The Current Pain Paradigm

Persistent pelvic pain (PPP) is a complex and multifactorial condition, affecting 1 in 5 Australian women (Endometriosis Australia., 2023). Despite its prevalence, the underlying pathophysiology remains poorly understood. Conditions like endometriosis have traditionally been linked directly to PPP, yet research shows that lesions are found in only 40–60% of individuals with PPP and up to 45% of pain-free women (ANZCA.,2024). This highlights that the link between endometriosis lesions and pain is no longer tenable. Despite this, laparoscopic surgery remains the ‘gold standard’ of treatment, although its effectiveness is questionable, with surgery potentially worsening pain outcomes in up to 30% of cases (Ball et al., 2021). This underscores the need for a more nuanced understanding and approach to treatment.

Historically, women’s pelvic pain was trivialised as an inherent aspect of ‘womanhood,’ leaving many without the validation or care they deserved. While progress has been made in destigmatising pelvic floor disorders within sports and exercise for females, many women still face barriers around the recognition and effective treatment of pelvic pain. As physiotherapists, we have a unique opportunity to make a real difference by embracing a more integrated, holistic, and evidence-based approach.

Understanding the Complexities of Persistent Pelvic Pain

Consistent with other chronic pain conditions, several multifactorial contributors impact the severity of PPP in women (Yosef et al., 2016).  Persistent pain may initially stem from a physical cause, but when it extends beyond the typical healing period, neuroplastic changes in the nervous system can lead to heightened sensitivity and an overprotective response.

These factors include but are not limited to:

• Biological factors: such as period pain, endometriosis, adenomyosis, irritable bowel syndrome (IBS), pelvic floor muscle (PFM) dysfunction, painful bladder syndrome (PBS), urinary tract infections (UTIs), vulvodynia, chronic pelvic pain syndrome, inflammation and hormonal changes (Continence Foundation of Australia, 2024)
• Pelvic Floor Influences: While Padoa et al. (2021) suggested that increased pelvic floor muscle (PFM) tone could both initiate and perpetuate pelvic pain, Kadah et al. (2023) emphasise that this relationship is more likely influenced by biopsychosocial factors.
• Pain Catastrophising: Pain catastrophising plays a key role in both peripheral and central sensitisation, where the brain and spinal cord become overly sensitive to stimuli. This heightened sensitivity results in exaggerated pain responses to otherwise harmless triggers (De Ridder et al., 2021).
• Trauma and Nervous System Dysregulation: Developmental and systemic trauma can disrupt the autonomic nervous system (ANS), impairing the body’s ability to regulate stress responses. This can heighten sympathetic arousal, increasing pain perception. Adverse childhood experiences may also contribute to pain sensitivity in adults, with heightened sensory sensitivity playing a key role (Pierce et al., 2023).
• The Gut-Pelvic Pain Connection: The gut microbiota and its metabolites play a significant role in pain regulation, with growing evidence linking them to the severity of PPP (Hearn-Yeates, Horne, O'Mahony, & Saunders, 2024).

Mind-Body Connection in Pelvic Health: How the Brain, Gut, and Nervous System Influence Pain

Given the multifactorial nature of pelvic pain, a shift toward a sociopsychobiomedical approach is essential for more effective treatment. Managing pelvic pain requires a holistic approach that extends beyond the pelvis, considering the brain, gut, immune system, and overall lifestyle (Wright, 2024).

Key Treatment Approaches for Pelvic Pain:

• Pain Science Education (PSE):
  Over 150 minutes of PSE combined with physiotherapy is effective in reducing psychological factors like pain catastrophising, even if immediate pain reduction is not seen (Starzec-Proserpio et al., 2024). Teaching pain science (how pain is made) empowers people to understand their pain and not be threatened by it.
• Multimodal Physiotherapy:
  •  This includes manual therapy, pelvic floor muscle (PFM) therapy, general exercise, pain education, and self-therapy (Starzec-Proserpio et al., 2024). Usually with PPP the PFM become overactive, tight and painful. Relaxation or 'down training' exercises can help to restore the normal function of these muscles. Collaboration with pelvic health physiotherapists is critical for effective treatment of PPP.
• Holistic Approach
  • Shared Decision-Making: Involving patients in their treatment decisions enhances engagement and outcomes.
  • Multidisciplinary Team Approach: Collaboration with other healthcare professionals ensures comprehensive care, including pelvic health physiotherapists, GPs, specialists (gynaecologists, urologists, colorectal, and vulval dermatologists), pain psychologists, psychotherapists, psychiatrists, nurses, allied health professionals (dietitians, nutritionists, occupational therapists), and sexual health experts.
• Psychological and Mind-Body Approaches:
  • Cognitive Behavioural Therapy (CBT) & Acceptance and Commitment Therapy (ACT): These therapies address psychological factors that contribute to chronic pain, such as catastrophising and stress.
  • Mindfulness: Can help improve pain management by promoting relaxation and better pain coping strategies.
  • Down-regulating the nervous system: Use diaphragmatic breathing, meditation, mindfulness, adequate sleep and mindful movement practices like yoga, Qi Gong, and tai chi to downregulate the sympathetic nervous system (SNS).
• Trauma-Informed Care:
  • Many individuals with pelvic pain have a history of physical or emotional trauma. Understanding its impact on the autonomic nervous system (ANS) is essential for creating a safe and validating environment for healing.
• Gut Health Considerations:
  • Many individuals with pelvic pain experience gastrointestinal issues, such as IBS. Addressing gut health through dietary changes may improve overall pelvic pain outcomes.

Making a Change ~ Raising Awareness and Reducing Stigma Around Pelvic Pain

• Advocacy and Language: Social media often portrays conditions like endometriosis as incurable and lifelong, with language that can negatively impact patient outcomes. It is important to advocate for more empowering and realistic portrayals of these conditions to improve patient outcomes.
• Further Research: Continued research into the biopsychosocial aspects of pelvic pain and trauma-informed care is essential to improving treatment approaches.
• Supporting Pelvic Pain Awareness: Supporting initiatives that aim to reduce stigma and raise awareness around pelvic pain can help improve public understanding and treatment outcomes. As healthcare professionals, we can play an important role in this advocacy.

Empowering Patients:

By embracing a holistic, biopsychosocial approach, physiotherapists have the power to transform the management of pelvic pain, empowering patients to take control of their health and healing journey. For further support, clinicians can refer to the following helpful websites and resources:

• Continence Foundation of Australia
• Jean Hailes
• Pain Australia
• Pelvic Pain Foundation of Australia
• Tame the Beast – Rethinking Persistent Pain
• Pain Revolution
• MindSpot – Chronic Pain Course
• Curable App
• This Way Up – Chronic Pain Course
• Nerva Hypnotherapy

References:

Australian and New Zealand College of Anaesthetists (ANZCA). (2024). PS15(PM) Statement on the clinical approach to persistent pelvic pain, including endometriosis-associated pain: Background paper [Pilot version]. https://www.anzca.edu.au/getattachment/f9b26906-f91f-4855-ac94-d10ba2fbddac/PS15(PM)-BP-Statement-on-the-clinical-approach-to-persistent-pelvic-pain-including-endometriosis-associated-pain-Background-paper-2024-(PILOT)

Ball, E., Karavadra, B., Kremer-Yeatman, B. J., Mustard, C., Lee, K. M., Bhogal, S., Dodds, J., Horne, A. W., Allotey, J., & Rivas, C. (2021). Systematic review of patient-specific pre-operative predictors of pain improvement to endometriosis surgery. Reproduction & fertility, 2(1), 69–80. https://doi.org/10.1530/RAF-20-0057

Continence Foundation of Australia. (n.d.). Persistent pelvic pain. Retrieved December 8, 2024, from https://www.continence.org.au/news/persistent-pelvic-pain

De Ridder, D., Adhia, D., & Vanneste, S. (2021). The anatomy of pain and suffering in the brain and its clinical implications. Neuroscience and Biobehavioral Reviews, 130, 125–146. https://doi.org/10.1016/j.neubiorev.2021.08.013

Endometriosis Australia. (2023). 2023 National Women's Health Survey: Pelvic pain in Australia. Retrieved December 8, 2024, from https://endometriosisaustralia.org/wp-content/uploads/2023/09/2023-National-Womens-Health-Survey-Pelvic-Pain-in-Australia-FINAL.pdf

Frawley, H. (2024). Pelvic health physiotherapy: Understanding musculoskeletal influences on pelvic pain.

Grover, M. (2024). Central sensitisation and chronic pain: A neurological perspective.

Hearn-Yeates, F., Horne, A. W., O'Mahony, S., & Saunders, P. T. K. (2024). The impact of the microbiota-gut-brain axis on endometriosis-associated symptoms: Mechanisms and opportunities for personalised management strategies. Reproduction & Fertility, 5(2), e230085. Advance online publication. https://doi.org/10.1530/RAF-23-0085

Kadah, S., Soh, S. E., Morin, M., Schneider, M., Ang, W. C., McPhate, L., & Frawley, H. (2023). Are pelvic pain and increased pelvic floor muscle tone associated in women with persistent noncancer pelvic pain? A systematic review and meta-analysis. The Journal of Sexual Medicine, 20(9), 1206–1221. https://doi.org/10.1093/jsxmed/qdad089

Krantz, T. E., Andrews, N., Petersen, T. R., Dunivan, G. C., Montoya, M., Swanson, N., Wenzl, C. K., Zambrano, J. R., & Komesu, Y. M. (2019). Adverse childhood experiences among gynecology patients with chronic pelvic pain. Obstetrics and Gynecology, 134(5), 1087–1095. https://doi.org/10.1097/AOG.0000000000003533

Padoa, A., McLean, L., Morin, M., & Vandyken, C. (2021). "The overactive pelvic floor (OPF) and sexual dysfunction" part 1: Pathophysiology of OPF and its impact on the sexual response. Sexual Medicine Reviews, 9(1), 64–75. https://doi.org/10.1016/j.sxmr.2020.02.002

Painaustralia. (2020, May 7). New AIHW report reveals escalating health impact of chronic pain. Retrieved December 8, 2024, from https://www.painaustralia.org.au/static/uploads/files/media-release-aihw-report-on-chronic-pain-in-australia-7-may-20-wfltlarhuoek.pdf

Pierce, J., Harte, S. E., Afari, N., Bradley, C. S., Griffith, J. W., Kim, J., Lutgendorf, S., Naliboff, B. D., Rodriguez, L. V., Taple, B. J., Williams, D., Harris, R. E., Schrepf, A., & MAPP Research Network (2023). Mediators of the association between childhood trauma and pain sensitivity in adulthood: A Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network analysis. Pain, 164(9), 1995–2008. https://doi.org/10.1097/j.pain.0000000000002895

Rossi, M., Seidita, I., Vannuccini, S., Prisinzano, M., Donati, C., & Petraglia, F. (2023). Epigenetics, endometriosis, and sex steroid receptors: An update on the epigenetic regulatory mechanisms of estrogen and progesterone receptors in patients with endometriosis. Vitamins and Hormones, 122, 171–191. https://doi.org/10.1016/bs.vh.2023.01.007

Schrepf, A., Naliboff, B., Williams, D. A., Stephens-Shields, A. J., Landis, J. R., Gupta, A., Mayer, E., Rodriguez, L. V., Lai, H., Luo, Y., Bradley, C., Kreder, K., Lutgendorf, S. K., & MAPP Research Network (2018). Adverse childhood experiences and symptoms of urologic chronic pelvic pain syndrome: A multidisciplinary approach to the study of chronic pelvic pain research network study. Annals of Behavioral Medicine, 52(10), 865–877. https://doi.org/10.1093/abm/kax060

Starzec-Proserpio, M., Frawley, H., Bo, K., & Morin, M. (2024). Multimodal physiotherapy for chronic pelvic pain in women – A systematic review and meta-analysis. The Journal of Sexual Medicine, 21(Supplement_6), qdae161.116. https://doi.org/10.1093/jsxmed/qdae161.116

Wright, P. (2024). Patient-centred pelvic health.

Yosef, A., Allaire, C., Williams, C., Ahmed, A. G., Al-Hussaini, T., Abdellah, M. S., Wong, F., Lisonkova, S., & Yong, P. J. (2016). Multifactorial contributors to the severity of chronic pelvic pain in women. American Journal of Obstetrics and Gynecology, 215(6), 760.e1–760.e14. https://doi.org/10.1016/j.ajog.2016.07.023