Emergency Period Pain: Why Menstrual Cramps Should Not Be Overlooked in Outpatient Clinics and Ambulances

While it may be frightening for many, there are situations when there is no choice but to dial 911. This applies even when dealing with (presumed) endometriosis-related symptoms, as time is of the essence in many instances.

But how often do symptoms resembling “menstrual cramps” escalate into a genuine emergency? What other medical conditions can trigger pain similar to that of endometriosis? In the following section, we have gathered essential information for paramedics, emergency physicians, and concerned family members to be aware of during emergencies.

When Endometriosis Symptoms Require Emergency Attention

No exact figures are available regarding how many endometriosis patients visit the emergency room. However, since the Aubrion Rogers case, awareness of this issue has increased in our community. Some time ago, we conducted a small survey with 453 participants. Nearly half of them (49%) reported having contacted an emergency doctor or visiting the emergency room due to their symptoms. For many, this was not an isolated occurrence; on average, each sought emergency medical care 2.5 times.

While these results are not definitive, they indicate that endometriosis emergencies are not uncommon. Our survey did not capture the patient’s experience with the treatment received. Like a regular doctor’s visit, there is often a heightened fear of being ridiculed and not taken seriously when seeking emergency care.

When Should Endometriosis Be Considered an Emergency?

As with less severe symptoms, the same variability applies to endometriosis: it is a true chameleon. Endometriosis-related complaints are incredibly diverse, manifesting in virtually all areas of the body. The triggers for these symptoms can often originate from entirely different sources. The following list is not exhaustive but provides a comprehensive overview of potential symptoms necessitating emergency medical attention. Medical professionals, take note:

Reproductive organs/abdomen: Endometriosis can result in ruptured cysts and ovaries. Larger endometriosis lesions and adhesions can also cause severe pain [1, 2]. Pregnancy complications such as abdominal bleeding, bowel perforation, uterine rupture, and placenta previa can be associated with deep infiltrating endometriosis [3].

Digestive tract: Deep infiltrating endometriosis can affect the bowel in many patients, leading to bowel obstruction, bowel rupture, and anal bleeding, which may require immediate medical intervention [4, 5].

Urinary tract: Endometriosis lesions on or in the bladder are often undetected for a long time. Patients may suffer from frequent bladder infections, which cannot be attributed to a microbial infection. If left untreated, these insidious symptoms can lead to irreversible damage to the bladder, ureters, and kidneys [6, 7].

Cardiovascular: General circulatory problems in endometriosis patients can be triggered by certain medications. Migraine and depression, among the side effects of endometriosis, can have a negative impact on circulation. Chest pain in individuals with endometriosis may be caused by lung lesions, which can lead to pneumothorax, hematothorax, or hemoptysis [8]. Additionally, endometriosis patients have a statistically higher risk of developing coronary heart disease [9].

General Recommendations for Emergency Medical Personnel

First and foremost, it is essential to understand that individuals with endometriosis should be treated with the same care and respect as any other patient during an emergency. However, it is crucial to recognize that those with chronic conditions may have encountered numerous, often negative, experiences with healthcare providers throughout their illness. Feelings of fear, shame, and insecurity may have developed throughout their medical history, and these emotions can persist in the ambulance or emergency room. To ensure the best possible care and to alleviate these fears, consider the following points when dealing with endometriosis:

  1. Take Their Concerns Seriously: Many individuals with endometriosis have faced difficulties being taken seriously by healthcare professionals, even those with established medical backgrounds. In an emergency, it’s vital not to dismiss their pain and symptoms as routine complaints. Due to their prior experiences, many patients may find it challenging to seek help. Going to the emergency room or calling an emergency doctor often represents significant steps for them. Therefore, it is essential to be attentive to endometriosis symptoms.
  2. Investigate the Causes: Diagnosing endometriosis can be complex. The condition presents with a wide range of symptoms, and the characteristic pain, often located in the lower abdomen, is not always precisely localized. Pain may radiate to adjacent body regions, such as the legs or back, making accurate identification challenging.
  3. Timeliness Matters: Promptly addressing endometriosis complaints is critical for the patient’s well-being. If emergency personnel do not take these symptoms seriously and respond promptly, it can lead to severe consequences. Delayed diagnosis of conditions like ruptured cysts may result in irreparable damage to the patient’s reproductive organs, affecting their life planning significantly, particularly for women who wish to have children.

Medical History and Examination

The patient’s medical history plays a crucial role in identifying the cause of their symptoms. The first step is determining whether the symptoms indicate endometriosis or another condition. The patient’s medical history can provide valuable clues, especially when the individual has been dealing with these symptoms for an extended period.

Valuable questions to include in the medical history interview may be:

  • What phase of the menstrual cycle is the patient currently in?
  • Has the patient experienced similar pain before? What is their intuition regarding the source of this pain?
  • Have there been recurrent endometriosis-related symptoms in the past?

As mentioned, endometriosis symptoms can manifest in various patterns, complicating the differential diagnosis process. Therefore, it is advisable to collaborate with colleagues from multiple specialties to confirm your initial assessment and ensure the patient feels reassured. If you have a colleague with experience in endometriosis on your team, their expertise can be precious, especially in imaging and evaluation. Endometriosis lesions can be pretty small and challenging to detect, requiring specialized knowledge in the field of reproductive organs [10].

Simultaneously, consider administering pain relief to alleviate the patient’s suffering. It is important to note that, according to research, women often receive pain relief later than men, with sedatives being more frequently prescribed [11]. This may be due to gender differences in pain perception and response. Recognizing these distinctions can significantly enhance the quality of care, promoting fairness for all patients [12, 13]. However, long-term pain management is typically not feasible in a clinical setting.

Excluding Endometriosis

In cases where you and your medical team have ruled out endometriosis as the cause of the patient’s symptoms, there are numerous other potential diagnoses to consider. Given the prevalence of lower abdominal pain, acute appendicitis is typically the initial concern [14, 15]. Conditions like acute kidney disease or chest pain may also originate from various causes. Therefore, while it is crucial not to disregard the possibility of endometriosis and its associated symptoms, it is equally essential not to become solely fixated on this diagnosis. Your comprehensive medical expertise as a healthcare professional is invaluable in these situations!

Supporting a Loved One in an Emergency

When your partner or girlfriend experiences severe discomfort, it is expected to feel uneasy, even as a relative. After all, such situations are not a regular part of most people’s lives. We have created a simple mnemonic to ensure you can respond appropriately and effectively when needed. With it, you will be well-prepared to face an emergency together. All you need to remember is “ENDO.”

E – Let Them Explain: Allow them to explain their symptoms to you. A vital question you can ask here is whether they have experienced this pain before. Individuals with endometriosis often have a good intuition about their symptoms, and your friend or partner may be able to provide valuable insights into the seriousness of the situation.

N – Nod: This should be understood metaphorically. Take their complaints and accompanying fears seriously. Their endometriosis symptoms may have been dismissed in the past, and your role here is to provide support. If you believe going to the emergency room is unnecessary, respect their decision. After all, they know their body better than anyone.

D– Don’t Hesitate: Anxiety and severe pain can lead to paralysis. Your friend or partner may be hesitant to visit the hospital due to the fear of being ridiculed or sent home by medical staff. Or it could be the pain itself that hinders their decision-making. If you genuinely believe that calling an ambulance is necessary and are seriously concerned, take the initiative to seek help for both of you. You do not need to face this situation alone; having professionals by your side will provide security.

O – Organize: While waiting or before heading to the emergency room, you can help by packing a hospital bag for them. If they wish, you could also inform other friends or family members. Once you are in the emergency room or when the emergency doctor arrives, you have one crucial responsibility: Be a strong advocate for your friend or partner. If you feel the symptoms might be dismissed or not taken seriously, you can communicate to the medical staff that severe, possibly life-threatening endometriosis symptoms are entirely possible.

In a Nutshell

Endometriosis can escalate into a genuine medical emergency, demanding urgent attention. Delayed recognition of the causes can lead to severe repercussions.

Injuries to the reproductive organs, complications in other organ systems, and potential cardiovascular issues can trigger an emergency.

Nonetheless, with specific medical and personal support, the psychological and physical impact can be minimized or even entirely averted.

References

  1. Hecht, S. et al. 2018. “Akutes Abdomen der Frau: gynäkologische Ursachen.” Der Radiologe 59: 126-132.
  2. Propora, M.R. 1999. “Korrelation zwischen Endometriose und Beckenschmerzen”. The Journal of the American Association of Gynecologic Laparoscopists 6 (4): 429-434.
  3. Roberti Maggiore, U.L. et al. 2017. “Geburtshilfliche Komplikationen der Endometriose, insbesondere der tiefen Endometriose.” Fertility and Sterility 108 (6): 895-912.
  4. Baden, N.D. 2015. “Endometriose mit akutem Dickdarmverschluss: A case report.” Journal of Medicial Case Reports 9.
  5. Garg, N.K. 2009. “Intestinal endometriosis: Eine seltene Ursache für eine Kolonperforation”. Journal of Gastroenterology 15 (5): 612-614.
  6. Carl, P. 2003. “Urologische Komplikationen der Endometriose”. Der Urologe 42: 255-262.
  7. Metzger, K. et al. 2020. “Tiefinfiltrierende Endometriose mit ausgeprägter Darm- und Ureterbeteiligung – ein Fallbericht.” Geburtshilfe und Frauenheilkunde 80 (10): 256-257.
  8. Nezhat, C. et al. 2019. “Thoracic Endometriosis Syndrome: A Review of Diagnosis and Management.” Journal oft he Society of Laparoscopic and Robotic Surgeons 23 (3).
  9. Mu, F. et al. 2016. “Endometriosis and Risk of Coronary Heart Disease”. Circulation: Cardiovascular Quality and Outcomes 9: 257-264.
  10. Fleischmann, P. 2016. “Seltene Ursache eines Leistenschmerzes.” Zeitschrift für Allgemeinmedizin 92 (4): 167-168.
  11. Calderone, K. L. 1990. “Der Einfluss des Geschlechts auf die Häufigkeit der Verabreichung von Schmerz- und Beruhigungsmitteln an postoperative Patienten”, Sex Roles 23: 713-725.
  12. Hoffmann, D. E. et al. 2001. “The girl who cried pain. Eine Voreingenommenheit gegenüber Frauen bei der Behandlung von Schmerzen”. The Journal of Law, Medicine and Ethics 29(1): 13-27.
  13. Bartley, E. J. et al. 2013. “Sex differences in pain: A brief review of clinical and experimental findings.” British Journal of Anaesthesia 111 (1): 52-58.
  14. Assenza, M. et al. 2004. “Akute Appendizitis oder etwas anderes? Ein Fallbericht über eine zökale Endometriose in einer Notfallsituation”. Annali Italiani di Chirurgia 75 (5): 583-586.
  15. Agrusa, A. 2013. “Akute Appendizitis und Endometriose: retrospektive Analyse in einer Notfallsituation”. Giornale Italiano di Ostetricia e Ginecologia 35 (6): 728-732.

Have you ever rushed to the hospital or dialed emergency services due to severe symptoms?
Were your concerns treated seriously, and did you receive the needed assistance?

Please share your experiences with us in the comments.

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Meike Fischer
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