Phantom Period Pain: What to Know

A common question in the doctor’s office is “I’ve been experiencing what feels like menstrual cramps except I don’t actually bleed... What gives?”

What may or may not surprise you is the origin of phantom period pain can be within the uterus or from somewhere else in the abdomen. Read on for more specifics about these root causes and when it might be time to visit your physician:

Read more: Painful Periods: When to See a Doctor

Business as Usual

Whether you keep a careful calendar or just know when your period is going to begin by the tell-tale cramping that starts, you know that cramping and bleeding are usually a package deal.

The reason there is cramping during your period is because of the muscular layer of your uterus is contracting and trying to squeeze out the monthly menstrual debris. This of course exits the vagina onto a pad/ tampon/ cup for discarding.

The more bleeding you have, the more sizeable the clots are and the more forceful are the contractions necessary to do the job. The inside of your uterus is actually a space, and your uterus does not like something to be in that space, whether it’s a blood clot or even a baby (the same contractions—in a much bigger uterus—causing labor to push the baby out). Many women who have had IUDs (intrauterine devices) inserted also experience this cramping for the same reason.

The cramping serves the function of expelling the period tissue to make the lining of the uterus pristine for new tissue to brew up via the hormonal stimulation of your cycle. And cycle it does, of course. This means monthly, if it’s regular.

The Mystery of Phantom Periods

Then one cycle when you’re expecting a period, you feel the cramping. You ready yourself with the items you need…stay ready…perhaps even apply a pad or insert a tampon…and nothing happens. What’s the deal?

There are many reasons you could experience “menstrual-like” cramping, whether it comes at a time you expect bleeding (but which never comes) or at any other points of your cycle. These various causes can occur as related to the prime “suspect” (your uterus), or they can be unrelated to your uterus, hormones, or cycle. Let’s break it down:

What Causes Uterine Cramping in the Absence of Menstrual Bleeding

The things that can provoke the muscular layer of your uterus to begin contracting (producing a ghost period) include:

Early Pregnancy:

•  An implantation of a fertilized egg on the inner lining of your uterus will cause a mild inflammation that might irritate the muscular layer to contract a bit. This is harmless, normal, and self-limited. It also may result in some mild spotting.

Decidual Cast:

• An organized clot. Sometimes, depending on harmless fluctuations in your hormones, especially when there is a dominance of progesterone, the lining won’t shed but organize into a clump of tissue and clotted blood too big to fall out from the contractions. The contractions can become stronger for the increased effort to do the job. Eventually, they succeed, but before they do, you will get the cramping without any bleeding.  

Foreign Body:

• As explained above, foreign things occupying your uterus will provoke contractions to expel them. However, your uterus can be fooled by fibroids or polyps that hang into the intrauterine cavity. This will provoke contractions but may have no outward signs (bleeding). 

Infection (Endometritis):

• any inflammatory process within your uterus can stimulate uterine contractions at any time during your cycle. 

False Uterine Cramping—Cramping That Mimics Uterine Contractions

All of your pelvic organs are covered with a thin layer of tissue called the “peritoneum.” This layer wraps around your organs and when it meets the floor of your pelvis wraps up and around the entire abdominal cavity as an inclusive covering. Peritoneum is weird stuff, because you can cut it and it won’t hurt; you can burn it and it won’t hurt; in fact, you can do almost anything to it and it won’t hurt: unless you stretch it. Then it hurts!

The pain receptors in the peritoneum only fire off with distension. Since they cover everything—your uterus, tubes, ovaries, bladder, rectum, and intestines—the same cramping that occurs due to its irritation from your uterine contractions can occur with distention of all of the other structures.

It is why babies get colic so easily when a gas bubble tries to navigate its way down a newborn’s tiny intestinal tract (causing distention in a wave along its journey). It’s why diarrhea can give you similar discomfort.

Thus, you can suffer non-uterine cramping and phantom periods from the following:

• Constipation, gas, or diarrhea.
• Infection. This, like inside your uterus, can evoke an inflammatory reaction anywhere else—your bladder (e.g., urinary tract infection), intestines (diverticulitis), tubes (sexually transmitted infections), etc. When the peritoneum itself is infected, it is called peritonitis.
• Ectopic pregnancy. Easily the most serious of these causes, a blocked tube will hold a stuck embryo that will grow until it distends and finally ruptures a tube, which is covered in peritoneum. This results in internal hemorrhage. 
• Ovarian cyst. When a cyst enlarges, it distends the peritoneum covering the ovary, hence, cramp-like sensations. 
• Mittelschmerz: a German term for “middle pain,” that is, pain from ovulation which occurs in the middle of your cycle. 
• Adhesions. Adhesions are tissues stuck together from previous sites of bleeding or infection. The body tends to want to wall off such problems, but when the problem resolves, the tissues stay stuck together. This can cause kinks in the intestines leading to distention; or blocks of ovulation when a follicle in your ovary cannot release an egg. 

Ghost Periods - The Take Home Message

The frustrating thing—and the real take-home message—is that since your peritoneum covers everything, there is cross-talk among the pain fibers. This means that an irritation of your ovary from a cyst can feel like it’s coming from the center of your pelvis; or constipation putting pressure on your rectum can feel like ovary pain. Of all of these causes, only the ectopic pregnancy is life-threatening.

But because you cannot tell from where pelvic pain is originating specifically, any pain that is persistent or debilitating, with or without uterine spotting or bleeding, requires a visit to your doctor to pinpoint the cause. Pain can be easier to tolerate without the worry of something dangerous. And if pain isn’t your thing, a doctor can begin a rational therapeutic plan (which can include herbal remedies) to eliminate it and take steps to prevent occurrences in the future.

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This article was reviewed by Dr. Jessica Ritch.

Dr. Jessica Ritch is a board-certified and fellowship-trained minimally invasive gynecologist who specializes in the management of benign gynecologic conditions such as abnormal bleeding, pelvic pain, fibroids, endometriosis, and polycystic ovarian syndrome. She completed residency training in obstetrics and gynecology at Columbia University, where she was selected as chief resident and received the prestigious AAGL Outstanding Resident in Minimally Invasive Gynecology award.