It is common, as it occurs at some point in the lives of most women. Pelvic pain is often caused by the normal function of the reproductive organs. For example, many women who ovulate experience pain of varying intensity during menstruation. This pain is often described as “physiological,” provided that no pathological condition is present.
The pelvis is a complex area containing the uterus, fallopian tubes, ovaries, bladder, and part of the lower bowel. Nearby is also the appendix. In addition, pain originating from the kidneys, muscles, or the abdominal wall may be referred to the pelvis. Common gynecological causes of pelvic pain include:
- ectopic pregnancy
- endometriosis
- fibroids
- pelvic inflammatory disease
- ovarian cysts
The clinical history will raise suspicion for some of these conditions, and the diagnosis will be made through physical examination, which includes abdominal, pelvic, and sometimes rectal examination.
Diagnostic investigation may also include blood tests, ultrasound, magnetic resonance imaging (MRI), and laparoscopy.
Acute and chronic pelvic pain
Acute pain comes on suddenly and lasts hours or a few days. It usually has one specific cause that needs to be found quickly. Chronic pain persists or keeps coming back for six months or longer. Here the picture is more complex: often more than one cause coexists, gynecological and non-gynecological.
Causes of acute pain
- Ectopic pregnancy: pain on one side, with a late period or light bleeding. It is ruled out first, with a pregnancy test.
- Rupture or torsion of an ovarian cyst: sudden, strong pain, often with nausea.
- Pelvic Inflammatory Disease: pain on both sides, with discharge or fever.
- Ovulation pain: in the middle of the cycle, on one side, passing within a few hours.
- Non-gynecological causes: appendicitis, cystitis, a stone in the ureter.
Causes of chronic pain
- Endometriosis: pain that gets worse before and during the period, pain during intercourse.
- Adenomyosis and fibroids: a feeling of heaviness, heavy and painful periods.
- Adhesions after surgery or a past infection.
- Pelvic congestion syndrome: varicose veins in the pelvis, with pain that gets worse when standing.
- Irritable bowel syndrome and interstitial cystitis, which often coexist with gynecological conditions.
- Musculoskeletal causes, such as spasm of the pelvic floor muscles.
When you need urgent examination
- sudden, very severe pain,
- pain with fever, vomiting or feeling faint,
- pain with a late period or a positive pregnancy test,
- pain with heavy vaginal bleeding.
In pregnancy the causes are different. Read about lower abdominal pain in pregnancy.
Treatment
Treatment follows the diagnosis. Infections are treated with antibiotics, endometriosis with hormonal therapy or surgery, cysts and fibroids with monitoring or laparoscopy. Chronic pain usually needs a combination: pain medication, pelvic floor physical therapy and, where needed, collaboration with a gastroenterologist or urologist. A pain diary, where you note when the pain appears and what it is linked to (period, intercourse, urination, food), helps a great deal with the diagnosis.
How to describe your pain to the doctor
Describing your pain accurately often leads to the diagnosis before any test is even done. Before your appointment, think about the answers to these questions:
- Where exactly does it hurt? On one side, in the middle, deep inside the pelvis or near the surface? Does it radiate to your lower back or thighs?
- What does it feel like? Cramping, heaviness, stabbing, burning? Burning pain points to a nerve, heaviness to congestion or an enlarged uterus.
- When does it appear? Before or during your period, in the middle of the cycle, after intercourse, when your bladder fills, after eating or when you stand for a long time?
- How severe is it? Rate it from 0 to 10 and note whether it stops you from working, sleeping or having sex.
- What relieves it? Heat, painkillers, lying down, a bowel movement?
Also mention previous surgeries, cesarean sections, infections, your method of contraception and whether you are trying to get pregnant. All of these change the order of the tests.
Pelvic pain at different ages
Puberty
The most common cause is primary dysmenorrhea, which starts shortly after the first period. But when the pain does not respond to anti-inflammatory drugs or gets worse every year, we need to consider early endometriosis or, less often, a congenital abnormality of the uterus or vagina that blocks the flow of blood. Teenage girls in pain who miss school every month should not be told that “that's just how periods are”.
Reproductive years
This is where the widest range of causes lies: infections, cysts, endometriosis, fibroids, pregnancy complications. The first rule stays the same: every woman of reproductive age with acute pain gets a pregnancy test.
After menopause
Hormone-dependent causes recede, so the pain more often comes from the bowel, bladder, bones or muscles. A new ovarian mass at this age always needs careful evaluation, with ultrasound and, where needed, tumor markers. Persistent bloating, feeling full quickly and pelvic pain for weeks are symptoms that should not be ignored.
What each test shows and what it does not
- Transvaginal ultrasound: the first and most useful imaging test. It shows cysts, endometriomas, fibroids, signs of adenomyosis and fluid in the pelvis. A normal ultrasound, however, does not rule out superficial endometriosis or adhesions.
- Cultures and molecular testing for chlamydia and gonorrhea: essential when inflammation is suspected, even without discharge.
- Blood tests: complete blood count, CRP, β-hCG and, where appropriate, tumor markers. Markers such as CA-125 can also rise in benign conditions, so they are interpreted only together with the rest of the clinical picture.
- Pelvic MRI: useful for mapping deep endometriosis and adenomyosis before surgery.
- Diagnostic laparoscopy: no longer the first step. Current ESHRE guidelines recommend starting treatment based on symptoms and imaging, with laparoscopy done when tests are negative and the pain persists, or when a therapeutic procedure is also needed.
The pelvic floor as a source of pain
The pelvic floor muscles support the bladder, uterus and bowel. When they are chronically contracted, they cause pain that feels gynecological, pain during intercourse, a feeling of incomplete emptying or frequent urination. This tension is often a reaction to another source of pain, such as endometriosis, and persists even after the original cause has been treated.
Specialized pelvic floor physical therapy includes manual therapy, relaxation exercises, biofeedback and breathing training. These are not classic Kegel exercises: in this case, tightening can make the problem worse. Most women see improvement after a few weeks of sessions.
When the pain continues without an obvious cause
In some women with chronic pelvic pain, tests show no damage that explains how severe the symptoms are. This does not mean the pain is “psychological”. After months or years of persistent stimulation, the nervous system can become oversensitive and amplify pain signals. This is called central sensitization.
Treatment here takes several approaches:
- medications that act on the nerve transmission of pain, in selected cases and always under medical supervision,
- physical therapy and a gradual increase in physical activity,
- cognitive behavioral therapy or pain management techniques, which have proven benefit,
- better sleep, which directly affects how pain is perceived,
- collaboration with a pain clinic when the above are not enough.
Avoid long-term use of opioids. In chronic pain they do not help in the long run and have significant side effects.
What you can do yourself until your appointment
- A heating pad on the abdomen or lower back for 15 to 20 minutes.
- Anti-inflammatory drugs, if you have no contraindication, starting one to two days before your expected period when the pain is cyclical, not after it becomes severe.
- Prevent constipation with fiber and water. Pressure from the bowel makes pelvic pain worse.
- Cut down on bladder irritants, such as caffeine and alcohol, if the pain gets worse as your bladder fills.
- Gentle exercise, such as walking, swimming or yoga, which reduces muscle tension.
If the pain comes with difficulty conceiving, ask for your fertility to be evaluated at the same time. Endometriosis, adhesions and a past infection are common causes of both. Read more in the guide on infertility.
Pain during intercourse: superficial or deep
Dyspareunia (painful intercourse) often goes along with pelvic pain, but it is not a single condition. Where you feel the pain points to different causes.
Superficial pain, at the vaginal opening
- Infections, such as vaginal yeast infections or herpes.
- Dryness from low estrogen, during breastfeeding, with certain contraceptives or after menopause.
- Vulvodynia, meaning chronic pain or burning in the vulva without a visible cause.
- Vaginismus, an involuntary tightening of the muscles that makes penetration painful or impossible.
Deep pain, with penetration
- Endometriosis, especially when it affects the space behind the uterus.
- Adhesions or chronic inflammation.
- Ovarian cysts or a retroverted uterus with adhesions.
- Tightness of the deep pelvic floor muscles.
Pain during intercourse is not something you have to put up with. Most causes can be treated, and the sooner this happens, the less the vicious circle of pain, fear and muscle tension takes hold.
Pelvic congestion syndrome: when to suspect it
This is a widening of the veins around the uterus and ovaries, similar to varicose veins in the legs. It occurs mainly in women who have given birth. The pain is heavy and dull, gets worse at the end of the day or after standing for a long time, and eases when you lie down. It may be accompanied by pain after intercourse and varicose veins in the vulva or thighs.
Diagnosis is based on Doppler ultrasound and specialized venous imaging. However, enlarged veins are also found in women with no symptoms at all, so the decision to treat is based on the combination of findings and pain. Options include hormonal therapy that reduces venous congestion and endovascular embolization of the veins by an interventional radiologist.
Pain after a cesarean section or other abdominal surgery
Previous surgery adds some specific causes that are often overlooked:
- Adhesions: fibrous bands that join organs together. They do not always cause pain, but when they pull on the bowel or ovaries you may feel pain with certain movements.
- Nerve entrapment at the incision: burning or electric-shock-like pain at one end of the scar, radiating toward the groin or vulva. It is often relieved by a local injection.
- Scar endometriosis: a painful nodule at the incision that grows and hurts every time you have your period.
- Isthmocele (cesarean scar niche): a small “niche” at the site of the old uterine incision, which can cause spotting after your period and pelvic pain. It can be seen on transvaginal ultrasound.
If the pain started after surgery, tell your doctor from the start. It significantly changes the direction of the workup.
Three misconceptions that delay diagnosis
- “Severe period pain is normal.” Pain that does not ease with anti-inflammatory drugs or keeps you in bed needs to be investigated. Endometriosis is often diagnosed several years late precisely because of this belief.
- “The ultrasound was clear, so there is nothing wrong with me.” Ultrasound does not show every cause, such as small endometriosis lesions, adhesions or muscle problems.
- “It will go away with time.” Chronic pain that is left untreated tends to become harder to manage, as the nervous system becomes sensitized. Early treatment gives better results.
For a personalized assessment, book an appointment with Dr. Panagiotis Polyzos at his office in Athens or Volos.
Frequently Asked Questions
When is pelvic pain considered chronic?
When it lasts or keeps coming back for six months or more, whether or not it is related to your period.
Is pain in the middle of the cycle normal?
Yes, mild pain on one side around ovulation is common and passes within a few hours to a day. If it is severe or persists, it needs to be checked.
Can pelvic pain come from the bowel or bladder?
Yes. Irritable bowel syndrome and bladder conditions are common causes and often coexist with gynecological problems.
Which tests will I need?
A gynecological examination, transvaginal ultrasound, blood and urine tests and cultures. MRI or laparoscopy is requested when the cause is not clear from the basic workup.
Is pain during intercourse related to pelvic pain?
Often, yes. Deep pain during intercourse may be due to endometriosis, inflammation or adhesions and is worth mentioning to your doctor.
Can stress cause pelvic pain?
Stress does not damage the pelvic organs by itself, but it can increase pelvic floor muscle tension and heighten the perception of pain. Before pain is attributed to stress, physical causes must have been ruled out.
Should I worry about pelvic pain after menopause?
It needs to be checked, especially if it is new, persistent or accompanied by bloating, a change in bowel habits, weight loss or vaginal bleeding. Most causes are benign, but at this age ovarian masses are always evaluated carefully.
Do birth control pills help with chronic pelvic pain?
When the pain is cyclical and linked to your period, taking a birth control pill or a progestin continuously often reduces symptoms significantly, because it stops the period. They do not help with pain from the bowel, bladder or muscles.
Can pelvic pain affect fertility?
The pain itself does not, but some of its causes can. Endometriosis, adhesions and pelvic inflammatory disease can damage the fallopian tubes or ovaries. If you are planning a pregnancy, tell your doctor so that treatment does not delay it.
