For 10 years, Sarah Banks, 37, from Derbyshire, took co-codamol for period pain every month. Then she started to question whether taking the pills “round the clock” for at least the first four days of her period, was an efficient way of dealing with cramps – or a sign she had become dependent on the codeine-based drug. “I would feel woozy and not quite myself – a little spaced out almost,” she recalls.
“Some months I would take them for a few more days than necessary – there was an element of [liking] the sensation, but also a fear that I would be in pain if I didn’t,” she says. “I was worried that I was developing an addiction.”
Banks ditched the drugs five years ago, and now manages her period symptoms through lifestyle changes such as a diet overhaul and new exercise regime. But for women unable to find a different approach that works for their symptoms, popping codeine-based pills every month is often the norm – big brands such as Nurofen Plus, for example, contain the ingredient.
But with data suggesting a rise of codeine addiction in the UK, should women be worrying about our reliance on it for relief from period pain?
Codeine is a form of opioid, which means it is part of the same family as heroin, and works by stopping pain signals from travelling along the nerves to the brain. You can become tolerant to the drug, resulting in people taking higher doses in order to get the same effect or to avoid withdrawal symptoms such as nervous tremors, anxiety, sleep disorders, vomiting and diarrhoea.
Strong codeine is only available on prescription – a doctor may recommend it to patients with particularly painful periods, such as women with endometriosis – but lower strength codeine is available from pharmacies and is mixed with paracetamol (co-codamol), with aspirin (co-codaprin) or with ibuprofen. It’s often marketed as effective period pain relief.
“Use it in the lowest possible dose.”
- Professor Helen Stokes-Lampard, chair of the Royal College of GPs
Professor Helen Stokes-Lampard, chair of the Royal College of GPs, says for most women, paracetamol and ibuprofen is “usually the most appropriate form of treatment” for period pain. It’s what you should look to first.
But she acknowledges that for some women, menstrual cramps can have a “really detrimental impact on their everyday lives” and they may need stronger painkillers
“For those with more troublesome pains, paracetamol combined with a modest dose of codeine tablets are the strongest form of pain relief patients can buy from a pharmacy, and might help women suffering from particularly acute symptoms,” she says.
“Codeine, however, is an opiate and has the potential to become addictive, which is why we recommend women only use it in the lowest possible dose to obtain pain relief and then for the shortest possible time.”
Dee Montague, 35, says she developed a codeine addiction after she was prescribed the drug for endometriosis-related period pain 15 years ago. “I was prescribed the strongest form of co-codamol, with no warnings or information and told to take eight tablets every day and sent on my way. It was horrible and I had no idea what was happening to me,” she recalls.
“I don’t think I knew I had an addiction until far too late; I woke each day with what felt like severe hangovers.”
The US opioid crisis is well-documented – 130 people are dying every day from opioid overdoses – but experts are also raising concerns over prescription practices in the UK.
A 2018 study led by University College London, found the number of opioid drugs being prescribed to patients in England has been steadily rising since 2010 and that “prescriptions of codeine increased faster than all other opioids”.
In January, UKAT, a chain of private treatment centres, told HuffPost UK it had seen a 45% rise in admissions for codeine addiction in the past three years. And in April, researchers from Dundee University recommended more frequent check-ups and reviews for patients taking codeine to avoid overprescription and potential misuse.
A spokesperson for Reckitt Benckiser, which makes Nurofen Plus, told HuffPost UK the drug is sold for the short-term treatment of pain, such as period pain, which is not relieved by other medication such as paracetamol, ibuprofen or aspirin.
“We make it clear on our packaging, and within product leaflets, that Nurofen Plus should be used at the lowest effective dose for the shortest period of time necessary to relieve symptoms and should not be used for more than three days as it can cause addiction,” they said, stressing that patients should seek medical advice if symptoms persist.
“When medication is taken responsibly and in line with the instructions provided, addiction should not occur.”
“I wish there were better alternatives and that women were more listened to.”
- Dee Montague
Montague eventually found a different GP who helped her ween herself off the drugs. Her endometriosis symptoms had also become less severe, so for some years she had less need to rely on strong painkillers. However, the debilitating pain has returned, and Montague is now cautiously taking co-codamol again.
“I try not to take it for more than three days or at the recommended dosage, but when my pain is very bad sometimes I’m left with little choice,” she says. “I wish there were better alternatives and that women were more listened to and helped when it comes to chronic pain.”
When it comes to those alternatives, Professor Stokes-Lampard advises women with painful period cramps to visit their GP, who can prescribe hormonal treatments including the contraceptive pill, other painkiller options, or specialist intervention, if necessary.
“We know that lifestyle factors can sometimes play a part in the severity of menstrual cramps, and stopping smoking and taking up regular exercise can really help alleviate some patients’ symptoms,” she says. “For others, use of a hot water bottle or taking a warm bath can help.”
Women’s health practitioner Maisie Hill, author of Period Power, began researching menstruation due to her own debilitating period pain, studying at the Integrative Women’s Health Institute, among other places.
She says altering the way you take nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen for period pain may make them more effective. Instead of waiting for your period pains to really kick in, it’s worth taking the painkiller ahead of the cramps starting.
“NSAIDs block the production of prostaglandins – hormone-like substances that cause inflammation, period pain, and uterine contractions,” she explains. “So taking them for 24 hours before period pain is expected to start is more likely to have an effect rather than once you’re already in agony.”
Dr Clare Morrison, GP and medical advisor at Medexpress, agrees this advice “does make sense”, provided you know reliably when the period is due to start.
“For those who have an irregular cycle, this may be difficult to predict. In this case, I would suggest starting ibuprofen as soon as the period starts, and certainly not wait until the pain becomes severe,” she says.
Something else worth considering, she says, is that not everyone can safely take ibuprofen. “It can cause dyspepsia, and stomach ulcers in some people, and shouldn’t be taken by those with kidney disease, heart problems, or high blood pressure. Occasionally it may aggravate asthma and trigger allergies,” she says.
“Some days my back pain is so bad during ovulation that I can’t stand or get off the sofa, so taking it helps me get to work.”
- Dawn McGuigan
Hill argues that there are also other reasons that you may wish to avoid codeine, as some studies suggest it is linked to low sexual desire if used longterm – something the NHS reiterates.
Long term codeine can also impact fertility, Hill adds. According to the NHS, taking codeine occasionally can temporarily reduce fertility in men and women, and taking high doses of codeine for a long time can cause a health problem called hypogonadism, where the body does not make enough sex hormones. This can make conception more difficult. Because of this, Hill argues that: “We need to use other treatment options where possible”.
Other known side effects of codeine that may affect some (but not all) patients include sedation, constipation and itching, Dr Morrison adds. “There is quite a problem with increasing numbers of patients becoming addicted to codeine, and other opiates, so I agree that one needs to be careful,” she says.
For some though, scrapping codeine altogether simply does not feel like a viable option. Dawn McGuigan, 36, from Houghton-le-Spring near Sunderland, has endometriosis and takes codeine to help her cope with ovulation and period pain. Without it, her pain would be unmanageable, she says.
“Codeine definitely has a positive impact - some days my back pain is so bad during ovulation that I can’t stand or get off the sofa, so taking it helps me get to work,” she says. “It also helps me sleep as the dull aching pain usually keeps me awake into the early hours if I don’t take codeine.”
McGuigan worries about addiction as well as the side effects of codeine – the drug makes her drowsy and constipated, so she’s forced to take it “with a laxative chaser to avoid further discomfort”. However, she’s yet to find an alternative solution to her pain – which is the crux of the problem, says Hill.
“More research into the reasons behind debilitating period pain and ways of treating it is sorely needed,” she says. “We deserve better medical care.”