Pelvic pain has many causes. Pelvic pain can arise from a number of different organs or from different medical problems within the pelvis.
The causes include:
- Pain from the uterus – fibroid pain, prostaglandin pain, clot colic, adenomyosis
- Pain from the ovaries – ovarian cysts, ovulation pain, ovarian remnant syndrome
- Pain from the bowel – irritable bowel syndrome, bloating, food intolerance, constipation, inflammatory bowel disease
- Pain from the bladder – interstitial cystitis
- Pain from adhesions Pain from nerves – neuropathic pain Pain from veins – ovarian vein syndrome, pelvic congestion syndrome
- Pain from muscles, joints or ligaments
- Pain from the appendix
- Pelvic infections – pelvic inflammatory disease
Pain arising from the uterus
Uterine pain occurs on the first one or two days of a menstrual period. The uterus is a hollow muscular organ and when the uterine muscle contracts during a period the result is a cramp-like pain that comes and goes every few minutes. Between the contractions there is little pain. The pain may be referred to the thigh (but not below the knee) or into the lower back when the pain is severe. Uterine pain is usually felt across a large area in the centre of the lower abdomen. If the pain is present in one small area or on one side of the pelvis then other reasons for the pain are more likely.
Pain during the month is less common but possible. If it is uterine pain then it typically worsens as a period becomes closer and eases off in the week after the period. Some women with bleeding between periods are aware that whenever they bleed they experience pain that feels like a period.
See this article on this site: Fibroid Pain
Prostaglandins are chemicals that cause the uterus to contract and therefore lead to a cramp-like pain. Prostaglandin pain is especially common in teenage girls and young women, and may cause pain in older women too, particularly if they have never had children. If the prostaglandins affect the nearby large bowel then they may cause diarrhoea and bowel cramps. If they spread to or affect the whole body then they lead to fainting, nausea or a slight rise in body temperature. Lesions of endometriosis can produce prostaglandins and this may be one way in which endometriosis causes pain. There is no specific test for prostaglandin pain. Prostaglandins do not alter the appearance of the pelvic organs, so no abnormalities are seen on an ultrasound scan or during a laparoscopy. Blood tests are unhelpful. The diagnosis is therefore made on the history of the symptoms. If pain is present on the first day of the menstrual cycle and improves or disappears with anti-prostaglandin medication such as NSAIDs then prostaglandin pain is the likely cause.
Treatment of prostaglandin pain
- Non-steroidal anti-inflammatory drugs (NSAIDs) are anti-prostaglandin medications and include drugs such as ibuprofen, naproxen, diclofenac, mefenamic acid and indomethacin.
- The combined oral contraceptive pill. A combined pill that is progesterone dominant, in other words one that is low in estrogen and higher in progesterone is best for period pain. Using the contraceptive pill to skip periods means less periods and less pain.
- The progesterone only pill. Contraceptive pills that contain only progesterone are usually effective. These include the mini-pill, Depo-Provera and Implanon.
- A progesterone releasing intra-uterine device such as the Mirena IUD can be particularly effective. This releases progesterone locally into the uterus with only a tiny amount being absorbed into the body.
- Analgesics such as paracetamol, codeine, tramadol.
Clot colic is a particular type of period pain that occurs in women who have heavy periods. Heavy menstrual bleeding results in the formation of clots which then cause colicky cramp-like pains. After a clot has been passed the uterine pain improves. Clot colic pain only occurs on the days when clots are passed. Pain which occurs on days with light bleeding is not clot colic. There is a similar type of uterine pain that is much less common may occur if women have a very narrow cervical opening. This condition is called cervical stenosis. Menstrual blood from the uterus has difficulty passing through the cervix into the top of the vagina and the uterus contracts strongly to push the blood out.
Any form of treatment that makes menstrual periods lighter will reduce clot colic. There are a number of treatments that make periods less heavy including:
- The combined contraceptive pill makes periods lighter.
- Tranexamic acid (Cyklokapron) works as an antifibrinolytic and makes periods lighter.
- A levonorgestrel-releasing intrauterine device (IUD). This releases a low dose of progestogen medication into the lining of the uterus every day. This makes the endometrium thinner and menstrual periods lighter.
- An endometrial ablation is an operation which removes or destroys the endometrial lining of the uterus, making it much less likely to bleed during a period. It is unsuitable for those women who want to become pregnant in the future.
Adenomyosis is a condition where lesions that look like the endometrium are found within the muscular wall of the uterus. ‘Adeno means gland and ‘myo’ means muscle. So adenomyosis is glandular tissue within muscle. Adenomyosis causes painful periods. Some women experience pelvic pain throughout the month which worsens as their period gets closer. Other symptoms include heavy periods pelvic pain and painful sex (dyspareunia). The uterus is usually slightly enlarged, and your gynaecologist may describe it as “bulky”. Adenomyosis is commonest in women between the ages of 30 and 50 years. Occasionally young women do develop adenomyosis. Adenomyosis and endometriosis can co-exist.
For a more detailed article about adenomyosis please follow this link: Adenomyosis
Pain from the Bowel
There are many causes of pain from the bowel. The commonest are irritable bowel syndrome (IBS), bloating, constipation and food intolerance.
What type of pain is bowel pain?
The bowel is made up of the small intestine (ileum) and large intestine (colon). Pelvic pain is usually from the colon, which is a long hollow muscular organ (like the uterus) with smooth muscle within its wall. Therefore one common type of bowel pain is a colicky or cramp-like pain that comes and goes at regular intervals (but not always regular). The bowel wall can contract forcefully as if a person has diarrhoea. If it is the large bowel contracting then the pain is felt in the lower abdomen or pelvis (usually centrally). If it is the small intestine contracting hard then the pain is around the umbilicus or above it, usually.
Another type of bowel pain is a constant aching pain or discomfort, often in the lower left quadrant of the abdomen, near the final sections of the colon known as the sigmoid colon and rectum. Or, the discomfort maybe in the lower right side of the abdomen - near the part of the colon known as the caecum. These types of discomfort or pain are particularly common in women with constipation. This discomfort is difficult to distinguish from pain arising from endometriosis, ovarian cysts or adhesions. Fibroid pain tends to be central in location.
The most typical aspect of bowel pain is that the discomfort often improves after a bowel action. In addition, there are often other bowel symptoms such as diarrhoea, constipation, a need to strain to open your bowels, a sensation that the bowel is never empty, an urgency to open your bowels, excessive wind or bloating. These are the symptoms of IBS.
Bowel pain occurs at any time of the month, not just with periods, although some women do notice that their bowel symptoms are worse before a period.
Irritable Bowel Syndrome
As already mentioned bowel pain and endometriosis can be easy to confuse. Irritable bowel syndrome (IBS) often causes bowel pain that is similar in nature and location to endometriosis. There are many women who thought that, or were advised that, their pain was coming from IBS, when in fact it was due to endometriosis, and once their endometriosis was removed , their discomfort resolved. And others who were told at that their symptoms were secondary to endometriosis, but improved when their IBS was treated.
IBS is a syndrome, which means that it is a collection of symptoms arising from the bowel, as described above, all loosely put together under one name. Some people with IBS have a tendency to constipation, whilst others are prone to diarrhoea. Very few people have all the symptoms of IBS, so your IBS symptoms may not be the same as others you are affected.
What is the cause of IBS?
Irritable bowel syndrome is a complex condition, about which a lot is known, but it is still not fully understood. IBS may be due to a change or problem in the way that the nerves within the bowel work. Some these nerves are 'motor' nerves that control how the bowel contracts or moves. A change in the activity of these nerves can lead to diarrhoea, constipation or a combination of both. Other nerves are 'sensory' nerves that provide information to us about how the bowel feels. An alteration in the behaviour of these nerves may cause symptoms of bloating, excess wind, a feeling that the bowel is never empty or urgency before the bowels are opened.
How does food affect IBS?
The food we eat inevitably affects irritable bowel syndrome. Many find that there are certain foods that aggravate their symptoms or discomfort.IBS and diet is a complex subject. In general it is best to eat a healthy, low fat, low salt, low caffeine, high or fairly high fibre diet, which is the kind of diet we should all be following anyway. Fibre and IBS is a subject fraught with difficulties and detailed advice is outside the remit of this article. Some with IBS find that too much fibre, particularly insoluble fibre, makes their symptoms worse. Often those with IBS respond to food in an exaggerated way, and may find, for example, that while a large fatty meal may upset anyone’s stomach, a person with IBS will find it upsets them more.
Even women who do not have irritable bowel syndrome may find that eating a healthy diet actually in time improves their pelvic pain. If you have discomfort from endometriosis or fibroids the last thing you need is IBS and bowel pain as well.
Diagnosis of IBS
IBS is very prevalent and if you have some of the bowel symptoms already described then at least some of your discomfort may well be due to IBS. However, irritable bowel syndrome is a diagnosis of exclusion, and can really only be diagnosed with certainty after all other possible causes of the symptoms have been excluded. So, for example, in a young woman, this may require ruling out endometriosis with a laparoscopy and/or ruling out other bowel conditions with blood tests, X-rays, upper GI endoscopy, colonoscopy and breath tests.
Through a laparoscope an irritable bowel looks normal, as indeed it does during a colonoscopy, although distension of the large bowel during a colonoscopy may provoke symptoms that are typical for IBS and help to make the diagnosis.
It is important to note that many women have both IBS and endometriosis (or IBS and fibroids).
Important symptoms to tell your doctor:
There are some symptoms that should always be reported to your doctor straightaway.
These include any bleeding from the bowel, bowel incontinence, unexplained weight loss, getting up in the night to empty your bowels, or malabsorption of food. Women over the age of 50 hardly ever develop IBS for the first time, so if you are over 50 and you experience a change in bowel habit, then you should see your doctor straight away.
There are many non-serious conditions that cause these symptoms, but bowel cancer needs to be excluded.
Treatment of IBS
Firstly ensure that the diagnosis is IBS. Report any warning or red-flag symptoms to your doctor. Ensure that you do not have a serious condition such as bowel cancer. Also exclude other significant diseases such as coeliac disease, inflammatory bowel disease, lactose intolerance, fructose intolerance. Review your medications and herbal supplements.
Certain drugs such as, antibiotics, antacids, thyroid hormone and laxatives can cause or worsen diarrhoea. Other drugs such as analgesics, iron tablets, amitriptyline, tranquilisers and some blood pressure medications can cause or worsen constipation. There are some herbal medications that can affect your bowel, so discuss these with your doctor or herbal therapist.
Here are some treatment suggestions for IBS:
- Lifestyle changes
This means trying to avoid any factors that make the symptoms worse, such as stress, alcohol, vegetables like onions or any foods which worsen the symptoms. It is important to eat regular meals in an unhurried way, and to get sufficient sleep. Nicotine can irritate the bowel, so stopping smoking is a good idea.
- A better diet
It helps to start by eating a healthy, low fat, low salt, low caffeine and high or fairly high fibre diet.
- Eat more fibre
Western diets generally do not contain enough fibre. Fibre rich foods include bran, wholemeal, granary and soft grain varieties of bread, jacket potatoes, new potatoes in their skins and baked potato skins, wholegrain breakfast cereals, e.g. Weetabix, branflakes, unsweetened muesli, shreddies and porridge oats, wholemeal pasta and brown rice, beans, lentils and peas, fresh and dried fruits – particularly if the skins are eaten, vegetables – particularly if the skins are eaten, nuts and seeds. Soluble fibre (like oats) is often better tolerated than insoluble fibre (like bran). Sometimes a diet high in insoluble fibre can worsen IBS. One way of getting plenty of soluble fibre is to take a daily dose of ispaghula (psyllium) husk which can be bought as Fybogel (UK) or Metamucil (US).
- Look after you gut bacteria
The bacteria in our bowel help us to digest our food. Some foods contain live bacteria and may help the symptoms of IBS.
- Complementary therapies
Herbal teas and slippery elm are often taken for IBS symptoms. Peppermint oil capsules taken 3 or 4 times a day 30 minutes before meals are often helpful in easing bloating and abdominal pain, but may aggravate heartburn and indigestion (peppermint relaxes the valve between the stomach and esophagus).
- Manage your stress
This can be a very important aspect of IBS management. Stress worsens IBS and bowel symptoms are especially common in women who have suffered physical or sexual abuse in the past. For advice about treating anxiety and learning to relax please see this page:
Most women with IBS do not need medications. There are no medications that help all the symptoms and no drug that will cure IBS. The most helpful drug depends on the symptoms.
Fibre supplements such as Fybogel or Metamucil aid constipation, bowel pain and sometimes diarrhoea.
Antispasmodics such as alverine citrate, dicycloverine (merbentyl) and mebeverine help bowel spasms and colic.
Antidepressants in low dose, such as amitriptyline can help bowel spasms.
Laxatives help to treat and prevent constipation, but stimulant laxatives cause bowel spasms, and are often not required enough fibre and fluid is consumed.
Read more about irritable bowel syndrome here:
Irritable bowel syndrome
- Dietary advice for specific symptoms
If you have indigestion or burping, then avoid chocolate, alcohol and coffee. If you have an easily irritated stomach then avoid tomatoes, citrus fruits, alcohol and spicy foods are best avoided. If you have heartburn, acid reflux disease or GERD then please see this page:
Food Intolerance or food allergy ?
Are your bowel symptoms aggravated by your diet? There are two main ways that food can cause problems: food intolerance and food allergy.
This means that the bowel is unable to digest certain foods easily. Consuming a small amount of a certain food may result in no problem, because the bowel is able to cope with small amounts. However, eating larger quantities of that particular food overloads the bowel and results in bowel cramps, colicky pain, bloating and/or diarrhoea. The foods that commonly cause food intolerance are lactose (in milk products) and fructose (a sugar found in fruit).
This means that the immune system of the body reacts to a particular protein in a food. Sometimes the immune system reacts very quickly resulting in a potentially life-threatening condition known as anaphylaxis. This is fortunately quite rare. In food allergy the immune system usually reacts slowly leading to a number of symptoms that it may be hard to identify as a food allergy. The common culprits are foods such as milk, eggs, nuts, fish, shellfish, soybeans and gluten (in wheat). Food allergies are less common than food intolerances.
Bloating is a symptom that doctors tend to think of as an inconvenience rather than a major problem. This is because bloating rarely indicates a serious illness, and because it is poorly understood and there are few easy answers to the problem. But, when women are asked about bloating they see it as a major problem. Bloating makes women feel unfeminine, uncomfortable and unattractive. It may also cause any other pelvic pains worse.
What is bloating?
There are two types of bloating:
- Bloating where the abdomen is distended due to excess wind.
This may be secondary to swallowing excess air when eating or talking, or to certain foods which have been consumed. If your body is unable to absorb some foods then they remain in the bowel for longer. The bacteria in the intestine then ferment these foods to produce gas. Unless you have coeliac disease, you are not allergic to these foods, but it may help to eat them in smaller quantities.
- Bloating where the abdomen looks normal, but feels bloated.
This is usually due to irritable bowel syndrome. In women with IBS, the bowel does not move normally and therefore wind does not pass through easily. The nerve endings within the bowel are oversensitive and the bowel therefore feels uncomfortable as well. This type of bloating becomes worse as the day progresses and is generally best on waking.
Treatment for bloating
Everyone is different and what causes one person to bloat may not be a problem in someone else. The following list covers some of the factors that may lead to bloating. It is unlikely that they will all apply a particular individual but one or two factors may.
- Swallowing excess air when eating or talking. This is more likely to occur if you are eating quickly, drink carbonated drinks, chew gum or smoke cigarettes. Chewing gum also contains sorbitol which can cause bloating and diarrhoea.
- Eating too much fructose or fructan? Cutting down on foods containing flour such as biscuits and bread often helps.
- Do you spend a lot of time sitting down? A brisk walk helps the bowels to move and helps the the wind to pass through.
- Wearing tight clothes around the waist. These can lead to discomfort. Wearing looser clothes can help.
- Eating a lot of fermenting vegetables. Foods such as beans, lentils, Brussels sprouts, legumes and cabbage naturally produce gas whilst being digested. They are not bad foods, but they do produce gas. Cutting down or avoiding can help.
Very few people in Western countries eat enough fibre for their bowel to work well. Constipation is very common, and can cause a colicky or cramp-like pain that gets better once the bowels have been opened well. Mild constipation may be one reason that eating a healthy diet helps some bowel and pelvic pain. It is treating the constipation that no-one was aware of.
In addition to a low fibre diet, many women do not place a low priority on their bowel function. We lead busy lives. Women tend to rush in, strain and then if no bowel action takes place quickly, give up and hope that something happens later in the day. They have lost an opportunity.
The best time to open your bowels is in the morning after breakfast because this is when bowel contractions are the strongest. They begin while you are asleep, about one hour before your bowel actually opens.
These contractions start high up in the bowel, move the bowel action around to the lower bowel and then out through the anus. They can open your bowel much more effectively than you can by straining, but they do take time. Rushing around, stress, anxiety or tension can interfere with the bowel contractions or with the awareness of the need to open the bowels. Straining is harmful to the pelvic floor and should not be required if you have a normal intestine. Give your bowels time and eat plenty of fibre.
Treatment of constipation
Before consulting your doctor, try these measures:
- Eat enough fibre
- Eat breakfast every day, ideally high in fibre.
- Allow plenty of time to go to the toilet in the morning.
- Stay relaxed.
- Drink enough fluid. Fibre does not work properly unless enough water is drunk. At least two litres a day, mostly water is best.
- Take regular exercise, such as walking every day.
If constipation persists, then see your doctor.
- Discuss your symptoms with your doctor.
- Tests such as thyroid function tests may be necessary. Constipation is a symptom of an underactive thyroid gland
- Review your medications. Some drugs such as amitriptyline, analgesics (especially opiate painkillers), some medications for mental health problems and the long-term use of stimulant laxatives can all cause constipation
- See a dietician to review your diet
- Consult a pelvic floor physiotherapist to improve your pelvic muscle function and bowel habits
If problems persist then obtain a referral to a gastroenterologist.
Pain from Adhesions
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