Understanding pelvic pain with Endometriosis

Medically reviewed by Dr. Karen Amaniampong 

Although it’s not the same as dysmenorrhea (period cramps), it can feel similar since they both happen in the same location. For many, pelvic pain usually lasts a few days, mostly starting right before their period and intensifying during heavy bleeding. Sometimes, the pain even persists when bleeding slows. However, pelvic pain can also happen outside of your period; one study showed that 50% of women with endometriosis experience non-cyclic pelvic pain. Women without endometriosis can also have non-menstrual pelvic pain, but is less common (19%) and can be caused by other factors like gynaecological conditions and infections. 

Pelvic pain can feel different for everyone, and endometriosis symptoms are non-specific, making them challenging to diagnose. People with endometriosis describe pelvic pain as feeling pressure at various locations including ovaries, unilateral pain, pain spreading to the back, or anal pain.

Chronic pelvic pain is defined as non-menstrual pain that persists over 6 months. Some women have described it as severe, incapacitating, debilitating, and interfering with daily life. An interview with one woman experiencing chronic pelvic pain reported it as ‘’somebody’s punched you really hard…but constantly’’. 

Keep in mind that pelvic does not always indicate endometriosis. One study even outlined that pelvic pain could be caused by at least 69 different conditions! Some gynaecological conditions associated with pelvic pain include fibroids, ovarian cysts, adenomyosis, and pelvic inflammatory disease. Non-gynaecological conditions that can cause pelvic pain include urinary tract infections, inflammation of the bladder (Interstitial cystitis), hernias, irritable bowel syndrome, etc. Many of these conditions share similar symptoms, which is why doctors may perform diagnostic laparoscopy in severe cases where pelvic pain persists.

Dr. Karen Amaniampong, Gynaecologist and Medical Consultant, provides insight into some of the possible causes of your pelvic pain, when associated with endometriosis. 

Adhesions in the pelvic area 

Studies have reported that in 64% of endometriosis cases, pelvic adhesions were the source of pain. Adhesions are bands of scar tissue that form when lesions become inflamed and bleed. They can create hidden pockets for new lesions to grow, and sometimes can stick organs together, causing physical distortion and pain during movement. 

Inflammation 

Since endometriosis lesions are composed of tissue similar to the endometrium, it also responds to hormonal changes that happen during your menstrual cycle. This is why your pain may be more intense and severe right before and throughout your period. As the lesions bleed, they form small wounds and local inflammation. Immune cells arrive at the site and release inflammatory molecules in an attempt to remove the damaged tissue and promote healing. This inflammation causes blood vessels to swell in order to allow for more immune cells to enter the site more easily. However, these events all cause swelling and pain. Lesions also release factors called prostaglandins which cause more inflammation.

These all result in pelvic pain if the lesions are located around organs in the pelvis area, including ovaries, fallopian tubes, uterus, bladder, bowel, and even pelvic nerves. 

Neuropathic pain 

The pelvis contains a major network of nerves located deep under the muscle. Especially in cases of deep endometriosis where lesions penetrate the tissue, this can cause neuropathic pain, or nerve pain. Prostaglandins are also known aggravators of nerve pain. This pain can occur around the pelvis but also radiate to other parts of the body such as back, hip, or leg, depending on where the nerves are connected.