Pelvic Pain During Perimenopause: Causes, Assessment, and Management
Pelvic pain during perimenopause can stem from multiple hormonal and structural causes. This guide helps you understand what is happening and what can help.
Why Pelvic Pain Increases During Perimenopause
Pelvic pain in perimenopause is more common than is often acknowledged. Falling estrogen affects the tissues of the uterus, ovaries, bladder, and pelvic floor directly. Irregular menstrual cycles during perimenopause can mean heavier, longer, or more cramping periods, which are a direct source of pelvic pain. Pelvic floor muscles that lose tone and elasticity due to lower estrogen can become hypertonic (too tight) rather than simply weak, contributing to aching, pressure, and discomfort during sitting or intercourse. Pre-existing conditions like fibroids and endometriosis can also become more symptomatic as hormone levels shift unpredictably.
Common Causes to Know About
Uterine fibroids (non-cancerous growths) often enlarge during perimenopause and cause pelvic pressure, heavy periods, and lower abdominal pain. Adenomyosis, where uterine tissue grows into the muscle wall, causes painful, heavy periods and is more often diagnosed in women in their 40s. Pelvic floor tension can produce a persistent ache or heaviness in the lower pelvis that is unrelated to the menstrual cycle. Ovarian cysts are also common during the anovulatory cycles of perimenopause and may cause intermittent sharp or dull pelvic discomfort. Vulvodynia and vestibulodynia (pain in the external vulval tissues) can worsen as estrogen falls and tissue atrophies.
When to Seek Medical Evaluation
Always see your doctor if you develop new or worsening pelvic pain. In particular, seek assessment promptly if pain is accompanied by abnormal bleeding (very heavy, between periods, or after sex), pain during or after sexual intercourse, unexplained weight loss, bloating that is persistent, or urinary changes. These symptoms need investigation to rule out gynaecological conditions including endometrial changes. Pelvic ultrasound and gynaecological review are appropriate first steps and can identify fibroids, cysts, and adenomyosis.
Pelvic Floor Physiotherapy
A pelvic floor physiotherapist is a specialist in musculoskeletal dysfunction of the pelvis and is often the most effective practitioner for pelvic pain that is not clearly structural. They can assess whether the pelvic floor is tight (hypertonic) or weak, and provide targeted treatment including internal and external manual therapy, breathing and relaxation techniques, and exercises tailored to the specific problem. Many women are surprised to find that their pelvic pain significantly reduces after pelvic floor treatment alone. This is an underused but highly effective resource.
Self-Management Strategies
Heat is one of the most effective self-help tools for pelvic pain, particularly around period-related cramping. A warm wheat bag or hot water bottle on the lower abdomen for 20 minutes can significantly reduce cramping pain. NSAIDs such as ibuprofen, taken at the first sign of cramping and continued for the first day or two, are more effective than taking them only when pain is severe. Magnesium may reduce period cramps by relaxing smooth muscle. Gentle yoga, particularly poses that open the hips and stretch the pelvic floor, is valued by many women with chronic pelvic discomfort.
Medical and Hormonal Treatment
HRT can reduce pelvic pain driven by atrophy of pelvic tissues and instability of menstrual cycles. Local vaginal estrogen is particularly effective for vulvovaginal atrophy-related pain without significant systemic absorption. For heavy painful periods caused by fibroids or adenomyosis, options include the levonorgestrel intrauterine system (hormonal coil), tranexamic acid, and progesterone. Fibroids can also be treated with uterine artery embolisation or myomectomy if they are causing significant symptoms. In some cases, hysterectomy is the most appropriate resolution for severe symptoms that do not respond to hormonal management.
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