Chronic Pelvic Pain

Chronic pelvic pain is pain in the pelvic area that lasts for 6 months or longer. Chronic pelvic pain can disrupt work, physical activity, sexual relations, sleep, or family life. It can also affect your mental and physical health.

Chronic pelvic pain can be caused by a variety of conditions. It can be treated even if a specific injury or disease is not found. In this case, treatment focuses on reducing your pain or lessening its effects on your life.

Pelvic pain may be either acute or chronic.

Acute pain:

• lasts a short time (a few minutes to a few days)

• often has a single cause

• may be a warning of a problem that needs immediate medical care, such as infections, ectopic pregnancy, or an ovarian cyst that has twisted or ruptured (burst)

Chronic pain is more complex:

• It can come and go, or it can be constant. Pain does not have to happen every day for it to be considered chronic.

• It sometimes follows a regular cycle. For example, it may happen or get worse during menstruation.

• It may only happen at certain times, such as before or after eating, with bowel or bladder function, or during sex.

Chronic pelvic pain can happen with 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.

There appears to be a link between chronic pelvic pain and sexual, emotional, or physical trauma. About one-half of all women with chronic pelvic pain have a history of trauma. The reason for this connection is not clear. Mental health conditions can make pain worse. But trauma is rarely the only cause of chronic pelvic pain. Physical causes should always be considered.

Your pain is real even if an injury or disease cannot be found. If you’ve been in pain for a long time, your nerves and brain can start to create pain on their own, even after the condition that caused the pain has gone away. If you have this kind of pain, there are treatments that can help teach your brain to send pain signals in a different way. This can lessen your pain or reduce its effects on your life.

• 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. One cause of dysmenorrhea is high levels of prostaglandins, chemicals made by the lining of the uterus during menstruation. Read more about dysmenorrhea.

• Endometriosis—Endometriosis may be the cause of your pelvic pain if menstrual pain gets worse over time, if the pain lasts beyond the first 1 or 2 days of your period, you have bowel or bladder symptoms that get worse during your period, or if you have pain throughout the month or during sex. Read more about endometriosis.

• Adenomyosis—Adenomyosis is when the endometrium grows into the wall of the uterus. Signs and symptoms may include heavy menstrual bleeding and menstrual pain that worsens with age.

• Fibroids—Fibroids are benign (not cancer) growths that can grow 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. Fibroids attached to the uterus may twist and cause acute pain. 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 painful bladder syndrome, also called interstitial cystitis. It is an inflammation of the bladder wall and lining. Symptoms include pelvic pain, frequent urination, and urinary 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.

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

  • 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. Trigger points in the abdomen, vagina, and lower back may lead to chronic pelvic pain.

Because pelvic pain can have many causes, it is often hard to diagnose. Talk with your obstetrician–gynecologist (ob-gyn) or other 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 if the cause is rooted in a condition.

It may be necessary to see other specialists to help treat your pain, such as a gastroenterologist (a doctor who focuses on digestive problems), urogynecologist (a gynecologist specializing in urinary and related problems), pelvic floor physical therapist, pain specialist, or mental health professional. You may see more than one of these specialists.

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?

• What makes your pain worse or better?

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 (either prescription or nonprescription) or supplements have you tried?

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

Chronic pelvic pain does not have one easy treatment. You may need several kinds of treatment, some of them at the same time. But with time and a good health care team, you can start feeling better.

If the cause of the pain is found, your treatment options can be focused on that cause. It is important to not give up on treatment if a cause is not found. There are many ways to retrain your brain to lessen the effects of pain on your daily life.

If your chronic pelvic pain is caused by a specific condition, you and your health care team may try treating it with medication or surgery:

• 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).

• Endometriosis may also be treated with medications that either block or increase certain types of hormones (such as gonadotropin-releasing hormone [GnRH]).

For some problems, surgery may be done if medications do not work:

• Fibroids and cysts can be removed surgically.

• Endometriosis tissue can sometimes be removed with a special type of laparoscopic surgery.

Some surgeries should only be done if you don’t want to get pregnant in the future:

• Endometrial ablation may be recommended for some health conditions.

• In certain cases, hysterectomy may be a treatment option.

There are several options to treat chronic pelvic pain. They can be used alone or at the same time as other treatment options.

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

• Physical therapy—Pelvic floor physical therapy focuses on desensitizing the muscles linked to chronic pelvic pain. Physical therapy can also address myofascial aspects of pain. Working with a pelvic floor physical therapist can help give you a sense of control over your body. Some types of physical therapy also teach mental techniques for coping with pain, like diaphragmatic breathing, mindfulness exercises, and biofeedback.

• Lifestyle changes—Good posture, regular physical activity, a healthy diet, good sleep habits, and social connections may help reduce pelvic pain. These changes are usually recommended at the same time as other treatments.

• Procedures—Nerve stimulation therapies (neuromodulation) and injections of pain medications or steroids may be useful in treating pain.

• Alternative therapies—Acupuncture and acupressure may be recommended too. Vitamin B1 and magnesium may be used to relieve dysmenorrhea.

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, especially if you have a history of physical or sexual trauma or depression. These experiences may be contributing factors to your pain. In addition, learning techniques that help you relax or manage stress may help retrain your brain to ease pain.

Adenomyosis [ad-uh-noh-my-OH-sis]: A condition that causes the tissue lining the uterus to grow into the muscle wall of the uterus.

Antibiotics: Medications that treat or decrease the risk of certain infections caused by bacteria.

Antidepressants: Medications 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 that holds urine.

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.

Cyst: A sac or pouch filled with fluid.

Cystoscopy [sis-TAH-skuh-pee]: A procedure that looks at the inside of the urethra and bladder.

Depression: Feelings of sadness that last for at least 2 weeks.

Dysmenorrhea [dis-men-uh-REE-uh]: Discomfort and pain during the menstrual period.

Ectopic Pregnancy: A pregnancy in a place other than the uterus, usually in one of the fallopian tubes. An ectopic pregnancy cannot move or be moved to the uterus, so it always requires treatment. 

Endometrial Ablation [en-doh-MEE-tree-uhl uh-BLAY-shuhn]: A minor surgical procedure that destroys the lining of the uterus to stop or reduce menstrual bleeding.

Endometriosis [en-doh-mee-tree-OH-suhs]: A condition that causes tissue that lines the uterus to grow outside of the uterus, usually on the ovaries, fallopian tubes, and other parts of the pelvis.

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

Gonadotropin-Releasing Hormone [goh-nad-uh-TROH-puhn ri-LEE-sing] (GnRH): A hormone made in the brain that tells the pituitary gland when to produce follicle-stimulating hormone (FSH) and luteinizing hormone.

Gynecologist: A doctor and surgeon with special training and education in the female reproductive system. 

Hormones: Substances made in the body that control the function of cells or organs.

Hysterectomy [his-tuhr-REK-tuh-mee]: Surgery to remove the uterus. 

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

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.

Intrauterine Device [in-truh-YOO-tuhr-ruhn] (IUD): A small device that is inserted and left inside the uterus to prevent pregnancy, lighten or stop periods, or reduce the risk of endometrial cancer.

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 [lap-uh-RAH-skuh-pee]: A surgical procedure using a thin, lighted telescope called a laparoscope. The laparoscope is inserted through a small incision (cut) in the abdomen and used to view the pelvic organs. Other long, thin instruments can be used with it to perform surgery.

Menstruation: The shedding of blood and tissue from the uterus that happens monthly except during pregnancy. Also called menstrual periods.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Medications that relieve pain by reducing inflammation. Many types are available over the counter, including ibuprofen and naproxen.

Obstetrician–Gynecologist (Ob-Gyn): A doctor with medical and surgical training and education in the female reproductive system.

Pelvic Exam: A physical examination of the pelvic organs, including the vagina, cervix, uterus, and ovaries. 

Pelvic Inflammatory Disease (PID): An infection of the uterus, fallopian tubes, or ovaries.

Prostaglandins [prah-stuh-GLAN-duhnz]: Chemicals that are made by the body that have many effects, including causing the muscles of the uterus to contract, usually causing cramps.

Sigmoidoscopy [sihg-moy-DAH-skuh-pee]: A screening test to look inside the lower colon with a thin device that is passed through the rectum.

Ultrasound Exam: A test that uses sound waves to examine inner parts of the body. During pregnancy, ultrasound can be used to check the fetus. Also called ultrasonography or sonography.

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

Urinary Urgency: A strong desire to urinate that is difficult to control.

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

Vagina: A tube-like structure surrounded by muscles. The vagina leads from the uterus to the outside of the body