Chronic pelvic pain

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

Chronic pelvic pain can have more than one cause. It may be a symptom of another disease, or it can be a condition in its own right.

If chronic pelvic pain seems to be caused by another health condition, treating that problem may get rid of the pain.

But tests may not be able to find a cause for chronic pelvic pain. In that case, the goal of treatment is to ease pain and other symptoms. That could make your quality of life better.

You may feel chronic pelvic pain in different parts of your pelvic area, rather than in just one spot. You might describe the pain in one or more of the following ways:

• Serious and steady.
• Pain that comes and goes.
• Dull aching.
• Sharp pains or cramping.
• Pressure or heaviness deep within the pelvis.

The pain also may happen:

• During sex.
• While having a bowel movement or urinating.
• When you sit or stand for a long time.

Chronic pelvic pain may be mild. Or it may be so intense that you miss work and can't sleep or exercise.

Other symptoms can include:

• An urgent or frequent need to urinate.
• Bloating.
• Upset stomach.
• Constipation or diarrhea.

When to see a doctor

In general, see your healthcare professional if the pain disrupts your daily life or if your symptoms seem to get worse.

Chronic pelvic pain is a complex health problem. Sometimes, tests may find that a single disease is the cause. In other cases, the pain may stem from more than one medical condition. For example, you might have endometriosis and interstitial cystitis, both of which play a role in chronic pelvic pain.

Some causes of chronic pelvic pain include:

• Endometriosis. This is a disease where tissue that's like the lining of the uterus grows outside the uterus. It may cause pain or infertility.
• Muscle and bone problems. Health issues that affect bones, joints and connective tissues can lead to pelvic pain that keeps coming back. These problems include fibromyalgia, tension in pelvic floor muscles, swelling of the pubic joint or a hernia.
• Nerve injury. Injured or trapped nerves in the pelvis or lower stomach area can lead to ongoing pelvic pain. Nerve problems might happen after surgery in the lower stomach area, such as having a C-section. Or lasting pain could result after injury to a nerve in the pelvis called the pudendal nerve from repetitive activities such as cycling, riding horses or sitting for long periods of time. This condition is called pudendal neuralgia.
• Chronic pelvic inflammatory disease. This can happen if a long-term infection, often spread through sex, causes scarring that involves the pelvic organs.
• Ovarian remnant. After surgery to remove one or both ovaries, a small piece of ovary may be left inside by mistake. Later, this leftover tissue may form painful cysts.
• Fibroids. These growths inside, on or attached to the uterus aren't cancer. But they may cause pressure or a feeling of heaviness in the lower stomach area or lower back. Rarely, they cause sharp pain.
• Irritable bowel syndrome. Symptoms linked with irritable bowel syndrome — bloating, constipation or diarrhea — can be a source of pelvic pain and pressure.
• Painful bladder syndrome. This also is called interstitial cystitis. It's linked with pain in the bladder that keeps coming back. It's also tied to a frequent need to urinate. You may have pelvic pain as your bladder fills. The pain may get better for a while after you empty your bladder.
• Pelvic congestion syndrome. Enlarged, varicose-type veins around the uterus and ovaries can lead to pelvic pain.
• Mental health risk factors. Depression, long-term stress, or a history of sexual or physical abuse may raise your risk of chronic pelvic pain. Emotional distress can make pain worse. And long-term pain can fuel distress. These two factors often become a vicious cycle.

Many conditions are linked to chronic pelvic pain. Having more than one condition that causes pelvic pain, such as endometriosis and fibroids, raises the risk. A history of sexual or physical abuse also may raise the risk.

To figure out what's causing your chronic pelvic pain, your healthcare team asks you about your symptoms. You'll also answer questions about health conditions that you and your blood relatives, such as parents and siblings, have had over the years.

Your care team may ask you to keep a journal of your pain and other symptoms. This can help you describe the effect that the pain has on your daily life.

You also might need tests or exams such as:

• Pelvic exam. This can find symptoms of illnesses, unusual growths or tense pelvic floor muscles. Your healthcare professional checks for areas that feel tender. Speak up if you feel any pain during this exam, especially if it feels like the pain you've had lately. And if the exam makes you anxious, you can ask your care professional to stop at any time.
• Lab tests. These can check for illnesses such as chlamydia or gonorrhea. You also may need a blood test to measure your blood cells or a urine test to check for a urinary tract infection.
• Ultrasound. This test uses sound waves to make pictures of tissues, organs and other parts inside the body. It can help find growths or cysts in the ovaries, uterus or fallopian tubes.
• Other imaging tests. You might need computerized tomography (CT) scans or magnetic resonance imaging (MRI). These imaging tests can help find growths or other unusual structures inside the body.
• Laparoscopy. During this surgery, a small cut is made in the stomach area. A thin tube with a small camera is placed through the cut. The camera lets your surgeon look at your pelvic organs and check for unusual tissues or infections. This procedure can help find and treat problems such as endometriosis and chronic pelvic inflammatory disease.

Finding the cause of chronic pelvic pain can take time. A clear reason for the pain may never be found. Talk openly with your healthcare team during this process. Work together to find a treatment plan that helps you live well with as little pain as possible.

With chronic pelvic pain, the goal of treatment is to ease symptoms and make your quality of life better.

If your healthcare professional can find a specific cause, treatment focuses on that cause. If a cause can't be found, the focus of treatment is to manage pain and other symptoms. You may need more than one treatment.

Medications

Depending on the cause, certain medicines may be used to treat chronic pelvic pain, such as:

• Pain relievers. Medicines that you can buy without a prescription may ease some of your pain. These include aspirin, ibuprofen (Advil, Motrin IB, others) and acetaminophen (Tylenol, others). Sometimes you may need a strong prescription pain reliever. But pain medicine alone rarely gets rid of chronic pain.
• Hormone treatments. Some people find that the days when they have pelvic pain may overlap with a phase of their period. When this is the case, birth control pills or other hormonal medicines may help relieve pelvic pain.
• Antibiotics. If an illness caused by bacteria is the source of your pain, you may need antibiotics.
• Antidepressants. Some types of medicines that treat depression also can be helpful for chronic pain. These include tricyclic antidepressants, such as amitriptyline, nortriptyline (Pamelor) and others. They also include serotonin norepinephrine reuptake inhibitors, such as duloxetine (Cymbalta) and venlafaxine (Effexor XR). They may help ease chronic pelvic pain even if you don't have depression.
• Muscle relaxers. Medicines such as cyclobenzaprine (Amrix) might help relax muscles linked with pelvic pain.

Other therapies

In addition to medicines, other treatments may help for chronic pelvic pain. These may include:

• Physical therapy. For some people, physical therapy can manage chronic pelvic pain. It can involve more than learning helpful stretches and relaxation techniques and getting a massage. It also can include procedures that treat pain.

  For example, a physical therapist might find stiff areas in tissue that are linked with pelvic pain. The therapist can then stretch and put pressure on these areas to loosen them up. This is called myofascial release.

  Sometimes, physical therapists target specific points of pain with a medical device called transcutaneous electrical nerve stimulation. This sends low-voltage electric currents to nearby nerves.

  Physical therapists also may use a psychology technique called biofeedback. This helps you become aware of areas where your muscles are tight, so you can learn to relax those areas.

  Some people also get pain relief from a procedure called dry needling. The therapist places very thin needles into and around stiff, sensitive areas tied to pain called trigger points.

• Spinal cord stimulation. This also is called neuromodulation. The 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. Trigger points are tight, sensitive spots on the body. Shots of numbing medicine may help block pain in these spots.

• Talk therapy. Some people with chronic pelvic pain also have a mental health condition, such as depression, anxiety or a personality disorder. Others have lasting trauma from sexual or emotional abuse. Talk therapy with a psychologist or a psychiatrist can help both the body and the mind. It can ease stress and help you learn ways to cope with pain.

  One type of talk therapy that may help is called cognitive behavioral therapy. It involves learning how to be mindful of negative and faulty thoughts. Sex therapy also might help. A therapist teaches couples how to have sex without pain and may help ease pelvic pain.

Surgery

Your healthcare professional may suggest surgery to treat a problem that causes chronic pelvic pain. Surgeries include:

• Laparoscopy. If you have endometriosis, this type of surgery can treat or remove the tissue outside of the uterus that causes pain. During surgery, a slender viewing tool is placed through a small cut near the bellybutton. The painful tissue is removed through one or more other small cuts.
• Hysterectomy. In rare cases, you may need surgery to remove your uterus, called hysterectomy. You also may need to have one or both ovaries removed. This is called oophorectomy. These surgeries have key health consequences. Ask your healthcare professional to explain the benefits and risks in detail.

Pain rehabilitation programs

It may take a combination of treatment approaches before you find what works best for you. If appropriate, you might consider entering a pain rehabilitation program.

Long-term pain can have a major impact on your daily life. When you're in pain, you may have trouble sleeping, exercising or doing everyday tasks.

Long-term pain also can cause anxiety and stress. And these might make your pain worse.

Relaxation techniques such as meditation and deep breathing may help you get some relief. They can help release tension, ease pain, calm emotions and help you fall asleep.

Other lifestyle changes also may help ease chronic pelvic pain:

• Practice good posture.
• Lose extra weight. This may lower the risk of straining joints and muscles in the pelvis.
• Get regular exercise. Do an activity you enjoy, and pace yourself. Talk to your doctor first if working out causes pain.

Some research suggests that acupuncture may be helpful for some causes of pelvic pain.

During acupuncture treatment, tiny needles are placed into the skin at precise points. Pain relief may come from the release of endorphins, the body's natural painkillers. But that's only one theory about how acupuncture works. Acupuncture, in general, is a safe treatment.

Talk with your healthcare team before you try a complementary or alternative therapy.

You're likely to start by seeing your primary healthcare professional. Or you might see a gynecologist, a doctor trained to find and treat conditions that affect female reproductive health.

Depending on what might be causing your pain, you also may need to see one of these providers:

• A gastroenterologist, who helps people with digestive problems.
• A urogynecologist, who treats urinary and female reproductive system problems.
• A physiatrist or physical therapist, who helps people with muscle and skeletal pain.

What you can do

To prepare for your appointment:

• Make a list of your symptoms. Include any that don't seem related 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 your medicines. Write down any prescription and nonprescription medicines, vitamins, or other supplements you're taking. Include the amount you take, called the dose.
• Think about taking a family member or friend with you. It can be hard to recall all the information given during an appointment. Someone who goes with you may remember something that you missed or forgot.
• Prepare questions for your healthcare professional. This can help you make the most of your time together.

Some basic questions to ask include:

• What might be the cause of my symptoms?
• What tests might I need?
• If tests find the cause of my pain, what types of treatments might help me? If no clear cause is found, what treatments do you suggest?
• Are there any lifestyle changes I need to make?
• 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?

Feel free to ask other questions during your appointment. And tell your healthcare professional if you don't understand something.

What to expect from your doctor

Your healthcare professional likely will ask you some questions. Be ready to answer questions about the pain itself, such as:

• When did the pain first start? Has it changed over time?
• How often do you feel the pain? Does it come in waves or is it constant?
• How bad is your pain, and how long does it last?
• Where do you feel the pain? Is it always in one place?
• How would you describe your pain?

You also can expect questions about things that seem to trigger or affect your pain, such as:

• Do you feel pain when you urinate or have a bowel movement?
• Does your period affect your pain?
• Does anything make your pain better or worse?
• Does your pain limit your ability to do everyday tasks or things you enjoy?

You'll be asked about your health history too. These questions might include:

• Have you ever had pelvic surgery?
• Have you ever been pregnant?
• Have you gotten treatment for a urinary tract or vaginal infection?
• Have you ever been touched against your will?
• What treatments for pelvic pain have you tried so far? How have they worked?
• Are you being treated, or have you recently been treated, for any other health concerns?
• Have you recently felt down, depressed or hopeless?