A single copy of this article may be reprinted for personal, noncommercial use only.
Chronic pelvic pain in womenBy Mayo Clinic staff
Original Article: http://www.mayoclinic.com/health/chronic-pelvic-pain/DS00571
Pelvic pain in women refers to pain in the lowest part of your abdomen and pelvis. If asked to locate your pain, you might sweep your hand over that entire area rather than point to a single spot. Chronic pelvic pain is pain in your pelvic region — the area below your bellybutton and between your hips — that lasts six months or longer.
Chronic pelvic pain can be a symptom of another disease, or it can be a condition in its own right. The cause of chronic pelvic pain is often hard to find. If the source of your chronic pelvic pain can be found, treatment focuses on that cause.
Some women never receive a specific diagnosis that explains their pain. But that doesn't mean your pain isn't real and treatable. If no cause can be found, treatment focuses on managing the pain.
Chronic pelvic pain has many different characteristics. Signs and symptoms may include:
- Severe and steady pain
- Pain that comes and goes (intermittent)
- Dull aching
- Sharp pains or cramping
- Pressure or heaviness deep within your pelvis
In addition, you may experience:
- Pain during intercourse
- Pain while having a bowel movement or urinating
- Pain when you sit for long periods of time
Your discomfort may intensify after standing for long periods and may be relieved when you lie down. The pain may be mild and annoying, or it may be so severe that you miss work, can't sleep and can't exercise.
When to see a doctor
With any chronic pain problem, it can be difficult to know when you should go to the doctor. In general, make an appointment with your doctor if your pelvic pain disrupts your daily life or if your symptoms seem to be getting worse.
Several conditions may be the source of chronic pelvic pain. Sometimes, chronic pelvic pain may develop for no apparent reason and without any definitive source or cause. In addition, psychological factors may contribute to your pain. The emotional distress that may result from dealing with pain that has no good explanation over a long period of time often in itself makes the pain feel worse.
Some causes of chronic pelvic pain include:
- Endometriosis. This is a condition in which tissue from the lining of your womb (uterus) grows outside your uterus. These deposits of tissue respond to your menstrual cycle, just as your uterine lining does — thickening, breaking down and bleeding each month as your hormone levels rise and fall. Because it's happening outside your uterus, the blood and tissue can't exit your body through your vagina. Instead, they remain in your abdomen, where they may lead to painful cysts and fibrous bands of scar tissue (adhesions).
- Tension in your pelvic floor muscles. Spasms or tension of the pelvic floor muscles can lead to recurring pelvic pain.
- Chronic pelvic inflammatory disease. This can occur if a long-term infection, often sexually transmitted, causes scarring that involves your pelvic organs.
- Ovarian remnant. During a complete hysterectomy — surgical removal of the uterus, ovaries and fallopian tubes — a small piece of ovary may accidentally be left inside and later develop painful cysts.
- Fibroids. These noncancerous uterine growths may cause pressure or a feeling of heaviness in your lower abdomen. They rarely cause sharp pain unless they become deprived of a blood supply and begin to die (degenerate).
- Irritable bowel syndrome. Symptoms associated with irritable bowel syndrome — bloating, constipation or diarrhea — can be a source of uncomfortable pelvic pain and pressure.
- Painful bladder syndrome (interstitial cystitis). This condition is associated with chronic inflammation of your bladder and a frequent need to urinate. You may experience pelvic pain as your bladder fills, which may improve temporarily after you empty your bladder.
- Psychological factors. Depression, chronic stress or a history of sexual or physical abuse may increase your risk of chronic pelvic pain. Emotional distress makes pain worse, and living with chronic pain contributes to emotional distress. These two factors often get locked into a vicious cycle.
- Pelvic congestion syndrome. Some doctors believe enlarged, varicose-type veins around your uterus and ovaries may result in pelvic pain. However, other doctors are much less certain that pelvic congestion syndrome is a cause of pelvic pain because most women with enlarged veins in the pelvis have no associated pain.
Preparing for your appointment
You're likely to start by seeing your family doctor or a doctor who specializes in conditions affecting the female reproductive tract (gynecologist). Depending on the suspected cause of your pain, he or she may refer you to a specialist in digestive system problems (gastroenterologist), a specialist in urinary and gynecologic problems (urogynecologist) or a specialist in musculoskeletal pain (physiatrist or physical therapist).
What you can do
To prepare for your appointment:
- Make a list of any signs and symptoms you're experiencing. Include any that may seem unrelated to the reason for your appointment.
- Make a note of key medical information. Include any major stresses or recent life changes.
- Make a list of all medications and the doses. Include any prescription and nonprescription drugs, vitamins or other supplements you're taking.
- Consider taking a family member or friend along. Sometimes it can be difficult to remember all the information provided during an appointment. Someone who goes with you may remember something that you missed or forgot.
- Prepare questions. Your time with your doctor is limited, so preparing a list of questions can help you make the most of your time together.
Some basic questions to ask your doctor include:
- What are the possible causes of my symptoms or condition?
- What tests do you recommend?
- If these tests don't pinpoint the cause of my symptoms, what additional tests will you schedule?
- What approach will you recommend if we can't locate an underlying cause?
- What types of treatments are most likely to improve my symptoms?
- How long will I need to be treated?
- How long might it take for me to feel better?
- Are there any restrictions that I need to follow?
- Should I see a specialist?
- Is there a generic alternative to the medicine you're prescribing?
- Are there any brochures or other printed material that I can have? What websites do you recommend?
In addition to the questions you've prepared in advance, don't hesitate to ask questions during your appointment at any time that you don't understand something.
What to expect from your doctor
Your doctor will likely ask you a number of questions. Being ready to answer them may leave extra time to go over any points you'd like to have clarified. Your doctor may ask:
- When did you first begin experiencing pelvic pain?
- Has your pain changed or spread over time?
- How often do you experience pelvic pain?
- How severe is your pain, and how long does it last?
- Where is your pain located? Does it always occur in one place?
- How would you describe your pain?
- Does your pain come in waves or is it constant?
- Do you feel pain during urination or a bowel movement?
- Does your menstrual cycle affect your pain?
- Does anything make your pain better or worse?
- Does your pain limit your ability to function?
- Have you recently felt down, depressed or hopeless?
- Have you ever had pelvic surgery?
- Have you ever been pregnant?
- Have you ever been treated for a urinary tract or vaginal infection?
- Have you ever been touched against your will?
- What treatments have you tried so far for this condition? How have they worked?
- Are you currently being treated or have you recently been treated for any other medical conditions?
Tests and diagnosis
Figuring out what's at the root of your chronic pelvic pain often involves a process of elimination because many different disorders can cause pelvic pain. In addition to a detailed interview about your pain, your personal health history and your family history, your doctor may ask you to keep a journal of your symptoms.
Possible tests or exams your doctor might suggest include:
- Pelvic exam. This can reveal signs of infection, abnormal growths or tense pelvic floor muscles. Your doctor checks for areas of tenderness and changes in sensation. Let your doctor know if you feel any pain during this exam, especially if the pain is similar to the discomfort you've been experiencing.
- Cultures. Lab analysis of cell samples from your cervix or vagina can detect infections, such as chlamydia or gonorrhea.
- Ultrasound. This test uses high-frequency sound waves to produce precise images of structures within your body.
- Other imaging tests. Your doctor may recommend abdominal X-rays, computerized tomography (CT) scans or magnetic resonance imaging (MRI) to help detect abnormal structures or growths.
- Laparoscopy. During laparoscopy, your doctor makes a small incision in your abdomen and inserts a thin tube attached to a small camera (laparoscope). The laparoscope allows your doctor to view your pelvic organs and check for abnormal tissues or signs of infection in your pelvis. This procedure is especially useful in detecting endometriosis and chronic pelvic inflammatory disease.
Finding the underlying cause of chronic pelvic pain can be a long process, and in some cases, a clear explanation may never be found. With patience and open communication, however, you and your doctor can develop a treatment plan that helps you live a full life with minimal discomfort.
Treatments and drugs
If your doctor can pinpoint a specific cause, your treatment will focus on eliminating that cause. However, if the cause of your pelvic pain can't be found, treatment will focus on managing your pain.
Depending on the cause, your doctor may recommend a number of medications to treat your condition, such as:
- Pain relievers. Over-the-counter pain remedies, such as aspirin, ibuprofen (Advil, Motrin IB, others) or acetaminophen (Tylenol, others), may provide partial relief from your pelvic pain. Sometimes a prescription pain reliever may be necessary. Pain medication alone, however, rarely solves the problem of chronic pain.
- Hormone treatments. The days when you have pelvic pain may coincide with a particular phase of your menstrual cycle and the hormonal changes that control ovulation and menstruation. Birth control pills or other hormonal medications may help relieve cyclic pelvic pain.
- Antibiotics. If an infection is the source of your pain, your doctor may prescribe antibiotics.
- Antidepressants. Certain types of antidepressants can be helpful for a variety of chronic pain syndromes. Tricyclic antidepressants, such as amitriptyline, nortriptyline (Pamelor) and others, seem to have pain-relieving as well as antidepressant effects. They may help improve chronic pelvic pain even in women who don't have depression.
Your doctor may recommend specific therapies or procedures as a part of your treatment for chronic pelvic pain. These may include:
- Physical therapy. Applications of heat and cold to your abdomen, stretching exercises, massage and other relaxation techniques may improve your chronic pelvic pain. Your doctor might also recommend exercises to strengthen your pelvic floor muscles. A physical therapist can assist you with these therapies and help you develop coping strategies for the pain. Sometimes physical therapists target specific points of pain using transcutaneous electrical nerve stimulation (TENS), in which electrodes deliver electrical impulses to nearby nerve pathways, or by teaching biofeedback, a technique that helps you identify areas of tight muscles so you can learn to relax those areas.
- Neurostimulation (spinal cord stimulation). This treatment involves implanting a device that blocks nerve pathways so the pain signal can't reach the brain. It may be helpful, depending on the cause of your pelvic pain.
- Trigger point injections. If your doctor finds a specific point where you feel pain, you may benefit from direct injection of a numbing medicine into a painful spot (trigger point). The medicine, usually a long-acting local anesthetic, can block pain and ease discomfort.
- Counseling. Your pain could be intertwined with depression, sexual abuse, a personality disorder, a troubled marriage or a family crisis. Getting help for psychological, social, spiritual and emotional challenges may be an essential part of your treatment plan.
To correct an underlying problem that causes chronic pelvic pain, your doctor may recommend a surgical procedure, such as:
- Laparoscopic surgery. If you have endometriosis, doctors can remove the adhesions or endometrial tissue using laparoscopic surgery. During laparoscopic surgery, your surgeon inserts a slender viewing instrument (laparoscope) through a small incision near your navel and inserts instruments to remove endometrial tissue through one or more additional small incisions.
- Hysterectomy. Relatively rarely, your doctor might recommend a hysterectomy and bilateral oophorectomy — surgery to remove your uterus and ovaries. Removing the ovaries deprives endometriosis of estrogen, which it needs in order to grow. Hysterectomy and oophorectomy may be an option for certain causes of pelvic pain in women past childbearing age, but usually isn't recommended.
Pain rehabilitation programs
You may need to try a combination of treatment approaches before you find what works best for you. If appropriate, you might consider entering a pain rehabilitation program. These types of programs, such as the Pain Rehabilitation Center at Mayo Clinic, typically provide a team approach to treatment, including medical and psychiatric aspects.
Lifestyle and home remedies
One frustrating aspect of chronic pain is that it can have a major impact on your daily life. When pain strikes, you may have trouble sleeping, exercising or performing physical tasks.
Anxiety and stress may worsen chronic pain. Effective stress management techniques not only help reduce your stress levels but also may help ease stress-triggered pain. Use or learn strategies for managing stress, such as:
- Practicing meditation
- Using simple deep breathing
- Increasing physical activity and exercise
- Getting enough sleep
Some types of alternative and complementary therapies may reduce pain associated with certain medical conditions. Ask your doctor if you should consider trying these approaches, and whether he or she can recommend a trusted practitioner.
Depending on your medical history, life situation and test results, your doctor may be able to tell you how likely these therapies are to relieve your symptoms. He or she can also let you know about any potential risks based on your personal health history. Examples of therapies include:
- Relaxation techniques. Deep breathing and, in some cases, targeted stretching exercises for the pelvic region might help minimize bouts of pain when they occur.
- Acupuncture. During acupuncture treatment, a practitioner inserts tiny needles into your skin at precise points. Pain relief may come from the release of endorphins, your body's natural painkillers, but that's only one of many theories about how acupuncture works. It's generally considered a safe treatment. Acupuncture is used for treating many types of chronic pain. However, its effectiveness in treating pelvic pain is uncertain.
- Howard F. Causes of chronic pelvic pain in women. http://www.uptodate.com/home. Accessed April 7, 2013.
- Howard F. Treatment of chronic pelvic pain in women. http://www.uptodate.com/home. Accessed April 7, 2013.
- Gallenberg MM (expert opinion). Mayo Clinic, Rochester, Minn. April 19, 2012.
- Rakel RE. Textbook of Family Medicine. 8th ed. Philadelphia, Pa.: Saunders Elsevier; 2011. http://www.mdconsult.com/das/book/body/191205553-4/0/1481/0.html#. Accessed April 7, 2013.
- Chronic pelvic pain. The American Congress of Obstetricians and Gynecologists. http://www.acog.org/~/media/For%20Patients/faq099.pdf?dmc=1&ts=20130418T1809515975. Accessed April 18, 2013.
- Howard F. Evaluation of chronic pelvic pain in women. http://www.uptodate.com/home. Accessed April 7, 2013.
- Interstitial cystitis/painful bladder syndrome. National Kidney and Urologic Diseases Information Clearinghouse. http://kidney.niddk.nih.gov/kudiseases/pubs/interstitialcystitis/index.htm. Accessed April 7, 2013.
- Carinci AJ. Complementary and alternative treatments for chronic pelvic pain. Current Pain and Headache Reports. 2013;17:316.
- Stones W, et al. Interventions for treating chronic pelvic pain in women. Cochrane Database of Systematic Reviews. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000387/abstract. Accessed April 7, 2013.
- Relaxation techniques for health: An introduction. National Center for Complementary and Alternative Medicine. http://nccam.nih.gov/sites/nccam.nih.gov/files/relaxation_introduction.pdf.Accessed April 14, 2013.
- Noncyclic chronic pelvic pain therapies for women: Comparative Effectiveness Review No. 41. AHRQ Publication No. 11(12)-EHC088-EF. https://www.ncbi.nlm.nih.gov/books/NBK84586. Accessed April 28, 2013.
- Martinez B. Management of patients with chronic pelvic pain associated with endometriosis refractory to conventional treatment. Pain Practice. 2013;13:53.
- George SE, et al. Physical therapy management of female chronic pelvic pain: anatomic considerations. Clinical Anatomy. 2013;26:77.
- 14. Kotarinos RK. Pelvic floor physical therapy for management of myofascial pelvic pain syndrome in women. http://www.uptodate.com/home. Accessed April 8, 2013.
- Hunter C, et al. Neuromodulation of pelvic visceral pain: Review of the literature and case series of potential novel targets for treatment. Pain Practice. 2013;13:3.
- Acupuncture for pain. National Center for Complementary and Alternative Medicine. http://nccam.nih.gov/health/acupuncture/acupuncture-for-pain.htm. Accessed April 14, 2013.