Painful periods — how much pain is normal?

During menstruation, the muscular wall of the uterus contracts. Chemicals called prostaglandins are involved in these contractions and can contribute to cramping pain. This is why some period pain can occur even when there is nothing structurally wrong. For many women it is manageable and responds to simple pain relief. The question becomes more important when the pain is severe, persistent, worsening or interfering with ordinary life.

Think about what the pain makes you do. Do you regularly:

• miss school, university or work?
• stay in bed because of the pain?
• cancel plans?
• need repeated or strong painkillers?
• vomit, faint or feel unable to function?
• dread your period because you know what is coming?

Those are good reasons to ask for assessment. How much your friends can bear cannot define what you should put up with.

Endometriosis occurs when tissue similar to the lining of the uterus is found elsewhere in the pelvis.

Symptoms can include:

• period pain that does not stop even after the period has;
• pelvic pain at other times;
• pain during or after sex;
• pain opening the bowels or passing urine around the time of periods;
• sometimes difficulty becoming pregnant.

Symptoms vary considerably between women. And importantly, the severity of the pain doesn't necessarily correlate with how much endometriosis is present.

Adenomyosis, in which tissue from the lining of the womb grows into its muscular wall, can cause painful and often heavy periods. Fibroids can sometimes contribute to pain or pressure symptoms. Pelvic infection and ovarian problems can cause pelvic pain too, although their pattern may be different from ordinary menstrual cramps. And many women with painful periods have primary dysmenorrhoea — period pain without another pelvic disease being found.

Where pain and heavy bleeding go together, see Heavy periods — when should I worry?.

Ultrasound is useful for assessing the uterus and ovaries and can identify some signs of endometriosis, adenomyosis, fibroids and ovarian cysts.

But a normal ultrasound does not exclude endometriosis.

So if your symptoms strongly suggest endometriosis, they shouldn't simply be dismissed because a scan looks normal.

Yes. And you don't necessarily need a diagnosis from an operation before anybody can help your symptoms.

Anti-inflammatory painkillers can be effective for menstrual cramps when suitable for you.

Hormonal treatments — including the contraceptive pill, progestogen treatments and hormonal intrauterine systems — can also reduce period pain for some women.

If an underlying condition is suspected or symptoms persist despite treatment, further assessment may be appropriate.

The right approach depends on your symptoms, medical history, contraception needs and whether you are trying for pregnancy.

Seek urgent medical advice for sudden or unusually severe pelvic pain, particularly if accompanied by heavy bleeding, fever, vomiting, fainting or feeling very unwell.

If pregnancy is possible, significant pain and/or bleeding also needs prompt assessment because an ectopic pregnancy is one of the conditions that must be excluded.