Chronic Pelvic Pain in Women: When Veins Are the Overlooked Cause

Chronic pelvic pain is pain low in the abdomen or pelvis that has lasted for six months or more. It is common, and it can wear down work, sleep, sex and mood. Doctors describe it as a symptom rather than a diagnosis, because many different problems can cause it, and more than one is often involved. This guide walks through the main causes in women, and explains why pelvic veins are often overlooked.

What counts as chronic pelvic pain?

UK gynaecology guidance defines it as constant or on-and-off pain in the lower abdomen or pelvis that has lasted at least six months. Pain that happens only with periods or only during sex is usually considered separately, although they often overlap.

The pain may be:

• A dull, heavy ache, or sharp and stabbing
• On one side, both sides or in the middle
• Linked to periods, bowel movements, a full bladder, sex or standing
• Present most days, or coming in flares

Why it is often hard to pin down

The pelvis is crowded. The womb, ovaries, bladder, bowel, muscles, nerves and veins all sit close together and share nerve pathways. Pain from one can be felt as if it comes from another.

Long-term pain also changes how the nervous system works. Nerves can become more sensitive, so pain continues even after the original cause has settled. This does not mean the pain is imagined. It is one reason why treatment often needs more than one approach.

Common causes of pelvic pain in women

These are the main conditions doctors consider. Many women have more than one.

Gynaecological causes

• Endometriosis. Tissue similar to the womb lining grows outside the womb. It typically causes very painful periods, deep pain during sex and sometimes pain on opening the bowels.
• Adenomyosis. Womb-lining tissue grows into the muscle wall of the womb, often causing heavy, painful periods and a tender, enlarged womb.
• Fibroids. Non-cancerous growths in the womb. They may cause heavy periods, pressure or a dragging feeling.
• Pelvic inflammatory disease (PID). An infection of the womb, tubes or ovaries. Past infection can leave lasting pain and scar tissue.
• Ovarian cysts and adhesions. Some cysts and bands of scar tissue after surgery or infection can cause ongoing pain.

Bowel and bladder causes

• Irritable bowel syndrome (IBS). Pain is usually linked to bowel habits, with bloating, constipation or diarrhoea, and often eases after opening the bowels.
• Bladder pain syndrome (interstitial cystitis). Pain builds as the bladder fills, with a frequent, urgent need to pass urine, but urine tests show no infection.

Muscle, nerve and joint causes

• Pelvic floor muscle tension. Tight, overactive pelvic floor muscles can cause aching, pain with sex and difficulty with bladder or bowel emptying.
• Nerve pain. Irritation of nerves such as the pudendal nerve can cause burning or shooting pain, often worse when sitting.
• Back, hip and joint problems can send pain into the pelvis.

Vein causes

• Pelvic congestion syndrome (PCS). Veins in the pelvis widen and blood flows backwards in them, causing a dull, dragging ache. Estimates of how often PCS explains chronic pelvic pain vary widely between studies. See below for the clues.

When the cause may be your veins

Pelvic vein problems are often missed. Routine pelvic scans focus on the womb and ovaries, are done lying down when veins drain, and do not always measure blood flow in the veins. Clues that point towards veins include:

• A dull, heavy or dragging ache rather than sharp pain
• Pain that builds through the day or after standing, and eases when you lie down
• A deep ache during and for hours after sex
• Pain that is often worse on the left
• Varicose veins on the vulva, upper inner thigh, buttocks or back of the thigh
• Having had two or more pregnancies

None of these proves a vein cause. Widened veins are also found in women without pain. But if several fit, it is reasonable to ask whether your veins have been checked. Read more about pelvic congestion syndrome and its typical symptoms. If you are weighing up veins against endometriosis, see how PCS compares with endometriosis.

How doctors investigate it

Assessment usually starts with a detailed conversation. It helps to bring a pain diary noting when pain happens, what makes it better or worse, and its link to periods, bowels, bladder, sex and standing.

Depending on your story, your doctor may:

• Examine your abdomen and pelvis, including the pelvic floor muscles
• Test urine and take swabs to look for infection
• Arrange a pelvic ultrasound, often through the vagina
• Arrange an MRI scan if endometriosis or adenomyosis is suspected
• Arrange a vein-focused ultrasound if pelvic congestion is suspected. See how pelvic congestion syndrome is diagnosed.
• Discuss a laparoscopy (keyhole surgery to look inside). This can find endometriosis and adhesions, but it can easily miss pelvic veins, because the veins collapse when you lie flat with gas in the abdomen.

How chronic pelvic pain is managed

Treatment depends on the causes found. Because several factors often combine, care often works well when it is shared between specialists. It may include:

• Treating specific causes, such as hormonal treatment for endometriosis, or closing faulty veins for PCS
• Pain relief and, for nerve pain, medicines that calm nerve signals
• Pelvic floor physiotherapy, to relax and retrain muscles
• Pain education, which helps you understand why pain persists
• Psychological support such as cognitive behavioural therapy, which can reduce the impact of pain on daily life
• Lifestyle measures, such as pacing activity, managing constipation and improving sleep

A Singapore vascular surgeon’s article on PCS symptoms and diagnosis describes how vein causes are assessed.

Living with chronic pelvic pain

While you are waiting for answers or treatment, some everyday steps may help:

• Pace yourself. Break up long periods of standing or sitting, and plan rest into busy days.
• Use heat. A warm pack on the lower abdomen or back eases many types of pelvic ache.
• Keep your bowels regular. Straining and constipation can make pelvic pain worse.
• Stay gently active. Walking, swimming or stretching can help, even when you need to adjust how much you do.
• Talk about it. Pain that affects sex and relationships is common. Telling your partner and your doctor can ease the strain.

If the pain affects your mood, sleep or work, say so. These are part of the condition, and support is available.

When to see a doctor

See a doctor if you have pelvic pain that has lasted for months, pain that affects work, sex, exercise or sleep, pain with new bowel or bladder changes, or bleeding after sex or between periods. Our pelvic symptom check can help you organise your symptoms before your appointment.

Get urgent medical help for sudden severe pelvic or abdominal pain, pain with fever, vomiting or fainting, heavy vaginal bleeding, or pain or bleeding when you might be pregnant. In Singapore, call 995 in an emergency.

This article is general information, not personal medical advice. Please speak to a doctor about your own symptoms. How we create our content.