From your first menstrual cramps, you learned that pelvic pain can be pretty disruptive to your life. Pelvic pain at night can be particularly brutal because it affects your sleep. This can create a vicious cycle since poor sleep can exacerbate all kinds of pain. That time-of-the-month cramps aside, about one-quarter of women experience chronic pelvic pain, persistent physical aches, and related emotional distress that lasts for six months or more.

The first step to relieving your pelvic pain at night is to understand the different issues that cause it. Here, learn more about what causes pelvic pain at night, and how to prevent and treat it - especially with exercises from our Hinge Health physical therapists.

What Is Pelvic Pain?

Pelvic pain comes in many forms. The pelvis is a bowl-shaped structure that holds a number of organs, including your reproductive, digestive, and waste-eliminating organs. At the bottom of the bowl, between the sit bones, lie three layers of pelvic floor muscles, which are responsible for holding or releasing contents (like urine) and your sexual function. You could experience pelvic pain anywhere in the area, between the belly button and the groin, depending on which structures are involved.

You may experience acute, stabbing, or severe pain due to an injury or medical issue, predictable monthly pain with your menstrual cycle, or dull aches associated with a muscular imbalance.

"Pelvic pain can also radiate. Pain that may originate from the pelvic floor muscles can travel up to the belly button or into the lower back. That's one reason it's missed - people think they just have lower back pain," says Lori Walter, PT, DPT, a physical therapist at Hinge Health. 

Causes of Pelvic Pain at Night

Pelvic pain has many possible causes, including infection, inflammation, or traumatic injury. Here are some of the most common reasons you may experience pelvic pain at night:

Pelvic floor muscle pain. One underappreciated cause of pelvic pain is an imbalance in the pelvic floor muscles. They can become too tight (hypertonic pain), especially if you clench your pelvic floor muscles when stressed. The result: a dull ache that comes and goes after certain activities or positions. Hypertonic pain is particularly noticeable at night, says Dr. Walter. "It's a bit like people who clench their jaw and don't notice until they get a headache. You may be squeezing your pelvic floor muscles all day because you're super stressed, and you're not even aware of it until you go to bed. Then you finally relax and notice that there's pelvic pain."

Sustained tightness may also lead to compressed nerves in the area, leading to burning or radiating pain. Incontinence and constipation are other signs you could have pelvic floor dysfunction since those muscles are responsible for holding in and letting out waste.

Pregnancy-related pelvic pain. Pelvic pain occurs because of your ligaments stretching and loosening to accommodate a growing baby. Pregnant women are prone to pelvic floor muscular pain as well. "As your body produces hormones to loosen the area in preparation for giving birth, the pelvic floor muscles have to work even harder to hold everything together," says Dr. Walter. Pelvic floor physical therapy in advance of giving birth may help optimize muscle strength and flexibility, putting you in a better place to recover after giving birth, adds Dr. Walter.

Other types of pelvic pain during pregnancy: round ligament pain (sharp pain with sudden movements) and Braxton Hicks contractions ("practice" contractions in advance of labor). Most pelvic pain during pregnancy is not serious, but seek advice if you have any concerns (see "When to See a Doctor" below).

Other medical causes of pelvic pain that can cause symptoms at night:

Endometriosis. The lining of the uterus grows outside the uterus and responds to your monthly menstrual cycle by cramping and bleeding during your period. This leads to pain, inflammation, and scarring. Pain may last throughout the month and happen during sex.

Pelvic inflammatory disease. This infection of the reproductive organs causes aching in the lower abdomen. You may also notice discharge, vaginal bleeding, fever, and urination problems. PID may be caused by a sexually transmitted infection (STI).

Painful periods (dysmenorrhea). Painful periods affect up to 81 percent of all women, according to the American College of Obstetricians and Gynecologists - an incredibly common source of pelvic pain. Prostaglandins, chemicals made by the lining of the uterus during your period, are associated with severe pain in the pelvic area. The pain can feel like a muscle spasm, a dull ache, or a backache.

Fibroids. These overgrowths of cells in the wall of your uterus may put pressure on the back and pelvis, leading to pain.

Urinary tract problems. Urinary tract infections (UTIs) produce pelvic pain (especially around the pubic bone), along with burning or stinging while peeing. You may feel a constant urge to pee even if you've just emptied your bladder. Repeat UTIs increase your risk of chronic pelvic pain. Interstitial cystitis, or inflammation of the bladder wall, has symptoms similar to a UTI and also causes pelvic pain.

Digestive system problems. Irritable bowel syndrome (IBS) is one of the most common causes of pelvic pain. Inflammatory bowel disease (Crohn's disease and ulcerative colitis) and diverticulitis are other digestive conditions associated with inflammation in the digestive tract that can lead to pelvic pain.

When to See a Doctor

Many causes of pelvic pain are not serious, but if you have pelvic pain that doesn't go away or constantly returns, it's worth seeing your primary care provider or gynecologist for an evaluation, recommends urogynecologist Tamara Grisales, MD, expert physician at Hinge Health. Your doctor can screen for different pelvic pain causes (such as STIs, digestive issues, and musculoskeletal issues) through a physical exam, blood work, and imaging like ultrasounds.

Your doctor may refer you to a specialist - for example, a urogynecologist if your pain involves pelvic floor disorders or the bladder or urethra. You may need to see a gastroenterologist if your pelvic pain is related to digestive conditions. You'll likely be referred to a physical therapist with experience treating the pelvic floor if a musculoskeletal cause of pelvic pain is suspected.

See a doctor if you notice any of the following:

• Severe pain that's not responding to treatment

• Pain accompanied by nausea, vomiting, fever, or chills

• Foul-smelling or bloody urine

• Foul-smelling vaginal discharge

• Heavy or irregular vaginal bleeding

• Difficulty or pain with urination

• Difficulties with bowel movements, including constipation, diarrhea, gas and bloating, or rectal bleeding

Prevention Tips

Stand up and stretch every hour during the day. "Sitting for prolonged periods, especially on hard surfaces, can be challenging for people with pelvic pain," says Dr. Walter.

Practice good posture. A slouched spine can affect how you tilt and move your hips, which are connected to your pelvic floor muscles. A healthy posture reduces the risk of strained joints and muscle imbalances. While there's no such thing as "perfect posture," moving around frequently (see above!) can help.

Pregnant? Snooze on strategically placed pillows. During your second and third trimesters, avoid sleeping on your back, which puts the weight of your growing uterus on your spine and back muscles. Instead, sleep on your side with one or both knees bent, advises the American College of Obstetricians and Gynecologists. Sleeping with a pillow between your knees and another under your belly may provide needed support to your pelvic and back muscles.

“Anything not supported when sitting or sleeping will have more strain on it,” says Dr. Walter. “Muscles are trying to hold you up. So if you can put pillows or towels under anything that’s unsupported, it can allow your muscles to truly relax.” Some pregnant women may need a full-body pillow for optimal support.

Stay hydrated and eat a high-fiber diet. Regular bowel movements promote good pelvic health. “Constipation puts more pressure on the pelvic floor,” says Dr. Walter.

Experiment with different sex positions. If you have tight hip flexor muscles, switching from missionary to side-lying positions, which require less-open legs, may be more comfortable, says Dr. Walter. If you have organ prolapse, positions where you lie down rather than hold yourself upright work better, so gravity isn’t bringing organs down even further.

Tame painful periods. Vitamin B1 and magnesium supplements may help prevent menstrual pain, according to the American College of Obstetrics and Gynecology. Your doctor may prescribe birth control to reduce a painful menstrual cycle. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (Advil) bring relief by targeting prostaglandins.

Get daily physical activity and maintain a healthy weight. Excess weight increases the load on your musculoskeletal frame, including the hip and pelvic floor muscles. Regular exercise is a go-to way to relieve stress (which can worsen tight pelvic floor muscles) while improving overall strength, balance, and flexibility.

Treatments and Exercises for Pelvic Pain at Night

Treatment begins with a diagnosis from your healthcare provider and choosing remedies targeted to your issue. But treating only the physical causes of nighttime pelvic pain may not be enough, especially for complex or chronic pelvic pain. For example, up to 28% of women who get surgery for endometriosis do not experience relief afterward. Ongoing pain may change areas of the brain that process pain perception, amplifying sensations and causing increased sensitivity. This leads to chronic pain that persists even after the physical cause has been treated. Women who have chronic pelvic pain are also more prone to depression and anxiety, which make the pain worse.

Experts, therefore, recommend a comprehensive and holistic treatment approach (which may require a team of care providers) that addresses your physical, emotional, sexual, and quality-of-life needs. The following tips from the 2020 pelvic pain treatment guidelines from the American College of Obstetrics and Gynecologists and Hinge Health physical therapists and medical doctors can provide relief for nighttime pelvic pain:

Pelvic floor physical therapy (PFPT). A physical therapist who specializes in pelvic health can treat pain that has a musculoskeletal cause. The physical therapist will do a thorough evaluation, assessing whether certain positions or activities trigger or relieve pain. “I use identifiers like, ‘It hurts when I do this; it feels better when I do that,’” says Dr. Walter. This helps them determine which pelvic floor muscles are involved and whether connecting areas, such as the hips and back, have imbalances that also contribute to the pain.

PFPT usually involves exercises that strengthen weak (hypotonic) muscles and stretch tight (hypertonic) ones so the pelvic floor functions optimally. The physical therapist may also recommend strengthening supportive muscles in the core, hips, and back.

“Education is also a really big part of PFPT. Understanding where the pain is coming from brings relief in itself and helps people be their own advocate. We also address issues like optimal breathing, toileting positions, and sex positions,” says Dr. Walter.

Cognitive behavioral therapy. This therapy method teaches you to examine your thoughts and behaviors around pain, which changes your pain perception and improves coping skills. CBT also treats depression and anxiety, which often accompany chronic pelvic pain and make it worse.

Sex therapy. Your doctor may recommend sex therapy or couples counseling in addition to pelvic floor physical therapy. For many couples, the return to pain-free sex requires addressing physical, emotional, and relationship issues. Sex therapy has also been shown to improve female orgasmic disorder and genito-pelvic pain.

Complementary or alternative remedies. Yoga and acupuncture have significant evidence that they help relieve other complex chronic pain syndromes, making them good options for pelvic pain that has a musculoskeletal cause.

Antidepressants. A systematic review of 37 trials found that certain antidepressants improved depression, pain, and quality of life for people who have chronic pain syndromes such as fibromyalgia and diabetic neuropathy. Based on this, these drugs are often prescribed for chronic pelvic pain.

Other prescription medications. Pain medications gabapentin and pregabalin may be prescribed based on their success in other complex neuropathic pain syndromes. These may enhance the effects of pelvic floor physical therapy.

Trigger point injections. Your gynecologist can inject an anesthetic or Botox into sensitive areas of the pelvic floor to bring relief, particularly if your pelvic pain involves muscle spasms (known as myofascial chronic pelvic pain). Trigger point injections may be used in tandem with pelvic floor physical therapy.

Surgery. Conditions such as endometriosis and fibroids may require surgery if less invasive treatments aren’t effective.

Here are a few gentle exercises from Hinge Health that are commonly used to relax pelvic floor muscles. All can be done before bed, but try incorporating them into your routine throughout the day. “If you tend to grip your pelvic floor muscles if you can relax more routinely through the day, your nighttime pain is going to be better,” says Dr. Walter.

The information contained in these videos is intended to be used for educational purposes only and does not constitute medical advice or treatment for any specific condition. Hinge Health is not your healthcare provider and is not responsible for any injury sustained or exacerbated by your use of or participation in these exercises. Please consult with your healthcare provider with any questions you may have about your medical condition or treatment.

PT Tip: Try Progressive Muscle Relaxation at Bedtime

“Progressive muscle relaxation involves tightening and then relaxing different muscles one at a time, moving from head to toes,” says Lori Walter, PT, DPT, a physical therapist for Hinge Health. 

“By getting familiar with what muscle tension feels like, you’ll become more aware of when you’re tightening your pelvic floor muscles when you’re stressed. This subconscious gripping of the pelvic floor causes pain, so simply becoming aware of how often you do this brings relief.” Do this routine when you’re lying in bed, just before you fall asleep: 

• As you inhale slowly and deeply, tense your forehead muscles as hard as you can. 

• As you exhale, let the muscles quickly fall and relax. Repeat this with your shoulders, biceps, forearms, abdomen, thigh, buttocks, calf, and feet muscles. 

• Pay attention to how it feels to release the tension from each muscle group. This naturally relaxes you and helps you sleep. 

How Hinge Health Can Help You

If you have joint or muscle pain that makes it hard to move, you can get the relief you’ve been looking for with Hinge Health’s online exercise therapy program.

The best part: You don’t have to leave your home because our program is digital. That means you can easily get the care you need through our app, when and where it works for you.

Through our program, you’ll have access to therapeutic exercises and stretches for your condition. Additionally, you’ll have a personal care team to guide, support, and tailor our program to you.

See if you qualify for Hinge Health and confirm free coverage through your employer or benefit plan here.

This article and its contents are provided for educational and informational purposes only and do not constitute medical advice or professional services specific to you or your medical condition.

References

1. As-Sanie, S., Harris, R., Napadow, V., Kim, J., Neshewat, G., Kairys, A., . . .& Schmidt-Wilcke, T. (2012). Changes in regional gray matter volume in women with chronic pelvic pain—A voxel based morphometry study. Pain, 153(5), 1006–1014. doi:10.1016/j.pain.2012.01.032

2. Ball, E., & Khan, K. S. (2020). Recent advances in understanding and managing chronic pelvic pain in women with special consideration to endometriosis. F1000Research, 9, F1000 Faculty Rev-83. https://doi.org/10.12688/f1000research.20750.1

3. Can I sleep on my back when I’m pregnant? (2021). American College of Obstetricians and Gynecologists. https://www.acog.org/womens-health/experts-and-stories/ask-acog/can-i-sleep-on-my-back-when-im-pregnant 

4. Chronic Pelvic Pain. (2022). American College of Obstetricians and Gynecologists. https://www.acog.org/womens-health/faqs/chronic-pelvic-pain 

5. Chronic Pelvic Pain. (2020). Obstetrics & Gynecology, 135(3), e98–e109. doi:10.1097/aog.0000000000003716 

6. Ghetti, C., Lee, M., Oliphant, S., Okun, M., & Lowder, J. L. (2015). Sleep quality in women seeking care for pelvic organ prolapse. Maturitas, 80(2), 155–161. doi:10.1016/j.maturitas.2014.10.015