Ask an expert: What causes pelvic pain?

As well as causing discomfort, recurrent or severe pelvic pain can disrupt daily life and significantly impact women’s quality of life. With many possible causes, accurate diagnosis is key in finding effective treatment and management to relieve pelvic pain. In this informative and detailed guide, highly respected consultant gynaecologist Dr Mahesh Jude Perera shares his expert insight on the most common causes of pelvic pain and how a diagnosis of conditions such as endometriosis and pelvic inflammatory disease is made.

What does pelvic pain feel like?

Pelvic pain is pain felt in the lower tummy, lower abdomen and in the pelvic region. This can be a constant pain that’s there all the time or could be cyclical and related to other symptoms.

Pelvic pain can be very bad, so much so that the patient can be doubled over in pain or needs to go into hospital for pain killers. It may also come in waves, similar to colic which builds up and becomes very severe, like a cramp, and then settles.

What causes pain in the pelvic area?

There are many causes of pelvic pain. The first is pain associated with the menstrual cycle as pelvic pain can be due to painful periods, where pain comes on with the period and settles as it ends.

Pelvic pain could also be related to gynaecological problems, such as a condition called endometriosis. Endometriosis is when the lining of the womb, called the endometrium, lies outside of the womb. At the time of a period, a woman sheds the lining of the womb and so if this lining lies outside the womb, it sheds wherever it is. That gives pain because blood is very irritant to the lining of the abdomen. With classic endometriotic pain, the woman feels pain before her period starts and importantly, it carries on throughout the period, with the bleeding settling before the pain.

The other symptom that endometriosis also gives is pain with intercourse which can be quite severe and can be so bad that the woman has to stop having sex. This occurs because of where the endometriosis is located as it is positional and therefore, if the couple changes positions, it can sometimes be less uncomfortable.

In term of other causes, sometimes women experience pelvic pain at the time of ovulation. This is because the egg is produced in a fluid-filled small cyst and when it is released at ovulation, the fluid around this egg is quite irritant. One thing that is constant in every woman’s cycle is that the period from ovulation until the next period is always two weeks. Therefore, if a woman has pelvic pain two weeks before a period every month, it is likely ovulatory. Although a woman’s cycle length can vary, from twenty-eight days to twenty-four or thirty-one for example, it is the first part of the cycle which is variable.

Another cause of pelvic pain is ovarian cysts. If a bleed into this cyst or torsion (twisting) occurs, this can cause pain symptoms.

Additionally, an infection in the pelvis, what we call pelvic inflammatory disease (PID), can be the cause of pelvic pain. This may be accompanied by other symptoms of an infection, such as vaginal discharge. In the acute stages of a pelvis infection, a simple vaginal swab can establish the diagnosis but if it is a case of chronic pelvic inflammatory disease, any swabs would be show as negative. That means that the consequences, or sequalae, of a previous pelvic infection may be behind the pelvic pain, such as adhesions that it has caused.

On the subject of adhesions, another common cause of pelvic pain is previous surgery. If someone has undergone a prior operation, just like on the skin’s surface, there is a scar which has formed as part of the healing process, there is also scar tissue which has formed inside the tummy. This scar tissue is what we refer to as adhesions which can give pain.

A very common cause of pelvic pain which is very difficult to diagnose is pain caused by the gut and the intestines because of spasm, known as irritable bowel syndrome, or IBS. It is a diagnosis more of exclusion, meaning that if all of the other causes of pelvic pain have been excluded and we are unable to establish another cause, the likely cause would be IBS. Some women have additional symptoms with IBS, such as feeling bloated after eating and needing to open the bowels, which can relieve pain and discomfort. Although some women experience these IBS-associated symptoms, many others only have pelvic pain.

How can pelvic pain affect quality of life?

Pelvic pain can affect quality of life in a major way, particularly as the time taken to establish a diagnosis of endometriosis, for example, is well recognised, especially in the UK. From the time a woman presents to her GP with symptoms, lots of studies have shown that it takes an average of over two years for a diagnosis of endometriosis to be made.

Endometriotic pain in particular has a significant impact on a woman’s quality of life because every month, she may be unable to carry out her work and may require time off and so forth. Very often, a woman’s life has to be planned around the pain and so it has an impact on every aspect of her life.

When should women see a gynaecologist for pelvic pain?

Women experiencing pelvic pain should first see their general practitioner who can try to exclude the common causes of pelvic pain. They can also administer management with simple pain killers or hormonal manipulation. If this is not sufficient and the pelvic pain persists, she should be seen by a gynaecologist for further investigations.

What tests are performed for pelvic pain?

Firstly, we would examine the tummy and also perform a vaginal examination to see whether one can feel cysts and so forth. As I have mentioned, one of the possible causes of pelvic pain is infection in the pelvis and so a bacteriology swab and a chlamydia swab can be taken.

The next most important investigation is a pelvic scan. Ideally, this would be a transvaginal pelvic scan because this allows us to see whether there are any cysts in the ovaries or signs of endometriosis.

The final and most definitive investigation is a diagnostic laparoscopy. To perform this, we put the patient under a general anaesthetic and make a cut near her navel and insert a telescope that has a camera. This allows us to look at the ovaries, tubes and womb to see whether there is any obvious evidence of endometriosis. It also permits us to take biopsies, excise or treat the endometriosis and drain or remove any ovarian cysts as needed.

Can pelvic pain be treated?

Pelvic pain can be treated but to do so, one needs to know its cause. Some causes of pelvic pain are easier to treat than others.

Pelvic pain caused by a cyst in the ovary can be relieved by removing the cyst. If it’s caused by endometriosis, treating or excising the endometriosis in a laparoscopy or using hormonal manipulation, such as continuous treatment using the contraceptive pill for example, can help. As endometriosis is hormone dependent, we sometimes put women through what we call a medical menopause, which stops the ovaries from working for as usual for a few months at a time. Obviously, this can’t be done over long period of time as it brings on the side effects of an early menopause.

In cases where adhesions are causing pelvic pain, this can be more difficult to resolve. Although a laparoscopy to divide the adhesions can be performed, the process of doing so can actually result in more adhesions.

In cases of irritable bowel, anti-spasmodic medication can help to stop the spasm in the bowel. There is also some evidence which shows that drugs like Amitriptyline in low doses can help to relieve pelvic pain. In some instances, pelvic pain is very difficult to treat and therefore we look to keep symptoms at bay.

If you are suffering from pelvic pain and wish to schedule a consultation with Dr Perera, you can do so by visiting his Top Doctors profile.