Chronic pelvic pain (CPP) is characterized by pain in the lower abdomen and pelvic area that has been present for at least six months. Sometimes the pain may travel downward into the legs, upwards into the chest or around to the lower back. The pain may be felt all of the time or it may come and go, perhaps recurring or intensifying each month with a woman's menstrual period. In either case, the pain is felt internally, not externally as in another common pain disorder in women called vulvudynia. In vulvudynia (or burning vulva syndrome), the external genital area stings, itches, becomes irritated or hurts when any kind of pressure, from tight clothing to intercourse, is experienced.
Women with CPP have one or more of the following symptoms:
Abnormal menstrual periods
- painful periods (dysmenorrhea)
- prolonged periods
- heavy periods
- premenstrual spotting
- severe cramps
- constant or intermittent pelvic pain
- low backache for several days before period which subsides once it starts
- pain during intercourse (rarely, some vaginal bleeding after intercourse)
- pain on urination and/or during bowel movements (rarely, blood in urine or stool)
- rectal itching or burning
- vaginismus — difficulty initiating sexual intercourse
The course of -CPP is unpredictable, both for the individual woman and from patient to patient. Symptoms may stay constant, disappear without treatment or suddenly increase. Generally they decrease during pregnancy and usually improve after menopause.
The severity of pain is also unpredictable. It may range — even in the same woman — from mild and tolerable at times to so severe it interferes with her normal activities. A woman's physical or mental state can cause the level of pain to fluctuate. Fatigue, stress and depression all serve to increase pain. Moderate to severe pain generally requires medical or surgical treatment, although such therapies are frequently unsuccessful at relieving pain entirely.
Unrelieved, unrelenting pelvic pain may affect a woman's sense of well being, as well as her work, recreation and personal relationships. She begins to limit her physical activities and show signs of depression (including sleep problems, eating disorders and constipation); her sex life and role in the family change. Upon examination, the level of pain she describes may be out of proportion with detectable tissue damage. When pelvic pain leads to such emotional and behavioral changes, the International Pelvic Pain Society (IPPS) calls the condition "chronic pelvic pain syndrome" and says that the "pain itself has become the disease." The pain is more of a problem than the original cause.
Causes and Risk Factors
There are two kinds of pain. Acute pain typically occurs with an injury, illness or infection. A warning signal that something is wrong, it lasts only as long as it takes for the person to recover. In contrast, chronic pain lasts long after recovery from the initial injury or infection or is associated with a chronic disorder or underlying condition.
Among women with -CPP, four out of five (80 percent) are diagnosed with pelvic disease or disorder. The most common is endometriosis, in which pieces of the lining of the uterus attach to other organs or structures within the abdomen, and grow outside the uterus. In three major studies done since 1989, 71 to 83 percent of patients with chronic pelvic pain had endometriosis, either alone or in combination with one or more other disorders. Two of those disorders are adhesions (scar tissue resulting from previous abdominal or pelvic surgery) and fibroids (clumps of tissue that grow inside, in the wall of, or on the surface of the uterus). One study that used a laparoscope to examine 141 pelvic pain patients, found that 12.7 percent had endometriosis alone, 9.2 percent had fibroids alone, and 8.5 percent had adhesions alone; most patients had a combination of these or other disorders. (A laparoscope is a long, thin telescope-like instrument that is inserted through a woman's belly button and allows a surgeon to view abdominal organs.)
Other causes of and contributors to pelvic pain include but are not limited to pelvic infections and diseases of the urinary tract or bowel as well as hernias, slipped discs and psychological problems. (See the Diagnosis section at this Web site for a more complete discussion of all causes.)
Despite the number of causes, 20 percent of women with chronic pelvic pain have no diagnosable condition that even partly explains their pain. These are often the women who make the rounds of various specialists seeking relief, only to be told the pain is "all in their heads" or subjected to multiple tests and even surgery unnecessarily.
Simply put, there is no simple answer to the question, "What causes chronic pelvic pain?" and no "typical patient." Still, a woman with pelvic pain is more likely to:
- have been sexually or physically abused
- be married rather than single or divorced
- be in her early 30s
- be white rather than from another racial group
- have a history of drug and alcohol abuse
- have sexual dysfunction
- have a mother or sister with chronic pelvic pain
- have history of PID
- have had abdominal or pelvic surgery or radiation therapy
- have previous or current diagnosis of depression
- have a structural abnormality of the uterus, cervix or vagina.
Some of these, like family history, surgery and PID, are obvious risk factors; others (drug abuse, depression) may be risk factors or result from having chronic pain.
The Impact of Chronic Pelvic Pain
According to the IPPS, nearly 15 percent of 18- to 50-year-old American women have chronic pelvic pain. It is also one of the most common reasons why American women see a physician, accounting for 10 percent of gynecologic office visits, up to 40 percent of laparoscopies, and 12 to 16 percent of hysterectomies in the U.S. Total treatment costs may run as high as $2.8 billion annually.
The cost to the patient is also enormous. Studies and surveys show that a quarter of affected women are incapacitated by pain two to three days each month. More than twice that many are forced to curtail their normal activities one or two days each month. Nine of ten women with chronic pelvic pain have pain during intercourse. More than half say they have significant emotional changes, many reporting they feel "downhearted and blue" at least some of the time. For many, the pain and underlying conditions lead to fertility problems, just at the age when they want children.