The pain is real, even when the cause is not immediately apparent: RSU explores approaches to chronic pelvic pain

Writer: Elizabete Ārgale (gynaecologist, doctoral student and lecturer at the RSU Department of Obstetrics and Gynaecology) 

Some women experience pelvic pain for months or even years, see various specialists, yet still receive no clear answer as to why the pain has developed or how to get better. Sometimes identifying the cause of persistent pelvic pain equire a doctor to do some detective work. In some cases, moreover, the original ‘culprit’ may already have disappeared, while the pain persists as a nervous system response. Such cases require a different approach – one that goes beyond simply looking for and treating a physical cause. 

What can cause chronic pelvic pain, and how can this puzzle be solved? I explored these questions while writing a chapter for the recently published book Gynaecology, issued by Rīga Stradiņš University (RSU). In this article, I will explain the subject in simpler terms. 

Chronic pain – what is it and why does it occur? 

In cases of sharp, acute pelvic pain, the cause can usually be identified quickly. For example, if the patient has appendicitis (inflammation of the appendix) or a ruptured ovarian cyst, the necessary surgery is performed and the problem is resolved – the abdominal pain stops. Chronic pain, however – pain that lasts for more than three to six months – is different. 

If a person does not respond to pain signals for a prolonged period, or fails to receive an accurate diagnosis and treatment, acute pain can become chronic. 

Ordinary painkillers do not always relieve it. The cause of the pain, such as inflammation, may already have disappeared, while the response in the nervous system remains. This can be compared to phantom pain: for example, a person may have had a leg amputated, yet the nervous system continues to send signals as though the leg were still painful. 

When investigating the causes of chronic pelvic pain, doctors often have to work through a process of excluding diagnoses before they can determine what hurts and why. Chronic pain is not necessarily sharp and unbearable – people generally do not tolerate pain of that intensity for long. Although cyclical pain associated with menstruation is often discussed, chronic pain linked to the menstrual cycle may, over time, also occur outside menstruation because of sensitisation of the nervous system, or increased sensitivity. 

It is extremely important for any doctor consulted about persistent lower abdominal pain to believe the patient, even if the cause cannot be identified during a single appointment. I also encourage patients to look for a doctor who listens to them and seeks solutions. Even if the doctor does not find a large cyst or suppurative appendicitis, if the patient is suffering and reports pain, it is important not to give up. Normalising or denying a patient's sensations very easily leads to a heavy psychological toll. 

This is one of the greatest challenges associated with chronic pain: prolonged suffering can lead to feelings of helplessness and hopelessness, low mood and sometimes anxiety. 

If doctors say that they cannot find any health problem, a person may start thinking, ‘Maybe there is something wrong with me mentally.’ By contrast, when we begin exploring possible causes and provide a clear direction for investigations, the patient gains hope. 

Endometriosis – one of the most common causes 

One of the most common causes of chronic pelvic pain is endometriosis. In this condition, tissue similar to the lining of the uterus is present outside the uterus. Within the uterus, this tissue can regenerate with each menstrual cycle and leave the body through the cervix during menstruation, whereas tissue outside the uterus cannot do so. 

The body recognises that this tissue is in the wrong place and sends signals, which the woman experiences as very severe pain. 

If this pain recurs every month, it very often becomes chronic resulting in constant abdominal discomfort. The pain may no longer be as severe, but it does not disappear. There may be a pulling sensation or discomfort during sexual intercourse or bowel movements. 

Endometriotic lesions outside the uterus cannot always be seen on ultrasound or magnetic resonance imaging (MRI). If a woman experiences very severe pain during menstruation, laparoscopy may sometimes be necessary – an operation in which a camera is used to examine the abdominal cavity. 

Adhesions are another common cause. These can develop after inflammation and also in cases of the endometriosis mentioned above. They are, in a sense, the body’s attempt to deal with a problem by producing an inflammatory response. Adhesions can also develop after surgery. 

Inflammation can sometimes result in dilated fallopian tubes. If an organ is stretched, the pain may be persistent. Such changes can be seen on ultrasound, although they may sometimes appear insignificant. If this is the only medical problem identified, surgery may be offered – either to separate the adhesions or to remove the damaged fallopian tube. 

A painful bladder or changes in bowel habits 

The bladder can also be a source of pain. One example is interstitial cystitis, also known as painful bladder syndrome. No infection is found in this condition, as the problem is more closely related to increased sensitivity of the nervous system. Treatment therefore needs to focus on calming the nervous system’s response. 

It is also important to evaluate gastrointestinal function and determine whether there are changes in bowel habits, constipation or bloating. 

People often become accustomed to their symptoms and think that ‘this is simply how it is’, but these details may be diagnostically significant. 

The musculoskeletal system should also be assessed. A sedentary lifestyle and insufficient physical activity are very common today. The spine can be compared to Lego, with each vertebra resembling a building block. Nerves pass between the connections of these ‘blocks’, almost as if wrapping around them from behind. If a nerve becomes compressed or displaced somewhere along its path, pain may radiate into the abdomen even when there is no back pain. 

Sometimes repetitive physical strain is to blame – for example, when a woman habitually carries a child on one hip. This means leaning to one side, usually the right, which can compress the nerves. Trigger points, or painful points in the muscles, and nerve entrapment can develop. Sometimes simply changing the side on which the load is carried can help. 

However, if a woman has been in pain for several months and the pain has shifted from acute to chronic, changing the load or stretching alone may not be enough. Even minor nerve compression can cause chronic pain, even without a herniated disc. 

If a nerve is irritated for a prolonged period, it can cause persistent pain. 

Dilated pelvic veins 

Another potential problem is dilated veins in the pelvis, which can also cause pain. Ultrasound may show, for example, a network of dilated veins near the ovaries. In such cases, it is advisable to consult a phlebologist. The problem may involve deep rather than superficial veins and therefore cannot be seen with the naked eye. A phlebologist can recommend the most appropriate solution. 

Paradoxically, when there is one problem in the pelvis, responses in other parts of the pelvic region may gradually seem to become ‘synchronised’. Painful urination, irritable bowel syndrome, other bowel problems, bloating and musculoskeletal pain may develop. Very often, several symptoms occur at the same time. 

Nuanced questions about lifestyle 

A doctor’s careful attention and detailed questions can help uncover answers. It is useful, for example, to understand what makes the pain worse and what relieves it, which medicines help and which do not, and whether the pain is worse in the morning or evening. If it is worse in the evening, for instance, this may suggest a possible venous problem. Keeping a pain diary to record these details is also advisable, as it can provide the doctor with valuable clues when looking for answers. 

Drinking enough water is important, as insufficient fluid intake can contribute to constipation and may be a cause of pain. 

A person may not even realise that they are constipated if, for example, they have a bowel movement every day. However, stool consistency also matters: pellet-like, hard stools are considered constipation even when bowel movements occur daily. It is also important to note that repeatedly ignoring the urge to go to the toilet can stretch the walls of the bladder and cause pain. This can also disrupt the body’s natural signalling system for urination and bowel movements. 

Pain may also be related to gastrointestinal problems, such as irritable bowel syndrome. It is useful to note whether particular foods trigger the pain. 

There are also other conditions characterised by pain that is difficult to explain, such as chronic fatigue syndrome or fibromyalgia. It should be remembered, however, that fibromyalgia does not cause pain in just one area of the body. These issues should always be discussed with the patient, because people sometimes mention only what they believe a particular specialist needs to know. If, for example, a woman presents with complaints of pelvic pain, I ask whether she has any other symptoms. Her shoulder may also hurt, but she may not mention it because she thinks it is irrelevant to a gynaecologist. In fact, this information is also useful because it helps us see the overall picture. 

Pain during or after sex 

A woman may also notice pain during or after sex. Sometimes the cause is chronic pelvic inflammation or, for example, chlamydia – an infection that is often asymptomatic and may present without obvious symptoms, but can lead to adhesions and, over time, pain. 

Pain during sex may also be associated with the endometriosis mentioned above, or may occur after surgery, including a caesarean section, or after abdominal infections because adhesions develop. The organs in the abdominal cavity are mobile and are covered by the peritoneum. However, if adhesions form between adjacent organs, an organ can effectively become ‘fixed in place’. There is even a condition known as a ‘frozen pelvis’, in which the organs are effectively stuck together and normal bowel movements, a full bladder or sex can cause pain. 

Pain during or after sex may also have psychological causes, for example if a woman has experienced sexual abuse in the past. 

Even after the original cause of painful sex has been resolved, post-traumatic stress or memories of the pain may remain. As a result, sex may continue to be painful even when there is no longer a physical cause.  

Very often, the woman herself can provide the most useful clues as to why the pain occurs. Conversation is therefore essential, and unfortunately a 20–30-minute consultation may not be enough. If either the doctor or the patient feels that not everything has been fully discussed, the first steps can be agreed at the initial consultation, but the patient should continue keeping a pain diary while the search for answers and the dialogue continue. 

Pain that persists after the medical problem has been resolved 

Unfortunately, women with chronic pain sometimes experience a particular phenomenon: the medical problem is resolved, but the pain remains. For example, in some women whose pain was caused by chronic inflammation of the ovaries and fallopian tubes (chronic pelvic inflammatory disease), the pain may persist even after an ovary has been removed. 

In chronic pain, treating the underlying cause may not be enough – treatment may also need to target the nervous system as a whole. 

In such cases, psychotherapy, psychiatric support, antidepressants or other medicines that act on the nervous system may be needed. Chronic pain causes considerable suffering and can leave a person feeling constantly tense and on edge. 

I always ask patients about their emotional wellbeing as well and ask them to complete depression and anxiety screening questionnaires. For example, I have noticed that young women experience more painful periods during exam periods. Sometimes it emerges that their parents have separated. Emotional factors of this kind can also affect the body’s physical responses. Within the limits of my competence, I also palpate the anterior abdominal wall muscles. I ask about bowel movements, urination, eating habits and daily routine as well. 

When, despite thorough investigation, no cause of the pain can be found, a doctor may temporarily recommend antidepressants or medicines that calm the nervous system. The same may apply, for example, if dilated fallopian tubes have been removed but the pain persists. Antidepressants may seem an unusual solution, but this is precisely one of the approaches used for chronic pain. The original cause of the pain has been resolved, but the nervous system has not yet settled down. Although the cause is gone and, in theory, there should no longer be pain, the response remains. It originally developed in response to an acute stimulus, but because the pain persisted for so long, the pain response has effectively been left on ‘autopilot’. 

Could this have been prevented if the acute problem had been treated earlier? Most likely, yes. But at the time, the pain may not have seemed severe enough, the person may not have been able to see a doctor, or the doctor may not have listened or taken the pain seriously. As a result, the pain can persist and eventually become chronic. There are, however, many different stories and circumstances. 

I must emphasise that these difficulties predominantly affect young women of working age who have active professional lives and children, and the pain can severely diminish their enjoyment of life and desire to socialise. It can also have psychological and financial consequences. 

Different treatment options 

As evident from the above, treatment will depend greatly on the underlying cause of the particular pain. 

Treatment usually begins with pain-relieving medication. Patients are often afraid even to take painkillers because they believe the medicines may be harmful and hope that the pain will simply go away. In fact, the stress caused by pain is more harmful to the body than medicines used to relieve these symptoms. For example, if young women have painful periods, taking one or two pain-relief tablets will not place as much stress on the body as enduring the pain and avoiding everyday activities. Sometimes one or two months of adequate pain relief is enough to make it possible to assess clearly whether the pain is related to the menstrual cycle or whether it is influenced by something else, such as particular foods. 

If endometriotic lesions are the cause, hormonal medication may be necessary. Hormonal treatment is also recommended after surgery for endometriosis to help prevent new lesions from developing. Today, hormonal medicines have been studied much more thoroughly, and their benefits and risks are well established, allowing their use to be assessed on a sound basis. 

Botulinum toxin can sometimes be useful. It was once known primarily as a cosmetic treatment for reducing facial expression lines, but we now know that it can help with migraine and with various forms of otherwise unexplained pain characterised by myofascial pain and increased muscle tone. 

Patients can also consult a pain specialist, or algologist, who specialises in the use of pain-relieving medicines and is familiar with other methods, such as electrical nerve stimulation and nerve blocks. Other potentially useful approaches include physiotherapy, psychotherapy (with particularly strong evidence supporting cognitive behavioural therapy), medicines that calm the nervous system, and antidepressants. 

Women who have not found solutions in doctors’ consulting rooms often look for ways to help themselves. There are indeed complementary methods that can help reduce pain and stabilise the nervous system, such as meditation and yoga. Acupuncture and acupressure are also described in the literature as possible approaches. 

Finding the right doctor 

Unfortunately, people often do not speak up and simply endure pain. This is typical of chronic pain: people hope that it will resolve on its own, but with each passing day the path to recovery becomes more difficult. 

If a patient has reached a dead end, has not received help and the pain has not eased over a prolonged period, I would encourage them to look for doctors who not only practise clinically but are also involved in research and teach students at a university. Students are a highly demanding and inquisitive audience, so these doctors also need to be familiar with more ‘unusual’, less common diagnoses and to analyse combinations of different conditions. This helps them maintain a broad knowledge of diagnostic methods and treatment, even when they do not often encounter such patients in everyday practice. 

I strongly encourage pursuing answers to the causes of chronic pelvic pain, because finding them can significantly improve quality of life. 

The article has been published in full on the LSM portal.