When the problem is not the bleeding

Painful periods and premenstrual mood disturbance are separate axes again — a cycle can be perfectly regular, normal in volume and duration, and still be disabling.

Dysmenorrhea

Primary dysmenorrhea is period pain with no underlying pelvic pathology, driven by prostaglandin-mediated uterine contraction. It typically begins within the first year or two after menarche, once cycles become ovulatory, starts with or just before the bleeding, and lasts one to three days.

Secondary dysmenorrhea is period pain caused by identifiable pathology — most often endometriosis or adenomyosis, also fibroids, pelvic inflammatory disease, and obstructive anomalies of the reproductive tract. The historical features that point to it: pain that began years after menarche rather than at the outset, pain that has been worsening, pain extending beyond the days of bleeding, deep pain with intercourse, and pain with bowel movements during the period.

One thing is worth stating plainly, because it is the most common reason for delay: period pain that stops you functioning is not something to be endured as normal. Pain that keeps you from school or work, that does not respond to over-the-counter anti-inflammatories taken properly, or that makes you vomit is a reason to be assessed — not a low pain threshold. The Period Pain Navigator works through exactly these features and tells you which of four situations you are in.Diagnostic delay in endometriosis remains measured in years, and the dominant contributor is normalisation of pain by patients, families and clinicians. Failure of adequate NSAID therapy, absenteeism, dyspareunia, dyschezia or cyclical bowel or urinary symptoms warrant evaluation; empirical treatment is reasonable, but laparoscopy is no longer required to make a working diagnosis before initiating it. The Period Pain Navigator applies the ACOG 3-to-6-month review interval and the ESHRE 2022 diagnostic pathway.

Premenstrual disorders

Premenstrual syndrome (PMS) is physical and mood symptoms in the luteal phase that resolve with or shortly after the onset of bleeding, and that are absent in the follicular phase. That symptom-free interval is the defining feature — symptoms present all month are not PMS.

Premenstrual dysphoric disorder (PMDD) is the severe form, and it is a distinct diagnosis rather than a matter of degree, with mood symptoms — marked lability, irritability or anger, depressed mood, anxiety — causing significant impairment. Diagnosing it properly requires tracking symptoms daily across at least two cycles, because recall alone is unreliable; roughly half the women who report the pattern do not show it once it is charted prospectively.DSM-5 requires prospective daily ratings over at least two symptomatic cycles for confirmation; retrospective report substantially over-identifies. Timing, not symptom content, distinguishes PMDD from premenstrual exacerbation of an underlying mood or anxiety disorder — the latter does not remit in the follicular phase, and the management differs.