Seriousness of Menstrual Cramps: Addressing Emergency Period Pain in Outpatient Clinics and Ambulances

For many, it is a nightmare scenario, but sometimes dialing 911 is the only option. This holds true even for (presumed) endometriosis symptoms, where swift action is often crucial.

How frequently do “menstrual cramps” escalate into genuine emergencies? What other ailments can mimic endometriosis-related pain? This guide compiles essential information for paramedics, emergency physicians, and family members to have at their fingertips during critical situations.

Emergency Situations: More Common Than You Think

The lack of exact figures on the frequency of endometriosis-related emergency room visits makes it challenging to quantify. Nevertheless, awareness of the issue has grown within our community, particularly following the Aubrion Rogers case. In response, we conducted a modest survey involving 453 participants. Almost half of them (49%) had sought assistance from an emergency doctor or visited an emergency room due to their endometriosis-related symptoms. For a significant number, this was not an isolated event; on average, they had sought emergency medical care 2.5 times.

While these findings may not be completely conclusive, they underscore the reality that endometriosis-related emergencies are not unusual. Our survey, unfortunately, could not capture the patients’ perspectives on the care they received.  Similar to routine doctor visits, the apprehension of being belittled and not taken seriously in relation to their symptoms is often heightened during emergency room visits.

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, occurring in practically all regions of the body, and their triggers can often stem from entirely different areas. The following list is not exhaustive, but it offers a comprehensive overview of possible symptoms that necessitate emergency medical treatment. All medical professionals, pay heed:

Reproductive organs/abdomen: Ruptured cysts and ovaries can result from endometriosis. Larger endometriosis lesions and adhesions can also cause severe pain. [1, 2] Pregnancy complications may arise, such as bleeding into the abdomen, bowel perforation, uterine rupture, and placenta previa, all associated with deep infiltrating endometriosis [3].

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

Urinary tract: Endometriosis lesions on or in the bladder often go unnoticed for extended periods. Patients may experience frequent bladder infections that cannot be attributed to evidence of infection. Due to the insidious nature of symptoms, prolonged untreated cases may result in irreversible damage to the bladder, ureters, and kidneys [6, 7].

Cardiovascular: General circulatory issues can be triggered in endometriosis patients, potentially by certain medications. Migraine and depression, known side effects of endometriosis, can adversely affect circulation. If a patient complains of chest pain, endometriosis lesions in the lungs might be the cause, leading to symptoms such as pneumothorax, hematothorax, or hemoptysis [8]. Additionally, statistically, endometriosis patients face a higher risk of developing coronary heart disease [9].

General Tips for Emergency Medical Personnel

First, it is essential to recognize that individuals with endometriosis should be treated no differently from anyone else during an emergency. However, it is important to keep in mind that those with chronic conditions, like endometriosis, may have encountered numerous, often negative, interactions with medical professionals throughout their illness journey. Feelings of fear, shame, and insecurity might have accumulated over their medical history and could still be present in the ambulance or emergency room. To ensure optimal treatment and alleviate anxieties, consider these specific points when dealing with endometriosis:

  1. Take symptoms seriously: Even experienced healthcare providers may sometimes struggle to treat endometriosis patients with the gravity their symptoms warrant. Hence, during emergencies, it is crucial not to dismiss pain and other symptoms as routine issues. Many patients find seeking help challenging due to prior experiences with doctors. Going to the emergency room or contacting an emergency doctor often requires significant effort to overcome hesitation. Therefore, giving attention to endometriosis symptoms is vital.
  2. Investigate causation: Investigating the cause of symptoms can be challenging with endometriosis. The condition presents itself in various forms, and the characteristic pain, particularly in the lower abdomen, is not always precisely localized. Pain might radiate to adjacent body areas like the legs or back, further complicating pinpointing the origin.
  3. Time sensitivity: Neglecting endometriosis symptoms during an emergency can have severe consequences for the patient. Delayed recognition of issues like ruptured cysts can lead to irreparable damage to the reproductive organs. This can disrupt life plans significantly, not only for women seeking to conceive.

Medical History and Examination

Undoubtedly, the patient’s medical history holds a critical role in uncovering the underlying cause. Initially, it is paramount to determine whether the symptoms align with those of endometriosis. The patient interview during anamnesis can offer pivotal clues. Most afflicted individuals have grappled with their symptoms for an extended duration, making them adept at discerning whether the pain is characteristic of endometriosis.

Effective anamnesis inquiries may encompass:

  • The current phase of the patient’s menstrual cycle
  • Familiarity with this type of pain and the patient’s intuition about its origin
  • Past occurrences of endometriosis-related symptoms

As previously outlined, the range of potential symptom patterns is diverse, posing a challenge in differential diagnosis. To validate your suspicions and provide reassurance to the patient, it is prudent to collaborate with specialists from other fields. You might even have a team member experienced in endometriosis, who can offer insights, especially in imaging and subsequent interpretation. Expertise is pivotal as endometriosis lesions can be minuscule and exhibit poor echoes. Proficiency in assessing reproductive organs is also indispensable [10].

Simultaneously, contemplate the administration of pain relievers to provide a temporary reprieve. It is crucial to recognize that studies indicate women tend to receive pain medication later than men, with sedatives being more commonly prescribed [11]. This phenomenon might be attributed to gender-specific pain perception and response differences. Acknowledging this disparity can enhance overall treatment quality, fostering an equitable healthcare environment [12, 13]. Yet, it is evident that comprehensive, long-term pain management is not tenable within a clinical context.

Excluding Endometriosis

Once you and your team have systematically ruled out endometriosis as the underlying cause of the patient’s distress, numerous other potential diagnoses could be at play. Given the prevalence of lower abdominal pain, acute appendicitis typically emerges as a primary consideration [14, 15]. Additionally, acute kidney issues or chest discomfort may be driven by alternative factors. As imperative as it is to maintain a serious approach and eliminate endometriosis and its diverse array of associated symptoms from the equation, it is equally vital not to fixate solely on this possibility. Your seasoned comprehensive perspective as a medical professional becomes pivotal in these instances.

Tips for Loved Ones

When your partner or girlfriend is grappling with severe discomfort, it is natural to feel queasy, even as a relative. Such situations are not common occurrences for most people. To help you respond appropriately and effectively during an emergency, we have devised a simple mnemonic for you. With this tool, you will be well-prepared for an urgent situation and can navigate it together as effectively as possible. All you need to remember is “ENDO”!

Engage – Encourage them to describe their symptoms thoroughly. A crucial question you could ask is whether they are familiar with this kind of pain. Given that endometriosis patients typically possess an intuitive understanding of their symptoms, your friend or partner might gauge the severity of the situation accurately.

Nurture – Interpret this in a metaphorical sense. Above all, take their complaints and accompanying fears seriously. It is likely that their endometriosis symptoms have been brushed aside in the past. Your role is to be a supportive presence. Even if you think a trip to the emergency room is excessive, honor their wish. After all, they know their body best.

Drive – Anxiety and intense pain can sometimes paralyze decision-making. Your friend/partner might be experiencing this too. They might hesitate to go to the hospital, fearing potential dismissal by medical staff. Alternatively, the distress itself could be clouding their ability to decide. If you believe it is necessary to call for professional help, and you’re genuinely concerned, do not hesitate to take charge and seek assistance for both of you. You need not navigate this situation alone, and having professionals involved can lend a sense of security.

Organize – While awaiting care or before heading to the emergency room, consider preparing a hospital bag for them. You could also inform other friends or family members if they so desire. Once you are at the emergency room or medical professionals are attending to them, there is only last but crucial responsibility: be their staunch advocate! If you sense their symptoms might be dismissed or belittled, do not hesitate to communicate to the doctors that severe and potentially life-threatening endometriosis symptoms are very real possibilities.

Short and to the Point

Endometriosis can escalate into a critical medical emergency demanding immediate attention. Delayed recognition of underlying causes could result in grave implications for the patient.

Damage to reproductive organs, complications arising in other areas due to endometriosis, and cardiovascular issues may trigger emergency admission.

Yet, strategic medical intervention and personal support can mitigate psychological and physical harm, offering a chance to minimize or avert damage.

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 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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Meike Fischer
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