The Ultimate Guide to Pelvic Pain in Women

A gynaecologist’s guide to understanding, diagnosing and treating pelvic pain

Pelvic pain is one of the most common, and often most frustrating reasons women seek gynaecological care.

For many, the journey to a diagnosis can take years. Symptoms are often dismissed, normalised, or misunderstood.

If you’re experiencing pelvic pain, it’s important to know this:
pain is not something you should have to live with - and there are effective ways to investigate and treat it.

What is pelvic pain?

Pelvic pain refers to discomfort felt in the lower abdomen, pelvis, or deep within the pelvis. It can present in many different ways:

• Period pain that is severe or worsening

• Pain between periods

• Pain with intercourse (deep dyspareunia)

• Pain with bowel motions or urination

• A constant dull ache or heaviness

• Sharp, stabbing, or cramping pain

Pelvic pain may be:

• Cyclical → linked to your menstrual cycle

• Non-cyclical → present most or all of the time

• Acute → sudden onset

• Chronic → lasting more than 6 months

👉 A key message: severe pain - even if it occurs with periods - is not “normal.”

Understanding the causes of pelvic pain

Pelvic pain is often multifactorial, meaning there may be more than one contributing cause. Understanding this is crucial - it’s why a simple “one treatment fits all” approach often doesn’t work.

Endometriosis

Endometriosis is one of the most common causes of pelvic pain, particularly in younger women.

It occurs when tissue similar to the lining of the uterus grows outside the uterus - commonly affecting:

• Ovaries

• Pelvic ligaments

• Bowel and bladder

• Peritoneum

Typical symptoms include:

• Severe period pain (often progressive)

• Pain with sex

• Pain with bowel movements (especially during periods)

• Fatigue

• Subfertility

👉 Importantly, endometriosis does not always show on ultrasound or MRI scan, which can delay diagnosis.

Adenomyosis

Adenomyosis occurs when endometrial tissue grows within the muscle of the uterus.

It is more common in women in their 30s and 40s and is often under-recognised.

Symptoms include:

• Heavy menstrual bleeding

• Severe cramping or “labour-like” pain

• Pelvic pressure or fullness

• A tender, enlarged uterus

Fibroids (Leiomyomas)

Fibroids are benign growths of the uterine muscle and are very common.

While many women have no symptoms, fibroids can cause:

• Heavy or prolonged bleeding

• Pelvic pressure

• Pain (especially if degenerating)

• Bladder or bowel symptoms

Abnormal uterine bleeding (AUB)

Heavy or irregular bleeding is not only distressing - it can also contribute to:

• Cramping

• Anaemia-related fatigue

• Reduced quality of life

We categorise causes into structural and non-structural factors - helping guide targeted treatment.

Non-gynaecological contributors

Pelvic pain often involves other systems. These contributors are commonly missed:

• Pelvic floor dysfunction
  → muscles become tight, overactive, and painful

• Bladder pain syndrome / interstitial cystitis
  → urinary urgency, frequency, pelvic discomfort

• Bowel conditions (e.g. IBS)
  → bloating, altered bowel habits, pain

• Central sensitisation
  → the nervous system becomes more sensitive to pain over time

👉 This is why a multidisciplinary approach is often essential.

Why diagnosis can be delayed

Many women experience delays of 5 -10 years, particularly with endometriosis.

Common reasons include:

• Symptoms being normalised (“period pain is normal”)

• Imaging not detecting conditions like superficial endometriosis

• Overlap with gastrointestinal or urinary conditions

• Trial-and-error treatment approaches

• Limited access to specialist care

👉 One of the most important steps is being listened to and taken seriously.

When should you see a gynaecologist?

You should seek specialist review if you experience:

• Pain that affects work, exercise, or daily life

• Pain requiring regular strong analgesia

• Pain with intercourse

• Heavy or irregular bleeding

• Difficulty conceiving

• Ongoing symptoms despite treatment

How pelvic pain is assessed

A thorough assessment is the foundation of effective treatment.

1. Detailed history

This is often the most valuable part of the consultation. We explore:

• Timing and pattern of pain

• Relationship to periods

• Impact on quality of life

• Fertility goals

• Previous treatments

2. Examination

A pelvic examination (when appropriate) may assess:

• Uterine size and tenderness

• Pelvic floor muscle tone

• Areas of localised pain

3. Imaging

• Pelvic ultrasound (first-line)

• Specialist endometriosis ultrasound in selected cases

• MRI scan in complex situations

👉 It’s important to understand: a normal scan does not exclude endometriosis.

4. Laparoscopy (keyhole surgery)

In some cases, laparoscopy is recommended to:

• Diagnose endometriosis

• Treat disease at the same time

👉 The quality of surgery matters significantly, particularly for endometriosis.

Treatment options: personalised and stepwise

Treatment should be tailored to your:

• Symptoms

• Diagnosis

• Fertility goals

• Preferences

Medical management

Often first-line, particularly if surgery is not immediately required.

Options include:

• Hormonal treatments

  • Mirena IUD

  • Combined oral contraceptive pill

  • Progestins

• Non-hormonal options

  • NSAIDs

  • Tranexamic acid (for heavy bleeding)

👉 These aim to control symptoms, not necessarily cure underlying conditions.

Surgical management

Surgery is considered when:

• Symptoms are severe

• Medical treatment is ineffective or not tolerated

• There is a structural cause (eg. fibroids)

• Fertility is a priority

Procedures may include:

• Laparoscopic excision of endometriosis

• Myomectomy (fibroid removal)

• Hysterectomy (in selected cases)

👉 For endometriosis in particular, complete excision by an experienced surgeon is key to good outcomes.

🧘‍♀️ Multidisciplinary care

For many women, the best results come from combining treatments:

• Pelvic floor physiotherapy

• Pain specialist input

• Psychological support

• Dietary and lifestyle strategies

👉 This approach recognises that pain is both physical and neurological.

Why individualised care matters

Pelvic pain is complex - and every woman’s experience is different.

Effective care involves:

• Listening carefully to your story

• Identifying all contributing factors

• Creating a tailored treatment plan

• Supporting you over time

Pelvic pain care in Auckland

Navigating care in New Zealand can feel challenging, particularly when balancing public and private options.

At Auckland Gynaecology Specialists, our focus is to provide:

• Clear, timely diagnosis

• Evidence-based treatment options

• Advanced minimally invasive surgical care

• A compassionate, patient-centred experience

Final thoughts

If you’ve been told your pain is “normal” but it doesn’t feel normal - trust that instinct.

Pelvic pain is common, but it is not something you need to accept. With the right assessment and a personalised approach, there are effective ways to improve symptoms and quality of life.

Need support?

If you’re experiencing pelvic pain and would like a specialist assessment, you’re welcome to get in touch.

👉 Book a consultation or speak with your GP about a referral.