Chronic Pelvic Pain: What’s a Woman to do?
By: Elim Shih, MD • Posted on March 18, 2015
What Is Chronic Pelvic Pain?
Chronic pelvic pain is a condition that affects approximately one in seven women in the United States. It is defined as pain greater than a six months duration located beneath the belly button. As you can imagine, although your physician may make the diagnosis of chronic pelvic pain, further information is required to determine the exact cause (or causes) of your condition. Determining this cause may not be straightforward and often requires multiple visits to your provider. Despite the large number of women who suffer from chronic pelvic pain, research suggests that only one third of them seek care from a doctor. Chronic pelvic pain may be challenging in many different aspects, but the good news is there is a growing knowledge and a better understanding of its causes, its course and its treatment.
What Causes Chronic Pelvic Pain
The causes of chronic pelvic pain can be grouped into categories:
- Gynecologic (ovarian, uterine, fallopian tubes)
- Gastrointestinal (small bowel, colon, rectum)
- Urological (bladder)
- Musculoskeletal (abdominal wall pain, hip pain, pelvic floor pain and back pain)
This is not exhaustive and many women have more than one cause of their pain.
The endometrium is the inner lining of the uterus and is the tissue shed with each menstrual cycle. Endometriosis is a condition where the endometrium is found outside the uterus. The endometrial tissue may attach to the ovary, the bowel, or the fallopian tubes. Symptoms that may suggest endometriosis include:
- Painful periods
- Pain with intercourse
- Pain with bowel movements
- Pain with urinating
Endometriosis and Pregnancy
Because this endometrial tissue can cause scarring inside the pelvis, it may make it more difficult to achieve pregnancy. Some women have the endometrial tissue outside the uterus, but are entirely without symptoms and are able to achieve pregnancy easily. The diagnosis is made by performing a surgery known as a laparoscopy. During the surgery your gynecologist looks inside the abdomen for endometriosis and may remove a small piece of tissue or treat the endometriosis with ablation.
There are many different treatment options available, including:
- Physical Therapy
Also, many women will have complete resolution of their symptoms following menopause.
Similarly, there is a condition in which the endometrial tissue starts to grow into the wall of the uterus called "adenomyosis." Women with this condition may notice heavy bleeding and painful periods. Occasionally, this can usually be suspected by ultrasound imaging, but unfortunately only a surgery in which the uterus is removed can confirm the diagnosis. Your physician may decide to order a saline-infusion sonogram in which the uterus is filled with saline (salt water) and ultrasound pictures are taken. This type of ultrasound can provide more information on abnormalities inside the uterus. Sometimes a pelvic MRI is needed.
Fibroids are benign tumors located within the wall of the uterus. The location of these fibroids within the uterine wall is important to determine as it has implications for treatment. There are sub-serosal fibroids located on the outer most edge of the uterus and intramural fibroids located in the middle of the uterine wall. These types of fibroids generally do not cause significant bleeding. However, if they get large enough, they may cause symptoms including:
- Difficulty urinating
- Passing your bowels
Finally, the submucosal fibroids are along the inner lining of the uterine wall. This type of fibroid can lead to heavy and painful periods. The following are associated with an increased risk of fibroids:
- Genetic factors
- Increased consumption of alcohol
- Increased consumption of red meats
Treatment for Fibroids
Contrary to popular belief, oral contraceptives are generally not associated with any increased risk for fibroids. In fact, they are often used as part of the medical treatment.
Another popular treatment option is an intrauterine device, containing a progestin hormone which can be placed by your physician inside the office. There are different surgical treatments depending on your goals of treatment. Sometimes the fibroid can be removed leaving the uterus in place through a procedure called a myomectomy. Another option includes removal of the entire uterus. Consultation with your surgical gynecologist is important to determine which option is best for you.
Pelvic Inflammatory Disease
Pelvic inflammatory disease (PID) occurs when an infection travels up the genital tract to the uterus, fallopian tubes or ovaries. Common infections include those that are transmitted sexually including:
Many women previously diagnosed and treated with pelvic inflammatory disease suffer from chronic pelvic pain in the future. The infection can result in scarring in the pelvis and damage to the fallopian tubes, ovaries and other organs. Furthermore, this damage can lead to difficulties with achieving pregnancy.
The best way to prevent PID is through:
- Safer sex activities to avoid sexually transmitted infections (STI)
- Use latex condoms consistently
- Avoid douching which can introduce infection into the uterus.
Interstitial cystitis also known as painful bladder syndrome is another common cause of chronic pelvic pain. Research has not identified a single underlying cause for interstitial cystitis, however, it is much more common in women than in men. Symptoms include:
- Painful bladder
- Constant urge to urinate
- Pain with urination
- Unexplained painful intercourse
These symptoms are very similar to a simple urinary tract infection and thus, a thorough evaluation by a urologist, urogynecologist or a specialized gynecologist is imperative before making the diagnosis of interstitial cystitis. Different foods and beverages can aggravate symptoms. These bladder irritants include frequently consumed items such as:
- Spicy foods
- Citrus fruits
- Artificial sweeteners
For some women, avoiding these bladder irritants can diminish symptoms.
Interstitial Cystitis Treatment
Potential treatment options for interstitial cystitis include:
- Medications such as Elmiron
- Calcium citrate supplements
- Bladder instillations
- Implantable electrical stimulation devices under the skin
Physical Therapy to Relax the Pelvic Floor Muscles
The pelvic floor consists of a network of muscles which work to support the weight of your internal organs. Many women are aware of kegel exercises that strengthen pelvic muscles to improve bladder leakage. With chronic pelvic pain, the goal of physical therapy is to RELAX the pelvic floor muscles.
In chronic pelvic pain, the pelvic floor muscles can:
- Become tense
- Tender to touch
Sometimes this is the sole cause of pain, but more often it occurs simultaneously or results from other chronic pelvic pain disorders. Pelvic floor physical therapy is a common treatment for chronic pelvic pain. This type of physical therapy is performed by a therapist with specialized training in the pelvis. The physical therapist can coach patients on how to relax the pelvic floor musculature and use various manual techniques to treat pain and release trigger points of muscle tension.
Treating Chronic Pelvic Pain
Chronic pelvic pain may be difficult, BUT it is also treatable. You should first seek counsel from your primary care physician who may recommend a chronic pelvic pain specialist in your local area. You may need to visit a gastroenterologist if irritable bowel syndrome is thought to be a problem. Often a team of physicians may work together to treat your pain. Those physicians include:
- Pain medicine specialist
These "multi-disciplinary" clinics are available at select locations. Chronic pelvic pain, like any other chronic pain disorder, can be very complex and challenging. In general, chronic opiate use is not the answer. Often the realistic goal of treatment is to reduce, but not eliminate the pain and to improve your quality of life. Quick, immediate fixes are rare in this setting, so don't be discouraged as you begin your treatment!
Be Strong, Be Healthy, Be in Charge!
-Elim Shih, MD
To make an appointment with a Chronic Pelvic Pain Specialist at Cleveland Clinic:
Abigail Smith, CNP
Certified Nurse Practitioner, Obstetrics and Gynecology
Chronic Pelvic Pain and Urogynecology
(Please note that Chronic Pelvic Pain referral patients need a consult order for "Gyn Pelvic Pain" from their PCP or referring doctor.)
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- Are You at Risk for Uterine Fibroids?
- Endometriosis: More Treatment Options than Ever
- What Causes Female Sexual Pain?