Pelvic Pain

"Pelvic pain" is a general term used to describe pain that occurs mostly or only in the region below a woman's belly button. This region includes the lower stomach, lower back, buttocks, and genital area.¹

Pelvic pain is chronic if it lasts for more than 6 months and affects a woman's quality of life.² This condition is a common reason why women seek medical care.³

Although pain is the core symptom of pelvic pain, the specifics of that pain and other symptoms vary from woman to woman. Pelvic pain can be severe enough that it interferes with normal activities, such as going to work, exercising, or having sex.

Women describe pelvic pain in many ways. Pelvic pain can be steady, or it can come and go. It can be a sharp and stabbing pain felt in a specific spot, or a dull pain that is spread out. Some women have pain that occurs only during their menstrual periods. Some women feel pain when they need to use the bathroom, and some feel pain when lifting something heavy. Some women have pain in the vulva (the external genitals), which is called vulvodynia (pronounced vuhl-voe-DIN-ee-yuh), during sex or when inserting a tampon.^1,2

Researchers are not sure exactly how many women in the United States have chronic pelvic pain.

Because it is often linked to other disorders, such as endometriosis or vulvodynia, chronic pelvic pain may be misdiagnosed as another condition, making it difficult to estimate reliable prevalence rates for pelvic pain.¹ According to one study, about 15% of women of childbearing age in the United States reported having pelvic pain that lasted at least 6 months.² Worldwide, the rates of chronic pelvic pain for women of childbearing age range from 14% to 32%.² Between 13% and 32% of these women have pain that is severe enough to cause them to miss work.³

There are many possible causes of pelvic pain, and it may be difficult to figure out the specific cause or causes.¹ A woman's pain may result from multiple causes occurring all at the same time. And a woman with one chronic pain condition is at increased risk for other types of chronic pain.

In many cases, pelvic pain indicates a problem with one or more of the organs in the pelvic area, such as the uterus, vagina, intestine, or bladder. Problems may include infection, inflammation, or conditions such as endometriosis.

The intensity of a woman's pelvic pain may not relate to the severity of the problem or condition causing the pain. For example, a woman with only small areas of endometriosis may experience intense pain.

The following health problems can cause or contribute to pelvic pain:

Adhesions.^1,2 Adhesions are bands of scar tissue that form between internal tissues and organs. They can form as a result of surgery or infections, such as pelvic inflammatory disease. There is disagreement about whether adhesions can cause pain. It has been proposed that pain may occur when adhesions prevent normal movement of internal organs, such as the bowel.³

Endometriosis.^1,2 This condition (pronounced en-doh-mee-tree-OH-sis) occurs when tissues that normally grow inside the uterus grow somewhere else in the body, usually in other parts of the pelvis, such as on the outside of the uterus, ovaries, or fallopian tubes. The two most common symptoms of endometriosis are pain and infertility.

Interstitial cystitis/painful bladder syndrome.^1,2 This syndrome (pronounced IN-tur-STISH-uhl siss-TY-tiss) is associated with pain in the region of the bladder as well as the need to urinate frequently and urgently. This pain may be a burning or sharp pain in the bladder or at the opening where urine leaves the body (urethra), and it is often relieved by emptying the bladder.⁴

Irritable bowel syndrome.^1,2 This syndrome is a digestive problem that can cause pain, bloating, constipation, or diarrhea. Researchers have yet to find a specific cause for irritable bowel syndrome but stress or certain foods can trigger symptoms in some people.⁵

Pelvic floor disorders.^1,2 These disorders occur when the muscles and connective tissues that hold the pelvic organs in place weaken or are injured, such as may occur during childbirth. These organs include the uterus, bladder, and rectum. Pelvic floor disorders can cause discomfort as well as functional problems, such as the uncontrolled loss of urine (urinary incontinence) or stool (fecal incontinence). With pelvic floor disorders, pain may also be caused by spasms or an increase in pelvic floor muscle tone.

Uterine fibroids.^1,2 Uterine fibroids (pronounced YOO-ter-in FAHY-broidz) consist of an overgrowth of muscle cells within the wall of the uterus. These noncancerous tumors may cause heavy, irregular, or painful periods and local pressure symptoms, including frequent urination, trouble defecating, and lower back pain.

Vulvodynia.² This condition (pronounced vuhl-voh-DIN-ee-uh) involves pain or discomfort of the vulva (the external female genitalia)), especially during intercourse. The pain may range from sharp pain to burning to itching. Although the vulvar pain is outside the pelvis, health care providers who see patients with pelvic pain may also care for patients with this disorder.

To find out the cause of a woman's pain, her health care provider will:¹

• Ask questions about the woman's pain and health history. How a woman describes her pain can help her health care provider figure out the pain type and what might be causing it.
• Perform a physical exam. The health care provider will examine the abdomen and pelvis, and check the woman's organs, muscles, and tissues in the pelvic region for tenderness or abnormalities that suggest a pain disorder.

The information the doctor gathers from the questions and physical exam will help the doctor decide whether additional tests or procedures are needed to help diagnose the cause of the pelvic pain. These tests or procedures may include:^1,2

• Lab tests, such as blood work or a urine test
• Pelvic ultrasound, a procedure that uses sound waves to look at organs and structures inside the pelvic region³
• Pelvic laparoscopy, a minor surgery in which the doctor inserts a viewing instrument called a laparoscope through a small cut in the skin below the belly button to look inside the pelvis⁴
• Pelvic MRI (magnetic resonance imaging) scan, an imaging test that uses powerful magnets and radio waves to create pictures of the pelvis⁵
• Cystoscopy, looking into the bladder by inserting a viewing instrument⁶
• Colonoscopy, looking into the bowel by inserting a viewing instrument⁷

Finding the cause of pelvic pain can be challenging and can take time. Some women must check with more than one doctor or with a specialist to get help for their pain. Sometimes, the cause of the pain is not found. But failure to locate the cause does not mean that the pain a woman feels is not real or that it cannot be treated.¹ Understanding what triggers the pain also can be helpful.

What are the symptoms of pelvic pain?

How many women have pelvic pain?

What causes pelvic pain?

How is pelvic pain diagnosed?

How is pelvic pain treated?

How can I describe my pain to my health care provider?

Can there be more than one reason for my pelvic pain?

Can pelvic pain affect my ability to become pregnant?

Can alternative therapies treat my pain?

Can pelvic pain affect my emotional well-being?

How can I cope with long-lasting pain?

Treatment depends on the cause of pelvic pain, how intense the pain is, and how often the pain occurs. No single treatment approach has been shown to be better than another in all cases.¹

Some treatment options include:

• Medicines. Many types of medicine are used to treat pelvic pain. These include pain relievers that are swallowed or injected, muscle relaxants, and antidepressants.^1,2,3
• Hormonal treatment. Hormones can help pain related to endometriosis 
  and menstruation.⁴ These include hormones that are swallowed, injected, or placed in the uterus, such as birth control pills, gonadotropin-releasing hormone injections, or progestin-releasing intrauterine devices. Hormonal treatment for pelvic pain is not the same as hormone therapy that is sometimes used to treat the symptoms of menopause.
• Lifestyle changes. Some women's pain is helped by changes in diet, improved posture, and regular physical activity.¹
• Physical therapy. Some types of pain, such as muscle and connective tissue pain, respond well to physical therapy. This type of therapy might involve massage, stretching, strengthening, or learning to relax or control pelvic muscles.⁵
• Surgery. Some women may need surgery to remove adhesions,⁶ fibroids, and/or endometriosis. In some cases, the surgery might also reduce or relieve pelvic pain. Some women may have surgery to cut or destroy nerves to interrupt pain signals,¹ but such pain surgeries often are not successful. Depending on the cause of the pain, a woman's health care provider might recommend a hysterectomy (pronounced hiss-tur-EK-toh-mee), surgery to remove a woman's uterus, to help relieve or reduce pelvic pain.
• Counseling. Counseling or "talk therapy" may help treat pain. In fact, talk therapy, when combined with medical treatment, appears to work better for improving some symptoms than does medical treatment alone.¹

Finding a treatment that works can take time. Some women want to try alternative therapies to relieve their pain. Learning healthy ways to cope with pain is an important aspect of any treatment approach.

Describing your pain accurately and thoroughly may help your health care provider find the cause of the pain and treat it.

Information that is helpful to your doctor includes:¹

• How long you have had your pain
• Where you feel the pain
• Whether your pain is in one spot or spread out
• How the pain feels and how severe it is
• Whether pain is constant or comes and goes
• What activities make pain worse or improve it
• How your pain limits what you can do
• How often the pain occurs and how long it lasts
• Anything that triggers the pain

Keeping a pain diary or record of your pain is a good way to track your pain triggers as well as symptoms over time. Be as specific as possible. Some words that can help you describe the way your pain feels include:²

• Aching
• Cramping
• Fearful
• Gnawing
• Heavy
• Hot or burning
• Sharp
• Shooting
• Sickening
• Splitting
• Stabbing
• Punishing or cruel
• Tender
• Throbbing
• Tiring or exhausting

Yes. Studies have found a good deal of overlap among pain conditions.^1,2 For instance, a woman may have endometriosis, irritable bowel syndrome, and depression at the same time—each of which may contribute to the overall pain she feels.

Having more than one pain condition can complicate diagnosis and treatment. To be effective, treatment needs to address all the conditions that are contributing to a woman's pain.

Some pelvic conditions that are associated with pain also are associated with difficulty getting pregnant.

These include:

• Endometriosis. Up to 30% to 50% of women with endometriosis are not able to get pregnant,¹ making this condition one of the top three causes of female infertility.
• Pelvic adhesions. Adhesions that form on the ovaries, fallopian tubes, or uterus can make it difficult or impossible to get pregnant.²
• Uterine fibroids. Most women with fibroids do not have problems with fertility and can get pregnant. If a woman's fibroid is located in the uterine cavity, she may face an increased risk of early pregnancy loss. Some women with fibroids may not be able to get pregnant naturally, but advances in treatments for infertility may help some of them get pregnant.

Some treatments for pelvic pain also can affect a woman's ability to get pregnant. For example, hormonal birth control commonly is used to treat endometriosis. Hysterectomy, which is surgery to remove a woman's uterus, may be an option for women who are not helped by other treatments, but it makes pregnancy impossible. However, a woman may still be able to become a mother through other means, such as a surrogate carrier.

Some women choose alternative medicine to treat their pain.¹ Although there is little evidence on how effective these remedies are for treating pain, alternative treatments may help in some cases.

For instance, the following approaches may help relieve menstrual pain:²

• Vitamin B1 or magnesium supplements
• Acupuncture, acupressure, and nerve stimulation therapies

If you are thinking about trying an alternative product or therapy to cope with your pain, make sure to talk to your health care providers first. Ask them what the scientific evidence indicates about the safety of the product or therapy and how well it works.¹ Keep in mind that dietary supplements can interact with other medicines you might be using or can cause problems if not used correctly.³

The relationship between pelvic pain and emotional health is complex.¹ Many women with long-lasting pelvic pain also have depression or anxiety, but how these conditions are linked is not well understood.

For instance, long-lasting pain can lead to depression, but depression also can cause pain or make existing pain worse.² Women with pelvic pain also have higher rates of having a history of sexual or physical abuse.³ Ongoing pelvic pain also can contribute to sleep problems, sexual problems, relationship stress, and problems at work and at home.¹

All these factors can play a role in how a woman feels pain, in her emotional wellness, and in her quality of life.¹ Learning healthy ways to cope with pain is an important aspect of treatment.

Living with pelvic pain can be difficult. Not only does pain hurt, but it also can limit how well you get around or perform daily tasks. Finding a treatment or treatments that help and getting a diagnosis may be emotionally trying, too. For these reasons, finding healthy coping strategies is an important aspect of living with pain.

These strategies may help you cope with pain:¹

• Counseling or "talk therapy." A mental health professional can help you identify thoughts, feelings, and behaviors that may contribute to your pain and help you realize how you cope with your pain. A therapist can help you set goals and learn new ways of thinking about and reacting to your pain, and these strategies may improve your outlook and the way you feel about your pain.² Women with pain seem to have better treatment outcomes when counseling is added to medical treatment.³
• Pain support groups. Talking to other people who have pain can give you ideas for how to deal with your pain or the problems your pain creates.
• Physical activity. Pain may make you inactive, and this lack of activity can lead to other health problems and loss of function. Regular physical activity can keep you fit and also prevent weight gain, can lower risk of depression, and may improve sleep quality.⁴ Talk to your health care provider about physical activities that are good for you to try. Some types of activity may contribute to pain.

Keep in mind that unhealthy coping strategies, such as overeating and smoking, can make pain problems worse.

NICHD research addresses pelvic pain and some of the numerous gynecologic and nongynecologic disorders associated with it.

Within this broad context, NICHD research on pelvic pain aims to:

• Investigate the etiology of pelvic pain disorders as well as characterize the underlying mechanisms and contributors to pain
• Examine the relationship between pelvic pain disorders and other diseases or conditions
• Describe the physical, emotional, interpersonal, economic, and other burdens of pelvic pain
• Improve standardization of measurement and diagnostic criteria to aid in pain assessment and diagnosis of pain disorders, facilitate the comparison of clinical trial results, and support evidence-based practice
• Develop minimally invasive approaches to treat pelvic pain disorders and their symptoms

NICHD conducts and supports research on pelvic pain and on some of the gynecologic and nongynecologic disorders associated with it, with the ultimate goal of reducing morbidity among women through prevention or improved treatment.