Painful Periods
Painful periods are extremely common: 50% of women in the UK complain of moderate pain, and 12% suffer severe, disabling pain. Primary dysmenorrhoea is pain with no organic pathology, usually starting when ovulatory cycles begin. Secondary dysmenorrhoea is associated with pelvic pathology, and appears later in life.
Differential diagnosis
Common Diagnoses
- Primary Dysmenorrhoea
- Endometriosis
- Chronic PID
- IUCD
- Pelvic Pain Syndrome (‘Venous Congestion’)
Occasional Diagnoses
- Retroverted Uterus
- Cervicitis
- Chocolate Cyst of Ovary
- Endometrial Polyp
Rare Diagnoses
- Uterine Malformation
- Imperforate Hymen
- Uterine Hypoplasia
- Cervical Stenosis
- Psychogenic
Ready reckoner
Key distinguishing features of the most common diagnoses
| Primary | Endometriosis | PID | Pelvic Congestion | IUCD | |
|---|---|---|---|---|---|
| During First Few Days of Period Only | Yes | No | No | No | No |
| Deep Dyspareunia | No | Yes | Yes | Yes | No |
| Colicky Pain | Yes | No | No | No | Yes |
| Begins in Adulthood | No | Yes | Yes | Yes | Yes |
| Enlarged Uterus O/E | No | Possible | No | Possible | No |
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 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 clinical 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.