Painful Periods

Most women will have some pain just before and during bleeding. It can vary from cycle to cycle with some periods being pain free while at other times there can be pelvic cramps, pain radiating down the inner thighs or a dull aching sensation in the pelvis. Simple remedies such as taking a painkiller such as ibuprofen or putting a hot water bottle on your lower abdomen is usually enough to ease the discomfort.

Women can develop painful periods as they get older and this may be a sign that there is an underlying medical condition causing the pain. Endometriosis, fibroids, pelvic inflammatory disease and adenomyosis are all causes of progressive period pain.

Endometriosis

Uterine Fibroids

Fibroids (sometimes called leiomyomas or myomas) are caused by normal uterus muscle cells clumping together so they are benign, non – cancerous tissue. There is often more than one fibroid present.

They are very common. Up to 70% of women will have developed at least one fibroid by the age of 40. Women of black African origin have an even greater likelihood of having fibroids and they tend to happen at a younger age. If other women in the family have fibroids, then it increases the chances that you will have them too

Many women who have fibroids have little or no symptoms. Where there are symptoms the most common are:

Heavy or prolonged menstrual bleeding
Bleeding in between periods
Pelvic pressure or pain
Frequent urination
Difficulty emptying the bladder
Constipation
Backache
Very occasionally a fibroid can cause severe pain as it out grows its blood supply and the tissue starts to break down.

Diagnosis

Depending on the size and position of the fibroid/s it may be palpable on pelvic or abdominal examination. Pelvic ultrasound scan can usually clearly identify and measure the size of the fibroid/s. Occasionally an MRI scan is needed for a complete diagnosis.

Treatment

Where the woman has little or no symptoms no treatment is needed. The growth patterns of fibroids vary – they may grow slowly or quickly or they may remain the same size. Some even shrink spontaneously.

Tablets to take at period time (tranexamic acid) or an intrauterine hormone releasing coil (Mirena) will often control heavy painful period bleeding but they will not reduce the size of the fibroid. Treatment continues until the menopause.

If the blood supply to the fibroid is easily seen on a scan, then blocking the blood vessel (uterine artery embolisation) can cause the fibroid to shrink.

If the fibroid is pushing into the lining of the uterus i.e. submucosal – see diagram – then it may be possible to remove via a hysteroscope that goes into the uterus through the cervix.

Where there is irregular bleeding endometrial ablation may be an option. This is a technique where a device goes in through the cervix and destroys the lining either by microwave or heat or cold. This is not suitable for someone who has not completed their family.

If the fibroid/s are too large or too many ultimately the only effective solution may be hysterectomy – surgery to remove the uterus – but this is only considered where other less invasive possibilities have been explored.

Pelvic Inflammatory Disease

Pelvic Inflammatory Disease is an infection of the pelvic area which can affect the general pelvic area including the uterus, fallopian tubes, ovaries and pelvis.

PID can be caused by many different types of bacteria. Usually PID is caused by bacteria from STIs. Sometimes PID is caused by normal bacteria found in the vagina.

Many women do not know they have PID because they do not have any signs or symptoms. When symptoms do happen, they can be mild or more serious.

What are the signs and symptoms of PID?

Signs and symptoms include:

Pain in the lower abdomen (this is the most common symptom)
Fever (100.4° F or higher)
Vaginal discharge that may smell foul
Painful sex
Pain when urinating
Painful periods
Irregular menstrual periods
Pain in the upper right abdomen (this is rare)

PID can come on fast, with extreme pain and fever, especially if it is caused by gonorrhoea.

How is PID diagnosed?

To diagnose PID, doctors usually do a physical exam to check for signs of PID and test for STIs. If you think that you may have PID, see a doctor or nurse as soon as possible.

If you have pain in your lower abdomen, your doctor or nurse will check for:

Unusual discharge from your vagina or cervix
An abscess (collection of pus) near your ovaries or fallopian tubes
Tenderness or pain in your pelvis

Your doctor may arrange tests to find out whether you have PID or a different problem that looks like PID. These can include:

Tests for STIs, especially gonorrhoea and chlamydia. These infections can cause PID.
A test for a urine infection or other conditions that can cause pelvic pain
Ultrasound or another imaging test so your doctor can look at your internal organs for signs of PID

A smear test is NOT used to detect PID.

How is PID treated?

PID needs antibiotic treatment. Most of the time, at least two antibiotics are used that work against many different types of bacteria. You must take all of your antibiotics, even if your symptoms go away. This helps to make sure the infection is fully cured.

Your doctor or nurse may suggest going into the hospital to treat your PID if:

You are very sick
You are pregnant
Your symptoms do not go away after taking the antibiotics or if you cannot swallow pills. If this is the case, you will need IV antibiotics.
You have an abscess in a fallopian tube or ovary

If you still have symptoms or if the abscess does not go away after treatment, you may need surgery. Problems caused by PID, such as chronic pelvic pain and scarring, are often hard to treat. But sometimes they get better after surgery.

What can happen if PID is not treated?

Without treatment, PID can lead to serious problems like infertility, ectopic pregnancy, and chronic pelvic pain (pain that does not go away). Antibiotics will treat PID, but they will not fix any permanent damage done to your internal organs.

Can I get pregnant if I have had PID?

Usually. Your chances of getting pregnant are lower if you have had PID more than once. When you have PID, bacteria can get into the fallopian tubes or cause inflammation of the fallopian tubes. This can cause scarring in the tissue that makes up your fallopian tubes.

Scar tissue can block an egg from your ovary from entering or traveling down the fallopian tube to your uterus (womb). The egg needs to be fertilised and then attach to your uterus for pregnancy to happen. Even having a small amount of scar tissue can keep you from getting pregnant without fertility treatment.

Scar tissue from PID can also cause an ectopic pregnancy (a pregnancy outside of the uterus) instead of a normal pregnancy. Ectopic pregnancies are more than six times more common in women who have had PID compared with women who have not had PID. Most of these pregnancies end in miscarriage.

You may not be able to prevent PID. It is not always caused by an STI. Sometimes, normal bacteria in your vagina can travel up to your reproductive organs and cause PID.

Lower your risk of getting an STI with the following steps:

Use condoms. Condoms are the best way to prevent STIs when you have sex. Because a man does not need to ejaculate (come) to give or get STIs, make sure to put the condom on before the penis touches the vagina, mouth, or anus. Other methods of contraception, like contraceptive pills, injection, implant, or intrauterine coils will not protect you from STIs.
Get tested. Be sure you and your partner are tested for STIs. Talk to each other about the test results before you have sex.
Limit your number of sex partners. Your risk of getting STIs goes up with the number of partners you have.
Do not douche. Douching removes some of the normal bacteria in the vagina that protect you from infection. Douching may also raise your risk for PID by helping bacteria travel to other areas, like your uterus, ovaries, and fallopian tubes.
Do not abuse alcohol or drugs. Drinking too much alcohol or using drugs increases risky behavior and may put you at risk of sexual assault and possible exposure to STIs.

The steps work best when used together. No single step can protect you from every single type of STI.

Can women who have sex with women get PID?

Yes. It is possible to get PID, or an STI, if you are a woman who has sex only with women.

Talk to your partner about her sexual history before having sex, and ask your doctor about getting tested if you have signs or symptoms of PID.

Material on PID adapted from information from the Office on Women’s Health in the Department of Health and Human Services in conjunction with Centre for Disease Control (CDC) USA

Adenomyosis

What is adenomyosis and why do I have it?

Adenomyosis is a condition where the cells of the lining of the womb (endometrium) are found in the muscle wall of the womb (myometrium). Around one in 10 women will have adenomyosis. It can occur in any woman who still has periods but is most common in women aged 40-50 and in women who have had children. It cannot be spread between people and it is not cancerous. We do not know exactly why adenomyosis happens. One theory is that in certain conditions when the lining of the womb tries to heal itself after injury, this re-growth happens inwards instead of outwards, resulting in adenomyosis. It is likely that your genes, hormones and immune system may play a part as well. It is no one’s fault if adenomyosis occurs, and there are no known ways to prevent it.

What are the signs and symptoms?

The most common symptoms are:

heavy, painful or irregular periods
pre-menstrual pelvic pain and feelings of heaviness/discomfort in the pelvis.

Less common symptoms are:

pain during sexual intercourse
pain related to bowel movements. Around one third of women will not have any symptoms.

Adenomyosis may just have been found coincidentally on a scan, for example. It is a long-term condition and can affect many areas of a woman’s life, including emotional wellbeing, relationships and daily routines. Any symptoms will stop when you have the menopause. Adenomyosis does not seem to decrease the chance of getting pregnant, but it may increase the risk of miscarriage or having a premature baby.

Do I need any tests to confirm the diagnosis?

It can take a long time (years even) to get a diagnosis.

This is because:

women may have different symptoms
symptoms of pelvic pain can be caused by many other conditions (for example, pelvic inflammatory disease or irritable bowel syndrome)
some women have no symptoms at all.

Unfortunately, this means that for many women, by the time they receive the diagnosis they may be starting to give up on getting the right help. In at least half of cases, adenomyosis can be detected by an internal transvaginal ultrasound scan. A probe is inserted into the vagina and images (created using high-frequency sound waves) are transmitted to a monitor. If an ultrasound scan does not clearly show if you have adenomyosis, it may be necessary to have a magnetic resonance imaging (MRI) scan. This scan uses magnets and radio waves to produce a picture of the inside of your body. If the doctor thinks you should have a scan to help diagnose adenomyosis, you will be given more information about what to expect and how to prepare for the scan.

What treatments are available?

Difficulty diagnosing this condition has made it difficult to develop treatments, many of which address symptoms rather than the underlying cause. Before making a decision about treatment, you should be given full information about all the options including risks and benefits of each.

Several factors may influence your decision-making, such as:

your age and how close you are to having the menopause • whether you want to become pregnant
treatments you have already tried
how you feel about surgery.

Depending on your situation, options could be:

doing nothing – if your symptoms are mild, you are trying for a baby, or you are nearing menopause (when symptoms tend to stop)
non-hormonal medicines (for example, tranexamic acid and mefenamic acid) to help reduce pain and bleeding with your period see section on Heavy Menstrual Bleeding
hormonal medicines – this can include the combined oral contraceptive pill, progestogen only pill or the intra uterine system (the IUS/hormonal coil, Mirena)
injections of hormones to make a false menopause – GnRh agonist injections shrink the womb lining by causing a temporary and reversible menopause, but cannot be used long term
hysterectomy (surgery to remove the womb) can be an effective option for women who do not want to become pregnant – it should not be necessary to remove your ovaries (unless you also have endometriosis) so you should not enter menopause after the hysterectomy.
uterine artery embolisation – tiny particles are injected into your blood vessels through a catheter in the groin. The particles aim to cut off the blood supply to the adenomyosis. This is less invasive than surgery and may help preserve fertility. It is likely to improve symptoms for a couple of years.

Symptoms may recur in the future, however. Sometimes treatments for another condition (for example, fibroids) have been found to improve symptoms of adenomyosis. However, these treatments (for example, endometrial ablation and surgical excision during myomectomy) are not advised for the treatment of adenomyosis only. This is because they reduce the bleeding, but not the pain.

What happens if I do not receive treatment?

If you do not have any treatment the condition will stay the same. In some women the pain will get worse but it will stop after the menopause.

Is there anything I can do to help myself?

Complementary therapies such as yoga, meditation, and gentle exercise may help with painful periods. Some women find that changing their diet is helpful. Others report that TENS (transcutaneous electrical nerve stimulation) machines are helpful.

More research is needed on how effective these strategies are.

Information adapted from a Guy’s and St Thomas’ NHS Foundation Trust leaflet

Help and information on adenomyosis is available from www.adenomyosisadviceassociation.org