When Period Pain Isn't Normal: Understanding PCOS, Endometriosis, and Red Flags

By Nektaria Riso

Periods aren’t fun for anyone! For generations, we have been conditioned to accept pain and discomfort during our periods as “normal”. As a result, many symptoms are brushed off as just “regular period pains.” So, how do you know what’s truly normal and what’s not? And when should you see a doctor? 

If you want to learn what defines a normal period and to explore common menstrual disorders, this is just the post for you!​

Image created with OpenAI

What do doctors consider to be a “normal” period? 

A normal menstrual cycle varies from person to person, but there are a few general patterns doctors look for when discussing your cycle: 
​

• A typical cycle lasts between 21 and 35 days and is considered “regular” if it comes at roughly the same interval each month.
  
  
• Bleeding usually lasts 3 to 7 days, with a heavier flow during the first two days that gradually lightens.
  
  
• It’s hard to measure exactly how much blood is lost, but changing pads or tampons every few hours is typical. If you’re soaking through products every hour or passing large clots, that may indicate heavy bleeding.
  
  
• Mild symptoms such as cramps, bloating, fatigue, and mood changes are normal, especially if they’re manageable with rest or over-the-counter medication.
  
  
• Your period tends to follow a predictable pattern — similar timing, flow, and symptoms each month.
  
  
• Most importantly, your period should not interfere significantly with daily life. If pain, bleeding, or fatigue prevent you from working, sleeping, or engaging in normal activities, it’s a good idea to talk with a healthcare provider.

What are the most common menstrual disorders to look out for?

Polycystic Ovarian Syndrome (PCOS)
​
Most of us have probably heard of PCOS — and for good reason. It affects about 1 in 10 people with ovaries around the world. PCOS is a hormonal disorder that often leads to irregular or missed periods (oligomenorrhea or amenorrhea), higher levels of androgens (sometimes called “male hormones”), and polycystic-appearing ovaries (ovaries that appear to have many small, fluid-filled follicles). 

The exact cause isn’t fully understood, but researchers think a mix of genetics, insulin resistance, and chronic inflammation plays a role. High insulin levels, for example, can signal the ovaries to make more androgens, which then disrupts ovulation.

PCOS can be tricky to diagnose, and many cases go unnoticed. Doctors often make the diagnosis based on symptoms and medical history, but they may also check hormone and insulin levels or perform a transvaginal ultrasound to look at the ovaries. 
​
According to the Rotterdam criteria, you need to meet two out of three of the following features for a PCOS diagnosis:
​

• Irregular or absent ovulation — missing periods or having long gaps between them.
  
  
• High androgen levels — which can show up as acne, excess hair growth, or elevated hormones in blood tests.
  
  
• Polycystic ovaries — fluid-filled follicles (not true cysts) or a higher number of eggs can be seen on the ovaries on ultrasound

It’s also important to know that PCOS is a diagnosis of exclusion, meaning other conditions that could cause similar symptoms need to be ruled out first.

Although PCOS has no cure, it can be very effectively managed by a combination of lifestyle modifications and medical treatment aimed at regulating menstrual cycles, reducing hyperandrogenic symptoms, and addressing metabolic health.

Photo by Reproductive Health Supplies Coalition on Unsplash

Endometriosis

Endometriosis is another condition that has been in the spotlight in recent years. It’s a chronic disease where tissue similar to the lining of the uterus (the endometrium) grows outside the uterus, such as on the ovaries, fallopian tubes, bladder, or even the intestines.

It often presents with what’s known as the “classic triad” of symptoms:
​​

• Dysmenorrhea (painful periods)
• Dyspareunia (pain during intercourse)
• Infertility

Women can also present with menorrhagia (heavy bleeding) or bleeding between periods.

Endometriosis is difficult to diagnose and often warrants an ultrasound, MRI or, more invasively, laparoscopic surgery. Laparoscopic surgery is a procedure that involves making small incisions to insert a camera and surgical instruments to look for and remove the endometrial tissue. If someone is considering laparoscopic surgery, it is crucial to find a qualified gynecologic surgeon who specializes in endometriosis surgeries, since expertise can make a big difference in outcomes and recovery!

Fibroids

Fibroids are the most common noncancerous pelvic tumors found in people with uteruses. They’re made of smooth muscle tissue and grow within or on the walls of the uterus.

The size and location of a fibroid can influence the symptoms. Some people don’t experience any symptoms at all, while others may have heavy menstrual bleeding (menorrhagia), pelvic pain or pressure, painful periods (dysmenorrhea), or even infertility.

Fibroids are usually detected during a pelvic exam and confirmed with imaging such as an ultrasound or MRI.
​​
Uterine fibroids can be managed with options including hormonal and non-hormonal medical therapy to control bleeding and pain, minimally invasive procedures, and surgical management when indicated.

Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD)

Almost 90% of people with periods experience some form of premenstrual syndrome (PMS) in the one to two weeks before menstruation. Symptoms can range from emotional changes—like mood swings, irritability, anxiety, or difficulty concentrating—to physical ones such as bloating, fatigue, headaches, or nausea.

Premenstrual dysphoric disorder (PMDD) is a more severe form of PMS. It involves similar symptoms, but at an intensity that significantly disrupts daily life, affecting work, relationships, and overall well-being. For a diagnosis, symptoms must appear in the luteal phase—the days leading up to your period—and resolve shortly after bleeding begins. They also can’t be better explained by another medical or mental health condition.

Photo by Clearcut Derby on Unsplash

Let’s Talk about Menstruation Red Flags!

• Severe pain: If your cramps keep you in bed all day and cannot be relieved by even the strongest of painkillers, it’s time to visit your doctor!

• Severe bleeding: If you bleed so significantly that you cannot leave the house without a pad and a tampon and even period underwear,  please seek medical attention ASAP.

​

• Missed periods: It is a common misconception that missing a period is abnormal or a definite sign of pregnancy. In fact, it can be completely safe to skip periods on purpose using continuous hormonal birth control, which ensures the endometrial lining doesn’t thicken too much. 
  
  While a missed cycle here and there is usually harmless, if you haven’t had your period in more than three months if you’re regular, or more than six months if you’re irregular, it would be important to see a doctor to rule out any underlying causes. A missed period can be caused by factors such as stress or insomnia or other conditions that should be treated by your doctor.
  
  Fun fact: The period you get on many birth control pills isn’t a true period at all—it was built into the pill by men to seem more “natural,” not because your body needs to bleed every month. As such, some professionals—like pilots and athletes—choose to safely skip their periods altogether!

• Bleeding between periods:  Some spotting can happen from hormonal changes, stress, or birth control, but frequent or unexplained bleeding is a red flag. It can signal issues like fibroids, infections, hormone imbalances, or (rarely) cervical or uterine cancer. If bleeding happens often and is heavy, it’s often a good idea to talk about this with your doctor.

• Sudden changes in your cycle: Everyone’s cycle is different, but it is also generally predictable and follows the same pattern every month. If you have a new symptom suddenly or your period just doesn’t feel like it usually does, that could be your body trying to tell you something. Listen to your gut-- or your uterus!

Understanding your period means listening to your body and knowing what’s normal for you. Mild cramps, bloating, or mood changes are usually okay, but severe pain, heavy bleeding, or sudden changes are signs to check in with a healthcare provider.

You don’t have to just tough it out—periods are part of life, but they shouldn’t control it. Recognizing what’s normal and knowing the red flags helps you take charge of your reproductive health and live a happier, healthier life. 

Nektaria Riso

Nektaria Riso is a current medical student at McGill University with prior degrees in physiology and in child studies. Associate editor at Scientista, she is passionate about highlighting the exploits of women in STEM, whose work often goes unnoticed, through her articles. In her free time, she can be found in a bookstore or in child's pose at her favourite yoga studio.