Endometriosis – why period pain can be a diagnosis
It takes years to diagnose, largely because severe period pain gets normalised. What it is, what raises suspicion, and what helps.
What it is, and why it is missed
Endometriosis is tissue similar to the womb lining growing outside the womb — on the ovaries, the pelvic lining, the bowel or bladder. It responds to the menstrual cycle, so it bleeds and inflames each month with nowhere to drain, causing pain, scarring and adhesions.
Diagnosis is commonly delayed by many years. The reasons are consistent: severe period pain is treated as normal by patients and clinicians alike, symptoms are attributed to a low pain threshold or stress, and scans are often normal even when disease is present.
The pattern that should raise it
- Period pain severe enough to miss work or school, or that painkillers do not control.
- Pain that begins days before bleeding starts.
- Deep pain during or after sex.
- Pain on opening the bowels or passing urine, worse around the period.
- Bowel symptoms that flare cyclically — frequently misdiagnosed as irritable bowel.
- Chronic pelvic pain between periods.
- Difficulty conceiving.
- Fatigue that tracks the cycle.
Treatment
There is no cure, and the goal is controlling symptoms and protecting fertility. Most treatment works by suppressing the monthly cycle so the tissue is not repeatedly stimulated.
Commonly used:
Mefenamic Acid — Ponstan, Adco-Mefenamic, Mefac, Ponstel
Dysmenorrhoea; mild to moderate pain; menorrhagia
Ibuprofen — Nurofen, Brufen, Advil, Ibupain
Mild to moderate pain; inflammation; fever; dysmenorrhoea
Levonorgestrel / Ethinylestradiol (Combined OCP) — Ovral, Nordette, Triphasil, Yasmin (drospirenone/EE)
Contraception; menstrual regulation; dysmenorrhoea; acne
Norethisterone (Progestogen-only pill) — Microval, Noriday
Contraception — suitable for breastfeeding women and those who cannot use oestrogen
Levonorgestrel Intrauterine Device — Mirena
Long-acting reversible contraception (up to 5 years); heavy menstrual bleeding; endometrial protection during HRT
Medroxyprogesterone Acetate (Depo-Provera) — Depo-Provera, Petogen, Nur-Isterate
Contraception (injectable — every 12 weeks)
- Taking the combined pill continuously, skipping the break, is a common and effective approach — fewer periods means fewer flares.
- Surgery to remove or destroy deposits can substantially reduce pain and improve fertility, and is done by laparoscopy.
- Physiotherapy for pelvic floor muscles helps a subset, particularly where pain has become chronic.
- Pain management approaches used for long-term pain apply here too, and are not an admission that the pain is not physical.
Getting taken seriously
- Track symptoms against your cycle for two or three months. A written record is much harder to dismiss than a description.
- Describe impact, not just severity: days missed, painkillers taken, activities given up.
- Say explicitly if pain occurs with sex, bowel movements or urination — those specifics change the clinical picture.
- Ask directly whether endometriosis is being considered, and what would rule it in or out.
- Ask for a referral if symptoms persist despite first-line treatment. You are entitled to one.
Common questions
- Does endometriosis always cause infertility?
- No. Many women with endometriosis conceive without difficulty. It does reduce fertility for some, particularly with more extensive disease, which is why earlier diagnosis matters if you are planning a pregnancy.
- Will pregnancy or a hysterectomy cure it?
- Neither is a cure. Symptoms often improve during pregnancy because cycles stop, and usually return afterwards. Hysterectomy removes the womb but not deposits elsewhere, so pain can persist.
- Is the severity of pain related to how much disease there is?
- Poorly. Extensive disease can cause little pain and minimal disease can be agonising. That mismatch is one reason symptoms get dismissed, and it is not a reason to discount them.
Sources
- Primary Healthcare Standard Treatment Guidelines and Essential Medicines ListNational Department of Health, South Africa
- Clinical and public health guidanceWorld Health Organization
Last reviewed 4 August 2026.