@seventyfivepercent Can you be more specific about her symptoms. If your pain is severe, it might be an underlying condition, which it looks like, but it could be multiple or one. It could be fibroids or ovarian cysts or something else, but further investigations would be needed, and she'd need to try first-line treatments before a gyne referral.
I recommend going to your GP ask for a pelvic ultrasound, a transabdominal ultrasound and a transvaginal one to see what they find. Not giving children TVs is not completely prohibited, but it is advised against. Sometimes, if sonographers are locum, they may not be certain about the regulations per hospital. Normally, in the referral, the doctor should advise against it to avoid the sonographer refusing. It's no longer the current guidelines, but it is not something they want to jump to for no reason.
Are her symptoms just on her period or elsewhere during the month? Use this a good way to push for further intervention.
Also what symptoms do you say she has, as in all of them? The tiredness is likely low iron, so that can be easily fixed and spotted with a blood test. What symptoms does she have during her period? And if you have symptoms not on your period - what are they? Is the pain worse on or off the period?
If you had a transvaginal and/or pelvic ultrasound, it can normally pick up adenomyosis, endo is common in people with adenonymosis, though not everyone, but is a good way of getting further secondary care intervention.
I recommend asking the GP to try the pill and/ or mirena coil can be amazing with heavy bleeding and pain. You might try different pills first. Yes, they treat the real cause as well (the mirena will may the uterus lining thinner, less bleeding and less cramps), but the pill, will treat symptoms. So definitely try that, sometimes the progesterone only pill (mini-pill) can be better for some. Essentially, it mimics the luteal phase, which stops estrogen secretion and prevents further tissue growth.
Also ask your GP for mefenamic acid and/or naproxen (NSAIDs which help a lot) and tranexamic acid (helps reduce heavy bleeding) - she needs to start taking it days before your period starts so that it can work at best capacity. The same with ibuprofen and/or paracetamol. Start taking it 3/4 days before and it will be much better.
She will need to try NSAIDs and mirena/pill and Tranexamic acid first before any further scans like ultrasound and MRI. In terms of a gyne referral, she will have needed to be on the pill or mirena for around 9 months, otherwise they can and often do reject the referral, as in the consultant will just write back to GP to use it for 9 months and if it doesn't work, re-refer, gyne in secondary care is overwhelemed and so I'd try all these meds first otherwise its likely a wasted referral.
Then if ultrasounds pick up on anything (pelvic ultrasound or transvaginal) you may need to have an MRI to see endometriosis. However, the only way for definite diagnosis is a laparoscopy and then they will often excise the endometriosis tissue if they find it etc. But endometriosis is a chronic illness and cannot be cured, after surgery it will grow back, it cannot be excised from everywhere to leave organ functioning intact and then post-surgery adhesions often form.
The main symptom of endometriosis is not actually period pain because endo is not a period condition - it's a whole body inflammatory condition where the endometriosis tissue even produces its own oestrogen and the pain is felt throughout the month not just when on your period. Often endometriosis on the ovaries can form cysts containing old blood called endometriomas (also known as chocolate cysts) which can be very painful. Another popular cyst is a haemorrhagic ovarian cyst with endometriosis.
But she could also have adenomyosis where the lining of the womb grows into the muscle of it, but unlike endo is localised to the uterus only - is normally spotted on a transvaginal scan or definitely MRI as its more about the uterus muscle, so more easy to see. Thus, symptoms are mainly a week or two, before a period and during your period. Main endo symptoms:
• Irregular or heavy periods
• Pelvic pain
• Pelvic pain on opening bowels (dyschezia) and wider gastrointestinal symptoms (diarrhoea and constipation)
• Pelvic pain on passing urine (dysuria) and bladder symptoms sometimes
• Referred pain to the tops of the legs or back
• Fatigue
Crucially, you can still have endo even if they don't see it on the scan, the only clear way for diagnosis is a diagnostic laparoscopy and then management can look like pain medication, depending on how severe your pain and symptoms are (can be opioids, NSAIDs) and contraception and hormonal treatments (gonadotropin-releasing hormones).
The links below have much more detailed and useful information.
https://www.leedsth.nhs.uk/patients/resources/endometriosis-2/
https://www.nhs.uk/conditions/adenomyosis/
The stages of endometriosis are actually about how it impacts your fertility - so a higher stage has more impact on fertility but not pain. So a person with stage 1 endo could be disabled by it and have severe complications, but a person with stage 4 may not, so don't let them only focus on that. None of this is fair, but if you know the regulations, then you can 'easily' get through the system, because everything will meet the criteria, that's what I'd advise you to do, to get the quickest care. Maybe ask reception if there is a GP with a special interest in women's health as they often are much better.