Period pain - or more?

April 2013

From fluctuating weight and mood swings, to bloated tummy’s and stomach cramps, period symptoms can be hard to live with. Although most women tend to simply grin and bear it, we should all be aware of other possible underlying causes.

Mr Edward Morris, Consultant Gynaecologist at Spire Norwich Hospital explains: endometriosis is a condition only women can suffer from and can affect women at any age from when their periods begin until they stop (the menopause). It is thought the commonest cause is when a small number of cells, known as endometrial cells, from the lining of the uterus (womb) are shed during menstruation. Instead of passing into the vagina the cells pass back up the fallopian tubes into the pelvis (lower tummy). These cells then implant into the lining of the pelvis (the peritoneum) where they carry on functioning as the lining of the womb, but in the wrong place.

These cells respond to the natural hormones the ovaries release and bleed a little each month. The blood they produce causes inflammation in the pelvis which may go on to cause pain, adhesions (scar tissue) formation between the ovaries, tubes, womb and other pelvic structures.


Symptoms of endometriosis
The commonest symptom is period-type pain. The classic, or text-book description of the sort of pain that endometriosis causes is one that starts a few days before the period is due, rising in severity until the onset of bleeding when the pain starts to subside. Endometriosis can also present with pain at other times of the month and may also cause pain during intercourse or on opening your bowels.

Endometriosis may also cause difficulty conceiving. We know that the adhesions through scar tissue formation can block the tubes, thus preventing the passage of egg from the ovary to the womb. Scientific research has also demonstrated that the inflammation caused by endometriosis produces cells in the pelvis called macrophages that have been shown to impair conception.

Causes of endometriosis
The cause of endometriosis is not known. What researchers have found confusing over the years is that whilst most women, to a degree, pass a small amount of menstrual blood up the fallopian tubes into the pelvis not all women develop endometriosis. Overall, it is thought that in women who do not have endometriosis the body has developed an effective system to ‘mop up’ the cells. However in women who have endometriosis this ‘mopping up’ is not working correctly. At the moment it is thought to explain how endometriosis can be seen to run in families, with sisters, Aunts etc inheriting the lack of ability to ‘mop up’ endometrial cells.

Complications of endometriosis
Thankfully serious complications of endometriosis are rare. If the condition is left untreated for many years it is possible for endometriosis to damage the bowel and bladder.

Perhaps the commonest complication is the growth of a cyst in one or both ovaries. In endometriosis this is a cyst caused by the collection of blood from the implanted endometrial cells within the ovary. The cyst is known as an endometrioma, or ‘chocolate cyst’, named after the brown colour of old blood. If an endometrioma is allowed to become too big it can seriously impair the function of the ovary which is another way in which endometriosis may lead to infertility.

Diagnosis of endometriosis
Period pains are very common which means it is very difficult for any nurse or doctor to separate the pains of a possible diagnosis of endometriosis from that of normal period pains. Sometimes on internal examination it may be possible for your GP or nurse to suspect endometriosis.

In a woman with severe pelvic pain in whom endometriosis is suspected an ultrasound scan may be helpful in making sure she does not have any ovarian cysts. It is very important, however, to ensure that she understands that a normal scan does not exclude a diagnosis of endometriosis.


The only definitive method of diagnosing endometriosis is to perform a keyhole examination of the abdomen (laparoscopy). This can only be performed under a brief general anaesthetic. If performed by an experienced surgeon it is possible at the same time to obtain tissue to confirm the diagnosis and also treat some aspects of the condition. Most surgeons also take High Definition digital photos to help the patient understand her condition, explain what treatment may be necessary and these pictures also form part of the medical records.


Treatment of endometriosis
Once a woman is diagnosed with endometriosis the treatment depends very much on the severity of the condition, her plans for future pregnancies and how close she is to the menopause.

It is important for a patient to understand endometriosis tends to be a recurrent problem and once diagnosed endometriosis may give symptoms which can be present until the menopause.

Mild or early endometriosis may be helped with simple painkillers such as Paracetamol or Ibuprofen. Your family doctor may be able to supply stronger painkillers to help control your symptoms.

If painkillers do not help then a large number of women find great relief with hormonal treatments such as the contraceptive pill and similar treatments. These can give many years of pain control and there is some evidence they reduce the progression of endometriosis. The main problem with these hormonal treatments is they are contraceptives, which is not helpful if the woman is trying to become pregnant.

Another group of medication, known as GnRH analogues are given as injections and are one of the most effective treatments for endometriosis. They work by temporarily switching off the ovaries, creating a non-permanent menopause. This makes the endometrial cells inactive and reduces the inflammation, and pain in the pelvis. This is not normally a permanent treatment but is very helpful in helping relieve symptoms in women just before surgery or fertility treatment.

Keyhole surgery by a gynaecologist who specialises in endometriosis is the most effective way of reducing the symptoms of endometriosis. A research study has shown that removal of tissue affected by endometriosis can improve fertility and improve symptoms better than drug treatment.

Many women misunderstand the diagnosis of endometriosis in that once they are diagnosed they have to have a hysterectomy. The good news is that with modern technology and keyhole surgery this form of radical therapy is now a thing of the past, occurring in only a very small number of women.

I think I may have endometriosis, what should I do?
Your doctor is the best person to see to start the process of investigating whether you have endometriosis. Keeping a diary of your symptoms will greatly aid your GP in establishing patterns. You can keep a simple paper diary but if you wish there are several period tracking smartphone apps that can record your symptoms and generate reports for your doctor. This information will also be very useful to your gynaecologist if your GP decides to refer you. You would also be helped by preparing for your consultation by visiting appropriate internet resources and self-help groups. In the UK these are the National Endometriosis Society and Womens Health Concern /

The content of this page is provided for general information only. It should not be treated as a substitute for the professional medical advice of your doctor or other healthcare professional

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