideally, you’d get 150 minutes of moderate-intensity aerobic activity and two days of muscle strengthening activity a week. At the very least, this movement will make you healthier overall, and it will likely help your body deal with the stress of menstruation. If you find that exercise during your period helps, great; do it. If you find that it makes things worse, then don’t do it.
Dietary Supplements
Despite what you might see on Instagram, Facebook, and TikTok, there is no quality evidence supporting supplements for painful periods. It’s important to acknowledge that even the information I’ve included here is based on lower-quality studies.
There are two kinds of supplements: those that contain a single active ingredient (for example, magnesium or calcium) and those that contain multiple products (usually combinations of vitamins, minerals, and botanicals/herbs). Single-ingredient supplements that have been studied, may make some sense biologically, and seem low-risk include:
- Magnesium: 360 to 400 mg a day for three days, starting one day before the onset of bleeding. Magnesium can cause diarrhea, so keep that in mind.
- Thiamine (vitamin B1): 100 mg daily.
- Fish oil capsules: 6 g (containing 1,080 mg EPA and 720 mg DHA), divided into two doses a day, or 2 g of krill oil a day.
- Vitamin B6: 200 mg a day.
- Ginger capsules: 750 to 2,000 mg a day for the first three days of bleeding.
It’s best to avoid products with multiple ingredients, especially those with “proprietary blends” listed on the label. These combination products have not been tested, and with a “proprietary blend,” you have no idea the exact amount of each ingredient in the blend. So you, the consumer, assume all the potential risks.
My advice to anyone who wants to try any of these products for period pain is to give them a go for three cycles, then decide if the benefit is worth it. If you do go this route and try a supplement, I suggest a brand that has been verified by an independent third party (for example, the label should say USP verified), meaning the ingredients have been independently verified for quality and the bottle contains what is listed on the label.
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Pain is an individual experience, and for some people who want to avoid pharmaceuticals, trying less-studied interventions, such as supplements, may be appealing. In addition, dietary changes such as adding more fiber, fish, and plant-based protein and meeting the health guidelines of exercise may or may not directly help with pain, but they will help overall health and should always be encouraged.
