Part of being a woman involves dealing with discomfort in the pelvic region at one point or another. For some women, it may entail monthly menstrual cramps that are short-lived and manageable. For others, pain can linger and be quite severe, possibly signaling a condition known as chronic pelvic pain.

Women with chronic pelvic pain experience discomfort anywhere below the belly button and between the hip bones for six months. The pain can vary. For some, sharp and stabbing pain (sometimes similar to menstrual cramping) comes and goes. For others, it’s steady and dull, like a mild stomach ache. 

Often, pelvic pain can make it hard to live the kind of life you want, interfering with your ability to work, exercise, or have sex.

Chronic pelvic pain can be a symptom of a gynecologic problem, including endometriosis (when tissue that normally lines the uterus grows outside the uterus) or adenomyosis. It can also occur in certain conditions that affect the bladder, intestines, the muscles in the pelvic floor, or even your spine. Often, multiple sources of pain can be identified at the same time. Sometimes, the cause of chronic pelvic pain remains unknown.

While not understanding the source of your pain can be frustrating, our Yale Medicine physicians are skilled at determining an appropriate treatment plan. We can help alleviate your symptoms using a variety of options, from medications to surgery, to get you back to your normal activities.

“It all begins with a full medical history and thorough physical exam. Once we identify the possible sources, we can start treatment. Sometimes we can cure their pain. For others, we may have to focus on improving their symptoms,” says Linda Fan, MD, director of Yale Medicine Gynecologic Specialties. “We believe in listening to our patients and building trust in order to maintain a therapeutic relationship.” 

Pain in the lower abdominal area and pelvis is the universal symptom of chronic pelvic pain, but the severity and specifics of the pain can vary widely. It may be intense and sudden and occur in a specific spot, or it can be a more widespread, dull pain. The pain can be constant, or it can come and go.

For some women, pain is felt internally (an ache inside the uterus, for example); for others, the discomfort is external (a pelvic area that is tender to the touch). Vaginal bleeding or discharge, as well as fever, nausea, vomiting, sweating, and/or dizziness may also be present. Some women experience pelvic pain when they need to use the bathroom or if they lift something heavy.

Many conditions (and usually a combination of several different conditions) are associated with chronic pelvic pain. For example, a woman might have irritable bowel syndrome (IBS) and endometriosis, both of which cause pelvic pain. Sometimes, though, the cause remains unknown.

“There are many causes of chronic pelvic pain, and a patient is not necessarily going to be able to know exactly where the pain is coming from,” Dr. Fan explains. “Various organs are in such close proximity and the sensory nerves sometimes overlap. It takes an expert to figure out which body parts are hurting, and it could be from multiple contributing factors.”

The following disorders are often linked to chronic pelvic pain: 

• Endometriosis: When tissue that normally lines the inside of your uterus grows outside of it (on the ovaries, behind the uterus, on the bowels, or in the bladder), it can cause pain in the abdomen and pelvic area, as well as other problems.
• Adenomyosis: In this disorder, endometrial tissue grows into the muscle wall of the uterus, causing pain and heavy bleeding.
• Pelvic adhesions: Also known as scar tissue, adhesions from infections, endometriosis, or past surgeries can cause pain.
• Gastrointestinal conditions: Pain can be caused by IBS, a digestive disorder involving recurrent bloating, diarrhea, constipation, and abdominal discomfort. Chronic constipation and diverticulitis (when small bulging patches form in the digestive tract) can also contribute to pelvic pain.
• Interstitial cystitis: This chronic condition, which is most common in women, causes inflamed or irritated bladder walls, leading to pain in the bladder and pelvic region.
• Pelvic inflammatory disease (PID): An infection of the reproductive organs, PID is usually caused by a sexually transmitted infection (STI), including chlamydia or gonorrhea. Pain can remain even after the infection is treated.
• Uterine fibroids: These noncancerous tumors in the uterus can cause pelvic discomfort.
• Pelvic floor disorders: When the muscles and connective tissues that support the pelvic organs are weakened or injured (often from childbirth), you might experience problems including incontinence and pain caused by muscle spasms.

If you are experiencing pelvic pain, your medical provider will first ask about your symptoms and health history and conduct a thorough physical examination. 

In particular, he or she will want to know if the pain is severe or sudden. Such symptoms could indicate appendicitis, ovarian torsion (when the ovary twists around the ligaments that keep it in place), ectopic pregnancy (when a fertilized egg implants outside the uterus), or other conditions that require immediate surgery. Your doctor will also want to make sure you don’t have a fever, which could indicate pelvic inflammatory disease, or other types of infection.

Your doctor will gently touch your abdomen and the organs, muscles, and tissues in the pelvic area to check for pain and sensitivity. He or she will also perform a pelvic exam to inspect the vagina, cervix, vulva, ovaries, and uterus.

The examination, along with your reported symptoms, helps your doctor determine which organs are affected, if an infection is possibly present, and what additional tests and procedures are needed. These may include the following: 

• Lab tests, including urinalysis to look for bladder infections, STIs, kidney stones, or pregnancy. If you are pregnant, your doctor will do an ultrasound to look for an ectopic pregnancy. Blood work may also be ordered to check your blood cell count for signs of an infection.
• Pelvic ultrasound, which uses sound waves to create images of your pelvic organs to look for cysts (fluid-filled sacs), growths, or other problems.
• Laparoscopy, in which a surgeon makes a tiny incision near your belly button and inserts small tools and a laparoscope (with a light and camera at its tip) to look for the source of your pain.
• Pelvic MRI (magnetic resonance imaging), in which magnets and radio waves create pictures of your pelvis. Computed tomography (CT) scans, which use computerized X-rays, may also be done.
• Cystoscopy, a procedure that uses a thin tube with a camera to examine the inside of your bladder.
• Colonoscopy, which uses a long, flexible instrument to gather images from inside your colon.

When your doctor determines the condition causing your chronic pelvic pain, he or she will create an appropriate treatment plan. For example, if you have endometriosis, your doctor may prescribe hormonal medications (such as an oral birth control pill) to suppress menstruation, which causes pain. Surgery is also an option for endometriosis and other conditions, including fibroids.

If the source of your pain cannot be identified, your physician will focus on the following treatments that can ease your symptoms and improve your quality of life: 

• Pain medications, often in the form nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. Muscle relaxants may also help. “We do not rely on opioids or a medication-only approach by any means,” Dr. Fan says.
• Hormone treatment, which can help with pain associated with menstruation. Medication can be taken by pill, injection, or intrauterine devices.
• Lifestyle changes, including diet improvements, better posture, and regular exercise may offer relief.
• Heating pads, rest, or pelvic floor physical therapy, which may alleviate muscle pain.
• Counseling, or talking to a mental health professional, can help you develop coping methods for your pain. Chronic pain can also lead to depression, sexual problems, and relationship issues, which talk therapy can help you work through, too. 

At Yale Medicine our physicians are skilled in treating a variety of gynecologic problems—from straightforward to more complex cases. When it comes to chronic pelvic pain, we draw from our experience in treating this challenging disorder, as well as the expertise of our various specialists from multiple disciplines, including gynecologic surgeons, urogynecologists, pain experts, and physical therapists.

“We work as a team with other specialists and offer the patient a holistic approach to their pain,” Dr. Fan says.