Endometriosis: what is 'normal' and when should you seek treatment?

Endometriosis is a condition that affects one in 10 women, according to the Royal College of Nursing. Although it can often be very painful, its symptoms and their severity can vary considerably, which sometimes makes it difficult for those with the condition to realise they could benefit from seeking treatment. Endometriosis symptoms occur because tissue similar to that which lines the inner surface of the womb begins to grow elsewhere, such as on the ovaries, fallopian tubes, bowel and tissues lining the pelvis.  

What are common endometriosis symptoms?

Some of the symptoms of endometriosis may at first seem to overlap with normal symptoms that occur during the menstrual cycle. This is because menstruation affects women differently; some experience longer periods or heavier bleeding, some experience bloating or lower back pain while others do not. This means it is important to be aware of what is normal for you, so you can more easily identify when things feel different. 

Endometriosis symptoms can also overlap with symptoms of other conditions, such as pelvic inflammatory disease or irritable bowel syndrome. This is because symptoms vary according to where the excess tissue growth is located. Common endometriosis symptoms include: 

• Period pain that prevents you from following your normal routines
• A cramping or stabbing pain in your pelvis that gets worse during your period
• Lower back pain or lower tummy pain that gets worse during your period
• Pain when urinating or defecating during your period
• Constipation, diarrhoea, nausea or blood in your urine during your period
• Pain during or after sex
• Difficulty getting pregnant
• Excessively heavy periods

Of these symptoms, excessively heavy periods is often one of the hardest to judge. While every woman’s menstrual cycle differs slightly, there is some general guidance on what is normal.

Your periods: heavy or normal?

The average menstrual cycle lasts 28 days from the first day of one period to the first day of the next. However, a menstrual cycle can be as short as 21 days or as long as 40 days. Some women experience PMS (premenstrual syndrome) as part of their menstrual cycle, which includes symptoms such as breast tenderness, headaches, mood swings, tiredness, bloating and changes in sex drive and appetite. PMS usually goes away once a period starts.  

A period refers to the time during a menstrual cycle when you bleed from your vagina. This can last for three to eight days, with the bleeding being heaviest for the first two days. The colour of the blood can change from red during the heaviest days of bleeding to pink, brown or black as the bleeding lessens. On average, women lose 30–72ml of blood during a period. This is equivalent to five to 12 teaspoons of blood. A heavy period is generally considered to be the loss of 80ml or more of blood during a period and/or a period lasting seven or more days. 

On a practical level, signs you can look out for that your period is excessively heavy include:

• Needing to use two types of sanitary products at the same time, such as using a tampon and a pad
• Needing to change your sanitary product every two hours or less
• Passing blood clots larger than 2.5cm
• Bleeding through your sanitary products and onto your clothes

Do heavy periods mean you have endometriosis?

Not in all cases. According to the NHS, the cause of heavy periods is unknown in about half of women. For the remaining women with heavy periods, endometriosis is only one potential cause. Other conditions that can cause heavy periods include fibroids, pelvic inflammatory disorder and adenomyosis. In post-menopausal women, vaginal bleeding can also be a sign of cancer of the womb. 

Certain medicines, namely anti-coagulants, can also increase bleeding during a period as can an IUD (intrauterine contraceptive device) or coil in the initial three to six months after insertion. 

Treatment for heavy periods

Heavy periods can negatively impact your lifestyle, cause anxiety and in some instances lead to anaemia. Depending on how heavy your periods are, there are several treatment options available. One common treatment is the use of an intrauterine system (IUS), which is a small device inserted into the womb that releases the hormone progestogen. There are also medicines without hormones, such as non-steroidal anti-inflammatory drugs (NSAIDS), and medicines with hormones, such as progestogen tablets or the combined oral contraceptive pill. 

If these treatments are not successful, there are also surgical options, including endometrial ablation surgery. This surgery removes the lining of the womb using small surgical instruments which are inserted through the vagina. This surgery is carried out under general anaesthetic and does not usually require an overnight stay. 

When should you visit a doctor?

You know your body and your menstrual cycle better than anyone else. If you are worried about how much you are bleeding during your menstrual cycle, have noticed your periods have become heavier or are experiencing some of the other common endometriosis symptoms we’ve discussed, such as severe period pain, then it is time to visit a doctor. 

At Spire Healthcare, we have experienced consultants specialising in women’s health, who can thoroughly investigate your symptoms and where appropriate, offer treatment to resolve or reduce them. 

Investigating your symptoms

When you visit a doctor to discuss your symptoms, they may carry out a physical examination of your abdomen and pelvis. This can help them detect the presence of fibroids. They may also recommend an ultrasound scan, which uses high-frequency sound waves to create images of the tissues within your body. This can help detect a range of conditions, including fibroids, endometriosis and cancer. 

If the results of these tests and examinations are unclear and depending on your symptoms and medical history, you may be referred to a gynaecologist for further tests, such as a laparoscopy. This is a type of keyhole surgery where a small incision is made into the abdomen so that a thin tube can be passed through. This tube has a light and a camera at the end of it which allows your consultant to detect the presence of any excess tissue growth caused by endometriosis.

Treating endometriosis

If you are diagnosed with endometriosis, there are several treatment options available to reduce your symptoms. Your doctor will advise you on which are best depending on how severe your symptoms are and your medical history. 

Current treatment options fall into two main categories: 

• Hormone treatments — taking the combined oral contraceptive pill, using a contraceptive patch, taking medicines called gonadotrophin-releasing hormone (GnRH) analogues or using an IUS
• Surgical treatments — surgery to remove patches of excessive tissue growth or surgery to remove parts of or entire organs affected by endometriosis, such as a hysterectomy to remove the womb