Chronic Female Pelvic Pain

Topic Overview

Is this topic for you?

This topic focuses on pelvic pain that has lasted longer than 6 months. If you have new, sudden pelvic pain, see your doctor as soon as you can. To learn more about new pelvic pain, see the topic Abdominal Pain, Age 12 and Older.

What is chronic female pelvic pain?

Female pelvic pain is pain below a woman's belly button. It is considered chronic (which means long-lasting) if you have had it for at least 6 months, and it's not related to pregnancy. The type of pain varies from woman to woman. In some women, it is a mild ache that comes and goes. In others, the pain is so steady and severe that it makes it hard to sleep, work, or enjoy life.

If your doctor can find what's causing the pain, treating the cause may make the pain go away. If no cause is found, your doctor can help you find ways to ease the pain and get back your quality of life.

What causes chronic female pelvic pain?

Some common causes include:

Problems of the reproductive system, such as:
Scar tissue (adhesions) in the pelvic area after an infection or surgery.
Diseases of the urinary tract or bowel, such as:
- Irritable bowel syndrome.
- Chronic bladder irritation.
Problems with the muscles, joints, and ligaments in the pelvis, lower back, or hips.

Doctors don't really understand all the things that can cause chronic pelvic pain. So sometimes, even with a lot of testing, the cause remains a mystery. This doesn't mean that there isn't a cause or that your pain isn't real.

Sometimes, after a disease has been treated or an injury has healed, the affected nerves keep sending pain signals. This is called neuropathic pain. It may help explain why it can be so hard to find the cause of chronic pelvic pain.

What are the symptoms?

The type of pain can vary widely and may or may not be related to menstrual periods. Chronic pelvic pain can include:

Pain that ranges from mild to severe.
Pain that ranges from dull to sharp.
Severe cramping during periods.
Pain during sex.
Pain when you urinate or have a bowel movement.
Pain in certain postures or positions.

Chronic pain can make it hard to sleep, work, or enjoy life. It can lead to depression. Depression can cause you to feel sad or hopeless, eat and sleep poorly, and move slowly.

How is chronic female pelvic pain diagnosed?

At your first visit, your doctor will do a complete pelvic examination to look for problems with your reproductive system. The doctor will also ask questions about your past and present health and about your symptoms. You may have some tests, such as:

Blood and urine tests to look for signs of infection.
A pregnancy test.
Tests for sexually transmitted infections (STIs).

Emotional issues can play a big role in chronic pain. Your doctor may ask questions to find out if depression or stress is adding to your problem. You may also be asked about any past or current sexual or physical abuse. It can be hard to talk about these things, but it's important to do it so you can get the right treatment.

If the first tests don't find a cause, you may have other tests that show pictures of the organs in your belly. These may include:

You may also have a type of minor surgery called laparoscopy (say "lap-uh-ROS-kuh-pee"). In this surgery, the doctor puts a thin, lighted tube with a tiny camera through a small cut in your belly. This lets the doctor look for problems like growths or scar tissue inside your belly.

Finding the cause of pelvic pain can be a long and frustrating process. You can help by keeping notes about the type of pain you have, when it happens, and what seems to bring it on. Show these notes to your doctor. They may give clues about what is causing the problem or the best way to treat it. And whether or not a cause is found, your doctor can suggest treatments to help you manage the pain.

How is it treated?

If your doctor found a problem that could be causing your pelvic pain, you will be treated for that problem. Some common treatments include:

Birth control pills or hormone treatment for problems related to your periods.
Surgery to remove a growth, cyst, or tumour.
Medicine to treat the problem, such as an antibiotic for infection or medicine for irritable bowel syndrome.

Chronic pain can become a medical problem in itself. Whether or not a cause is found, your doctor can suggest treatments to help you manage the pain. You may get the best results from a combination of treatments such as:

Pain relievers called NSAIDs, like ibuprofen (such as Advil or Motrin) or naproxen (such as Aleve). You can buy these over the counter, or your doctor may prescribe stronger ones. These medicines work best if you take them on a regular schedule, not just when you have pain. Your doctor can tell you how much to take and how often. Be safe with medicines. Read and follow all instructions on the label.
Tricyclic antidepressant medicine or anticonvulsants, which can help with pain and with depression.
Cognitive-behavioural therapy or biofeedback, to help you change the way you think about or react to pain.
Counselling, to give you emotional support and reduce stress.
Physiotherapy to help you relax your muscles, improve your posture, and be more active.
Pain relievers that are injected (local anesthetic) into specific areas to help with pain.

You may need to try many treatments before you find the ones that help you the most. If the things you're using aren't working well, ask your doctor what else you can try. Taking an active role in your treatment may help you feel more hopeful.

Cause

Female pelvic pain is typically caused by a medical condition involving the reproductive organs, urinary tract, lower gastrointestinal tract, or nerves or muscles of the abdominal wall, hips, or pelvic floor. Some causes are always short-term (acute), and others can become long-lasting (chronic) unless successfully treated. Sometimes, no cause can be found.

Pain with no known cause

Experts don't yet understand all possible causes of pelvic pain, especially when it has become chronic. So even after a lot of testing, many women never find out the reason for their pain.

One reason might be what's called neuropathic pain. Long after a disease or injury has healed, nerves can continue firing pain signals. This is thought to be caused by an overloading of the nervous system by extreme or long-lasting pain.

Not finding a cause doesn't mean that there isn't one or that there's no possible treatment.

Problems with the reproductive system that can cause chronic pain

Endometriosis
. This is when the tissue lining the inside of the uterus starts growing outside of the uterus.
Adenomyosis
. This is when the lining in the uterus starts growing into the uterine muscle.
Non-cancerous (benign) tumours of the uterus, such as fibroids or polyps.

Physical or sexual abuse

Although the link isn't well understood, past or current abuse is strongly linked to chronic pelvic pain.

Symptoms

Female pelvic pain symptoms can include:

Pain that ranges from mild to severe.
Pain that ranges from dull to sharp.
Severe cramping during periods.
Heavy or irregular vaginal bleeding.
Pain during sex.
Pain when you urinate or have a bowel movement.

Depression symptoms are commonly linked to chronic pain. Signs of depression include:

Sleep problems.
Appetite changes.
Feelings of emptiness and sadness.
Slowed body movements and reactions.

For the best chance of recovery from pain, depression must be treated along with any known physical causes of pain.

What Happens

It can sometimes be hard to know how long pelvic pain will last and how best to treat it. It's a little different for every woman. But in general:

When a cause is found and treated, such as an ovarian cyst, the pain will most likely go away.
When it's hard to find a cause, your doctor can do a number of tests and try certain treatments to see if they work.
Symptoms that are caused by hormone fluctuations often go away without treatment when menopause occurs and the ups and downs of hormone levels settle down.

What Increases Your Risk

Risk factors are things that increase your chances of getting a certain condition or disease. Risk factors for pelvic pain that becomes chronic include:

History of pelvic inflammatory disease.
History of physical or sexual abuse. Women with chronic female pelvic pain are more likely to report abuse in their past.^{footnote 1}
History of radiation treatment or surgery of the abdomen or pelvis. This includes some surgeries for urinary incontinence.
History of depression. Pain and depression seem to be related.
Substance use disorder.
Something abnormal in the structure of the female organs.
Pregnancy and childbirth that put stress on the back and pelvis, such as delivery of a large baby, a difficult delivery, or a forceps or vacuum delivery.

When should you call your doctor?

Call a doctor for immediate care if you have sudden, severe pelvic pain, with or without vaginal bleeding.

Call a doctor if:

Your periods have changed from relatively pain-free to painful.
Pain interferes with your daily activities.
You start to have pain during intercourse.
You have painful urination, blood in your urine, or an inability to control the flow of urine.
You have blood in your stool or a significant, unexplained change in your bowel movements.
You notice any new pelvic symptoms.
You haven't yet seen a doctor about your chronic pelvic pain.

Watchful waiting

Watchful waiting is a period of time during which you and your doctor watch your pelvic pain symptoms without using medical treatment.

During this period, you can keep a daily record of your symptoms and menstrual cycle and any other life events that you consider important. A watchful waiting period may last from a few days to weeks or possibly months.

Who to see

Your family doctor, general practitioner, or nurse practitioner can generally evaluate and help you manage the symptoms of female pelvic pain.

For advanced treatment methods, you may be referred to a gynecologist or a urologist who specializes in female pelvic disorders.

If you have ever been physically or sexually abused, that trauma may be playing a part in your pain. So you'll need to let your doctor know about the abuse. This may be hard for you, but it may be easier if you find a doctor you feel comfortable talking to.

Examinations and Tests

Although your condition may be diagnosed during your first examination, don't be surprised if you need to have a series of medical appointments and tests. For many women who have pelvic pain, diagnosing the cause is a process of elimination that takes a while.

Even if tests don't find any problems, it doesn't mean that there's no physical cause for your chronic pain. Tests aren't yet able to detect all causes.

Initial tests

It's a good idea to make a calendar or diary of your symptoms , menstrual cycle, sexual activity, and physical exertion. And keep track of any other things that you think are important, such as stressful events or illnesses. Bring it with you when you see your doctor.

To begin narrowing down the list of possible causes of your pain, your doctor will review your symptom diary and:

Ask about your health history. This includes the history of your menstrual cycle and any pelvic surgery, radiation treatment, sexually transmitted infection, pregnancy, or childbirth.
Do a pelvic examination to look for signs of abnormalities. You may also have a digital rectal examination. Your doctor may conduct these examinations in a slow, thorough manner, carefully checking for tender areas.

You may also have tests, such as:

A pregnancy test. If your test is positive, you'll also have an ultrasound to check for signs of a tubal pregnancy.
Blood tests, to look for infection, anemia, and other problems.
- Complete blood count.
- Sedimentation rate.
Tests for sexually transmitted infections.
Urine tests, to look for infection and kidney stones.
- Urinalysis.
- Urine culture.
Stool tests, to check for signs of blood.

Further testing

Sometimes more tests are needed. Your doctor may recommend one or more of the following:

Imaging tests (tests that take pictures of the pelvic area), such as:
- Abdominal ultrasound and/or transvaginal ultrasound of the pelvic area using a small ultrasound device inserted into the vagina.
- Intravenous pyelogram, which uses an injected dye combined with X-rays to create pictures of the kidneys, bladder, ureters, and urethra.
- CT scan, which uses X-rays to create pictures of organs and bones.
- MRI, which uses a magnetic field and pulses of radio wave energy to create pictures of organs and bones.
Laparoscopy. This surgical procedure uses a thin, lighted viewing instrument inserted through a small cut in the belly. If needed, scar tissue or a growth can also be removed during the procedure.
Cystoscopy, which uses a viewing instrument inserted through the urethra into the bladder.
Urodynamic studies. In these tests, a catheter is inserted through the urethra into the bladder to check for bladder problems.
Other evaluations:
- For irritable bowel syndrome.
- For abdominal wall "trigger points." These are specific places on your abdomen that cause pain when pressed.

Your mental health

Chronic pain can have a wearing effect on the mind and emotions, which can in turn make harder to manage pain.

Your doctor may recommend a mental health assessment. You'll be asked questions to find out whether such conditions as depression, insomnia, or stress are adding to or being caused by your chronic pain.

For the best chance of recovering from pain, you will need treatment for emotional problems like these, plus treatment for any known physical causes of pain.

Treatment Overview

Treatment for chronic female pelvic pain can be approached in two ways: treating a known, specific cause of the pain or treating the pain itself as a medical condition. When it's possible, your doctor will do both.

Treating a known or suspected cause

Depending on the cause, treatment may include:

Medicine to control or stop the ovulation cycle. This is done if cyclic hormonal changes seem to make your symptoms worse.
Medicines to treat other diseases, such as an antibiotic for infection or medicine for irritable bowel syndrome.
Cognitive-behavioural therapy, counselling, or biofeedback to treat depression or other mental health problems.
Surgery to remove painful growths, cysts, or tumours.
Healthy lifestyle choices, such as regular exercise to manage stress and improve strength, mood, and general health, along with dietary changes, such as those recommended to manage irritable bowel syndrome.

Treating the pain itself

Finding a treatment that works may take a while. It's common for women to try many treatments before finding one or more that help.

Medicines that may help manage your pain include:

Non-steroidal anti-inflammatory drugs (NSAIDs). These medicines are the first-choice treatment for relieving pain and inflammation. They work well for menstrual pain. Be safe with medicines. Read and follow all instructions on the label.
Medicines that control hormone levels, such as birth control pills. They sometimes work well for pain that seems to be caused or made worse by menstruation.
Certain antidepressant medicines. These are used to treat chronic pain in other areas of the body also.

Counselling and mental skills training, such as cognitive-behavioural therapy, help you manage your pain and the stress that makes it worse. For more information, see Other Treatment.

Alternative pain treatments that may help you manage pain include such things as acupuncture and transcutaneous nerve stimulation (TENS). For more information, see Other Treatment.

If your chronic pain hasn't responded to treatment or seems to have no physical cause, you may have neuropathic pain. This means that your nerves still create pain signals long after an original injury or disease has healed. If your doctor suspects that you have neuropathic pain, he or she may refer you to a pain management clinic for evaluation and treatment.

What to think about

Decisions are complicated when you are considering treatment for chronic pelvic pain. Think about these questions, and talk to your doctor about them:

Are the symptoms bothersome enough to require treatment?
Do you want to have a child or more children?
Has a specific cause of the pain been discovered? Or is the cause unclear?
Is menopause, which may stop symptoms, going to occur soon?
Would an opinion from another doctor be helpful?
Would an opinion from a doctor who specializes in chronic pain be helpful?

If you are close to menopause (usually around age 50) and your symptoms are likely related to hormones, your best option may be home treatment and medicine while you wait for menopause.

The hormone changes of menopause may get rid of your chronic pain, but the pain may come back if you use hormone therapy. If you are nearing menopause, talk with your doctor about your options.

Prevention

Early diagnosis and treatment of pelvic pain may help keep the pain from becoming chronic.

One cause of chronic pelvic pain is pelvic inflammatory disease. You can greatly lower your risk of getting this disease by practicing safer sex. Safer sex includes using condoms and using them correctly.

Home Treatment

You can try these steps at home to ease pelvic pain:

Try non-prescription medicine, such as ibuprofen (for example, Advil or Motrin) or acetaminophen (for example, Tylenol).
Try heat. Put a heating pad, a hot water bottle, or a warm compress on your lower belly, or take a warm bath. Heat improves blood flow and may relieve pain.
For back pain, lie down and elevate your legs by placing a pillow under your knees. When lying on your side, bring your knees up to your chest.
Try relaxation techniques, such as:
Exercise regularly. It improves blood flow, increases pain-relieving endorphins naturally made by the body, and reduces pain.
Try sexual activity, which may relieve pelvic cramping and backache. If your pain is related to endometriosis, though, sex may make the pain worse.

Medications

Medicine won't cure female pelvic pain. But it can help control the pain and keep it from getting worse or becoming chronic. There is no one medicine that works for all women.

Medicines to control hormones

Birth control pills are commonly used for menstrual pain. They are also often prescribed for endometriosis-related pain.
High-dose progestin is sometimes prescribed for pain related to endometriosis.
Gonadotropin-releasing hormone agonists can relieve pain from endometriosis by stopping production of the hormones that make endometriosis worse. This treatment may also relieve pelvic pain that comes in cycles but isn't related to endometriosis and pelvic pain related to irritable bowel syndrome. This short-term treatment brings on menopausal symptoms, though, with side effects such as hot flashes and loss of bone density, for as long as you take it.

Medicines to control pain

Prescription non-steroidal anti-inflammatory drugs (NSAIDs), taken on a regular schedule, help relieve pain caused by inflammation or menstruation. If one type doesn't work for you, then your doctor may recommend another.
Tricyclic antidepressant medicines are sometimes used to treat chronic pain in other areas of the body. Limited research suggests that they help relieve chronic pelvic pain in some women.^{footnote 2}
Anticonvulsant medicines such as gabapentin are sometimes used to treat chronic pelvic pain.
Opioid pain medicine is only recommended as a last-resort treatment for severe pelvic pain.

Surgery

Surgery is most likely to help when it's done for a specific condition, such as fibroids or endometriosis.

Hysterectomy, the removal of the uterus, is sometimes used as a last-resort treatment. Depending on the cause, hysterectomy may relieve pain for some women.

Most studies have shown that surgery to remove scar tissue (adhesions) from previous surgery or from pelvic inflammatory disease or endometriosis doesn't relieve pain.^{footnote 3}

With any surgery for chronic pelvic pain, such as hysterectomy or cutting of specific pelvic-area nerves, there is a risk of persistent pain or pain that is worse after surgery. And it can have serious side effects.

Laparoscopy to diagnose chronic pelvic pain may be done before other treatment. Areas of endometriosis or scar tissue may be removed or destroyed during the laparoscopy.

Other Treatment

Chronic pelvic pain takes time to develop and can take a long time to treat. Take charge of how you cope with pain by using one or more of the treatment choices below. Combining your medical treatment with these practices can help you keep a positive state of mind.

Counselling and stress management

Counselling and mental skills training help you learn the mental and emotional tools for managing chronic pain and the stress that makes it worse. Combining medical and psychological treatment increases your chances of treatment success.

Commonly used treatments include:

Cognitive-behavioural therapy focused on changing the way you think about and mentally manage pain. See a psychologist, licensed counsellor, or clinical social worker who specializes in pain management skills.
Biofeedback. This is the conscious control of body function that is normally unconsciously controlled.
Interpersonal counselling, focused on managing your life events, stressors, and relationships.

For more information, see the topic Stress Management.

Physiotherapy

Physiotherapy can help you learn specific exercises to stretch and strengthen certain muscle groups. This helps you to improve posture, gait, and muscle tone.

Alternative pain treatments

Alternative pain treatments for chronic female pelvic pain aren't well-studied. But they are considered helpful for managing stress and building mental mastery over pain.

Acupuncture and transcutaneous nerve stimulation (TENS) have shown some success in relieving painful menstrual periods. Acupuncture and TENS have also been used as a treatment for non-menstrual chronic pelvic pain, but it isn't yet well-studied.^{footnote 3}

Other low-risk alternative pain treatments that many people use to help manage pain include:

References

Citations

Andrews J, et al. (2012). Noncyclic Chronic Pelvic Pain Therapies for Women. Comparative Effectiveness Review No. 41 (AHRQ Publication No. 11(12)-EHC088-1). Rockville, MD: Agency for Healthcare Research and Quality. Available online http://www.ncbi.nlm.nih.gov/books/NBK84586.

Rapkin AJ, Nathan L (2012). Pelvic pain and dysmenorrhea. In JS Berek, ed., Berek and Novak's Gynecology, 15th ed., pp. 470–504. Philadelphia: Lippincott Williams and Wilkins.

Andrews J, et al. (2012). Noncyclic Chronic Pelvic Pain Therapies for Women. Comparative Effectiveness Review No. 41 (AHRQ Publication No. 11(12)-EHC088-1). Rockville, MD: Agency for Healthcare Research and Quality. Available online http://www.ncbi.nlm.nih.gov/books/NBK84586.

Credits

Current as of:
July 17, 2020

Author: Healthwise Staff
Medical Review:
Sarah Marshall MD - Family Medicine
Thomas M. Bailey MD - Family Medicine
Kathleen Romito MD - Family Medicine
Adam Husney MD - Family Medicine
Martin J. Gabica MD - Family Medicine
Kirtly Jones MD - Obstetrics and Gynecology
Kevin C. Kiley MD - Obstetrics and Gynecology