by Ros Wood and Ellen T Johnson

Most of us with endometriosis know quite a bit about having pain. Unfortunately, we know a lot less about how to manage that pain. In our attempts to deal with pain, many of us have used various medications such as aspirin, Paracetamol, Panadol, or Tylenol. These drugs alleviate pain by reducing the body’s sensitivity to pain.

Fewer of us are familiar with the use of the non-steroidal anti-inflammatory drugs (NSAIDs) for managing pain. Some of the more common NSAIDs include ibuprofen (ACT-3, Advil, Brufen, Motrin, Nurofen), naproxen sodium (Aleve, Naprogesic, Naprosyn, Naproxen), ketoprofen (Orudis KT), and mefenamic acid (Ponstan). These drugs can be effective in alleviating pain and inflammation, but to do so, they must be used correctly. Too often, women are prescribed NSAIDs without clear instructions about their use, so they use them the same way they use analgesic drugs. However, when used incorrectly, NSAIDs don’t work.

It is thought that much of the pain of endometriosis, especially menstrual pain, is due to inflammation that may be caused in part by high levels of “bad prostaglandins.” Prostaglandins are hormone-like chemicals that can be found in every cell of the body. Prostaglandins have beneficial effects (enhance immune function, block inflammation, relax muscles, maintain the integrity of the stomach lining, dilate blood vessels, etc.), as well as detrimental effects (produce inflammation, decrease oxygen flow, contract muscles, induce pain, etc.). The bad news is that women with endometriosis have been shown to produce an excess of a prostaglandin called PGE2, which causes inflammation, pain, and uterine contractions.

Theoretically, NSAIDs would seem to be a good choice for relieving menstrual pain because most of them work by blocking the production of all prostaglandins. The result is less pain, swelling, and inflammation. However, since NSAIDs work by stopping the production of the pain-causing prostaglandins, they must be taken before any of these chemicals are produced. In other words, you must start taking NSAIDs at least 24 hours before you expect to experience pain. If you delay taking them until after you feel pain, the medication cannot block the pain-producing chemicals that have already been released, so they will not alleviate pain.

If you are using NSAIDs for ovulation pain or menstrual pain, it is recommended that you start taking them as directed at least 24 hours before you expect to ovulate or 24 hours before you expect to start bleeding. If you have an unpredictable menstrual cycle, you may want to take them for a week or more before you expect menstruation to begin. To be effective, it is important to take NSAIDs regularly every six hours so that no pain-producing chemicals are produced during ovulation or menstruation. Another advantage of taking certain NSAIDs is that they decrease the amount of menstrual bleeding (1, 2).

There are many different brands of the NSAIDs available. Some are available over-the-counter at your local pharmacy, while some are available by prescription only. It is difficult to predict which type of NSAID will be effective for a particular individual, so you may need to try two or three brands before finding one that relieves your pain. Talk to your pharmacist or doctor about suitable brands to try. If you’ve already tried an NSAID without success, you may want to try again. If you were using them incorrectly before, try starting them well in advance of your pain so that no pain-producing prostaglandins are produced.

The most important thing to remember is that unlike analgesics, NSAIDs do not block existing pain. Instead, they block the production of prostaglandins that produce the pain. Therefore, they must be taken before you feel any pain. And they must be taken every six hours around the clock if they are to work effectively.

Like many drugs, NSAIDs can have side effects – some quite serious. Because NSAIDs block all prostaglandin production, they also block the good prostaglandins responsible for maintaining the integrity of the stomach lining. That’s why the most common side effects of NSAIDs include nausea, vomiting, diarrhoea, irritation of the stomach, and stomach ulcers. To help reduce stomach irritation, NSAIDs should be taken with food. Newer NSAIDs called selective COX-2 inhibitors (Vioxx, Celebrex, Bextra) were originally thought to cause less bleeding and fewer ulcers than traditional NSAIDs. However, follow-up studies on these drugs have shown there is no clinically meaningful safety advantage over traditional NSAIDs. Therefore, COX-2 inhibitors should be used with the same caution as any other NSAID. If you are considering taking any type of NSAID, be sure to ask for a complete list of potential side effects, warnings, and possible drug interactions from your pharmacist or healthcare practitioner. Also be sure to inquire about the types of side effects that should be reported to your doctor immediately.

Finally, it’s important for you to know that the effects of “bad prostaglandins” can also be moderated in part by diet and supplements. As we’ve discussed in prior articles and interviews with Dian Shepperson Mills, reducing animal fats, caffeine, and alcohol, and adding flax oil, fish oil, and olive oil to your diet can increase the production of “good prostaglandins” and decrease the production of “bad prostaglandins.” If you cannot take NSAIDs (or choose not to), dietary changes may be a good option to try.

  1. Nonsteroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev 2000;(2):CD000400, ISSN: 1469-493X, Lethaby A; Augood C; Duckitt K; Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
  2. Medical management of dysfunctional uterine bleeding, Baillieres Best Pract Res Clin Obstet Gynaecol 1999 Jun;13(2):189-202, ISSN: 1521-6934, Irvine GA; Cameron IT Ayshire Central Hospital, Irvine, UK

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