Behavioral Therapy: Chronic Pelvic Pain & Menstrual Cramps

Highlights

• Chronic menstrual and pelvic health conditions impact many people. Increasing behavioral therapy has been shown to improve their symptoms.
• Behavioral therapy including cognitive behavioral therapy, as well as stress management or mindfulness focused therapy have also shown to be impactful.
• A behavioral therapist can help you manage symptoms and make lifestyle changes.

Today, in the US, chronic illness affects 6 out of 10 adults, and 4 out of 10 adults are living with two or more chronic illnesses. In particular chronic pelvic pain and menstrual cramps impact many women and those with ovaries. While management of the medical condition is critical, there has been proven evidence of the strong mind-body link between chronic pain and psychological factors.

In particular, clinical studies have shown the connection between chronic pelvic pain, menstrual cramps and emotional health. Thus, not surprisingly, behavioral therapy is one key tool that has shown to be effective for those with this chronic pain.

Prevalence of chronic pelvic and menstrual pain

Chronic pelvic pain and menstrual cramps affect a large share of women. Chronic pelvic pain syndrome (CPPS) is defined by the persistent pain in the pelvic floor that is consistent for at least six months. Dysmenorrhea is the formal name for severe and frequent period cramps before or during menstruation.

The primary cause of painful menstruation is the hormonal changes that occur during menstruation, especially when there is a chemical imbalance. However, chronic menstrual pain can also be caused by a medical condition, such as endometriosis. 

Dysmenorrhea and pain

Depending on the country, reports indicate that dysmenorrhea can impact between 43% and 90% of the female population. Non-endometriosis related menstrual pain has been reported to affect quality of life, and up to 33% experience severe pain lasting for 1-3 days each month during their period.

This pain can be severe enough to cause 1% of those of reproductive age to miss 1 to 3 days of work each month and 14% of school-age girls to miss  class for a day or two per month.  

Endometriosis symptoms and pain

Similarly, endometriosis  also has a high prevalence and is thought to affect between 4 to 15% of those in the US of childbearing age. In endometriosis, tissue that is similar to tissue that lines the uterus (or endometrium) grows outside the uterus. When hormonal changes associated with a menstrual cycle occur each month, these tissues respond to these hormones by building up and breaking down just as tissue in the uterus does.

Because this tissue has no way of leaving the body, it can cause scarring, adhesions and cysts in the areas around where the tissue is located – often the fallopian tubes, ovaries or tissues of the pelvis. This can then cause severe pain, especially during menstrual cycles. Pain can also be common during sexual intercourse or bowel movements. 

Having chronic pain associated with dysmenorrhea (painful menstruation) and endometriosis can be distressing. Some of the common pains and symptoms women with dysmenorrhea experience include:

• General fatigue or weakness
• Pain and cramps in the lower abdomen
• Lower back pain and cramps
• Pain radiating down the legs
• Nausea and vomiting
• Diarrhea 
• Headaches

With endometriosis, a study found that 71% reported chronic pelvic pain and 69% of those with Endometriosis had dysmenorrhea.

Treatment of physical symptoms of pelvic pain

There are many options for treating chronic pelvic pain syndrome, especially if the cause is in pelvic floor muscle dysfunction. Some options include physical therapy, pelvic massage, pelvic floor exercises and other alternative therapies such as acupuncture or traditional Chinese medicine.

Pelvic pain, menstrual cramps, and mental health

Menstrual cramps, pelvic pain and associated pain symptoms are difficult to manage. However, living with these conditions and changes can often cause anxiety and depression because of their impacts to quality of life. 

In a 2004 study, those who experienced high stress had a 2x higher rate of pain from menstruation than those with low stress in their prior cycle. There is a bi-directional connection between stress and increased pain.

The study also found that the risk of menstrual cramps was the highest amongst those who had both high stress and a prior history of menstrual pain. While not conclusive, there have also been multiple studies that point to a potential link between those with dysmenorrhea and increased depression as well.

There is an even stronger link between mental health and endometriosis. It has been proven that people with endometriosis suffer from higher rates of  depression and anxiety disorders. In fact, studies showed up to 15.1% of those with endometriosis had a diagnosis of depression and 29% had anxiety. 50% of these people also reported that their pain reduced their physical, sexual and work activity in the prior 3 months. 

Thus, it is not surprising that behavioral therapy has been shown to help people change the way they perceive their illness and to increase the positive outcomes of those with chronic illness. 

Behavioral therapy approaches

There is no one size fits all approach to behavioral therapy and most who suffer from chronic pain don’t necessarily have mental illness but can still benefit from this type of short-term therapy. Generally, most approaches focus on one or both of the following two aspects of emotional health: self-monitoring and changing distressing thoughts. 

Some example approaches include:

• Cognitive Behavioral Therapy (CBT):Through this short-term structured process you’ll work with a trained therapist to diagnose the thinking that is negatively impacting your chronic illness. For example, you might keep a diary and self-monitor your moods and problem behaviors. Then, you will build skills and tools that help change those negative thought patterns. You would then practice these skills through ‘homework’ assignments and review these assignments over during your treatment sessions with your therapist. Your therapist might also include other tools focused on relaxation techniques and overall stress management. 

• Mindfulness Focused Therapy: Mindfulness techniques were developed by Shakyamuni Buddhi over 2500 years ago. These techniques focus on bringing awareness to your present state of mind through your senses, thoughts and emotions. This process of focusing on present-moment experiences works to calm the mind and release fixation. A trained mindfulness focused therapist can guide you through meditation techniques to improve your emotional well being. 
• Stress Management Therapy:Through relaxation, breathing techniques and mindfulness techniques, a therapist will help you develop skills to improve your stress management. 

Working with a behavioral therapist in addition to your primary care provider or your other comprehensive medical providers can help you create a holistic chronic pelvic pain and menstrual cramp management plan, ultimately allowing you to improve your quality of life. See our list of qualified providers to find one to suit your individual needs.