8 common causes of pelvic pain

1) Endometriosis
Endometriosis is a condition where tissue similar to the lining of the uterus grows outside the uterus, which can cause pelvic pain. This tissue can be found on the ovaries, fallopian tubes or other pelvic structures. Endometriosis can lead to inflammation, scarring and the formation of adhesions within the pelvic area, resulting in chronic pelvic pain. Endometriosis can cause pain that feels like severe menstrual cramps, lower back pain, painful urination and discomfort during sexual intercourse.

Endometriosis also can contribute to pelvic pain through the development of endometriomas, a type of ovarian cyst that forms when endometrial tissue grows within the ovaries and becomes filled with old blood, leading to sharp pelvic pain and discomfort. Scar tissue caused by pelvic adhesions can form from endometriosis, which can cause some pelvic organs to stick together. This can cause pelvic organ prolapse or pelvic floor dysfunction, both of which can make pelvic pain worse. Advanced endometriosis may be treated through minimally invasive gynecologic surgery.

2) Ovarian cysts

Ovarian cysts are fluid-filled sacs that can develop on the surface of the ovaries. These cysts can vary in size and may form as a result of the normal monthly ovulation process, when they are known as functional cysts, or due to other underlying conditions. Ovarian cysts can cause pelvic discomfort when they grow large, rupture, bleed or twist the ovary, leading to sudden and sharp pain in the lower abdomen. The sudden onset of severe pelvic pain sometimes may be an indication of a ruptured ovarian cyst, which requires immediate medical attention to prevent further complications.

3) PCOS
Polycystic ovary syndrome (PCOS) is a complex hormonal disorder that often leads to the formation of multiple small cysts on the ovaries, along with other symptoms such as irregular menstrual periods, excessive hair growth and hormonal imbalances. The hormonal imbalances characteristic of PCOS can disrupt the normal menstrual cycle and result in irregular or missed periods. Additionally, the hormonal fluctuations in PCOS can trigger inflammation in the pelvic region, increasing symptoms of pain or discomfort.

4) Pelvic floor myalgia

Pelvic floor myalgia refers to the chronic contraction and spasm of the muscles in the pelvic floor, which can lead to ongoing pain and discomfort in the pelvic region. These persistent muscle contractions can result from various factors such as stress, trauma or repetitive strain, causing the muscles to become tense and inflamed over time.

Chronic tightness or spasms in the pelvic floor muscles can irritate nearby nerves and cause pain. This condition can cause chronic pelvic pain by impairing the normal function of the pelvic floor muscles, which support proper function of the pelvic organs, including bladder and bowel control, and sexual intercourse.

Physical therapy can help treat pelvic floor conditions by focusing on strengthening and relaxing the muscles in the pelvic area. Through tailored exercises and techniques, a pelvic floor physical therapist can help you improve your pelvic floor muscle function and relieve pain. Additionally, physical therapists can provide education on proper body mechanics and lifestyle modifications to help you manage symptoms effectively.

5) Uterine fibroids

Uterine fibroids are noncancerous growths that develop in the uterus. When these fibroids enlarge or press on surrounding organs, they can cause pelvic pain. Fibroids that grow large can press on nearby pelvic muscles or structures that resulting in chronic pelvic pain, extreme menstrual cramps or pain during intercourse. In some cases, the location and size of the fibroids also can contribute to lower back pain or abdominal pain.

6) Pelvic inflammatory disease

Pelvic inflammatory disease is an infection of the female reproductive organs, often caused by sexually transmitted infections, such as chlamydia or gonorrhea. When left untreated, it can lead to inflammation and infection of the uterus, fallopian tubes and ovaries, resulting in chronic pelvic pain. 
 

7) Urinary tract infection

A urinary tract infection (UTI) or interstitial cystitis are common causes of pelvic pain in women. UTIs occur when bacteria enter the urinary tract and cause infection, leading to symptoms such as pelvic pain, frequent urination and a painful or burning sensation during urination. Treatment for UTIs typically involves antibiotics to clear the bacterial infection, which in turn alleviates the pelvic pain. Drinking plenty of water and maintaining good hygiene practices can help prevent UTIs. 

8) Interstitial cystitis

Interstitial cystitis is a chronic condition characterized by bladder pain and urinary urgency. The inflammation of the bladder wall in interstitial cystitis can result in pelvic pain that is often described as a constant, dull ache in the lower abdomen and pelvic region. Managing interstitial cystitis may involve a combination of dietary changes, bladder training, physical therapy and medications to help reduce inflammation and alleviate symptoms of pelvic pain.

Other causes of pelvic pain 

Not all causes of pelvic pain are due to an underlying gynecologic health condition. For example, some women may experience normal cramping during their period or ovulation. More causes of pelvic pain involve other organs, muscles, diseases or conditions.

Treating pelvic pain

It is important to work with your health care provider to discuss any symptoms of pelvic pain that you are experiencing. They can help detect or rule out any underlying causes of your pelvic pain, diagnose conditions and help treat your symptoms effectively. 

Treatment options can vary, depending on a patient’s unique condition, including age, a desire to get pregnant, preexisting conditions or health concerns. Treatments also can vary based on a patients’ diagnosis, and may include medications (including hormonal medications, such as birth control, for some conditions), physical therapy or minimally invasive gynecologic surgery (MIGS).

A MIGS procedure may be considered for patients with certain complex conditions. Patients should speak to their provider about a referral for a MIGS evaluation for the following conditions: 

• Advanced endometriosis (affecting bladder, gastrointestinal tract, diaphragm, etc.)
• Chronic pelvic pain without apparent cause
• Frozen pelvis
• Severe scar tissue
• Large leiomyomas (fibroids)
• Large ovarian cysts
• Conditions that may make surgery more complicated, such as obesity, diabetes, chronic anticoagulation, circulatory issues, etc.

Norton Women’s Care Pelvic Health Program specializes in caring for patients with pelvic health conditions.

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“You should visit your OB/GYN once a year for a well-woman visit after you turn 21 or when you become sexually active,” said Katherine K. Holland, APRN with Norton Women’s Care. “Although it’s common to feel some apprehension about this type of visit, your provider can help ease any anxiety and answer whatever questions you may have — about your health and what to expect during the visit.”

READ MORE: What’s the right age to start getting Pap smear tests?

Many young patients have questions about Pap smears and pelvic exams. Here’s what to expect, why an OB/GYN visit is important and how often you should have one.

Is a pelvic exam the same as a Pap smear?

No, a pelvic exam is not the same thing as a Pap smear. They commonly occur during the same visit, but both are not a requirement for every appointment. Both serve as important ways to keep you healthy, including prevention of certain medical conditions and screening for cancer.

What is a Pap smear test?

A Pap smear (or Pap test) checks for cervical cancer and/or human papillomavirus (HPV). A Pap test can detect abnormal cells that can lead to cervical cancer. A Pap smear is a very brief test and involves brushing a tool against the cervix. This sample of cells is then tested for abnormalities.

How often should you get a Pap test?

Women should get their first Pap test at age 21. This test should occur every three years for woman ages 21 to 29. Women ages 30 to 65 should have a Pap test every three to five years.

What is a pelvic exam?

A pelvic exam consists of a physical exam of the outer and inner portions of your pelvic organs, including the vulva, vagina, cervix and uterus.

After your provider looks at your external genitals, they will insert a tool, called a speculum, into your vagina, which opens the vaginal walls enough to see the cervix. This is when a Pap test happens if it is needed. Afterward, your provider will check your uterus and ovaries by inserting a gloved finger (or two) into the vagina while palpating your abdomen.

If, at any point during the exam, you become uncomfortable, you can ask the provider to stop or pause. If it improves your comfort level, you can request that the provider explain what they are doing during each step of the exam and why it is happening.

How often you should get a pelvic exam?

A pelvic exam is required if you are experiencing symptoms, such as pelvic pain, abnormal vaginal discharge or bleeding, or pain during sex. A pelvic exam also is necessary if you are pregnant or have a history of gynecological conditions. A routine pelvic exam serves as an important part of preventive care and can catch some medical conditions early. However, the American College of Obstetricians and Gynecologists recommends patients have pelvic exams only when they have symptoms or have a medical history that requires it. Talk to your OB/GYN provider to discuss your medical history, concerns and goals — and make this decision together.

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Although a pelvic exam can help screen for various gynecological conditions, including fibroids and cancer, the procedure may feel intrusive or triggering for some trauma survivors, said Rebecca P. Walker, M.D., OB/GYN with Norton Women’s Care.

“A pelvic exam can be traumatizing for patients who have experienced sexual abuse, and it may not be necessary to conduct one every time a patient sees us,” said Dr. Walker. “Providers should be patient, listen to their patient’s concerns and take the appropriate trauma-informed approach during the visit.”

How to feel more relaxed before a pelvic exam

If the patient feels comfortable, they can share their trauma history with their provider so they can make adjustments to help ease any discomfort. Patients also can advocate for more control over their visit, and should speak up if they feel uncomfortable. The provider can stop the exam for them at any time.

Providers also can keep the patient informed before and during each step of the exam, so the patient knows what is supposed to happen during the procedure and why it is happening. The patient also may ask to bring a trusted person, like a relative or friend, to accompany them inside the exam room to help them remain comfortable and work through any triggers. A nurse also can be in the room with the patient for additional support.

The encounter also can be broken down into more than one visit, allowing the patient to have the opportunity to get used to the office, staff and the exam.

For many women, it may be difficult to relax during a pelvic exam, but it can be a traumatizing experience for survivors of sexual abuse.

Although a pelvic exam can help screen for various gynecological conditions, including fibroids and cancer, the procedure may feel intrusive or triggering for some trauma survivors, said Rebecca P. Walker, M.D., OB/GYN with Norton Women’s Care.

“A pelvic exam can be traumatizing for patients who have experienced sexual abuse, and it may not be necessary to conduct one every time a patient sees us,” said Dr. Walker. “Providers should be patient, listen to their patient’s concerns and take the appropriate trauma-informed approach during the visit.”

How to feel more relaxed before a pelvic exam

If the patient feels comfortable, they can share their trauma history with their provider so they can make adjustments to help ease any discomfort. Patients also can advocate for more control over their visit, and should speak up if they feel uncomfortable. The provider can stop the exam for them at any time.

Providers also can keep the patient informed before and during each step of the exam, so the patient knows what is supposed to happen during the procedure and why it is happening. The patient also may ask to bring a trusted person, like a relative or friend, to accompany them inside the exam room to help them remain comfortable and work through any triggers. A nurse also can be in the room with the patient for additional support.

The encounter also can be broken down into more than one visit, allowing the patient to have the opportunity to get used to the office, staff and the exam.

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Urinary Incontinence — Bladder Control Issues More Common Than You Think

One in four women over age 18 experience episodes of incontinence, according to the National Association for Continence. In addition to physical discomfort, women experience emotional pain, isolation and fear of ridicule that often prevents them from seeking treatment. On average, a woman will live with incontinence for more than six years before seeking medical advice, due to embarrassment or believing myths such as “incontinence is just a part of aging or being a woman” or “it’s brought on from sexual activity or drinking too much water.”

A woman’s pelvic floor is like a trampoline –– sometimes a bladder can become displaced through a lifetime of activity, including heavy lifting, coughing, constipation and childbirth.

Chances increase with subsequent pregnancies, and there’s also evidence of a genetic predisposition to incontinence issues. Other risk factors for stress incontinence include obesity and previous gynecologic surgery such as hysterectomy.

Treating the Most Common Bladder Control Issues — Stress Incontinence and Urge Incontinence

The two most common types of bladder control issues that lead to urinary incontinence are:

• Urinary stress incontinence: This type includes an involuntary loss of urine when a woman coughs, sneezes or laughs. This is the most common type and is often a symptom of a weakened pelvic floor.
• Urge incontinence: In this type, the bladder contracts when it shouldn’t, and urine leaks through the sphincter muscles that hold the bladder closed. It is sometimes called overactive bladder.

A common treatment for both types is Kegel exercises to strengthen the pelvic floor. A woman can find the muscles by stopping and starting the urine stream. Regular exercises to strengthen these muscles can improve bladder control symptoms. A urogynecologist or pelvic floor physical therapist can evaluate if the patient is doing the exercises effectively.

A urogynecologist can help a patient evaluate the full range of treatments available and offer a customized solution. Whether that is medication, surgical procedures, internal or external devices, physical therapy, behavior modification, injections or a combination of treatment options, a urogynecologist can help the patient reach her treatment goals.

The Norton Women’s Care Pelvic Health Program specializes in caring for women with pelvic conditions. A full range of specialists, therapists and health care professionals are available to ensure you get back to the life you were meant to live — full of joy, activity, intimacy and strength.

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For Jonathan H. Reinstine, M.D., becoming a surgeon was in the cards almost from the start. Coming from a family that included pediatric and general surgeons, he knew that’s what he wanted to do. What he didn’t know was the specialty.

“I was going to be a pediatric surgeon originally,” said Dr. Reinstine, an OB/GYN  with Associates in Obstetrics and Gynecology, a Part of Norton Women’s Care. “But during medical school I worked with some gynecological oncologists and was attracted to the art of surgery for pelvic issues. It was a way I could make more of a difference for people.”

During his residency, he discovered even more.

“I really enjoyed the perfect mix of medicine and surgery,” he said. “I also really liked that I could have lifelong relationships with my patients. Obstetrics was also an unexpected joy as I was able to watch families grow.”

Minimally invasive gynecologic surgery

Dr. Reinstine was a pioneer in bringing new surgical techniques to patients in Louisville and Southern Indiana. He performed some of the earliest laparoscopic hysterectomies in 1991. He was at the leading edge in developing laparoscopic surgery and hysteroscopy to treat fibroids, endometriosis and bleeding issues with less pain and recovery time.

He was also instrumental in Norton Women’s & Children’s Hospital becoming a Center of Excellence in Minimally Invasive Gynecology^TM (COEMIG) recognized by the American Association of Gynecologic Laparoscopists (AAGL) as well as a Center of Excellence in Robotic Surgery ^TM (COERS).

The COEMIG and COERS programs are focused on improving the safety and quality of gynecologic patient care and are designed to expand access to minimally invasive gynecologic procedures performed by surgeons.

Treating complex pelvic issues

“An estimated 25 to 30 percent of women live with pelvic health issues,” Dr. Reinstine said. “The key to treating them is examining other functions of the body and bringing multiple specialists and services together.”

While many patients have been with him for years, Dr. Reinstine and the rest of the pelvic health team also help women who have not been able to find answers elsewhere.

“Sometimes we also need to start from scratch and take fresh looks at everything if a woman is not getting relief,” Dr. Reinstine said. “The main goal is finding an answer.”

Sometimes that can include new treatments for endometriosis and fibroids.

The pelvic health team

The Norton Women’s Care Pelvic Health Program includes specialists in gynecology; urogynecology; pediatric and adolescent gynecology; urology; allergy; colorectal surgery; interventional radiology; anesthesiology; physical therapy and mental health.

Their goal is to bring together expertise not always found elsewhere to help women with often complex conditions. This can include women who have large fibroids, women who have already had multiple procedures or surgeries that can make treatment more complex, and those wishing for less invasive options.

Minimally invasive procedures for pelvic health include:

• Laparoscopic, robotic-assisted and hysteroscopic myomectomy along with uterine artery embolization as an alternative to hysterectomy for uterine fibroids
• Laparoscopic or robotic-assisted procedures for uterine prolapse, including sacral colpopexy and native tissue repairs
• Vaginal and laparoscopic options to abdominal hysterectomy
• Laparoscopic and robotic-assisted conservative resections for endometriosis

Other Norton Women’s Care Pelvic Health Program physicians include David L. Doering, M.D.; Sarah M. Kane, M.D.; Marjorie L. Pilkinton, M.D. and Dwight D. Pridham, M.D.

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• A test for high-risk strains of human papillomavirus  (hrHPV) every five years
• A Pap test (cervical cytology) every three years, or
• Co-testing with both the HPV and Pap test every five years.

Keeping with its past guidelines, the task force continues to recommend that women ages 21 to 29 should be screened every three years using a Pap test (also called a Pap smear).

Related: Can you get a Pap smear or pelvic exam on your period?

David L. Doering, M.D., gynecologic oncologist with Norton Cancer Institute, said it is important to understand screening recommendations and guidelines are about analyzing and evaluating risks and benefits on a large scale across numerous tests. Overscreening can lead to false positives and unnecessary procedures, but underscreening can lead to a missed chance to catch early abnormal changes before they become cancerous.

“We know that stage one cervical cancer is relatively easy to treat with good outcomes. After stage two, cervical cancer is harder to treat, plus the risk of spread goes up as the stage of cancer goes up,” Dr. Doering said. “The ultimate goal of screening is to detect lesions in the pre-invasive phase, when they are easily cured, with very little risk of complications or side effects.”

According to Dr. Doering, the new guidelines (published in the journal JAMA) raise some concerns. For one thing, the false positive rate for HPV testing alone is yet unknown. For another, they conflict with current American College of Obstetricians and Gynecologists guidelines, which advise against HPV testing alone.

Who can forgo screening?

The task force recommends against cervical cancer screening for women under age 21. Also, the group does not recommend HPV testing for women ages 21 to 29. This is because HPV infection is common in this age group, but such infections often are able to clear on their own.

Women over age 65 can skip annual screening if they have had adequate prior screening and have no history of being at high risk for cervical cancer.

Screening is not recommended for women who have had a hysterectomy with removal of the cervix and no history of a high-grade precancerous lesion or cervical cancer.

Regular screening is key

By most measures, cervical cancer screening in the United States qualifies as a real success story.

READ MORE: What’s the right age to start getting Pap smear tests?

The U.S. Preventive Services Task Force reports that the number of deaths from cervical cancer nationwide has decreased substantially since the start of widespread cervical cancer screenings. From 2000 to 2015, deaths from cervical cancer dropped from 2.8 to 2.3 deaths per 100,000 women.

The task force emphasizes that for women ages 30 to 65, getting screened on a regular basis is far more important than which of the three recommended screening approaches is used.

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