Chronic Pelvic Pain

Chronic pelvic pain is pain in the pelvic area that lasts for 6 months or longer. Chronic pain can come and go, or it can be constant. It does not have to occur every day for it to be considered chronic.

Sometimes chronic pelvic pain follows a regular cycle. For example, it may occur during menstruation. Or it may only occur at certain times, such as before or after eating, while urinating, or during sex.

Chronic pelvic pain can be caused by a variety of conditions. Some of these conditions may not be related to the reproductive organs but to the urinary tract or bowel.

Sometimes there is more than one condition that might be the cause of the pain. Sometimes no cause is found. Not finding a cause does not mean that the pain is not real. Experts agree that with pelvic pain, it is not always possible to pinpoint a specific cause.

• Pelvic inflammatory disease (PID)—PID is an infection of the reproductive organs that may cause both acute and chronic pelvic pain. Symptoms may include abnormal vaginal discharge, fever, and pain in the lower pelvic area. But many cases of PID do not cause any symptoms. Read more about PID.

• Dysmenorrhea (painful periods)—Although mild pain is common during the menstrual period, some women have severe pain that lasts 1 or 2 days a month. One cause of dysmenorrhea is high levels of prostaglandins, chemicals made by the lining of the uterus during menstruation. Read more about dysmenorrhea.

• Endometriosis—If menstrual pain gets worse over time, if the pain lasts beyond the first 1 or 2 days of menstrual flow, or if pain occurs throughout the month or during sex, endometriosis may be the cause. Read more about endometriosis.

• Fibroids—Fibroids are growths that can occur on the inside of the uterus, within the wall of the uterus, or attached to the outside of the uterus by a stalk. They may cause heavier or more frequent menstrual periods. You may feel pain or pressure in the abdomen or lower back. Read more about fibroids.

• Urinary tract problems—Many urinary conditions have been linked to chronic pelvic pain, including kidney stones, repeated urinary tract infections (UTIs), and cancer of the bladder. One of the most common conditions is interstitial cystitis, an inflammation of the bladder wall and lining. Symptoms include pelvic pain, frequent urination, and urgency.

• Digestive system problems—Irritable bowel syndrome (IBS) is one of the most common conditions associated with chronic pelvic pain. Other digestive problems that may cause pelvic pain include inflammatory bowel disease (IBD), diverticulitis (inflammation of a pouch bulging from the wall of the colon), or cancer. Read more about digestive system problems.

• Muscular and skeletal problems:

  • Lower back pain, disk injuries, and pelvic muscle spasms all may cause chronic pelvic pain.

  • Being overweight can strain joints and muscles, including those in the pelvis.

  • Pregnancy can strain ligaments in the pelvis and spine. Pain that starts during pregnancy or right after pregnancy may point to a condition called peripartum pelvic pain syndrome.

  • Poor posture may contribute to pain.

  • Myofascial pain syndrome is a condition in which tender spots in the muscle, called trigger points, cause pain in nearby areas of the body.

There appears to be a link between chronic pelvic pain and sexual or physical abuse. About one half of all women with chronic pelvic pain have a history of abuse. The reason for this connection is not clear.

Depression also appears to be a complicating factor. But it is rarely the sole cause of chronic pelvic pain. Physical causes should always be considered.

Because pelvic pain can have many causes, it’s often hard to diagnose. Talk with your health care professional if you have pain that does not go away.

Tell your health care professional about your medical history. Talk about the pain and its effect on your daily life. You may have a physical exam, including a pelvic exam. Tests may be done to find the cause.

It may be necessary to see other specialists to find out the cause of your pain, such as a gastroenterologist (a doctor who focuses on digestive problems) or urogynecologist (a gynecologist specializing in urinary and related problems).

Your health care professional should ask about the degree and location of the pain. You may be asked the following questions:

• When did the pain start?

• When and how often do you feel it?

• How severe is the pain?

• How does the pain affect your daily life?

You should be asked about your medical and sexual history, including questions about pregnancies and any physical, sexual, or emotional abuse. You may be asked to keep a journal describing the pain.

A record of your pain can help find its cause. You may be asked to keep a pain journal so that more complete information can be gathered. In your pain journal, note the following information:

1. When do you feel pain?

   • Time of day

   • At certain times of your menstrual cycle

   • Before, during, or after the following activities: eating, urination, bowel movement, sex, physical activity, or sleep

2. How would you describe the pain?

   • Is it a sharp stab or a dull ache?

   • Does it come in waves or is it steady?

   • How long does it last?

   • How intense is it?

   • Is it mostly in one place or over a broad area?

   • Is it always in the same place?

   • What makes it better or worse?

3. What medications have you taken?

The tests you need depend on your symptoms and the results of the pelvic exam. You may have lab tests, such as tests of your blood or other tissue. Some of the following imaging tests may be performed:

• Ultrasound exam

• Laparoscopy

• Cystoscopy

• Colonoscopy

• Sigmoidoscopy

If the cause of the pain is found, it can be treated. If a cause is not known, treatment focuses on pain relief. It’s important to not give up on treatment if a cause is not found. There are many ways to lessen or relieve pain or to avoid making it worse.

Chronic pelvic pain that is caused by a specific condition is treated with medication or surgery. For example:

• PID is treated with antibiotics.

• Dysmenorrhea and endometriosis may be managed with birth control pills, the birth control implant, the birth control injection, or the hormonal intrauterine device (IUD). Drugs that stop hormone release may also be used to treat endometriosis.

• For some problems, surgery may be done if medications do not work. Fibroids and cysts can be removed surgically. Endometriosis tissue can also be removed with a special type of laparoscopic surgery. Hysterectomy may be an option.

Several pain-relief measures can be used to treat chronic pelvic pain. They include medications, physical therapy, nutritional therapy, and surgery:

• Lifestyle changes—Good posture, regular exercise, and weight loss may help reduce pelvic pain.

• Medication—Nonsteroidal anti-inflammatory drugs (NSAIDs) are pain relievers that target prostaglandins and are helpful in relieving pelvic pain, especially dysmenorrhea. Other medications, including antidepressants and nerve pain medication, may be recommended.

• Physical therapy—Acupuncture, acupressure, and nerve stimulation therapies may be useful in treating pain caused by dysmenorrhea. Pelvic floor physical therapy focuses on the muscles linked to chronic pelvic pain. Physical therapy that eases trigger points may give relief of muscular pain. Some types of physical therapy teach mental techniques for coping with pain. Such types include relaxation exercises and biofeedback.

• Nutrition therapy—Vitamin B₁ and magnesium may be used to relieve dysmenorrhea.

• Surgery—Pelvic pain that does not respond to other treatments can be relieved by surgery. Cutting or destroying nerves blocks pain signals from reaching tissues and organs.

A type of therapy called cognitive behavioral therapy (CBT) may be helpful. Sex therapy may be helpful too. Sex therapy can help you have sex without pain, feel pleasure from sex, and relieve pelvic pain in general.

If your health care professional suggests counseling, it does not mean that your pain is "all in your head." Counseling may be helpful as part of an overall treatment plan.

Antibiotics: Drugs that treat certain types of infections.

Antidepressants: Drugs that are used to treat depression.

Biofeedback: A technique used by physical therapists to help a person control body functions, such as heartbeat or blood pressure.

Bladder: A hollow, muscular organ in which urine is stored.

Cognitive Behavioral Therapy (CBT): A type of psychotherapy. During CBT, you learn specific skills that help you change the way you think about and cope with problems.

Colonoscopy: An exam of the large intestine using a small, lighted instrument.

Cysts: Sacs or pouches filled with fluid.

Cystoscopy: A test in which the inside of the urethra and bladder are examined.

Dysmenorrhea: Discomfort and pain during the menstrual period.

Endometriosis: A condition in which tissue that lines the uterus is found outside of the uterus, usually on the ovaries, fallopian tubes, and other pelvic structures.

Fibroids: Growths that form in the muscle of the uterus. Fibroids usually are noncancerous.

Gynecologist: A doctor with special training and education in women’s health.

Hormone: A substance made in the body that controls the function of cells or organs.

Hysterectomy: Surgery to remove the uterus.

Inflammation: Pain, swelling, redness, and irritation of tissues in the body.

Intrauterine Device (IUD): A small device that is inserted and left inside the uterus to prevent pregnancy.

Inflammatory Bowel Disease (IBD): The name for a group of diseases that cause inflammation of the intestines. Examples include Crohn’s disease and ulcerative colitis.

Irritable Bowel Syndrome (IBS): A digestive disorder that can cause gas, diarrhea, constipation, and belly pain.

Kidney: An organ that filters the blood to remove waste that becomes urine.

Laparoscopy: A surgical procedure in which a thin, lighted telescope called a laparoscope is inserted through a small incision (cut) in the abdomen. The laparoscope is used to view the pelvic organs. Other instruments can be used with it to perform surgery.

Menstruation: The monthly shedding of blood and tissue from the uterus that happens when a woman is not pregnant.

Pelvic Exam: A physical examination of a woman’s pelvic organs.

Pelvic Inflammatory Disease (PID): An infection of the upper female genital tract.

Prostaglandins: Chemicals that are made by the body that have many effects, including causing the muscles of the uterus to contract, usually causing cramps.

Sigmoidoscopy: A test in which a slender device is placed into the rectum and lower colon to look for cancer.

Ultrasound Exam: A test in which sound waves are used to examine inner parts of the body. During pregnancy, ultrasound can be used to check the fetus.

Urinary Tract Infections (UTIs): Infections in any part of the urinary system, including the kidneys, bladder, or urethra.

Uterus: A muscular organ in the female pelvis. During pregnancy, this organ holds and nourishes the fetus. Also called the womb.