Endometriosis is a disease where tissue resembling the endometrium (the tissue that lines the uterus) grows in lesions or patches outside the uterus. These lesions swell and shed with the menstrual cycle, as does the normal endometrium, but because they are located outside the uterus, the lesions cannot be expelled properly, causing pain.

What is dysmenorrhea?

Dysmenorrhea is a term used to describe painful periods, sometimes called menstrual cramps. Most women have mild cramps that can start one or two days before their period, and last two to four days.

Normal cramping is relatively mild pain or discomfort in the lower abdomen or back that is usually relieved with over-the-counter medication.

Dysmenorrhea refers to painful, debilitating cramping, which may be caused by endometriosis or other conditions. This pain is so strong that it often prevents women from going to school, work, or participating in activities. It usually cannot be relieved with over-the-counter painkillers.

Some women may have other symptoms that accompany dysmenorrhea, including nausea, diarrhea, headache, dizziness, and very heavy menstrual bleeding.

What causes dysmenorrhea?

Cramping before or during a period is caused by uterine contractions in response to hormonal changes. These contractions ensure that blood leaves the uterus. This is a normal part of the menstrual cycle. Sometimes, the contraction of the uterus may constrict blood flow to an area, which can also cause cramping.

Conditions such as adenomyosis (the thickening of the uterine walls as endometrial tissue moves into the muscle) or uterine fibroids can cause more painful cramps around the time of the period. The hormone signals that trigger menstruation are also produced by endometrial lesions, so dysmenorrhea is often associated with endometriosis.

How is dysmenorrhea diagnosed?

Patients who have had several months of heavy menstrual flow and painful periods that are not relieved by over-the-counter medication should see a gynecologist. The gynecologist will discuss the patient’s medical history and perform a pelvic exam. He or she may also perform an abdominal ultrasound, which may reveal large uterine fibroids. Small fibroids may not be visible by ultrasound, however.

Adenomyosis as a cause of dysmenorrhea may be diagnosed by ultrasound if large masses are present in the uterus; however, it is more likely to be diagnosed by magnetic resonance imaging (MRI) or after a hysterectomy (surgical removal of the uterus).

The only way to diagnose endometriosis as a cause of dysmenorrhea is by laparoscopy.

How is dysmenorrhea treated?

Painful cramps can be treated by non-steroidal anti-inflammatory drugs (NSAIDs) or hormonal therapy to reduce the levels of hormones that cause cramping.

Dysmenorrhea caused by adenomyosis can be treated with NSAIDs, hormonal therapy, or hysterectomy.

While hormonal therapy may help reduce the incidence of uterine fibroids (which are often associated with endometriosis), the primary treatment is myomectomy (surgical removal of the fibroids).

If dysmenorrhea is caused by endometriosis, there are several treatments that can help. For example, opioid-based pain relievers such as codeine might be prescribed.

Many women find that hormonal therapies greatly reduce dysmenorrhea and other endometriosis-associated pain. These include Depo-Provera and Depo-subQ-Provera 104, Nexplanon,  Lybrel, and Seasonique.

Gonadotropin-releasing hormone (GnRH) receptor antagonists treat pain by reducing the amount of estrogen produced by the ovaries and the endometrial lesions. Orilissa (elagolix) is a GnRH receptor antagonist that has been approved by the U.S. Food and Drug Administration (FDA) to treat endometriosis. Two other similar experimental therapies, Linzagolix and Relugolix, are undergoing clinical trials.

Other GnRH receptor agonists that may be used to reduce dysmenorrhea and pain caused by endometriosis include Lupron Depot (leuprolide acetate), Zoladex (goserelin), and Synarel (nafarelin).

Finally, aromatase inhibitors may be used to reduce dysmenorrhea and other pain caused by endometriosis. They work by reducing the amount of estrogen produced by the ovaries and the endometrial lesions. In patients who are pre-menopausal, they are combined with an oral birth control treatment or a GnRH receptor agonist to reduce the risk of ovarian cystsFemara (letrozole) and Arimidex (anastrozole) are examples of aromatase inhibitors.


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