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Diagnosis: Endometriosis

When can severe period pains be a sign of endometriosis?

Period (menstrual) pain is very widespread: About half of all women have it. Some women have such severe pain that every month, for one to three days they are unable to pursue their daily activities. Often, normal doses of painkillers do not help anymore. If this is the case with you, you could have endometriosis.

Endometriosis is one of the most common gynecological illnesses in women between puberty and menopause. Despite being so widespread, it is not very well known and is frequently only diagnosed many years after symptoms first occur. With endometriosis, the lining of the womb (endometrium) also grows outside the womb. This endometriotic tissue is benign and does not always cause noticeable pain. You can read more about endometriosis here.

If you suspect that you have endometriosis, it is important to find a doctor who will take your symptoms seriously and will take time to fully discuss your problems with you.

A lot of girls and young women do have very severe pain and cramps connected with menstruation, but believe for a long time that this is normal. Until they go to a doctor due to their symptoms, most women try to somehow manage. Another common reason for seeking medical help besides the pain is difficulty getting pregnant. When endometriosis is finally diagnosed, it can often be treated so that pain is relieved or even eliminated. This – and ruling out cancer – is a big relief for many women. Certain treatments can also help many women to get pregnant if they are having difficulties doing so.

Medical history

Examination starts with a detailed discussion with your family doctor or gynecologist about the kind of symptoms you have (medical history). It is important that you explain in detail all your symptoms so that the doctor gets a full picture of the situation: how long you have had the pain; how severe it is; where, exactly, you feel it; how you experience it; and when or in what circumstances it occurs (for example, in connection with your period, during or after sexual intercourse). The effects that pain has on you can also provide information about your illness, for example whether your pain regularly prevents you from carrying out daily activities or whether your sex life suffers as a result.

Pelvic exam

For a pelvic exam the doctor puts on sterile gloves and feels the shape and consistency of the pelvic organs. This is done with one or two fingers of one hand in the vagina and/or the anus and the other hand on the outside of the tummy. The doctor checks whether gentle movement of the uterus or pressure on the sides, the ligaments of the uterus and on the area between the uterus and the rectum are painful. If lumps and hard areas in the pelvic connective tissue can be felt, it may also be an indication of endometriosis. During a pelvic exam the doctor usually has a look with the help of a medical instrument called a speculum as well. Only if the history and the pelvic exam (both feeling and looking) indicate that the woman has endometriosis can a decision be made about whether further tests are needed.

Ultrasound

An ultrasound examination does not involve surgery and does not hurt. Larger areas of endometriotic tissue and bigger cysts can be detected by carrying out an ultrasound exam through the abdominal wall. In this way you can also see whether other organs like the kidneys are affected. Smaller tissue areas and growths cannot be seen in the ultrasound picture and so cannot be picked up with this diagnostic procedure. An ultrasound exam through the vagina is better suited to find indications for ovarian endometriosis.

It is sometimes possible to make a treatment decision at this point based on these examinations. Whether or not further tests are needed will depend on how bad the symptoms are, among other things.

Laparoscopy

To be able to determine with some certainty whether you have endometriosis, you may need to have a laparoscopy. This is an operation carried out under general anesthesia and involves making at least two small cuts (incisions). Because a laparoscopy, like any other surgery, has some risks it is usually only done if the woman has serious pain that is interfering with her daily life and her quality of life or if the affected organs are no longer functioning very well. Laparoscopy is done to confirm the diagnosis before deciding about further treatment options. For instance, hormonal therapy with GnRH analogs should not be started without a confirmed diagnosis because of the possible adverse effects.

During a laparoscopy, a tiny camera is inserted into the abdominal cavity through a small cut near the woman’s belly button. This provides pictures of the organs in the abdominal and pelvic cavities. In this way, even small areas of endometriotic tissue and growths that are not found in a pelvic exam can be seen. It is also possible to remove some endometriotic tissue or take tissue samples (a biopsy) during this procedure to find out whether the woman has endometriosis or another illness. How well the laparoscopy succeeds in treating endometriosis depends to a considerable extent on the surgeon’s experience. In most cases, further tests are not necessary.

You can find out about menstrual pain in our fact sheet.