Painful periods can occur for a number of different reasons, and the underlying cause is not always straightforward. In many cases, increased prostaglandins drive stronger uterine contractions, contributing to cramping and pain. This can be further influenced by inflammation, hormone imbalances, and heightened nervous system sensitivity.

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While period pain is common, moderate to severe pain — or pain that is worsening over time — is not considered normal and should be investigated. Conditions such as endometriosis may be involved. Affecting approximately 1 in 7 women and those assigned female at birth, it is now recognised as a chronic inflammatory and immune-mediated condition.

Persistent pelvic pain can also point toward additional underlying drivers beyond primary dysmenorrhoea. These may include:
 

Pelvic floor tension (myofascial pain):
Often presents as a sense ofburning pain, discomfort or tenderness on examination. This may develop independently or as a secondary response to chronic pelvic inflammation.
 

Pelvic venous disease (pelvic congestion syndrome):
Associated with dilated pelvic veins, typically causing a sense of pelvic heaviness that worsens with prolonged standing and improves when lying down.
 

Other underlying pathologies:
Conditions such as adenomyosis, fibroids, or bladder pain syndrome (interstitial cystitis) may also contribute. Pain with intercourse or bowel movements can be suggestive of more invasive endometriosis.

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Additional contributing factors may include altered immune activity, inflammatory signalling, and gut-related dysfunction, all of which can influence pain severity and persistence.

Identifying the underlying drivers is key.
Management should be targeted and individualised, rather than focused solely on symptom suppression.

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