Over one-third of reproductive-aged women will experience nonmenstrual pelvic pain at some point during their lives. Up to 16% of women experience chronic pelvic pain, and only one-third of this population will seek medical care (15). Unfortunately, up to half of those who do will not be given a definitive diagnosis for the underlying cause of pain (41). 

Chronic pain of any etiology is associated with significantly reduced quality of life and productivity and increased risk for psychiatric disorders, including suicide. Therefore, an integrative, multi-disciplinary approach to the diagnosis and treatment is warranted and necessary in improving clinical outcomes in patients suffering from pelvic pain.

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Understanding Pelvic Pain

Pelvic pain refers to discomfort or pain that is localized in the pelvic region, which is the area between the lower abdomen and the thighs. Pelvic pain is classified as acute or chronic, depending on its chronicity. Pain lasting less than three months is acute, whereas persistent, non-cyclic pain lasting at least three to six months is chronic. 

Diagnosing pelvic pain can be challenging because many of the signs and symptoms the patient will experience are nonspecific and can be related to gynecologic, urological, gastrointestinal, musculoskeletal, and neurological disorders (28). Signs and symptoms commonly associated with pelvic pain include (41): 

• Pain during intercourse, bowel movements, or urination
• Heavy or irregular menstrual periods
• Spotting or bleeding between menstrual periods
• Nausea and vomiting
• Fever and chills
• Painful/Difficult urination or bowel movements
• Pain that worsens during certain activities 

Differential Diagnosis for Pelvic Pain

Pelvic pain in females is often associated with gynecological problems such as (20, 33): 

• Menstrual cramps (dysmenorrhea)
• Endometriosis
• Uterine fibroids
• Ovarian cysts
• Pelvic inflammatory disease (PID)
• Ectopic pregnancy
• Adenomyosis
• Pelvic organ prolapse

Pelvic pain is common during pregnancy due to the changing position of the uterus and the pressure on surrounding structures.

Pelvic pain can also be related to problems with the urinary system, such as urinary tract infections (UTIs), kidney stones, or interstitial cystitis.

Conditions affecting the digestive tract, such as irritable bowel syndrome (IBS), diverticulitis, and appendicitis, can sometimes cause pelvic pain (20). 

Issues with the pelvic area's muscles, ligaments, or bones, including pelvic floor dysfunction, can lead to chronic pelvic pain (33). 

Neurological and vascular conditions like pudendal neuralgia, entrapment of pelvic nerves, and pelvic congestion syndrome can cause chronic pelvic pain (15). 

Pelvic pain is not specific to women. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) estimates that chronic pelvic pain syndrome affects 10-15% of men in the United States. Genitourinary infections, prostatitis, and testicular inflammation are common causes of pelvic pain in men (29).  

Pelvic Pain & Quality of Life

Chronic pelvic pain can significantly diminish an individual's overall quality of life. Chronic pelvic pain is associated with impaired quality of life, uncertainty of diagnosis, ongoing discomfort, negative effects on intimate relationships, and reduced productivity. Additionally, the financial burden of medical expenses related to diagnosing and treating chronic pelvic pain can be substantial. Estimated direct medical costs for outpatient visits for chronic pelvic pain for the U.S. population of women aged 18-50 years are $881.5 million per year. (24)

Functional Medicine Labs to Test for Root Cause of Pelvic Pain

While patient history and physical examination are the most important components of the diagnostic evaluation of pelvic pain, laboratory and imaging diagnostics play a role in narrowing the differential diagnosis to identify the underlying cause of pain. 

Transvaginal Ultrasound

Transvaginal ultrasonography (TVUS) is the imaging modality of choice for pelvic pain to visualize the pelvic structures. TVUS helps detect small pelvic masses that cannot be palpated on physical exam, fibroids, cysts, and PID. An abdominal ultrasound may be ordered simultaneously to evaluate for gastrointestinal causes of pain, such as appendicitis. In cases where ultrasonography is inconclusive, CT and MRI imaging can be considered. (20, 33) 

Standard Testing

As part of a standard, initial diagnostic workup, a complete blood count (CBC) with differential, inflammatory markers (CRP and ESR), urinalysis with culture, gonorrhea/chlamydia STI panel, and pregnancy test may be ordered to screen for infections, inflammation, and pregnancy.

Hormone Testing

Many female gynecological conditions, including dysmenorrhea, fibroids, and endometriosis, have an etiological component related to imbalanced hormones, predominantly estrogen dominance. A serum hormone panel measures reproductive hormones to identify imbalances contributing to pain and reproductive health disorders. 

Precision Analytical also offers a variety of urine/salivary tests to measure the metabolites of estrogen, progesterone, and testosterone. These panels can help assess how the body metabolizes and eliminates hormones, an important aspect of hormonal health that standard bloodwork cannot evaluate. Many of these panels also include cortisol and melatonin measurements, which are important for assessing how the stress response and sleep-wake cycle influence pain perception (41).  

Gut Testing

Comprehensive gut testing identifies digestive issues manifesting as pelvic pain for patients without an identifiable gynecological cause of pelvic pain. Studies have estimated that up to 35% of women with chronic pelvic pain have IBS. A functional medicine laboratory evaluation of IBS typically includes comprehensive stool testing, SIBO breath testing, and food sensitivity testing.

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Conventional Treatment for Pelvic Pain

Treatment aims to address any obvious disease process (e.g., infection) and maximize the patient's quality of life. Evidence-based therapy options for chronic pelvic pain are focused on symptom relief with pain-relieving medications (e.g., acetaminophen, gabapentin, opioids), anti-depressants, and hormonal therapies. (33) 

The Role of Integrative Medicine in Pelvic Pain

Integrative pain management is an approach to addressing and treating pain that combines conventional medical treatments with complementary therapies. Integrative pain management aims to provide comprehensive care that addresses not only the physical aspects of pain but also the emotional, psychological, and social aspects, focusing on improving overall well-being and function. 

Nutritional Recommendations

There is no one-size-fits-all dietary approach for treating pelvic pain, and nutritional modifications should vary between individuals based on their underlying cause of pain and specific needs.

Because inflammation can contribute to the manifestation of pain, an anti-inflammatory diet could be applied to all patients. This type of diet includes foods rich in antioxidants, such as fruits and vegetables, as well as sources of healthy fats like omega-3 fatty acids found in fish, flaxseeds, and walnuts. Reducing the consumption of processed foods, sugary snacks, and saturated fats can also help reduce inflammation. The Mediterranean diet, one of the most well-studied anti-inflammatory dietary plans, has improved pain associated with menstruation, sexual intercourse, and bowel movements in women with endometriosis (26). 

The low-FODMAP diet, designed for treating IBS, removes/limits fermentable carbohydrates from the diet. Research has shown that it is 86% effective in improving gastrointestinal symptoms, including pain, for patients adhering to the diet. 

Supplements & Herbs

Dietary and herbal supplements show promise for treating health conditions associated with chronic pelvic pain. Saw palmetto and quercetin have positively affected men with chronic prostatitis and pelvic pain syndrome. Other botanical supplements, including cayenne, devil's claw, white willow bark, curcumin, and calendula, show promise for treating chronic pain disorders, including chronic pelvic pain syndrome. (34) 

The use of cannabinoids, mainly Cannabis sativa, for pain management is being explored as an alternative to opioids, especially for chronic neuropathic pain. Cannabis has improved pain, muscle spasms, mood, and sleep without adverse effects in individuals with chronic pelvic pain syndrome. However, long-term data are still needed to fully understand its role and benefits for chronic pain. (34) 

Physical Therapy and Pelvic Floor Exercises

Pelvic floor physical therapy (PFPT) provides significant advantages for individuals coping with chronic pelvic pain. This specialized therapy concentrates on the muscles, ligaments, and connective tissues within the pelvic region, offering tailored solutions to address the root causes of pelvic discomfort. These benefits encompass pain reduction, rehabilitation of pelvic floor muscles, improvement in bladder and bowel function, enhanced sexual well-being, effective pain coping strategies, and the potential for long-term relief and improved quality of life. A 2021 systematic review concluded that PFPT is an efficacious treatment option, resulting in improved pelvic floor muscle tone and function, pain reports, sexual function, pelvic floor symptom scores, and quality of life for patients with a variety of chronic pelvic pain syndromes associated with pelvic floor hypertonicity. (34, 41) 

Other Complementary Therapies

Acupuncture has shown promise in managing chronic pelvic pain, particularly in conditions involving disrupted blood circulation, like chronic prostatitis and PID. It appears to alleviate pain and tissue fibrosis through various mechanisms, including stimulating relevant acupoints, enhancing the production of endogenous opioids, and promoting anti-inflammatory effects. Case reports also suggest its effectiveness in suppressing chronic neuropathic and myofascial pain components by releasing neurotransmitters and hormones. (34) 

In many cases of pelvic pain, patients exhibit pelvic floor dysfunction and myofascial trigger points. The 'Thiele' technique is a form of transvaginal massage that effectively reduces pelvic pain and dyspareunia (painful intercourse) caused by pelvic floor muscles. (34) 

Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, such as in times of chronic stress, can lead to a heightened perception of pain. Cognitive behavioral therapy (CBT) is a non-pharmacological intervention that aims to alleviate chronic pelvic pain by addressing the mental and emotional aspects of pain. CBT is particularly valuable due to its minimal side effects and effectiveness in reducing anxiety and depression, common in pelvic pain patients. Studies have demonstrated that CBT can reduce pain severity, improve quality of life, and provide stable benefits for conditions like endometriosis-associated pelvic pain and vulvodynia. (34) 

Mind-body therapy, including modalities such as biofeedback, yoga, and meditation, is another approach to stress management that activates the body's relaxation response to restore balance to the HPA axis. In one study, women with chronic pelvic pain who practiced yoga experienced improved physical health, reduced pain, and enhanced mood.

Multidisciplinary Collaboration 

A team-based approach is essential for the integrative treatment of chronic pelvic pain because this condition often involves multiple contributing factors and requires a comprehensive and holistic approach to management. A well-coordinated healthcare team can address the diverse aspects of chronic pelvic pain and provide patients with a higher level of care. 

A team of specialists from different fields ensures that all potential causes are thoroughly assessed, reducing the risk of misdiagnosis and ensuring that all aspects of the condition are considered. Here are key members to consider adding to your integrative healthcare team:

• Gynecologist (OB/GYN)
• Gastroenterologist 
• Naturopathic doctor or other functional medicine provider
• Acupuncturist
• Chiropractor
• Functional nutritionist or dietician 
• Physical therapist
• Psychologist or other mental health counselor

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Summary

Pelvic pain, especially when chronic, is a complex and often debilitating condition that affects a significant number of individuals, predominantly women. This article underscores the imperative need for an integrative approach to diagnosing and treating pelvic pain. Chronic pelvic pain frequently arises from a constellation of gynecological, urological, gastrointestinal, musculoskeletal, and psychological factors. Consequently, a multidisciplinary healthcare team comprising specialists from various disciplines is essential for a comprehensive assessment and personalized treatment plan. The integrative approach not only facilitates accurate diagnosis but also considers the psychosocial aspects of the condition and emphasizes the use of holistic strategies to improve patients' overall quality of life. By embracing integrative care, healthcare providers can address the multifaceted nature of pelvic pain and provide individuals with more effective and patient-centered management options.