Dysmenorrhoea is defined as painful menses and is reported by up to 50-90% of women.
It is described as
primary dysmenorrhoea if no underlying cause of the pain is found and the reproductive organs and pelvis are seemingly normal. This appears to be more common in younger women and tends to resolve with increasing age.
Other risk factors include BMI <20 kg/m2, smoking, menarche before age 12, longer cycles and longer duration of bleeding, irregular or heavy flow, and a history of sexual assault.
Secondary dysmenorrhoea is menses pain where an underlying condition causing the pain is found by your doctor. For example this may be endometriosis, adenomyosis, fibroids or pelvic infection. The most common cause of secondary dysmenorrhoea is endometriosis.
Endometriosis is a common condition affecting around 8 percent of the female population.
It is caused by the lining of the womb (endometrium) appearing in other places in the body. Most commonly, endometriosis occurs inside the pelvic area and attaches to the ovaries, the ligaments behind the womb, the tissue layer lining the pelvis, the bladder and ureters or the intestine.
Endometriosis can occur in minimal
amounts (Stage 1) through to severe
amounts (Stage 4). The cause of
endometriosis is still unknown.
Adenomyosis is endometriosis in the
muscle layer of the womb itself.
Endometriosis may cause pelvic pain or
infertility although many women with
endometriosis have neither problem.
Having more endometriosis does
not mean you will have more pain, as
women with only a minimal amount
can have more pain than women with
Pelvic pain in endometriosis is mostly
associated with menses and occurs
on a monthly basis. However, other
significant symptoms may be:
These also tend to be worse during
menses. Pain can also occur throughout
the month and may then be described
as chronic pelvic pain.
Although it is normal to have some
discomfort during menses, it is not
normal to have pain that is not relieved
by simple painkillers or if it forces you
to take time off work or miss social
events. These may suggest that you
have endometriosis and should seek
In more rare cases, you may have
bleeding from the back passage or
bleeding when you pass urine during
menses, suggesting that endometriosis
is affecting the rectum or bladder.
Cyclical pain during menses in an
old operation scar (e.g. caesarean
section scar) may suggest that there is
endometriosis in it. Coughing up blood
during your menses may indicate lung
When we look at women who are
struggling to become pregnant,
we find that a greater number of
them have endometriosis than we
would expect to find in the general
population showing a link between
endometriosis and infertility but
this is poorly understood.
The average age of onset of pain
symptoms in endometriosis is 20 years
old but the average age of diagnosis is
28. This is because many women ignore
the pain symptoms because they think
it must be normal and do not wish to
appear as if they are complaining or
doctors dismiss their complaints too
Your gynaecologist may suspect you
have endometriosis after asking about
your symptoms. Normally they will
arrange for you to have an ultrasound
scan which can diagnose endometriotic
cysts in ovaries. An expert endometriosis
scanner can detect severe endometriosis
in other areas also.
However, minimal to mild
endometriosis cannot be detected
by any test or scan. The only way to
diagnose it is to undergo a diagnostic
laparoscopy (keyhole surgery)
under general anaesthetic and to
see it directly. A gynaecologist who
specialises in endometriosis would then
aim to remove all visible endometriosis
at the same time.
If your doctor suspects or
finds you to have more
severe disease affecting
the bowels, bladder or
ureters, you may need
further specialist tests
to assess the problem
before it is removed.
It is crucial that your endometriosis treatment is tailored to your own specific circumstances and that you see a specialist in endometriosis who can advise you on this. Your treatment will depend upon your age, desire for a diagnosis, fertility requirements and pain symptoms.
Do not just accept the first treatment
offered without understanding why
it is being offered in your situation. A
consultation for complex endometriosis
will take at least 45 minutes.
There is no absolute cure for
endometriosis and it tends to be an
issue that remains with you for most of
your fertile years.
Both medical and surgical treatments
give a measure of relief from
pain depending on the type of
endometriosis you have. The amount of
pain relief can vary greatly depending
on many factors. Pain can recur after
stopping medical treatments or at a
later date after surgery.
If you are not keen to have a diagnostic
laparoscopy (keyhole surgery) to
confirm that you have endometriosis,
then it may be reasonable to try
medical treatments first and then
consider a diagnostic laparoscopy later
if the medical treatments do not work.
All of the hormonal treatments have
been shown to be equally effective as
each other at relieving pain but none
of them improve fertility. The choice of
drug treatment is decided by your age,
requirement for birth control and the
potential side effects of the drugs.
Some women may decide to proceed
directly to a diagnostic laparoscopy
because they wish to be certain if
they do have endometriosis. Knowing
the cause of the problem helps them
psychologically to deal with it.
Surgical treatment requires the help
of a gynaecologist who specialises in
endometriosis and minimally invasive
surgery (keyhole surgery).
For minimal to moderate disease
(Stage 1-3), the surgeon should be
comfortable to diagnose the problem
during laparoscopy and surgically
remove it, preferably by excision,
and at the same time, to get the best
chance of pain relief. Many general
gynaecologists are not fully trained in
If your gynaecologist discovers severe
disease then, to treat it at the same
time, they should have discussed
with you the pros and cons of surgical
removal. In severe cases, endometriosis
surgery is a high-risk complex operation
that should only be attempted by a
fully-trained expert in specialist centres.
Not everyone requires surgical removal
of severe disease as it can compromise
your fertility. Robotic keyhole surgery
now potentially offers the most
accurate and precise surgery for severe
cases of endometriosis with the lowest
risks of complications. About 80 percent
of patients undergoing surgery say that
their pain improves to varying extents.
Your gynaecologist should also be able
to offer you access to other specialists
as required, for example:
• Pain, intestinal or urinary system
• Psychological and psycho-sexual
If you are found to have endometriosisassociated
infertility then the choice
is whether to have surgery or assisted
fertility treatments (IVF or IUI) or both.
With minimal to moderate
endometriosis, there is evidence that
surgically removing the endometriosis
deposits and endometriotic ovarian
cysts improves your chances of
conceiving spontaneously reducing
the need for assisted conception
There is some evidence that surgically
removing severe endometriosis before
infertility treatment improves your
chances of success. However, there is
a small risk of damaging your fertility
with surgery in some cases and so
assisted conception techniques may be
recommended in the first instance so as
not to risk affecting your fertility further
from surgical complications.
Surgery may also be needed first if:
Dysmenorrhoea and endometriosis
can be physically and mentally
debilitating, affecting every aspect
of a woman’s life.
Women with endometriosis tend to
have more problems maintaining
their careers and relationships as
they may be fighting with chronic
pain and fertility issues.
Seeing a gynaecologist who
specialises in this area gives a
good opportunity to keep the pain
under control and achieve fertility
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