Understanding Pelvic Pain

Ask the Expert – Ready, Healthy & Able: Understanding Pelvic Pain

Shea O’Neill, M.D. an Obstetrics & Gynecology Specialist, answers questions about pelvic pain.​

The Expert: 

Shea O’Neill, M.D. is an Obstetrics & Gynecology Specialist based in San Diego, CA.

What is chronic pelvic pain?

Ultimately, chronic pelvic pain, to put a short answer to it, is the pelvic floor muscles are contracted and tight and they’re like cement. And so anything that hits them, moves them, touches them – a uterus, a bladder that’s full, stool moving through the intestine, an ovary that’s biologically active because it is an appendix, it just moves. Anything that touches that tight pelvic floor causes pain, and it’s the same thing, like somebody that has pain from clenching all the time. It’s a, it’s a musculoskeletal response that’s a very slowly evolving response. It does not happen in a week or a month.

What are examples of acute pelvic pain vs. chronic pelvic pain?

A really good definition of chronic pain is somebody with painful periods. That’s chronic. Classically, most doctors for for whatever reason, and most women, sadly, don’t think of it. They just think it’s part of being a woman: you have heavy painful periods. That’s just not true. So a chronic pain condition is heavy painful periods. So that’s one definition of a chronic pain condition. An acute pain condition would be, for instance, an ovarian cyst. Ovaries kind of make cysts, kind of like your skin makes freckles if you’re a light-skinned person. So ovaries make cysts. Many of them come and go. Many of them can be acutely painful, but acute pain, usually you can nail down really started at a very specific time, a very specific place. And, um, and so ovarian cysts can be an acute problem. Um, a pelvic infection can be an acute problem. Sometimes a kidney stone can be be pelvic pain. Um, a GI infection. So there’s anything that’s in the pelvis, um, the bladder, the intestines, the uterus, the vagina. Anything that’s in the pelvis, the back, the hips, that can be injured or affected, can cause an acute pelvic pain.

What are some causes of pelvic pain in servicewomen and service members with female biology? 

Pelvic pain is sort of a chronic pain condition that’s actually an end result of lots of things, so it’s sort of a warning sign of a lot of different things that can be going on. Sort of like headaches are. If somebody has a headache, you know, we all sort of understand that something’s wrong. And so for chronic pelvic pain, it’s much the same way, so you have to really rule out what I like to call point-and-shoot things, sort of things that started Tuesday at two, and they’re very straightforward things. And it’s what most, you know, providers on a variety of levels can take care of, and then the chronic pain is more of a long-term issue, and sometimes you can have an acute issue on top of a chronic issue, which is probably the more complicated one. So there’s a large, large list of things that can cause both acute and chronic pelvic pain.

Is endometriosis a common cause of pelvic pain? What are the symptoms? 

Endometriosis is commonly seen in people with pelvic pain, so I should probably say so. People with pelvic pain, 70% of them have endometriosis, but everybody with endometriosis does not have chronic pelvic pain. So endometriosis is a chronic pain syndrome and it it sort of works on on a continuum. The classic story is that they, a woman, starts out with heavy painful periods at the time of her first cycle, and then it turns into pain outside of her cycle, and then it turns into pain every single day, and sort of the final, classic symptom is pain with intercourse. Um, so there’s a spectrum that people can be on, and if they start right at the time of their first period, hopefully somebody has intervened and moved towards the most common way to manage it, which is hormonal suppression. Suppressing the cycle is sort of the ultimate key to managing endometriosis, but endometriosis, the way I look at it, is a chronic pain condition, kind of like getting migraines in your teen years or having chronic low back pain or chronic constipation, so endometriosis can be classified as a chronic pain condition.

What is the treatment for endometriosis? 

The treatment for endometriosis is cycle suppression. It’s really simple and we can suppress our cycle with hormones, we can suppress it, um, later on in life, and if they’re close to menopause, certainly Lupron or surgery, but cycle suppression is how you treat endometriosis.

Is pain during sex normal? 

Pain with intercourse is probably more important than pelvic pain. Um, I think that people don’t come and talk about pain they’re having with intercourse until their relationships are are on such a teetering edge, but they’ll deal with pain for a long time. So so by the time I see someone with pelvic pain, it’s very unusual if they don’t have pain with intercourse, but they feel like they have a socially acceptable reason to make an appointment. So people people who have pelvic pain but don’t have pain with intercourse, or just early on, then they’re lucky that they’ve come in sooner than later. But more often not, what’s really driving people is they’re having pain with intercourse and they thought it was normal, just like they thought it was normal to have pain with your periods. I’m like, no, it’s not, it’s not, so if you’re having pain, it’s a problem. So pain with intercourse can be treated, um, and so it’s treated exactly the same way chronic pelvic pain is. Let’s figure out all the things that are wrong. Let’s get you into physical therapy. Let’s get you straightforward medications that primary care can take care of. Let’s manage your headaches. Let’s, um, rehabilitate your pelvis, and let’s give you a different way to manage your stress other than stuffing your feelings in your pelvis. Um, and that’s what causes pain with intercourse.

When should someone see their healthcare provider for pelvic pain? 

I would say they should see their healthcare provider anytime they have any pain. Commonly, they finally come in to be evaluated for pelvic pain when something in their life is being disrupted. For instance, if they have pain with intercourse, then their relationship is being disrupted. If they have pain that prevents them from completing their, um, very physical duties, they come in for evaluation. But it’s very unusual that the pain started a month ago. They’ve been dealing with the pain for a long time and they’ve mustered through it and finally, all of their self-adaptive techniques are worn out. So I would encourage them to come in sooner than later, but I think that’s a human, um, I guess response and also a military response to sort of push through it. So anybody should come in when they have any kind of pain. Pain is a signal that something’s wrong, and so if you have recurrent pain, you should come in.

What advice do you have for a service member who might need a second opinion or a specialist because their provider isn’t experienced with pelvic pain?

Servicewomen and service, people, and I’m going to actually extend this to people, commonly don’t have providers that are well-versed in pain. They commonly don’t have providers that are well-versed in chronic pain. And so women have more chronic pain than men. So you can sort of sub-categorize this, but I guess it goes back to what I said earlier. Pain is a signal that something’s wrong, so if you feel like somebody has done a workup with … The the most common response is, you must have missed something, and I try to educate people that no, they probably didn’t miss anything. That doesn’t mean you’re not in pain. Now you’re going to have to address it in probably a longer appointment, um, and continue to advocate for yourself that something is wrong. I understand it’s not the straightforward things that can cause acute pain, but something’s wrong. So asking for a second opinion sometimes can be difficult. Um, I, sometimes in the military, they have a very hierarchical way of dealing with things. It depends on their deployments. It depends on, um, sort of mission-critical issues. So if there are mission-critical issues, um, then they they may or may not have the luxury of a second opinion. But mission-critical issues are never long-term, so they can always look for that when they are finished with whatever critical issues there are. They there are several levels of ancillary health providers in the military, so they may go to their independent duty corpsman. They may go to their physician assistant. They may have a nurse practitioner, a nurse midwife, and then finally an OB-GYN or a primary care doc or a flight doc. There’s so many people they could go to, but they are always able to ask for a second opinion. That’s kind of all they need to remember. They still have that right. Anybody receiving healthcare has a right to get another opinion about what’s going on, or to perhaps see somebody in a different specialty. So it’s more about reassuring people they can advocate for themselves, and if something’s wrong, and they think something’s wrong, they need to just ask for someone else with, you know, new eyes.

What can a service member expect from a medical appointment?

Evaluating chronic pain is not done by many people, to be quite honest. Um, so I can’t really give them what to expect. It’s much easier to tell them what to expect when they’re having an acute issue. When they’re having a chronic issue, um, it probably takes probably more classic approaches. They would see their primary care person. Um, and they would have to feel like that primary care person is listening to them. And if that primary care person is listening to them, I wouldn’t expect much in the first visit or two. I would expect perhaps one or two things to be ruled out each time. Most people with chronic pain are very patient and have no problem with that. They really just don’t want to feel brushed off, so if they feel, they’re not being listened to or something’s being missed, that’s where advocating for yourself comes in. But also, um, allowing the provider they’re seeing to say, all we can handle today is this, um, then we’ll move on to that. And sometimes if patients walk in with, I understand I have a lot going on, but my more pressing issue is this and this, there’s usually never just one thing, because then if they had one thing wrong, they would expect that one thing to be looked at. But as I said, chronic chronic pelvic pain is the end result to many things that have come before, and sadly, the patients are usually at their wit’s end, and so they’re trying to give a very long history in five minutes.

Why is it sometimes difficult to get a diagnosis for a pelvic pain condition? 

The most important thing they need to understand is, I would say, 99% of providers, what their main goal is to make sure that what’s wrong with you is not going to kill you or isn’t a cancer. Sort of, that’s our training, is to make sure it’s not the most extreme and the most awful of diagnoses. And so, when we are saying, well, we don’t see anything wrong, what the patient hears is that, they’re they’re, what do you mean you don’t see anything? But I’m in pain. And we’re not very good at saying, so, I’m gonna see you next time because we need to figure out why this is hurting. So their expectations are to be ruled out for something dangerous. That’s an expectation, but once that happens, um, they’re going to need to assume it’s not dangerous and really advocate for themselves for some validation, that I understand that I don’t have chronic appendicitis, but I still have this pain down here and I’d really like to know what it might be and what steps I can take to figure that out.

Can you speak to the stigma associated with pelvic pain? 

Doctors, um, providers in general, we are not trained on chronic pelvic pain, or really chronic pain conditions. We’re really trained on point and shoot, so a lot of chronic pain conditions, essentially, after of course, lesions are ruled out, something that has an actual cause and effect, a lot of chronic pain conditions actually have a root in a traumatic event in this person’s life. And because they have a trauma-informed, response to anything that happens to them, both physically and emotionally, sadly, what gets attributed to pelvic pain is a history of sexual trauma, and so that’s the stigma. Not necessarily because it’s a male-dominated profession, but I promise you plenty of female providers make an assumption of somebody’s chronic pelvic pain – they’ve been sexually traumatized.

How can servicewomen and service members with female biology overcome pelvic pain stigma?

I again, this is kind of, I I think it’s going to be a hard thing to not to avoid, because it’s on our end. It’s not on the patient’s end, so the stigma has more to do with we don’t know what to do with you, so we’re going to project that onto you. That’s the stigma, um, but but I’ve, you know, been working for a long time trying to educate providers and kind of flip things because chronic pain patients in general are the easiest patients in in my practice to deal with. They’re very straightforward. There’s no secondary gain, and they they really are fairly textbook, which can frustrate a lot of pain patients by the time they come see somebody who deals with chronic pain because they’re like, I don’t I don’t understand why nobody put this together. Well, we don’t put it together because we usually have 10 minutes with you and we don’t have 10 minutes with an automatic follow-up appointment and an automatic follow-up appointment. So we have 10 minutes with you that took you four months to get in. Now, it’s going to be another four months before we see you. So there’s so many things really wrong with this system. I don’t think it’s male dominated. I think it’s provider dominated.

What would you tell your best friend if they were struggling with pelvic pain?

I tell them pain means something’s wrong. You need to go advocate for yourself and you need to go be seen. And you need to try to find a pain specialist in the area, not an anesthesia pain specialist, but an OB-GYN pain specialist. Or, just ask your primary care doctor to get you into therapy, suppress your cycle, and you know, perhaps we talk about what might be causing it. So I just, I tell my friends and family and children and their friends the same thing I tell all patients. Um, I don’t treat them any differently. So pain means something’s wrong, and pain with intercourse is not normal. 


This resource was created with support from the Ready, Healthy & Able program funders.

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