Painful Periods Are NOT Normal - A Gynaecologist Explains What’s Really Going On

She takes the day off from work every month. Has done for years. The first two days of her period are spent curled up with a hot water bottle, a painkiller every four hours, and the quiet management of pain that has simply become part of her monthly calendar. Her mother had the same thing. Her friends say theirs are bad too. So she has concluded, somewhere along the way, that this is just what periods are like.

It is one of the most persistent and most damaging misconceptions in women’s health – and it is costing women years of avoidable pain, progressive underlying disease, and in some cases, fertility consequences that could have been avoided with earlier diagnosis.

Periods can be uncomfortable. Some cramping in the first day or two is a normal physiological process. But pain that requires prescription-strength analgesia, pain that forces a change in daily plans, pain that radiates into the back and thighs, pain that comes with vomiting or is severe enough to cause fainting – none of this is a normal variation that women are simply expected to tolerate. These are symptoms. They have causes. And the causes are treatable.

This post explains what a gynaecologist actually looks for when a patient presents with severe period pain – and why the conversation matters far more than the painkiller.

Primary vs Secondary Dysmenorrhoea – A Critical Distinction

The medical term for painful periods is dysmenorrhoea, and it is divided into two clinically distinct categories. Understanding the difference is the starting point for everything else.

Primary Dysmenorrhoea

Primary dysmenorrhoea is period pain without an identifiable underlying structural cause. It is caused by the release of prostaglandins – inflammatory compounds produced by the uterine lining – that cause the uterine muscle to contract intensely to shed the endometrium. Higher prostaglandin levels produce more intense contractions and more severe pain.

This type is more common in adolescents and younger women, typically begins within a year or two of the first period, and produces cramping pain that starts at or just before the onset of bleeding and eases within one to three days. It generally responds to anti-inflammatory medications like ibuprofen or mefenamic acid, which work by blocking prostaglandin production rather than simply masking pain.

Primary dysmenorrhoea is real and can be genuinely severe. But its management is usually straightforward, and importantly, it tends to improve with age, sometimes significantly after a first pregnancy. What changes the picture is when the pain has a different pattern, doesn’t respond to standard medication, or comes with additional symptoms that point toward a structural cause.

Secondary Dysmenorrhoea

Secondary dysmenorrhoea is period pain caused by an identifiable gynaecological condition. This is the category that gets missed for years – because the pain is attributed to primary dysmenorrhoea, managed with over-the-counter painkillers, and never investigated properly.

The distinguishing features of secondary dysmenorrhoea:

• Pain that begins before menstruation – several days earlier rather than at the onset of bleeding
• Pain that continues beyond the period, into the days after bleeding has stopped
• Pain that has worsened progressively over time rather than remaining stable or improving
• Pain that doesn’t respond adequately to standard anti-inflammatory medications
• Pain accompanied by pelvic pain at other times in the cycle, not just during menstruation
• Pain during intercourse – deep dyspareunia is a particularly significant red flag
• Heavy bleeding alongside severe pain
  
  

Any woman whose period pain fits this pattern deserves a thorough gynaecological evaluation, not another blister pack of painkillers.

The Conditions That Are Actually Causing the Pain

Endometriosis

Endometriosis is the condition where tissue similar to the uterine lining – the endometrium – grows outside the uterus, most commonly on the ovaries, fallopian tubes, the outer surface of the uterus, and the lining of the pelvis. This tissue responds to the menstrual hormonal cycle just as the uterine lining does: it thickens, breaks down, and bleeds with each cycle. But unlike uterine endometrial tissue, it has nowhere to go. The result is internal bleeding, inflammation, scarring, and adhesions that can affect multiple pelvic organs.

The pain of endometriosis is characteristically severe, often begins before menstruation, and frequently continues after bleeding has stopped. It radiates into the lower back, rectum, and thighs. Deep pain during intercourse – particularly with certain positions – is one of the more specific symptoms that should prompt investigation. Painful bowel movements or urination during menstruation are additional flags, reflecting endometrial tissue affecting the bowel or bladder.

Endometriosis affects roughly 10 to 15 percent of women of reproductive age globally. In India, it is significantly underdiagnosed – the average diagnostic delay from first symptoms to confirmed diagnosis is seven to ten years in many studies. That delay is not inevitable. It happens because pain is normalised, because the condition requires active investigation to diagnose, and because many women have been managed with painkillers for years without a diagnosis being sought.

The consequences of untreated endometriosis compound over time: adhesions form and progress, ovarian endometriomas (cysts) develop and can affect ovarian reserve, and fertility implications accumulate the longer the disease remains unmanaged. Earlier diagnosis means earlier management and meaningfully better outcomes.

Adenomyosis

Adenomyosis is a condition where the endometrial tissue grows into the muscular wall of the uterus itself rather than into the pelvic cavity. The uterine muscle becomes infiltrated with endometrial glands and stroma, which bleed during menstruation within the muscle wall. This produces a uterus that is characteristically enlarged, boggy, and tender on examination.

The hallmark symptoms are heavy, prolonged menstrual bleeding and severe cramping that tends to be diffuse and deep rather than sharp and localised. The uterus can be two to three times its normal size in significant adenomyosis. Pain typically worsens progressively over years and is often more severe than endometriosis-associated pain in the acute phase of menstruation.

Adenomyosis is more common in women in their thirties and forties, and in women who have had previous uterine surgery or multiple pregnancies. It was historically diagnosed only at hysterectomy, but MRI and high-resolution ultrasound in experienced hands can now identify it non-invasively in most cases.

Uterine Fibroids

Fibroids are benign smooth muscle tumours of the uterus, and they are extremely common – affecting up to 70 to 80 percent of women by the age of 50 to varying degrees. Most fibroids are asymptomatic. Symptomatic fibroids, however, can cause heavy menstrual bleeding, prolonged periods, pelvic pressure, and in some cases significant period pain.

Submucosal fibroids – those that grow into the uterine cavity – are the most likely to cause heavy bleeding and pain, because they distort the uterine cavity and interfere with the normal contractile mechanism of menstruation. Large intramural fibroids – within the uterine wall – can cause similar symptoms. The pain from fibroids tends to be a heavy, pressure-like discomfort rather than the sharp cramps of primary dysmenorrhoea, and it often comes with significant heaviness or passage of clots.

Pelvic Inflammatory Disease (PID)

Pelvic inflammatory disease is an infection of the upper reproductive tract – the uterus, fallopian tubes, and ovaries – typically caused by bacteria that ascend from the lower genital tract. Chronic or inadequately treated PID causes scarring and adhesion formation within the pelvis that can produce significant period pain and chronic pelvic pain between periods. It is also a significant cause of tubal factor infertility.

PID often presents with fever, pelvic tenderness, and abnormal discharge in its acute form. Chronic PID, however, can be more subtle – presenting primarily as painful periods with chronic pelvic discomfort and dyspareunia. A history of pelvic infection or an untreated sexually transmitted infection is relevant clinical information that a gynaecologist will specifically ask about.

Ovarian Cysts

Most ovarian cysts are functional – they form as part of the normal menstrual cycle and resolve without intervention. But certain types of cysts cause significant period pain. Endometriomas – cysts filled with old menstrual blood, sometimes called ‘chocolate cysts’ – are a direct manifestation of endometriosis on the ovary and are associated with severe period pain. Large cysts of any type can cause pelvic pressure and discomfort that worsens during menstruation.

The Cultural Silence That Allows This to Continue

There is a pattern in how period pain is discussed in Indian families that directly contributes to diagnostic delay. Painful periods are treated as an expected feature of womanhood – something to manage and endure rather than investigate. Mothers who had severe period pain pass on the expectation that their daughters will too. The phrase ‘all women have this’ is stated as fact by relatives, sometimes by pharmacists, and occasionally by clinicians who should know better.

The result is that women who are genuinely suffering – who are missing work, missing school, missing social life for two or three days every month – have internalised the idea that seeking help is an overreaction. That asking for investigation is being dramatic. That the pain they’re managing is simply the price of being female.

None of this is true. And the cumulative consequence of this silence is measured in years of undiagnosed endometriosis, in adenomyosis that has been progressing for a decade before anyone looks, in fibroids that have grown large enough to affect the uterine cavity before a scan is done.

A gynaecologist hearing a woman describe period pain that stops her daily life for two days every month does not hear a normal variation. They hear a symptom that needs investigation. That is the correct clinical response, and it is available to every woman who makes the appointment.

What a Gynaecological Evaluation for Painful Periods Actually Involves

The assessment for painful periods is neither complicated nor invasive in its initial stages. A structured gynaecological evaluation includes:

• A detailed menstrual history – cycle length, duration of bleeding, flow heaviness, pain character, pain timing relative to bleeding, pain location and radiation, response to analgesia, and associated symptoms including dyspareunia, bowel or bladder symptoms during menstruation
• A general examination and pelvic examination – assessing for uterine size, tenderness, and adnexal masses. Tenderness on uterine movement (cervical motion tenderness) is a specific finding that points toward endometriosis or PID
• Transvaginal or transabdominal ultrasound – the primary imaging modality for identifying fibroids, ovarian cysts, adenomyosis features, and occasionally endometriosis deposits in specific locations
• Blood tests where indicated – including CA-125 as an adjunct in endometriosis investigation, though this marker has limitations and is not a standalone diagnostic test
• MRI of the pelvis – for detailed assessment of adenomyosis, deep infiltrating endometriosis, and complex fibroids where ultrasound findings are inconclusive
• Diagnostic laparoscopy – the definitive investigation for endometriosis, which allows direct visualisation of pelvic organs and biopsy of suspicious lesions. It is recommended when clinical suspicion of endometriosis is high and non-invasive investigations are inconclusive or the patient is not responding to medical management
  
  

The investigation pathway is guided by the clinical picture. Not every woman with painful periods needs a laparoscopy. But every woman with painful periods that affects her daily life deserves at least a thorough history, examination, and ultrasound as a starting point.

Treatment – What’s Available Beyond the Painkiller

The treatment for painful periods depends entirely on the underlying cause and the patient’s priorities – including whether she is trying to conceive. Broadly, the options include:

For Primary Dysmenorrhoea

NSAIDs (ibuprofen, mefenamic acid, naproxen) taken at the onset of pain or even slightly before anticipated pain are significantly more effective than paracetamol. Combined oral contraceptive pills suppress ovulation and dramatically reduce prostaglandin production, producing major improvement in period pain in most women who use them. The hormonal IUS (Mirena) reduces endometrial shedding and is highly effective for both pain and heavy bleeding.

For Endometriosis

Medical management of endometriosis includes hormonal therapies that suppress the menstrual cycle – combined oral contraceptives, progestins, GnRH agonists, or the Mirena IUS – which reduce the activity of endometrial deposits and manage pain. Surgical management through laparoscopy allows excision or ablation of endometriotic tissue and drainage of endometriomas. For women trying to conceive, the balance between surgical intervention and its impact on ovarian reserve requires careful specialist discussion. Management of endometriosis is long-term – it is a chronic condition requiring ongoing care rather than a single intervention.

For Adenomyosis

Medical management with the hormonal IUS or GnRH agonists can significantly reduce symptoms in adenomyosis. For women who have completed their family and have severe, refractory symptoms, hysterectomy is the definitive treatment and produces complete resolution of symptoms. Uterine-sparing options including uterine artery embolisation are available in selected cases.

For Fibroids

Symptomatic fibroids can be managed medically (hormonal therapy to reduce size and bleeding), hysteroscopically (removal of submucosal fibroids via the uterine cavity without abdominal incision), laparoscopically (myomectomy – removal of the fibroid while preserving the uterus), or through uterine artery embolisation. The approach depends on fibroid size, location, number, the patient’s fertility intentions, and symptom severity.

Women’s Health Consultations at Sayee Specialty Hospital, Padappai

Sayee Specialty Hospital’s Obstetrics & Gynaecology department provides specialist consultations for painful periods, heavy menstrual bleeding, endometriosis, fibroids, adenomyosis, and all women’s health concerns. If your period pain is affecting your daily life – whether it has been for years or months – a proper gynaecological assessment is where that changes. The pain you have been managing is not inevitable. It has a cause. And in the majority of cases, that cause is treatable.

You don’t have to just live with it.

Book a women’s health consultation at Sayee Specialty Hospital, or call us at 9 976 976 976. Serving Padappai, Vandalur, Chromepet, and South Chennai.