Painful Periods Are Common, but They Are Not Always Normal

Period pain is one of the most frequently dismissed symptoms in women’s health. Many women grow up being told that painful periods are simply something to endure, and that reaching for a painkiller and a hot water bottle is the extent of what can be done. I hear this story in my clinic every week — women who have suffered for years, sometimes decades, because they were told their pain was normal. While some degree of menstrual discomfort is indeed common, pain that significantly interferes with your daily life deserves proper investigation.

Primary versus secondary dysmenorrhoea

When we talk about period pain clinically, we distinguish between two types. Primary dysmenorrhoea is period pain without an underlying cause. It is driven by prostaglandins — chemicals released as the womb lining breaks down — which trigger uterine contractions and reduce blood flow to the myometrium. This type of pain typically starts within hours of your period beginning, is crampy and central in the lower abdomen, and settles within one to three days. It tends to begin in adolescence and may improve with age or after childbirth.

Secondary dysmenorrhoea is period pain caused by an identifiable condition. The pain pattern is often different: it may start days before the period, last longer, worsen over time, or occur at other points in the cycle. This distinction matters because the treatment approach is entirely different.

Red flags that warrant investigation

I encourage every woman to take her period pain seriously, but certain features should prompt an assessment without delay:

• Pain so severe that it regularly prevents you from attending work, school, or social activities
• Standard painkillers (ibuprofen, paracetamol) do not adequately control it
• The pain is getting progressively worse over time
• Pain occurs at other times in your cycle, not only during your period
• You also experience heavy bleeding, pain during sex (deep dyspareunia), or bowel and bladder symptoms around your period
• Pain radiates to the back, legs, or rectum
• You are struggling to conceive alongside painful periods
• There is a family history of endometriosis (a first-degree relative with the condition increases your risk significantly)

What I tell my patients is this: if you have rearranged your life around your periods — cancelling plans, calling in sick, dreading that week every month — that alone is reason enough to investigate.

Keeping a pain and symptom diary

Before your appointment, one of the most useful things you can do is keep a symptom diary for two to three cycles. Record when the pain starts and stops, its severity on a scale of 1 to 10, what makes it better or worse, and any associated symptoms — bloating, nausea, bowel changes, fatigue, pain with intercourse. Note which painkillers you use and whether they help. This information is genuinely valuable. It allows me to see patterns that might not emerge from memory alone, and it speeds up the diagnostic process considerably.

Conditions that cause severe period pain

Endometriosis is the most common cause of severe period pain in younger women. Tissue similar to the womb lining grows outside the uterus — on the ovaries, the peritoneum, the bladder, the bowel, and sometimes in more distant locations. It affects an estimated 1 in 10 women of reproductive age. The average time from symptom onset to diagnosis in the UK remains around seven to eight years, which is a statistic I find unacceptable. Endometriosis can cause cyclical pain, chronic pelvic pain, pain during sex, painful bowel movements, and subfertility.

Adenomyosis occurs when the endometrial tissue grows into the muscular wall of the uterus itself. The uterus becomes bulky and tender. Adenomyosis causes heavy, prolonged periods and a deep, aching pain that can be debilitating. It is increasingly well recognised on transvaginal ultrasound and MRI, and I diagnose it regularly in women who have been told for years that their scans were normal — because their previous imaging was not specifically looking for it.

Fibroids are benign growths of the uterine muscle. Their impact on pain depends largely on their location and size. Submucosal fibroids (those that project into the uterine cavity) are particularly associated with heavy bleeding and cramping. Large intramural fibroids can cause pressure symptoms and generalised pelvic discomfort.

Pelvic inflammatory disease (PID) is an infection of the reproductive tract, most commonly caused by untreated chlamydia or gonorrhoea. PID can cause deep pelvic pain, abnormal discharge, and pain during intercourse. Left untreated, it can lead to tubal damage and fertility problems.

The treatment ladder

Treatment for painful periods depends entirely on the cause, but there is a logical stepwise approach that I follow in practice:

NSAIDs (non-steroidal anti-inflammatory drugs): Ibuprofen or mefenamic acid are first-line for primary dysmenorrhoea. They work by blocking prostaglandin production. The key is timing — start them at the first sign of pain (or even slightly before if your cycle is predictable), rather than waiting until the pain is established. Mefenamic acid at 500mg three times daily is particularly effective and also helps reduce menstrual flow.

Hormonal options: The combined oral contraceptive pill suppresses ovulation and thins the endometrium, reducing prostaglandin production and pain. Running pill packs back-to-back (without a break) can eliminate periods altogether — something I often recommend for women with severe cyclical pain. The hormonal coil (Mirena IUS) is another excellent option: it delivers a low dose of progesterone directly to the womb lining, significantly reducing both pain and bleeding over time. For endometriosis, continuous progestogen-only therapy (such as norethisterone or dienogest) can suppress disease activity.

Surgical options: When hormonal treatments are not suitable or have not worked, surgical approaches may be considered. For endometriosis, laparoscopic excision surgery can remove disease deposits. For adenomyosis causing severe symptoms, options range from uterine artery embolisation to hysterectomy as a definitive treatment. For fibroids, myomectomy (surgical removal of the fibroids) or hysteroscopic resection may be appropriate depending on their location.

When referral to a specialist is appropriate

Your GP is well placed to start initial treatment with NSAIDs and hormonal options. But if these do not bring adequate relief, or if endometriosis, adenomyosis, or fibroids are suspected, referral to a gynaecologist is the right next step. A specialist can perform a detailed transvaginal ultrasound, arrange further imaging if needed, and discuss the full range of medical and surgical options.

If your period pain is affecting your quality of life, the first step is a thorough gynaecological assessment including a detailed history, examination, and pelvic ultrasound. In many cases, a clear diagnosis can be reached without invasive procedures, and effective treatment can begin. What matters most is that you are heard, properly assessed, and offered a plan that takes your pain seriously.