The Pelvic Pain Playbook | Episode 01
Practical strategies for managing difficult pain days.
If you live with persistent pelvic pain, you'll know that some days are harder than others.
You might be managing reasonably well, only to experience a sudden increase in pain that disrupts work, sleep, exercise or everyday activities.
These episodes are often called pain flares.
Flares can be frustrating, exhausting and sometimes frightening, particularly when they happen without an obvious explanation.
One of the most useful things you can do is develop a plan before a flare occurs, so you know which strategies may help and when to seek further support.
Welcome to the first instalment of The Pelvic Pain Playbook, a series of practical, evidence-based resources to help you better understand and manage persistent pelvic pain.
Why do pelvic pain flares happen?
Persistent pelvic pain is complex and often involves several overlapping factors.
Conditions such as endometriosis and adenomyosis may contribute to pain, but pelvic floor muscle dysfunction, bowel and bladder conditions, musculoskeletal problems and increased sensitivity within the nervous system can also play a role.
Pain flares may be associated with:
Menstruation or hormonal changes
Physical activity or prolonged sitting
Constipation, bloating or bladder symptoms
Pelvic floor muscle tension
Poor sleep, stress or fatigue
Sometimes there is no identifiable trigger.
Importantly, a flare doesn't necessarily mean your underlying condition has worsened.
When pain has been present for a long time, the nervous system can become more sensitive, meaning symptoms may fluctuate even without new tissue damage.
However, new or significantly different pain should not automatically be attributed to an existing pelvic pain condition.
1. Start with comfort strategies
When pain escalates, simple measures may help reduce discomfort.
Heat therapy
A warm bath, shower or heat pack can help some people manage pelvic cramping and muscle tension.
Use a comfortable temperature and protect your skin from burns.
TENS therapy
Transcutaneous electrical nerve stimulation (TENS) uses a mild electrical current delivered through pads placed on the skin.
Some people find TENS helpful for managing pelvic pain, although the evidence for persistent pelvic pain is limited and it won't work for everyone.
Ask a healthcare professional about appropriate use, particularly if you're pregnant or have an implanted electronic medical device.
Comfortable positioning
Try lying on your side with a pillow between your knees, resting with your knees supported or another position that reduces discomfort.
Relaxed breathing
Slow, comfortable breathing may help reduce muscle guarding and the physical stress response associated with pain.
These strategies don't treat every underlying cause of pelvic pain, but they can be useful components of a broader management plan.
2. Have a medication plan
When pain becomes severe, it can be difficult to think clearly about medications.
Having an agreed plan in advance can help.
Depending on your medical history and underlying condition, this might include paracetamol, anti-inflammatory medications or other prescribed treatments.
Your plan should cover:
Which medications are appropriate for you
When and how to take them
Maximum safe doses
Medications or combinations to avoid
What to do when pain isn't responding
For people with cyclical pain, such as dysmenorrhoea, the timing of medication may be particularly important.
It's also worth reviewing your longer-term treatment plan if flares are occurring frequently.
Regularly needing escalating pain relief is a reason to reassess your management, rather than simply continuing to increase medications.
3. Pace yourself
One of the challenges of persistent pelvic pain is finding the right balance between rest and activity.
During a flare, it's reasonable to temporarily reduce activities that aggravate your symptoms.
But prolonged inactivity can contribute to stiffness, muscle tension and reduced physical conditioning.
When you're able, gentle movement such as walking, stretching or regularly changing positions may help.
The key is pacing.
Rather than pushing through severe pain or doing everything on a good day, aim for a manageable and relatively consistent level of activity.
Pacing can also mean breaking larger tasks into smaller steps, taking planned breaks and asking for help when needed.
The goal isn't to ignore pain signals. It's to gradually develop a sustainable approach to movement and everyday activities.
4. Consider your pelvic floor
The pelvic floor is a group of muscles that supports the pelvic organs and contributes to bladder, bowel and sexual function.
In people with persistent pelvic pain, these muscles can sometimes become overactive, tense or tender.
This can contribute to pelvic aching, pain with intercourse, urinary symptoms and discomfort associated with bowel movements.
During a flare, muscle guarding can sometimes make symptoms worse.
Relaxed breathing, comfortable positions and avoiding unnecessary straining may help.
If pelvic floor dysfunction is contributing to your pain, a specialist pelvic health physiotherapist can assess your muscle function and recommend appropriate treatment.
Importantly, pelvic floor treatment isn't always about strengthening.
For someone with an overactive pelvic floor, relaxation and improving muscle coordination may be more helpful than repeatedly performing Kegel exercises.
5. Don't overlook your bowel and bladder
The reproductive organs, bowel and bladder share anatomical space and overlapping nerve pathways within the pelvis.
It's common for people with persistent pelvic pain to experience several symptoms at once.
Constipation, bloating, urinary urgency or bladder discomfort may contribute to an overall increase in pain.
During a flare, consider whether you're also experiencing bowel or bladder symptoms.
Practical strategies may include maintaining adequate hydration, avoiding straining, addressing constipation and following an individualised bowel or bladder management plan.
If symptoms are frequent, specialist assessment may help identify conditions such as irritable bowel syndrome or bladder pain syndrome.
New urinary symptoms, fever or significant changes in bowel function should not simply be assumed to be part of an existing pelvic pain condition.
6. Help your nervous system settle
Pain isn't simply a signal travelling from an injured part of the body.
It's a complex experience involving the nervous system, influenced by biological, physical and emotional factors.
When pain persists, the nervous system can become sensitised, increasing the intensity of pain signals.
During a flare, pain may also trigger a stress response, leading to increased muscle tension, changes in breathing and difficulty sleeping.
Strategies that help you feel calmer and more supported may reduce some of this additional tension.
These might include:
Slow, relaxed breathing
Guided relaxation
Listening to music
Reducing unnecessary demands
Reaching out to someone you trust
Creating a comfortable environment for rest
Using relaxation or psychological strategies doesn't mean your pain is imaginary or caused by stress.
These approaches recognise that the nervous system is an important part of the pain experience.
7. Know when to seek medical help
Not every episode of pelvic pain is a flare.
Even if you have an established diagnosis of endometriosis or persistent pelvic pain, new symptoms may indicate another condition requiring assessment.
Seek urgent medical attention if you experience:
Sudden, severe or rapidly worsening pelvic pain
Fainting, marked dizziness or feeling very unwell
Pelvic pain with a possible pregnancy
Heavy vaginal bleeding
Fever or persistent vomiting
New pain that feels significantly different from your usual symptoms
In New Zealand, call 111 for a medical emergency.
You should also arrange medical review if your flares are becoming more frequent, lasting longer or no longer responding to your usual treatment plan.
Build your personal pelvic pain flare plan
Everyone's experience of pelvic pain is different.
What helps one person may not help another, so the most useful approach is to develop a personalised plan with your healthcare team.
Your plan might include your preferred comfort strategies, medications, movement and pacing techniques, relevant bowel or bladder management, and when to contact a healthcare professional.
Keeping this information somewhere accessible, such as a note on your phone, can make it easier to respond during a difficult pain day.
The take-home message
Pelvic pain flares can be difficult, but you don't have to navigate them without a plan.
A combination of comfort measures, appropriate medication, pacing, pelvic floor strategies and support may help make flares more manageable.
However, frequent or severe flares also deserve appropriate medical assessment and review of your longer-term treatment.
Persistent pelvic pain often requires an individualised, multidisciplinary approach. Self-management strategies are one part of that care, not a replacement for it.
The goal isn't to push through pain. It's to understand it, find strategies that help and get the right support.
Dr Anna Brownson
Gynaecologist | Endometriosis | Minimally Invasive Surgery
The Pelvic Pain Playbook is a series of practical, evidence-based resources exploring persistent pelvic pain, pelvic floor dysfunction, movement, pain sensitisation and multidisciplinary care.
Further reading
Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Australian Living Evidence Guideline: Endometriosis. 2025, with living updates.
Pelvic Pain Foundation of Australia. Understanding and Managing Pelvic Pain — For Patients.
NHS. Pelvic Pain — Symptoms and When to Seek Medical Help.
This article provides general health information and is not a substitute for individualised medical advice.
