“My periods have always been bad, but now I’m missing work — and the scan was normal”

Suspect endometriosis with chronic pelvic pain, period-related pain affecting daily life, deep dyspareunia, period-related painful bowel movements or painful urination, or infertility. A normal examination or ultrasound does not exclude it — refer anyway when symptoms are persistent, severe or affect daily life, or when initial treatment fails, is not tolerated or is contraindicated. Initial management runs in parallel with referral: NSAIDs and/or paracetamol, and hormonal treatment (combined hormonal contraception or a progestogen). In migraine with aura, combined hormonal contraception is UKMEC 4, so use progestogen-only options. Suspected deep endometriosis involving bowel, bladder or ureter, or an endometrioma, should be referred to a specialist endometriosis service. Women often wait years for a diagnosis; listening and validating are part of the treatment. Discuss fertility honestly and consider work adjustments.