Chronic pelvic pain in women

Chronic pelvic pain is pain in the area below your bellybutton and between your hips that lasts six months or longer.

Chronic pelvic pain can have multiple causes. It can be a symptom of another disease, or it can be a condition in its own right.

If your chronic pelvic pain appears to be caused by another medical problem, treating that problem may be enough to eliminate your pain.

However, in many cases it's not possible to identify a single cause for chronic pelvic pain. In that case, the goal of treatment is to reduce your pain and other symptoms and improve your quality of life.

Symptoms

When asked to locate your pain, you might sweep your hand over your entire pelvic area rather than point to a single spot. You might describe your chronic pelvic pain in one or more of the following ways:

• 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.

Causes

Chronic pelvic pain is a complex condition that can have multiple causes. Sometimes, a single disorder may be identified as the cause.

In other cases, however, pain may be the result of several medical conditions. For example, a woman might have endometriosis and interstitial cystitis, both of which contribute to chronic pelvic pain.

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).
• Musculoskeletal problems. Conditions affecting your bones, joints and connective tissues (musculoskeletal system) — such as fibromyalgia, pelvic floor muscle tension, inflammation of the pubic joint (pubic symphysis) or hernia — 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. After 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 pelvic pain and pressure.
• Painful bladder syndrome (interstitial cystitis). This condition is associated with recurring pain in 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.
• 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.
• 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 become a vicious cycle.

Diagnosis

Figuring out what's causing 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 pain and other symptoms.

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. Let your doctor know if you feel any discomfort during this exam, especially if the pain is similar to the pain you've been experiencing.
• Lab tests. During the pelvic exam, your doctor may order labs to check for infections, such as chlamydia or gonorrhea. Your doctor may also order bloodwork to check your blood cell counts and urinalysis to check for a urinary tract infection.
• Ultrasound. This test uses high-frequency sound waves to produce precise images of structures within your body. This procedure is especially useful for detecting masses or cysts in the ovaries, uterus or fallopian tubes.
• 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 this surgical procedure, 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. 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.

Treatment

The goal of treatment is to reduce symptoms and improve quality of life.

If your doctor can pinpoint a specific cause, treatment will focus on that cause. However, if a cause can't be identified, treatment will focus on managing your pain and other symptoms. For many women, the optimal approach involves a combination of treatments.

Medications

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. Some women find that the days when they have pelvic pain may coincide with a particular phase of their menstrual cycle and the hormonal changes that control ovulation and menstruation. When this is the case, birth control pills or other hormonal medications may help relieve pelvic pain.
• Antibiotics. If an infection is the source of your pain, your doctor may prescribe antibiotics.
• Antidepressants. Some types of antidepressants can be helpful for chronic pain. 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.

Other therapies

Your doctor may recommend specific therapies or procedures as a part of your treatment for chronic pelvic pain. These may include:

• Physical therapy. Stretching exercises, massage and other relaxation techniques may improve your chronic pelvic pain. 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 a medical instrument called transcutaneous electrical nerve stimulation (TENS). TENS delivers electrical impulses to nearby nerve pathways. Physical therapists may also use a psychology technique called biofeedback, which helps you identify areas of tight muscles so that you can learn to relax those areas.
• Neurostimulation (spinal cord stimulation). This treatment involves implanting a device that blocks nerve pathways so that 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 specific points where you feel pain, you may benefit from having a numbing medicine injected into those painful spots (trigger points). The medicine, usually a long-acting local anesthetic, can block pain and ease discomfort.
• Psychotherapy. If your pain could be intertwined with depression, sexual abuse, a personality disorder, a troubled marriage or a family crisis, you may find it helpful to talk with a psychologist or psychiatrist. There are different types of psychotherapy, such as cognitive behavioral therapy and biofeedback. Regardless of the underlying cause of your pain, psychotherapy can help you develop strategies for coping with the pain.

Surgery

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. In rare complicated cases, your doctors may recommend removal of your uterus (hysterectomy), fallopian tubes (salpingectomy) or ovaries (oophorectomy). There are important health consequences to having this procedure. Your doctor will discuss the benefits and risks in detail before recommending this option.

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.

Lifestyle and home remedies

Chronic pain can have a major impact on your daily life. When you're in pain, you may have trouble sleeping, exercising or performing physical tasks.

Chronic pain can also cause anxiety and stress, which in turn may worsen your pain.

Relaxation techniques can help release tension, reduce pain, calm emotions and induce sleep. Many techniques can be learned on your own, such as meditation and deep breathing.

Alternative medicine

Acupuncture

Limited evidence suggests that acupuncture may be helpful for some causes of pelvic pain.

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. Acupuncture is generally considered a safe treatment.

Talk with your doctor if you're considering trying a complementary or alternative therapy.

Preparing for an 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 digestive system specialist (gastroenterologist), a urinary and gynecologic specialist (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 might be necessary?
• 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 have 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?

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