Painful Periods – Could It Be Endometriosis?

Who can relate? The minute your period arrives you lose all ability to properly function because your period pains are so debilitating that you simply can’t go about your routine as normal. If this sounds familiar, whilst you’re not alone you shouldn’t have to put up with this.

1 in 7 women, or people born with a uterus, experience this intense period pain and have taken time off work or school, with many regularly needing time off during their menstrual cycle. Menstruation-related pain is a topic that is widely overlooked by the general population even though it has a huge impact on productivity at school or work, as well as the individual’s social life and mental wellbeing. Unfortunately, discussions around the topic of period pain still remain taboo, with many suffering with excruciating symptoms in silence, unaware that support exists. Whilst mild period cramps, changes to toilet habits and fatigue associated with your cycle can be considered ‘normal’, how do we know when there are signs of an underlying gynecological condition? What even is ‘normal’ anyway?

Painful periods can be due to a number of conditions including endometriosis, PCOS, adenomyosis, fibroids and more. Whether it is one of these conditions or not, various treatment options exist to reduce the impact on your life. If symptoms are impacting your ability to participate in your daily routines and hobbies, or your mental health, this is a sign to seek medical advice.

The current best evidence for explaining why we might experience pain or other symptoms during the menstrual cycle, without the presence of an underlying condition such as endometriosis can be explained by the hormonal changes that occur. If pregnancy does not occur, the uterus produces prostaglandins, a hormone which influences inflammation and causes the uterus to contract to shed its lining as menstrual blood. Changes in blood flow to the uterus during these contractions produce other chemicals locally, which can then lead to hypersensitisation of pain fibers, and therefore lower abdominal or pelvic pain. Increased levels of prostaglandins may also be associated with other symptoms such as fatigue, breast tenderness, gastrointestinal changes and headaches. There is some evidence that higher levels of prostaglandin production has been directly correlated with a more severe experience of period pain and other symptoms. 

In primary dysmenorrhea, defined as spasmodic and painful cramps in the lower abdomen that begin shortly before or at the onset of menses in the absence of any pelvic pathology, symptoms usually only occur shortly before or during menstruation and should not impact your ability to daily tasks and hobbies. They might not feel good, but they shouldn’t be impacting your day-to-day life.

If your symptoms are impacting daily life, you have irregularities or worsening of symptoms, pain with sex, bladder or bowel functions or if symptoms haven’t improved with conventional treatment, it might be a sign of an underlying condition. You are the advocate for your own body, so if in doubt, get it checked out! 

How do I know if my pain is endometriosis?

Endometriosis is a common condition affecting an estimated 200 million women, and those assigned female at birth around the world. In the U.S. this equates to roughly 1 in 10! Endometriosis can affect anyone regardless of factors like age, ethnicity and socioeconomic background. 

Endometriosis is the presence of endometrial-like tissue outside of the uterus. Primarily this will be in the pelvic region for example on the fallopian tubes, bladder or bowels, but this could also be elsewhere such as on the diaphragm. These are called lesions and cause internal inflammation, leading to pain, cramping and other symptoms that can be debilitating. 

Each month, these cells react to the changes in hormones (estrogen and progesterone) associated with the menstrual cycle by building up and then breaking down and bleeding. However, the presence of this blood causes local irritation, inflammation and pain as unlike the cells in the uterus, it has nowhere to go. Whilst there is no cure, it is treatable.

Endometriosis Symptoms

The symptoms of endometriosis will vary for each person but may include:

There is only one true diagnostic tool for endometriosis which is a type of surgery called a laparoscopy, where the surgeon will look for the visible endometriosis tissue outside of the uterus. If endometriosis is present, the surgeon may be able to remove some of it, aiming to improve the associated symptoms. It is important to note that not everyone with endometriosis will experience symptoms, and that the amount of endometriosis present does not always correspond to the severity of symptoms. But surgery can be expensive, or inaccessible to some people, so in the meantime you can use this medically validated assessment tool to help you determine if the symptoms you are experiencing might be endometriosis.

As with any surgery there are risks, and so not everyone will decide to do this. Instead, you can opt to manage and improve the pain and other symptoms in other ways - regardless of whether you have a diagnosis of endometriosis or not. To enhance long-term well-being and alleviate discomfort, healthcare professionals frequently recommend daily birth control pills, insertion of intrauterine devices (IUDs), or medications containing estrogen and progesterone to stabilize hormone levels and halt ovulation. Using hormonal medications to suppress menstruation can alleviate pain associated with endometriosis and deter its progression or exacerbation over time. However, hormones are not the only option or answer. There are lots of other ways to try and address and alleviate your symptoms, which you can find more information on here. 

Why is my period suddenly so painful?

Period pain that gradually gets worse over time, with every menstrual cycle, after pregnancy or when coming on and off birth control is not uncommon and you are not alone! This can be partly explained by how our body notices and responds to pain signals - whether the pain is caused by a condition like endometriosis or not. Pain is a defense mechanism against harm, so when it is present often (whether monthly or daily) the brain starts listening to that signal more intently, amplifying it further and making our body respond to it. This process is called central sensitization and explains why over time things that did not cause pain previously might now do, or why pain may start to be present on other days, not just those associated with your period. 

When this altered pain signaling process persists for more than 3 months, the body starts to adapt to protect itself from anticipated harm. This might be in the form of muscle tension, which in itself can start to generate more pain and perpetuate this unhelpful cycle. Imagine holding your shoulders up by your ears for an extended period of time - the effect is similar to muscles around the pelvic area, and can explain why someone might begin to have pain in their lower back, hips or legs too. Our pain sensing system is also very closely linked to our emotional state, stress levels and other psychological factors. This is why pain treatment plans should also take into account more holistic management options to help address any factors which might be making it harder to break the vicious cycle.

Many individuals experience symptoms of endometriosis or other underlying conditions, yet remain undiagnosed. At present, it takes an average of 7 years from the symptom onset to receive an accurate diagnosis of endometriosis in the U.S. If your periods are impacting you and/or you suspect you might have endometriosis but haven't been diagnosed, it's essential to seek medical advice. Early detection and treatment can significantly improve quality of life. To better understand your symptoms and assess your risk, consider taking a free endometriosis assessment available here.

Laura works within Chronic Pelvic Pain as a pelvic health physiotherapist in the UK. She is passionate about providing education and raising awareness of pelvic health conditions and issues which have such a profound impact on so many people across the world.

Sources: 

Menstrual symptoms linked to nearly 9 days of lost productivity through presenteeism every year | BMJ 

Endometriosis, Foundation, Endometriosis Foundation Of America | EndoFound 

About Us | Endometriosis UK (endometriosis-uk.org) 

Seckin, T.,  The Doctor Will See You Now: Recognizing and Treating Endometriosis. 2016. 

Primary Dysmenorrhea: Pathophysiology, Diagnosis, and Treatment Updates - PMC (nih.gov)

Hormonal treatments for endometriosis: The endocrine background - PMC (nih.gov)