Endometriosis: severe period pain is not normal and deserves investigation

What is endometriosis?

Endometriosis is a condition where tissue similar to the lining of the uterus grows in locations outside the uterus, most commonly on the ovaries, fallopian tubes and tissue around the uterus, and sometimes on the bowel or bladder. Like the uterine lining, this tissue responds to hormonal changes, thickening and bleeding with each menstrual cycle.

Unlike the blood from a normal period, this blood has no way out of the body. It accumulates, causing chronic inflammation, scarring and adhesions between organs. A comprehensive review published in JAMA in 2025 confirmed that these repeated cycles of inflammation and healing are responsible for the chronic pain and progressive tissue damage that define the condition.

A 2025 systematic review and meta-analysis published in Reproductive Biology and Endocrinology found global endometriosis prevalence to be around 10% of women of reproductive age, making it one of the most common gynaecological conditions worldwide and one of the least diagnosed. Millions of women in the Arab world are likely living with it without a name for what they have.

The exact cause remains unknown, but research points to a combination of genetic, hormonal and immune factors. A 2021 paper in the journal Cell reviewed the evidence on pathobiology and confirmed strong familial clustering: if your mother or sister has endometriosis, your risk is higher. It is not an infection, it does not spread between people, and it is not caused by any particular behaviour.

What is the difference between normal period pain and the pain that needs investigation?

Mild to moderate pain in the first one to two days of a period is common and is medically called primary dysmenorrhoea. This pain typically responds to ibuprofen and does not prevent normal daily activity. A 2018 study published in BMC Women's Health found high rates of dysmenorrhoea among female university students in Palestine, reflecting how widespread period pain is in the region.

The pain of endometriosis is different in a way that most women can recognise once they hear it described. It is pain that stops you working, studying or leaving bed for days. It often starts before the period begins, sometimes by three to five days, and continues after bleeding ends. It can affect the lower back, rectum or legs. It may come with pain during sex, during urination or during bowel movements, especially around the time of a period.

The serious problem is that many women learn to tolerate this pain and assume it is normal. Family members and sometimes healthcare providers offer reassurance without investigation. In regional settings, severe period pain is often normalised to a degree that delays diagnosis by years that matter for fertility and long-term tissue health.

The practical rule: pain that interferes with your daily life is not normal and is worth assessment. You do not need to justify the severity of your pain or apologise for seeking medical help.

Why does diagnosis take so long?

A qualitative systematic review published in Obstetrics and Gynecology in 2023 examined the barriers to timely endometriosis diagnosis and found a consistent average delay of seven to ten years across different healthcare systems. This delay has identifiable causes that could be addressed.

First, severe period pain is socially normalised in ways that discourage women from seeking care. Second, standard investigations including pelvic ultrasound are often normal in mild and moderate endometriosis, which falsely reassures both doctor and patient. Third, definitive diagnosis requires laparoscopic surgery, which is not done without sufficient clinical suspicion. These three factors combine to create long diagnostic journeys.

In the Arab world, additional barriers include reluctance to discuss symptoms related to sex or bowel function, financial cost of specialist appointments, and in some settings the unavailability of gynaecological specialists outside major cities. Awareness that these symptoms are medically significant is itself the first step toward breaking this pattern.

The scientific consensus is that earlier diagnosis improves outcomes. A 2019 paper in the American Journal of Obstetrics and Gynecology called explicitly for a change in clinical approach, arguing that the combination of typical symptoms and a failed response to standard pain relief is sufficient to make a clinical diagnosis and begin treatment without waiting for surgery.

How is the diagnosis made?

The only definitive diagnostic test for endometriosis is laparoscopy, a minimally invasive surgical procedure performed under general anaesthesia. A small camera is inserted through a tiny incision in the abdomen, allowing the surgeon to see endometrial tissue directly. Biopsies are taken from suspected areas and confirmed under the microscope.

This does not mean every woman with suspected endometriosis needs to go directly to surgery. Modern gynaecological guidelines allow hormonal treatment to begin on the basis of clinical presentation without waiting for laparoscopy, particularly in younger women. Surgery becomes more important when hormonal treatment fails, when fertility is the concern, or when the clinical picture is complex.

Transvaginal ultrasound can identify ovarian endometriomas, the cysts filled with old blood sometimes called chocolate cysts, but it cannot reliably detect small implants or adhesions in most cases. A normal ultrasound does not rule out the condition. MRI provides more detail but still does not replace laparoscopy in complex cases.

When you see your doctor, a detailed description of your pain helps more than you might expect. When does it start? How many days does it last? Where exactly does it go? How does it compare to your worst pain on a scale of one to ten? How many days does it affect your normal activity? This information guides clinical suspicion and investigation more effectively than you might think.

The stages of endometriosis and what they mean

Endometriosis is classified into four stages based on the extent and location of tissue implants and the degree of adhesions. Stage one and two indicate minimal and mild disease. Stage three involves ovarian cysts and noticeable adhesions. Stage four represents severe widespread disease that may involve the bladder or bowel.

However, this staging does not reliably predict pain severity. Some women with stage four disease have less pain than others with stage one. The staging is useful for planning surgery and assessing fertility impact, but pain experience correlates poorly with disease extent. A woman with minimal visible disease can have severe debilitating pain.

Endometriomas, the ovarian cysts associated with endometriosis, vary from a few centimetres to ten or more. Their presence increases fertility impact and warrants specialist assessment. A 2021 paper in Cell confirmed that the specific mechanisms linking ovarian endometriomas to reduced egg quality and fertilisation are now better understood, which is useful for counselling women about their specific fertility risk.

Treatment options and what they can achieve

There is no definitive cure for endometriosis, but the symptoms of most women can be brought under good control. The goals of treatment are to reduce pain, improve quality of life, and preserve or improve fertility where that is what the woman wants.

Hormonal treatment is first-line. The combined oral contraceptive pill reduces oestrogen stimulation of the endometrial tissue and controls the menstrual cycle. Progestogen alone can suppress the endometrial deposits further. Specialist medicines called GnRH agonists temporarily stop ovarian function, creating a hormone environment that halts disease activity, but they are used for limited periods because of effects on bone density.

A Cochrane systematic review published in 2020 confirmed that laparoscopic surgery improves fertility rates and reduces pain in moderate to severe endometriosis. The surgeon removes visible deposits, breaks down adhesions, and removes or drains ovarian endometriomas while preserving as much normal ovarian tissue as possible. A skilled endometriosis surgeon makes a significant difference to outcomes.

Non-steroidal anti-inflammatory drugs such as ibuprofen help with acute pain when taken regularly from the start of a period rather than waiting for pain to peak. They treat the symptom not the disease, but combined with hormonal treatment they form an effective overall plan. The combination of approaches tailored to your circumstances and goals is what modern management looks like.

Endometriosis and fertility

Endometriosis is a cause of delayed or difficult conception but it does not mean permanent infertility. Around 30 to 50% of women with endometriosis experience fertility difficulties, meaning that the other half or more conceive naturally. The impact on fertility depends on where the deposits are, whether there are adhesions involving the fallopian tubes, and whether significant ovarian cysts are present.

Laparoscopic surgery improves natural conception rates in moderate to severe endometriosis, particularly when fallopian tube adhesions or large ovarian cysts are present. When surgery does not achieve pregnancy, IVF is an effective next step and the endometriosis context does not prevent it from working well in most cases.

If you are diagnosed with endometriosis and planning a future pregnancy, discuss this explicitly with your doctor from the beginning because it changes the treatment strategy. Hormonal treatment prevents pregnancy while in use. Surgery may be prioritised over hormonal treatment if conception within the next year or two is your goal.

Living well with endometriosis

Endometriosis is a chronic condition but it is compatible with a full life. Many women with endometriosis have successful careers, stable relationships and children, provided they receive an accurate diagnosis and appropriate treatment. The key is not to spend years managing a diagnosis-less pain before finally getting the right care.

Chronic pain affects mental health and increases the risk of anxiety and depression. This is a normal physiological response to a painful chronic disease and not a sign of weakness. Psychological support is a legitimate part of endometriosis care and should be sought alongside physical treatment rather than as an afterthought.

A randomised trial published in the Journal of Physiotherapy in 2025 found that supervised exercise and pelvic floor muscle training reduced current pain levels in women with endometriosis. Yoga and relaxation-based approaches are also used as adjuncts to medical treatment, particularly for chronic pelvic pain management.

Regular follow-up with a gynaecologist every six to twelve months is worthwhile even when symptoms are currently controlled, because the disease can progress and treatment needs may change. If symptoms worsen or new symptoms appear, earlier review is sensible rather than waiting for a scheduled appointment.

Sources

• As-Sanie S, Mackenzie SC, Morrison L et al: Endometriosis: A Review, JAMA, 2025
• Davenport S, Smith D, Green DJ et al: Barriers to a Timely Diagnosis of Endometriosis: A Qualitative Systematic Review, Obstetrics and gynecology, 2023
• Agarwal SK, Chapron C, Giudice LC et al: Clinical diagnosis of endometriosis: a call to action, American journal of obstetrics and gynecology, 2019
• Bafort C, Beebeejaun Y, Tomassetti C et al: Laparoscopic surgery for endometriosis, The Cochrane database of systematic reviews, 2020
• Wang MH, Chen JH, Qi XY et al: Global prevalence of adenomyosis and endometriosis: a systematic review and meta-analysis, Reproductive biology and endocrinology, 2025
• Saunders PTK, Horne AW: Endometriosis: Etiology, pathobiology, and therapeutic prospects, Cell, 2021
• Abu Helwa HA, Mitaeb AA, Al-Hamshri S et al: Prevalence of dysmenorrhea and predictors of its pain intensity among Palestinian female university students, BMC women's health, 2018