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Medically reviewed guide · Last updated: 1 August 2026 · Reading time: approx. 8 min
Period Pain: Normal, Treatable — or a Sign of Endometriosis?
At a glance
Cramping lower abdominal pain at the start of your periodis very common. It is caused by messenger substances (prostaglandins) that make the muscle of the womb contract.
Primarymeans the pain has been there since your very first periods and has no identifiable underlying condition. Secondary means it appears later or changes over time — and then there is more often something behind it.
Painkillers work better when they are taken early enough— not once the pain has already peaked.
Severe pain is not “just normal”.If you regularly cancel appointments, stay in bed or need painkillers at the maximum dose, that deserves to be looked into.
Seek urgent medical advice ifyou have sudden, very severe one-sided lower abdominal pain, pain together with fever and foul-smelling discharge, faintness or collapse, or pain during a possible pregnancy.
The most common causes compared
Cause
Typical pain
Typical onset
First step
Primary dysmenorrhoea
Cramping, lower abdomen, radiating into the back and thighs, 1–3 days
From the first periods onwards, in adolescence
Heat, movement, an NSAID started early
Endometriosis
Increasingly severe, often also before bleeding starts, during sex, when opening your bowels
Usually in young adulthood, often slowly worsening
Gynaecological assessment, bring a symptom diary
Fibroids or adenomyosis
Dull, a feeling of pressure, often with very heavy bleeding
More often from the fourth decade of life
Ultrasound at a gynaecology practice
Copper coil
Cramping, with heavier and longer bleeding
New after the coil was fitted
Talk through your contraceptive method
Pelvic inflammatory disease
Persistent, often on both sides, with fever and discharge
Acute, independent of your cycle
Prompt medical assessment
Table scrolls to the right
Painkillers across your cycle: keep track
When you took them and how well they worked — recorded free of charge in the brite app.
At the start of bleeding, the lining of the womb releases prostaglandins. These messenger substances make the muscle of the womb contract strongly so that the lining can come away. If a lot of them are released, blood flow is briefly reduced — and that is exactly what you feel as cramping pain. Typical accompanying symptoms are nausea, diarrhoea, back pain and headaches, because prostaglandins also act on the bowel and on blood vessels.
The primary form usually starts within the first few years after your first period, lasts one to three days, and improves over the course of life for many people.
Endometriosis: the cause that is often missed
In endometriosis, tissue similar to the lining of the womb settles outside the womb — and follows the cycle along with it. Typical clues are pain that starts before bleeding does, increases over the years, occurs during sex, when passing urine or when opening your bowels, as well as difficulty getting pregnant.
It often takes years to reach a diagnosis — not because the condition is rare, but because severe period pain was dismissed as normal for a long time. If your gut feeling tells you this is more than “the usual cramps”, that is a good reason to raise it.
Fibroids, adenomyosis and the coil
Benign muscle growths in the womb and lining tissue growing into the wall of the womb tend to cause dull pressure with heavier bleeding. A copper coil can noticeably increase both period pain and how heavy the bleeding is, while hormonal coils reduce both for many people. Both are good topics for your next appointment.
Infections and other causes
Infections rising into the pelvis cause persistent pain, often with fever and a change in discharge — they are not a cycle phenomenon and need prompt treatment. Adhesions after surgery and bowel irritation can also shape the pain; if abdominal pain gets worse in step with your cycle, it is worth looking at both.
Self-tests: first clues at home
These observations do not replace a diagnosis. But in a few minutes they will make the conversation at your appointment much more precise.
A cycle and pain diary over three cycles: when does the pain start in relation to the bleeding? How severe on a scale from 0 to 10? How long does it last?
The everyday test: have you had to cancel school, work or appointments? Two or more lost days per cycle is a clear signal.
The painkiller test: does an over-the-counter painkiller at the usual dose work well enough? If not, that is a finding in itself — and not a reason to increase the dose on your own.
The timing test: does the pain also occur outside your bleeding, during sex or when opening your bowels? That argues against purely primary dysmenorrhoea.
How heavy the bleeding is: how often do you need to change a pad, tampon or cup? Changing very frequently over several hours is worth discussing.
Warning signs: when not to wait
Sudden, very severe one-sided lower abdominal pain
Pain with fever, shivering or foul-smelling discharge
Collapse, faintness or marked pallor
Lower abdominal pain during a possible or known pregnancy
Bleeding that lasts unusually long or is very heavy
Pain that increases from cycle to cycle despite the usual treatment
Do not miss an emergency Sudden, extremely severe one-sided lower abdominal pain can point to a twisted ovary or — during a pregnancy — to an ectopic pregnancy. Both are emergencies. If the pain is extreme and comes with circulatory symptoms or collapse, call 112 (emergency services in Germany) and do not wait to see whether “a hot water bottle helps”.
The treatment pathway: step by step
Period pain is usually approached in stages — first what is possible without a prescription, then targeted medication, then looking for a cause.
Heat and movement. A hot water bottle or a heat patch on your lower abdomen relaxes the muscle; gentle movement works about as well for many people. The evidence is limited, but the side-effect profile is unbeatable.
Time painkillers properly. NSAIDs block exactly the prostaglandins that trigger the cramping. That is why they work best when you start them at the first signs and take them regularly rather than sporadically across the painful days — within the limits given by your doctor or the patient information leaflet.
Gynaecological assessment. For severe, worsening or newly appeared pain: a conversation, an examination and an ultrasound.
Discuss hormonal options. Hormonal contraceptives can noticeably reduce bleeding and pain — that is a trade-off with its own pros and cons.
Specialist care. If endometriosis is suspected, a centre with experience makes sense; bring your pain diary with you.
Do not settle for less. “That is just how it is for women” is not a diagnosis. If you feel you are not being taken seriously, get a second opinion. How to prepare for the conversation is set out in the guide Preparing for your doctor's visit.
Medication: what helps and what makes the symptom worse
For period pain, ibuprofen and naproxen are the usual first choices; naproxen lasts longer and is therefore often preferred for pain at night. Diclofenac is another option. Paracetamol usually works less well here, because it has little effect on prostaglandin production in the tissue. The guide painkillers compared puts the different active ingredients into context.
Keep an eye on how long you take them Over-the-counter painkillers are intended for short-term self-treatment — usually a few days at a time. If you need them at a high dose over several days in every cycle, that should be medically supervised, not least because of your stomach and kidneys. What to watch out for is explained under medication-induced stomach problems.
Conversely, there are medicines and methods that can make the symptom worse:
Copper coil — can increase both how heavy the bleeding is and the cramping.
React early instead of gritting your teeth — if you only reach for a tablet at pain level 8, you need more of it and wait longer for it to work.
Regular exercise — moderate endurance activity is often described as easing the pain; the study data are limited, but the benefit for sleep and mood is well established.
Plan for heat in advance — a hot water bottle, a warm bath or a heat patch for when you are out, rather than starting to look for them once it kicks in.
Keep supplements in perspective — for magnesium and herbal remedies the evidence is limited. Trying them is reasonable, but it does not replace a proper assessment.
Document what happens — three documented cycles say more than any memory of things having “somehow got worse”.
Don't forget the tablet on day one
A reminder exactly when starting early makes the difference.
Mild to moderate cramping in the first one to three days is common. Pain that regularly throws you out of everyday life, that persists despite the usual painkillers, or that increases from cycle to cycle is not a normal state of affairs and should be looked into.
NSAIDs work best when they are started at the first signs, because they block the production of the messenger substances that cause the pain. If you wait until the peak, you usually need more and wait longer for an effect. Maximum amounts and how long to take them are set by the patient information leaflet or your doctor.
Heat relaxes the muscle and many people experience it as clearly easing the pain. The study data are limited, but the risk is minimal. As an addition to other measures heat makes sense; as the only treatment for severe pain it is usually not enough.
Clues are pain that starts before the bleeding does, increases over the years, occurs during sex, when passing urine or when opening your bowels, as well as difficulty getting pregnant. Only a gynaecological assessment can give certainty — a symptom diary covering three cycles helps a great deal with that.
For some people primary period pain improves after giving birth, for others it does not. That is not much of a treatment plan — and if there is an underlying condition such as endometriosis, a pregnancy changes nothing about the need for an assessment.
Hormonal contraceptives reduce how heavy the bleeding is and how much it hurts for many people. But they have their own pros and cons that are weighed up individually — the risk of thrombosis, for example. That decision belongs in a gynaecology practice.
The same prostaglandins that make the womb contract also stimulate the muscle of the bowel. That is why loose stools, diarrhoea and nausea are common in the first few days. If the symptoms become very severe or persist, they should be discussed.
German S2k guideline on the diagnosis and treatment of endometriosis (led by the DGGG, AWMF register) — German source. Accessed 2026.
Summaries of product characteristics for the active ingredients mentioned (ibuprofen, naproxen, diclofenac). Accessed 2026.
This article is for general information and does not replace medical advice, diagnosis or treatment. The self-observations described are a guide only and this does not replace a diagnosis. If you have sudden, extremely severe lower abdominal pain, pain with fever, circulatory weakness, or pain during a possible pregnancy, please contact a doctor or the emergency services.
