Menstria · pain
Is this ordinary period pain?
Period pain is the most common menstrual symptom, and most of it is primary dysmenorrhea — pain from the uterus contracting, with nothing else wrong. But a meaningful minority is secondary: pain caused by endometriosis, adenomyosis, or something else that will not resolve on its own.
The features that separate the two are historical, not radiological. This tool asks for them in the order a clinician would, and tells you which of four situations you are in.
Stop and get help now — do not finish this assessment — if any of these apply:
Sudden severe one-sided pain that came on over minutes to hours. Pain with fever or chills. Pain and you are pregnant or might be. Pain with feeling faint, dizzy or breathless. Pain with heavy bleeding you cannot control. Pain with foul-smelling discharge.
Call your ObGyn, midwife, or emergency services.
What this does
It separates three things that get collapsed together: when the pain happens relative to bleeding, how it has changed since it began, and what it has failed to respond to. Failure of an adequate treatment trial is not a reason to try harder — it is diagnostic information, and current guidance treats it that way.
It reports one of four outcomes, and shows you which of your answers produced it. Nothing you enter leaves your browser.
What it does not do
It does not diagnose endometriosis, adenomyosis or anything else. No history-based tool can. Endometriosis in particular has no symptom pattern specific enough to rule it in or out, which is part of why the average delay from first symptom to diagnosis runs to several years and, in some cohorts, a decade. The purpose here is to get the right people to the right conversation sooner.
Step 1 of 1
About your pain
Answer what you can. Leave anything you are unsure about on "not sure" — the tool accounts for it.
Urgent features
Tick anything that is true right now or has happened in the last few days.
When it started
Primary dysmenorrhea typically starts within a year or two of the first period, once cycles become ovulatory.
When the pain happens
How severe it is
Tick anything that has happened in the last few months.
What you have tried
A treatment that was taken properly and still did not work is one of the most informative answers on this page.
Other symptoms
These are the features that most often point away from primary dysmenorrhea. Tick all that apply.
Result
What your answers suggest
What produced this
Every feature below came from one of your answers. Nothing else was weighted.
Treatments with evidence
These are the options with the best evidence for period pain. They are listed so you know what to ask about, not as a prescription — what is right for you depends on your history, and some are not suitable for everyone.
First-line pharmacological and non-pharmacological options for dysmenorrhea, with the evidence grade behind each.
| Option | What the evidence shows | Notes |
|---|---|---|
| NSAIDs | More effective than placebo for pain relief in primary dysmenorrhea, OR 4.37 (95% CI 3.76–5.09), 35 RCTs, low-quality evidence. Roughly 18% get moderate or excellent relief on placebo versus 45–53% on an NSAID. Also better than paracetamol. | No single NSAID has been shown superior. Started at pain onset and taken on a schedule for the first days, rather than as needed. Adverse effects are more common than with placebo. |
| Combined hormonal contraception | Standard first-line hormonal option, alone or added to an NSAID. Continuous or extended regimens reduce the number of withdrawal bleeds and therefore the number of painful episodes. | Contraindications apply, including migraine with aura and thrombotic risk. Discuss with a clinician. |
| Progestogen-only options | Including the levonorgestrel intrauterine system. Used where estrogen is contraindicated or not wanted, and in suspected or confirmed endometriosis and adenomyosis. | ESHRE lists progestogens and hormonal contraceptives as the empirical treatments to consider in suspected endometriosis. |
| Heat | Local heat applied to the lower abdomen has trial evidence for pain reduction and is a reasonable adjunct. | No contraindications in ordinary use. Not a substitute where a secondary cause is suspected. |
| GnRH antagonists | Supported by ESHRE 2022 as a second-line option in endometriosis-associated pain. | Specialist initiation; add-back therapy considerations apply. |
NSAID data: Marjoribanks J, Ayeleke RO, Farquhar C, Proctor M. Cochrane Database Syst Rev. 2015;(7):CD001751. Hormonal and second-line options: ESHRE Endometriosis Guideline Group. Hum Reprod Open. 2022;2022(2):hoac009; ACOG Committee Opinion No. 760. Obstet Gynecol. 2018;132(6):e249–58.
When imaging, referral or surgery come in
The diagnostic pathway changed in 2022, and the change matters if anyone still tells you that only surgery can answer the question.
| Step | When it is considered |
|---|---|
| Pelvic ultrasound | Considered during evaluation for secondary dysmenorrhea regardless of what the pelvic examination shows. It can identify endometriomas, deep endometriosis, fibroids, adenomyosis and obstructive anomalies. |
| A normal ultrasound | Does not exclude endometriosis. Superficial peritoneal disease is not reliably visible on imaging. A negative scan is not an answer, and should not end the conversation. |
| Empirical treatment | Hormonal contraceptives or progestogens can be started on suspicion, without waiting for a confirmed diagnosis. ESHRE treats imaging plus empirical treatment and diagnostic laparoscopy as alternatives to be discussed, not a fixed sequence. |
| Laparoscopy | No longer the diagnostic gold standard. Now recommended where imaging is negative and/or empirical treatment has been unsuccessful or is inappropriate. |
| Gynecologic referral | When pain has not improved within 3 to 6 months of an adequate treatment trial, when a secondary cause is suspected on history, or when there is infertility alongside the pain. |
ESHRE Endometriosis Guideline Group. Hum Reprod Open. 2022;2022(2):hoac009. ACOG Committee Opinion No. 760. Obstet Gynecol. 2018;132(6):e249–58.
One thing worth saying plainly. Pain that stops you functioning is not something to be endured, and it is not a low pain threshold. If you have been told your pain is normal and it is disabling you, that is a reason to ask again — ideally with a written record of what you have tried and for how long. This page prints.
On normalisation. Patient- and provider-level normalisation of menstrual pain is a documented contributor to diagnostic delay, which averages years and in several cohorts approaches a decade. Absent red flags, the cost of an early referral is low; the cost of another year of empirical treatment without review is not.
Evidence base
Sources
Every threshold, interval and figure in this tool traces to one of these. Vancouver format, numbered in order of first use.
- American College of Obstetricians and Gynecologists' Committee on Adolescent Health Care. ACOG Committee Opinion No. 760: Dysmenorrhea and endometriosis in the adolescent. Obstet Gynecol. 2018;132(6):e249–e258. doi:10.1097/AOG.0000000000002978 Source of the 3-to-6-month rule: where dysmenorrhea does not improve within 3 to 6 months of starting therapy, investigate for secondary causes and for adherence. Also the source for considering pelvic ultrasonography during evaluation for secondary dysmenorrhea regardless of examination findings, for obstructive reproductive tract anomalies as a cause, and for the statement that endometriosis is the leading cause of secondary dysmenorrhea in adolescents.
- Becker CM, Bokor A, Heikinheimo O, et al; ESHRE Endometriosis Guideline Group. ESHRE guideline: endometriosis. Hum Reprod Open. 2022;2022(2):hoac009. doi:10.1093/hropen/hoac009 Source of the current diagnostic pathway. Laparoscopy is no longer the diagnostic gold standard and is recommended where imaging is negative and/or empirical treatment was unsuccessful or inappropriate. Imaging and empirical treatment with hormonal contraceptives or progestogens are alternatives to be discussed with the patient. Negative imaging does not exclude endometriosis. Also the source for GnRH antagonists as a second-line option. Author list abbreviated here; verify full order before formal citation.
- Marjoribanks J, Ayeleke RO, Farquhar C, Proctor M. Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. Cochrane Database Syst Rev. 2015;(7):CD001751. doi:10.1002/14651858.CD001751.pub3 80 RCTs, 5,820 women, 20 different NSAIDs. Source of the effect size used in this tool: OR 4.37 (95% CI 3.76–5.09) versus placebo across 35 RCTs, rated low-quality evidence; if 18% achieve moderate or excellent relief on placebo, 45–53% do so on an NSAID. Also the finding that no individual NSAID has been shown superior, and that adverse effects are more common than with placebo.
- Munro MG, Critchley HOD, Fraser IS; FIGO Menstrual Disorders Committee. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 2018;143(3):393–408. doi:10.1002/ijgo.12666 Source of the bleeding descriptors used where abnormal bleeding accompanies pain, and of adenomyosis and leiomyoma as structural causes in the PALM-COEIN framework.
- Li W, Feng H, Ye Q. Factors contributing to the delayed diagnosis of endometriosis — a systematic review and meta-analysis. Front Med (Lausanne). 2025;12:1576490. doi:10.3389/fmed.2025.1576490 Source for endometriosis affecting approximately 6–10% of women of reproductive age, and for diagnostic delay averaging several years. Reported delay varies widely by country and cohort, with some series approaching a decade; the tool states the range rather than a single figure.
What this tool deliberately does not do. It does not produce a probability of endometriosis. Published symptom-based prediction models for endometriosis have not achieved performance that would justify presenting a number to a patient, and a false-precision percentage would do more harm than a category. Where the evidence supports only a direction, this tool gives a direction.