What is it?

Overview

What Is It?
Chronic pelvic pain is characterized by pain in the lower abdomen and pelvic area that has been present for at least six months.Chronic pelvic pain (CPP) is characterized by pain in the lower abdomen and pelvic area that has been present for at least six months. Sometimes the pain may travel downward into the legs or around to the lower back. The pain may be felt all of the time or it may come and go, perhaps recurring or intensifying each month with your menstrual period.

In either case, the pain is felt internally, not externally as in another common pain disorder in women called vulvodynia. In vulvodynia (or burning vulva syndrome), the external genital area stings, itches, becomes irritated or hurts when any kind of pressure, from tight clothing to intercourse, is experienced. Chronic pelvic pain and vulvodynia sometimes occur together.

Symptoms of Chronic Pelvic Pain
Women with CPP have one or more of the following symptoms:

• constant or intermittent pelvic pain
• low backache for several days before menstrual period, subsiding once period starts
• pain during intercourse (rarely, some vaginal bleeding after intercourse)
• pain on urination and/or during bowel movements (rarely, blood in urine or stool)
• painful menstrual periods (dysmenorrhea)
• severe cramps or sharp pains

The course of CPP is unpredictable and different in every woman. Symptoms may stay constant, disappear without treatment or suddenly increase. They sometimes decrease during pregnancy and improve after menopause.

The severity of pain is also unpredictable. It may range—even in the same woman—from mild and tolerable to so severe it interferes with your normal activities. Your physical or mental state can also cause the level of pain to fluctuate, so you may experience fatigue, stress and depression. Moderate to severe pain generally requires medical or surgical treatment, although such therapies are sometimes unsuccessful at relieving pain entirely.

Chronic Pelvic Pain Syndrome
Unrelieved, unrelenting pelvic pain may affect your sense of well-being, as well as your work, recreation and personal relationships. You may begin to limit your physical activities and show signs of depression (including sleep problems, eating disorders and constipation), and your sex life and role in the family may change.

When pelvic pain leads to such emotional and behavioral changes, the International Pelvic Pain Society (IPPS) calls the condition "chronic pelvic pain syndrome" and says that the "pain itself has become the disease." In other words, the pain is more of a problem than the original cause. In fact, a medical examination may find nothing physically wrong with the area that hurts. Nonetheless, the nerve signals in that area continue to fire off pain messages to the brain, and you continue to hurt.

Causes of Chronic Pelvic Pain
There are two kinds of pain. Acute pain typically occurs with an injury, illness or infection. A warning signal that something is wrong, it lasts only as long as it takes for the injured tissue to recover. In contrast, chronic pain lasts long after recovery from the initial injury or infection and is often associated with a chronic disorder or underlying condition.

Endometriosis
The most common cause of pelvic pain is endometriosis, in which pieces of the lining of the uterus attach to other organs or structures within the abdomen and grow outside the uterus. In practices specializing in the treatment of endometriosis, 70 percent or more of patients with CPP are diagnosed with endometriosis. Two disorders that sometimes accompany endometriosis and are also linked to CPP are adhesions (scar tissue resulting from previous abdominal or pelvic surgery) and fibroids (clumps of tissue that grow inside, in the wall of, or on the surface of the uterus). Fibroids may also occur in the absence of endometriosis.

Pelvic Inflammatory Disease (PID)
The second most common cause of CPP is pelvic inflammatory disease (PID). PID is one of the most common gynecologic conditions, usually related to a sexually transmitted disease. As many as 30 percent of women with PID develop CPP. However, we don't know exactly why PID so often leads to CPP. One of the most common contributors to pelvic pain is dysfunction of the pelvic floor and hip muscles. This problem often accompanies pain originating from the reproductive organs, but can occur on its own or persist after other sources are successfully treated.

Other Causes of Chronic Pelvic Pain
Other causes of CPP are diagnosed more frequently by other kinds of specialists. They include diseases of the urinary tract or bowel as well as hernias, slipped discs, drug abuse, fibromyalgia, and psychological problems. In fact, many women with CPP collect a different diagnosis from each specialist they see. What is going on here? It is likely that CPP represents a general abnormality in the way the nervous system processes pain signals from the pelvic nerves, producing pain that involves the genital organs, the bladder, the intestine, pelvic and hip muscles and the wall of the abdomen, as well as pain involving the back and legs.

Characteristics of Pelvic Pain Patients
Despite the number of possible causes, up to 61 percent of women with chronic pelvic pain receive no diagnosis. These are often the women who make the rounds of various specialists seeking relief, only to be told the pain is "all in their heads." They may also be subjected to multiple tests or even unnecessary surgery. These women may feel that the pain is somehow their fault, when, in fact, the lack of a diagnosis represents the limitations of medical science. Simply put, there is no simple answer to the question, "What causes chronic pelvic pain?" and no "typical patient." Still, a woman with pelvic pain is more likely to:

• have been sexually or physically abused
• have a history of drug and alcohol abuse
• have sexual dysfunction
• have a mother or sister with chronic pelvic pain
• have history of pelvic inflammatory disease (PID)
• have had abdominal or pelvic surgery or radiation therapy
• have previous or current diagnosis of depression
• have a structural abnormality of the uterus, cervix or vagina
• be of reproductive age, especially aged 26 to 30 years.

Some of these, like family history, surgery and PID, are obvious risk factors; others (drug abuse, depression) may be risk factors or may result from having chronic pain.

Impact of Chronic Pelvic Pain
An estimated 4 to 25 percent of women have chronic pelvic pain, but only about a third of them seek medical care. It is also one of the most common reasons American women see a physician, accounting for 10 percent of gynecologic office visits, up to 40 percent of laparoscopies and 20 percent of hysterectomies in the United States. Total treatment costs may run as high as $2.8 billion annually.
The cost to the patient is also enormous. Studies and surveys show that a quarter of affected women are incapacitated by pain two to three days each month. More than twice that many are forced to curtail their normal activities one or two days each month. Nine of 10 women with chronic pelvic pain have pain during intercourse. More than half say they have significant emotional changes, many reporting they feel "downhearted and blue" at least some of the time. For many, the pain and underlying conditions lead to fertility problems, just at the age when they want children.

Diagnosis

Diagnosis

As with many pain conditions, chronic pelvic pain (CPP) can be difficult to diagnose. For one thing there is no screening test. For another, because symptoms may be variable, it can be difficult for a woman to define and localize her pain. Finally, there are all those possible causes and associated conditions to investigate.

Conditions that can cause pelvic pain may be divided into several categories:

Gynecologic conditions

• Endometriosis is a condition in which tissue that makes up the lining of the uterus (endometrium), exits the uterus and attaches to the ovaries, fallopian tubes, bowels or other organs in the abdomen. Because endometrial tissue responds to hormonal changes during a woman's menstrual cycle, the abnormally located tissue swells and bleeds, sometimes causing pain.

  Endometriosis pain is not always restricted to the menstrual cycle. Many women with endometriosis have pain at other times of the month. Endometriosis can also scar and bind organs together, cause tubal (ectopic) pregnancies and lead to infertility, although these outcomes are unusual.

• Fibroids are benign (noncancerous) tumors or clumps of abnormal tissue that can grow inside, in the wall of or outside the uterus. Many women don't know they have fibroids since often they have no symptoms. However, depending on their location and size, fibroids may cause pelvic pain, backaches, heavy menstrual bleeding, pain during intercourse and such urinary problems as incontinence, frequent urination and repeated urinary tract infections (UTIs). They can interfere with fertility or pregnancy if they distort the shape of the inside of the uterus, but this is unusual. Pain with fibroids is uncommon; heavy bleeding is more common.

• Adenomyosis, like endometriosis, involves the abnormal growth of cells from the uterine lining. In this case the cells grow into the wall of the uterus, pressing against the muscle fibers there. The result is painful cramps and heavy menstrual bleeding.

• Adhesions are fibrous bands of scar tissue that form after surgery or a condition that causes inflammation. When these bands tie organs and tissues together inappropriately, even normal movements and sex may stretch the scar tissue and cause pain. When adhesions block the fallopian tubes or ovaries, infertility can result. If they wrap around the bowel, they can result in bowel obstruction.

• Pelvic inflammatory disease (PID) includes any infection or inflammation of the fallopian tubes, uterine lining and ovaries. It often begins as a sexually transmitted infection. Many women with PID have no symptoms or only mild symptoms (abnormal vaginal bleeding or discharge or pain with intercourse) and may not seek treatment. However, left untreated, PID may cause scar tissue to form that can lead to chronic pelvic pain, abscesses, tubal pregnancies and infertility.

• Ovarian remnants can sometimes cause pelvic pain. During a complete hysterectomy, where the uterus, ovaries and fallopian tubes are removed, a small piece of ovary may be left behind, which can later develop a small painful cyst.

Urinary Tract Disorders

• Interstitial cystitis (IC) is an inflammatory condition in which the bladder wall becomes chronically inflamed. The lining of the bladder that protects the wall from irritation seems to break down. The resulting discomfort can range from tenderness to intense pain in the bladder and surrounding area. Symptoms include more urgent and frequent need to urinate. Ninety percent of those with IC are women, whose symptoms may get worse during menstruation. Pain may also intensify during intercourse.

• Chronic urethritis is inflammation and irritation of the urethra (the tube through which urine is eliminated from the bladder) caused by either an infection or a narrowing of the tube.

Intestinal disorders

• Irritable bowel syndrome (IBS) is characterized by abdominal discomfort or painful cramping, bloating and gas and constipation or diarrhea (or bouts of both). Stress and depression can increase the symptoms, as can particular foods and beverages. Women are more than twice as likely to have IBS as men, and their symptoms are often worse during their periods.

• Diverticulosis occurs when small pockets develop in the wall of the large intestine. When these pockets get plugged with undigested food, an infection can develop in the bowel wall causing diverticulitis. Usual symptoms are pain in the lower left abdomen, fever and constipation.

Musculoskeletal disorders

• Pain and tension in the pelvic floor and hip muscles. Pain from these sources can be transferred to the low back and abdominal wall.

• Scoliosis (curvature of the spine), herniated disks in the lower region of the back and other disorders of the bones in the pelvic region can result in chronic pelvic pain.

Psychological disorders

• Depression is a common and treatable illness; chronic pain can be one symptom of depression.

Other conditions

• Hernias, which occur when the intestine pushes through the abdominal wall, can cause pelvic pain. These are quite uncommon in women, and hernias rarely occur more than once in any individual.

• After abdominal surgery, nerves may get entrapped by regrown tissue, causing pain. Pelvic pain can also develop from a nerve disorder similar to phantom limb pain. In this case, the discomfort remains even after the pelvic organ has been removed.

Diagnostic Tests for Pelvic Pain

When you first seek medical help for pelvic pain, you may see either your internist (primary care physician) or gynecologist. In either case, your health care professional should consider every possible source of pain. Each may require different diagnostic tests and distinct treatments. If you have more than one diagnosis, each can be diagnosed and treated accordingly. Depending on the problem and the training of your primary care provider, you may need to see other specialists.

Your health care professional will begin by asking you specific questions about your past and present health, your menstrual cycle, sexual history, previous abdominal surgeries and your symptoms. You may be asked to describe the kind and severity of your pain (aching, burning, stabbing), where it is and how it affects your life.

You should tell your health care professional if the pain is constant or intermittent, related to your period, or worse during urination, bowel movements or sex. Also discuss any urinary or intestinal problems you may be having. Do you have constipation or diarrhea? Can you associate the start of your pain with a bladder infection or backache? All information about your pain and other symptoms can help your health care professional with his or her diagnosis. Keep a pain diary with detailed information about the pain and associated symptoms. This strategy can provide important clues.

Because pelvic pain appears to run in families, your health care professional will also ask you about related illnesses and problems in your parents and siblings, especially your mother and sisters. Finally, the health care professional may ask you about any treatments and therapies you've already used for the pain and what the outcomes were.

Following the medical history, your health care professional will conduct a general physical examination, including a pelvic and rectal exam to determine areas of tenderness and find such potential problems as fibroids, masses and hernias. If you have muscle pain, skeletal problems or backache, your health care professional may check your posture and gait and look for relations between those problems and your pelvic pain.

Depending on what he or she finds, these simple, standard tests may be ordered:

• blood tests to check for infection (complete blood count or CBC) and inflammation (sedimentation rate or ESR)

• urinalysis and other urinary tests

• tests for sexually transmitted diseases

If certain conditions are suspected, more tests may be recommended. These include:

• laparoscopy

• pelvic ultrasound

• pregnancy test

• MRI

• X-ray

• CT scan

Treatment

Treatment

A diagnosis provides a starting point for treatment. The type of treatment your health care professional recommends depends on you, your reproductive health stage (childbearing years vs. menopause, for example), your condition and your level of pain.

The goals of treating CPP are to allowyou to manage your pain, restore your normal activities and improve your quality of life and to prevent chronic symptoms from recurring. While this sounds simple, these goals are often difficult to achieve.

The fact is that managing any kind of chronic pain is one of the most difficult jobsin medicine. You may find that your health care professional recommends a "watchful waiting" period using nonmedical therapies such as exercise, relaxation techniques and yoga to see how your symptoms develop or whether they decrease on their own. As hard as this approach may seem at first, it may provide more information about your symptoms and prevent rushing into surgery. It is also important to see a gynecologic specialist with specific experience and training in chronic pelvic pain.

If and when you decide on a specific treatment, a team approach involving specialists in several medical fields often offers the best results. This is especially true if you've been diagnosed with several conditions, all of which may represent a single pain-processing problem.

Medications

• Pain-relieving nonsteroidal anti-inflammatory drugs, or NSAIDs, such as ibuprofen (Motrin) and naproxen (Aleve), are available over-the-counter (OTC) and by prescription.

  Because they reduce the amount of the hormone prostaglandin, which is involved in producing inflammation, these drugs reduce swelling and relieve menstrual cramps and pain. Studies have shown that women with painful periods have higher than normal levels of prostaglandin. To be most effective, NSAIDs must be taken regularly, but long-term use can lead to serious side effects, including stomach ulcers and intestinal bleeding; discuss these risks with your health care professional.

• Hormonal therapies like birth control pills and Depo-Provera injections are used to regulate ovulation and menstruation. These medications can be used to help menstrual-related pelvic pain. High-dose progestin and GnRH agonists (gonadotropin-releasing hormone drugs) completely stop menstruation. And Danazol is an androgen that helps ease pelvic pain related to menstruation. Side effects are a disadvantage of this therapy, however. These drugs all work by stabilizing or reducing the production of estrogen, which causes endometrial tissue to grow. In practice, many clinicians will diagnose endometriosis on clinical grounds, then treat with Lupron, a GnRH agonist. If the pain is then relieved, the conclusion is reached that the patient has endometriosis. This conclusion is incorrect because other causes for pain, besides endometriosis, will also get better with Lupron. The response to this drug is nonspecific.

• Pain medication may be injected into abdominal trigger points, tender areas in the abdominal wall, to block pain.

• Elmiron (pentosan polysulfate sodium) is an oral drug approved to treat interstitial cystitis. How Elmiron relieves interstitial cystitis is not completely understood, but it is believed to work by gradually helping repair and restore the damaged bladder lining. While some women find their symptoms improve in as little as four weeks, studies show that it usually take three months to see a significant benefit, and some women never experience a benefit.

• Antibiotics may be prescribed for underlying infections such as PID. However, there is no substantial evidence showing that antibiotics improve CPP.

• Antidepressant drugs are often prescribed for chronic pain. They seem to affect pain transmission signals to the brain as well as help relieve any underlying depression.

Surgery

Surgery may be recommended to remove endometriosis, adhesions and fibroids, correct physical abnormalities or remove a diseased or damaged uterus and ovaries that may be contributing to the pain.

• Laparoscopy is recommended for both diagnosis and treatment. During the procedure, sites of endometriosis and adhesions may be destroyed by laser beam or electric current or cut out. In experienced hands, even advanced stages of endometriosis can be treated laparoscopically.

• A laparotomy is a more invasive surgical procedure that involves an abdominal incision. It's used to remove endometriosis, adhesions or ovarian cysts that can't be removed laparoscopically.

• A hysterectomy is the surgical removal of the uterus. It may be a reasonable treatment for chronic pelvic pain after other options have been considered. Most hysterectomies can be performed laparoscopically.

Other Therapies

Various other therapies may be helpful alone or in combination with medical and surgical treatment:

• relaxation and breathing techniques to reduce stress and anxiety

• stretching exercises, massage therapy and biofeedback to reduce muscle tension in the pelvic floor, hips and low back that can cause or enhance pelvic pain

• physical therapy to improve posture, gait and muscle tone and to work with painful muscle groups, especially pelvic floor and hip muscles.

• cognitive behavioral therapy that includes various pain-coping strategies

• counseling to treat depression and associated pain symptoms

The chronic nature and complexity of pelvic pain may require multiple treatment strategies, and the right combination may take some time to discover. Often, a combination of medical, surgical and alternative therapies works best. Counseling and support groups can help you to keep a positive attitude during treatment. Meanwhile as research continues on the possible causes of chronic pelvic pain, improved drug treatments and less invasive surgical techniques are being developed.

Prevention

Prevention

Many conditions that cause chronic pelvic pain (CPP) cannot be prevented. However, reducing your risks for developing sexually transmitted infection can reduce your chances of developing pelvic inflammatory disease (PID), a common cause of CPP. Regular pelvic exams-once a year for women age 18 and older-are also important. They can give you the opportunity to discuss any concerns or symptoms with your health care professional and help identify health conditions, such as CPP, early in their development. If you experience pelvic pain, don't wait; make an appointment to discuss your symptoms with your health care professional.

Facts to Know

Facts to Know

1. Chronic pelvic pain (CPP) is constant or intermittent pain in the lower abdomen and pelvic area that has been present for six months or more. The exact symptoms and course of disease are unique for each woman, but the condition usually improves after menopause. It affects 4 to 25 percent of women.

2. In addition to pelvic pain, other symptoms may include severe menstrual cramps, pain during sex, urination or bowel movement, low backache right before a your menstrual period and rectal pain.

3. As with other chronic pain conditions, the unrelenting nature of pelvic pain and the difficulties encountered in its diagnosis and treatment may lead to depression, anxiety, fatigue, behavioral changes and impaired mobility.

4. Common causes of pelvic pain include fibromyalgia, endometriosis, fibroids, adenomyosis, post-surgical adhesions, pelvic inflammatory disease, interstitial cystitis, chronic urethritis, irritable bowel syndrome, diverticulitis, spinal problems, muscular dysfunction, hernias and psychological problems.

5. Risk factors for CPP are varied. They include past sexual and physical abuse; sexual dysfunction; a mother or sister with chronic pelvic pain; history of pelvic inflammatory disease; abdominal or pelvic surgery; depression; and a structural abnormality of the uterus, cervix or vagina.

6. The process of diagnosing chronic pelvic pain may take time and require numerous tests. The goal is to identify all underlying causes of pain; in some patients no underlying condition is found. In some women, no diagnosis other than chronic pain is established, which can be frustrating for both the patient and health care professional.

7. The goal of treatment is to manage pain, restore normal activities, improve quality of life and prevent recurrence of symptoms.

8. Treatment may involve a combination of medications, surgery, alternative therapies and counseling. The approach used depends on the individual's condition(s), level of pain and age.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about chronic pelvic pain (CPP) so you're prepared to discuss this important health issue with your health care professional.

1. Why am I having pain? Do I have a condition causing the pain?

2. I've tried over-the-counter pain relievers but they're not enough. What drugs can you prescribe that will relieve my pain? What are their side effects? Will they interact with other drugs I'm taking?

3. Do I need surgery? What kind? What is its success rate in reducing pain or curing the condition? What will happen if I choose not to have surgery?

4. If I have surgery, won't that increase my chances of developing adhesions that can cause pelvic pain in the future? What methods do you use during surgery to reduce the chance of adhesions developing?

5. Is there a specialist in laparoscopic surgery you could refer me to?

6. Are there nondrug, nonsurgical therapies that can help reduce my pain and improve my condition? What can I do to cope with the pain and continue my normal activities?

7. Is there a pain management specialist you could refer me to?

8. Are there support groups for chronic pelvic pain? Where can I get more information?

Key Q&A

Key Q&A

1. When should I consult a health care professional about pelvic pain?

   You should make an appointment with your health care professional if your periods have become painful, you have vaginal bleeding at times other than during your normal menstrual cycle, you have pain during intercourse, urination or bowel movements, or you have blood in your urine or stool. If severe pelvic pain suddenly appears, you should see a health care professional immediately. Generally, a woman with pelvic pain and symptoms will see her primary care provider or gynecologist first. Depending on his or her findings, you may be referred to other specialists such as a urologist, for example, if there is a structural problem with your urinary tract. Ideally, you should be treated by a gynecologist who specializes in chronic pelvic pain. You may also require physical therapy.

2. What kinds of tests will I need for a diagnosis?

   Your health care professional will first conduct a medical history followed by a routine physical exam, including a pelvic and rectal exam, to locate your pain and find such potential problems as fibroids, masses and hernias. The specialist should also examine the muscles of the pelvic floor and hips. Your posture and gait may be examined to look for relations between those problems and your pain. Depending on those results, you may be given standard blood tests, urinalysis and tests for sexually transmitted diseases. If your doctor suspects certain conditions, he or she may order an exploratory or diagnostic laparoscopy, pelvic ultrasound or MRI.

3. Why can't I get complete pain relief?

   Complete relief from chronic pain, whether from chronic pelvic pain or other chronic conditions like backache, arthritis and fibromyalgia, can be difficult to achieve. No one medication works on all women with pain symptoms. A combination of medication, surgery, physical therapy, alternative therapies and lifestyle changes is often recommended to manage chronic pain symptoms.

4. Why did I get this disease? What causes it?

   Although there are risk factors that may have increased your chances for developing chronic pelvic pain, most are not things you could have prevented or controlled. The most common causes of chronic pelvic pain are endometriosis, adenomyosis, PID, muscular problems, interstitial cystitis, irritable bowel syndrome and depression.

5. Why are my symptoms different from a friend's, who also has chronic pelvic pain?

   Because of the wide range of conditions that can cause or contribute to chronic pelvic pain, symptoms vary from woman to woman. You may even notice that your own symptoms vary during your monthly cycle or over time. This variability adds to the difficulty in diagnosing the disease.

6. What can I expect from medical treatments?

   Your pain symptoms may not be totally relieved by taking medications. However, by working closely with your team of health care providers and using some self-care techniques, you may be able to reduce the impact your pain symptoms have on your lifestyle.

7. Should I have surgery? When should I consider surgery?

   The decision to have surgery is a personal one. In general, surgery to relieve pelvic pain is most successful only when the cause of the pain is structural, for example adhesions, ovarian cysts or an abnormality in the uterus, or when a disease like cancer is present and can be treated with surgery. For other conditions that cause chronic pelvic pain, surgical options may not be an option. In either case, surgery should be carefully discussed with your health care professional to determine risks, benefits and the chances that the surgery will relieve your pain symptoms.

Lifestyle Tips

Lifestyle Tips

1. A combination of therapies works best

   Don't rely solely on over-the-counter or prescription analgesics to relieve pain. They may be more effective if combined with other drugs such as antidepressants. Complementing drug therapy with one or more alternative therapies, including physical therapy, massage and psychological counseling, also improves pain relief.

2. Pay attention to posture

   Bad posture, lumbar spine disorders and hip problems can all contribute to pelvic pain, as can muscle strength and length imbalances, leg length discrepancy and foot problems. If you have chronic pelvic pain, be sure to get a complete evaluation of your musculoskeletal system from a doctor or physical therapist. If problems are detected, they will recommend solutions, perhaps range of motion exercises to increase flexibility of the spine, strengthening exercises for certain muscle groups or an orthotic for your shoe. These "solutions" should then be practiced at home regularly; they may reduce your pain by relieving one of its underlying causes.

3. Relax to reduce stress

   Stress appears to be a contributor to many recurrent and chronic conditions, including chronic pelvic pain. Stress can increase blood pressure, reduce the immune system's ability to fight infection and affect our hormone production, including turning on cortisone production in the adrenal glands and upsetting the balance between estrogen and progesterone. Research has shown that fibroids grow during times of stress, and many women report that when they are stressed, their periods are more painful. Managing stress by learning to relax at home on a daily basis is an important part of any pain relief program. There are many relaxation techniques you can easily learn and practice at home, including focusing (what women in labor are advised to do), meditation, deep breathing and progressive muscle relaxation. Learning biofeedback techniques takes much more training but can help you learn to recognize which muscles are tense and how to relax them. Listening to classical music or relaxation CDs of nature sounds will also help calm you.

4. Heat and hot water relaxes muscles

   Any kind of heat will improve blood flow and relax tense muscles. A heating pad or hot water bottle applied to the lower abdomen can help relieve menstrual cramps or pain associated with trigger points; use one on your lower back if that is where your pain originates. Treat yourself to a warm bath with relaxing ingredients added to it.

5. Exercise and eat right

   Regular exercise improves circulation and increases the production of natural pain-relieving substances (endorphins) in your body. By staying fit and active, you will also reduce your chances of increasing pain due to tight muscles. It may also help you to stay positive and ward off depression. Good nutrition and getting enough rest also help you manage pain.