Causes, Conditions, and Clinical Insight
Secondary dysmenorrhoea refers to period pain that results from an underlying medical condition. It differs from primary dysmenorrhoea, which is common in younger individuals and not associated with disease.
Women with secondary dysmenorrhoea often notice that their pain worsens over time, begins later in life, or occurs alongside other symptoms like heavy bleeding, fatigue, or pain during sex. These may indicate a treatable gynaecological disorder.
Understanding what causes this pain is key to identifying serious health conditions and improving long-term wellbeing.
What Causes Secondary Dysmenorrhoea?
Secondary dysmenorrhoea is not a diagnosis on its own, it’s a symptom of something else going on in the reproductive system. Several common conditions are responsible:
- Endometriosis
This occurs when tissue similar to the uterine lining (endometrium) grows outside the uterus. These growths may be found on the ovaries, bowel, bladder, or pelvic wall. During menstruation, this tissue breaks down but has no way to exit the body, causing inflammation, internal bleeding, and severe pain. - Adenomyosis
In adenomyosis, endometrial tissue grows into the muscle wall of the uterus itself. This leads to a thickened, tender uterus that contracts abnormally during menstruation, producing deep, throbbing pain. - Uterine fibroids
Fibroids are non-cancerous tumours made of muscle and fibrous tissue. They can grow inside the uterine wall, on its surface, or even within the uterine cavity. Larger fibroids may press on nearby organs or interfere with normal blood flow, resulting in heavy periods and cramping. - Pelvic Inflammatory Disease (PID)
PID is an infection of the female reproductive organs, typically caused by bacteria from sexually transmitted infections. If left untreated, it can lead to chronic pelvic pain, fever, unusual discharge, and scarring of the fallopian tubes. - Congenital abnormalities or ovarian cysts
Issues such as a septate uterus (a wall dividing the uterus) or large ovarian cysts can disrupt normal menstrual flow or increase tension in the pelvic area, leading to discomfort before and during menstruation.
Each of these conditions triggers abnormal inflammatory responses, muscle tension, or structural changes that amplify menstrual pain.
When and Where the Pain Occurs
Pain from secondary dysmenorrhoea typically starts after the age of 25 and often becomes more intense with each cycle. Unlike primary cramps, this pain doesn’t always go away with over-the-counter medication.
- Pelvic or abdominal cramps
Pain may begin several days before your period and last beyond the end of menstruation. It’s often described as sharp, stabbing, or dragging. - Lower back and thigh pain
The ache may radiate into the back or legs, especially if nerves are affected by fibroids or inflammation. - Pain during intercourse
Particularly common in endometriosis and adenomyosis, this may feel like deep pelvic discomfort during or after sex. - Bowel or bladder pain
If endometrial tissue affects the bowel or bladder, urination or defecation during periods may become painful.
These symptoms often coincide with the location of the underlying pathology and can help guide diagnosis.
Symptoms Beyond Cramps
Secondary dysmenorrhoea often comes with other clues that distinguish it from regular period pain:
- Heavy bleeding (menorrhagia)
Periods may last longer than 7 days or involve soaking through sanitary products every hour. - Spotting between periods
Unexplained bleeding outside the menstrual cycle could indicate a structural abnormality or hormonal imbalance. - Nausea, fatigue, or bloating
Some individuals feel physically run down or experience digestive discomfort around their period. - Chronic pelvic pain
Unlike primary dysmenorrhoea, pain may occur outside of menstruation, signalling a more serious underlying issue. - Pain during urination or bowel movements
These symptoms point to possible involvement of pelvic organs, often seen in endometriosis or PID.
Tracking these symptoms over time can help pinpoint patterns and assist healthcare providers in making a diagnosis.
How Common Is It?
Secondary dysmenorrhoea is common but frequently underdiagnosed. Research shows:
- Around 10% of women of reproductive age have endometriosis [1]
- Uterine fibroids affect up to 70% of women by age 50, though not all experience symptoms [2]
- Adenomyosis affects 20–35% of women, most often those in their 30s and 40s [3]
- Pelvic Inflammatory Disease remains a leading cause of chronic pelvic pain and infertility in women under 25 [4]
These numbers highlight how widespread these conditions are, even though many suffer in silence or delay seeking help.
How Is It Diagnosed?
If you suspect your period pain has changed or worsened, your GP or gynaecologist may use the following steps to evaluate secondary dysmenorrhoea:
- Clinical history
You’ll be asked about when your pain started, how it feels, and whether it affects other areas (e.g. back, bladder, bowel). - Pelvic examination
The doctor may feel for an enlarged or tender uterus, fibroids, or signs of infection. - Imaging
Transvaginal ultrasound is commonly used to detect fibroids, cysts, or abnormal uterine tissue. MRI may be needed in more complex cases. - Laparoscopy
A minimally invasive surgery where a small camera is inserted through the abdomen to confirm diagnoses like endometriosis. - Laboratory tests
These may include STI screening, hormone panels, or full blood counts to rule out infection or anaemia.
An early and accurate diagnosis can prevent long-term complications, including infertility and chronic pain syndromes.
Common Misconceptions
Several myths often prevent people from seeking help:
- “Period pain is normal”
Mild cramps are common, but pain that disrupts daily life or gets worse over time is not. - “If my cycle is regular, I must be healthy”
Many gynaecological conditions don’t interfere with the timing of periods, only their quality. - “Birth control or painkillers fix everything”
These may relieve symptoms temporarily, but they don’t treat underlying structural or inflammatory causes.
Challenging these misconceptions is the first step toward receiving proper care.
Why Early Treatment Matters
Leaving secondary dysmenorrhoea untreated can lead to:
- Infertility – Especially in cases of endometriosis, PID, or tubal scarring.
- Chronic pain – Persistent inflammation can lead to long-term nerve sensitisation.
- Mental health issues – Ongoing discomfort increases risk of anxiety and depression.
- Reduced quality of life – Missing school, work, or social events becomes the norm.
Getting evaluated early allows for more treatment options and better long-term outcomes.
Conclusion
Secondary dysmenorrhoea is often a red flag for deeper gynaecological issues. Unlike primary period pain, it usually points to a treatable condition like endometriosis, adenomyosis, fibroids, or infection.
If your menstrual pain is worsening, starting later in life, or affecting your daily activities, don’t wait, speak to a healthcare professional. Timely diagnosis can protect your fertility, improve your quality of life, and help you reclaim control of your cycle.
References
[1] Giudice LC. Endometriosis. Harrison’s Principles of Internal Medicine. https://accessmedicine.mhmedical.com/content.aspx?bookid=3095§ionid=263132056
[2] Stewart EA. Uterine fibroids. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMra1810765
[3] Garcia L, Isaacson K. Adenomyosis: Review of the literature. J Minim Invasive Gynecol. https://doi.org/10.1016/j.jmig.2010.07.006
[4] Brunham RC et al. Pelvic inflammatory disease. New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMra0804690
