Chronic pelvic pain (CPP) is recurrent or constant pain in the lower abdominal region that has lasted for 6 months or more. CPP can be caused by many conditions and the symptoms are similar and nonspecific. CPP is a common disorder with 3.8% population occurrence and it is as high as 40% in women with infertility. CPP is a heavy burden in women of reproductive age, with a direct affect of their quality of life. The treatment is focusing on identifying underlying cause and treatment. If there is no underlying cause identified, pain management is essential.
Inflammation and injury can be a problematic for internal organs. The organs become highly sensitive to any stimulation and pain sensation is very common. In women pain associated with their reproductive system is prevalent, such as period pain, labour pain etc. There is a particular sensory receptor that responds to potentially harmful stimuli by sending nerve signals to the spinal cord and brain. The receptors respond not only to intense mechanical stimuli such as distension and overstretching but also to irritant chemicals especially to the products of inflammation. They are very important in signalling pain from inflamed area. The uterus, cervix and adnexa share the same visceral innervations as the lower ileum, sigmoid colon and rectum. Signals from these organs pass through the sympathetic nerves to spinal cord segments T10-L1. Because of the shared pathway, gynaecological pain is difficult to be distinguished from gastrointestinal pain. Gynaecological pain can be felt in places far from the location of the reproductive organs. This is known as referred pain. The pain can be felt in the abdomen, pelvic region, or lower back. This pain sometimes cannot be located very accurately. The pain can be sensitized by altering sensory neurons so that they respond more intensely to the stimuli; and also by enhancing sensitivity of the sensory pathways in the brain that modulate sensation.
Some gynaecological conditions cause acute abdominal pain: ectopic pregnancy which occurs in 1% of pregnancies; pelvic inflammatory diseases; endometriosis, when large chocolate cysts ruptured; ruptured ovarian cysts.
In women, two conditions are very common: endometriosis related pelvic pain and pelvic inflammatory diseases and adhesions.
Endometriosis related pelvic pain. Endometriosis is an estrogen-dependent inflammatory disorder that occurs in women during reproductive years. CPP is one of the most common symptoms of endometriosis. The pelvic pain caused by endometriosis may vary with menstrual cycle, typically with severe pain toward the end of the cycle and pain declined during menstruation. Some women may have constant pain with various severities without association with menstrual cycle changes. Period pain, pain during intercourse, irregular period and infertility may coexist in these women with endometriosis. The causes for CPP in endometriosis are not clear. There are a few theories. One of them is that the lesions cause pain, but how they contributing to the pain remains mystery. Another hypothesis is that local inflammation contributes to the pain in endometriosis in which prostaglandins are activated. This established a foundation for new treatments involving agents and methods that can inhibit immunological and inflammatory factors. Recent studies suggested that innovation by newly sprouted nerve fibres underlies pain in endometriosis. This is supported by some clinical findings and studies from animal experiment. In animal experiment, transplanted pieces of uterine tissue become vascularised and grow rapidly and innervations and pain symptoms are seen. In clinical studies, various neuronal fibre types are found in different types of lesions and nerve fibre densities are associated with severity of pelvic pain.
Pelvic inflammatory diseases and adhesion: If women with pelvic pain have a history of previous sexually transmitted infection, intercourse pain, backache, infertility, ectopic pregnancy or fever, pelvic inflammatory disease is very likely an underlying cause of CPP. If the pain is associated with stretching movements or organ distension, adhesion may exist.
Acupuncture may benefit. There are some good reasons to choose acupuncture to treat CPP. First, acupuncture is effective to treat some underlying causes of CPP, such as endometriosis, pelvic inflammatory diseases; second, acupuncture is effective way to release the pain in CPP; third, acupuncture has no side effect.
Acupuncture reduces back and pelvic pain in pregnant women
More than two-thirds of pregnant women have low back pain (LBP) and one-fifth have pelvic pain. With pregnancy advanced pain increases which could affects work, daily activities and sleep. Pennic V and Liddle SD assessed the effects of different interventions for preventing and treating pelvic and back pain in pregnancy. They studied 26 randomised trials involved in 4093 pregnant women in the review. Usual prenatal care was added to the interventions. For LBP exercises significantly reduced pain and disability, though the evidence was low quality. Water-based exercise significantly reduced LBP-related sick leave. There was no significant difference in pain or function between two types of pelvic support belt, between osteopathic manipulation and usual care or sham ultrasound. Specially-designed pillow may relief night pain better than a regular pillow. For pelvic pain, the quality evidence was moderate which showed that acupuncture significantly reduced evening pain better than exercise; both approaches were better than usual care. A rigid belt plus exercise improved average pain. An eight to twenty wee exercise program reduced the risk of having lumbo-pelvic pain. Exercise and significantly reduced lumbo-pelvic-related sick leave and improved function. Osteopathic manipulation reduced pain and improved physical function. Acupuncture was started at 26 rather than 20 weeks of pregnancy improve pain and function more. Adverse events were minor and transient.
Acupuncture is as effective as pain killers for period pain (dysmenorrhoea).
Dysmenorrhoea is the medical term for the painful period cramps. It is also known as period pain. Period pain is very common affecting about over 50% women. The pains can be mild dull pain which may rarely noticeable or severe which may affect women’s daily life. They can be periodic or continual. It presents cramping pain in the abdomen before or during the menstrual period. Women with period pain may also feel pressure in the abdomen, pain in the hips, lower back and inner thighs. They may have other symptoms including upset stomach with or without vomiting and loose stools or constipation. Period pain may be accompanied by a headache, dizziness, fainting and fatigue and urgent frequent urination. Period pain is caused by uterine muscle contractions in response to prostaglandins and other chemicals. Uterine lining is shed off during menstruation and uterus contracts to squeeze the tissue out of the uterus.
Symptoms could start as early as immediately after ovulation and last until the end of menstruation. Common period pain often starts immediately before or at the beginning of the period and last for one to three days. Period pains generally begin one to two years after a woman starts getting her period and they become less painful as a woman ages and may stop entirely after the woman has a baby.
Why some women get more painful periods than others? Painful period is associated with changing of hormonal levels with ovulation. Prostaglandins produced in the endometrium of uterus cause uterine contraction which causes pain. Compared with other women, women with severe painful periods have increased uterine contractibility and more frequency of contraction. Women with more painful periods have higher level of prostaglandins compared with those with less painful period. Some factors including narrow cervical canal, backward tilting uterus, lack of exercises and emotional stress increase the period pain.
There are two types of period pain: primary period pain and secondary. In primary period pain, there is no cause of underlying gynaecological condition. Normally period pain occurs in the ovulatory cycles. In secondary period pain, some gynaecological conditions such as endometriosis or ovarian cysts are underlying causes of the period pain.
The treatment is aimed reducing pain. Non-steroidal anti-inflammatory drugs (NSAID) known as pain killers are common used to relieve the pain. These drugs decrease prostaglandins production and reduce pain. Contraceptive pills can be used to treat period pain because they stop ovulation.
Can acupuncture help period pain? Yes, acupuncture is well known to reduce pains in various conditions and it is very effective to relieve period pain. Acupuncture at particular points stimulates nerve ends producing pain releasing substances such as endorphins and neuropiptide which acts as endogenous painkillers.; acupuncture reduces inflammation by increasing blood flow and releasing vascular and immunomodulatory fators; acupuncture makes uterus relaxed.
Recently Kiran et al compared the effect of acupuncture and medicines (NSAID) for the treatment of primary period pain. The study is involved in 35 young women with a diagnosis of primary dysmenorrhea. They were divided into two groups: acupuncture group and medicine group. One month treatments were given to these women with dysmenorrhea and then the pain scores were assessed. They found that acupuncture is as effective as NSAID to reduce period pain.
When is a good time of acupuncture treatment for period pain
It is well known that acupuncture is effective in treating period pain. When is the best time to seek acupuncture treatment if you suffer from period pain? Ma YX et al studied this time related treatment. They recruited 600 patients with period pain. They compared the effect of acupuncture treatment with no treatment. They also compared the effect of acupuncture treatment before the period started with the effect of immediate acupuncture treatment as soon as pain occurrence. They found that acupuncture significantly relieves period pain compared with the control group with no treatment. The pain has been relieved within 5 min after acupuncture treatment. By comparing the pain scores used for the pain assessment, they found the acupuncture treatment before period has better effect than that when the pain occurred. This study suggests that acupuncture prevents period pain. Acupuncture reduces period pain by a few mechanisms. Acupuncture regulates hypothalamus-pituitary ovary axis; acupuncture relaxes uterine smooth muscles and inhibits uterine contraction; acupuncture increases relaxation and reduces tension; acupuncture releases endorphins and other neurohumoral factors and changes pain processing in the brain and spinal cord; acupuncture reduces inflammation by increasing release of vascular and immunomodulatory factors.
Which acupuncture points for women’s period pain
If you see an acupuncturist for period pain, you might like to know which acupuncture points were used. There is a lot variation for acupuncture points used. A study analysed research data from January 1978 to April 2014 to assess the acupuncture points for period pain. They found that there were 20 acupuncture points frequently used. Acupoints on lower limbs were most frequently used. Three points including Sanyinjiao (SP06), Guanyuan (CV04), and Qihai (CV06) were used most frequently. The most frequently used meridians were Conception Vessel, Spleen Meridian of Foot Taiyin, and Bladder Meridian of Foot Taiyang. 67.24% of acupoints used were specific acupoints.
Case report for period pain and endometriosis with acupuncture treatment
Alice is 27 years old. She had severe period pain and sometimes lower tummy pain between periods. She was diagnosed endometriosis one year ago. She took painkillers and antibiotics, but she still had unbearable pain in her lower tummy. And then she was advised to use birth control pills to inhibit ovulation in order to stop the pain and endometriosis. But she still suffers from pain. She never got pregnant before, but she wanted to have a baby some day. So she decided to stop taking birth control pills and seek help from acupuncture for period pain. After a few sessions of acupuncture treatment, her pain reduced markedly. With continuing a few month acupuncture treatments, she was no longer having pain in her periods.
Kiran G et al Eur J Obstet Gynecol REprod Biol. 2013 Mar 19
Ma YX J Ethnopharmacol. (2013) 148:498-504
Pennic V & Liddle SD Cochrane Database Syst Rev. (2013) Aug.
Yu S et al Evid Based Completment Alternat Med (2015) 2015:752194