Period pain

Pain in the first days of a period is familiar to most women, and on its own it means very little. But it comes in two very different versions. One has been there since the teenage years, fits inside the first day or two, settles with ordinary painkillers and does not get in the way of anything. The other appeared later or has grown worse over the years, spills outside the period itself, wrecks work and study, and does not respond to the usual tablets. The first does not have to be endured, but it is harmless. The second is a symptom, and it is precisely there that "put up with it, everyone gets it" costs women years without a diagnosis. Working out which of the two you have is what this page is mainly for.

Why the womb hurts

Every cycle the lining of the womb prepares to receive a pregnancy and, when none arrives, peels away and comes out. To push it out and stop the bleeding, the womb contracts and the vessels in its wall are squeezed shut for a while. A muscle working without enough blood supply hurts — by the same mechanism as a cramped calf or the heart in angina. The contractions are driven by prostaglandins, substances made in the womb lining itself; the more of them there are, the stronger the cramps and the more often nausea, loose stools, headache and shivering come along too. That is why for some women a period passes unnoticed while for others it is an ordeal: it is not about being tough or having a high pain threshold.

Typical primary dysmenorrhoea — the sort that is not caused by any disease — looks like this: it started in the first year or two after periods began; the pain is cramping, low in the tummy, spreading into the lower back and thighs; it comes on a few hours before the bleeding or with it and lasts one to three days, then lets go. Year after year the picture is much the same. With age, and especially after childbirth, this kind of pain eases in many women.

When help is needed straight away

There are a few situations in which period pain stops being just pain.

Call an ambulance for heavy bleeding — when a pad or tampon soaks through within an hour, and does so for several hours running, when clots larger than a matchbox come away, when you feel dizzy, your vision darkens, and there is weakness and a racing heart. Fainting during a period is also a reason to call an ambulance rather than to lie down and hope.

A doctor is needed the same day if the pain comes with a temperature, shivering and discharge that is purulent or strong-smelling: that is the picture of infection in the womb and tubes, and it clears up far better the earlier antibiotics start. The same applies to sharp one-sided pain that began suddenly, is getting worse and comes with vomiting: that is how ovarian torsion and a ruptured cyst behave.

A separate warning concerns a missed period. If the period arrived late, was unlike the usual one and came with pain on one side, take a pregnancy test and see a doctor at the slightest doubt: an ectopic pregnancy can present this way. With weakness, dizziness and pain going up into the shoulder, call an ambulance immediately. The single European emergency number is 112, which works in Spain, Italy, Portugal, Poland and Ukraine; if the ambulance number where you live is different, use that one.

Where the line runs between ordinary pain and worrying pain

Secondary dysmenorrhoea is pain with a specific disease behind it. It is told apart not by how severe it is but by how it behaves. Any one of the following should prompt a closer look:

• the pain appeared for the first time in your twenties, thirties or forties, when periods used to pass quietly;
• the pain is getting worse from year to year rather than easing;
• it hurts not only during the period but on other days of the cycle too;
• sex is painful, particularly with deep penetration;
• periods have become heavy, with clots, or have got longer;
• there is bleeding or spotting between periods;
• opening the bowels or passing urine hurts specifically during the period;
• the usual painkillers have stopped working and you have to miss work or school;
• pregnancy has not happened after more than a year of trying.

One item is enough to go to a doctor and ask to be investigated rather than collect another suggestion to put up with it. If the pain is not tied to periods at all — dragging on for weeks, linked to bowel movements or passing urine — then the subject is no longer period pain but pelvic pain in general, which is approached differently and has a page of its own. And a short pain sitting exactly mid-cycle, on one side and swapping sides from month to month, is a separate and largely harmless story that also has its own page.

What lies behind secondary pain

Endometriosis. Tissue resembling the womb lining ends up outside it — on the peritoneum, the ovaries, the ligaments, the bowel — and bleeds each cycle wherever it has grown, causing inflammation and adhesions. The pain usually begins a day or two before the period and lasts longer; pain during sex, pain on opening the bowels during a period, fatigue and difficulty conceiving are often added. It is the commonest reason ordinary painkillers stop working, and at the same time the condition that takes longest to be found.

Adenomyosis. The same tissue grows into the thickness of the muscular wall of the womb. The classic picture is heavy, painful periods in a woman past thirty or thirty-five, often one who has had children, with a sense of heaviness and pressure low down.

Fibroids. Benign growths in the wall of the womb. They cause heavy and prolonged periods, pressure on the bladder and back passage, and a swollen abdomen. Pain appears when a fibroid grows into the cavity of the womb or when its blood supply is disturbed.

Pelvic inflammatory disease leaves adhesions and chronic pain behind it if it was not treated in time.

An intrauterine device. A copper coil makes periods heavier and more painful in itself, especially in the first months after it is fitted; a hormonal one usually does the opposite and eases them. If pain shoots up after fitting, or a temperature or unusual discharge appears, that is a reason to be seen rather than to wait for the body to get used to it.

Less often the cause turns out to be polyps, a congenital difference in the shape of the womb, or narrowing of the cervix after a procedure.

Pain relief: what matters is not which but when

The key rule almost nobody mentions: anti-inflammatory painkillers work noticeably better if taken before the pain has fully set in. They block the formation of prostaglandins but do nothing to the ones already made, so a tablet taken at the first sign of the period, or a few hours before it, relieves more than the same tablet at the peak. And over the first days it makes sense to take them on a schedule rather than only when things become unbearable.

This group includes ibuprofen, naproxen and several others; the particular medicine and the dose are chosen by a doctor, especially if you have stomach disease, asthma or kidney disease, or take anything else. Paracetamol is easier on the body but is usually weaker for period pain, because it barely touches the prostaglandins in the womb. Aspirin is best avoided for period pain: it increases bleeding, and it is not given to children or teenagers at all.

Among the non-drug measures, heat genuinely works: a heat pad or a warm shower over the lower tummy is comparable to a mild painkiller and can be combined with tablets. Regular physical activity reduces the pain, although there is no need to force yourself on the first day. A TENS machine — a small device delivering mild electrical impulses through the skin — also helps. Stopping smoking and going easy on alcohol pull in the same direction. Strict bed rest and avoiding movement, on the other hand, usually make things worse rather than better.

Hormonal treatment is treatment, not only contraception

The combined pill, the patch, the ring, the implant, the injection and the hormonal intrauterine system are prescribed for painful periods not as a by-product of contraception but as treatment in their own right. They thin the womb lining, make periods lighter and shorter, and some of them allow the number of periods a year to be reduced or stopped altogether.

This is worth knowing for one reason: many women turn the offer down as soon as they hear the word contraception, and go on enduring the pain for years. Yet in endometriosis and adenomyosis hormonal treatment is the mainstay rather than a fallback, and it can be arranged for those planning a pregnancy later on, because fertility returns after stopping.

It does not suit everyone — there are contraindications relating to migraine with aura, blood clots, smoking, certain liver diseases and high blood pressure — and that is exactly why the choice goes through a doctor rather than through a friend's advice. The effect is judged at three to six months, not after a week.

What the doctor will do

Here the conversation is worth more than any machine: when it started, how it has changed, how many days it hurts and how many days the bleeding lasts, how many pads are used, whether sex and the toilet hurt, what has already been tried and at what dose. It helps to keep a record over two or three periods — days, pain, bleeding, medicines taken and their effect; with that record the appointment is twice as productive.

An examination usually follows, along with swabs for infection, a blood test for anaemia and a pelvic ultrasound scan. Ultrasound shows fibroids, cysts and adenomyosis well, but a normal scan does not rule out endometriosis — superficial deposits are invisible on it, and this matters because "the scan was clear" far too often becomes the end of the discussion. If the symptoms do not fit the normal pattern, the next step may be an MRI scan or a laparoscopy with a gynaecologist.

Treatment follows the finding: anti-inflammatories and hormones for endometriosis and adenomyosis, with surgery where needed; medicines to reduce blood loss or removal of the growths for fibroids; antibiotics for infection; treatment to reduce blood loss plus iron for heavy periods. And even when no cause is found, treatment should not be abandoned: the pain itself can be treated without a settled diagnosis.

Online consultation

An Oladoctor doctor helps with the most important part of this journey: telling the two kinds apart. In the appointment they will ask about things you probably did not think mattered: what age the pain started, how it has changed over recent years, whether there is pain outside the period and during sex, how many days and how heavily you bleed, what you have taken, at what dose and at what point. From those answers they will say whether this looks like ordinary primary pain or whether it is time to look for a cause, which investigations are genuinely needed and in what order.

They will also help build a pain relief plan — which group of medicines suits you given your other conditions, and exactly when to take it — explain what hormonal treatment offers and what to expect from it, go through scans and blood tests you already have, and say when it is worth insisting on a face-to-face gynaecology appointment. And with heavy bleeding, a temperature with purulent discharge or a faint, they will say it plainly: this is not a matter for a remote appointment, this needs an ambulance.

This material is for information only and does not replace medical advice.