I don't know where to turn. I have extremely severe cramps one to two days before my period. I have had an ultrasound and an endometriosis biopsy and all the results have been negative. My doctor put me on Zoloft, which worked for about two months, but now the pains are back and more severe. They go all the way down to my thighs and around to my back, and I cannot even stand up or sit up straight. I was thinking maybe it was hormonal since I get these terrible headaches that I now have to use an ice pack on to relieve. I have been taking Fioricet with no relief. Where do I go from here -- back to my gynecologist or to an endocrinologist?

--Denise

By "endometriosis biopsy" I'm guessing you mean an endometrial biopsy, a test in which the doctor inserts a small device through the cervix into the uterine cavity in order to get a sample of the uterine lining tissue. An endometrial biopsy will not diagnose endometriosis. The only way to diagnose endometriosis for sure is to perform a laparoscopy, a surgical procedure in which the doctor inserts a telescope through a tiny slit in your belly button to view your pelvic organs directly.

Severe pains and cramps around the time of your period can be due to endometriosis, a condition in which the uterine lining tissue gets outside the uterine cavity, lands in places in doesn't belong and causes pain. Another possibility is adenomyosis, in which the uterine lining tissue penetrates into the wall of the uterus, again causing crampy pain; often bleeding is heavy with adenomyosis. A third possibility is abnormal production of prostaglandins by your uterus, again causing cramps -- we call this abnormal cramping "dysmenorrhea."

Often, birth control pills plus a medication that inhibits prostaglandins (like Motrin or Advil or Anaprox) are used to provide relief from severe cramps. This is frequently the first step and most of the time is very effective. If this conservative measure fails, then we will sometimes recommend a laparoscopy so we can look inside to see what is going on. During a laparoscopy, endometriosis can be diagnosed and treated, and nerves that go into the back of the uterus, transmitting pain signals, may be cut to provide relief.

As far as the headaches go, some women do experience migraine headaches related to their menstrual cycles. These are sometimes difficult to treat and require a lot of communication between you and your doctor and often some trial and error in finding the best therapy for you. For more information, see my article Migraines & Menstrual Cycle.

The best person for you to see regarding your cramps is your gynecologist. This is something we deal with every day. Often medical therapy like birth control pills and a medicine like Anaprox will do the trick; sometimes a laparoscopy is needed. You will need to discuss your options with your doctor.