KUALA LUMPUR: "Why are women today complaining about period pain? We have not heard of our grandmothers and mothers complaining of menstrual cramps."
These were among the comments raised under the discussion surrounding menstrual leave, questioning the prevalence of severe menstrual cramps (or medically known as dysmenorrhoea) and menstrual disorders including fibroids, endometriosis, adenomyosis, and polycystic ovarian syndrome (PCOS).
What could be the problem? Are women now 'weak'? Is it the lifestyle, diet, or environmental factors? Or are women just starting to recognise these problems? Also, is western medicine the only answer to the many menstrual disorders?
Experts - consultant obstetrician and gynaecologist Datuk Dr N.K.S. Tharmaseelan and Obstetrical and Gynaecological Society of Malaysia president Dr Hoo Mei Lin - spoke to the New Straits Times.
Read more on what gynaecologists, academicians, and stakeholders including the Malaysian Employers Federation (MEF) and the Malaysian Trades Union Congress (MTUC) had to say on this issue: Menstrual leave for women workforce in Malaysia: A boon or bane?
INCREASING PREVALENCE OF MENSTRUAL DISORDERS
"This phenomenon (menstrual problems) has been increasing steadily over the years," said Dr Tharmaseelan.
It is a known fact that late marriage, having fewer children, stress, and a changing lifestyle with possible smoking and alcohol produce inducing factors that damage the fertile landscape (the reproductive system) in women, he said.
"Most of the earlier generation of women, including our mothers and grandmothers were housewives who stayed at home, married very early, usually around 15 or 16 years old and had 'lots of children'.
"Times are changing. More and more women are joining the workforce and probably a majority of women are in the workforce to contribute to the family earnings to support their family.
"Along with this comes a changing lifestyle too. Marrying late or not at all, having fewer children or no children either by choice or unable to are among other reasons. A working wife who has to care for the family and goes to work leads a much more stressful life too."
He said fibroids , endometriosis , adenomyosis , and PCOS , pelvic inflammatory disease, obesity are some of the disorders associated with dysmenorrhoea and infertility.
PCOS, for instance, was said to be "rare" until the late 1990s, according to a 2020 study published in the Journal of Human Reproductive Sciences. The study noted that today, one in 10 women is diagnosed with PCOS across the world.
Dr Tharmaseelan said PCOS is associated with obesity, diabetes, and stress, thus a healthy lifestyle should be encouraged.
"Being active, maintaining an ideal weight, reducing refined carbohydrate and sugary drink intake, avoiding fried foods, processed meats, processed food are important preventive measures.
"These are very evident in today's daily lifestyle of Malaysians. Our lifestyles have changed compared to the previous generation.
"An unhealthy lifestyle has contributed immensely to many health problems that seem to sprout rapidly. We should start taking care of our personal health just as we are concerned with our financial health."
Dr Tharmaseelan, who is the former Malaysian Medical Association president said this when commenting on the debate surrounding menstrual leave in Malaysia.
Dr Hoo noted that endometriosis and fibroids are not uncommon among women in Malaysia.
"Out of the 100 women screened, 40 per cent have fibroids and out of that figure, 80 per cent did not even know they have fibroids as they were asymptomatic.
"I wonder if we are seeing a true increase in incidents or whether we are just getting better at picking up the symptoms and through screening. More research needs to be done."
Dr Hoo added that incidents of menstrual disorders could either be on the rise due to improved diagnostics, better tests, or increased awareness of symptoms.
According to Johns Hopkins Medicine, an estimated 20 per cent to 50 per cent of women of reproductive age currently have fibroids, and up to 77 per cent of women will develop fibroids sometime during their childbearing years.
Endometriosis affects roughly 10 per cent of the population globally, according to the World Health Organisation (WHO). The WHO described it as a chronic disease although there is no known cure for it at present and treatment is usually aimed at controlling symptoms.
The Endometriosis Association of Malaysia (MyEndosis) had in February this year shared that some 350,000 women in Malaysia are affected by the disorder.
Read more: Women: 'Menstrual leave, not an admission of weakness'.
Studies found that among other contributing factors to the increasing prevalence of dysmenorrhea and menstrual disorders were altered or impaired immunity, hormonal influences, genetics and environmental contaminants.
For instance, growing evidence suggests that endocrine-disrupting chemicals (EDCs) - found everywhere from plastics to pesticides and makeup - may be etiologically involved in the development and severity of menstrual disorders like dysmenorrhea caused by fibroids, endometriosis or PCOS.
'WE TREAT THE WOMEN, NOT THE REPORT'
Dr Hoo explained that treatment for dysmenorrhea (primary and secondary) is entirely dependent on the cause of the pain.
"We don't treat the report, we treat the woman. We are guided by symptoms in treating patients.
"For example, if the pain is due to uterine fibroid and if the benefits outweigh the risks, then it's worth doing any intervention such as surgery to remove the fibroid and eliminate the pain. It's an easy fix.
"Endometriosis could be tackled with medications where for some women, it can be as simple as taking multivitamins or paracetamol to control the pain, while others have tried traditional Chinese medicine like acupuncture to manage the pain."
Dr Hoo said there are also women who need to be put on hormonal treatment such as oral contraceptive pills to stop the period so they don't suffer every month.
"But if a 21-year-old young woman who has not had kids comes in with bad endometriosis, I may need to create a long term treatment plan tailored to her that will preserve her fertility because she might want to have children in the future.
"If I remove patients' uterus and ovaries, yes their problem with monthly pain may be solved but then they will be left with menopause at age 23 and other problems will arise.
"I always tell my patients to just persevere, have a little faith. Sometimes the treatment is not simple, it may take time. Find a doctor that you are comfortable with and work through it together."
Primary dysmenorrhea, she said is the cramping pain that comes before or during a period.
"We can't find the cause. What happens every month is that prostaglandins (a natural chemical made in the uterus lining) are released causing the muscles and blood vessels of the uterus to contract.
"The levels of prostaglandins are usually high on the first day of your menses, which is why pain tends to be the worst on day one and lessen after a few days. This is also the sort of period pain that some say will cease after pregnancy and childbirth."
While secondary dysmenorrhea, she said means there is a cause like having a disorder in the reproductive organs such as fibroids or endometriosis.
The pain tends to get worse over time and it often lasts longer, sometimes even after the period ends, Dr Hoo said.
"But for gynaecologists to say that one has secondary dysmenorrhea, we have to conduct a diagnosis of exclusion."
She pointed out that sometimes patients "doctor shop", moving from one to another, but they must understand treatment is not simple.
The mainstay of treatment, she said is dependent on the problem or cause, hence no one answer fits all.
Dr Hoo said endometriosis in women, for example is a difficult condition to tackle requiring long term treatment and it is a diagnosis that will be with the women until they stop menstruating.
"So the pain may recur and will only go away when they attain menopause."
WOMEN WITH DYSMENORRHEA SPEND HALF A LIFETIME IN PAIN
In Malaysia, the average age of menstruation among girls is 12 when they are in primary school. It was 17 in the 1800s.
While, Malaysian women enter menopause at an average age of 50 years, according to the Health Ministry.
It is said that typically, women start having dysmenorrhea in their adolescent years, within four to five years of their first menstrual period, or around the age of 16 or 17 when they are in Form 4 or Form 5 in secondary school.
Thus, on average, women with dysmenorrhea, especially secondary dysmenorrhea, may have to endure the pain every month for 34 years, throughout school, university, and well into their work and family lives.
In Malaysia, women have a life expectancy of 78.3 years.
Therefore, women with dysmenorrhea, who either have not sought treatment or have sought treatment, but still experience continuous pain, spend half their lives going through the monthly agony, an observation Dr Tharmaseelan concurred with.
With prolonged heavy bleeding, as in women with PCOS, they experience pain every day, sometimes for weeks and even months at a time.
Read more: NST Poll: Instagrammers vote 'Yes' for national menstrual leave policy.
A quick Internet check found that among the most searched long-tail keywords on periods and menstruation on Google were: "how to write menstrual leave application for school", "how to ask for menstrual leave", "how to write menstrual leave application", and "how to say I got my period in a professional way".
FEAR OF SIDE EFFECTS FROM MEDICATIONS
Dr Hoo said some women have expressed concerns over the possible side effects or complications of consuming prescribed medications, such as oral contraceptives.
She said any treatment has its pros and cons, and it is imperative for patients to have honest discussions with their doctors and be open about their family health history and their personal health and lifestyle.
This would help the doctors come up with tailor-made treatments to minimise side effects and potential complications, she said.
"People often worry about side effects. For instance, birth control pills can slightly increase the risk of developing blood clots in your legs, including deep vein thrombosis (DVT) but many are unaware that pregnancy increases your risk of a DVT as well.
"This does not stop everyone people from getting pregnant now, does it? But of course, if your family has a certain medical history, we will look at it before prescribing the right treatment.
"Besides, we will have regular follow ups with our patients to observe their condition and advice on symptoms to look out for."
HIDDEN COSTS
Financial cost is one of the factors that keep some women from seeking treatment, continuing medication or undergoing surgery, Dr Hoo said.
However, she said one needs to consider the hidden cost as well and not just look at the financial cost of seeking treatment for dysmenorrhea and menstrual disorders.
"There's the financial cost that you can see upfront and then there's the hidden cost such as the cumulative time that you have to take time off work, maybe you lose your job because of this, you cannot perform at work, you cannot be the person that you're meant to be, you may not be able to achieve your full potential because of your health condition. All these are hidden costs.
"And what about the emotional cost? So, we have to move away from thinking just about financial costs.
"Certainly, good treatment does not come cheap. I agree, unfortunately new treatments which may be more effective are also more expensive, which one can't deny."
Studies have shown that dysmenorrhea and menstrual disorders have a profound negative influence on the lives of women, adversely affecting the quality of life, participation in daily and social activities, mental health, educational and work productivity, well-being, relationships and physical and sexual functioning.
A 2021 study published in the International Journal of General Medicine noted that over the course of a lifetime, these daily challenges may translate into limitations in achieving life goals such as pursuing or completing educational opportunities; making career choices or advancing in a chosen career; forming stable, fulfilling relationships; or starting a family, all of which ultimately alter one's life trajectory.
CONSTRAINTS FACED BY GOVERNMENT FACILITIES
Weighing in on seeking treatment at government hospitals, Dr Hoo pointed out that the constraint lies in limited resources, which may not render patients the required medications.
Government hospitals have good doctors and specialists with access to a range of medications that the private sector has, she said adding that the main difference is that the government sector has to look after everyone and not just one patient.
"They only have a certain capital and they have to stretch the allocation so sometimes they may not be able to offer a patient the medication that she requires because they have to think about everyone else."
ALTERNATIVE MEDICINES
Dr Hoo said patients who decide to try traditional medicine should be upfront with their doctors so they can be advised on whether to continue with either western or traditional medicine.
This, she said was crucial as there could be side effects or a medication might not work in the intended manner when mixed with traditional medicines.
"As a doctor, I have to understand what my patients are doing with or without my blessings.
"Although there are some interesting studies that have come up. Acupuncture, for example has been said to help with pain. In fact there is some modern technology now in pain management that is based on acupuncture.
"I have worked alongside some traditional Chinese medicine (TCM) practitioners and I do see the benefit, whether it is placebo or not, it does ease some of the patients' worries. The problem is that there is no standardisation of dosing (for traditional medicine)."
"Doctors can still play a role by conducting screening and monitoring patients' symptoms."
A 2018 study published in the journal of Reproductive Health noted that TCM is often used to treat endometriosis.
Researchers have also looked at other alternative treatments, including Ayurvedic intervention to treat menstrual disorders.
A 2013 study on endometriosis in the journal of Ancient Science of Life found that Ayurvedic treatment reduced the inflammatory conditions and reduced pain.
According to a 2019 study published in the International Journal of Complementary and Alternative Medicine, it is said that Ayurvedic intervention not only help in relieving symptoms due to uterine fibroids but also restores fertility of the women and avoid further complications.
Another study published in the International Quarterly Journal of Research in Ayurveda in 2014 found that Ayurvedic formulations were "very effective in relieving uterine fibroid".
BREAKING THE TABOO
The more fundamental problem that women face, Dr Hoo said is the fact that people are not talking about periods.
"Conversations around menstrual leave will help break the taboo and menstruation stigma.
"Besides, I have always been invited to talk to girls in school about periods, but I have never been invited to talk to boys (about periods) when we should be educating them too. This is sad.
"It (menstruation) shouldn't be something that's so mysterious. We should all be comfortable talking about periods.
"But then again, even among the medical profession, unless you are O&G (obstetrics and gynaecology specialists), they (doctors) don't talk about periods. It appears to be an uncomfortable topic still," Dr Hoo added.