BAD menstrual cramps accompanying "that time of the month" for women are not normal, despite what your grandmother, mother, aunts and female friends might have told you. In fact, the pain is most likely an indication of endometriosis - a condition where cells from the lining of the womb grow in other areas of the body - and the earlier it is looked into, the sooner the pain can be alleviated and the problem addressed before it progresses to infertility.

A recent study conducted by the National University Hospital on young patients with endometriosis discovered that contrary to what had been believed, endometriosis can start in patients as young as in their teens, and is not a problem that only affects women in their 30s and above.

"In fact, our youngest patient was 14 years old. And 80 per cent of patients who required surgery had menstrual cramps, with half of that number having severe cramps," says Fong Yoke Fai, principal investigator of the study. He is also the head and senior consultant, division of benign gynaecology, in NUH's Department of Obstetrics and Gynaecology.

In stark contrast to studies elsewhere, such as in the US, where 90 per cent of young adolescent patients were found to have stage one endometriosis, 71 per cent of young patients in Singapore were diagnosed at stages three and four. "It begs the question - do Asian women suffer from a more serious endometriosis condition? Or is it because patients aren't seeking help early enough?" muses Dr Fong.

Progressive condition

Endometriosis usually progresses in stages, so it seems clear that patients aren't getting their diagnoses done early enough. Endometriosis is thought to be a backflow of menses through the fallopian tubes - that's one of the explanations of how the cells that line the womb form outside the ovaries.

That also explains why endometriosis develops in the lower part of the body, affecting the ovaries, bowel, rectum, bladder and the pelvic area.

"Endometriosis develops over a few cycles. We don't know why but some people are more susceptible to it and some are resistant," says Dr Fong. The main point he wants to emphasise is that pain during menses isn't normal - especially not to the extent that it affects work and requires one to take medical leave. "If the symptoms are so bad that you feel faint or giddy, or if you need painkillers and can only lie in bed, it's not normal," he says.

Another symptom of endometriosis is the constant feeling of having to pass motion, due to irritation of the rectum, when there is nothing much to pass. On the other hand, there are also some women who get endometriosis without feeling any pain, and the condition is only discovered when they are found to be infertile. "But cases like this are rarer," says Dr Fong.

NUH started the first study in South-east Asia involving adolescent and young adult females in 2008, and over 80 per cent - the majority of them Chinese - suffered from menstrual cramps.

More public awareness of endometriosis is necessary, Dr Fong says, especially as there is now new medication to control the problem. "The problem with older medication is the unfavourable side effects - bloatedness, mood changes, weight gain. So patients tend to discontinue medication after a while," Dr Fong explains.

Newer medications such as Visanne do not interfere with the body's hormone levels but block ovulation instead, thus suppressing endometriosis as they either stop or reduce menstrual flow. Apart from not causing menopausal side effects, Visanne can also be used for long-term treatment and not be limited to six- or 12- month courses.

There is no cure for endometriosis, but Visanne is said to be the world's first and only long-term oral therapy, proven to significantly reduce pain and lesions without increasing the risk of osteoporosis.

Dr Fong points out that the key to a diagnosis of endometriosis is a careful evaluation of symptoms, a clinical examination to check for painful spots or scarring in the pelvis, and an ultrasound scan. "But when endometriosis has been present for a long time, it may cause irreversible damage to the fallopian tubes and ovaries, which can result in infertility," he stresses, reiterating the need for early intervention.