What kinds of tests will I need for a diagnosis?

Overview

What Is It?

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.

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, a significant number 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 (benign, smooth muscle tumors that grow inside, in the wall of, or on the surface of the uterus). Fibroids often occur in the absence of endometriosis, without any pain at all, and are not a common source of chronic pelvic pain.

Pelvic Inflammatory Disease (PID)
Another 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. However, many women recuperate fully from STD-related PID, and we don't know exactly why PID sometimes 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 clinical care specialists, such as urologists, gastroenterologists, neurologists, orthopedic surgeons, psychiatrists and pain management physicians. 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, many 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.

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. Many women with chronic pelvic pain have pain during intercourse, and some have significant emotional changes. For many, the pain and underlying conditions lead to fertility problems, just at the age when they want children.

Signs and Symptoms

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.

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 that grow inside, in the wall of or on the outside surface of the uterus. Many women don't know they have fibroids because 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 and frequent urination. 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, growing into the muscle fibers there. The result is painful cramps and heavy menstrual bleeding.
Adhesions are fibrous bands of scar tissue that are caused by endometriosis or pelvic infection, or they may form after surgery. 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 may cause 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, most commonly chlamydia or gonorrhea. 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. After a hysterectomy with bilateral salpingo-oophorectomy, where the uterus, ovaries and fallopian tubes are removed, a small piece of ovary may be left behind, which can later develop a 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. In its most severe form, ulcers form in the bladder lining. The resulting discomfort ranges from annoying constant sensations of bladder fullness, even immediately after voiding, to intense bladder pain with associated cramping and spasm of the pelvic floor muscles. Symptoms include frequent urination that does not relieve the sensation of bladder fullness, pain or pressure. Ninety percent of IC sufferers are women, and symptoms may flare during menstruation. IC pain often gets worse during or after intercourse. Many women with IC are treated repeatedly for bladder infections, because symptoms overlap. With IC, however, antibiotics provide no relief, and urine testing for infection is negative.
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 noninfectious inflammation. Most urethritis occurs in men, and this rare female condition rarely responds to oral antibiotics and is often also diagnosed as bladder infection, again with negative urine infection test results and minimal or no response to oral antibiotics. Symptoms include a burning pain that may radiate into the vulva or groin, exacerbated by sex or activities that put direct pressure on the groin area, such as biking or horseback riding.

Intestinal disorders

Irritable bowel syndrome (IBS) symptoms include 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, constipation or bloody diarrhea. Diverticulosis is uncommon under the age of 50.

Musculoskeletal disorders

Pain and tension in the pelvic nerves, pelvic and hip bones and attached pelvic floor muscles are often the primary site of musculoskeletal chronic pelvic pain. Pain from these sources, including sciatica, pudendal neuropathy, sacroiliac inflammation, pelvic asymmetry and psoas muscle spasm, among others, may cause chronic low back, deep pelvic and lower abdominal wall pain symptoms.
Scoliosis (curvature of the spine), herniated disks in the lower region of the back, spinal stenosis, spine or hip arthritis and other disorders of the bones, nerves and muscles in the pelvic region can result in chronic pelvic pain.

Psychological disorders

Depression is a common and treatable illness; chronic pain is a common symptom of depression.

Other conditions

Hernias, which occur when the intestine pushes through the abdominal wall, can cause pelvic pain when the intestines become intermittently or permanently trapped in the hernia defect, effectively obstructing the small intestine. Although they are more common in men, hernias do occur in women. Hernias rarely occur more than once in any individual.
After abdominal surgery, nerves may get entrapped in the tissue layers of the healed wound, causing pain.

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 doctor will consider every possible source of pain. Each may require different diagnostic tests and distinct treatments, including referral to specialists for evaluation of specific organ systems. If you have more than one diagnosis, each can be diagnosed and treated accordingly. Depending on the problem(s) involved, your initial doctor may recommend evaluation with other specialists.

Your doctor, nurse practitioner, midwife or physician assistant will begin by asking you specific questions about your past and present health, your menstrual cycle, sexual history, previous abdominal surgeries, accidents and injuries 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, including activities that worsen or relieve the symptoms.

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? Do certain movements or physical activities affect the pain intensity or duration? All information about your pain and other symptoms can help your physician with your diagnosis. Keep a pain diary with detailed information about the pain and associated activities and symptoms.

Because pelvic pain appears to run in families, the clinician will also inquire about related illnesses and problems in your parents and siblings, especially your mother and sisters. You must be prepared to report and, if possible, provide documentation about any tests, treatments and therapies you've already undergone 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, pain trigger points, pelvic masses and abdominal wall 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)
pregnancy test
urinalysis and other urinary tests
tests for sexually transmitted diseases
imaging tests, such as pelvic or abdominal sonography, MRI defecography, spinal imaging, CAT scan of the abdomen and pelvis or other imaging tests

If certain conditions are suspected, endoscopic evaluations or surgery may be recommended. These include:

cystoscopy (look in the bladder)
sigmoidoscopy or colonoscopy (partial or complete look in the colon)
laparoscopy (minimally invasive endoscopic look into the abdomen and pelvis)

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 CPP treatment focus on creating self-management strategies that allow you to manage your pain, restore your normal activities, improve your quality of life and prevent symptoms from recurring. These goals may be difficult to achieve.

The fact is that managing any kind of chronic pain is one of the most difficult jobs in 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 produce 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, regulate ovulation and menstruation. These medications help menstrual-related pelvic pain. High-dose progestin and GnRH agonists (gonadotropin-releasing hormone drugs) completely stop menstruation. Danazol, an androgen, helps ease pelvic pain related to endometriosis. Androgenizing side effects, such as increased hair growth, clitoral enlargement, deepening of voice and weight gain are common side effects of danazol therapy, however; as a result, it is usually a therapy of last resort. These drugs all work by stabilizing or reducing the production of estrogen, which causes endometrial tissue to grow. To avoid laparoscopic surgery, which is the only secure way to diagnose endometriosis, clinicians often opt to diagnose endometriosis indirectly, based on clinical response to treatment with leuprolide (Lupron), a GnRH agonist. If leuprolide relieves the pain, a presumptive diagnosis of endometriosis may be made. This conclusion may still be incorrect because other causes for pain, such as adenomyosis or painful uterine fibroids, also tend to improve with Lupron.
Pain medication may be injected into abdominal or pelvic trigger points, tender areas in the abdominal wall or pelvic muscles to block pain.
Elmiron (pentosan polysulfate sodium) is an oral drug approved to treat interstitial cystitis. How this drug 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 residual 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 may be used 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 with a specially designed laparoscopic micro-scissor. 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. Hysterectomies may be performed laparoscopically, vaginally or by laparotomy.

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

Many conditions that cause chronic pelvic pain (CPP) cannot be prevented. However, reducing your risks for developing sexually transmitted infection such as chlamydia or gonorrhea can reduce your chances of developing pelvic inflammatory disease (PID), a common cause of CPP. Regular pelvic exams—once a year after commencing sexual activity or for all women age 18 and older—are also important. Regular pelvic health checkups give you the opportunity to discuss any concerns or symptoms with your physician 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 physician.

Facts to Know

Chronic pelvic pain (CPP) may be either 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. CPP tends to improve after menopause. According to various studies, CPP affects 4 percent to 25 percent of women.
Pelvic pain symptoms may include severe menstrual cramps; pain during sex, urination or bowel movement; low backache right before your menstrual period and rectal pain.
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.
Common causes of pelvic pain include fibromyalgia, endometriosis, fibroids, adenomyosis, pelvic adhesions related to prior pelvic surgery, endometriosis or sexually transmitted infections, pelvic inflammatory disease, interstitial cystitis, chronic urethritis, irritable bowel syndrome, diverticulitis, spinal problems, muscular dysfunction, hernias and psychological problems.
Risk factors associated with CPP 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 congenital structural abnormalities of the uterus, cervix or vagina.
The process of diagnosing chronic pelvic pain may take time, involving various tests. The goal is to identify all underlying causes of pain. In some women, no clear diagnosis or underlying cause for chronic pain is established, which can be frustrating for both the patient and physician.
The goal of treatment is to manage pain, restore normal activities, improve quality of life and prevent recurrence of symptoms.
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

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.

Why am I having pain? Do I have a condition causing the pain?
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?
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?
If I have surgery, will 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?
Is there a specialist in laparoscopic surgery you could refer me to?
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?
Is there a pain management specialist you could refer me to?
Are there support groups for chronic pelvic pain? Where can I get more information?

Key Q&A

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

Make an appointment with your physician or alternate pelvic health clinician if your periods are painful, if you have vaginal bleeding at times other than during your normal menstrual cycle, if you have pain during intercourse, urination or bowel movements or if you have blood in your urine or stool. If severe pelvic pain suddenly appears, see a health care professional immediately. Generally, a woman with pelvic pain and symptoms will see her primary care physician 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 urinary tract condition contributing to your pain syndrome. Or it may be best to undergo treatment with a gynecologist who specializes in chronic pelvic pain or a colorectal surgeon or rheumatologist, if gastrointestinal or rheumatologic conditions are contributing to your pain. In addition, you may require physical therapy.

What kinds of tests will I need for a diagnosis?

Your physician will first conduct a medical history followed by a comprehensive physical exam, including a pelvic and rectal exam, to locate your pain and find such potential contributing problems as arthritis, pelvic inflammatory disease, endometriosis, colitis, urinary tract conditions, fibroids, pelvic masses and lower abdominal hernias. The doctor may also examine the muscles of the pelvic floor and hips. Your posture and gait may be evaluated to look for relations between musculoskeletal imbalances and your pain. You may also undergo blood tests, urine tests and tests for sexually transmitted diseases. If your doctor suspects certain conditions, he or she may order an exploratory or diagnostic laparoscopy, abdominal or pelvic ultrasound, X-ray, CT scan or MRI.

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 personalized combination of therapies that may include medication, surgery, physical therapy, alternative therapies and lifestyle changes will be formulated to manage your chronic pain symptoms.

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.

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 find that your own symptoms vary during your monthly cycle or over time.

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.

Should I have surgery? When should I consider surgery?

The recommendation for surgery to diagnose or treat CPP varies from patient to patient, based on the evaluation test results and responses to medical therapies. In general, surgery to relieve pelvic pain succeeds when the cause of the pain is structural, for example adhesions, ovarian cysts, endometriosis or a congenital or acquired abnormality in the uterus that may be treated with surgery. For other conditions that cause chronic pelvic pain, surgery may not be an option. In either case, surgery should be carefully discussed with your physician(s) to determine whether the risks involved in surgery are outweighed by the likelihood that surgery will relieve your pain.

Lifestyle Tips

A combination of therapies works best
Over-the-counter (OTC) or prescription analgesics may not be adequate to relieve your pain. Complementing drug therapy with one or more alternative therapies, including physical therapy, massage and psychological counseling, may also improve pain relief.
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 such musculoskeletal problems are detected, range of motion exercises to increase flexibility of the spine, strengthening exercises for certain muscle groups or an orthotic for your shoe may be recommended.
Relax to reduce stress
Stress exacerbates many recurrent and chronic conditions, including chronic pelvic pain. Stress increases blood pressure, reduces the immune system's ability to fight infection and affects hormone production, increasing cortisone production in the adrenal glands and upsetting the balance of female hormones. Managing stress by learning to relax daily through meditation or other established therapeutic relaxation techniques is an important part of any pain relief program. Relaxation techniques include focused breathing (as women in labor are advised to do), meditation, deep breathing, progressive muscle relaxation and listening to classical music or nature relaxation recordings. Biofeedback techniques require formal instruction and training but can help you improve your ability to recognize which muscles are tense and how to relax them.
Heat and hot water relaxes muscles
Any kind of heat improves blood flow and relaxes 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, such as Epsom salts, added to it.
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.

Organizations and Support

For information and support on coping with Pelvic Pain, please see the recommended organizations, books and Spanish-language resources listed below.

American Association of Gynecologic Laparoscopists (AAGL)
Web Site: https://www.aagl.org
Address: 6757 Katella Avenue
Cypress, CA 90630
Hotline: 1-800-554-AAGL (1-800-554-2245)
Phone: 714-503-6200

American College of Obstetricians and Gynecologists (ACOG)
Web Site: https://www.acog.org
Address: 409 12th Street, SW
P.O. Box 96920
Washington, DC 20090
Phone: 202-638-5577
Email: resources@acog.org

American Society for Reproductive Medicine (ASRM)
Web Site: https://www.asrm.org
Address: 1209 Montgomery Highway
Birmingham, AL 35216
Phone: 205-978-5000
Email: asrm@asrm.org

American Urogynecologic Society
Web Site: https://www.augs.org
Address: 2025 M Street NW, Suite 800
Washington, DC 20036
Phone: 202-367-1167
Email: info@augs.org

American Urological Association
Web Site: https://www.auanet.org
Address: 1000 Corporate Blvd.
Linthicum, MD 21090
Hotline: 1-800-RING-AUA (1-866-746-4282)
Phone: 410-689-3700
Email: aua@auanet.org

National Association for Continence (NAFC)
Web Site: https://www.nafc.org
Address: P.O. Box 1019
Charleston, SC 29402
Hotline: 1-800-BLADDER (1-800-252-3337)
Phone: 843-377-0900
Email: memberservices@nafc.org

National Uterine Fibroids Foundation
Web Site: https://www.nuff.org
Address: P.O. Box 9688
Colorado Springs, CO 80932
Hotline: 1-800-874-7247
Phone: 719-633-3454
Email: info@nuff.org

Society of Interventional Radiology
Web Site: https://www.sirweb.org
Address: 3975 Fair Ridge Drive, Suite 400 North
Fairfax, VA 22033
Hotline: 1-800-488-7284
Phone: 703-691-1805
Email: info@sirweb.org

Books

A Gynecologist's Second Opinion: The Questions & Answers You Need to Take Charge of Your Health
by William H. Parker and Rachel L. Parker

A Seat on the Aisle, Please! The Essential Guide to Urinary Tract Problems in Women
by Elizabeth Kavaler

A Break in Your Cycle: The Medical and Emotional Causes and Effects of Amenorrhea
by Theresa Francis-Cheung

Coping With Endometriosis: A Practical Guide
by Robert Phillips and Glenda Motta

The Curse: Confronting the Last Unmentionable Taboo: Menstruation
by Karen Houppert

Endometriosis Sourcebook
by Mary Lou Ballweg and The Endometriosis Association

Endometriosis Survival Guide: Your Guide to the Latest Treatment Options and the Best Coping Strategies
by Margot Fromer

Endometriosis: The Complete Reference for Taking Charge of Your Health
by Mary Lou Ballweg

Honoring Menstruation: A Time of Self-Renewal
by Lara Owen

Uterine Fibroids: What Every Woman Needs to Know
by Nelson Stringer, M.D.

What Your Doctor May Not Tell You About Fibroids: New Techniques and Therapies--Including Breakthrough Alternatives to Hysterectomy
by Scott C. Goodwin, David Drum, and Michael Broder

Yale Guide to Women's Reproductive Health: From Menarche to Menopause
by Mary Jane Minkin and Carol V. Wright

Spanish-language resources

International Association for the Study of Pain
Website: https://www.iasp-pain.org/education/translatedresources?navItemNumber=4353
Address: IASP Secretariat
111 Queen Anne Ave N, Suite 501
Seattle, WA 98109
Phone: 206-283-0311

University of Maryland Medical Center: Prostatitis
Website: https://www.umm.edu/programs/prostate/services/prostatitis
Address: University of Maryland Medical Center
22 S. Greene St.
Baltimore, MD 21201
Hotline: 1-800-492-5538
Phone: 410-328-8667

Lauri Romanzi, MD, MScPH. FACOG, FPMRS

Lauri Romanzi, MD, MScPH, FACOG, FURPS

Obstetrics and Gynecology

New York, NY

Dr. Romanzi is an academic OB-GYN leader based in New York City with decades of experience working and collaborating in over 20 countries throughout Africa and South Asia, from Somaliland Rwanda, Ghana and the Democratic Republic of the Congo to Afghanistan, Pakistan, Bangladesh and Nepal. Her experience includes mentoring, clinical and public health research, clinical education, skills training, curriculum development, systematic needs assessments, strategic planning, public-private partnerships for health equity and quality, and advocacy coalition building.

In the United States, she is licensed to practice medicine and surgery in the state of New York and holds dual certification from the American Board of Obstetrics and Gynecology; one for obstetrics and gynecology and another in the subspecialty of female pelvic medicine & reconstructive surgery. Whether local or global, Dr. Romanzi is dedicated to health education and health systems’ equity, the breaking down of siloes, navigation across the humanitarian-development continuum, evidence-based quality assurance frameworks and cross-sector dynamics that facilitate women's health, well-being and empowerment.

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