Pelvic Pain and Endometriosis: Symptoms, Causes, and Treatment Options

June 10, 2020 | by Tamer Seckin, MD

What is pelvic pain?

Pelvic pain originates from the nerves of tissues that make up the pelvis. These include bones, ligaments, muscles, and organs such as the bladder, rectum, and uterus. The pelvis is the lower part of the abdominal cavity, and all organs of the abdominal cavity, including pelvic organs, are covered by peritoneum. All structures are supported with fine connective tissue, nerves, and blood vessels. Fine nerve endings carry pain signals to the brain, where they are perceived as discomfort and pain. Normal functions if pelvic organs are not associated with pain.

Pelvic pain is a vital sign alerting to dysfunction in one or more organs. Pelvic pain can also come with periods (dysmenorrhea), excessive menstrual bleeding (menorrhagia), and pain with sex (dyspareunia), all of which are common symptoms of endometriosis, along with bladder and rectal pain, painful bowel movements, constipation, and diarrhea. Among others, sciatic and pudendal pain are certainly also signs of deeper disease, and are commonly associated with other components of pelvic pain.

Classification of pelvic pain

While there is no specific classification system for pelvic pain, there are different levels of pain and cramping that women may experience.

While most women experience mild cramps, not all cramps are painful. However, for women with endometriosis, symptoms will often be more severe. This is because pain during menstruation can worsen with increased menstrual flow.

During the initial implantation stages of endometriosis, before deep infiltrating endometriosis or invasion, the pain is nonspecific and very commonly associated with gastrointestinal symptoms such as nausea, vomiting, bloating, gas, or diarrhea.

In later stages of deep-infiltrating and invading endometriosis, chronic pelvic pain can be accompanied by severe symptoms such as constipation, painful bowel movements, and painful intercourse. In fact, sometimes chronic pelvic pain can become so intense that it is referred to as “killer cramps”.

Causes of pelvic pain

A multitude of factors can cause female pelvic pain. However, it is very common that the cause is the dysfunction of abdominal and pelvic organs due to ovarian endometrioma or deeply infiltrating endometriosis.

Deeply infiltrating endometrioma leaves scar tissue on the abdominal and pelvic organs and the peritoneum. This invading uterine tissue can ultimately contribute to organ dysfunction.

Endometriosis pain is always pelvic and usually occurs with menstruation.

Retrograde menstruation is the most common theory as to how endometriosis causes pelvic pain. Every month, the normal uterus sheds its lining (endometrium). The lining is then expelled out of the cervix with minimal backflow of the endometrial cavity contents. However, in some cases, the volume of menstrual debris that flows back up into the uterus is excessive and can lead to endometriomas growing in and scarring either the uterus, causing adenomyosis, or areas outside of the uterus, causing endometriosis.

There are many gynecological conditions that can cause pelvic pain. Nevertheless, researchers believe that retrograde menstruation is also the primary mechanism underlying these conditions.

Symptoms that often accompany pelvic pain

Pelvic pain often doesn’t come alone—it’s frequently accompanied by a range of other symptoms that reflect how interconnected the pelvic organs are. When endometrial lesions or adhesions involve structures such as the uterus, bladder, bowel, or surrounding nerves, the effects extend well beyond localized discomfort.

Common symptoms that may occur alongside chronic pelvic pain include:

• Menstrual irregularities – such as heavy bleeding, irregular cycles, or severe menstrual cramps, often caused by hormone-responsive tissue cycling outside the uterus
• Gastrointestinal disturbances – including bloating, constipation, diarrhea, or painful bowel movements, especially during menstruation
• Urinary changes – like increased urgency, frequent urination, or burning sensations, particularly when endometrial implants affect the bladder lining
• Fatigue and mood swings – which are common in those dealing with chronic inflammation, disrupted sleep, and long-term pain

These symptoms underscore that conditions like endometriosis and other causes of pelvic pain often affect multiple systems. Recognizing the full symptom profile is crucial to achieving an accurate diagnosis and effective treatment plan.

Deep pelvic pain causes

Deep pelvic pain is often the result of conditions that irritate, inflame, or compress structures deep within the pelvis. It is commonly associated with:

• Endometriosis
• Pelvic inflammatory disease (PID)
• Adenomyosis
• Fibroids
• Dense adhesions from previous surgeries or chronic inflammation

These conditions frequently lead to chronic inflammation and scar tissue formation, which can tether pelvic organs such as the uterus, ovaries, and intestines. This restricted movement often results in persistent aching, pressure, or sharp pain—particularly during menstruation, physical activity, or sexual intercourse.

In cases of pelvic infections, bacteria ascending from the lower genital tract may inflame the fallopian tubes and uterine lining, triggering deep, throbbing pain that can worsen with motion.

Adenomyosis, a disorder where endometrial tissue grows into the muscular wall of the uterus, can further contribute to the enlargement of the uterus and pressure on surrounding organs. This may lead to a heavy, dragging sensation in the pelvis, in addition to severe cramps and abnormal bleeding.

Understanding the underlying cause of deep pelvic pain is essential for developing a targeted and effective treatment plan.

When to see a doctor for pelvic pain

You should absolutely seek medical attention for pelvic pain if the discomfort is persistent, severe, or comes with other worrying signs.

If you’re experiencing a persistent ache that lasts beyond a few days or keeps coming back every month in a way that messes with your daily routine, it’s definitely time for an evaluation. Conditions like endometriosis, pelvic inflammatory disease, or dense adhesions can actually get worse if left untreated.

Any sudden, intense spasms or sharp pain accompanied by fever, abnormal bleeding, changes in urination, or gastrointestinal symptoms need prompt assessment. These could be signs of something serious, like an infection, ovarian torsion, or even a bowel obstruction, and you’d want to rule those out quickly.

Risk factors of pelvic pain

Having any of the following disorders, or a family history of them, can increase a patient’s chances of experiencing pelvic pain:

• endometriosis
• adenomyosis
• fibroids

Pelvic inflammatory disease (PID) is also a risk factor. PID is an infection of the female reproductive organs, such as the uterus, fallopian tubes, or ovaries. The main cause is sexually transmitted diseases that harm the vagina and spread internally to the uterus and other locations. It is one of the main preventable complications that can cause infertility.

The following are personal risk factors that can increase a patient’s risk of pelvic pain:

• physical or sexual abuse
• radiation or surgical treatment to the abdomen and/or pelvis
• anxiety, depression, or other psychosomatic symptoms
• miscarriages
• infertility
• long-lasting menstrual flow

Types of pelvic pain and associated complications

Women may experience pelvic pain in different forms. These could include cramps, especially during periods, dyspareunia, dysmenorrhea, painful bowel movements, and painful urination.

Pelvic pain can also cause complications such as vaginal and rectal bleeding, lower back pain, and infertility.

Diagnosing pelvic pain

Taking the patient’s medical history is the simplest way for a physician to understand the severity and probable cause of pelvic pain. Provide as much information as possible about the type and frequency of the pain, and any other past medical or family history.

A pelvic exam can also help a doctor understand the intensity and point(s) of tenderness. This will be conducted in any comprehensive physical exam if a patient is displaying any gynecological signs or symptoms.

Your doctor will most likely also order lab tests and conduct a comprehensive physical exam. These lab tests can include blood work, urinalysis, and other tests to check for any infection, such as gonorrhea and chlamydia.

Imaging tests, such as an ultrasound or sonogram, that provide a picture of the inside of the uterus can also be useful in identifying endometriosis, adenomyosis, fibroids, and other intrauterine diseases that are impossible to detect via just pelvic exams and lab tests.

An MRI provides clearer and more precise imaging than an ultrasound. It is extremely useful in confirming that a patient’s pelvic pain is likely due to diseases such as endometriosis or adenomyosis. However, due to its high cost, you should have this test only if your physician recommends it after a comprehensive physical exam and lab tests.

Treatment of pelvic pain

It is crucial to first determine the cause of your pelvic pain, as it will determine your treatment plan.

Non-surgical treatments

There are a number of medications that can help relieve pelvic pain. These include painkillers, birth control pills, antibiotics, and antidepressants.

Painkillers may reduce pelvic pain in some cases. It is important to note that they will not treat the underlying cause of the pain. Painkillers range from analgesics such as nonsteroidal anti-inflammatory drugs like aspirin or ibuprofen to prescribed narcotics.

When a patient’s pain occurs during specific times in their menstrual cycle, birth control pills or hormonal medications may control it in some cases.

Doctors prescribe antibiotics only in cases of pelvic pain due to infections.

Research has shown that antidepressants can reduce pelvic pain, even for patients who do not have depression. However, antidepressants primarily treat depression and do not address the pain itself.

Surgical treatment

When a patient’s pain is caused by endometriosis, adenomyosis, or fibroids as opposed to an infection, surgery is often the most advised method. The type of surgery can vary depending on the patient’s diagnosis.

Laparoscopic deep excision surgery, if performed well, is the best way to remove all scar tissue in cases of this pain caused by endometriosis and focal adenomyosis.

Myomectomy removes fibroids, which can, in turn, relieve pain.

Hysterectomy involves the partial or complete removal of the uterus. It is only necessary in cases of pelvic pain due to severe, diffuse adenomyosis. A hysterectomy should always be a last resort.

Frequently asked questions

Is pelvic pain normal during menstruation?

Pelvic pain during menstruation is extremely common and often considered a normal part of the menstrual cycle. As the uterus contracts to shed its lining, it releases chemical messengers called prostaglandins. These substances trigger the mild to moderate cramping many people feel in the lower abdomen or lower back during the first few days of their period.

These uterine contractions are necessary to expel menstrual blood, but they can also cause pressure, soreness, and pelvic discomfort. Most of the time, this type of pain responds well to:

• Over-the-counter pain relievers (like NSAIDs)
• Heating pads or warm baths
• Gentle exercise, which can improve blood flow and reduce muscle tension

However, if your menstrual cramps become unusually severe, last beyond the first couple of days, or are accompanied by other symptoms—such as heavy bleeding, irregular periods, or pain during sex—it may be a sign of an underlying condition like endometriosis, adenomyosis, or fibroids.

Persistent or worsening period pain is not something to ignore. Seeking a proper evaluation can help identify the cause and guide effective treatment options.

What is the best position to relieve pelvic pain?

While everyone’s body responds differently, many people find that the knee-to-chest position can offer soothing relief during episodes of pelvic pain or cramping.

To try it, lie comfortably on your back and gently pull both knees toward your chest, wrapping your arms around your shins or behind your thighs. This posture may help relieve tension in the lower back and abdominal muscles, while also reducing pressure on the pelvic joints.

The stretch can also promote gentle spinal flexion, which may improve circulation and help ease discomfort from inflammation or cramping.

For added comfort:

• Place a soft pillow under your head
• Support your knees or lower back with a small cushion if needed
• Hold the position for 20–30 seconds, breathing deeply and slowly
• Repeat 2 to 3 times, or as needed

This isn’t a medical prescription—but rather a simple, restorative posture that might help your body relax and reset during moments of pelvic tension.

Is pelvic pain a sign of something serious?

Pelvic pain can sometimes be a sign of a serious underlying condition. If the pain comes on suddenly, becomes intense quickly, or is accompanied by symptoms like fever, unusual vaginal bleeding, nausea, or significant digestive issues, it may point to conditions such as pelvic inflammatory disease, an ectopic pregnancy, ovarian torsion, or, in rare cases, certain cancers.

Chronic pelvic discomfort that gradually worsens and begins to interfere with your daily life should also be evaluated. Conditions like endometriosis or pelvic adhesions can lead to infertility and bowel complications if not treated early.

If your pelvic pain is accompanied by urinary urgency or a burning sensation, this could suggest a bladder infection or interstitial cystitis. Digestive symptoms such as bloating, diarrhea, or constipation may indicate inflammatory bowel disease or other gastrointestinal conditions.

It’s important to pay attention to the pattern and severity of your symptoms. Early diagnosis and treatment can prevent complications and improve quality of life.

Our approach

Due to the myriad causes of pelvic pain, we believe that doctors must always first have a detailed discussion with their patients about their symptoms and medical history. This should be followed by a comprehensive pelvic exam and ultrasound. You are also advised to bring recent basic lab results and any imaging results, especially MRI. These will help us to better identify the probable cause of your pain.

When patients come to us, they are most often in need of surgical treatment. Our preferred method is laparoscopic deep excision surgery. Using this technique, we are able to remove all endometrioma and often able to relieve patients’ chronic pelvic pain. However, the pain can come from a variety of sources. It is important to find a surgeon who can not only operate with attention to detail, but also is patient and willing to discuss your medical history, symptoms, and complaints. By being open to discussion, we are able to work with our patients and find and treat the most probable source of their pain.

Patient story

Lindsay G. was experiencing severe pelvic pain for years. But she was told her symptoms were “just her.” After a history of ovarian cysts and surgical removal of one of her ovaries, Lindsay came to Dr. Seckin, who performed laparoscopic deep excision surgery on her in the spring of 2016. Read about Lindsay’s experience leading up to her surgery with Dr. Seckin.

You can read more patient stories in our testimonial section.

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