You don’t need to live with chronic pelvic pain. Innovative treatments, including new medications and advanced surgical techniques, offer patients more options than ever for minimizing or eliminating chronic pelvic pain.
Pelvic pain is a common condition affecting as many as one in five women ages 18 to 50. Many women endure symptoms of chronic pelvic pain for more than a year before seeking help. Chronic pelvic pain can diminish quality of life as well as physical and mental health, disrupting work, physical activity, sexual relations, sleep or family life.[1]
Dr. Nguyen Nguyen, a gynecologist on the medical staff at Texas Health Center for Diagnostics and Surgery Plano, is experienced in diagnosing and treating women with a broad range of conditions that cause chronic pelvic pain.
“It’s not always easy to get a definitive diagnosis to pinpoint the cause of pelvic pain,” she said. “But there are treatments available, including new medications and advanced, minimally invasive surgical options, which can alleviate your pain, so you can live a more comfortable life.”
What is Chronic Pelvic Pain?
Pelvic pain is any pain occurring in the area between the hips and the belly button. Many women may experience dysmenorrhea—cramping and mild discomfort just before or during their periods, which typically lasts only a few days. Pain that is short-lived and mild is generally not a cause for concern. [2]
However, when the pain lasts six months or longer, it’s considered chronic, according to the American College of Obstetricians and Gynecologists (ACOG). This pain may come and go, or it can be constant. Sometimes the pain may follow a cycle—for example, occurring around or during menstruation, or only at certain times: associating with sex, urination, or bowel movement.[3]
Chronic pelvic pain can be caused by a variety of conditions which may relate to the reproductive organs or to the urinary tract or bowel. Sometimes, more than one condition contributes to the pain.
Your medical provider will recommend a gastroenterologist or urologist if there’s reason to believe your pelvic pain is caused by conditions such as irritable bowel syndrome, which can cause chronic pelvic pain, including bloating, constipation, and diarrhea, or interstitial cystitis, which leads to pain in the bladder and frequent urination.
However, for women, pelvic pain is often related to gynecological conditions. These may include:
Endometriosis, in which tissue (similar to the tissue that normally lines the inside of the uterus, or endometrium) grows outside of the uterus. Endometriosis usually involves the fallopian tubes, ovaries and the tissue lining the pelvis. With endometriosis, the endometrial-like tissue thickens, breaks down and bleeds with each menstrual cycle. However, because the tissue has no way to exit the body, it becomes trapped. Surrounding tissue can become irritated, eventually developing adhesions and scar tissue. Endometriosis may cause fertility problems or pain—sometimes severe—especially during menstrual periods.
Chronic pelvic inflammatory diseases (PID), an infection of a woman’s reproductive organs, can cause chronic pain and scarring if left untreated. Often it is caused by some sexually transmitted diseases (STDs), like chlamydia and gonorrhea, although other infections may also play a role in PID. In addition to pelvic pain, other symptoms may include fever, an unusual, purulent vaginal discharge, pain and/or bleeding during intercourse or bleeding between periods.
Uterine fibroids are noncancerous tumors that develop in or on the muscular walls of the uterus, which may cause painful periods as well as heavy menstrual bleeding. Other symptoms may include menstrual periods lasting more than a week, pelvic pain and pressure, difficulty emptying the bladder, constipation, backache or leg pains. These growths appear during childbearing years. Many women develop uterine fibroids sometime during their lives but have no symptoms. Also called myomas or leiomyomas, uterine fibroids almost never develop into cancer, and are not associated with an increased risk of uterine cancer. Fibroids range in size from too small to be detected by the human eye, to bulky masses that can enlarge the uterus.
Getting the right diagnosis for chronic pelvic pain typically involves a process of elimination. The process begins with a visit to your health care provider, who will ask about your medical history and perform a physical exam, including a pelvic exam. Your doctor may ask you to keep a diary of your symptoms to help pinpoint what’s triggering the pain. Your doctor may also order labs, bloodwork and/or imaging tests (ultrasound, abdominal X-rays, computerized tomography (CT) scans or magnetic resonance imaging (MRI) tests) to help pinpoint the issue.
If your doctor can determine a specific cause of your chronic pelvic pain, treatment can focus on the underlying cause. However, sometimes a cause cannot be identified; in this case, treatment will focus on managing your pain and other symptoms.
First Line of Treatment for Chronic Pelvic Pain
Physicians can recommend several measures to treat chronic pelvic pain. These may include lifestyle changes, such regular exercise, physical therapy, including stretching exercises or relaxation techniques, and medications, such as antibiotics (if an infection is suspected), pain relievers, including nonsteroidal anti-inflammatory drugs (NSAIDs) or other over-the-counter pain remedies, and hormone treatments.
For heavy bleeding and pelvic pain caused by uterine fibroids, Dr. Nguyen has seen good results with a new medication, a once-daily pill that came on the market in 2021. 
“This medication helps decreases the blood loss from the fibroid,” she said. “We do not yet have evidence that it shrinks the fibroids, but theoretically, it may.”
If the chronic pelvic pain does not respond to these treatments, your doctor may recommend surgery to correct an underlying problem that is causing chronic pelvic pain.
Laparoscopic Surgery for Treating Chronic Pelvic Pain
If you have endometriosis, surgical removal of the adhesions or endometrial tissue, via laparoscopic surgery, may offer relief.
During laparoscopic surgery, the surgeon inserts a slender viewing instrument (laparoscope) through a small incision near the navel and inserts instruments to remove endometrial tissue through one or more additional small incisions.
“There are a couple new techniques that I’m utilizing in my practice with this surgery,” said Dr. Nguyen. “One is the ExCITE technique, which is a good option for removing very large fibroids in the uterus without the need for a large incision.”
In removing a uterine fibroid, the surgeon uses a technique called morcellation to reduce the size of the fibroids, by creating smaller pieces. This allows the tissue to be removed through small incisions or with laparoscopic instruments.
In the past, open or uncontained morcellation of the fibroids (myomas) was scrutinized because of the potential for spread if the patient had an undiagnosed or unsuspected malignancy.[4]
“With the ExCITE technique, the tissue that’s being removed is isolated inside a bag, and we do a carving technique that contains the tissue,” said Dr. Nguyen. “I have had a couple patients with huge fibroids who did not want to do open surgery. With ExCITE, those patients had the option of having the surgery done laparoscopically.”
The ExCITE technique may also be successfully used from a vaginal approach, eliminating the need for an incision to extract the tissue through the abdomen.
Hysterectomy for Chronic Pelvic Pain
In rare, complicated cases, doctors may recommend the removal of the uterus (hysterectomy), fallopian tubes (salpingectomy) or ovaries (oophorectomy). There are important health consequences to having this procedure, which patients must always discuss with their physicians before proceeding.
When hysterectomy is required, Dr. Nguyen offers a new surgical technique called vNotes (vaginal natural orifice transluminal endoscopic surgery). This advanced minimally invasive technique combines the benefits of the laparoscopic and vaginal approaches to gynecologic surgery and eliminates the need for an abdominal incision.[5]
With vNOTES, specialized instruments are placed through the vagina into the pelvic cavity, giving access to the uterus, fallopian tubes and ovaries. This allows complex surgery to be performed without visible incisions, leading to faster recovery and return to normal activities.
“vNOTES basically allows us to perform a vaginal hysterectomy,” Dr. Nguyen said. “There's a camera that goes through the vaginal orifice.”
vNOTES is performed under general anesthesia. An incision is made in the vagina, and a specialized vNOTES device is inserted to access the uterus and/or fallopian tubes and ovaries. The abdomen is inflated with carbon dioxide gas (similar to laparoscopic surgery) to give the doctor space to see and operate. With this approach, the surgeon can operate with precision and enhanced visualization.
“vNOTES allows me to see exactly where I’m cutting, what I’m grasping, and where the bowel and ureter are,” said Dr. Nguyen.
vNotes may be used with hysterectomy, salpingectomy or oophorectomy. vNotes may also be an option for treating fibroids as well as ovarian cysts, abnormal uterine bleeding and adenomyosis. The technique is also used for tubal sterilization surgery.[6]
Only a medical specialist can determine whether you are eligible for a vNOTES procedure.
But in cases when it’s appropriate, Dr. Nguyen notes, ACOG recommends vaginal hysterectomy as the preferred method of hysterectomy.
With vNotes, patients typically require a shorter hospital stay (often less than 24 hours), experience less postoperative pain, less need for pain medication, enjoy faster recovery times, and have no visible scarring. Some patients may leave the hospital on the same day as surgery. Individual results may vary.
“You get better pain control, and patients are up on their feet a lot faster after surgery,” said Dr. Nguyen.
THCDS Services
Texas Health Center for Diagnostics and Surgery is proud to offer a variety of surgical services for women.
Texas Health Center for Diagnostics & Surgery is an 18-bed physician-owned hospital serving the people of Collin, Dallas and Denton counties. The hospital is an award-winning facility that offers a wide range of services including robotic surgery, spine surgery, joint replacement surgery, orthopedic surgery, gynecological surgery, urological surgery, ENT surgery as well as spinal injections, outpatient GI procedures and advanced imaging studies.
Designed with a boutique hotel in mind, patients enjoy a more comfortable setting than what is typically offered in a large, full-service traditional hospital. From up-close parking to room service meals prepared by a culinary trained chef, our entire hospital staff provides compassionate care that is focused on you and your family.
The hospital is accredited by The Joint Commission, an independent, not-for-profit organization that accredits and certifies health care firms and is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards.
[1] Chronic Pelvic Pain Syndrome in Women: Causes, Diagnosis and Treatment Options; University Hospitals blog; https://www.uhhospitals.org/services/obgyn-womens-health/conditions-and-treatments/female-pelvic-health/conditions-and-treatments/chronic-pelvic-pain
[2] Dysmenorrhea: Painful Periods FAQ. American College of Obstetrics and Gynecology. https://www.acog.org/womens-health/faqs/dysmenorrhea-painful-periods
[3] Dysmenorrhea: Painful Periods FAQ. American College of Obstetrics and Gynecology. https://www.acog.org/womens-health/faqs/dysmenorrhea-painful-periods
[4] Uterine Morcellation for Presumed Leiomyomas. American College of Obstetrics and Gynecology. March 2021 Committee Opinion. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2021/03/uterine-morcellation-for-presumed-leiomyomas
[5] Systematic Review and Meta-Analysis on Hysterectomy by Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) Compared to Laparoscopic Hysterectomy for Benign Indications. Dec. 2020, Journal of Clinical Medicine. https://pubmed.ncbi.nlm.nih.gov/33297354/
[6] Transvaginal natural orifice transluminal endoscopic surgery (vNOTES) in gynecologic surgeries: A systematic review. ScienceDirect, 2019. https://www.sciencedirect.com/science/article/pii/S101595841930106X