If you have pain in the area below your belly button and above your legs, this is known as pelvic pain. A lot goes on in the pelvic area; it’s home to your bowel, bladder, ovaries, uterus (womb) and more. That’s why when you have pelvic pain, it’s important to know the differences between the common causes, to learn what’s normal and what’s not, and when you should seek help.
Persistent pelvic pain, also known as chronic pelvic pain, is pain that is present on most days for six months or more. Jean Hailes gynaecologist Dr Janine Manwaring explains that, for women with persistent pelvic pain, the journey to getting the right diagnosis can be a bumpy one.
When it comes to persistent pelvic pain, Dr Manwaring says there is a lack of education, both within the medical community and the general community.
“There are many misconceptions about pelvic pain, particularly period pain,” she says. “Pain can be downplayed by both doctors and by other women within the family. A lot of it comes down to getting the right information and knowing who the right people are to get in touch with.”
So here are some of the conditions that can cause persistent pelvic pain, as well as tips on how to spot the differences between them and when you need to see a trusted doctor.
Period pain is a very common experience for women and girls; the research varies a lot on just how widespread it is, but one Australian study found it affects 93% of female senior high-schoolers.
The pain occurs when the muscles in the uterus (womb) contract or tighten, and often feels like cramping or heaviness in the pelvic area, lower back or stomach. Despite it being a typical add-on of getting your period, if the pain is severe, it could be a sign of something more serious, such as endometriosis.
“If your period pain lasts longer than the first one or two days of your period, if it does not improve with period pain medications and/or the Pill, or if it’s stopping you from going about your life, then you should see your GP,” says Dr Manwaring.
Endometriosis (pronounced end-o-me-tree-oh-sis) is a condition that affects a woman’s reproductive organs and is commonly associated with pelvic pain.
In endometriosis, cells that are similar to those that line the uterus (the endometrium) grow in other parts of the body – typically in the pelvic area such on the bowel, bladder or ovaries.
These cells undergo the same menstrual changes as those inside the uterus, but unlike period blood, have no way of escaping, so they build up, causing problems such as pain, scarring and inflammation.
Three out of four women with endometriosis experience pain, and this pain can occur immediately before your period, during your period, or during or after sex. Pain can be felt in the pelvis, stomach, back, when passing wind, urine or stool (poo), or when you ovulate.
Often referred to as the ‘sister’ condition of endometriosis, adenomyosis also involves problematic cell growth. Instead of these endometrium-like cells growing on parts of the body such as the bowel or ovaries as they do in endometriosis, in adenomyosis, the cells grow into the muscle wall of the uterus.
Symptoms of adenomyosis can be quite similar to endometriosis and include abnormal or heavy menstrual bleeding, painful periods (often after years without pain) and painful sex.
Irritable bowel syndrome (IBS)
The exact cause of IBS still not 100% clear, but it is thought that the muscle wall of the bowel becomes sensitive and contracts unevenly, resulting in pain and bloating. This type of pelvic pain typically improves after passing wind or stool (poo) and is often managed by avoiding potential food triggers and reducing stress.
“However, if you see blood in your stool [bleeding may appear as bright red blood on the toilet paper, or a black colour in the stools], or if you experience extreme diarrhoea, incontinence or unexplained weight loss, see your GP,” says Dr Manwaring.
Pelvic muscle pain
Dr Manwaring explains that pelvic muscle pain can feel like you have an ongoing cramp in your pelvic area most of the time. “The pain can also be sharp or stabbing and shoot up the vagina or rectum,” she says. “You might have pain with sex or using tampons, which can last for hours afterwards.
“Pelvic muscle pain often gets worse with exercise, especially core-strengthening exercises such as pilates, sit-ups or crunches. Women can often find some relief by lying in the foetal position, using a heat pack, doing pelvic muscle stretches (visit pelvicpain.org.au) and seeing a pelvic floor physiotherapist.”
Bladder pain & urinary tract infections (UTIs)
Affecting more than 50% of all women during their lifetime, another common cause of pelvic pain are UTIs. The pain typically experienced with a UTI occurs when passing urine; a burning sensation and/or lower abdominal pain.
Although UTIs are common, if left untreated they can develop into more serious kidney infections. If your symptoms persist for more than 24 hours and include fever, chills, back pain, nausea or vomiting, you should see your doctor immediately.
The other common type of bladder pain is called interstitial cystitis (also known as painful bladder syndrome). This type of pain is different from a UTI in that there is irritation, but no infection.
Painful bladder syndrome is common in women with endometriosis.
Dr Manwaring advises you to see your GP if you have troublesome bladder symptoms that are persistent or frequent, including:
- needing to empty your bladder more than 8-10 times during the day
- needing to empty your bladder more than once a night
- pain with full bladder, which improves with emptying
- pain with intercourse
- a sense of urgency to urinate.
Vulval pain can occur due to irritation and inflammation of this sensitive body part – and not just due to candida (thrush), as is commonly believed. There are many different causes of vulval irritation, and ways to manage it.
Vulvodynia (pronounced vul-vo-din-ia) is a condition in which there is pain, discomfort or a burning sensation in the vulva that cannot be linked to a specific cause. The pain associated with vulvodynia may or may not be triggered by touch, it may be felt in one area of the vulva or across the whole area.
Vulvodynia is a chronic condition that can last for months or years. For some women, the pain can be so severe that using tampons, having sex or even sitting down for long periods is very difficult or impossible.
Key advice for persistent pelvic pain
In what can be a confusing time for women, Dr Manwaring offers five key pieces of practical advice for women with persistent pelvic pain.
1. If you feel as if you’re not being listened to by your current doctor or health professional, don’t be afraid to seek a second opinion.
2. A multidisciplinary team has been shown to be the best approach in managing persistent pelvic pain. Chronic pain is not just about the immediate pain, but also involves and affects multiple areas of health and life, so coming at it from different angles and treating the whole person is crucial.
3. Keep track of your symptoms in a form that is easy and accessible for you. Jean Hailes has an excellent Period pain & symptom diary that you can download for free. Having your symptoms and treatments written down can help a lot when talking to different health professionals and helps to assess if/when progress is being made.
4.Source reliable health material and self-care strategies. There is a lot of information on pain management on the internet and in chat forums. Try to focus on advice and information that is based on evidence and comes from a reliable source.
5. Always remember that you are not alone. Sometimes pelvic pain conditions can be difficult to manage and it can feel like other people can’t relate to it because your pain cannot be seen. But don’t feel like you can’t seek help for it; there are people who will listen to you and take you and your symptoms seriously.
Published with the permission of Jean Hailes for Women’s Health
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