Painful periods (dysmenorrhoea)
When periods first start they are usually painless. However, later on most girls notice an ache in their lower abdomen, back and tops of the legs, especially in the first few days of a period. The first two days are usually the worst. Some women have more pain than others. Painkillers or anti-inflammatory painkillers such as ibuprofen usually ease the pain if it is troublesome. Another web page called 'Painful Periods'
It is common to have some period pain. The cause of the pain in most women is not fully understood. Sometimes conditions such as endometriosis can make period pains become worse. See a doctor if:
- the pain becomes gradually worse each period.
- pain begins a day or more before the onset of bleeding.
- pain is severe over the whole time of the period.
Endometriosis is usually found in women aged between 25 and 49; it's rare in women under 20. It's estimated that up to 15 out of 100 premenopausal women have endometriosis.
Endometriosis is most common on the ovaries, fallopian tubes and the tissues that hold your womb in place. You can also get endometriosis on or around other organs in your pelvis and abdomen (tummy), such as your bladder or bowel. Endometriosis can cause cysts (endometrioma) to form on the ovaries. These cysts may not cause you any pain - you may only find out about them during an internal.
In some women, endometriosis gets better on its own, but for most, it gets worse without treatment.
Symptoms of endometriosis
The symptoms of endometriosis can vary. Some women have no symptoms at all, while others have severe pain. The most common symptom is pelvic pain that feels like period pain.
Other symptoms include those listed below.
- Chronic pelvic pain - a chronic illness is one that lasts a long time, sometimes for the rest of the affected person's life. The term chronic refers to time, not how serious a condition is.
- Pain during sex.
- Changes to your periods, such as a small loss of blood before the period is due (spotting), irregular bleeding or heavy periods.
- Painful bowel movements.
Endometriosis on the bowel may cause swelling of your lower abdomen, pain when you have a bowel movement or blood during a period. Endometriosis on the bladder can cause pain when you urinate or blood in your urine during a period. Symptoms of endometriosis usually disappear after the menopause.
Complications of endometriosis
Complications of endometriosis include those listed below.
- The bleeding can form bands of scar tissue (adhesions) that can attach to the organs in your pelvis and abdomen.
- Reduced fertility that may have no obvious cause or may be caused by adhesions forming on or near to your ovaries or fallopian tubes.
- Cysts can bleed or rupture, causing severe pain.
Causes of endometriosis
No one knows for certain what causes endometriosis or why some women get it and others don't. Endometriosis can affect any woman of childbearing age.
You're more likely to develop endometriosis if you:
- have a mother or sister who has endometriosis.
- have low fertility.
- start your periods early.
- go through the menopause late.
- have frequent, heavy or painful periods
Diagnosis of endometriosis
Your GP will ask you about your symptoms and examine you. He/she may also ask you about your medical history. Your GP may wish to perform a vaginal examination. If he/she thinks you may have endometriosis, he/she will refer you to a gynaecologist (a doctor specialising in women's reproductive health).
The only way to be sure that you have endometriosis is to have a laparoscopy. A laparoscopy is a procedure that allows your surgeon to look inside your abdomen. The procedure involves passing a narrow, flexible, tube-like telescopic camera (a laparoscope) into your abdomen through a small cut. Your surgeon will examine the organs in your pelvis by looking at pictures sent to a monitor.
The diagnostic procedure takes about 30 minutes and is usually done as a day case under general anaesthesia. This means you will be asleep during the procedure. You will be asked to follow fasting instructions. Typically you must not eat or drink for about six hours before a general anaesthetic. However, some anaesthetists allow occasional sips of water until two hours beforehand. You usually won't need to stay overnight in hospital.
If you have mild or moderate endometriosis, the affected tissue can sometimes be removed at the same time, which may prolong your procedure. If your surgeon finds that you have severe endometriosis, he or she will discuss treatment options post operatively.
Treatment of endometriosis
There is currently no cure for endometriosis, but treatments are available for managing the symptoms. These aim to:
- relieve pain and heavy bleeding.
- shrink or slow down the growth of the endometrial tissue on other organs.
- improve your fertility.
Medicines used to treat endometriosis don't improve fertility, but surgery can help if the endometriosis is interfering with the normal workings of the womb and ovaries. Some women with endometriosis who want to have children may need fertility treatment.
The type of treatment you have will depend on your age, the severity of your symptoms and whether or not you want to have children.
You can take over-the-counter medicines, such as ibuprofen. Always read the patient information that comes with your medicine and if you have any questions, ask your pharmacist for advice.
Hormonal medicines that reduce the amount of oestrogen in your body will reduce the size of the endometriosis and ease your symptoms. Some examples are:
- gonadotrophin-releasing hormone (GnRH) analogues (eg buserelin, proslap, 20ladex)
- progestogens (eg norethisterone)
- Mirena coil
- Oral contraceptive pill
The combined oral contraceptive can also be used.
These hormonal treatments all have different side-effects. Your doctor may suggest trying several hormonal medicines to find one that works best for you. Always ask your doctor for advice and read the patient information leaflet that comes with your medicine. Some hormonal medicines (but not oral contraceptives or GnHR analogues) can harm a developing baby, so you should use a barrier method of contraception (such as condoms) to prevent you becoming pregnant while taking these medicines.
Treatment with medicines won't cure endometriosis and symptoms usually return when you stop taking them.
The aim of surgery is to remove as much of the endometriosis as possible while still enabling you to have children. You may need surgery if:
- you have severe pain that isn't responding to painkillers or hormonal medicines
- you want to have children but are having trouble conceiving
- your examination showed that the endometriosis is larger than 4 to 5cm (1.5 to 2 inches)
- the endometriosis is interfering with the normal workings of organs such as your bowel
The endometriosis may be cut away, or it can be destroyed with heat from an electric current or a laser (endometrial ablation). This can usually be done by a procedure called laparoscopy (the same procedure you will have had during your diagnosis). Your surgeon will make small cuts in your abdomen and then use a laparoscope to view the inside of the pelvis and remove the endometriosis (this is called keyhole surgery).
There's a chance your surgeon may need to convert your keyhole procedure to open surgery. This means making a bigger cut on your abdomen. This is only done if it's impossible to complete the operation safely using the keyhole technique. Your surgeon will give you more information about which option is best for you.
In some women endometriosis can come back after surgery. Your surgeon may recommend you take hormonal medicines after the surgery to help delay the return of symptoms.
Some women find that complementary treatments such as acupuncture, aromatherapy, herbal remedies and homeopathy are helpful for relieving pain. However, there is no clinical evidence to support this. Your GP can advise you on these treatments and refer you to a qualified practitioner.
Gynaecologists can look inside the abdomen during the procedure. The objective is to inspect the internal organs. This procedure can greatly help in diagnosing certain conditions and can be used to treat conditions like scar tissue, endometriosis and ovarian cysts. This operation is often called minimal access surgery, keyhole surgery, or ‘endoscopy’, which means ‘to look inside’. You may hear your gynaecologist use these terms. Thin telescopic instruments called endoscopes are used in laparoscopy. A video camera is fitted to the endoscope so the gynaecologist and surgical team can view the images on a video monitor.
In laparoscopy the endoscope is inserted in to the abdomen through a small cut in the abdomen or navel. Sometimes a small piece of tissue (biopsy) is taken for further analysis. Surgery to treat many gynaecological conditions is performed safely and effectively during laparoscopy. Compared to laparotomy (Surgery through a larger incision in the abdomen), laparoscopy has significant benefits, which include:
- smaller less visible scars.
- less pain and discomfort during recovery.
- usually quicker recovery after surgery and an earlier return to daily activities.
Length of stay: It is generally performed as a day only procedure but 1/40 patients have to stay overnight.
The procedure: A thin hollow needle is inserted in to abdomen (usually through a small cut in the navel), and carbon dioxide gas is passed into the abdominal cavity. The gas gently inflates the abdomen raising the abdominal wall above the uterus, bowel and other organs so they can easily be inspected. The bladder will be emptied with a urinary catheter placed in the urethra temporarily.
The laparoscope is then inserted. If necessary, special instruments may be inserted through 1 to 4 incisions, usually near the pubic hairline. The gynaecologist uses these instruments to move the pelvic organs to get a clear view of the area. The instruments may also be used to perform surgical treatment, as discussed with your gynaecologist. An instrument is usually placed in the uterus through the vagina, so pelvic organs can be manipulated during the procedure.
When the instruments are removed, the carbon dioxide gas is released from the abdominal cavity. A stitch may be used to close each of the small cuts.
Conversion to open surgery (laparotomy);
In some cases, the gynaecologist may find that is not safe to continue the laparoscopy due to unexpected or life threatening problems. The gynaecologist may have to continue treatment through laparotomy, which is open surgery through a larger incision in the abdomen.
A woman may be disappointed that she has had open surgery instead of laparoscopy, but it is done in the interests of her safety and wellbeing. The decision to convert to open surgery should be considered sound judgement. Before you sign the consent form, it is best to discuss the possibility of open surgery and its benefits.
Recovery after laparoscopy; After laparoscopy your recovery will depend on the amount of surgery performed during your procedure. If you have general anaesthetic, do not drive for at least 24 hours, and do not make any important decisions for 2 days. Although some women feel able to return to work the next day, others take 1 or 2 days of work. Shower and bathe as normal. Tampons may be used and changed regularly. Expect to remain off work for at least 3 days
After your operation you may experience some symptoms that may last several days:
- Mild nausea.
- Muscle pain.
- Pain or discomfort at the site of the incision.
- Pain in 1 or both shoulders that may extend to your neck. This thought to be caused by the carbon. dioxide gas used during the procedure. This pain may last a few days. Lying down often helps improve it.
- Cramps similar to period cramps.
- A little vaginal discharge or bleeding may last a few days.
- A sensation of swelling in the abdomen.
Pain relief: Paracetamol is usually sufficient to relieve pain and discomfort. If you need stronger pain relief ask you gynaecologist.
Resumption of normal activities: Normal physical and sexual activities can be resumed once any bleeding and discomfort have disappeared, and you are feeling well enough.
1/500 Bowel injury
1/2000 Vessel injury
1/1000 Conversion rate (Laparotomy)
Uterine perforation (rare)
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