Chronic pelvic pain (CPP) can be a debilitating condition for women affecting many aspects of life. Find out what causes chronic pelvic pain, the symptoms & integrated care is the best way to manage this condition.
What is Chronic pelvic pain?
Chronic pelvic pain is estimated to affect up to 26% of the world’s female population. Chronic pelvic pain is pain experienced in the pelvis, that lasts for over 6 months.
CPP can be cyclical or non-cyclical i.e. it may or may not be related to the menstrual cycle). It is often associated with difficulties with mental and emotional health and challenges for sexual function and enjoyment. It can have significant impact on women’s quality of life.
It is defined by the American College of Gynecologists (ACOG 2020) as:
“pain symptoms perceived to originate from pelvic organs/structures typically lasting more than 6 months. It is often associated with negative cognitive, behavioral, sexual and emotional consequences as well as with symptoms suggestive of lower urinary tract, sexual, bowel, pelvic floor, myofascial, or gynecological dysfunction”
The pelvis is the lower part of the abdomen below the belly button. It is bound by the pelvic bones, the pelvic floor muscles, the abdominal wall and back muscles. At the top it is continuous with the rest of the abdominal cavity.
The female pelvis typically contains the vagina, uterus, fallopian tubes and ovaries. It also contains the urethra and bladder, and the anus, rectum large bowel and some small bowel.
The organs and tissues of the pelvis are in close physical proximity to each other and are closely interconnected by a spider web-like nerve network.
Signs and symptoms of chronic pelvic pain syndrome.
Women with chronic pelvic pain can experience a variety of symptoms associated with the:
- pelvic organs such as uterus, bowel, bladder, urethra, peritoneum
- pelvic nerves
- pelvic muscles, bones, fascia
- pelvic skin and nerves
Women with pelvic pain can also experience general body symptoms including pain elsewhere in the body, such as headaches and muscle pain, fatigue, low mood and anxiety.
Common symptoms include:
- pelvic, vulvovaginal pain described as ache, pressure, sharp, burning pain
- pelvic pressure
- urinary frequency
- needing to urgently pee or pass bowel movements
- bloating, nausea, constipation, or diarrhea
- pain associated with altered form or frequency of the bowel motion
- pain with sexual intercourse
- heavy or irregular periods
Some women also experience central sensitization symptoms such as:
- pain at multiple sites outside the pelvis
- sleep disturbances
- repeatedly thinking about pain
- worrying about the pain and the impacts on life
- pain to non-painful stimuli
Causes of chronic pelvic pain syndrome
There are many conditions that cause chronic pelvic pain, the most common ones involving pelvic organs include:
Endometriosis – With endometriosis, women often have pain associated with their periods that becomes worse over time or where they have pain for longer than the first 2 days of their cycle or debilitating pain.
Dysmenorrhea – Painful periods that lasts 1-2 days per cycle, usually a day before or first 2 days of your period. High levels of prostaglandins (pain chemicals) in the pelvis contributes to this type of pain.
Fibroids – Fibroids are non-cancerous growths on or in the uterus. They can cause pain due to cause pain or pressure in the pelvis or back.
Pelvis inflammatory Disease (PID)– PID is an infection of the reproductive tract. You may have pain, vaginal discharge or fever. Some women experience no symptoms.
Pelvic adhesions – Women who have had surgery can develop adhesions/scan tissue that connects pelvic organs to each other and this can be a source of pain in some women.
Pelvic congestion syndrome – This conditions is associated with enlarged veins in the pelvic region and can be associated with pregnancies. Women may have a dragging, pressure feeling in the pelvis around menstruation, varicose veins in the legs and vulva.
Gut conditions – Irritable bowel syndrome is one of the most gut common conditions associated with pelvic pain. It may also be accompanied by constipation, diarrhea or both. Inflammatory bowel disease and diverticular disease can also be a source of chronic pelvic pain.
Urinary tract conditions – Interstitial cycsitits or bladder pain syndrome is a common cause of chronic pelvic pain. kidney stones, recurrent urinary tract infections (UTIs), and cancer of the bladder can also cause pelvic pain.
Musculoskeletal Conditions – There is a wide variety of musculoskeletal causes of chronic pelvic pain including:
- Lower back pain, disk injuries, and pelvic muscle spasms.
- Carry extra weight that strains joints and muscles of the pelvis.
- Pregnancy can stretch/strain ligaments in the pelvis and spine as well as weaken the abdominal wall muscles. Pain that starts during pregnancy or right after pregnancy could indicate peripartum pelvic pain syndrome.
- Poor posture can contribute to pelvic pain.
- Myofascial pain syndrome is a condition in which tender spots in the muscle, called trigger points, cause pain in nearby areas of the body.
Centers that specialize in chronic pelvic pain report that 50-90% of women have pain that involves musculoskeletal structures so it is essential to see a women’s physical therapist to address this alongside any treatment directed towards specific conditions (Sedighimehr 2018).
Multiple Conditions can cause Chronic Pelvic Pain
Many women with chronic pelvic pain have overlapping conditions for example among women with bladder pain syndrome;
- 48% also have endometriosis,
- 30-75% also have irritable bowel syndrome (Lamvu 2021)
Despite different names and categories for diagnosing, there are overlapping mechanisms of chronic pain disorders including:
- Altered function of neuroendocrine (nerve-hormonal system), immune system and neurotransmitter, central nervous system (brain and spinal cord) and the peripheral nervous system (peripheral nerves – somatic and autonomic).
- Adverse childhood experiences and traumatic experiences such as sexual or physical abuse
- Psychological distress, mood and anxiety difficulties and difficult reactions to stress.
Because of these common mechanisms, more recent approaches to treatment focus on body system involvement in pelvic pain rather than specific diagnosis. The body systems that can be involved in chronic pelvic pain include:
- Reproductive systems – conditions of ovary, uterus, fallopian tubes, vagina, vulva
- Gastrointestinal system – large lower, rectum, anus
- Urinary system – urethra, bladder, ureter
- Musculoskeletal system- pelvic floor, abdominal muscles, back muscles
- Peripheral nerve system – nerves that innervate the pelvic organs, muscles, bones, fascia
- central nerve system – spinal cord and brain,
It is important to understand that organs (such as bowel, bladder and uterus) and body structures (skin, muscles, fascia and bone) in the pelvis share neural pathways.
Just as a person experiencing a heart attack could present with jaw or arm or chest pain or all three, women with chronic pelvic pain can experience pain from multiple organs or muscles because of the interconnectivity of each system.
Viscero-viscero cross sensitization in chronic pain
Additionally women experience organ to organ cross sensitization. This means 1 organ can hypersensitize another organ. For example if the uterus is contracting due to menstrual cramps, some women can also experience bowel or bladder cramping.
Viscero-somatic convergence in Chronic pain
Women can also experience organ to musculoskeletal convergence. This is when persistent pain messages from body organs can painfully irritate the musculoskeletal system producing increased muscle tension, muscle pain, and widespread pelvic, abdominal or lower back muscle dysfunction.
Likewise women who have malfunctioning pelvic floor muscles from injury, surgery or pregnancy can develop pelvic organ dysfunction.
Central Sensitization in CHronic pelvic pain
Over time as these mechanisms develop, there can be a strengthening of pain input into the spinal cord and up to the brain, and at the same time a reduction in pain inhibition signals from the brain, reinforcing and increasing pain hypersensitivity.
It also contributes to widespread pain (outside the pelvis), poor sleep, low mood, poor capacity to cope with the pain. Central sensitization also makes women susceptible to other pain conditions including:
- irritable bowel syndrome
- chronic low back pain
- temporomandibular joint (TMJ) disorder
- chronic fatigue syndrome
Risk factors of chronic pelvic pain syndrome
Risk factors are common factors found in women with chronic pelvic pain. They are not necessarily causal, in fact many of the risk factors may come about due to pain. However understanding risk factors helps your clinician create a comprehensive care plan that includes treatment for all relevant aspects of your wellbeing.
Trauma and chronic pelvic pain
The relationship between chronic pelvic pain and trauma is complex. Compared with pain-free women, women with chronic pelvic pain are more likely to have experienced:
- childhood physical abuse (4.3x more likely)
- childhood sexual abuse (4x more likely)
- childhood verbal or emotional abuse (3.2x more likely Krantz 2019).
Factors that increase pain and reduce quality of life with chronic pelvic pain include:
- fearing/worrying about the pain
- feeling helpless
These are important factors for you clinical team to know about so they can incorporate management of these into you care plan.
Other Risk factors in chronic pelvic pain
A large systematic review of 122 studies looked at risk factors in women with chronic pelvic pain (Latthe 2006). It identified a number of factors associated with increased and decreased risk of cyclical and non-cyclical pain.
Risk factors associated with an increased risk of period-related or cyclical chronic pelvic pain included:
- Age < 30 years,
- low body mass index,
- earlier menarche (< 12 years),
- longer cycles,
- heavy menstrual flow,
- premenstrual syndrome,
- clinically suspected pelvic inflammatory disease, including chronic pelvic inflammatory disease
- sexual abuse,
- psychological symptoms
Risk factors associated with a reduced risk of period-related or cyclical chronic pelvic pain included:
- Younger age at first childbirth,
- oral contraceptive use.
Risk factors associated with an increased risk of chronic vaginal pain occurring during or after sex included:
- pelvic inflammatory disease,
- sexual abuse,
- depression were associated with dyspareunia.
Risk factors for non-cyclical pelvic pain includes:
- Drug or alcohol abuse,
- heavy menstrual flow,
- pelvic inflammatory disease,
- previous caesarean section,
- pelvic pathology,
- psychological conditions.
Pelvic pain and pain related to sex are also more common in women with a lack of support, social stressors, and relationship discord (ACOG 2020).
Visiting your doctor
When you visit your doctor they will need to take a comprehensive history of the nature of your pain, the risk factors and associated symptoms to assess what systems are involved in your chronic pelvic pain.
A physical examination will include an examination of your back and abdomen. If you consent, you will also be offered an pelvic exam of your vulva and perineum (the area between the legs) and an internal exam to assess the vagina, cervix, uterus and ovaries as well as the pelvic floor muscles.
Investigations for Chronic Pelvic Pain
Investigations are mainly carried out to discover anatomical disease such as endometriosis, fibroids, infections etc. Many functional pelvic pain causes are best uncovered by a complete history-taking.
Some of the basic investigations your clinician may carry out include:
- routine bloods,
- a pregnancy test
- urine test
- vaginal swabs for STI, thrush, bacterial vaginosis and chronic pelvic inflammatory disease (ureaplasma and mycoplasma)
- cervical smear
Some women may need more intensive investigations including a pipelle biopsy of the endometrium (a sample taken from the lining of the uterus).
Imaging for Chronic Pelvic Pain
Current guidelines suggest that the first-line imaging for chronic pelvic pain is transvaginal ultrasound. However this could be extremely uncomfortable for some patients with chronic pelvic pain, especially those who experience vaginal pain or pelvic floor pain. It is also operator dependent, so experienced operators can detect signs of endometriosis which may be missed by those not trained to detect this.
MRI can also be performed, especially for those who would not tolerate a transvaginal ultrasound.
Laparoscopy for Chronic pelvic pain.
The role of laparoscopy (surgery) for chronic pelvic pain is controversial, in that 40 percent do not find any pathology, so subjecting women to surgery which in itself can contribute to adhesions (scar tissue), nerve hypersensitivities and low grade inflammation in the pelvic region in an already sensitized pelvis.
Integrative Care of Chronic Pelvic pain in WOmen
Chronic Pelvic pain is not as simple as just using pain relief. CPP is best managed by a multidisciplinary team approach (Lamvu 2021). Women who experience chronic pelvic pain benefit immensely from a treatment program that addresses all the factors known to influence the experience of pain.
Addressing these factors is beneficial for reducing pain that is manifest in all systems including central nervous system sensitization. An effective chronic pain treatment plan should include:
- education about pelvic anatomy and pain education
- whole food, anti-inflammatory diet or nutritional therapy – especially if there is gut involvement
- pelvic floor physical therapy/physiotherapy and rehabilitation
- stress reduction techniques including mindfulness and meditation
- cognitive behavioral therapy
- therapies to address trauma exposure
- personalized plan to manage triggers and flares
Additionally therapies can be directed to specific organ systems.
- Diarrhea predominant IBS: antispasmodics including peppermint oil, anti-depressant, Lactobacillus and Bifidobacterium combination probiotics
- Constipation predominant IBS: moderate fiber intake
- Medications such as amitriptyline, cimetidine or hydroxyzine
- Intravesical (in the bladder) instillations of heparin, dimethyl sulfoxide or lidocaine
- Botox injections
- Spinal cord neuromodulation
- continuous combined birth control pills (no sugar pills), progestins,
- hormone blocking agents (GnRH agonists or antagonists),
- aromatase inhibitors,
- surgery – excision or ablation, hysterectomy (uterus removal) or oophorectomy (ovary removal).
- heat packs, hot water bottle
- nonsteroidal anti inflammatory drugs
- continuous birth control
- hormone blockers (GnRH agonists or antagonists) + hormone replacement therapy
Musculoskeletal system (Pelvic floor/abdominal wall, lower back myalgias)
- physical therapy
- TENS, biofeedback, ultrasound, laser, vaginal dilators
- Medications: nonsteroidal anti inflammatory drugs, muscle relaxants
- Suppression of menstrual cycle if cyclical
- Injections using saline, anesthetics or botox
- 1st line medications: gabapentin/pregabalin or duloxetine/venlafaxine or amitriptyline
- 2nd line medications: capsaicin 8% patch, lidocaine patch
- 3rd line: botulinum
- Other: nerve block, epidural injection, surgical nerve release.
Herbal therapies for chronic pelvic pain relating to pelvic floor/vagina include:
Curcumin 350mg and Calendula 80mg extract suppository – this was tested in males in a phase II clinical trial with chronic pelvic pain and given as a 1 rectal suppository daily for 1 month (Morgia 2017). The treatment was associated with a significant reduction in pain and sexual function. Both herbs act as powerful anti-inflammatories and local application of these substances may reduce inflammatory cytokines which contribute to mediating pain signals. Further research applying this treatment to women is important.
Chronic Pelvic Pain is an important and significant health issue for women and deserves more research into effective integrated treatments to help women have reduced pain and improved quality of life.
For more information about Chronic Pelvic Pain see International Pelvic Pain Society
By Dr Deborah Brunt. Last updated 01/06/2022
ACOG Committee on Practice Bulletins–Gynecology; ACOG Practice Bulletin No. 218. Chronic pelvic pain. Obstet Gynecol. 2020;135(3):e98-e109.
Krantz TE, Andrews N, Petersen TR, et al. Adverse Childhood Experiences Among Gynecology Patients With Chronic Pelvic Pain. Obstet Gynecol. 2019;134(5):1087-1095.
Latthe P, Mignini L, Gray R, Hills R, Khan K. Factors predisposing women to chronic pelvic pain: systematic review. BMJ. 2006;332(7544):749-755.
Lamvu G, Carrillo J, Ouyang C, Rapkin A. Chronic Pelvic Pain in Women: A Review. JAMA. 2021;325(23):2381–2391.
Morgia G, Russo GI, Urzì D, et al. A phase II, randomized, single-blinded, placebo-controlled clinical trial on the efficacy of Curcumina and Calendula suppositories for the treatment of patients with chronic prostatitis/chronic pelvic pain syndrome type III. Arch Ital Urol Androl. 2017;89(2):110-113.
Sedighimehr N, Manshadi FD, Shokouhi N, Baghban AA. Pelvic musculoskeletal dysfunctions in women with and without chronic pelvic pain. J Bodyw Mov Ther. 2018;22(1):92-96.