Many girls grow up believing that painful periods are something they just have to live with. But when cramps are so bad that they keep you from school, sports, or social life, they might be a sign of something more serious. We spoke with Dr Mario Refalo, a specialist in obstetrics and gynaecology, to better understand when period pain stops being ‘normal’ and becomes a reason to seek professional advice.
Dr. Refalo, thank you for taking the time to collaborate with us on this important topic. Many young girls and their mothers believe that painful periods are just part of growing up. How can one tell the difference between what’s ‘normal’ period discomfort and what’s a cause for concern?
Thank you for inviting me here for this interview. While many women believe that period pain is simply a normal part of life that must be endured, it’s important to recognize that although mild period pain is indeed common, it should not be debilitating or significantly affect one’s quality of life. When it becomes severe, persistent more than 2 days, or unresponsive to over-the-counter pain relief, it is important to seek professional assessment. The doctor together with the patient needs to agree together on a tailored management plan depending on the assessment done.
Additionally, period pain becomes more concerning when accompanied by other symptoms such as very heavy bleeding (soaking through a pad or tampon every one to two hours), pain lasting more than two days, interference with daily activities such as work or school, or new changes in one’s usual menstrual pattern. Other warning signs include bleeding between periods or after sexual intercourse.
At what point should a parent consider taking their daughter to see a gynaecologist?
This is a question I get asked by from multiple parents who are worried about their child. It is very important to note that once a person gets their first period, the first 5 years may be a bit erratic, with irregular periods with prolonged or shortened cycles.
Also the following might occur – mild cramping, breast tenderness, mood changes, acne, and sometimes heavier or lighter bleeding from one cycle to the next. These are very common and usually do not warrant investigations if it’s in the first 5 years, as the hormonal system of the person is still maturing. However if there is ever anything of concern, or quality of life is being effected, or school days being missed due to these symptoms, this shows that professional help and advise is needed. It is also important that if these symptoms keep occurring after the first 5 years, one needs to seek help.
What are some of the most common medical conditions that can cause severe period pain?
While mild pain or discomfort during periods is considered normal and not usually linked to an underlying condition, there are many conditions that can cause pain. The most common and underdiagnosed one is Endometriosis, which can cause severe debilitating pain which can get worse and worse with each cycle.
There are other conditions such as fibroids, and adenomyosis that can cause the pain, sometimes even polycystic ovarian syndrome (PCOS) can cause pain – however the latter is more synonymous with irregular cycles.
Pelvic inflammatory disease and sexually transmitted diseases can cause pain and need to be evaluated and treated urgently as they can cause irreversible damage even on fertility.
Could you briefly explain what endometriosis or PCOS is, and what other symptoms might appear alongside painful periods?
Endometriosis is a condition where endometrial cells (cells from inside the uterus) escape the uterus with a period through the tubes and go inside the abdomen and pelvis. These cells attach to areas inside the pelvis and abdomen, mainly the uterus, ovaries, tubes, and intestines. They keep behaving like the uterine lining and so each month they shed blood, irritate and give pain, and this usually worsens with time. They can also cause endometriotic cysts. Apart from period pain, endometriosis can be accompanied with heavy periods, pain on urination or defaecation, and can also cause issues with fertility.
PCOS is a situation where the ovary would have a lot of small microcysts typically 1-2mm in side. These haywire the hormonal balance and cause irregular periods. PCOS is synonymous with insulin resistance and therefore limiting the sugar intake is important. PCOS causes irregular periods, acne, hirsutism, and obesity.
Both endometriosis and PCOS thrive in inflammatory conditions, and tackling inflammation and having an anti-inflammatory diet with good fibres as well may improve the microbiome and the inflammation in the body, and therefore help with these conditions. The best diet is the Mediterranean diet.
How common are these conditions among teenagers, and do they tend to be overlooked or misdiagnosed?
It is estimated that 3-11% of teenagers will have PCOS and 5-18% of women in their reproductive years will have it too. With regards to endometriosis 11% of women between age 15 and 44 have it. PCOS is easier to diagnose as there are criteria that one can satisfy for diagnosis through examinations, ultrasounds, signs and symptoms and maybe sometimes blood tests. When it comes to endometriosis it is estimated that there is a lag of 4-11 years from onset of symptoms to the diagnosis. This is mainly because the gold standard for diagnosing endometriosis is still laparoscopic surgery. In saying this, that does not meant that every one needs a surgery, most people are diagnosed based on signs and symptoms, and surgery is usually the last resort.
How important is early diagnosis when it comes to managing such conditions?
This is extremely important. When it comes to PCOS, some women suffer from not seeing any periods at all and this needs to be investigated and treated to protect their general health. Endometriosis can be a condition which affects a lot the quality of life, and that makes it top priority to treat and diagnose early. When it comes to fertility issues, both need to be caught early so as to treat in a timely manner and help women conceive if they are on that journey.
What are some treatment or management options for girls and women who suffer from these conditions?
There are many management options and science keeps improving, but there is no absolute treatment to cure these conditions. Lifestyle is very important for both of them. Both can be managed hormonally by pills depending on the woman’s need and medical history. Endometriosis can also be managed by hormonal intrauterine devices. PCOS can also be manage by non hormonal medicines – again this depends on the need of the woman.
Are there any lifestyle habits that can help ease painful periods?
Lifestyle is at the crux of all management. Women with PCOS are known to have insulin resistance as well, therefore healthy diet and exercise and avoiding sugars help a lot with this conditions. Endometriosis thrives in inflammation and now we know that if the microbiome is unhealthy, this also makes the situation worse. Therefore good healthy diet rich in anti-inflammatory foods and fibres is very important. Omega 3 is an essential fatty acid that is a major anti-inflammatory and so important for our body in general, but in these conditions having a good Omega 3 helps to decrease the inflammation and control or tame down the situation. Apart from Omega 3 there are other non-hormonal and non medicinal help and supplements available, such as Inositol.
How can parents support their daughters emotionally and practically during this time?
It is very important to listen and try to understand what they might be going through. Trivial issues for the parents may be huge issues for the children, so it’s very important to listen, support and seek help whenever there’s need. Never forget psychological help where it is need. Never underestimate the power of good mental health.
Periods are still a taboo topic in many households. How can we make it easier for girls to open up about their experiences?
Talk, talk, talk. We need to start making these topics common in discussions. Especially in social media as that’s the place that is affecting a lot of younger generations too. We need to normalize these discussions everywhere, even in schools – education is key.
What message would you give to teens who feel embarrassed or afraid to talk about painful periods?
Do not feel embarrassed. Most women (past, present and future) have passed through these situations. Today we are lucky, we are living in a more open society where you can speak about it and seek appropriate help. Remember, here we are talking about your quality of life, so speak up, live life.
And finally… I am aware that even to this day there are still women and girls who feel uncomfortable visiting a male gynaecologist simply because he’s a man. What would you say to help ease their minds and reassure them about seeking care, regardless of the doctor’s gender?
Well ours is a job like any other, we are here to help and hopefully to get you healthier and have a better life. On the other scenario I tend to meet a lot of women who only want a man as a gynaecologist. That’s life right to each his own. Whatever makes you comfortable, but please seek help.
Thank you Dr. Refalo for taking the time to walk us through such an important topic. Your advice will help many girls and parents feel more informed and less alone in dealing with painful periods.
Remember, painful periods should never be ignored or accepted as ‘normal’. Listening to your body, speaking up, and seeking help can make all the difference. Periods are a natural part of being a woman and no one should ever suffer in silence.
Dr. Mario Refalo is a dedicated Obstetrician and Gynaecologist committed to providing compassionate, evidence-based care. He successfully completed his specialist training by achieving certification as a European Fellow of Obstetrics and Gynaecology (EFOG-EBCOG).
His pursuit of advancing women’s health led him to obtain a Master of Science in Reproductive Health from the University of Malta, an achievement that broadened his expertise across fertility, reproductive endocrinology, and women’s health across the lifespan. Most recently, he further expanded his professional credentials by earning his MSCP and registering with the Menopause Society, reinforcing his dedication to the care of women navigating midlife and beyond.
Beyond his extensive medical knowledge, Dr. Mario is deeply committed to building meaningful, trusting relationships with his patients. He values attentive listening, empathy, and open communication, ensuring that each individual feels supported and understood. Collaboration forms the foundation of his practice; he works closely with multidisciplinary healthcare teams to deliver holistic, patient-centred care.
For enquiries or appointments, he may be contacted via WhatsApp messages at 99256521.
Claire Galea is a self-employed holistic care practitioner with formal training in nursing. She is passionate about patient-centered care and public education on health and social issues. Committed to lifelong learning, Claire enjoys exploring a broad range of topics, from spirituality to contemporary affairs.
Claire is also passionate about spreading awareness on the negative effects that domestic abuse leaves on its victims’ mental, emotional, social and physical wellbeing. She is the author of two downloadable ebooks, namely Heal Your Life Forever and 5 Simple Steps To Creating The Life Of Your Dreams.
Click here to check out Claire’s full bio as well as a list of all her Wham published articles
