Period pain… What’s normal?

Is your period pain ‘normal’… or a sign of PMS, endometriosis, or fibroids?

Yet again, the silence created by the menstrual taboo has led to unnecessary suffering, and confusion. Let’s bust some myths!

For all these facts and more- check out the ‘What’s normal? Myth-busting menstrual health e-booklet’- only £2.95!

What causes period pain?

First of all, it’s worth noting that there are different types of period pain. [Even ‘normal’ period pain, typically involves two different types; direct (e.g. womb/ uterine cramps), and indirect (e.g. associated pain caused by other menstrual changes)]

1. Womb or uterine cramps

These are exactly what they sound like; muscle cramps. Only in this case, they are happening for a specific purpose, and not just as a result of older age, over-exercising, or a drop in the body’s salt levels (i.e. like leg cramps) [1].

The womb is largely made up of a thick wall of smooth muscle (the myometrium). This muscle is extremely powerful, and is composed of three layers (in horizontal, vertical and diagonal directions) [2]. Muscle spasms enable important (i.e. critical to the survival of our species) functions of human reproduction: Regularly shaking off old endometrial cells (the inside lining of the womb) as quickly as possible during menstruation, and very occasionally pushing out baby humans during childbirth (known as ‘uterine contractions’).

Cramping is typically described as ‘suddenly intense’ or ‘sharp’ pain, lasting from a few seconds up to several minutes (but not usually any longer than 10 minutes), and tends to come and go in ‘waves’. Cramp pain can begin before the period starts, but it is usually most severe on days 1 and 2 (heavy flow). Technically, period cramps are caused by the destruction of the endometrial cells, and the resulting release of ‘prostaglandins’ [3]. These inflammation response-related chemicals cause the muscle in the womb to contract and spasm [3].

Note– The ‘copper coil’, or non-hormonal IUD (Intrauterine Device), is known to increase the severity of period cramps (and menstrual bleeding) in some people [4]. The cause is not fully understood, but a good quality clinical study found that for most people, this problem resolved between 3 and 6 months of usage [4].

2. Associated period pain

This is more variable in origin and experience. Lower back pain, a feeling of abdominal ‘heaviness’, or an aching vulva (the outside part of female genitals) are the most common forms. This pain is more of a constant ‘ache’ and I personally think that it is similar to ‘toothache’ albeit in a very different location! It certainly creates the same ‘urghhhh’ feeling, and unhappy facial expressions… This type of longer lasting pain is experienced during menstruation, but not usually before bleeding begins. It is usually caused by one or more of a range of menstrual changes; including pelvic muscle/ spine inflammation, water retention, constipation, diarrhoea, or trapped gas.

Back in 2012, the below Facebook post was published (by people who should know better) [5]. Since then it has been shared over a million times, and continues to pop up in menstrual health and sex education forums.

‘Fake news’ caption added by Menstrual Matters. Source: Apples and Ovaries

The post and image claim that there is a visible and significant size difference between a menstruating womb, and a non-menstruating womb. This is absolute nonsense, and yet another example of how profit-making companies don’t care if they spread unhelpful and misleading information about [female] health (so long as it makes them money). Whilst the muscle of the womb does become slightly inflamed during menstruation, there is no noticeable size increase [5]. The ‘heavy feeling’ is simply a form of associated pain, as described above. See this excellent myth-busting blog post by Health Line, for further information…

3. Endometriosis-related pain

This has a different origin to ‘normal’ cramps or associated period pain.

Common locations for endometriosis lesions… Source: Wikimedia

Endometriosis is a condition in which endometrial tissue, the type of cells normally found in the inside of the womb, grow outside it [6]. Typically, the cells form ‘lesions’ (like scar tissue) on the ovariesFallopian tubes, or around the womb, but rarely, they also grow in other parts of the body e.g. the lungs or brain [6].

These cells ‘bleed’ during menstruation and, since the blood has no means of leaving the body cavity, the build up can cause internal inflammation or further lesions [6]. Pain may be experienced as severe ‘cramping’ or ‘stabbing’ pain, anywhere in the abdomen, especially during menstruation, but also as more ‘chronic pain’ (i.e. throughout the entire cycle) [6]. Severe ‘sharp’ pain may also be experienced during sex, or when passing urine or faeces [6], please consult a doctor if you experience any of these symptoms.

Common locations of fibroids. Source: Wikimedia

4. Fibroid-related pain

This also has a different origin to ‘normal’ period pain, although it may feel very much like severe period ‘cramps’. Fibroids are abnormal growths that develop in or around the uterus/ womb. Fibroids are very common, but many people do not know they have them, since they do not experience any symptoms. The size of the growth (a type of benign tumour) makes all the difference; the larger it is, the more likely it will press against the surrounding tissue and organs, causing inflammation and pain.

Fibroid pain is typically worse during menstruation, when it can cause severe period cramps, and heavy bleeding. Pain can also be less severe, but continue throughout the cycle, causing a long lasting feeling of ‘heaviness’, ‘bloating’, or general abdominal discomfort [7].

Normal period pain vs PMS vs endometriosis vs fibroids…

Pain is a subjective symptom, meaning that it is not easily ‘observed’ or ‘detected’ by anyone other than the afflicted person. There is also no way to precisely ‘measure’ pain e.g. through the use of a clinical test. Instead, it is up to the patient to try to accurately describe the severity and type of pain experienced. The best way to do this for period pain, is to track your symptoms! Here is a useful chart with which to ‘score’ your period pain levels (remember to score your short sharp ‘cramp’ pain separately from more constant ‘ache’ pain );

Source: Wong DL, Baker MC, Comparison of Assessment Scale, 1988, Pediatric Nursing; 14; 1-9

Normal period pain– Anything below 5 on the scale, perhaps with occasional ‘bad cramps’ ranging between 5-8 on the scale, but not for longer than 10 minutes at a time or 3 days in a row. You can alleviate period pain through the use of painkillers (especially ibuprofen, so long as you do not have asthma), or even through some simple lifestyle changes.

PMS pain– period cramps and/ or associated period pain in most cycles, severe enough to disrupt daily functioning (5-10). Waking up during the night due to period pain(s). Period cramps might peak high up on the scale, but not for longer than 10 minutes at a time, or for more than 3 days in a row. Associated PMS period pain (abdominal, vulval, leg pain) is more likely to be between 5-8 on the scale, but longer lasting than cramp pain, and during menstruation, only.

Please speak to your doctor, because PMS pain responds well to lifestyle changes/ treatment, and other health issues such as endometriosis or fibroids must also be ruled out, first!

Endometriosis pain– Similar to PMS pain (above), except it might last longer than 3 days in a row, or could occur at times other than just before or during menstruation. Pain may also get worse over time (progressive pain), and is generally linked to lower back or pelvic pain (i.e. not just where the womb is located). You may feel bloated, with some abdominal discomfort, throughout the cycle [6]. Pain during sex, or when passing urine or faeces, can be a sign of endometriosis [6].

Please speak to your doctor, because endometriosis pain can be reduced or even eliminated (through lifestyle changes, the use of painkillers, or hormonal medication that prevents cyclical bleeding altogether), and other health issues such as fibroids must also be ruled out, first!

Fibroids pain– Similar to endometriosis pain (above), but you may also be able to feel a hard mass (lump) inside the abdomen and your periods may be very heavy (over 80ml of fluid per period) [7]. Constipation and/ or diarrhoea are also more likely to occur, throughout the cycle [7]. As with PMS and Endometriosis, please seek medical help as soon as possible, to reduce pain, and prevent the fibroid from getting any larger (if left untreated, fibroids may require surgery) [7].

How to reduce period pain

Even though mild-moderate period pain is ‘normal’, this doesn’t mean that there’s nothing you can do to help reduce it!

Even severe period cramps can be improved by some simple lifestyle changes, and/ or the use of anti-inflammatory painkillers (it’s best to start taking them a couple of days before your period is expected).

The severe pain caused by endometriosis or fibroids, may also be somewhat alleviated in this way, but it is important to seek medical advice because without specific treatment, these issues are likely to get worse over time (until menopause!).

For more detailed advice on what can help reduce, or even stop, period pain- please see our specific symptom management pages on period pain, endometriosis and fibroids.

For all these facts and more- check out the ‘What’s normal? Myth-busting menstrual health e-booklet’- only £2.95!

Citation: King, S. (2018) Period Pain… What’s normal? [ONLINE] Available at: [Accessed- insert date].

References and notes:

Main image at top of page: Peter Southwood (2011) Wikimedia;

[1] NHS (2018) Leg cramps. [ONLINE] Available at: [Accessed 5 November 2018].

[2] Medscape. 2015. Uterus Anatomy. [ONLINE] Available at: [Accessed 5 November 2018].

[3] Lethaby A, Duckitt K, Farquhar C (2013). “Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding”. The Cochrane Database of Systematic Reviews (1): CD000400. doi:10.1002/14651858.CD000400.pub3PMID 23440779

[4] Diedrich, J T. et al. (2014) Association of short-term bleeding and cramping patterns with long-acting reversible contraceptive method satisfaction American Journal of Obstetrics & Gynecology , Volume 212 , Issue 1 , 50.e1 – 50.e8

[5] Here is a great expose of the viral ‘womb inflammation’ photo- well done Healthline!

[6] NIH (2017) Endometriosis overview. [ONLINE] Available at: [Accessed 5 November 2018].

[7] NHS (2018) Fibroids. [ONLINE] Available at: [Accessed 5 November 2018].



Categories: No pain, Underlying conditions and What's normal?.


  1. Maria

    I had pain since I got my first period. In a last 3 years I feel like it has changed. I changed my diet, I am not using sugar at all and I started exercising. Also, I started using Lily cup instead of pads or tampons. Maybe just one of these things had an influence or maybe a combination of all of them.

  2. Kavya

    I need help. I have sever pain. Got it checked up to see if it is a pain for otherwise. No problem but pain is severe. I am anemic, cant stand blood i go pale, and i faint. I tried everything clean veg diet for a year. No go 🙁
    I dont eat junk ,fast food or sugar items. Hate sweets.
    What to do 🙁

    • SallyMM1

      It sounds like you need medical support. Anaemia makes menstrual blood loss and pain worse, so the first thing to recommend is iron supplementation/ treatment to improve your iron stores. You may also have a condition called ‘adenomyosis’ which is a type of endometriosis that occurs in the wall of the womb. If you are not currently trying to get pregnant, then Long Acting Removable Contraceptive options such as the Mirena or Skyla IUS devices are probably the best way to alleviate your symptoms. This would need to be fitted by a medical professional. Good luck and please let me know how you get on? Thanks for getting in touch.

  3. Ali

    I had tubal ligation sterilisation and uterine thermal ablation (novasure) 2 years ago and have been having severely painful periods since, but not every period and my life has been so busy I haven’t pursued it with the Dr. I was anemic before the op with heavy periods and now I hardly bleed at all and had more energy at first. But I keep getting UTIs and recently fatigue. Normally the pain was one or two days but like being in labour, but this time it has lasted for three nights, starting when I try to go to sleep and keeping me awake. I’m so tired, I can’t cope. I might just go to a & e. If I take both paracetamol and ibuprofen it might lessen enough for me to sleep a bit. I just want it to stop. I can’t get through to my GP at all during the day.

    • SallyMM1

      I’m so sorry that you are going through this. What you describe doesn’t sound like ordinary ‘period’ pain. A GP appointment would be best- I hope they pick up the phone soon/ otherwise I would suggest changing doctor… Unfortunately, an emergency doctor won’t be very interested in or knowledgeable about this type of chronic recurring pain. Do ask for an iron level test and a referral to a gynaecologist to make a full and proper examination of your womb. These experiences are losing you sleep which is really tough on your mood and ability to work – so your GP should take it super seriously. Do let me know how you get on?

  4. SJ

    Great overview, thanks. A lot of us learn to put up with and hide the pain.

    Adenomyosis – similar to endometriosis but inside the uterine muscle – can also cause severe pain and heavy bleeding leading to anemia.

  5. Amber Elaine ontiveros

    I need help. I’m 19yrs old my cramps have alway affected the way I live. I can not go to school or work or do anything when I’m on my period. Midol doesn’t help, out of being desperate I’ve taken 10 midols in a day before. I am vegetarian, I workout, I have a healthy life style, I barely eat any junk food. I am not anemic, but my cramps feel like they’re almost killing me every month. I take vitamins too, I just don’t understand why it hurts soo much when I’ve done everything I can to not feel so much pain. I use a Lilly cup and I haven’t felt any better from anything I’ve been doing. My symptoms include; nausea,vomiting, diarrhea, cold sweat, inability to do anything, cramps that will leave me shaking, my abdominal gets swollen(I’ve gone to the emergency and I told them I was on my period and they saw my stomach and immediately thought I was having organ failure) I kept telling them i was on my period but they ignored it because they seriously thought my organs were failing. I can not eat or drink water for my first two days of having my period because I will throw up anything. I will literally throw up water. My pain is so immense I need to use boiling water that can burn my skin to try to ease a little pain. I much rather feel my skin burning than my cramps. This is every month and I don’t know what to do anymore. I have been considering just admitting myself to the hospital to have my entire uterus removed if it meant no more cramps each month. Gynecologists have told me to take birth control and they don’t even spend the time to diagnose me, I can not take birth control because I’ve had a bad experience in the past, I almost killed myself. I need advice because I’m running out of options and I don’t know what to do.

    • MM

      Hi Amber, so sorry that you’ve been through this. It sounds very much like you probably have endometriosis or ademyosis. Please see your doctor again (or a different one)- who should take the time to conduct an ultrasound (to rule out fibroids) and then explain the different treatment options for suspected endometriosis/ ademyosis. Please do not rule out hormonal/ contraceptive medications or the IUS (Mirena/ Skyla) just because you had a previous bad experience. It is not the hormones that cause side effects but the way in which the medication interacts with your immune system/ underlying health issues. The pill tends to worsen an existing low mood/ depression/ anxiety rather than cause it directly- plus people taking the pill for pain symptoms tend to report fewer side effects than those using it for contraception- so it may be worth trying again? Different pills/ devices have very different effects in different people- or even the same people at a different time in their life. The IUS tends to be better tolerated than the pill but it involves an insertion procedure that can be a bit painful (but only for a couple of days- which may be worth it considering the monthly severe pain you experience). Please try not to use self-harm methods (skin burning) to manage your symptoms- this is damaging to both your physical and mental health. I’m sorry that the doctor(s) you have seen previously have not fully explained what is happening in your body and why it is important to manage your periods to avoid further damage. You need and deserve proper medical attention for your experiences. I hope you get help soon. Here’s the page on endometriosis just FYI-

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