Chronic pelvic pain: causes & treatments

Chronic is used to describe any symptom that lasts a long time (technically longer than 6 months). The opposite of chronic is acute, which describes something that (usually) comes on suddenly and lasts less than 6 months.

What is chronic pelvic pain?

Pelvic pain is pain that you feel in the area below your belly button. Both men and women can get pelvic pain but today we are just going to talk about pelvic pain in women.

Different people experience pain differently and this is true for chronic pelvic pain as well. Some people might have severe pain, while for others it is mild. Some people’s pain might be constant, while for others it comes and goes.

Quick note: In using the word “women” in this article, I am referring to anyone who has a uterus/ovaries/fallopian tubes. This obviously does not encompass everyone who identifies as a woman, and includes some people who identify as men or non-binary, however, the causes of pain are often related to the organs that we have.

Who gets chronic pelvic pain?

A lot of people.

Approximately 1 in 6 women are affected by chronic pelvic pain.

What causes chronic pelvic pain?

There are a lot of causes of chronic pelvic pain. Often the pain is being caused by a lot of different factors, some physical and some psychological or social.

Sometimes, and this is important, no one can find a physical cause for chronic pelvic pain. This is the case in about 30-50% of operations done to look for a cause of pelvic pain. This is very frustrating (for doctors and patients) and can make it hard to treat.

This next bit is possibly the most important part of my whole article so please read it carefully. Just because no one can find a cause for your pain does not mean it is not real. So don’t ever let anyone tell you your pain is not real. If we don’t have a cause then it makes the pain harder to treat but there are still ways to treat it. We will talk more about this later on.

Most common causes for pelvic pain

The most common causes for pelvic pain are:

• endometriosis,
• pelvic inflammatory disease and
• irritable bowel syndrome.

Now let’s look at those in-depth

Endometriosis

Endometriosis is a condition where cells that belong in the lining of the womb (the endometrium) are found elsewhere. The most common sites for endometriosis are the ovaries, fallopian tubes, and the walls of the pelvis but it can actually occur anywhere in your body.

It can cause very painful periods and chronic pelvic pain or it can cause no symptoms at all. Everyone with endometriosis is different.

Pelvic inflammatory disease (PID)

Pelvic inflammatory disease (PID) is caused by infection of the uterus, ovaries or fallopian tubes. It is most commonly caused by a chlamydia or gonorrhea infection from the vagina that gets through the cervix and up into the internal structures.

PID requires urgent treatment with antibiotics as it can lead to chronic pelvic pain and issues with fertility.

A note on STIs

PID is one of the reasons that regular checks for sexually transmitted infections (STIs) are so important. These infections often don’t cause any symptoms so you might not know you have an infection. If an STI is not treated it can turn into PID which can cause you to get very sick and also cause long-term complications.

Irritable bowel syndrome (IBS)

IBS is very common and causes bloating, cramping, diarrhea and constipation. There are dietary changes that can help so speaking to a doctor or a dietician is a good idea. The NHS website has more information if you are interested.

Other causes of chronic pelvic pain

There are also many other causes of chronic pelvic pain that are less common. These include:

• Recurrence of ovarian cysts or urinary tract infections (UTIs)
  • Ovarian cysts are normal (we all get them) but if they get too big, become twisted, or burst then they can cause pain.
  • UTIs can cause pain and if they keep coming back then they can cause chronic pelvic pain
• Lower back pain
• Pelvic organ prolapse
  • If the uterus (womb) starts to slip down into its normal position
    • This is common among older women and can be treated with pelvic floor exercises or possibly an operation. If you think you might have a prolapse then talk to your doctor about the options for you
  • Adenomyosis
    • Adenomyosis is a variation of endometriosis where cells from the lining of the womb (the endometrium) are found in the muscle wall of the womb (uterus). This causes heavy and painful periods.
  • Fibroids
    • Fibroids are growths of muscle in or around the uterus (they are not cancerous). If they get very large, get twisted, or start to deteriorate then they can cause pain. Uncomplicated fibroids can cause heavy periods but do not usually cause pain.
  • Hernia
    • This is when one of the organs in your abdomen (your belly) or some fat pushes through the muscle layer. This can cause pain and you may or may not need an operation to fix it. It is important to speak to your doctor if your think you have a hernia.
  • Nerve pain
    • If nerves get irritated, damaged, or trapped then they can cause pain
    • Nerve pain is usually sharp/stabbing in nature and may radiate to other nearby areas of the body
  • Inflammation of the bladder (chronic interstitial cystitis)
  • Inflammatory bowel disease (IBD)
    • This includes two conditions called ulcerative colitis and Crohn’s disease which affect the bowel (the gut)

My doctor told me it’s all in my head

First of all, I’m sorry. As doctors, we should not make our patients feel like they are imagining their pain or that it is “all in their head”. But that doesn’t mean it doesn’t happen.

If there is no cause for your pain that can be found, this makes it a bit harder to treat. Sometimes the best treatments for chronic pain are actually psychological treatments but this sometimes makes it seem like we don’t think your pain is real.

How pain works

Pain messages come from the site of the pain and travel to your brain. Your brain then decides whether to listen to the pain signal so you can do something about it or to ignore it. For example, if you touch the stove when it is hot the message goes from your hand to your brain. Your brain registers this message and sends a message back to your hand to move it off the stove. This is the function of pain – to keep us safe.

Sometimes, these messages get mixed up and our brains start getting signals about pain that isn’t being caused by a hot stove. These messages are tricky because we can’t just remove our hand from the stove and run it under cold water to get rid of the pain.

Chronic pain

Chronic pain can also be a physical manifestation of previous trauma or emotional distress. This also does not mean the pain isn’t real! It is real! It is just being caused through a different pathway than the hand on the hot stove. Psychological therapies can help with the brain’s ability to regulate the pain signals and can help improve your pain.

If you have been struggling with pain for a long time and feel that doctors have dismissed you or not listened to you, you probably don’t want to be told that psychological therapy can help. This is completely fair enough. Telling someone to go to therapy for their pain sounds so dismissive!

But hopefully, if someone has recommended psychological therapy for your pain, they did it in a sensitive and kind way and explained that they don’t think you are making it up. If they didn’t, I am so sorry! But please don’t reject the idea because someone suggested it in an unkind way. It can really help.

How can I treat my chronic pelvic pain?

The treatments for chronic pelvic pain depend on the cause. If the pain is being caused by one of the conditions outlined above then treating the condition should help the pain.

Pain relief

Pain relief might be appropriate for your kind of pain. It is important not to overuse pain relief if it is not helping though. Even paracetamol can cause other problems if it is used too often (such as paracetamol overuse headaches). Pain relief is best for acute pain so may not be appropriate for chronic pelvic pain.

Hormonal treatments

Some people find that their pain coincides with their menstrual cycle or is made worse at certain times of the month. Hormonal birth control that suppresses your cycle might be helpful if this is the cause of your pain. However, do remember that when you use hormonal contraceptives you stop the natural production of your hormones which in turn can lead to other side effects and complications long term.

 Other medicines

If an infection is causing the pain then antibiotics are probably the appropriate treatment. Other medications such as antidepressants also have pain-relief properties and are often useful for nerve-related pain. A doctor prescribing you antidepressants for pain does not necessarily mean they think you are depressed.

Other treatments

There are also a lot of other treatment options available for chronic pain conditions. It is important to remember that “Western medicine” doesn’t have all the answers and there are many other avenues to try. Understanding the root cause of your pain is often helpful for finding an effective treatment. But you don’t always need to know the cause to find things that help.

Physical therapy

Massage, stretching or other exercises can be helpful for chronic pain. Talking to a physiotherapist is a good idea if you are interested in trying these techniques as they are the experts.

Acupuncture

Acupuncture involves tiny needles that are inserted into your skin at very specific points in your body. This technique has a lot of uses and pain is one thing that it can help with.

Nerve stimulation

Some physiotherapists work with machines called TENS machines (this stands for transcutaneous electrical nerve stimulation). TENS can be helpful for all sorts of things from period pain, to labour pain. Some people also find it helpful for chronic pain.

Relaxation techniques

The stressors of daily life can make chronic pain a lot worse. And so improving stress levels can also improve pain. Relaxation techniques, meditation, yoga or deep breathing can help relax your nervous system and reduce your pain.

Generally, the best way to help with chronic pain is to try different things in combination. You might want to use pain relief or acupuncture but the benefits of these can also be helped with relaxation exercises or yoga. It is important to think of your life as a whole when trying to treat your pain and not just the pain in isolation.

Will surgery help my pain?

This is a good question.

Again, it depends on what is causing the pain.

There is a lot of misinformation that exists around chronic pelvic pain and the role of surgery in treating it.

If you have a lot of endometriosis that is causing you a lot of pain and you are wanting to have a baby, then a laparoscopy (keyhole operation) might be the most appropriate treatment for you. BUT (and this is a big but) it might not help your pain AND it might lead to new pain caused by the operation. Surgery always comes with risks, one of which is causing pain.

It is important to have a discussion with your doctor about what treatments are appropriate for you and your pain so that you can make an informed decision about what you would like to do.

Where else can I go for help?

There are a lot of support networks that exist for people with chronic pelvic pain that can be good sources of information or help.

Endometriosis UK: www.endometriosis-uk.org

IBS Network: www.theibsnetwork.org

Pelvic Pain Support Network: www.pelvicpain.org.uk

Bladder & Bowel Community: https://www.bladderandbowel.org/

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