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Pelvic Pain

by David H. Barad, MD, MS

Pelvic pain is discomfort that occurs in the lowest part of the torso, the area below the abdomen and between the hipbones. It does not include pain that occurs externally in the genital area (vulva). Many women have pelvic pain. Pain is considered chronic if it continues to occur for more than 4 to 6 months.

The pain may be sharp or crampy (like menstrual cramps—see Menstrual Cramps) and may come and go. It may be sudden and excruciating, dull and constant, or some combination. The pain may gradually increase in intensity, sometimes occurring in waves. Often, pelvic pain occurs in cycles that coordinate with the menstrual cycle. That is, pain may occur every month just before or during menstrual periods or in the middle of the menstrual cycle, when the egg is released (during ovulation).

The pelvic area may feel tender when touched. Depending on the cause, women may have bleeding or a discharge from the vagina. The pain may also be accompanied by fever, nausea, vomiting, sweating, and/or light-headedness.

Causes

Usually, pelvic pain is not caused by a serious disorder. It is often related to the menstrual cycle. However, several disorders that cause pelvic pain can lead to peritonitis (inflammation and usually infection of the abdominal cavity), which is a serious disorder.

Disorders that can cause pelvic pain include

  • Gynecologic disorders—those that affect the reproductive organs (vagina, cervix, uterus, fallopian tubes, and ovaries)

  • Disorders that affect other organs in the pelvis, such as the bladder, rectum, or appendix

  • Disorders that affect organs near but outside the pelvis, such as the abdominal wall, intestine, kidneys, ureters, or lower part of the aorta

Often, doctors cannot identify a disorder.

Gynecologic disorders

Gynecologic disorders may be related to the menstrual cycle or not. The most common causes include

  • Menstrual cramps (dysmenorrhea)

  • Pain in the middle of the menstrual cycle (mittelschmerz), occurring during ovulation

  • Endometriosis (abnormally located patches of tissue that is normally located only in the lining of the uterus)

Many other gynecologic disorders can cause pelvic pain (see Table: Some Causes of Pelvic Pain in Women).


Other disorders

Common causes include

  • Digestive tract disorders: Irritable bowel syndrome, gastroenteritis, inflammatory bowel disease, appendicitis, diverticulitis, constipation, a blockage or tear (perforation) in the intestine, collections of pus (abscesses), and tumors (cancerous or not), such as colon cancer

  • Urinary disorders: Infections (such as cystitis), stones in the urinary tract (such as kidney stones), and inflammation of the bladder without infection (such as interstitial cystitis)

  • Musculoskeletal disorders: Separation of the pubic bones after delivery of a baby, fibromyalgia, and strained abdominal muscles

  • Other disorders: Abscesses in the pelvis and a bulge in the lower part of the aorta (abdominal aortic aneurysm)

Psychologic factors, especially stress and depression, may contribute to any kind of pain, including pelvic pain, but, by themselves, rarely cause pelvic pain.

Many women with chronic pelvic pain have been physically, psychologically, or sexually abused. Young girls who have been sexually abused may have pelvic pain. In such women and girls, psychologic factors may contribute to the pain.


Evaluation

When a woman has new, sudden, very severe pain in the lower abdomen or pelvis, doctors must quickly decide whether emergency surgery is required. Disorders that require emergency surgery include appendicitis, a ruptured ectopic pregnancy (an abnormally located pregnancy—not in its usual place in the uterus), twisting of an ovary, a ruptured abscess in the pelvis, a tear in the intestine, and an abdominal aortic aneurysm.

Doctors check for pregnancy in all girls and women of childbearing age.

Warning signs

In women with pelvic pain, certain symptoms are cause for concern:

  • Light-headedness, sudden loss of consciousness however brief (fainting, or syncope), or dangerously low blood pressure (shock)

  • Vaginal bleeding after menopause

  • Fever or chills

  • Sudden, severe pain, especially when accompanied by nausea, vomiting, excessive sweating, or agitation


When to see a doctor

Women with warning signs should see a doctor immediately. However, if the only warning sign is vaginal bleeding after menopause, women can see a doctor within a week or so.

If women without warning signs have new pain that is constant and steadily worsening, they should see a doctor that day. If such women have new pain that is not constant and is not worsening, they should schedule a visit when practical, but a delay of several days is usually not harmful.

Recurring or chronic pelvic pain should be evaluated by a doctor at some point. Mild cramping and pain associated with menstrual periods is normal and does not require evaluation unless it is very painful (see Menstrual Cramps).


What the doctors does

After making sure that the woman does not require emergency surgery, doctors ask the woman questions about her symptoms and medical history. Doctors then do a physical examination. What they find during the history and physical examination often suggests a cause and the tests that may need to be done (see Table: Some Causes of Pelvic Pain in Women).

Doctors ask about the pain:

  • Whether it begins suddenly or gradually

  • Whether it is sharp or dull

  • How severe it is

  • When it occurs in relation to the menstrual cycle, eating, sleeping, sexual intercourse, physical activity, urination, and bowel movements

  • Whether any other factors worsen or ease the pain

The woman is asked about other symptoms, such as vaginal bleeding, a discharge, and light-headedness.

The woman is asked to describe past pregnancies and menstrual periods. Doctors also ask whether she has had any disorders that can cause pelvic pain and whether she has had abdominal or pelvic surgery.

Doctors may ask about stress, depression, and other psychologic factors to determine whether these factors may be contributing to the pain, especially if the pain is chronic.

Certain groups of symptoms suggest a type of disorder. For example,

  • Fever and chills suggest an infection.

  • A vaginal discharge suggests pelvic inflammatory disease.

  • Loss of appetite, nausea, vomiting, or relief or worsening of the pain during a bowel movement suggests a digestive tract disorder.

  • Vaginal bleeding suggests menstrual cramps, an ectopic pregnancy, or a possible miscarriage.

Menstrual cramps are diagnosed only after other, more serious causes are ruled out.

The physical examination focuses on the abdomen and pelvis. Doctors gently feel the abdomen and do a pelvic examination. This evaluation helps doctors determine which organs are affected and whether an infection is present. Often, doctors also check the rectum for abnormalities.

Some Causes of Pelvic Pain in Women

Cause

Common Features*

Tests

Related to the menstrual cycle

Menstrual cramps (dysmenorrhea)

Sharp or crampy pain that

  • Occurs a few days before or during menstrual periods

  • Is most intense about 24 hours after periods begin and subsides after 2–3 days

Often headache, nausea, constipation, diarrhea, or an urge to urinate often (urinary frequency)

A doctor's examination

Endometriosis (abnormally located patches of tissue that is normally located only in the lining of the uterus)

Sharp or crampy pain that occurs before and during the first days of menstrual periods

Often pain during sexual intercourse and/or bowel movements

May eventually cause pain unrelated to the menstrual cycle

Sometimes infertility

A doctor's examination

Sometimes laparoscopy (insertion of a thin viewing tube into the abdomen) to check for abnormal tissue and to obtain a sample

Mittelschmerz (pain in the middle of the menstrual cycle)

Severe, sharp pain that

  • Begins suddenly

  • Can occur on either side but on only one side at a time

  • Occurs at the same time during the menstrual cycle, usually midway between the start of menstrual periods (when the egg is released)

  • Is most intense when it begins, then subsides over 1–2 days

Often light spotty bleeding

A doctor's examination

Related to the reproductive system but not the menstrual cycle

Pelvic inflammatory disease

Aching pelvic pain that may be felt on one or both sides

Usually a vaginal discharge that sometimes has a foul odor and, as infection worsens, can become puslike and yellow-green

Sometimes pain during urination and/or sexual intercourse, fever or chills, nausea, or vomiting

Tests to detect sexually transmitted diseases using a sample of secretions taken from the cervix

Sometimes ultrasonography of the pelvis

A ruptured ovarian cyst

Pain that

  • Begins suddenly

  • Is most severe when it begins

  • Often rapidly decreases over a few hours

Sometimes light-headedness, fainting, slight vaginal bleeding, nausea, or vomiting

A doctor's examination

Sometimes ultrasonography of the pelvis

A ruptured ectopic pregnancy (an abnormally located pregnancy—not in its usual place in the uterus)

Constant (not crampy) pain that

  • Begins suddenly

  • Is at first confined to one area of the lower abdomen

Often slight vaginal bleeding

Sometimes light-headedness, fainting, a racing heart, or dangerously low blood pressure (shock) due to severe internal bleeding

Urine or blood tests to measure a hormone produced by the placenta (called human chorionic gonadotropin, or hCG)

Ultrasonography of the pelvis

Sometimes laparoscopy or laparotomy (a large incision into the abdomen enabling doctors to directly view organs)

Sudden degeneration of a fibroid in the uterus

Pain that begins suddenly

Most common during the first 12 weeks of pregnancy or after delivery or termination of a pregnancy

Vaginal bleeding

Ultrasonography of the pelvis

Adnexal torsion (twisting) of an ovary

Severe pain that

  • Begins suddenly

  • Occurs on one side

  • Peaks quickly

Occasionally pain that comes and goes (as the ovary twists and untwists)

Often occurs when women are pregnant, after drugs are used to treat infertility, or when ovaries are enlarged

Ultrasonography of the pelvis

Sometimes laparoscopy or laparotomy

Cancer of the ovaries or the lining of the uterus (endometrium)

Pain that develops gradually

Abnormal vaginal bleeding (bleeding after menopause or bleeding between menstrual periods) or a brown or bloody discharge

Sometimes weight loss

A Papanicolaou (Pap) test

Ultrasonography of the pelvis

A biopsy

Sometimes imaging tests of the pelvis such as MRI or CT

Adhesions (bands of scar tissue between normally unconnected structures in the uterus or pelvis)

Pelvic pain that

  • Develops gradually

  • Often becomes chronic

Pain during sexual intercourse

No vaginal bleeding or discharge

Sometimes nausea and vomiting (suggesting a blockage of the intestine)

In women who have had abdominal surgery (usually) or pelvic infections (sometimes)

A doctor's examination

Sometimes x-rays of the abdomen

A miscarriage (spontaneous abortion) or one that may occur (threatened abortion)

Crampy pain in the pelvis or back accompanied by vaginal bleeding

Other symptoms of early pregnancy such as breast tenderness, nausea, and absence of periods

Sometimes passage of tissue through the vagina

A pregnancy test

Ultrasonography of the pelvis to determine whether a miscarriage has occurred and, if not, whether the pregnancy can continue

Not related to the reproductive system

Appendicitis

Pain that usually settles in the lower right part of the abdomen

Loss of appetite and usually nausea and vomiting

Often fever

A doctor's examination

Sometimes CT or ultrasonography of the abdomen

Bladder infection

Pain just above the pubic bone

Sometimes an urgent need to urinate, more frequent urination, or burning during urination

A urine test

Diverticulitis

Pain or tenderness in the lower left part of the abdomen

Fever

Sometimes CT of the abdomen

Often colonoscopy after the infection subsides

Inflammatory bowel disease including

  • Crohn disease

  • Ulcerative colitis

Crampy abdominal pain

Diarrhea, which in ulcerative colitis is often bloody

Loss of appetite and weight

CT of the small and large intestine (CT enterography) to check for Crohn disease

Endoscopy (usually colonoscopy or sigmoidoscopy)

Sometimes x-rays of the upper digestive tract after barium is given by mouth (barium swallow) or of the lower digestive tract after insertion of barium into the rectum (barium enema)

Stones in the urinary tract

Excruciating intermittent pain in the lower abdomen, side, or lower back, depending on the stone's location

Nausea and vomiting

Blood in the urine

Urine tests (urinalysis)

Imaging tests, such as CT or ultrasonography

* Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present.

If women are of childbearing age, a pregnancy test is always done, regardless of the cause suspected. If symptoms have begun suddenly, recur, or are severe, ultrasonography of the pelvis is usually done. Typically, doctors also do a urine test to look for a urinary tract infection.

CT = computed tomography; MRI = magnetic resonance imaging.


Testing

The following tests are done:

  • Urine tests (urinalysis)

  • A urine test for pregnancy if women are of childbearing age

If a urine pregnancy test indicates that the woman is pregnant, ultrasonography is done to rule out an ectopic pregnancy. If results of ultrasonography are unclear, other tests, such as laparoscopy or a series of blood tests, are done to rule out ectopic pregnancy. For laparoscopy, doctors make a small incision just below the navel and insert a viewing tube (laparoscope) to look for an ectopic pregnancy directly. For the blood tests, doctors measure levels of a hormone produced by the placenta (human chorionic gonadotropin, or hCG). If hCG levels are low, the pregnancy may be too early for ultrasonography to detect. If levels are high and ultrasonography does not detect a pregnancy, ectopic pregnancy is possible.

If a very early pregnancy is possible and the urine test is negative, a blood test for pregnancy is done. The blood test is more accurate than the urine test when a pregnancy is less than 5 weeks.

Ultrasonography of the pelvis is usually done when doctors think a gynecologic disorder may be the cause and symptoms have begun suddenly, recur, or are severe. Ultrasonography is also done when a tumor is suspected. Doctors use a handheld ultrasound device that is placed on the abdomen or inside the vagina.

Other tests depend on which disorders are suspected. Tests may include

  • Examination and culture of samples of urine or a discharge to check for infections that can cause pelvic pain

  • Computed tomography (CT) or magnetic resonance imaging (MRI) of the abdomen and pelvis

  • If other tests do not identify a cause, laparoscopy


Treatment

If the disorder causing pelvic pain is identified, that disorder is treated if possible. Pain relievers may also be needed.

Initially, pain is treated with nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. Women who do not respond well to one NSAID may respond to another. If NSAIDs are ineffective, other pain relievers or hypnosis may be tried. If the pain involves muscles, rest, heat, or physical therapy may help.

Rarely, when women have severe pain that persists despite treatment, surgery to cut the nerves to the uterus may be done. However, this operation occasionally injures other organs in the pelvis, such as the ureters. If pain still persists, hysterectomy (surgery to remove the uterus) can be done, but it may be ineffective or even worsen the pain.

Essentials for Older Women

In older women, common causes of pelvic pain may be different because some disorders that cause pelvic pain become more common as women age, particularly after menopause. These disorders include

  • Bladder problems, including infections

  • Constipation

  • Diverticulosis

  • Pelvic floor disorders

  • Many cancers of the reproductive tract, including cancers of the lining of the uterus (endometrial cancer), fallopian tubes, ovaries, and vagina

After menopause, estrogen levels decrease, weakening many tissues, including bone, muscles (such as those of the bladder), and tissues around the vagina and urethra. As a result, fractures and bladder infections become more common. Also, this weakening may contribute to pelvic floor disorders, which may cause symptoms only when women become older. In these disorders, weakened or damaged tissues in the pelvis can no longer hold the uterus, vagina, or other organs in the pelvis in place. As a result, one or more of these organs may drop down (see Pelvic Floor Disorders).

Older women are more likely to take drugs that can increase the risk of some causes of pelvic pain, such as constipation and diverticulosis.

Obviously, disorders related to menstrual periods are no longer possible causes.

Evaluation

Evaluation is similar to that for younger women, except doctors pay particular attention to symptoms of urinary and digestive tract disorders. Older women should see a doctor promptly if they

  • Suddenly lose weight or their appetite

  • Suddenly start having indigestion

  • Have a sudden change in bowel movements

The doctor then does an examination to make sure that the cause is not ovarian or endometrial cancer.

Sexual intercourse may cause pain in older women (because the lining of the vagina thins and dries after menopause), and women may describe or experience this pain as pelvic pain. To check for this cause, doctors ask the woman questions to determine whether she is sexually active. If so, doctors may recommend a break from sexual intercourse until symptoms subside.


Key Points

  • Many women have pelvic pain.

  • Many disorders (related to reproductive organs or other nearby organs) can cause pelvic pain.

  • Doctors can determine likely causes based on a description of the pain, its relationship to the menstrual cycle, and results of a physical examination.

  • If women are of childbearing age, a pregnancy test is always done.

  • Urine tests and usually other tests, such as blood tests and ultrasonography of the pelvis, are done to confirm the suspected diagnosis.

  • Menstrual cramps are a common cause of pelvic pain but are diagnosed only after other causes have been ruled out.

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