Chronic Pelvic Pain in Women: The 4 Common Causes

Chronic  Pelvic Pain in Women: The 4 Common Causes

By: Jessica Strasburg, MD • Posted on November 08, 2018

Chronic Pelvic Pain in Women

Chronic Pelvic Pain (CPP) in women is a multi-faceted disorder defined as pain in the pelvis in a woman for more than six months. This type of pain syndrome affects 20 to 39 percent of patients, making it as common as asthma and low back pain. However, it is often under recognized and under diagnosed. The location of the pain includes:

  • Lower abdomen
  • Low back
  • Perineum
  • Buttocks

Typically, this pain can worsen with menstruation, but also can occur during other times of the month.

Chronic pelvic pain is complex in that patients can have a variety of overlapping symptoms, including:

  • Gynecological causes, 30% of the time.
  • Urological causes, including recurrent urinary tract infections and chronic interstitial cystitis.
  • Gastrointestinal causes like IBS.
  • Musculoskeletal problems: muscle spasms of the pelvic floor.

4 Common Causes of CPP


Endometriosis is one of the most common causes or triggers of CPP. Endometriosis is the presence of estrogen-sensitive endometrial glands associated with an inflammatory response outside of the uterus. Endometriosis can cause severe painful periods sometimes unresponsive to medical therapy. Depending on the location of the implants, it can cause a variety of symptoms and is one of the causes of infertility.

Endometriosis Symptoms

  • Painful intercourse
  • Painful periods
  • Urinary frequency and urgency
  • Diarrhea
  • Painful bowel movements (called tenesmus)

Endometriosis Treatment

The diagnosis of endometriosis is made by diagnostic laparoscopy.

  1. The treatments involve suppressing the growth of these implants usually with hormonal contraceptives and other hormonal options.
  2. Two doses of elagolix are now FDA approved for treatment of pelvic pain caused by endometriosis.
  3. If these treatments are ineffective, surgical treatment to remove as much of the implants may be necessary.

Irritable Bowel Syndrome (IBS)

Irritable bowel syndrome (IBS) is a syndrome involving a constellation of symptoms.

IBS Symptoms

  • Diarrhea
  • Constipation
  • Gas
  • Bloating
  • Cramping

Typically, patients are evaluated for other conditions such as celiac disease, crohn’s disease and ulcerative colitis before being diagnosed with IBS.

IBS Treatment

  1. Lifestyle modification
  2. Dietary changes
  3. Probiotics
  4. Anti-Spasmotics


Vulvodynia is chronic pain or discomfort at the entrance of the vagina with no identifiable cause.

Vulvodynia Symptoms

  • Pain
  • Burning
  • Stinging
  • Soreness
  • Dyspareunia
  • Painful intercourse

Sometimes the pain is only when the area is touched (provoked), but also can occur as a generalized (non-provoked) pain. Vulvodynia can be mistaken for bladder or yeast infections. To check for vulvodynia, the physician will use a Q-tip and apply it to the vulva in several areas to see if this reproduces the symptoms.

Vulvodynia Treatment

  1. Medications such as amitryptiline and gabapentin.
  2. For more severe cases, surgical excision may be indicated.

Pelvic Floor Dysfunction

Pelvic floor dysfunction (PFD) is also a common cause of CPP. This condition is also known as myofascial pain, high tone pelvic floor or levator ani muscle spasm. The triggers of PFD can be traumatic such as a fall on the tailbone. Sexual trauma can also cause PFD. The pelvic floor muscles spasm and “shorten” as a protective response to these triggers mentioned above and others such as painful periods. The pelvic floor muscles control the entrance to the vagina, bladder and rectum.

PFD Symptoms

  • Painful intercourse
  • Urinary frequency/urgency
  • Pain with and after a bowel movement

PFD pain typically worsens with stress and increased activity.

PFD Treatment

  1. Pelvic floor physical therapy
  2. Heat
  3. Non-steroidal medications
  4. Muscle relaxers
  5. Trigger muscle point injections

Even though CPP is complex and many times needs a treatment team, including physicians specializing in CPP, pelvic surgeons, pain medicine physicians, physical therapists and health psychologists, please know there is help available.

Be Strong. Be Healthy. Be in Charge!

-Jessica Strasburg, MD, FAAFP, NCMP

Jessica M. Strasburg, MD, is a Staff Physician in Gynecology in the Women's Health Institute. She is the medical director of the Chronic Pelvic Pain Program. Dr. Strasburg is board-certified in family practice and completed a Women's Health Fellowship after residency and is a certified educator by the North American Menopause Society. She sees patients on the 8th Floor Crile Building at Main Campus. She is also an Assistant Professor with the Cleveland Clinic Lerner College of Medicine.

Her treatment interests include treatment/diagnosis of chronic pelvic pain and general medical gynecology. To make an appointment with Dr. Jessica Strasburg, please call 216-445-3156.

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