This examination, done gently, helps to locate tender areas. We call these tender areas trigger points which are areas where the muscles and the nerves in the skin may be involved.

Pain mapping has proven to be very helpful in showing the sources of pain caused by endometriosis, by finding tender areas in the uterus, ovaries, bladder, or peritoneum. Pain mapping also helps to assess sources of pain from causes other than endometriosis, such as adhesions, ovarian cysts, hernias, musculoskeletal/myofascial conditions, and interstitial cystitis.

An internal (pelvic) exam and endovaginal ultrasound may also be performed to help locate any tender areas in and around the internal organs such as the uterus and ovaries.

At this point your physician will help you explore options for treatment, or may suggest further procedures such as diagnostic laparoscopy, based on your individual situation.

The number one most important thing is to help you learn about what chronic pain is and how it can be not only managed, but in some cases reduced. Many women with chronic pelvic pain also have a condition called central sensitization of the nervous system. Sensitization can be reduced.

Initial steps in treatment may involve life-style changes such as following tips in our Endometriosis: An Overview handout, adopting an anti-inflammatory diet, establishing an exercise routine, and exploring ways to reduce stress. Pain reducing medications may be suggested, but should be used cautiously to avoid side effects.

Visit health information for patients for resources for women experiencing chronic pelvic pain.

Medications

Medical treatment may involve the use of hormones to stop ovulation and the fluctuations in hormone levels (in particular, estrogen levels) that happen in a normal menstrual cycle. An ideal medical treatment would stop the pain, be inexpensive and easy to use, and have no side effects.

Unfortunately, some treatments may not always be effective and may be expensive, and almost every medication has some side effects. Women respond to hormone treatment in very individual ways. Careful monitoring will help to ensure a good outcome.

Medications that may help with pain by reducing or preventing bleeding and ovulation may include:

• Combinations of estrogen and progesterone such as birth control pills or NuvaRing® that can be used either cyclically or continuously.
  
• Progesterone medications such as Depo Provera® or Visanne®.
  
• Medications that decrease estrogen levels such as Danazol® or Lupron®.
  
• Intrauterine devices such as Mirena® IUD.

Some of the ongoing pelvic pain you are experiencing may be related to joint or muscle dysfunction. A physiotherapy screening assessment is helpful in identifying any issues of this nature.

Issues that may arise in physiotherapy assessments:

• Pelvic girdle pain (PGP) that can involve the low back, hips and pubic bone area, characterized by pain with sustained positions, e.g. sitting or standing for long periods or when changing positions e.g. turning over in bed and standing up from a seated position.
  
• Vaginal and vulvar pain during vaginal penetration with sexual intercourse or vaginal examination and tightening/spasm of the pelvic floor muscles which can make deeper penetration very painful, very restricted or even not possible.
  
• Bladder and bowel issues with full bladder, leakage of urine, gas, bowel movement constipation, diarrhea, Irritable Bowel Syndrome, pain with bowel movement.
  
• Allodynia which is pain with light touch - a sign of a very sensitive nervous system.
  
• Decreased activity and difficulty getting started with an activity and with flare ups with activity
  

Physiotherapy treatment may include:

• Education about chronic pain and about specific issues identified during the assessment.
  
• A combination of manual therapy, stretching, and coordination exercises to work towards muscle balance and good functioning.
  
• Manual therapy for hands-on assessment and treatment, joint movement, and soft tissue stretching.
  
• Body mechanics education for good posture and movement through your daily routine.
  
• Muscle balancing with stretches, coordination exercises, and relaxation/strengthening exercises.
  
• Behavioural modification for urinary issues to help calm the bladder urges and increase the time between urination.
  
• Bladder and fibre diaries to record fluid or fibre intake, time and volume of urination, and urine leakage
  
• Temporary diet eliminations of potential bladder irritants.
  
• Pelvic floor coordination exercises to help learn how to contract, hold, and relax the pelvic floor correctly and on demand. The focus is usually on learning how to relax the pelvic floor.
  
• Relaxation with the use of body scans  and breathing.
  
• Planning a strategy to start an exercise program that is manageable and below the flare-up level.
  

Tools often used in physiotherapy treatment:

• EMG biofeedback: A tool that uses sensors external to the vagina, to detect muscle activity which is shown on a computer screen, which can be used during assessment and treatment.
  
• Imaging ultrasound:  A tool that shows abdominal and pelvic floor muscles and their motion on a screen which can be used during assessment and treatment to help with core muscle coordination.
  

Physiotherapists can work with women with pelvic pain to assess and provide treatments to correct muscle and joint function, posture, and body mechanics. They can teach you how to begin and progress through participation in daily activities and exercises, how to improve bowel and bladder issues, and techniques for decreasing tension and sensitivity.

You can learn techniques for general relaxation, breathing, general movement and stretches that will not cause pain, and posture that will break unhelpful patterns. You can develop tools that will help you manage your pain and increase your activity.

Chronic pelvic pain is a complex issue, one that affects all aspects of a woman's life.If you are experiencing chronic pelvic pain, then you are likely very aware of all the areas in your life that can be affected such as work, school, physical activities, relationships, and sexual function. Chronic pain can also affect mood, thoughts, behaviour, and stress levels.

Effective treatment for chronic pelvic pain must include an interdisciplinary approach that pays attention to the psychosocial and emotional aspects of pain by providing counselling and emotional support in addition to the surgical, medical, and mechanical treatment approaches.

Counselling can help you cope with chronic pelvic pain by:

• Learning mindfulness-based techniques to help reduce stress and chronic pain.
  
• Helping to manage intense emotions and negative thoughts.
  
• Learning tools to help calm the nervous system and to reduce central sensitization.
  
• Practicing ways to make lasting lifestyle changes, including diet and physical activity.
  
• Finding ways to increase communication and support in relationships.
  
• Grieving the many pain-related losses.
  
• Addressing symptoms of anxiety, depression, or trauma that may coincide with chronic pelvic pain.
  
• Making decisions regarding fertility and surgery options.
  

Our counsellor can also help you access community and online resources for chronic pain, mental health, and wellness. Visit the health information for patients section for resources for women experiencing chronic pelvic pain.