Last updated on 16 October 2020
It is the time of the month and you’re curled up in bed with a hot pack on your tummy again. If this is starting to sound all too familiar, you are not alone.
It is not uncommon for women to experience painful periods in their teens when they first start getting their periods.
But when period pains become worse later in life, it may be a sign of an underlying problem. Such pains are more likely to reflect a problem in the womb or other pelvic organs – a problem that may affect your fertility and ability to conceive.
Here are 3 common causes of abnormally painful periods that can impact fertility, and how they can be treated.
Uterine fibroids are common non-cancerous growths that develop in the muscular wall of the uterus. They can range in size from very tiny (a quarter of an inch) to larger than a cantaloupe. You can have a single fibroid or multiple ones.
Many women have uterine fibroids sometime during their lives but remain unaware because they often show no symptoms. Your doctor may discover fibroids incidentally during a pelvic exam or prenatal ultrasound.
Fibroids may or may not affect fertility, usually depending on its location. Submucosal fibroids are the most likely type to affect your ability to get pregnant. These fibroids can distort the uterus and interfere with embryo implantation.
The treatment of choice would depend on the underlying problem, as well as the patient’s age and desire for fertility. Conservative surgery to remove submucosal fibroids while keeping the ovaries and uterus may be more appropriate for women who are keen to maintain their child-bearing abilities.
Hysteroscopic myomectomy is the advisable surgical procedure for the removal of fibroids. This procedure is performed as outpatient surgery without any incisions and virtually no postoperative discomfort. Laparoscopy (keyhole surgery) and laparotomy (open surgery) are alternative options to surgically remove uterine fibroids.
There are also non-surgical methods to treat uterine fibroids, such as:
- Uterine fibroid embolisation. This involves injecting small particles into the arteries to the uterus to cut off blood flow to fibroids, causing them to shrink and die. This technique can be effective but be cautioned that complications may occur if the blood supply to your ovaries or other organs is compromised.
- MRI-guided ultrasound. Magnetic resonance guided focused ultrasound (MRGFU) is a non-invasive outpatient procedure that uses high intensity focused ultrasound waves to destroy the fibroid tissue. During the procedure, an interventional radiologist uses magnetic resonance imaging (MRI) to see inside the body to deliver the treatment directly to the fibroid.
- Medical treatments. Medicines can also be used to treat fibroids. A commonly used medication is the gonadotrophin releasing hormone agonists (GnRHa), which act to induce a menopause-like state causing reduction in the size of the fibroid and uterus. Other medical therapies include androgenic agents, progestins, oral contraceptive pills, and anti-fibrinolytic medication.
Endometriosis is a painful disorder in which the tissue that normally lines the inside of your uterus grows outside your uterus, ie. in the ovaries, fallopian tubes, behind the uterus, and on the bladder. Like the lining of the uterus, endometriosis tissues break down and bleed during menstruation and this causes pain, especially during your period.
Adhesions (scar tissues) may form inside the pelvis where the bleeding occurs, and can cause organs to stick together, causing pain as well. Fertility problems may also develop as a result.
Treatment for endometriosis is usually with medication or surgery, depending on the severity of your symptoms and whether you hope to have a baby.
- Gonadotropin-releasing hormone agonists (GnRHa) block the production of ovarian-stimulating hormones, lowering oestrogen levels and preventing menstruation. This causes endometrial tissue to shrink. These induce a menopause-like state, and could lead to side effects such as hot flashes, vaginal dryness and bone loss. Taking a low dose of oestrogen or progestin along with GnRHa may decrease these side effects.
- Progesterone can halt menstrual periods and reduce the growth of endometrial implants, which may relieve endometriosis signs and symptoms.
- Oral contraceptives help menstrual periods become lighter, shorter, and more regular. They also help with pain relief while taking the pills as the endometriosis is suppressed. Some mild side effects may include weight gain, bloating, and bleeding between periods.
If you have endometriosis and are trying to become pregnant, surgery to remove as much endometriosis as possible while preserving your uterus and ovaries (conservative surgery) may increase your chances of success. If you have severe pain from endometriosis, you may also benefit from surgery – however, endometriosis and pain may return.
Your doctor may do this procedure laparoscopically or through traditional abdominal surgery in more extensive cases. In laparoscopic surgery, your surgeon inserts a slender viewing instrument (laparoscope) through a small incision near your navel and inserts instruments to remove endometrial tissue through another small incision.
If you are near to menopause and have severe symptoms, you may consider more definitive but drastic surgery like removing the uterus, ovaries and tubes. A hysterectomy is typically considered a last resort, especially for women still in their reproductive years. You can't get pregnant after a hysterectomy.
Cysts are fluid-filled sacs that can form in the ovaries as part of the follicle which develops monthly with the egg. When either the egg is not released (ie. ovulation does not occur) or the sac in which the egg forms does not dissolve after the egg is released, they can form a cyst. There also are benign (non-cancerous) and, rarely, cancerous cysts which can form in the ovary.
Most women will experience a cyst on their ovaries at least once. Most cysts go unnoticed because they are painless and show no symptoms, and are discovered during a routine pelvic exam.
Some ovarian cysts can be associated with decreased fertility, depending on the type of ovarian cyst you have.
Ovarian cysts that can affect your fertility include:
- Endometriomas. Endometriomas are cysts caused by endometriosis. These ovarian cysts may be associated with fertility problems.
- Ovarian cysts resulting from ovulation disorders. Polycystic ovary syndrome (PCOS) is a condition marked by irregular ovulation and high levels of certain hormones. PCOS is associated with irregular menstrual cycles, which may contribute to problems with fertility in some women.
Treating ovarian cysts
Most ovarian cysts will go away naturally. If you don’t display any bothersome symptoms, especially if you have yet to go through menopause, you would want to wait and watch for a while. Your gynae may check you every 1 – 3 months to see if there has been any change in the cyst.
If you are not convinced, though, you may choose to start on birth control pills. They may relieve the pain by preventing ovulation, which reduces the odds of new cysts forming.
Surgery to treat ovarian cysts
Alternatively, surgery may be needed to confirm the diagnosis of ovarian cysts, to remove cysts that is persistent, growing, or causing you pain.
A cystectomy is performed when there are concerns of malignancy (cancer) in ovarian cysts. This procedure is often performed with a laparoscopic (keyhole) surgery.
Alternatively, if the cyst doesn’t go away, grows, or causes you pain, surgery is an option.
Your gynae can perform a laparoscopy to remove the cyst (if your cyst is non-cancerous). The procedure involves making a tiny incision near your navel and then inserting a small instrument into your abdomen to remove the cyst.
If the growth is cancerous, the surgeon will remove as much of the tumour as possible. Depending on how far the cancer has spread, the surgeon may also remove other organs of the female genital tract and nearby lymph nodes.
Get it checked
If you experience severe period pains, do not brush it off as normal – consult your gynaecologist to be sure.
For women above 25, a routine visit to the gynaecologist for a check-up is advisable to make sure that you do not have any undiagnosed conditions that may affect your health (and, in particular, your reproductive health if you plan to have kids). The tests carried out at a routine gynae check-up will help to detect any issues early on so that you can access prompt treatment if necessary.
If you are having problems conceiving, see your gynaecologist. Your gynaecologist will help you find out the possible cause of your fertility problem and treat it. She should let you know all your options and the possible outcomes before starting any treatment. In this case, you are better off seeking treatment sooner rather than later, because fertility declines with age.
Article contributed by Dr Kelly Loi, obstetrician and gynaecologist at Mount Elizabeth Hospital.
Non-surgical Treatments for Fibroids (n.d.) Retrieved September 21, 2020, from https://www.brighamandwomens.org/obgyn/infertility-reproductive-surgery/cysts-and-fibroids/non-surgical-fibroid-treatment
What are the Treatments for Endometriosis? (2020, February 21) Retrieved September 21, 2020, from https://www.nichd.nih.gov/health/topics/endometri/conditioninfo/treatment