Emergency period pain – why menstrual cramps should not be laughed at in outpatient clinics and ambulances
It may be a horror scenario for many, but sometimes there is no other way than to pick up the phone and dial 112. Even in the case of (supposed) endometriosis complaints, it is important in many cases not to let any time pass.
But how often do “menstrual cramps” actually become a real emergency? What other conditions can cause endometriosis-like pain? We have compiled here everything that paramedics, emergency doctors and relatives should know in case of an emergency.
Emergency but not an isolated case
There are actually no exact figures on how many patients with endometriosis visit the emergency room. However, at the latest since the Aubrion Rogers case, the topic has also arrived in our community. Some time ago, we therefore launched a small survey in which 453 patients participated. Almost half of them (49%) have already called an emergency doctor or visited the emergency room because of their complaints. This was not an isolated incident for many of them – on average, each of them had received emergency medical treatment 2.5 times.
Of course, these are not reliable results, but they clearly show that endometriosis as an emergency is not uncommon. What we were also unable to capture with our survey was how the patients experienced the treatment. As with a normal visit to the doctor, the fear of being ridiculed and not taken seriously with the complaints is naturally even more pronounced during a visit to the emergency room.
When does endometriosis become an emergency?
As with the less severe symptoms, the same applies here: Endometriosis is a real chameleon. Endometriosis-related complaints are incredibly diverse, occur in practically all regions of the body and their triggers, in turn, can often lie in completely different parts. The following list is therefore not all-encompassing, but nevertheless gives a good overview of possible symptoms that require emergency medical treatment. So all medical professionals pay attention now:
Reproductive organs/abdomen: ruptured cysts and ovaries can be a result of endometriosis. Larger endometriosis lesions and adhesions can also cause severe pain. [1, 2] Pregnancy complications can also occur: Bleeding into the abdomen, bowel perforation, uterine rupture, and placenta previa are associated with deep infiltrating endometriosis. 
Digestive tract: In deep infiltrating endometriosis, the bowel is affected in many patients. Bowel obstruction, bowel rupture, and anal bleeding may result and may require emergency medical treatment. [4, 5]
Urinary tract: Endometriosis lesions on or in the bladder usually remain undetected for a long time. Patients suffer from frequent bladder infections, which, however, cannot be explained by evidence of infection. Since the symptoms are extremely insidious, irreversible damage to the bladder, ureters, and kidneys may result after prolonged non-treatment. [6, 7]
Cardiovascular: general circulatory problems in endometriosis patients can be triggered, for example, by taking certain medications. Migraine and depression are also among the side effects of endometriosis and can negatively affect the circulation. If the patient complains of chest pain, endometriosis lesions in the lungs could be the cause, which can lead to symptomatology such as pneumothorax, hematothorax, or hemoptysis.  In addition, endometriosis patients statistically have a higher risk of developing coronary heart disease. 
General tips for emergency medical personnel
First of all, of course, endometriosis patients are not subject to any different rules than other people when dealing with an emergency situation. However, you should always take into account that patients with a chronic disease have had many, often negative, encounters with medical staff during the course of their illness. Feelings of fear, shame and insecurity may have built up over the course of the medical history and are also companions in the ambulance or emergency room. So, to ensure the best possible treatment and alleviate fears, you should again pay special attention to the following points when talking about endometriosis:
- Take seriously: Even with established physicians, endometriosis sufferers often have the problem of not being taken seriously with their complaints. Therefore, especially in an emergency situation, it is important not to simply dismiss pain and other symptoms as “regular complaints”. Because of their experiences with doctors in private practice, many patients find it difficult to seek help. Therefore, going to the emergency room or calling an emergency doctor are usually big steps that cost an extra portion of overcoming. For this reason alone, you should pay attention to endometriosis symptoms.
- Causal research: This is often not so easy with endometriosis. On the one hand, endometriosis has countless faces. On the other hand, the pain typical of endometriosis, especially in the lower abdomen, often cannot be localized exactly. Radiation to neighboring regions of the body, such as the legs or back, often makes localization difficult.
- Time: If endometriosis complaints are not taken seriously in a timely manner by emergency medical personnel, this can lead to serious consequences for the patient. For example, if ruptured cysts and the like are discovered too late, this can lead to irreparable damage to the reproductive organs. This would mean a deep cut in life planning, not only for women who want to have children.
Medical history and examination
Clearly, the medical history plays an extremely important role in the search for the cause. Of course, the first question is whether the symptoms are endometriosis symptoms or not. The anamnesis interview with the patient can provide you with decisive clues here. Most of those affected have been suffering from their complaints for a long time and can therefore usually assess quite well whether they are familiar with this type of pain or not.
Useful anamnesis questions could be:
- Where in the cycle is the patient at the moment?
- Is the patient approximately familiar with this type of pain? What does her gut tell her?
- What have been the most common endometriosis-related complaints in the past?
As described earlier, however, the possible complaint patterns are extremely varied, which can make differential diagnosis very difficult. In order to confirm your assumption and to give the patient a feeling of security, it is therefore always useful to consult colleagues from other specialties. Perhaps there is even someone in your team who already has experience in endometriosis. This plays a major role, especially in imaging and subsequent evaluation. Endometriosis lesions, for example, can sometimes be very small and echo-poor, and expertise is also required in the area of the reproductive organs. 
In parallel to all this, the administration of painkillers must be considered in order to provide at least short-term relief from the pain. You should be aware that, according to studies, women are given painkillers much later than men. Instead, sedatives are more likely to be given.  One possible reason for this is that women perceive and respond to pain differently. Awareness of this can significantly improve the overall quality of your treatment, as it creates a more level playing field for everyone. [12, 13] Long-term pain therapies, however, obviously cannot be provided in the clinical setting.
If you or the team have ruled out endometriosis as the cause of the patient’s complaints, there could of course be countless other diagnoses to solve the mystery. With lower abdominal pain being so common, it is acute appendicitis that is first considered. [14, 15] Acute kidney disease or chest pain may also have other triggers. So, as important as it is not to smile and rule out endometriosis and its numerous accompanying symptoms, it is also important not to focus exclusively on them. Your trained all-round view as a medical professional is called for here!
Tips for relatives
If your partner or girlfriend complains of severe discomfort, you can quickly feel queasy, even as a relative. After all, such situations are not part of everyday life for most people. So that you can react appropriately and effectively in an emergency, we have come up with a little mnemonic for you. With it, you will be well prepared for an emergency and you can master this exceptional situation together as well as possible. All you have to remember is “ENDO”!
Let her explain – Let her explain to you exactly what her symptoms are. One important question you can definitely ask here is if she is already aware of the pain. Since endometriosis patients usually have a good intuition about their symptoms, your friend or partner may be able to tell you how serious she thinks the situation is.
Nod – Of course, this is to be understood in a figurative sense here. In any case, take the complaints and the associated fears seriously. I’m sure your friend/partner’s endometriosis symptoms have often been simply dismissed. You are here to support her. Even if you may feel that going to the emergency room is overkill, you should honor your loved one’s request. After all, she knows her body best of all.
Push – However, anxiety and severe pain can also paralyze. Perhaps your friend/partner feels the same way. She refuses to go to the hospital for fear of being ridiculed by the medical staff and sent home. Or maybe it’s the discomfort itself that makes it difficult for her to make decisions. However, if you think that you should call an ambulance and you are seriously worried, then take the initiative and get help for you and your friend. You don’t have to be alone in such a situation either, and with professionals by your side, you’ll definitely feel safer.
Organize – While waiting or before you go to the emergency room, you can pack your friend/partner a hospital bag, for example. If desired, you could also inform other friends or family members. Once you are in the emergency room or the emergency doctor is at the door, you have one last but very important task: Be your friend’s/partner’s full advocate! If you have the feeling that the symptoms will only be laughed at and dismissed, you can make the doctors aware that it is quite possible to have such severe and possibly life-threatening endometriosis symptoms.
Short and to the point
Endometriosis can become a real medical emergency that should be taken very seriously. After all, causes that are recognized too late can have serious consequences for the patient.
Injuries to the reproductive organs, but also consequences of endometriosis on other organs as well as cardiovascular problems could be the causes for an emergency admission.
However, with targeted medical and private support, psychological and physical damage to the patient can be reduced to a minimum or even completely avoided.
- Hecht, S. et al. 2018. “Akutes Abdomen der Frau: gynäkologische Ursachen.” Der Radiologe 59: 126-132.
- Propora, M.R. 1999. “Korrelation zwischen Endometriose und Beckenschmerzen”. The Journal of the American Association of Gynecologic Laparoscopists 6 (4): 429-434.
- Roberti Maggiore, U.L. et al. 2017. “Geburtshilfliche Komplikationen der Endometriose, insbesondere der tiefen Endometriose.” Fertility and Sterility 108 (6): 895-912.
- Baden, N.D. 2015. “Endometriose mit akutem Dickdarmverschluss: A case report.” Journal of Medicial Case Reports 9.
- Garg, N.K. 2009. “Intestinal endometriosis: Eine seltene Ursache für eine Kolonperforation”. Journal of Gastroenterology 15 (5): 612-614.
- Carl, P. 2003. “Urologische Komplikationen der Endometriose”. Der Urologe 42: 255-262.
- Metzger, K. et al. 2020. “Tiefinfiltrierende Endometriose mit ausgeprägter Darm- und Ureterbeteiligung – ein Fallbericht.” Geburtshilfe und Frauenheilkunde 80 (10): 256-257.
- 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).
- Mu, F. et al. 2016. “Endometriosis and Risk of Coronary Heart Disease”. Circulation: Cardiovascular Quality and Outcomes 9: 257-264.
- Fleischmann, P. 2016. “Seltene Ursache eines Leistenschmerzes.” Zeitschrift für Allgemeinmedizin 92 (4): 167-168.
- 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.
- 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.
- 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.
- 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.
- 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 had to go to the hospital or call an emergency doctor because of your severe complaints?
Were you taken seriously and could they help you?
Feel free to leave us a comment.
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