Painful Periods

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

Rare Diagnoses

  • Uterine Malformation
  • Imperforate Hymen
  • Uterine Hypoplasia
  • Cervical Stenosis
  • Psychogenic

Ready Reckoner

Key distinguishing features of the most common diagnoses

PrimaryEndometriosisPIDPelvic CongestionIUCD
During First Few Days of Period OnlyYesNoNoNoNo
Deep DyspareuniaNoYesYesYesNo
Colicky PainYesNoNoNoYes
Begins in AdulthoodNoYesYesYesYes
Enlarged Uterus O/ENoPossibleNoPossibleNo

Possible Investigations

Likely:None

Possible:FBC, ESR/CRP, HVS and endocervical swab, ultrasound, laparoscopy.

Small Print:None

  • FBC for anaemia if periods also heavy. WCC and ESR/CRP raised in PID.
  • HVS and endocervical swab for Chlamydia if vaginal discharge present: May help establish pathogen in chronic PID.
  • Ultrasound helpful to define uterine enlargement or other abnormalities and to detect ovarian cysts.
  • Laparoscopy is the usual investigation after referral to secondary care: Will make diagnosis of PID and endometriosis.

Top Tips

  • Explore the patient’s agenda: Young adolescents may use the symptom of painful periods as a passport symptom to obtain a prescription for the contraceptive pill.
  • Beware of the diagnosis of endometriosis. Even if detected laparoscopically, this may not be the actual cause of the patient’s pain (endometriosis is often asymptomatic). Unless it is explained that the treatment offered is not necessarily a panacea, the patient is likely to get frustrated at the apparent lack of progress
  • A long-forgotten IUCD can be a cause of dysmenorrhoea. Enquire specifically about this possibility – and check the notes too.
  • Explain to patients early on in your management that a precise organic diagnosis isn’t always possible; this will help maintain a good doctor–patient relationship, which will facilitate the subsequent unravelling of any significant underlying psychological problems.

Red Flags

  • The chances of organic pathology are greater if the patient has secondary dysmenorrhoea which is severe enough to disturb sleep.
  • Half of women who undergo laparoscopy for secondary dysmenorrhoea have no obvious organic pathology. Consider psychological problems and avoid over-investigating and overreferring – a number of these women end up having surgery (e.g. TAH) but even then continue to have pain.
  • Consider other pathologies if the patient presents acutely with a self-diagnosis of ‘severe period pain’ – non-gynaecological causes of pelvic pain such as appendicitis, renal colic or UTI may occur at the expected time of the period.
  • While painful periods are depressing, true clinical depression may lower the pain threshold of an otherwise normal woman and should not be missed.

Published: 2nd August 2022 Updated: 10th April 2024

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Based on the best-selling book Symptom Sorter, Nursing in Practice Reference is designed to help nurses working in primary and community care make sense of patient presentations. Written by GPs and adapted by nurses, it covers the vast majority of symptoms seen in primary care to inform different nursing disciplines with a range of responsibilities. Each symptom is organised into common, occasional or rare differentials, with distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

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Disclaimer

Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.