Pelvic Pain in Women: Why Effective Treatment Can Be Elusive

Most women experience pelvic pain at some point—menstrual cramps, ovulatory discomfort or tenderness in the vulva or vagina. But chronic pelvic pain, the kind that lingers for months, is one of the most underdiagnosed and unaddressed conditions in medicine.

Studies suggest about 15% of women suffer from chronic pelvic pain that affects everything from work to sleep to sex—but because diagnosis is often difficult, experts believe the actual number could be much higher.

“The sad truth is that many patients never get the care they need,” said Kacey Hamilton, MD, minimally invasive gynecologic surgeon (MIGs) at Cedars-Sinai. “A lot of women look for help online, but chasing social media influencers who promise an expensive solution is not the answer.”

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What Is Pelvic Pain and Why Is It Pervasive

Women with chronic pelvic pain experience discomfort between the hip bones and below the belly button for at least six months. Some women experience a sharp, stabbing pain that comes and goes. Others notice a constant dull ache.

“Chronic pelvic pain is both extremely common and extremely complex,” said Liron Bar-El, MD, a MIGs specialist at Cedars-Sinai. “The pelvis houses organs from multiple systems—reproductive, urinary, gastrointestinal—plus, muscles, nerves and blood vessels. Any of these can be the source of pain, and more commonly several sources overlap.”

Effective pelvic pain management often requires coordinated care across several specialties, including specialized gynecology, physical therapy, diet, functional medicine and mental health.

Common Causes of Pelvic Pain

Patients are often surprised to learn how many conditions are linked to pelvic pain—and how many of them can occur at the same time. Some of the most common reasons for pelvic pain include:

• ‍Endometriosis, a condition where the tissue that lines the uterus (the endometrium) is found outside the uterus. ‍
• Adenomyosis, where the endometrial tissue that lines the uterus invades into the muscular walls of the organ.‍
• Myofascial pain disorders, including pelvic floor hypertonic disorders. At specialized centers, 50%-90% of women have pain originating from musculoskeletal structures.‍
• Pelvic inflammatory disease, stemming from an ascending infection of the reproductive tract.‍
• Interstitial cystitis/painful bladder syndrome, a condition in which inflamed or irritated bladder walls can lead to bladder spasms, frequent urination and urinary urgency. ‍
• Uterine fibroids, noncancerous tumors in the uterus that may cause heavy menstrual bleeding and pelvic pain.‍
• Irritable bowel syndrome, an intestinal disorder that causes bloating, gas, diarrhea and constipation. ‍
• Inflammatory bowel diseases, such as Crohn’s disease and ulcerative colitis, are autoimmune disorders of the bowel causing bowel habit changes and pain.‍
• Pelvic congestion syndrome, a condition where enlarged, varicose-type veins around your uterus and ovaries can cause pelvic pain.‍
• Vulvodynia, or chronic vulvar pain, which may not have an identifiable cause, but can lead to chronic pain, burning or discomfort around the opening of the vagina.‍
• Nerve entrapment syndromes, where certain pelvic nerves are entrapped within ligaments and muscles and cause neurologic disorders and pain.

This list is far from complete, but it covers the most common causes of chronic pelvic pain. The best way to identify the source of pain is to see a qualified specialist who is part of a comprehensive care team.

Why Pelvic Pain Can Be Difficult to Diagnose

Standard screening tests for pelvic pain are limited, and when they come back normal, patients are often told nothing is wrong.

But pelvic pain symptoms can mimic conditions across gynecologic, urinary, gastrointestinal and musculoskeletal systems, which makes diagnosis more complicated.

“Many of these patients have histories of sexual abuse or other trauma, including being repeatedly dismissed by the medical system, which can change how the body and brain register pain,” said Bar-El.

No matter where pelvic pain originates, prolonged pain in the pelvis can throw off the nervous system.

“We call it central nervous system sensitization,” said Hamilton. “When that happens, the brain and spinal cord begin to amplify pain signals and may no longer accurately identify the source of pain, so minor events like emptying the bladder, having a bowel movement and even gentle touch can trigger excruciating pain.”

This shift in brain signaling means pelvic pain is no longer driven by the original condition. Instead, the nervous system, muscles and surrounding tissues may all contribute to ongoing symptoms.  

Women should never be embarrassed to ask for help—or accept the notion that there are no effective treatments for chronic pelvic pain.

A Multimodal Approach to Treating Pelvic Pain

The arc of pelvic pain care is increasingly hopeful. More nuanced pain interventions and integrated team models mean that fewer patients need to endure years of uncertainty.

“If you’ve reached the point of daily pain, your nervous system needs help, your muscles need help and we need to treat the source,” Hamilton said—reinforcing that relief usually comes from multiple directions, not a single fix.

A multimodal approach typically combines:

• ‍Careful diagnostics: To identify the source of pain, specialists take a complete medical history, perform a physical and pelvic exam and perform targeted imaging, such as advanced pelvic ultrasound and MRI. “We can now visualize endometriosis, including the peritoneal kind, and adenomyosis with advanced ultrasound skills,” Bar-El said.‍
• Physical therapy: Targeted physical therapy can address muscle spasm, myofascial trigger points (tight and sensitive muscle “knots” that can radiate pain), and coordination problems that perpetuate pain. ‍
• Medication: Nonsteroidal anti-inflammatory medications (such as ibuprofen), hormonal suppression medications, muscle relaxants and neuromodulators (that manage nerve pain), may help address underlying conditions. “Our goal is to use multi-modal, non-opioid treatment regimens to relieve pain without the risk of dependence,” said Bar-El. ‍
• Interventional pain procedures: When nerve sensitization is present, treatments that target the nervous system—including trigger-point injections, Botox for muscle spasm and nerve blocks with anesthesiology pain specialists—can help reduce chronic pain signals.‍
• Behavioral and psychological support: Chronic pain can significantly affect emotional wellbeing, and emotional wellbeing can also influence pain perception. Pain-directed psychotherapy, cognitive behavioral therapy (CBT), relaxation techniques and hypnotherapy can help patients manage pain responses and address the psychological impact of persistent pain. ‍
• Lifestyle and self-management: Sleep, exercise and dietary adjustments can help relieve pain. Tracking pain, including timing, severity, relation to your cycle, bowel or bladder symptoms, activities that worsen it and what relieves it, may help your provider diagnose the source and identify effective therapies. ‍
• Surgery: For certain conditions, such as advanced endometriosis, adenomyosis, fibroids or nerve entrapment, surgery may be necessary. But it’s not always the first step. “We usually don’t do surgery upfront since inflammation from surgery can make chronic pain worse if the system isn’t calmed first,” said Hamilton. Starting pelvic floor physical therapy before surgery typically improves recovery and pain resolution.  

When to Get Help for Pelvic Pain

If you’ve been experiencing persistent pain for six months or more, seek help from a medical provider. Symptoms such as fever, sudden severe pain, very heavy bleeding and fainting require immediate attention.

“Women should never be embarrassed to ask for help—or accept the notion that there are no effective treatments for chronic pelvic pain,” Hamilton said.

Increasing awareness that pelvic pain is common, pathologic and treatable, coupled with improved diagnostic techniques and the development of multidisciplinary programs, means more patients are getting the care they need.

“With the right expertise and a comprehensive, multidisciplinary approach, patients can achieve meaningful symptom relief and reclaim their quality of life,” said Bar-El.

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