Ask the doctor: What tests do I need to find a cause for my painful periods?

Q I've had very painful periods for years. I saw a gynaecologist about 10 years ago, in my 20s, and was told there is nothing wrong and I'm just unlucky. I don't remember what tests I had. I really would like to have another go at solving this. What tests should I be looking for? I would like to have more info before I go back to my GP.

A It's good to know that you were seen by a gynaecologist in the past, who reassured you that there was no underlying cause for your recurrent, painful, crampy periods - the medical term for this is dysmenorrhoea. This most likely means you do not have endometriosis, adenomyosis or uterine fibroids, three common causes for dysmenorrhoea. You probably have primary dysmenorrhoea, when there is no identifiable reason as to why you suffer excessive lower abdominal pain and cramps. The mainstay of treatment is providing sufficient pain relief to allow you to perform most, if not all, of your daily activities during menstruation.

The pain typically starts one or two days before your period is due and can last up to 72 hours after. The lower abdominal pain can sometimes travel to the low back or upper thigh region. Start with simple measures such as regular exercise and applying heat packs to the lower abdominal region.

Small clinical trials report reduced pain intensity and duration with any form of physical exercise, particularly in patients who have previously been sedentary. Exercise is an obvious first-line treatment option.

By adding an NSAID (Non-Steroid Anti-Inflammatory Drug) such as ibuprofen, diclofenac and particularly mefenamic acid at maximum dose, a reduction in pain and improvement in overall function is observed. In the management of dysmenorrhoea, it is advised to take paracetamol at full dose alongside the NSAID (this is known as 'piggybacking').

The next step involves adding hormonal contraception (you can skip straight to contraception if it is desired from the outset). Options include combined oestrogen-progestin products (oral pills, transdermal patch and vaginal ring) and progestin-only options (implant, injection, intrauterine device and oral pills).

Typically, treatment efficacy is monitored every three months and the patient is called for frequent review with the doctor or specialist nurse.

A second evaluation for underlying causes may need to be undertaken as it has been 10 years since your last assessment and you may have developed one of the three conditions mentioned above.

In patients with endometriosis, a painful disorder, endometrial tissue (the tissue that lines the womb) is found outside the womb. Endometriosis most commonly involves the ovaries, fallopian tubes and the tissues lining the pelvis.

Other symptoms like pain during intercourse, excessive vaginal bleeding or bleeding between periods, pain during bowel movements or infertility can occur with endometriosis.

There is no direct correlation between the severity of the pain and the severity of the disease. You may have severe painful periods due to very mild endometriosis or vice versa. There are a lot of overlapping symptoms with IBS (Irritable Bowel Syndrome) and PID (Pelvic Inflammatory Disease). Transcutaneous electrical nerve stimulation and/or treatment with 'gonadotropin-releasing hormone analogues' are effective treatment options for endometriosis.

Explorative laparoscopy (camera test) is often undertaken in patients who do not respond to the above treatments. Endometrial ablation (thinning of the lining of the womb) can be an option for patients whose dysmenorrhoea appears to be related to heavy menstrual bleeding and who do not desire to have children in the future. Unfortunately, for some women who have exhausted all treatment options, hysterectomy (removal of the womb) provides definitive treatment.

⬤ Dr Jennifer Grant is a GP with the Beacon HealthCheck