For many girls and women worldwide, painful periods are treated as something ordinary to push through – with a hot water bottle, tea, a painkiller, or a quiet excuse to a teacher or supervisor. Often, that assumption is correct: mild cramping during the first day or two of menstruation, known as primary dysmenorrhea, is common and rarely a sign of disease.

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But for many, the pain is not ordinary at all. It may signal endometriosis or Polyendocrine Metabolic Ovarian Syndrome (PMOS), formerly called polycystic ovary syndrome (PCOS), two hormonal and gynecological conditions that remain poorly researched, rarely diagnosed, and almost invisible in Rwanda&039;s public health conversation.

What the conditions actually are

Endometriosis occurs when tissue similar to the uterine lining grows outside it, on the ovaries, fallopian tubes, or pelvic lining, where it thickens, breaks down, and bleeds with each cycle but has no way to leave the body. This triggers inflammation, scarring, and often severe pain. It's estimated to affect roughly one in 10 women and girls of reproductive age worldwide. Symptoms include intense pelvic pain during or between periods, pain during sex, bowel or urinary discomfort, chronic fatigue, and difficulty conceiving.

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PMOS/PCOS is different: a hormonal and metabolic disorder in which the ovaries produce excess androgens. Doctors typically diagnose it using the Rotterdam criteria; at least two of three features: irregular or absent ovulation, clinical or lab signs of excess androgens (acne, excess hair growth), and polycystic-appearing ovaries on ultrasound. It's linked to insulin resistance, weight gain, acne, hair thinning, and long-term risk of type 2 diabetes and cardiovascular disease.

Where the line is

Health professionals increasingly distinguish pain that's uncomfortable but manageable from pain that disrupts daily life.

Ordinary dysmenorrhea should ease with rest and standard pain relief. Warning signs include pain severe enough to regularly keep someone home from school or work, pain unresponsive to over-the-counter medication, pain during intercourse, very heavy bleeding, pelvic pain that persists beyond menstruation rather than easing once the period ends, and long-standing difficulty conceiving alongside painful or irregular cycles.

The African blind spot

Even in well-resourced health systems, both conditions are notoriously under-diagnosed and the gap widens across Africa. A review of evidence on endometriosis among African women found prevalence on the continent remains unknown, with diagnostic delay worsened by high costs, a scarcity of trained specialists, and patients' difficulty describing symptoms amid the stigma surrounding menstruation.

Rwanda has no dedicated research footprint on either condition. Regional advocacy groups such as Kenya's Endo-Sisters East Africa Foundation have begun collaborating with organizations in Rwanda and Ethiopia to extend endometriosis awareness training. No Rwanda-specific prevalence study on endometriosis or PCOS appears in published literature.

Endometriosis is linked to long-term fertility difficulty, chronic pelvic pain, and, in some studies, higher risk of inflammatory and cardiovascular conditions. Unmanaged PCOS raises long-term risk of type 2 diabetes, hypertension, and endometrial cancer. For adolescent girls especially, pain dismissed as "normal" can mean years of missed school and unnecessary suffering before anyone considers a gynecological cause, with a mental health toll, too, as persistent unexplained pain contributes to anxiety, low self-esteem, and isolation.

Improving outcomes for women with PCOS and endometriosis requires a coordinated approach.

Strengthening the capacity of primary healthcare providers to recognize symptoms early and make timely referrals is a critical first step. At the same time, increasing public awareness, reducing barriers to diagnostic services, and expanding access to affordable specialist care are essential. Collaboration among healthcare providers, policymakers, civil society organizations, and communities will be key to ensuring that women receive timely diagnosis, appropriate treatment, and the support they need to improve their quality of life.

The writer is a global health specialist.