Period Pain: Could It Be Endometriosis?

What is a painful period (dysmenorrhea)?

Dysmenorrhea is the scientific term used to describe painful periods.

There are two types of dysmenorrhea: primary dysmenorrhea and secondary dysmenorrhea [1]. The former refers to period pain without an underlying medical condition. Secondary dysmenorrhea is caused by a disease or medical condition. Secondary dysmenorrhea is one of the primary symptoms of endometriosis and can be accompanied with painful ovulation. Women often describe the pain they experience during their periods as “killer cramps."

How can dysmenorrhea affect a patient's quality of life?

The symptoms of endometriosis can impact just about every aspect of a patient's life. In a 2017 study on endometriosis patients’ quality of life, researchers found that painful periods, irregular periods, and general abdominal pain significantly correlated with negative results on an endometriosis health profile questionnaire. It included five categories ranging from pain, control and powerlessness, emotional well-being, social support, and self-image.

Causes

The process of primary dysmenorrhea

Period pain is caused by an excess or imbalance in prostaglandin secretion from the lining of the uterus during periods [3]. Prostaglandins are hormones that control inflammation, blood flow, and the formation of blood clots [4].

Why and how endometriosis causes dysmenorrhea

In women with endometriosis, the levels of prostaglandins are even higher in menstrual blood than women without the disease [5]. This could explain why women with endometriosis experience periods with extreme pain. Research has also shown that the frequency, magnitude, and basal pressure tone of uterine contractions are higher in women with endometriosis compared to those without the disease [6]. As a result, the severe period pain experienced by women with endometriosis could also be the result of abnormal contractions of the uterus.

Symptoms

Symptoms of dysmenorrhea may include aching pelvic pain, abdominal pressure, and pain in the hips, lower back, and inner thighs [1].

How women with endometriosis describe the pain they experience during their periods

Many women experience pain during their periods, but those with endometriosis describe their menstrual pain to be so incapacitating, it prohibits performing even the simplest of tasks. Women with the disease also tend to have their period pain worsen over time [7]. Some women with endometriosis describe their period pain as “throbbing, gnawing, and dragging,” or “like their insides are being pulled down” [8].

Other symptoms that often accompany painful periods in women with endometriosis

In addition to extreme pain during menstruation, women with endometriosis often experience other symptoms, including:

• Painful ovulation

• Painful bowel movements

• Constipation with periods

• Diarrhea with periods

• Gas and bloating with periods

• Shooting leg pains with periods

Diagnosis

Are painful periods a sure sign of endometriosis?

Painful periods are not always a sure sign of endometriosis. Also, the absence of painful periods does not guarantee one does not have endometriosis. In addition to painful periods, endometriosis is often accompanied by a number of other symptoms. These include gastrointestinal abnormalities, such as diarrhea, constipation, and/or painful bowel movements, pain during intercourse, and neuropathy [9].

Other causes of painful periods

Secondary dysmenorrhea could be caused by a number of other underlying conditions [1]. These could include:

• Adenomyosis, otherwise known as endometriosis of the uterus; a condition where the endometrial tissue that lines the uterus grows into the uterine muscle wall [10]

• Uterine fibroids (benign tumors that grow from the muscle layers of the uterus) [11]

• Cervical stenosis (the narrowing of the opening of the cervix)

• Infections

Pain Management

OTC painkillers

The most common way to manage the pain of both primary and secondary dysmenorrhea are non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and aspirin. They work by reducing the menstrual flow, therefore, decreasing the pressure inside the uterus. They also reduce the levels of prostaglandins released during menstruation [12].

Hormonal contraceptives

A popular way to manage dysmenorrhea caused by endometriosis are combined oral contraceptives. They work by suppressing ovulation and inhibiting the growth of the endometrial implants and may reduce menstrual pain associated with endometriosis.

Other ways of reducing the pain

• Applying topical heat

• Exercising

• Avoiding the consumption of caffeine, alcohol, and tobacco

Treating endometriosis-related dysmenorrhea

The gold standard for the treatment of endometriosis is laparoscopic deep excision surgery [14]. During the surgery, the surgeon makes small incisions in the abdomen of the patient and introduces an instrument known as a laparoscope which allows them to visualize the inside of the abdomen. They then remove the endometrial lesions using dissection. Patients often report a decrease in symptoms, while others say their symptoms completely disappear. However, women should remember that there is a small risk of endometriosis recurring even after the best of surgeries.

Patient Story

"My pain started at a very young age, during my adolescent years. I remember dreading gym class because any physical activity on the days of my menstrual cycle would cause me to vomit due to the severity of my pelvic pain.

I remember my prom, an exciting time for me and my friends, getting dressed up, make-up and all, but all I can recall is getting my period, and being in so much pain that I cried the entire time I was getting ready. Fast forward to my honeymoon: period again, and my first few days as Mrs. Flores became days I just wanted to sleep and not feel the pain." –H.F.

Read more.

References

1. Dysmenorrhea, by clevelandclinic.org
2. The burden of endometriosis symptoms on health-related quality of life in women in the United States: a cross-sectional studyby Ahmed M. Soliman,Karin S. Coyne,Erica Zaiser,Jane Castelli-Haley &Mahesh J. Fuldeore
3. Dysmenorrhea and Endometriosis in Young Women by Tasuku Harada
4. Prostaglandins, by yourhormones.info
5. PGE2 and PGF2 Alpha Release by Human Peritoneal Macrophages in Endometriosisby U Karck, F Reister, W Schäfer, H P Zahradnik, M Breckwoldt
6. Characteristics of uterine contractility during menses in women with mild to moderate endometriosis, by Carlo Bulletti, M.D. *,'Correspondence information about the author M.D. Carlo Bullettia,Email the author M.D. Carlo Bulletti, Dominique De Ziegler, M.D.b, Valeria Polli, M.D.a, Elena Del Ferro, Ph.D.a, Simone Palini, Ph.D.a, Carlo Flamigni, M.D.c
7. Endometriosis, by Mayo Clinic
8. Endometriosis, by cedars-sinai.org
9. Symptoms of Endometriosis, by Tamer Seckin, MD
10. Adenomyosis Symptoms, Diagnosis, and Treatment Methods, by Tamer Seckin, MD
11. Fibroids, by Tamer Seckin, MD
12. onlinelibrary.wiley.com
13. Diagnosis and Initial Management of Dysmenorrhea, Amimi S. Osayande, MD, And Suarna Mehulic, MD
14. Endometriosis Excision Surgery, by Tamer Seckin, MD