Persistent pelvic pain

Stress activates your nervous, hormone and immune systems, which causes changes in your body and brain. These changes can affect you physically and psychologically, which can contribute to persistent pelvic pain.

Poor sleep can increase the likelihood of pain and pain sensitivity. And pain can affect the quality and duration of your sleep. Disturbed sleep is also linked to depression and anxiety, which are more common with persistent pelvic pain.

Traumatic experiences, such as sexual assault and abuse, can contribute to persistent pelvic pain.

The way you think about pain can influence the way your body responds and how you cope with it. If your nervous system is overly sensitive, even thinking about pain can make you feel pain.

Being on high alert for pain might also intensify your pain experience.

If you live with persistent pelvic pain, it can be hard to connect with others. This may cause you to withdraw and have fewer social contacts. But social isolation is associated with anxiety and depression, which can influence persistent pelvic pain.

Your work environment can contribute to persistent pelvic pain. Poor job satisfaction, an unhappy workplace and lack of support from employers are also linked to increased pain.

At your appointment, give your doctor as much information about your pain as possible. This will help them to investigate potential causes.

It’s a good idea to bring:

• your medical records, including your past medical history
• blood test results
• X-rays and other scans, such as pelvic ultrasound reports
• information about previous surgeries.

It’s also helpful to keep a record or pain diary, and bring it with you to your appointment.

Keep track of important details, such as:

• when you have pain
• where you feel pain
• how the pain affects you
• what the pain feels like (sharp, cramping, dull ache)
• anything that makes the pain worse
• things you’ve tried to help manage your pain, like heat packs.

Your doctor may ask questions about your pain and how it affects your life. For example:

• How and when did your pain begin?
• How long does your pain last?
• How does your menstrual cycle affect your pain?
• Does your pain affect your sleep?
• Has your pain spread or become worse since it began?
• Do you have pain when going to the toilet?
• Does the pain affect your mood?
• Which medicines have you used in the past? Have they helped?
• Which medicines or supplements are you taking now?
• Does your pain affect your daily life, such as work, study and social activities?
• Does your pain affect your relationships or sex life?

Your doctor may check:

• your posture and the way you walk and move (gait) – this may suggest pelvic muscle pain
• your lower back, hips, tailbone (coccyx) and pelvic joints – this is often associated with pelvic muscle dysfunction
• your lower abdomen – for lumps or tender areas
• your vulva and vagina
• your pelvic floor muscles
• your skin – to see if you have a skin condition, numbness or tenderness.

You may need tests and procedures to check for other causes of pain, such as:

• blood or urine (wee) tests
• swabs to check for sexually transmitted infections (STIs), bacteria or other infections
• a cervical screening test
• imaging tests, such as an ultrasound, CT scan or MRI scan
• keyhole surgery (laparoscopy) to check your internal organs, such as your uterus or stomach
• a procedure to examine your bladder (cystoscopy).

It’s important to ask questions and learn as much as possible about persistent pelvic pain. These questions may also help you find the best doctor to treat your pain.

For example:

• Which treatments are available and how much do they cost?
• Are there any potential side effects?
• What practical things can I do to help manage my pain?
• Can you recommend any resources to learn more about my condition?
• Can I access any programs that make it more affordable to see different health professionals? For example, a GP Chronic Condition Management Plan or Mental Health Care Plan.
• What experience do you have in managing persistent pelvic pain?
• Do you work with other health professionals to manage persistent pelvic pain?
• Which other health professionals should I see for my pain?
• Which tests will I need?
• How much will the tests cost?
• Where can I have these tests?

It’s a complex process to diagnose and manage persistent pelvic pain.

Your doctor might:

• refer you to one or more health care professionals
• suggest you try different medical and non-medical treatments to help manage your pain
• organise other tests to learn more about your pain.

Your doctor will provide most of your care and will start your treatment.

They will refer you to specialists and coordinate care with the rest of your health care team. They will also continue to manage your overall health.

A gynaecologist is a specialist in the female reproductive system.

They can diagnose and treat conditions like endometriosis, adenomyosis, fibroids and complex period problems.

Pain specialists are medical doctors with advanced training in pain management.

They understand the complex nature of pain and use different approaches to help reduce your pain.

Pelvic floor physiotherapy is widely used to manage persistent pelvic pain. Pelvic floor physiotherapists have extra training and special skills in women’s health.

They can:

• help improve how your pelvic floor and abdominal muscles, back and hips work
• help you learn how to move and exercise in a way that’s right for you
• help you learn about pain, which is an important part of managing pain
• explain basic pain-relief techniques.

Psychologists may use a range of techniques, including cognitive behavioural therapy (CBT) to help manage your pain.

They can:

• help you understand how your thoughts, emotions, physical sensations, behaviours and pain are linked
• recommend coping strategies to help manage your pain
• help with anxiety and depression, which are common in people with persistent pelvic pain.

Sex therapists can help you understand how persistent pelvic pain might cause painful sex.

Past experiences of painful sex may cause you to fear pain. This fear can create stress, tension and reduced sex drive and arousal.

If you want to improve your sexual experience, it may help to discuss your feelings with a sex therapist.

Dietitians can help you identify food that might trigger a pain flare. They can also recommend a balanced diet to help reduce your pain.

Naturopaths can provide complementary ways to manage your pain, including:

• supplements
• herbal medicine
• acupuncture
• lifestyle changes.

Many women use these therapies to manage their health, but there is limited evidence to support their safe and effective use.

If you’re using complementary therapies to manage your pain, it’s important to discuss the benefits and risks with your doctor.

Learn more about natural therapies

Urogynaecologists are specialists in pelvic health.

They can diagnose and treat bladder and pelvic floor problems that may contribute to pelvic pain.

Gastroenterologists specialise in conditions that affect the digestive system.

They can diagnose and treat digestive conditions that may be causing pain.

Sleep specialists are doctors who diagnose and treat sleep disorders.

They can help with medicines and sleep routines to improve the quality of your sleep.

Exercise physiologists design safe, personalised exercise plans to help manage your pain.

Physical activity is an important part of staying healthy. But many people who have persistent pelvic pain avoid moving, as they fear it will make their pain worse.

Low-impact activities, such as swimming and walking can help to reduce your pain sensitivity.

Talk to your health care team about a tailored physical activity plan.

Some mind-body practices, such as yoga and stretching, can help you manage pelvic pain.

Pelvic pain can lead to tense muscles, especially:

• pelvic floor muscles
• abdominal muscles
• hip muscles.

When your muscles stay tight, you can have painful muscle cramps.

A pelvic floor physiotherapist can help you relax your pelvic floor muscles and stretch your stomach and the muscles on the outside of your pelvis.

These exercises may reduce pain and improve your bladder, bowel and sexual function.

For easy stretches to relax the pelvis, visit the Pelvic Pain Foundation of Australia website.

Guided-relaxation exercises and yoga can reduce tension in other areas of your body, which may also reduce pelvic pain.

Pacing means you do enough exercise to improve your pain without causing a pain flare. It’s a fine balance – and it may take time to learn your limits.

It can be helpful to keep track of your activities and responses to see if you can find where your limits are. By pacing, you gradually build your strength while staying within your comfort zone.

Why activity pacing matters

Many people with persistent pelvic pain experience higher pain sensitivity and fatigue after activity. Pacing helps to prevent these flare-ups.

By learning to listen to your body and understanding your limits, you can avoid the frustration of setbacks. Over time, consistent pacing can help you improve your:

• fitness
• confidence
• quality of life.

How to pace your activity and find your baseline

• Choose the type of activity you want to do.
• Track how much activity you can do without having a pain flare.
• Record 3 days of activity (they don’t have to be consecutive days).
• You can record your activity in different ways (minutes, distance or repetitions).
• Work out the average amount of activity you can do without a pain flare. This is your ‘baseline’.
• Work out your ‘starting point’ by reducing your baseline by 20%. This encourages you to move, even on bad days.
• Gradually increase your activity by 10% each week.

Example

Activity: walking.

• Day 1: 20 minutes
• Day 2: 30 minutes
• Day 3: 25 minutes
• Total: 75 minutes

Baseline: 25 minutes (total divided by 3)
Starting point: 20 minutes (baseline minus 20%)

Use the example above to find your baseline and starting point.

Track your activity

It’s important to keep track of your activities and how you feel afterwards. You can use a journal, a spreadsheet or an app on your phone.

Record:

• the activity you did
• when you did it
• the minutes, distance or repetitions you did
• how much rest you had
• how you felt during and after the activity (e.g. pain and fatigue levels).

Helpful tips

• Focus on activities you want to do.
• Start with smaller, easier activities.
• Schedule pacing into your day.
• Have planned rest breaks.Try to stick to your plan.

If you’re having a difficult day, you can:

• try to stay active, but take more rest breaks
• reduce your activity if you need to.

Things to remember

• If you’re having a good day, don’t be tempted to do more.
• If your activity is getting easier, or you want to try a new activity, work out a new baseline and starting point.
• It’s normal to have sore muscles for a day or so after doing a new or more challenging activity. This will reduce as your muscles get stronger. This is not a pain flare.

Don’t be concerned about mild discomfort that goes away about 30 minutes after the activity. This is not a pain flare.
While you’re learning how to pace yourself, it can be helpful to work with:

• a pelvic floor physiotherapist
• an exercise physiologist.

When you’re stressed, your body releases chemicals that are similar to the ones released when you feel pain.

These chemicals can turn up the volume of your pain. Stress management is an important part of managing persistent pelvic pain.

Learn more about looking after your mental health on the Beyond Blue website.

It can be hard to get a good night’s sleep when you have persistent pelvic pain, but there are practical things you can do to improve your sleep and quality of life.

For more information about sleep, visit the Sleep Health Foundation website.

Persistent pelvic pain can make you feel emotionally drained and withdrawn. It’s important to seek support from people close to you.

Talking to friends or family about your pain can be helpful. Find ways to connect that work for you, like a walk or phone call.

If you have a partner, they might not understand what you’re going through. You can tell them about your pain, what causes it and what makes it better.

If your pain is affecting your sex life, try to communicate openly with one another. It may also help to speak to a psychologist, sex therapist or relationship counsellor.

Warm baths and heat packs can provide relief from cramping and muscle spasms.

Massage therapy can relieve tightness and pain in soft tissues.

Research suggests that massage can help you become more aware of your body and where you hold tension. This awareness can support changes that reduce muscle tightness, lower stress and reduce pain.

Deep breathing (belly breathing) brings more oxygen into your body and slows your heart rate. It can help you relax your pelvic floor muscles and other muscles in your body.

When you focus on your breath, it can distract you from unhelpful thoughts and sensations such as pain.

How to deep breathe

• Find a quiet, comfortable place to sit or lie.
• Breathe in slowly through your nose.
• Allow your chest and lower belly to rise while you breathe in.
• Let your belly fully expand as it fills with air.
• Slowly breathe out through your mouth.

You can also focus on calming images or a word that helps you relax while you practise your deep breathing.

A TENS machine is a small, battery-operated device with sticky pads (electrodes) that are attached to your skin. When the machine is turned on, it sends small electrical impulses, which causes a tingling feeling.

A TENS machine:

• changes the signals that go to the spinal cord and brain
• helps the body release endorphins, which are the body’s natural pain relievers.

Learn more about TENS on the Healthdirect website.