What is the difference between primary and secondary dysmenorrhoea?

Primary dysmenorrhoea is period pain with no underlying pathology — caused by prostaglandin-driven uterine hypercontractility. It typically starts within 1–2 years of menarche, responds well to NSAIDs and the combined oral contraceptive, and often improves with age or after pregnancy. Secondary dysmenorrhoea has an underlying cause — endometriosis is the most important, but adenomyosis, fibroids, PID, and IUD-related pain are others. Secondary dysmenorrhoea tends to worsen over time, may include pain outside the period (dyspareunia, dyschezia), and is less responsive to standard NSAID dosing.

Do I need a laparoscopy to be diagnosed with endometriosis?

Not necessarily. Current RANZCOG guidance and eTG Reproductive health support empirical treatment based on symptoms and imaging without requiring laparoscopic biopsy. A pelvic ultrasound (preferably by a gynaecological sonographer with expertise in deep-infiltrating endometriosis) can detect endometriomas and adenomyosis. MRI is useful for mapping deep-infiltrating disease involving the bowel, bladder, or ureter. Starting treatment empirically reduces the 7-year diagnostic delay that affects most Australian women with endometriosis. Laparoscopy is reserved for patients who need surgical treatment — excision rather than diagnosis alone.

What is dienogest (Visanne) and how does it compare to other options?

Dienogest 2 mg daily (Visanne) is a progestogen with TGA approval and PBS Authority Required status specifically for endometriosis — it is distinct from the combined oral contraceptive and works by suppressing oestrogen-driven endometrial tissue growth. It is well-tolerated, does not carry the bone-density risk of GnRH analogues, and is usually taken continuously without a break. It is a reasonable second-line option after COC or as first-line in patients for whom oestrogen is contraindicated. Irregular spotting is the most common side effect, usually settling after the first 3 months.

How does endometriosis affect fertility and what should I do if I am trying to conceive?

Endometriosis affects fertility through several mechanisms: distorted pelvic anatomy from adhesions, endometriomas reducing ovarian reserve, inflammation affecting the embryo, and impaired tubal function. Moderate-to-severe disease is associated with reduced natural conception rates. The key message is early referral: if you have known or suspected endometriosis and are considering pregnancy within 1–2 years, ask your GP for a referral to a gynaecologist with endometriosis expertise before you start trying. AMH (anti-Müllerian hormone) testing can assess ovarian reserve. IVF significantly improves outcomes for many women with moderate-to-severe disease.

What is the best pain management for endometriosis beyond hormonal therapy?

Multidisciplinary management is the standard of care for endometriosis-associated chronic pelvic pain. Pelvic floor physiotherapy addresses muscle tension, trigger points, and co-existing pelvic floor dysfunction — it is an evidence-based component of care accessible under the GPCCMP. Pain psychology (CBT for chronic pain, acceptance and commitment therapy) addresses central sensitisation and the psychosocial burden of chronic pain. Low-FODMAP dietary assessment is helpful when IBS symptoms overlap (occurs in ~30–40% of endometriosis patients). Opioids should be minimised — multimodal non-opioid management is preferred, with amitriptyline or gabapentin for a neuropathic pain component.

Dysmenorrhoea and endometriosis

Dysmenorrhoea and endometriosis: the Australian GP management guide

By Dr HB Lo, FACRRM Reviewed 27 May 2026 8 min read

Dysmenorrhoea affects up to 90% of menstruating women. Endometriosis affects ~1 in 9 Australian women, with a typical 7-year diagnostic delay. Empirical treatment without laparoscopy is now the standard approach.

First-line: NSAID plus continuous combined oral contraceptive (COC). Second-line: Mirena LNG-IUD, or dienogest 2 mg daily (Visanne — PBS Authority Required for endometriosis). Laparoscopic excision is preferred over ablation for moderate-to-severe disease.

Early gynaecology referral for suspected deep-infiltrating disease, fertility difficulty, refractory pain, or adolescent dysmenorrhoea unresponsive to first-line therapy.

What dysmenorrhoea and endometriosis are

Dysmenorrhoea — painful menstruation — is one of the most common gynaecological presentations in Australian general practice. Primary dysmenorrhoea occurs without underlying pathology: prostaglandin overproduction (PGF2α, PGE2) drives uterine hypercontractility and ischaemic-like cramping, typically starting within 1–2 years of menarche. It responds well to NSAIDs and the combined oral contraceptive (COC) and often improves with age or after pregnancy.

Secondary dysmenorrhoea has underlying pathology. Endometriosis is the most important cause — ectopic endometrial-like glands and stroma growing outside the uterus (peritoneum, ovary, bowel, bladder, ureter, diaphragm), driven by oestrogen, causing chronic inflammation, adhesions, and visceral hypersensitivity. Adenomyosis (endometrium within the myometrium), fibroids, pelvic inflammatory disease, and IUD-related causes are also relevant differentials.

Endometriosis affects approximately 1 in 9 Australian women (~14%). The National Action Plan for Endometriosis 2018 estimates the condition costs the Australian economy approximately $9.7 billion annually in lost productivity and healthcare. The average diagnostic delay remains approximately 7 years — often because symptoms are dismissed or attributed to normal periods. Early recognition and empirical treatment are now the standard of care.

Symptoms are variable and often disproportionate to disease extent: cyclical and worsening pelvic pain, dyspareunia (especially deep), dyschezia (pain with defaecation, cyclically worse), dysuria, fatigue, bloating, and infertility. IBS-like symptoms overlap in approximately 30–40% of patients.

A. Core clinical — the AU general-practice framework

History to take

Pain pattern: onset (at menarche or acquired later?), cyclical or non-cyclical, severity (0–10), location and radiation, character.
Associated symptoms: dyspareunia, dyschezia, dysuria, fatigue, bloating, abnormal uterine bleeding.
Menstrual history: cycle length, heavy menstrual bleeding (HMB), passage of clots.
Fertility and obstetric history: current pregnancy intentions, prior investigations.
Drug history: current analgesics, hormonal therapies, prior responses.
Family history: endometriosis (5–7-fold familial risk), ovarian cancer, colorectal cancer.
Mental health: chronic pain-related depression and anxiety are prevalent — screen routinely.
Adolescent: severe dysmenorrhoea unresponsive to first-line NSAID plus COC should prompt early endometriosis consideration — do not reassure and discharge; early referral prevents diagnostic delay.

Examination

Abdominal palpation for tenderness and mass. Bimanual pelvic examination looking for uterosacral nodularity, fixed retroverted uterus, adnexal tenderness, and posterior fornix tenderness — all suggestive of endometriosis. Pelvic floor tension and trigger points on digital examination (chronic pelvic pain with floor dysfunction). Speculum for cervical pathology and STI sampling if relevant.

Investigations

Per RANZCOG Endometriosis Clinical Practice Statement and eTG Reproductive health:

First-line: FBC and ferritin (HMB-related anaemia), CRP (PID differential), pregnancy test, STI screen. Transvaginal pelvic ultrasound (TVS) is the first-line imaging — but sensitivity for deep-infiltrating endometriosis (DIE) is operator-dependent; referral to a sonographer with specific gynaecological endometriosis expertise significantly improves yield. CA-125 is non-specific and not routinely useful.

Second-line: MRI pelvis for DIE (bowel, bladder, ureter involvement) and pre-surgical mapping. AMH (anti-Müllerian hormone) for ovarian reserve assessment in fertility planning. Laparoscopy — no longer required before starting empirical treatment; reserved for surgical excision.

Diagnostic laparoscopy is not required before empirical treatment — this is a key shift endorsed by RANZCOG and eTG that significantly reduces diagnostic delay.

Treatment hierarchy

NSAIDs + continuous COC — first-line.
Mirena LNG-IUD or progestogen-only alternatives — second-line or when oestrogen is contraindicated.
Dienogest 2 mg daily (Visanne) — PBS Authority Required specifically for endometriosis.
GnRH analogues (with add-back HRT) or relugolix combination — specialist-led.
Laparoscopic surgical excision — for moderate-to-severe or refractory disease.
Multidisciplinary — pelvic physiotherapy, pain psychology, dietitian.

B. Endometriosis pharmacotherapy — hormonal options

Per eTG Reproductive health and AMH:

NSAID and COC — first-line

NSAIDs work best when started one day before menstruation and continued for 2–3 days: ibuprofen 400 mg three times daily, mefenamic acid 500 mg three times daily, or naproxen 500 mg loading then 250 mg three times daily. Continuous (or extended-cycle) COC is preferred over cyclical dosing — it suppresses oestrogen-driven endometrial proliferation and reduces the frequency of bleeding and pain episodes.

Mirena LNG-IUD

The Mirena intrauterine device delivers levonorgestrel locally, causing endometrial atrophy and amenorrhoea in most users. It is first-line for combined dysmenorrhoea and heavy menstrual bleeding, and PBS Authority Required for menorrhagia. It is also an effective progestogen option for endometriosis when the COC is not tolerated or contraindicated.

Dienogest 2 mg daily (Visanne) — endometriosis-specific

Dienogest is a progestogen with specific TGA approval and PBS Authority Required for endometriosis. It suppresses oestrogen-dependent endometrial tissue without the vasomotor symptoms or bone-density risk of GnRH analogues. Taken continuously; irregular spotting in the first three months is common and usually resolves. A reasonable second-line option, or first-line when oestrogen is contraindicated. Available on PBS with Authority Required prescription for endometriosis indication.

GnRH analogues — specialist territory

Goserelin and leuprorelin suppress oestrogen profoundly, achieving hypoestrogenism equivalent to surgical menopause. Add-back HRT (small doses of oestrogen plus progestogen) is essential to prevent vasomotor symptoms, bone density loss, and cardiovascular effects — RANZCOG mandates this with any GnRH analogue course. Maximum duration without add-back is approximately 3–6 months. PBS Authority Required; specialist initiation.

Relugolix combination (Ryeqo) — emerging option

Relugolix-oestradiol-norethindrone (Ryeqo) is a daily oral GnRH antagonist combination with built-in add-back HRT — TGA-approved 2023 for endometriosis and uterine fibroids (Al-Hendy NEJM 2021). PBS listing is evolving — currently private script or specialist-led. Advantages over GnRH analogues: no flare effect, no injection, and add-back included in the combination.

C. Surgical management and multidisciplinary chronic pelvic pain

Laparoscopic excision preferred over ablation

RANZCOG recommends laparoscopic excision (removing endometriotic lesions) over ablation (burning them) for moderate-to-severe disease — excision is more effective for pain reduction and is associated with lower recurrence rates. The procedure should be performed by a gynaecologist with specific endometriosis surgical expertise. For endometrioma >3 cm, cystectomy (removing the cyst wall) is preferred over drainage — it preserves more ovarian reserve and reduces recurrence.

Deep-infiltrating endometriosis involving bowel, bladder, or ureter requires a multidisciplinary surgical team (gynaecologist, colorectal surgeon, urologist) at a specialist endometriosis centre.

Multidisciplinary chronic pelvic pain management

The chronic pelvic pain associated with endometriosis has central sensitisation components that do not resolve with hormonal suppression or surgery alone. Per Pelvic Pain Foundation Australia:

Pelvic floor physiotherapy — addresses pelvic floor hypertonicity, trigger points, and movement patterns contributing to pain. Accessible under the GPCCMP allied health pathway.

Pain psychology — CBT for chronic pain and acceptance and commitment therapy address catastrophising, fear-avoidance, and the psychosocial burden. Better Access MHCP can fund sessions.

IBS overlap — present in ~30–40% of endometriosis patients. Low-FODMAP dietary management with a dietitian (GPCCMP pathway) often improves bowel-related symptoms.

Avoiding long-term opioids — opioid dependence in chronic endometriosis pelvic pain is a recognised harm. Multimodal management (NSAIDs, hormonal therapy, physiotherapy, psychology, gabapentinoid or amitriptyline for neuropathic component) is strongly preferred.

D. Australian operations

PBS authority codes: NSAIDs (general schedule). COC, POP, DMPA (general schedule). Mirena — PBS Authority Required for menorrhagia (general schedule for contraception). Dienogest (Visanne) — PBS Authority Required for endometriosis — document indication clearly. GnRH analogues (goserelin, leuprorelin) — PBS Authority Required. Relugolix combination (Ryeqo) — TGA approved; PBS evolving. Tranexamic acid (general schedule for HMB). Amitriptyline and gabapentin/pregabalin (general schedule or Authority for chronic pain).

MBS items: Standard consultation 23, 36, 44. TVS (55066); MRI pelvis (63491). AMH for ovarian reserve (73292). GPCCMP (965, 967) — chronic endometriosis qualifies; enables direct-referral allied health pathway (pelvic physiotherapist, dietitian, psychologist) for 5 sessions/year (10 for ATSI patients). MHCP (2715, 2717) for comorbid anxiety or depression. ATSI Health Assessment (715).

National Action Plan for Endometriosis 2018: Funded awareness, GP education, and improved access to specialist care. The Endometriosis Australia website is a patient resource linked to the Plan.

Referral: Gynaecologist with endometriosis expertise for suspected moderate-to-severe disease, fertility planning, DIE, or adolescent severe dysmenorrhoea. Pelvic pain multidisciplinary clinic (where available). Fertility specialist when pregnancy is planned within 1–2 years in a patient with known or suspected endometriosis.

E. Special populations

Adolescents: Severe dysmenorrhoea in adolescents that is unresponsive to NSAID plus COC should prompt early endometriosis consideration — not dismissal as “normal periods.” The RANZCOG position is that severe adolescent dysmenorrhoea warrants gynaecology referral without waiting until reproductive age. Continuous COC, Mirena, and dienogest are all options in appropriately counselled adolescents. Early intervention reduces the diagnostic delay and potential fertility impact.

Pregnancy: Endometriosis often improves during pregnancy due to progesterone dominance. NSAIDs should be avoided in the third trimester (risk of premature closure of the ductus arteriosus). Paracetamol is the preferred analgesic in pregnancy. Hormonal suppression resumes postpartum or post-breastfeeding. Adenomyosis may worsen postpartum.

Fertility planning: Endometriosis-associated infertility requires early specialist input. AMH testing and referral to a gynaecologist with endometriosis expertise are appropriate when the patient is planning pregnancy within 1–2 years. Surgical excision improves fertility in selected cases. IVF is often required for moderate-to-severe disease, particularly with tubal involvement or endometrioma. Counsel that treatment with hormonal suppression (dienogest, GnRH analogues) does not improve and may defer fertility — it is a bridge while planning, not a fertility treatment.

Mental health: Depression and anxiety are prevalent in endometriosis patients — the chronic pain, diagnostic odyssey, impact on work, relationships, and body image all contribute. Screen routinely and initiate MHCP referral proactively. The Jean Hailes for Women’s Health website has patient-friendly mental health resources specific to women’s health conditions.

When to escalate

Urgent ED referral:

Acute severe pelvic pain with haemodynamic compromise — suspected ectopic pregnancy, ovarian torsion/rupture, or appendicitis.
Adnexal mass with ascites, postmenopausal bleeding, or features of malignancy — urgent gynaecological oncology.
Severe pelvic inflammatory disease.

Urgent or same-week gynaecology referral:

Suspected adnexal malignancy.
Severe pain inadequately controlled on current treatment.
Fertility difficulty — when planning pregnancy imminently and endometriosis is suspected.

Routine gynaecology referral:

Suspected endometriosis (symptoms + TVS features) unresponsive to first-line NSAID plus COC trial.
Adolescent with severe dysmenorrhoea not responding to initial therapy.
Planning dienogest or GnRH analogue in a patient new to these agents.
Pre-surgical planning for excision or endometrioma management.

What this article is and is not

This is general health information drawn from current Australian general practice guidelines — RANZCOG Endometriosis Clinical Practice Statement, eTG Reproductive health, AMH, RACGP, and the National Action Plan for Endometriosis 2018. It is not personal medical advice and does not create a doctor–patient relationship. Diagnosis, prescription of PBS Authority medicines, surgical planning, and fertility assessment are undertaken with your own GP and treating specialists.

For consumer-friendly information: Endometriosis Australia, Pelvic Pain Foundation Australia, Jean Hailes for Women’s Health, HealthDirect — Endometriosis, HealthDirect — Period pain.

Sources cited

Frequently asked questions

What is the difference between primary and secondary dysmenorrhoea?

Primary dysmenorrhoea is period pain with no underlying pathology — caused by prostaglandin-driven uterine hypercontractility. It typically starts within 1–2 years of menarche, responds well to NSAIDs and the combined oral contraceptive, and often improves with age or after pregnancy. Secondary dysmenorrhoea has an underlying cause — endometriosis is the most important, but adenomyosis, fibroids, PID, and IUD-related pain are others. Secondary dysmenorrhoea tends to worsen over time, may include pain outside the period (dyspareunia, dyschezia), and is less responsive to standard NSAID dosing.
Do I need a laparoscopy to be diagnosed with endometriosis?

Not necessarily. Current RANZCOG guidance and eTG Reproductive health support empirical treatment based on symptoms and imaging without requiring laparoscopic biopsy. A pelvic ultrasound (preferably by a gynaecological sonographer with expertise in deep-infiltrating endometriosis) can detect endometriomas and adenomyosis. MRI is useful for mapping deep-infiltrating disease involving the bowel, bladder, or ureter. Starting treatment empirically reduces the 7-year diagnostic delay that affects most Australian women with endometriosis. Laparoscopy is reserved for patients who need surgical treatment — excision rather than diagnosis alone.
What is dienogest (Visanne) and how does it compare to other options?

Dienogest 2 mg daily (Visanne) is a progestogen with TGA approval and PBS Authority Required status specifically for endometriosis — it is distinct from the combined oral contraceptive and works by suppressing oestrogen-driven endometrial tissue growth. It is well-tolerated, does not carry the bone-density risk of GnRH analogues, and is usually taken continuously without a break. It is a reasonable second-line option after COC or as first-line in patients for whom oestrogen is contraindicated. Irregular spotting is the most common side effect, usually settling after the first 3 months.
How does endometriosis affect fertility and what should I do if I am trying to conceive?

Endometriosis affects fertility through several mechanisms: distorted pelvic anatomy from adhesions, endometriomas reducing ovarian reserve, inflammation affecting the embryo, and impaired tubal function. Moderate-to-severe disease is associated with reduced natural conception rates. The key message is early referral: if you have known or suspected endometriosis and are considering pregnancy within 1–2 years, ask your GP for a referral to a gynaecologist with endometriosis expertise before you start trying. AMH (anti-Müllerian hormone) testing can assess ovarian reserve. IVF significantly improves outcomes for many women with moderate-to-severe disease.
What is the best pain management for endometriosis beyond hormonal therapy?

Multidisciplinary management is the standard of care for endometriosis-associated chronic pelvic pain. Pelvic floor physiotherapy addresses muscle tension, trigger points, and co-existing pelvic floor dysfunction — it is an evidence-based component of care accessible under the GPCCMP. Pain psychology (CBT for chronic pain, acceptance and commitment therapy) addresses central sensitisation and the psychosocial burden of chronic pain. Low-FODMAP dietary assessment is helpful when IBS symptoms overlap (occurs in ~30–40% of endometriosis patients). Opioids should be minimised — multimodal non-opioid management is preferred, with amitriptyline or gabapentin for a neuropathic pain component.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.