Persistent pelvic pain is common, yet diagnosis and adequate treatment are often delayed.
Dr. Kathryn Witzeman is a clinical professor in the Department of Obstetrics and Gynecology at the University of Colorado and a gynecologic surgeon at Grand River Health. She presented 'When pain persists: chronic pelvic and sexual pain in midlife women through a biopsychosocial lens' at The Menopause Society 2026 Annual Meeting, held October 20 to 24 in San Diego, California. Her talk was part of the plenary symposium 'When the pelvis hurts: bleeding, urgency, and pain.',
Most clinicians who specialize in women’s health learned the reproductive causes of pelvic pain in training, so that is where they look, Dr. Witzeman explained. In a fragmented health care system, it is also easy to focus on what can be seen or fixed surgically. But focusing only on reproductive causes may miss about 80% of the underlying causes, which can lie in the gastrointestinal, urologic, neurosensory, and musculoskeletal systems.
Why a single-specialty lens may miss the full picture of pelvic pain
Clinicians 'tend to treat what we know best,' Dr. Witzeman said. A gynecologist may rule out pelvic pathology and may discharge a patient who might still be in pain. She compared pelvic pain to an iceberg, with central sensitization, pelvic floor dysfunction, and trauma below the waterline. 'You can't sink an iceberg only chipping at the top of it,' she said.
Viscero-visceral crosstalk also confuses the origin of pain, she explained, because the bladder, bowel, and uterus share the same hub in the nervous system. Persistent pain in one organ can sensitize the others. Central sensitization then breaks the 'volume dial,' and 'what might be a very mild input turns into a very loud sensation.' Finding one pain condition is therefore a reason to screen for others.
Pelvic floor muscles are part of this network too, and 50% to 90% of people with persistent pelvic pain have pelvic floor dysfunction, Dr. Witzeman noted. Still, she stressed ruling out red flags such as postmenopausal bleeding or a palpable abdominal or pelvic mass. She recommended a trauma-informed history every time, 'because you never actually know what type of trauma a person had early in their life.'
How a multimodal, biopsychosocial approach may help women with pelvic pain
'True healing and recovery requires a symphony of care instruments, treatment modalities, and therapies layered to address the peripheral triggers, musculoskeletal dysfunction, and the central nervous system amplification simultaneously,' Dr. Witzeman said.
She described four pillars of care. The first is hormonal and local therapy, such as vaginal estrogen for genitourinary syndrome of menopause. Medication can calm central sensitization, but 'we want to avoid opioids,' she said. Pelvic floor physical therapy is 'essential,' because surgery or hormones cannot fix a dysfunctional pelvic floor. Behavioral and sex therapists can help when the brain has linked pain to intimacy, even after the physical triggers are gone.
Dr. Witzeman closed by calling for a unified care system that puts the patient at the center.