Patient education: Chronic pelvic pain in females (Beyond the Basics)

CHRONIC PELVIC PAIN DEFINITION — Chronic pelvic pain is defined as pain that occurs in the pelvic area (below the belly button) and lasts for at least six months. It may or may not be associated with menstrual periods. While chronic pelvic pain can be a symptom caused by one or more different conditions, in many cases, it is a chronic condition related to how the central nervous system processes pain signals (often called "centralized pain"). When this happens, the nervous system overreacts to various triggers, and the person experiences more pain than would normally be expected.

CAUSES OF CHRONIC PELVIC PAIN — A variety of gynecologic, gastrointestinal, urologic, musculoskeletal, and body-wide disorders can cause chronic pelvic pain.

Gynecologic causes — Chronic pelvic pain is thought to have gynecologic causes (originating in the female reproductive tract) in approximately 20 percent of women (figure 1). Some of the gynecologic causes of pelvic pain include:

Endometriosis — The tissue lining the inside of the uterus is called the endometrium. Endometriosis is a condition in which endometrial-like tissue is also present outside of the uterus. Some people with endometriosis have no symptoms, while others experience marked discomfort and pain and may have problems with fertility. (See "Patient education: Endometriosis (Beyond the Basics)".)

Uterine fibroids — Fibroids, also called leiomyomas, are growths in the uterus. They are not cancerous. While most people with fibroids do not experience symptoms, approximately 25 percent of people with fibroids experience symptoms such as pelvic pain, heavy periods, or fertility problems. (See "Patient education: Uterine fibroids (Beyond the Basics)".)

Adenomyosis — This is a condition in which endometrial-like tissue (the tissue that normally lines the inside of the uterus) grows inside the uterine walls. While many people with adenomyosis experience no symptoms, it sometimes causes an enlarged uterus and heavy, painful periods. Adenomyosis often occurs in people who also have endometriosis or uterine fibroids. (See 'Endometriosis' above and 'Uterine fibroids' above.)

Pelvic inflammatory disease — Pelvic inflammatory disease (PID) is an acute infection of the female reproductive organs (uterus, ovaries, and fallopian tubes (figure 1)) that is typically caused by a sexually transmitted infection. Occasionally, it is caused by a different type of infection (tuberculosis), happens after placement of an IUD, or spreads from another abdominal infection such as a ruptured appendix or diverticulitis.

About one-third of people with PID develop scar tissue that can result in chronic pelvic pain and/or infertility. The reasons for this are not clearly known, but is likely due to altered responses of the central nervous system to normal sensory information from the uterus, ovaries, and fallopian tubes. It does not mean the person has an ongoing infection. (See "Patient education: Gonorrhea (Beyond the Basics)" and "Patient education: Chlamydia (Beyond the Basics)".)

Pelvic adhesive disease — Adhesions are scar tissue that cause internal organs or structures, such as the ovaries and fallopian tubes, to "adhere" or stick to one another. It is very controversial whether adhesions cause pelvic pain, and medical experts are not in agreement. However, most evidence suggests that surgery for pelvic adhesive disease is not a reliable or long-lasting treatment for pelvic pain in most situations. One exception is the case of severe adhesions that bind one organ to another (such as the ovary to the colon) from deep infiltrating endometriosis (see 'Endometriosis' above). Surgery may work well to treat these types of adhesions and pain.

Other causes — Nongynecologic causes of chronic pelvic pain may be related to the digestive system, urinary system, or to irritation in the muscles and nerves in the pelvis:

Irritable bowel syndrome — Irritable bowel syndrome is a gastrointestinal condition characterized by chronic abdominal pain and altered bowel habits (such as loose stools, more frequent bowel movements with onset of pain, and pain relieved by defecation) in the absence of any identifiable cause. (See "Patient education: Irritable bowel syndrome (Beyond the Basics)".)

Bladder pain syndrome and interstitial cystitis — Bladder pain syndrome and interstitial cystitis (BPS/IC) are the terms given to chronic bladder pain that is not caused by infection. Symptoms usually include bladder pain or discomfort, which often worsens as the bladder fills up; the need to urinate frequently (urinary frequency); and a feeling of urgently needing to urinate (urgency), which can occur even right after urinating. BPS/IC is discussed in more detail separately. (See "Patient education: Diagnosis of interstitial cystitis/bladder pain syndrome (Beyond the Basics)".)

Pelvic floor pain — Symptoms of pelvic floor dysfunction may include pelvic pain, pain with urination, difficulty urinating (such as urgency, frequency, or a sense of incomplete emptying), constipation, and/or pain with intercourse. Pelvic floor dysfunction can be diagnosed by a clinician feeling the pelvic floor muscles (muscles that support the pelvic organs and hips) through the vagina and/or rectum; muscles that feel tight, tender, or band-like and cause pain indicate that pelvic floor dysfunction could be contributing to pelvic pain.

Abdominal myofascial pain (trigger points) — Pain can originate from the muscles of the abdominal wall due to myofascial pain. This problem usually has small, localized areas of abnormal tenderness of the abdominal muscles that are called trigger points. Abdominal myofascial pain is diagnosed by the clinician examining the abdominal muscles for trigger points; tightening of these muscles while they are examined causes increased pain and assists in diagnosis.

Fibromyalgia — Fibromyalgia is one of a group of chronic pain disorders that is characterized by widespread muscle pain (or "myalgia") and tenderness. Fibromyalgia itself may cause heightened sensitivity to pain in the pelvic area. However, in people whose central nervous system is not functioning normally, this likely contributes to both chronic pelvic pain and fibromyalgia-related pain. People with fibromyalgia may also experience fatigue, sleep disturbances, memory difficulties, and mood disturbances such as depression and anxiety. (See "Patient education: Fibromyalgia (Beyond the Basics)".)

Physical, sexual, or psychological abuse — People with chronic pain in general appear to have a higher incidence of prior traumatic experiences, such as procedures at an early age, familial instability in childhood, or physical or sexual abuse; the same appears to be true for people who experience chronic pelvic pain. Do not be afraid to tell your health care provider if you have ever been (or are currently being) hurt by someone or if you feel unsafe at home or in your relationship. They can help you.

DIAGNOSIS OF THE CAUSE OF CHRONIC PELVIC PAIN — Because a number of different conditions can cause chronic pelvic pain, there may be more than one condition that is causing pain. However, it is also sometimes difficult for doctors to pinpoint the specific cause.

History and physical examination — Your health care provider will talk to you about your history (including past health problems and any symptoms you are having) and examine your abdomen, lower back, hips, and pelvis. This should include an internal pelvic examination.

Your provider might order laboratory tests, but this will depend on your history and examination findings. Laboratory tests that are sometimes helpful include a white blood cell count, urinalysis, tests for sexually transmitted infections, and a pregnancy test.

Pelvic ultrasound — A pelvic ultrasound can help your provider look for certain causes of pelvic pain, including ovarian cysts (sometimes caused by ovarian endometriosis) and uterine fibroids. Endometriosis can sometimes be detected on ultrasound, but not always. However, ultrasound is not helpful in the diagnosis of irritable bowel syndrome, diverticulitis, or bladder pain syndrome.

Laparoscopy — A surgical procedure called a laparoscopy may be helpful in diagnosing some causes of chronic pelvic pain such as endometriosis and chronic pelvic inflammatory disease. Laparoscopy is a procedure that is often done as an outpatient surgery under general anesthesia. A thin tube with a camera is inserted through a small incision inside or just below the navel. This allows the surgeon to see inside your abdomen and evaluate for endometriosis or pelvic adhesions.

If the laparoscopy is abnormal (eg, shows areas of endometriosis or abnormal tissue), these areas should be biopsied and removed during the procedure. If no problems are found during laparoscopy, this does not mean that your pain is not real. It only means that endometriosis and adhesions are not the cause.

Laparoscopy should be performed by a gynecologic surgeon who is qualified to correctly diagnose and surgically remove endometriosis.

COPING WITH CHRONIC PELVIC PAIN — Some people find that counseling helps them manage their pelvic pain. There are several types of psychosocial support:

●Therapy – Psychotherapy involves meeting with a psychologist, psychiatrist, or social worker to discuss emotional responses to living with chronic pain, treatment successes or failures, and/or personal relationships. A specific form of psychotherapy called cognitive behavioral therapy (CBT) has been found to be helpful in many people with chronic pain. Psychotherapy can be done with a therapist individually or as part of a group.

●Mindfulness training – Mindfulness exercises, such as meditation, may help manage the pain symptoms and reduce stress, which is known to be a powerful trigger of pain sensations even in the absence of a known pain source.

●Support groups – Online or local support groups that deal with chronic pain may also be helpful, such as the American Chronic Pain Association (acpanow.com). Other resources include online programs or phone apps.

●Relaxation techniques – Relaxation techniques can relieve musculoskeletal tension, and may include meditation, progressive muscle relaxation, self-hypnosis, or biofeedback.

●Physical activity – Getting regular physical activity can also help with pain, and has many other health benefits as well. Try to find activities you enjoy that do not make your pain worse, such as walking, and increase your level of activity as you feel ready.

CHRONIC PELVIC PAIN TREATMENT — Chronic pelvic pain has multiple possible treatments; these are often used in combination.

Pain relief — Initially, your health care provider might suggest trying to treat your pain with medications such as:

●Nonsteroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen (sample brand names: Advil, Motrin) and naproxen (sample brand names: Aleve, Naprosyn)

●Acetaminophen (brand name: Tylenol)

●For some people, a muscle relaxant such as cyclobenzaprine (brand names: Amrix, Flexeril) may be helpful

In general, most providers try to avoid or limit the use of opioids (drugs derived from morphine) in treating chronic pain. These drugs have been found to be of limited benefit in the long term, and they are associated with a risk of worsening chronic pain, misuse, or addiction.

Addressing the source when possible — In addition to relieving your pain, your health care provider will also try to treat whatever condition is causing your pain. If no cause of your pain is found, another option is to treat the pain response system.

●Treating the direct cause – If a likely cause of your symptoms (such as endometriosis) has been identified, you and your provider will make a plan for treatment. While it is ideal to be able to diagnose and treat the underlying cause of chronic pelvic pain, this is not always possible because a clear cause is not always found.

●Treating the pain response – Another approach involves directing treatment at the nervous system pathways responsible for processing pain as a response to triggers. The goal is to change these pathways so the brain no longer perceives pain. Nonsteroidal anti-inflammatory drugs (listed above), antidepressants (ie, nortriptyline, duloxetine), and anticonvulsive medications (ie, pregabalin, gabapentin, topiramate) are often used for this.

Physical therapy — Pelvic floor physical therapy (PT) is often helpful for people with abdominal myofascial pain or with pelvic floor pain. This type of PT aims to release the tightness and pain in these muscles and is performed through a variety of techniques. The most common technique is manual "release" of the tightness; treatment is directed to the muscles in the abdomen, vagina, hips, thighs, and lower back. Physical therapists who perform this type of PT must be specially trained. (See "Patient education: Treatment of interstitial cystitis/bladder pain syndrome (Beyond the Basics)".)

Multidisciplinary pain management clinics — If the above approaches are not effective in treating your pain, you may be referred to a medical practice specializing in pain management. Pain services utilize multiple treatment modalities including:

●Multidrug regimens

●Acupuncture

●Biofeedback and relaxation therapies

●Nerve stimulation devices

●Injection of tender sites with a local anesthetic (eg, lidocaine) to numb the area

Surgical treatment — A few gynecologic causes of pelvic pain can be treated with surgery. For example, some people benefit from surgical removal of endometriosis tissue, ovarian cysts, or fibroids.

Hysterectomy (surgery to remove the uterus) may alleviate chronic pelvic pain, especially when it is due to uterine disorders such as adenomyosis or fibroids. However, pain can persist even after hysterectomy, particularly in younger people (under 30) and in people with a history of chronic pelvic inflammatory disease or pelvic floor dysfunction. Hysterectomy is not a good choice for the management of chronic pelvic pain in people who want to get pregnant in the future. (See "Patient education: Abdominal hysterectomy (Beyond the Basics)" and "Patient education: Vaginal hysterectomy (Beyond the Basics)".)

Surgery to cut some of the nerves in the pelvis (presacral neurectomy) has also been studied as a treatment for chronic pelvic pain. However, this approach has shown effectiveness mostly for cyclical midline pelvic pain and has additional surgical risks, so it is not recommended in most situations.

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Chronic pelvic pain in females (The Basics)
Patient education: Endometriosis (The Basics)
Patient education: Painful periods (The Basics)
Patient education: Pelvic inflammatory disease (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Endometriosis (Beyond the Basics)
Patient education: Irritable bowel syndrome (Beyond the Basics)
Patient education: Diagnosis of interstitial cystitis/bladder pain syndrome (Beyond the Basics)
Patient education: Diverticular disease (Beyond the Basics)
Patient education: Fibromyalgia (Beyond the Basics)
Patient education: Hormonal methods of birth control (Beyond the Basics)
Patient education: Treatment of interstitial cystitis/bladder pain syndrome (Beyond the Basics)
Patient education: Abdominal hysterectomy (Beyond the Basics)
Patient education: Vaginal hysterectomy (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Chronic pelvic pain in nonpregnant adult females: Causes
Chronic prostatitis and chronic pelvic pain syndrome
Interstitial cystitis/bladder pain syndrome: Clinical features and diagnosis
Evaluation of the adult with abdominal pain
Causes of abdominal pain in adults
Chronic pelvic pain in adult females: Evaluation
Dysmenorrhea in adult females: Clinical features and diagnosis
Chronic pelvic pain in adult females: Treatment
Interstitial cystitis/bladder pain syndrome: Management
Dysmenorrhea in adult females: Treatment
Hysterectomy: Laparoscopic

The following organizations also provide reliable health information.

●The International Pelvic Pain Society

     (www.pelvicpain.org)

●The Mayo Clinic

      (www.mayoclinic.com)