Chronic pelvic pain
Filed under: Women's Health
Chronic pelvic pain refers to pain in your pelvic region — below your
bellybutton and between your hips — lasting six months or longer. If
asked to locate your pain, you might sweep your hand over that entire
area rather than point to one spot. Chronic pelvic pain can be a symptom
of another disease, or it can be designated as a condition in its own
The cause of chronic pelvic pain is often hard to find. Like many women,
you may never receive a specific diagnosis that explains your pain. But
that doesn't mean your pain isn't real and treatable.
If the source of your chronic pelvic pain is found, treatment focuses on
that cause. If no cause can be found, treatment for chronic pelvic pain
focuses on managing the pain.
Chronic pelvic pain exhibits many different characteristics. Among the signs and symptoms are:
* 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
* Pain when you sit down
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 gynecologic problems may be the source of chronic pelvic pain.
However, other diseases can cause pelvic pain, such as irritable bowel
syndrome and interstitial cystitis. In addition, psychological factors
may contribute to your pain.
Some of the more common causes of chronic pelvic pain include:
* Endometriosis. This is a condition in which tissue from your
uterine lining (endometrium) 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 and become
trapped in your abdomen. This can lead to painful cysts and adhesions
(fibrous bands of scar tissue).
* 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 involving your
* Pelvic congestion syndrome. This condition may be caused by enlarged, varicose-type veins around your uterus and ovaries.
* Ovarian remnant. During a complete hysterectomy — surgical removal
of the uterus, ovaries and fallopian tubes (salpingo-oophorectomy) — a
small piece of ovary may be left inside, which can later develop tiny,
* Fibroids. These noncancerous uterine growths may cause pressure or
a feeling of heaviness in your lower abdomen. They rarely cause sharp
(acute) pain unless they become deprived of nutrients and begin to die
* Irritable bowel syndrome. Symptoms associated with irritable bowel
syndrome — bloating, constipation or diarrhea — can be a source of
uncomfortable pelvic pain and pressure.
* Interstitial cystitis. Chronic inflammation of your bladder and a
frequent need to urinate characterize interstitial cystitis. You may
experience pelvic pain as your bladder fills, which may improve
temporarily after emptying your bladder.
* Psychological factors. If you are depressed, experience chronic
stress or have been sexually or physically abused, you may be more
likely to experience chronic pelvic pain. Emotional distress makes pain
worse, and likewise living with chronic pain makes emotional distress
worse. So chronic pain and emotional distress frequently get locked into
a vicious cycle.
Preparing for your appointment
You're likely to start by first seeing your family doctor or primary
care provider. However, in some cases when you call to set up an
appointment you may be referred immediately to a doctor who specializes
in conditions affecting the female reproductive tract (gynecologist).
Here's some information to help you prepare for your appointment and what to expect from your doctor.
What you can do
* Be aware of any pre-appointment restrictions. At the time you make
the appointment, be sure to ask if there's anything you need to do in
advance to prepare for common diagnostic tests.
* Write down any symptoms you're experiencing, including any that
may seem unrelated to the reason for which you scheduled the
appointment. For example, if you've been feeling blue or stressed, this
is important information to share with your doctor.
* Write down key personal information, including any recent changes
or difficulties in your life. It will help your doctor to know if you've
been going through struggles in your marriage or other family
relationships. These psychological challenges can play a very real role
in your physical well-being.
* Make a list of your key medical information, including any other
conditions for which you're being treated and the names of any
medications, vitamins or supplements you're taking.
* Take a family member or friend along, if possible. Sometimes it
can be difficult to soak up all the information provided to you during
an appointment. Someone who accompanies you may remember something that
you missed or forgot.
* Write down questions to ask your doctor. Creating your list of
questions in advance can help you make the most of your time with your
For chronic pelvic pain, some basic questions to ask your doctor include:
* What are the possible causes of my symptoms or condition?
* What tests do you recommend now?
* 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?
* For 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? What will that cost, and will my insurance cover seeing a specialist?
* Is there a generic alternative to the medicine you're prescribing me?
* Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?
In addition to the questions that you've prepared to ask your doctor,
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 is likely to ask you a number of questions. Being ready to
answer them may reserve time to go over any points you want to spend
more time on. 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?
* Would you describe your pain as sharp or dull?
* Does your pain come in waves or is it constant?
* Can you anticipate when the pain is coming?
* Is your pain usually triggered by a specific event, such as intercourse or exercise?
* 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? For example, have you ever had to miss school or work because of your pain?
* Is your pain causing difficulty in your marriage or other important personal relationships?
* Have you recently felt down, depressed or hopeless?
* Have you recently lost interest in things you once enjoyed?
* 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 do you think is causing your pain?
* 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?
What you can do in the meantime
While you're waiting for your appointment, you may find some relief by
using over-the-counter pain relievers, such as aspirin, ibuprofen
(Advil, Motrin, others) or acetaminophen (Tylenol, others). Try to use
relaxation and stress-reduction techniques that have worked for you in
the past, such as exercise, meditation or simple deep breathing.
Activities that reduce psychological tension are also likely to reduce
Finding the underlying cause of chronic pelvic pain can be a long
process, and in many cases, a clear explanation may never be found.
However, with patience and open communication with your doctor, you will
be able to develop a treatment plan that helps you live a full life
with minimal discomfort.
Tests and diagnosis
Figuring out what's at the root of your chronic pelvic pain often
involves a process of elimination, because numerous disorders could be
responsible. 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 examination. This can reveal signs of infection, abnormal
growths or tense pelvic floor muscles. Your doctor will check for areas
of tenderness and changes in sensation. This pelvic examination may be
more extensive than what you're used to during a routine gynecologic
examination. It's important to 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. Samples can be taken from your cervix or vagina to check
for infection, including sexually transmitted diseases, such as
chlamydia, herpes and gonorrhea.
* Laparoscopy. Using a thin tube attached to a small camera
(laparoscope), your doctor (gynecologist) checks for abnormal tissues or
signs of infection in your pelvis. This is especially useful in
detecting endometriosis and chronic pelvic inflammatory disease.
* Imaging studies. Your doctor may use ultrasound, abdominal X-rays
and computerized tomography (CT) and magnetic resonance imaging (MRI)
scans to help detect abnormal structures or growths.
Treatments and drugs
If your doctor can pinpoint a specific underlying cause, your treatment
will focus on eliminating that particular cause. However, if no cause
for your pelvic pain can be found, your treatment goals will focus on
managing your pain.
Possible treatments for chronic pelvic pain include:
* Pain relievers. Over-the-counter pain remedies, such as aspirin,
ibuprofen (Advil, Motrin, others) or acetaminophen (Tylenol, others),
may provide partial relief from your pelvic pain. Sometimes a
prescription pain reliever may be prescribed, but rarely will a
medication be the sole solution for chronic pain.
* Hormone treatments. Some causes of pelvic pain have a cyclical
pattern, meaning that they're tied to your menstrual cycles and the
hormones your body produces. You may tend to feel the pain at certain
times of the month rather than on a daily basis. Using 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. Antidepressants can be helpful for a variety of
chronic pain syndromes. Tricyclic antidepressants, such as
amitriptyline, nortriptyline (Aventyl, 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.
* Physical therapy. Applications of heat and cold to your abdomen,
stretching exercises, massage and other relaxation techniques, or
transcutaneous electrical nerve stimulation (TENS) therapy 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 can help you develop coping strategies for
* Counseling. Your pain could be intertwined with a serious
psychological or social problem stemming from such factors as
depression, sexual abuse, a personality disorder, a troubled marriage,
difficulty in maintaining relationships or a family crisis, for example.
Getting help for psychological, social, spiritual and emotional
challenges may be an essential part of your treatment plan.
* Trigger point injections. If your doctor finds a specific point
where you feel pain, a possible treatment option is the direct injection
of a numbing medicine into a painful spot (trigger point). The
medicine, usually a long-acting local anesthetic, can block pain and
* Nerve separation (ablation). Sometimes the source of chronic
pelvic pain is linked to complex pathways in your neurological system.
Procedures to control the pain impulses sent to or from your pelvic
region might reduce or stop the pain. Such procedures include removing
(excising) targeted nerves, injecting a medicine into the nerve to block
its sensitivity, or using heat or a laser to destroy nerve tissue.
* Surgery. Your doctor might recommend surgery to correct certain
underlying problems. For instance, pelvic adhesions or endometriosis
deposits can be removed by laparoscopic surgery. In laparoscopic
surgery, your surgeon performs the operation through several small
incisions in your abdominal wall, using instruments with an attached
camera. As a last resort, your doctor might recommend a hysterectomy.
Hysterectomy may be an option for certain causes of pelvic pain.
You will often need to try a combination of treatment approaches before you find what works best for you.
Lifestyle and home remedies
One of the more frustrating aspects of chronic pain is that it can have a
strong impact on your daily life. When pain strikes, you may have
trouble sleeping, exercising or performing physical tasks, and you may
withdraw from social situations because of the pain.
Self-care measures to bolster your emotional and mental health may ease your discomfort:
* Emotional support. Chronic pain can trigger some intense, negative
emotions, such as pain, grief and anger, which can affect your
self-esteem and your relationships with others. Admit your feelings to
yourself and others — to supportive family members and friends, as well
as to your doctor. Acknowledging and talking about your feelings is the
first step toward improved emotional health. Keep your family in the
loop on the nature of your problem, what treatments might be advised and
what to expect down the road.
* Stress management. Becoming too anxious or stressed over certain
situations may exacerbate chronic pain. Effective stress management
techniques not only help reduce your stress levels, but may also have
the indirect effect of easing stress-triggered pain.
Several types of alternative therapies may reduce pain associated with
certain medical conditions. Ask your doctor whether you should consider
trying these approaches, and whether he or she can recommend a trusted
Depending on the underlying cause of your chronic pelvic pain, if it's
known, your doctor may be able to tell you how likely these alternative
therapies are to relieve your symptoms. He or she also can let you know
about any potential risks based on your personal health history.
* Relaxation techniques. Deep breathing and targeted stretching
exercise for your pelvic region could help minimize bouts of pain when
* Biofeedback. This alternative therapy is based on the idea,
confirmed by scientific studies, that you can use your mind to control
your body. Working with a biofeedback therapist, you'll use special
monitoring equipment that beeps or flashes when your body is sending
cues that pain is on the way. As you recognize these cues, you can train
your body to respond differently and decrease the sensation of pain.
* 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 how
this method works isn't known for sure. Acupuncture isn't safe if you're
taking blood thinners or if you have low blood counts.
* Transcutaneous electrical nerve stimulation (TENS). This approach
may help improve localized or regional pain. During TENS therapy,
electrodes deliver electrical impulses to nearby nerve pathways — which
can help control or relieve some types of pain.