Minor cramps when you have your period? Totally normal. But chronic pelvic pain—meaning it lasts more than six months—is a whole different story, and up to one in four women may experience it, according to a 2014 review published in Pain Physician. "Pelvic pain is a big puzzle that can be caused by many factors," says Barbara Diakos, MD, a gynecologist at Northwestern Medicine Lake Forest Hospital. "That’s why it’s so important for your doctor to listen to you, to hear what all your symptoms are, and to take you seriously." (If she doesn’t, find another gyno for a second opinion.) The good news is that once you and your doctor play detective to pinpoint the cause of pelvic pain, there’s plenty you can do to relieve it. Read on for the most common culprits.
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Culprit #1: It’s a gyno thing
One major cause of pelvic pain is endometriosis, in which the tissue that lines the inside of your uterus, called your endometrium, grows outside the uterus. The pain can range from mild to excruciating; it’s often related to menstruation—it can start a few days before and continue through your period—but can occur at any time. Endo can also cause pain during sex and while having a bowel movement. It affects about 10 percent of all reproductive-age women, but it’s woefully underdiagnosed, says Mark Dassel, MD, director of the Center for Endometriosis at the Cleveland Clinic: It can take from 5 to 20 years to get the right diagnosis.
If your pelvic pain comes with superheavy periods and you find you are peeing frequently and/or often constipated, it may be something else entirely: fibroids, which are benign tumors in your uterus. They’re incredibly common—about 70 percent of white women and 80 percent of black women will get them by age 50, according to one study—but most of the time, they don’t trigger symptoms.
What to do
The first step in treating either endo or fibroids might be a hormonal birth control method, such as the pill or Mirena IUD. If you still have pain that’s interfering with daily life and your doctor suspects endometriosis, you might consider laparoscopy—in which a specially trained gynecological surgeon looks inside your abdomen and removes endometrial tissue—to both confirm the diagnosis and treat the problem, says Magdy Milad, MD, medical director for the Northwestern Medicine Center for Comprehensive Gynecology. Treatment options for fibroids include embolization (in which small particles are injected into uterine arteries to cut off blood flow, causing the fibroids to die) and a range of surgical methods.
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Culprit #2: It's your gut
“It can be hard to figure out whether pain is GI-related or gyno-related, since parts of your colon lie near your pelvic area,” says Health’s contributing medical editor, Roshini Rajapaksa, MD, a gastroenterologist at NYU Langone Health. But if your pain is accompanied by bloating, gas, diarrhea, and/or bouts of constipation, and if you also sometimes see mucus in your poop, you might have irritable bowel syndrome (IBS), the most common functional GI disorder worldwide (10 to 15 percent of people struggle with it, and it is twice as common in women).
What to do
See a gastroenterologist, who will run tests to rule out other conditions, such as celiac, and then suggest first-line treatments for IBS. These may include dietary tweaks, like cutting back on possible trigger foods (dairy or gluten, say). You can also try a probiotic to build up “good” bacteria in your gut. (Two over-the-counter options Dr. Rajapaksa recommends are Culturelle and Align.) A relatively new treatment option is a 14-day course of Xifaxan, an antibiotic that was FDA-approved in 2015 to treat IBS. Prescription antispasmodic medications, such as Viberzi, can also help.
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Culprit #3: It’s a pee problem
Got pelvic pain plus always feel like you have to pee? You may have painful bladder syndrome (also known as interstitial cystitis). The cause of this condition, which affects 3 to 7 percent of women, is still a mystery, but one theory is that there’s a breach in the protective lining of your bladder, allowing urine to irritate your bladder wall. It’s often associated with another chronic pain disorder, such as IBS or fibromyalgia. “My patients describe it as if it were a constant low-level UTI: They feel discomfort and pressure in their pelvic area and are always running to the bathroom, with very little urine coming out,” says Suzanne Fenske, MD, assistant professor of ob-gyn at the Icahn School of Medicine at Mount Sinai in New York City. It can also cause pain during sex.
What to do
Your physician should first double-check that you don’t indeed have a UTI. Painful bladder syndrome is usually diagnosed only after ruling out a number of other conditions, like kidney stones and even bladder cancer, says Dr. Fenske. Your doc may recommend eliminating foods and drinks that can irritate your bladder, like citrus, or making other lifestyle changes. Several different meds can help relieve the pain. The Rx med Elmiron is specifically approved for painful bladder syndrome; it may help repair the inner surface of the bladder. Your gyno can also inject a cocktail of prescription meds directly into your bladder to help numb it. This usually involves six to eight weekly treatments, and then follow-ups as needed. Nerve stimulation may also be an option.
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Culprit #4: It’s your muscles
If your pelvic pain is accompanied by the feeling that you have to pee and poop a lot (and when you do poop, you’re pushing really hard to get it out, or you never totally feel like you’re done), you could have a condition called pelvic floor dysfunction. “Imagine the bones of your pelvis as a bowl, and on top of them are muscles that support organs such as your uterus, bladder, and bowel,” says Dr. Milad. “When these muscles are inflamed, they can contract, which causes pain and other symptoms, such as constipation and even pain during intercourse.” About one in four women have this problem, according to a 2008 study published in the Journal of the American Medical Association. Risk factors include past vaginal childbirth or pelvic surgery, being overweight or obese, and having a genetic predisposition.
What to do
Your doctor can do a physical exam to check your pelvic floor muscles for spasms, knots, or weakness. If she suspects pelvic oor dysfunction, there are tests she can do, like checking muscle control in the area using electrodes. To treat it, you should work with a pelvic oor physical therapist, says Dr. Milad. Treatment can involve learning to relax and contract your pelvic muscles, often with the help of techniques such as biofeedback, which improves symptoms in more than 75 percent of cases, according to the Cleveland Clinic. Your PT will also give you exercises to do at home. Some physicians now inject Botox directly into a patient’s pelvic floor muscles, adds Dr. Milad. Research—including a 2013 Harvard study—has found that these injections are effective at relieving this type of pelvic pain.