Long-Term Pelvic Pain

Published November 2005

About this Information

This information is intended to help you if you have long-term pelvic pain. It is based on the Royal College of Obstetricians and Gynaecologists (RCOG) guideline The Initial Management of Chronic Pelvic Pain (published by the RCOG in April 2005).

This information tells you about:

• the main factors that may contribute to long-term pelvic pain
• what your doctors can do to investigate and identify the cause of your pain
• the most effective methods recommended in the UK for managing long-term pelvic pain.

This information tells you about the recommendations the RCOG guideline makes and aims to help you and your healthcare team make the best decisions about your care. It is not meant to replace advice from a doctor or nurse about your own situation. This information does not tell you about what can be done for women whose initial treatment has not been successful. It does not tell you in detail about conditions that may be the cause of long-term pelvic pain, or about treatments for those conditions. For further information about these conditions see the section on Other organisations. Some of the recommendations here may not apply to you. This could be because of some other illness you have, your general health, your wishes, or some or all of these things. If you think the treatment or care you get does not match what we describe here, talk about it with your doctor, nurse or another member of your healthcare team.

• you experience it either constantly or intermittently for at least six months
• it happens at times other than when you have your period or sexual intercourse.

Long-term pelvic pain is common. It affects around one in six women. Long-term pelvic pain is not a diagnosis in itself but a description of a symptom.

The reasons for long-term pelvic pain are not always easy to diagnose. It is not always possible to treat. Women may need support in managing and coping with their pain.

Even if no reason can be found for the pain, many women find that the quality of their lives improves when they get a better understanding of what is involved.

Long-term pelvic pain is often caused by a combination of physical, psychological and/or social factors, rather than a single underlying condition.

These factors include:

• endometriosis (a condition where cells of the lining of the womb (the endometrium) are found elsewhere in the body, usually in the pelvis)
• adenomyosis (a condition where the endometrium is in pockets within the muscle wall of the womb)
• pelvic inflammatory disease (PID) (an infection of the womb, fallopian tubes and/or pelvis)
• interstitial cystitis (bladder inflammation)
• musculoskeletal pain (pain in your joints, muscles, ligaments and bones)
• irritable bowel syndrome (IBS)
• depression, including postnatal depression
• previous or ongoing traumatic experiences such as sexual abuse in some women
• adhesions (areas of scarred tissue that may be a result of a previous infection, endometriosis or surgery) – although these are common, they do not always cause pain
• trapped or damaged nerves in the pelvic area.

For some women with long-term pelvic pain none of these factors may be found.

• the pattern of your pain
• what makes your pain better or worse (certain sorts of movement, for example)
• whether you have noticed other problems that might be linked to the pain (intercourse, bladder, bowel or psychological symptoms, for instance).

You may be asked about aspects of your everyday life including your sleep patterns, appetite and general wellbeing. You may also be asked about how you are feeling and whether you are feeling depressed or tearful. This is because long-term pain is known to cause depression, which in turn may make your pain worse. If your healthcare professional knows how your pain is affecting you personally, this can be taken into account with your treatment.

Your doctor should explain the various factors that can lead to long-term pelvic pain (see section ‘What causes long-term pelvic pain?’).

Then depending upon your own situation, you may be offered any of the following types of tests:

• You will probably be offered an ultrasound scan.
• You may be offered screening tests for sexually transmitted infections.
• If your pain is related to psychological, bladder or bowel symptoms, your consultant may refer you to a specialist or suggest you see your GP. If you have bowel symptoms, for example, you may be referred to a gastroenterologist who may offer you tests for irritable bowel syndrome (IBS)
• If your pain occurs on a regular basis at a specific time in your menstrual cycle, then you may be offered drugs to suppress your periods for a few months. This may help your doctor in making a diagnosis.
• You may be offered a diagnostic laparoscopy. This is a procedure carried out under general anaesthetic. It involves a small cut in the abdomen to examine your reproductive organs and look for any abnormality, problems or damage. The surgeon will insert a tiny telescope (called a laparoscope) so that your reproductive organs can be seen more clearly. As with any surgical procedure, there are risks and benefits and these will be explained fully to you when you are offered the test.
• If your health professional thinks that your pain is due to a particular cause, you may be offered treatment on a ‘try it and see’ basis. Such treatment could help you to avoid a diagnostic laparoscopy, which carries small but significant risks.

You should be offered treatment and advice if:

• your pain is related to your menstrual cycle and you have heavy periods
• your pain varies with movement
• you have symptoms suggestive of irritable bowel syndrome
• you may have symptoms suggestive of a sexually transmitted infection or PID.

Your doctor will provide you with full information about all treatment options

• bleeding from your rectum
• a change in your bowel habits which has lasted for more than six weeks
• new pain after you have passed the menopause
• any unusual swelling in your abdomen
• suicidal thoughts
• excessive weight loss
• irregular vaginal bleeding, such as bleeding between periods, or vaginal
• bleeding after the menopause or vaginal bleeding during or after sex.
• No treatment can be guaranteed to work all the time for everyone.
• You have the right to be fully informed about your health care and have the opportunity to share in making decisions about it. Your healthcare team should respect and take account of your wishes.
• If you are not comfortable with the final diagnosis, you can ask for a second opinion.

Sources and acknowledgements

This information is based on the Royal College of Obstetricians and Gynaecologists (RCOG) guideline The Initial Management of Chronic Pelvic Pain (published by the RCOG in April 2005). The guideline contains a full list of the sources of evidence we have used. You can find it online at: www.rcog.org.uk/index.asp?PageID=1124.

Clinical guidelines are intended to improve care for patients. They are drawn up by teams of medical professionals and consumers’ representatives, who look at the best research evidence there is about care for a particular condition or treatment. The guidelines make recommendations based on this evidence.

This information has been developed by the Patient Information Subgroup of the RCOG Guidelines and Audit Committee, with input from the Consumers’ Forum and the authors of the clinical guideline. It was reviewed before we published it by women attending clinics in London, Oxford and Southampton. The final version is the responsibility of the Guidelines and Audit Committee of the RCOG.

© Royal College of Obstetricians and Gynaecologists