Chronic Female Pelvic Pain: Treatment Overview

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Treatment Overview

Treatment for chronic female pelvic pain can be approached in two ways: treating a known, specific cause of the pain or treating the pain itself as a medical condition. If possible, your health professional will combine the two approaches.²

Treatment of a known or suspected cause of pelvic pain

Based on your history, pelvic exam, and testing results, your health professional may find one or more conditions that could be causing your pelvic pain or making it worse, such as endometriosis, irritable bowel syndrome, or uterine fibroids. Depending on the cause, your treatment may include:

• Medication to control or stop the ovulation cycle, if cyclic hormonal changes seem to make your symptoms worse.
• Other disease-specific medication, such as an antibiotic for infection or medication for irritable bowel syndrome.
• Cognitive-behavioral therapy, counseling, or biofeedback.
• Surgery to remove painful growths, cysts, or tumors. (However, studies have shown that surgery to remove scar tissue, or adhesions, does not relieve pain unless the adhesions are severe, referred to as stage IV adhesions.²)
• Healthy lifestyle choices, such as regular exercise to manage stress and improve strength, mood, and general health, along with dietary changes, such as those recommended to manage irritable bowel syndrome.

Pain treatment

For both new (acute) and chronic pelvic pain, nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-choice treatment for relieving pain and inflammation. NSAIDs are also highly effective for relieving menstrual pain because they block production of prostaglandin, which is responsible for cramping pain. Your health professional may recommend a nonprescription NSAID, such as ibuprofen, taken on a regular schedule. Different types of NSAIDs work for some people but not others. If your first trial doesn't work, your health professional will recommend a different type, possibly a prescription NSAID.

For cyclic pain that seems to be caused or made worse by menstruation, stopping ovulation and controlling hormone levels is commonly recommended and sometimes effective.

• Birth control pills (oral contraceptives) or high-dose progesterone are commonly prescribed to reduce painful menstruation. Oral contraceptives are often prescribed for endometriosis-related pain, though there is little research that shows them to be effective.¹ However, when the risk of using an oral contraceptive is low, it is typically worth trying for several months.
• Gonadotropin-releasing hormone agonists (GnRH-As) can relieve endometriosis-related pain by stopping production of the hormones that make endometriosis worse. GnRH-A treatment may also relieve cyclic pelvic pain not related to endometriosis, as well as pelvic pain related to irritable bowel syndrome.¹ However, this short-term treatment induces menopause for as long as you take it, with side effects such as hot flashes and loss of bone density. For more information, see the topic Endometriosis.

For chronic pelvic pain, combining medical and psychological treatment increases your chances of treatment success. Medications that may help manage your chronic pelvic pain include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs), taken on a regular schedule to relieve pain caused by inflammation or menstruation. If one type doesn't work for you, your health professional may recommend trying another before discontinuing NSAID therapy. Talk to your health professional about whether NSAID therapy is safe for you, how much to take, and what type of schedule to follow.
• Tricyclic antidepressant medications (TCAs), which are used to treat chronic pain in other areas of the body as well. Limited research suggests that TCA therapy decreases chronic pelvic pain intensity for some women.¹
• Narcotic pain medication, which is only recommended as a last-resort, short-term treatment for severe pelvic pain because of the risk of addiction.

Counseling and mental skills training help you learn the mental and emotional tools for managing chronic pain and the stress that makes it worse. Commonly recommended approaches include:

• Cognitive-behavioral therapy focused on changing both the way you think about pain and your ability to mentally influence how pain affects you.
• Biofeedback, which is the conscious control of body function that is normally unconsciously controlled.
• Interpersonal counseling focused on best managing your life events, stressors, and relationships.

Alternative pain treatments such as acupuncture, transcutaneous nerve stimulation (TENS), hypnosis, guided imagery, aromatherapy, meditation, and yoga are low-risk pain treatments that many people use to manage pain. Acupuncture and TENS have shown some success in relieving painful menstrual periods. Acupuncture has also been used as a treatment for nonmenstrual chronic pelvic pain but has not been well studied.¹

Surgical treatment for chronic pelvic pain should be limited to the treatment of surgically correctable problems. Surgery is most useful for treatment of a specific cause of pelvic pain, such as fibroids or endometriosis.

There is no evidence that surgical removal of the reproductive organs relieves chronic pelvic pain when the cause of pain cannot be found. It can even make the pain worse.⁵ When surgery is done for pain with no known cause (hysterectomy or cutting of specific pelvic-area nerves), there is a risk of persistent or worsened pain after surgery as well as surgery-related side effects.

What To Think About

After 4 to 6 months of pain, some people develop chronic pain, which is a medical disorder that is separate from the original pain-causing condition. Because chronic pain and female pelvic pain have yet to be fully understood, treatment can be a trial-and-error process. It is common for women with chronic female pelvic pain to try many treatments before finding one or more that are helpful.

Decisions are complicated when considering treatment for chronic pelvic pain. Evaluate the following:

• Are the symptoms bothersome enough to require treatment?
• Do you want to have a child or more children?
• Has a specific cause of the pain been discovered, or is the cause unclear?
• Is menopause, which may stop symptoms, going to occur soon?
• Would an opinion from another health professional be helpful?
• Would an opinion from a physician who specializes in chronic pain be valuable?
• Have you tried cognitive-behavioral therapy?

Last updated:	January 30, 2007
Author:	Kathe Gallagher, MSW
Reviewed By:	Renée M. Crichlow, MD - Family Medicine, Kirtly Jones, MD - Obstetrics and Gynecology
Editors:	Kathleen M. Ariss, MS, Pat Truman, MATC