Pelvic pain can be complex. It may be related to the reproductive organs, pelvic floor, bladder, bowel, muscles and joints, nervous system — and sometimes several of these at the same time.
Chronic pelvic pain generally refers to persistent or recurrent pain experienced in the pelvis or lower abdomen over an extended period of time.
Conditions such as endometriosis and adenomyosis can contribute to pelvic pain, but they aren't the only possible causes.
For people living with persistent pelvic pain, understanding the different factors contributing to their symptoms can help create a more individualised approach to care.
Chronic Pelvic Pain, Endometriosis & Adenomyosis: Why Does My Pelvis Hurt?
Pelvic pain doesn't always feel the same or occur in one specific location.
You may experience:
Lower abdominal or pelvic aching
Period pain
Deep pelvic pain
Lower back or sacral pain
Groin or hip pain
Pelvic floor tension
Pain during or after sex
Pain with bowel movements
Bladder pain or urgency
Rectal pain
Vulval or vaginal pain
Pain that changes throughout your menstrual cycle
Symptoms that flare with exercise, stress or fatigue
Some people experience pain every day, while others have symptoms predominantly around menstruation or particular activities.
What Does Chronic Pelvic Pain Feel Like?
Endometriosis is a chronic condition where tissue similar to the lining of the uterus grows outside the uterus.
It can occur in different areas of the pelvis and, less commonly, elsewhere in the body.
Symptoms may include:
Painful periods
Persistent pelvic pain
Pain during or after sex
Pain with bowel movements
Pain with urination, particularly around menstruation
Bloating
Fatigue
Fertility difficulties
However, symptoms vary significantly. Some people with endometriosis experience severe pain, while others have relatively few symptoms.
What Is Endometriosis?
Adenomyosis occurs when tissue similar to the uterine lining is found within the muscular wall of the uterus.
Symptoms may include:
Painful periods
Heavy menstrual bleeding
Pelvic aching or pressure
Abdominal bloating
Pain during sex
Endometriosis and adenomyosis are different conditions, although someone can have both at the same time.
What Is Adenomyosis?
The main difference is where the endometrial-like tissue is located.
With endometriosis, tissue similar to the lining of the uterus occurs outside the uterus.
With adenomyosis, similar tissue is located within the muscular wall of the uterus.
Both can contribute to painful periods and pelvic pain, which is why symptoms alone aren't always enough to distinguish between them.
What's the Difference Between Endometriosis and Adenomyosis?
Period pain is common, but pain that significantly interferes with everyday life deserves further investigation.
It may be worth speaking with your GP if your period pain:
Stops you attending work or school
Regularly requires significant pain relief
Causes vomiting or fainting
Prevents you exercising or completing normal activities
Is becoming progressively worse
Occurs alongside very heavy bleeding
Is associated with significant bowel, bladder or sexual pain
Being told that severe period pain is simply something you need to tolerate can contribute to delays in investigating conditions such as endometriosis.
Is Severe Period Pain Normal?
Yes.
A normal ultrasound does not necessarily exclude endometriosis.
Specialist ultrasound can identify some forms of endometriosis and may provide valuable information, but not all endometriosis is visible on imaging.
This means your symptoms and clinical history still matter, even when previous imaging has been reported as normal.
If endometriosis is suspected, discussing appropriate investigation with your GP or gynaecologist is important.
Can You Have Endometriosis With a Normal Ultrasound?
Not necessarily.
The amount or extent of visible endometriosis doesn't always correlate directly with the severity of someone's pain.
Someone with relatively limited disease may experience significant symptoms, while another person with more extensive endometriosis may experience comparatively little pain.
Persistent pain is influenced by many factors, including the location of disease, inflammation, pelvic floor function and changes in how the nervous system processes pain.
This is why management needs to consider the person experiencing the pain, not simply what appears on imaging or during surgery.
Does the Amount of Endometriosis Determine How Much Pain You Have?
Endometriosis can contribute to deep pain during or after penetrative sex.
However, pelvic floor muscle overactivity can also develop alongside persistent pelvic pain.
For some people, this means there may be more than one contributor to painful sex.
If your body has repeatedly experienced pain, the pelvic floor may begin guarding or tightening protectively, which can add another component to the symptoms.
Why Does Endometriosis Cause Pain During Sex?
Endometriosis can be associated with bowel symptoms, particularly when disease involves areas around the bowel.
Symptoms may include:
Pain opening the bowels
Pain around menstruation
Constipation
Diarrhoea
Bloating
Rectal pain
However, bowel symptoms can have many causes and don't automatically mean endometriosis is affecting the bowel.
Persistent or significant changes in bowel function should be appropriately investigated.
Can Endometriosis Affect My Bowels?
Some people with endometriosis experience bladder symptoms such as pain, urgency or discomfort with urination.
Endometriosis can involve structures around the urinary system, although this is not the explanation for every bladder symptom in someone who has endometriosis.
Pelvic floor dysfunction and other bladder conditions can also coexist.
Can Endometriosis Affect My Bladder?
Living with recurrent or persistent pelvic pain can influence the way the pelvic floor muscles behave.
For some people, the muscles may begin to guard or remain more active as a protective response to pain.
Over time, this may contribute to:
Pelvic floor tenderness
Pain with penetration
Difficulty relaxing the pelvic floor
Pain with bowel movements
Urinary symptoms
Pelvic aching or pressure
This doesn't mean the pelvic floor caused the endometriosis.
Rather, pelvic floor dysfunction can develop alongside the underlying condition and become another factor contributing to someone's symptoms.
Why Does My Pelvic Floor Feel Tight With Endometriosis?
No.
This distinction is important.
Pelvic floor treatment does not remove endometriosis lesions or cure endometriosis.
Where pelvic floor or musculoskeletal dysfunction is contributing to someone's symptoms, pelvic health care may instead help address those associated components of their presentation.
Medical and/or surgical management of endometriosis should be discussed with the appropriate medical team.
Does Pelvic Floor Treatment Get Rid of Endometriosis?
Pelvic pain can sometimes persist even after medical or surgical treatment of endometriosis.
This doesn't necessarily mean treatment has failed or that endometriosis has definitely returned.
Persistent pain can involve multiple contributors, including:
Pelvic floor muscle overactivity
Musculoskeletal pain
Bladder or bowel dysfunction
Scar sensitivity
Nerve sensitivity
Nervous system changes associated with persistent pain
Other pelvic health conditions
This is one reason some people benefit from multidisciplinary care rather than relying on one treatment alone.
Why Can Pelvic Pain Continue Even After Endometriosis Treatment?
Persistent pain can sometimes change the way the nervous system processes sensory information.
The nervous system may become more protective or sensitive, meaning symptoms can be triggered more easily or feel more intense.
This doesn't mean the pain is imaginary.
Pain is a genuine experience influenced by information from the tissues, nerves, spinal cord, brain and wider nervous system.
Understanding this can sometimes help broaden treatment beyond simply trying to find and “fix” one painful structure.
Can the Nervous System Become More Sensitive With Chronic Pelvic Pain?
Exercise can still form an important part of overall health and pain management, but the appropriate type and amount will vary.
During a significant flare, you may need to temporarily adjust your exercise.
Over time, gradually building movement and physical capacity may be more helpful than repeatedly cycling between doing too much and then completely stopping when symptoms flare.
Exercise should be individualised around your symptoms, goals and medical circumstances.
Should I Exercise if I Have Chronic Pelvic Pain or Endometriosis?
Because chronic pelvic pain can involve multiple contributing factors, management may involve several healthcare professionals.
Depending on your presentation, this could include:
Medical management
Gynaecological care
Pelvic floor rehabilitation
Musculoskeletal treatment and rehabilitation
Pain education
Exercise
Bladder or bowel management
Dietetic support
Psychological support
Sexual health support
Pain specialist involvement
The aim is to understand which factors are relevant to you rather than assuming every person with pelvic pain requires the same treatment.
How Is Chronic Pelvic Pain Managed?
How Can Pelvic Health Osteopathy Support Chronic Pelvic Pain?
At Yarra Valley Women's Health, pelvic health osteopathy focuses on the musculoskeletal and pelvic floor components that may accompany persistent pelvic pain.
Depending on your presentation, this may include:
Pelvic floor assessment
Pelvic floor relaxation and coordination
Hands-on osteopathic treatment where appropriate
Assessment of the abdomen, pelvis, hips and lower back
Exercise and rehabilitation
Breathing and pressure-management strategies
Scar assessment where relevant
Pain and nervous-system education
Bladder and bowel strategies
Self-management strategies
Where appropriate, we work alongside your GP, gynaecologist and other members of your healthcare team.
At Yarra Valley Women's Health, we recognise that chronic pelvic pain can involve more than one system and more than one contributing factor.
Our pelvic health osteopaths provide individualised assessment and management of pelvic floor and musculoskeletal factors that may occur alongside endometriosis, adenomyosis and other persistent pelvic pain conditions.
Our aim is to help you better understand your symptoms and provide you with the education, knowledge and strategies to feel more empowered in your ongoing care.