Four reasons for period pain

Period pain, also known as dysmenorrhea, is a very common symptom in women during their reproductive years. 

There are two types of period pain; primary dysmenorrhea and secondary dysmenorrhea. 

Primary dysmenorrhea occurs when your womb contracts to release blood during your period in response to an increase in the hormone prostaglandin. There is no underlying health condition responsible for this type of period pain and it usually starts just before or during a period. 

Secondary dysmenorrhea refers to period pain that is caused by an underlying health condition and can occur both during your period and in between your periods. You may also notice that you have irregular periods and heavy periods. 

Here we will look at the most common causes of secondary dysmenorrhea.

1. Endometriosis

Endometriosis affects around one in 10 women in the UK. 

Due to a lack of awareness and its symptoms overlapping with other conditions, reaching a diagnosis of endometriosis takes, on average, eight years in the UK. 

Endometriosis occurs when the lining of your womb (endometrium) grows outside your womb. Endometrial tissue grows in response to increased levels of the hormone oestrogen, which rises during your menstrual cycle. This affects the endometrial tissue lining your womb but also that which has grown beyond your womb, leading to the inflammation and pain associated with endometriosis. 

Symptoms

Symptoms of endometriosis include pelvic pain, painful periods, pain when urinating and/or opening your bowels that is worse during your periods, pain during or after sexual intercourse, fatigue, anaemia and difficulty getting pregnant. 

Getting a diagnosis

If you present with symptoms of endometriosis, you will need further investigations to reach a diagnosis. 

The gold standard for diagnosing endometriosis is a laparoscopy (keyhole surgery) to look for endometrial tissue (lesions) in your pelvic area, outside of your womb. However, new evidence now suggests that an ultrasound scan and MRI scan can effectively diagnose endometriosis without the risks associated with a surgical procedure. 

However, if your MRI scan doesn’t detect any endometrial lesions despite your symptoms, your doctor may recommend a laparoscopy.

Treating endometriosis

Endometriosis is initially treated through taking over-the-counter painkillers and anti-inflammatory medication alongside hormonal therapies to reduce your period flow or stop your periods, such as the oral contraceptive pill. 

This also includes gonadotropin-releasing hormone (GnRH), which stops your periods and lowers your oestrogen levels to help shrink your endometrial tissue. This triggers an artificial menopause, which can be treated with further medication to ease menopausal side effects, such as hot flushes and vaginal dryness. 

Progesterone therapy also stops your periods and reduces the growth of your endometrial tissue. This can be administered as a coil inserted into your womb, three-monthly injections or daily pills. 

If hormonal therapies aren’t effective, your doctor may recommend a laparoscopy to remove the endometrial tissue that has grown outside of your womb. 

2. Adenomyosis

Adenomyosis occurs when the lining of your womb (endometrium) grows into the muscle wall of your womb — this differs from endometriosis where the endometrial tissue grows outside the womb. 

It most often occurs in women aged 40–50 years who have given birth at least once, or women who have had prior surgery on the womb (eg dilatation and curettage or fibroid removal) where an opening is created into the womb wall and part of the endometrium seeps into the muscle layer. 

Symptoms 

Symptoms of adenomyosis include painful periods, pelvic pain, pain during sex, a feeling of pressure in your abdomen and bloating. 

Adenomyosis treatment

Adenomyosis is treated in the same way as endometriosis, starting with more conservative treatments, such as pain relief medication and hormonal therapies, and if ineffective, keyhole surgery to remove the endometrial tissue that has invaded the muscle wall of the womb. 

3. Pelvic inflammatory disease

Pelvic inflammatory disease (PID) refers to infection of a woman’s upper genital tract, that is, the womb, fallopian tubes and ovaries. It is usually caused by a sexually transmitted infection (STI), such as chlamydia, gonorrhoea or Mycoplasma genitalium, spreading from your vagina.

Symptoms

PID causes painful periods, pelvic pain, deep pain during sexual intercourse, pain when urinating, bleeding in between your periods and unusual vaginal discharge. Rare symptoms include severe pain, a high fever and nausea. 

Treating PID

If diagnosed at an early stage, PID can be effectively treated with a 14-day course of antibiotics. Your sexual partner(s) will also need treatment. It is important that you complete the full course of antibiotics and avoid sex during this time. You should also use barrier contraception (ie condoms) until you have your next sexual health check-up. 

If PID is left untreated, it can cause narrowing of your fallopian tubes due to scar tissue, which will reduce your fertility. This also increases your risk of an ectopic pregnancy, which can be life-threatening. 

4. Uterine fibroids

Uterine fibroids are non-cancerous growths that grow in and around your womb. Around one in five women aged 30–50 years in the UK has uterine fibroids, which can range in size from one centimetre to 10 centimetres or more. 

Uterine fibroids can grow in the muscle wall of the womb and remain contained there or can project into the inside of the womb or out into the surrounding pelvic area.

Symptoms

Around one in three women with uterine fibroids will develop symptoms, which can include heavy periods, painful periods, lower back pain, pain during sex, abdominal pain, constipation and a frequent urge to urinate. 

Treating uterine fibroids

Uterine fibroids are often first treated with hormonal therapies, such as the oral contraceptive pill, oral progestogen, progestogen injections or a device placed in your womb that releases the hormone levonorgestrel (LNG-IUS; levonorgestrel intrauterine system). Your doctor may alternatively recommend a non-hormonal treatment called tranexamic acid. 

If these conservative treatments aren't effective in managing your symptoms, you may need an invasive procedure to remove your uterine fibroids or reduce bleeding. This may include endometrial ablation, uterine fibroid embolisation, hysteroscopic resection or morcellation of your fibroids, or a myomectomy (open surgery to remove your fibroids). 

In severe cases, where it is clear that you do not want to become pregnant, a hysterectomy (complete removal of your womb) may be appropriate.