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Pelvic Pain

By

David H. Barad

, MD, MS, Center for Human Reproduction

Last full review/revision Apr 2020| Content last modified Apr 2020
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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.

Pelvic pain can be a gynecologic symptom. That is, it can result from a disorder affecting the female reproductive system.

The pain may be sharp or crampy (like 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).

Causes of Pelvic Pain

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 what is causing pelvic pain.

Gynecologic disorders

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

Fibroids Fibroids A fibroid is a noncancerous tumor composed of muscle and fibrous tissue. It is located in the uterus. Fibroids can cause pain, abnormal vaginal bleeding, constipation, repeated miscarriages... read more Fibroids in the uterus are noncancerous tumors composed of muscle and fibrous tissue. They can cause pelvic pain if they are degenerating or cause excessive bleeding or cramping. Most uterine fibroids do not cause pain.

Other disorders

Other common causes of pelvic pain include

Psychologic factors, especially stress and depression Depression A short discussion of prolonged grief disorder. Depression is a feeling of sadness and/or a decreased interest or pleasure in activities that becomes a disorder when it is intense enough to... read more , 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 of Pelvic Pain

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 usually require emergency surgery include

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:

When to see a doctor

Women with most 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 menstrual cramps are normal. Menstrual cramps do not require evaluation unless they are very painful.

What the doctor 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 Gynecologic Causes of Pelvic Pain Some Causes of Pelvic Pain in Women* 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... read more ).

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,

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 Gynecologic Examination For gynecologic care, a woman should choose a health care practitioner with whom she can comfortably discuss sensitive topics, such as sex, birth control, pregnancy, and problems related to... read more . This evaluation helps doctors determine which organs are affected and whether an infection is present. Often, doctors also check the rectum for abnormalities.

Table
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Testing

The following tests are routinely done:

  • Urine tests (urinalysis)

  • A urine pregnancy test if women are of childbearing age

The same urine sample can be used for a pregnancy test. 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.

If a urine pregnancy test indicates that the woman is pregnant, ultrasonography is done to rule out an ectopic pregnancy. For ultrasonography, doctors use a handheld ultrasound device that is placed on the abdomen or inside the vagina.. Ultrasonography of the pelvis is done for many reasons. It is whenever doctors think a gynecologic disorder may be the cause of the symptoms and the symptoms have begun suddenly, recur, or are severe.

If results of ultrasonography are unclear, other tests, such as a series of blood tests or laparoscopy, are done to rule out ectopic pregnancy. For the blood tests, doctors measure levels of a hormone produced by the placenta called human chorionic gonadotropin (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. For laparoscopy, doctors make a small incision just below the navel and insert a viewing tube (laparoscope) to directly look for an ectopic pregnancy or other causes of pelvic pain.

Tests depend on which disorders are suspected. Tests may include

Treatment of Pelvic Pain

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, hysterectomy (surgery to remove the uterus) can be done, but it may be ineffective.

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

Common disorders in older women include

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 organ prolapse, which may cause symptoms as 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 (prolapse).

Older women are more likely to take drugs (especially opioids) that can cause painful constipation.

In older women, the lining of the vagina thins and dries after menopause. This condition (called atrophic vaginitis) may make sexual intercourse painful, and women may describe or experience this pain as pelvic pain.

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.

To check for age-related thinning of the vaginal lining, 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, or they may prescribe an estrogen cream Forms of hormonal therapy Menopause is the permanent end of menstrual periods and thus of fertility. For up to several years before and just after menopause, estrogen levels fluctuate widely, periods become irregular... read more Forms of hormonal therapy .

Key Points about Pelvic Pain

  • 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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