Chronic Pelvic Pain in Women: Causes and When to See a Specialist

What counts as chronic pelvic pain?

Chronic pelvic pain (CPP) is generally defined as non-cyclic or cyclic pain located in the pelvis, lower abdomen, or lower back lasting 6 months or longer, significant enough to cause functional impairment or require medical attention. It is one of the most common reasons people seek gynecologic care. CPP can be constant, come and go, or peak with certain activities like sex, urination, or bowel movements.

Because multiple organ systems (reproductive, urinary, digestive, musculoskeletal, and neurological) share the pelvic space, identifying the source requires a thorough evaluation — and in many cases, more than one cause is present.

What are the most common causes of chronic pelvic pain?

Endometriosis — Tissue similar to the uterine lining grows outside the uterus, most commonly on the ovaries, fallopian tubes, and pelvic lining. It causes inflammation, scarring, and pain that often worsens with menstruation. Endometriosis is frequently underdiagnosed; symptoms can predate diagnosis by several years 1Ref 1American College of Obstetricians and Gynecologists (2010).Management of Endometriosis: ACOG Practice Bulletin, Number 114 (Reaffirmed 2022).Endometriosis as a major cause of chronic pelvic pain; hormonal and surgical management options2Ref 2Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D'Hooghe T, De Bie B, Heikinheimo O, Horne AW, Kiesel L, Nap A, Prentice A, Saridogan E, Soriano D, Nelen W; ESHRE (2014).ESHRE guideline: management of women with endometriosis.Diagnostic and treatment approaches for endometriosis as a cause of chronic pelvic pain, including laparoscopy and medical management.

Uterine fibroids — Benign muscle tumors in the uterine wall. They can cause pelvic pressure, heaviness, pain, and heavy periods. Smaller fibroids may cause no symptoms at all 3Ref 3American College of Obstetricians and Gynecologists (2021).Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228.Uterine fibroids as a cause of chronic pelvic pain and heaviness; management options including surveillance, minimally invasive procedures, and surgery.

Adenomyosis — Similar to endometriosis, but the tissue grows into the muscle wall of the uterus itself. It causes heavy periods and uterine tenderness.

Ovarian cysts — Fluid-filled sacs on the ovaries. Functional cysts often resolve on their own; larger or persistent cysts may cause persistent pelvic pain.

Pelvic floor dysfunction — The muscles and connective tissue of the pelvic floor can become tight, weak, or dyscoordinated, causing pain during sex, with bowel movements, or chronically.

Interstitial cystitis (IC) — A bladder condition causing chronic pelvic pain, urinary urgency, and frequency without infection.

Pelvic inflammatory disease (PID) — Past or ongoing infection of the uterus, fallopian tubes, or ovaries; can lead to chronic pain from scarring.

Irritable bowel syndrome (IBS) — Bowel-related pain frequently overlaps with and can be mistaken for gynecologic pelvic pain.

How is chronic pelvic pain evaluated?

A gynecologist evaluating CPP will typically:

1. Take a detailed history — the character, location, timing, and triggers of pain; menstrual cycle patterns; sexual activity and pain with sex; bowel and urinary symptoms; prior infections, surgeries, or trauma 2. Perform a pelvic exam — including assessment of the uterus, ovaries, and pelvic floor muscles 3. Order imaging — pelvic ultrasound is usually the first step; MRI is more sensitive for conditions like endometriosis and adenomyosis 4. Order labs — to check for infection or other contributors 5. Consider laparoscopy — for suspected endometriosis, a surgical procedure that directly visualizes the pelvis is often the only way to confirm the diagnosis and treat it simultaneously

A thorough evaluation takes time and may involve more than one specialty. Urology, gastroenterology, and pelvic floor physical therapy are frequently part of the picture.

What treatments are available for chronic pelvic pain?

Treatment depends entirely on the underlying cause:

• Endometriosis: Hormonal suppression (combined pills, progestins, GnRH agonists) reduces pain in many cases; surgery can remove lesions and improve pain for those who have not responded to medical therapy 1Ref 1American College of Obstetricians and Gynecologists (2010).Management of Endometriosis: ACOG Practice Bulletin, Number 114 (Reaffirmed 2022).Endometriosis as a major cause of chronic pelvic pain; hormonal and surgical management options2Ref 2Dunselman GA, Vermeulen N, Becker C, Calhaz-Jorge C, D'Hooghe T, De Bie B, Heikinheimo O, Horne AW, Kiesel L, Nap A, Prentice A, Saridogan E, Soriano D, Nelen W; ESHRE (2014).ESHRE guideline: management of women with endometriosis.Diagnostic and treatment approaches for endometriosis as a cause of chronic pelvic pain, including laparoscopy and medical management
• Fibroids: Range from monitoring, to hormonal management, to minimally invasive procedures (uterine fibroid embolization, focused ultrasound) or surgery 3Ref 3American College of Obstetricians and Gynecologists (2021).Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228.Uterine fibroids as a cause of chronic pelvic pain and heaviness; management options including surveillance, minimally invasive procedures, and surgery
• Pelvic floor dysfunction: Pelvic floor physical therapy is a primary treatment, often with significant benefit
• Interstitial cystitis: Bladder-specific therapies, dietary adjustments, and pelvic PT
• Neuropathic or unexplained CPP: Pain management specialists, nerve blocks, and psychological support (CBT) for pain management can all be part of a multidisciplinary approach

Chronic pelvic pain is often undertreated and over-normalized, particularly in people who are dismissed with "it is just bad periods." If prior evaluations have not led to answers, a second opinion from a gynecologist who specializes in CPP or endometriosis is appropriate.