Pelvic Pain

What is Chronic Pelvic Pain?

Chronic pelvic pain is pain in the lower abdomen lasting six months or more, disrupting daily activities and affecting overall health.

Types of Pelvic Pain

• Acute Pelvic Pain: Sudden, sharp pain that signals an urgent health issue, such as infections, ectopic pregnancy (a pregnancy growing outside the uterus), miscarriage (pregnancy loss), a ruptured ovarian cyst (a fluid-filled sac on the ovary that can cause severe pain if it bursts), or ovarian torsion (twisting of the ovary and/or fallopian tube affecting its blood supply).
• Chronic Pelvic Pain: Pain that may come and go or be constant, often worsening with certain activities like urination, eating, or menstruation.

Common Causes of Chronic Pelvic Pain 

Chronic pelvic pain may result from multiple conditions:

• Pelvic Inflammatory Disease (PID): An infection of reproductive organs, often from STIs like gonorrhea and chlamydia, leading to scarring or adhesions.
• Dysmenorrhea: Severe menstrual pain due to high prostaglandin levels, causing strong uterine contractions.
• Endometriosis: Endometrial-like tissue (tissue similar to the inner-lining of the uterus) grows outside the uterus, causing pain during periods or sexual activity.
• Adenomyosis: endometrial tissue invades into the uterine muscle wall causing heavy bleeding and pain with periods
• Fibroids: Non-cancerous growths in the uterus, leading to pain or pressure.
• Urinary and Digestive Issues: Conditions like Painful Bladder Syndrome (bladder inflammation sometimes known as interstitial cystitis), urinary tract infections, irritable bowel syndrome, inflammatory bowel disease, and diverticulitis can contribute to pelvic pain.
• Muscular and Skeletal Problems: Pain can stem from muscle spasms, vaginismus (involuntary muscle spasms of the pelvic floor), lower back issues, obesity, pregnancy-related changes, pelvic floor dysfunction, or myofascial pain syndrome (pain from muscle trigger points).
• Psychological Factors: History of physical or sexual abuse, depression, or trauma may intensify pelvic pain.

Diagnosing Chronic Pelvic Pain 

A thorough diagnosis includes:

• Medical History and Pain Journal: Your provider will ask detailed questions about the pain’s impact, possible trauma, previous pregnancies, and other health conditions. A pain journal may help identify triggers and patterns.
• Physical Exam and Specialist Consultation: A physical and pelvic exam may lead to consultations with specialists for specific symptoms.
• Diagnostic Tests: Your doctor might recommend:
  • Ultrasound: Uses sound waves to visualize pelvic organs.
  • Laparoscopy: A small incision allows a scope to examine the pelvic area directly.
  • Cystoscopy: Examines the bladder and urethra.
  • Colonoscopy and Sigmoidoscopy: Explore parts of the colon to rule out abnormalities.
  • Lab Tests: Blood or other samples based on exam findings.
  • Pelvic MRI: Specialized imaging through Radiology office

Treatment Options 

Treatment varies based on the underlying cause:

• Condition-Specific Treatments:
  • Pelvic Inflammatory Disease (PID): Antibiotics.
  • Dysmenorrhea and Endometriosis: Hormonal options like birth control, IUDs, or hormone-blocking medications, and surgery.
  • Fibroids or Cysts: Medications and surgery to remove growths or endometriosis tissue if medications don’t help. 
• Pain-Relief Approaches:
  • Lifestyle Adjustments: Good posture, exercise, diet, and weight management can reduce pelvic pain.
  • Medications: NSAIDs manage pain from dysmenorrhea, while antidepressants or nerve pain treatments may help other cases.  We typically avoid narcotic medications for chronic pelvic pain due to their dependency and side effect profile.
  • Physical Therapy: Techniques include acupuncture, pelvic floor exercises, and trigger point release. Biofeedback and relaxation exercises also aid in managing pain.
  • Nutrition Therapy: Supplements like vitamin B1 and magnesium may reduce menstrual pain.
  • Surgical Options for Pain Relief: Nerve-cutting surgery is considered if other treatments fail to control pain.
• Counseling and Cognitive Support: Cognitive behavioral therapy (CBT), stress management, and sex therapy address the emotional impact of chronic pain. Counseling is part of a comprehensive approach, not an indication that the pain is solely psychological.

Managing Chronic Pelvic Pain

Managing chronic pelvic pain involves combining treatments and ongoing follow-ups with healthcare providers. Even if a specific cause isn’t found, relief options can still effectively manage the pain. Working closely with a provider can identify the best approaches to reduce or control pain over time.

Endometriosis

What is Endometriosis?

Endometriosis is a condition where tissue similar to the lining of the uterus (endometrium) grows outside the uterus, typically in the pelvic or abdominal area. This tissue can cause pain, inflammation, and scarring, especially around menstrual periods. 

• 1 in 10 females of reproductive age have endometriosis.
• 7 out of 10 females with chronic pelvic pain have endometriosis.
• Up to 50% of females with infertility (difficulty getting pregnant) have endometriosis.
• The diagnosis of endometriosis is delayed on average by 6 years, if you are concerned you have this condition talk to your healthcare provider.

Where Endometriosis Occurs

Endometrial tissue outside the uterus can form on:

• The peritoneum (lining of the abdominal cavity)
• Uterus, ovaries and fallopian tubes
• Bladder, digestive tract
• Rarely on other organs

These tissue implants may vary in size, appearance and how they affect the organs nearby. Sometimes endometriosis causes the organs to stick together through scar tissue called adhesions. This tissue responds to hormonal changes, growing and breaking down with the menstrual cycle, which can cause severe pain and inflammation.

Who is Affected by Endometriosis?

Endometriosis can occur at any age.

Risk factors

• Genetics: A family history of endometriosis, particularly in mothers or sisters, increases the likelihood.
• Low BMI (Body Mass Index) has been associated with endometriosis
• Prolonged and Heavy menstrual bleeding
• Periods started earlier than age 12 years old
• Structures issues with the vagina, cervix or uterus
• Never giving birth
• Higher levels of estrogen in your body
• Starting menopause at an older age (average age for menopause is 52 years old)

Symptoms

The main symptom of endometriosis is chronic pelvic pain, especially around menstruation.

Other symptoms include:

• Painful periods (dysmenorrhea), often worsening over time, and can pain hurt between your periods
• Pain during sexual intercourse
• Painful urination or bowel movements if the bladder or bowels are affected
• Heavy menstrual bleeding
• Infertility
• Bloating, nausea, significant bowel movement or bladder changes during your periods
• If you become pregnant there can be a higher risk of preterm delivery, preterm labor and other complications

The severity of pain doesn’t always reflect the extent of endometriosis; some women with severe pain have few visible implants, while others with extensive implants may experience minimal discomfort.

Diagnosing Endometriosis

If symptoms suggest endometriosis, an obstetrician-gynecologist (OB-GYN) may conduct a pelvic exam and rule out other conditions like infections, irritable bowel syndrome (IBS), or urinary tract problems. Frequently, an ultrasound will be performed to rule in or out other causes. Note – endometriosis is not frequently seen on this imaging, but if it is then it is more likely a severe stage.  Surgery, often a laparoscopy, is the only way to confirm endometriosis. In this procedure, a small camera is inserted through an incision in the belly button to examine the pelvic area, and a biopsy (tissue sample) is taken.

Treatment Options

Treatment depends on symptom severity, disease extent, and whether the patient wants to have pregnancy potential.

• Medications include:
  • Pain relievers (NSAIDs like ibuprofen) to ease pain.
  • Hormonal medications like birth control pills, progestins, or gonadotropin-releasing hormone (GnRH) agonists and antagonists, which reduce estrogen and may slow tissue growth. These medications don’t eliminate existing tissue but can reduce pain and prolong time until another surgery.
• Side Effects: Birth control may cause headaches or nausea along with other side effects; GnRH agonists and antagonists may lead to hot flashes, bone density loss, and temporary menopause-like symptoms.
• Surgery can remove endometrial tissue and adhesions. The most common approach is laparoscopic surgery, where implants are removed with a small incision. Surgery can relieve pain, but symptoms may return within a few years, especially if some tissue couldn’t be removed.
• Lifestyle changes: while not well studied – exercise, acupuncture, reduction in inflammatory diet may improve symptoms for patients and has minimal risk to patients. For Painful Bladder Syndrome associated we will recommend bladder irritants be avoids – you can see the full list here

For women with severe, unrelenting pain, a hysterectomy (removal of the uterus) may be considered as a last resort, sometimes with removal of the ovaries to reduce estrogen. This procedure stops menstruation but also eliminates the possibility of carrying a pregnancy.

Endometriosis and Fertility

Endometriosis is a leading cause of infertility. Up to 50% of patients with infertility can have endometriosis.  In cases with extensive adhesions, fallopian tubes may be blocked, preventing eggs from traveling to the uterus. In less severe cases, inflammation from endometriosis may damage sperm or eggs or interfere with their movement. Surgery may improve fertility by removing obstructive tissue.

In some cases removal of block fallopian tubes or collections of endometriosis may be recommended. In cases of infertility, we offer to send to Reproductive Endocrinology and Infertility subspecialists within our field to work together to help best care for our patients.

Coping and Managing Symptoms

Endometriosis is a chronic condition, and symptoms may continue until or even past menopause. Treatment plans can be adjusted over time to find what works best. Some women find relief through exercise, relaxation techniques, or support groups. Talking to an ob-gyn about support resources, such as local or online support groups, may also help manage the emotional impact of endometriosis.