The Mental Health & Pelvic Connection

The pelvis and pelvic floor hold serious responsibilities: they connect our upper and lower body,  bear weight from our trunk, help us walk, and support our core and organs. They also support the functions of sex and elimination. 

When pelvic health becomes disturbed, it sends waves through the body. The ripples impact the state of the mind.  

This can seem unlikely on the surface, but I experienced debilitating chronic pelvic pain and its heavy impact on my mental health. When I’m not okay down there, I’m not okay up here. The best way I can describe it is a kind of helplessness and urgency to fix the unfixable. It was extremely difficult to relax and stay relaxed. 

Why such an impact?

Firstly, it is well established that chronic pain and mental health issues go hand in hand. Mental Health America (MHA), in an article called Chronic Pain and Mental Health, states that “chronic pain is often associated with other health conditions such as anxiety and depression, resulting in a low health-related quality of life.”

I see additional cultural, biological, and systemic factors that exacerbate mental health symptoms, particularly after researching the psychology of chronic pelvic pain (CPP).

Cultural Factors

Among cultural factors that impact mental health is stigma around mental illness and the pelvis. Furthermore, pelvic floor dysfunction symptoms can lead to social isolation. Lastly, there is sexism and racism in medicine, which create barriers to receiving appropriate care. All of these cultural factors exacerbate mental health. 

The Stigma of Mental Health 

The first layer is that it’s not okay to say that we’re not okay. There is a strong stigma around mental illness. The Institute for Chronic Pain states that,

“It’s safer to insist that chronic pain and its related difficulties are solely and only physical because in our society it is acceptable if you struggle with a medical condition. It’s not acceptable to acknowledge that you’re psychologically struggling.’’

In my experience, the longer I hid my psychological struggles, the more exacerbated my physical and emotional symptoms became. 

The Stigma of the Pelvis

The second layer is that it is socially and culturally unacceptable to talk about the region above our knees and below our navels. The pelvis and pelvic floor is a “mysterious” and stigmatized part of the body.

As a result, public health takes a heavy hit. Few people have awareness of their pelvic floors, know how to identify when they are having pelvic issues, or even know how to go about getting support for it. 

MHA discusses how taboo can be a barrier. Because talking about menstruation is still a no-no, many symptoms such as “fatigue, heavy bleeding and/or bleeding between cycles, frequent urination, and severe pelvic pain or cramping” go unexpressed to doctors. Additionally, menstruation pain is normalized, leading to further delay in diagnoses.

 I can’t remember the number of times I filled out OB/GYN forms reporting that I had menstrual cramps. Because of that, I never thought to report I was losing 1-2 weeks each month to the anticipation of my period, the deep abyss it sucked me into, and the recovery afterwards. That’s just normal, right?

Symptoms that Lead to Social Withdrawal 

There are symptoms that lead to further isolation. MHA reports that some people with endometriosis or fibroids “may experience debilitating pain that keeps them bed-ridden, face embarrassment and shame if they don’t have menstrual products on hand or decline invitations due to worry about bathroom access.” 

My partner still reminds me of the early days of our relationship when I would not see him for a week or two each month during my debilitating periods. It was only after about six months of dating when I finally let him see: how I would hunch over walking from the cramps, the many period underwear I had to wash, the Tylenol and Ibuprofen bottles that were always within hands reach, and the electric heating pad that basically stayed glued to my abdomen. 

Gender

A lot of pelvic issues are attributed to people with uteruses, so-called “women’s issues.” However, I believe that folx who are assigned male at birth or trans folx can also have an extremely challenging time seeking out care for chronic pelvic pain. Pelvic issues happen regardless of gender or sex. 

MHA reports that “people with uteruses often have their pain delegitimized.” For example, with the historical misdiagnosis of hysteria, we can see patriarchy in motion. Hysteria is defined by Merriam-Webster as “a state in which your emotions are so strong that you behave in an uncontrolled way.” It also comes from the root Greek word of the uterus (hello, again, patriarchy). 

In an article called Endometriosis: ancient disease, ancient treatments, the origins of the condition was explored. There is now substantial evidence that, 

“hysteria, the now discredited ‘mystery’ disorder presumed for centuries to be psychological in origin, was most likely endometriosis in the majority of cases. If so, then this would constitute one of the most colossal misdiagnoses in human history, one that over the centuries subjected women to murder, madhouses, and lives of unremitting physical, social, and psychological pain.”

One study, Psychology of Chronic Pelvic Pain: Prevalence, Neurobiological Vulnerabilities, and Treatment, showed that “many patients with [CPP] may have felt that their pain complaints have been dismissed or minimized in the past and may be hesitant to divulge details of psychological symptoms for fear that these conditions will detract attention from their pain complaints.” 

In his book The Doctor Will See You Now, Dr Tamer Seckin highlights how consistent pain leads to lasting emotional distress. It is now surmised that when Freud diagnosed a woman with hysteria, it had more to do with how she was reacting to her pain, than the actual cause of the pain. Dr Seckin confirms that this type of thinking remains in many cases today. 

It is no wonder that patients with CPP hesitate to report psychological symptoms. 

I vividly remember the anxiety I felt last year when I returned to the medical system and doctor circuit for debilitating pelvic pain. I was so afraid I would seek help and nothing would change. 

Race

In a study called Behind the Referral: How Race Influences the Chronic Pelvic Pain Experience, similar diagnosis rates were found for endometriosis with White and Black patients. The difference lay in the types of treatments offered. White patients have a higher chance of trying birth control and antidepressants to manage pain. They also have a greater chance of seeing more doctors and having a diagnosis for endometriosis via laparascopic surgery. Black patients have a higher chance of reporting use of more opioids and a higher severity of pain. 

All of these cultural issues create scenarios that force a person to isolate themselves from their day-to-day life and communities. Some folx may fall at the intersection of all of these barriers, leading to exacerbated psychological symptoms. 

Biological Factors

In Leslie Howard’s book Pelvic Liberation, she describes the pelvic floor like a feral cat. It is very sensitive. Just as it does for a feral cat to gain trust and safety, it can take a very long time, as well as a very winding journey, to build and maintain the ability to relax and engage the pelvic floor as needed. 

The reason that the pelvic floor is so sensitive is twofold: our nervous system and the fascial deep front line. 

The Nervous System

The Nervous System is made up of the Central Nervous System and Peripheral Nervous

System. The Central Nervous system is composed of neurons in the brain and in the spine. Its functions include thinking, planning, mental activity, feeling, and processing. 

The Enteric Nervous System and Gastrointestinal Innervation: Integrated Local and Central Control

The Peripheral Nervous System is composed of many neurons around the body and controls both automatic functions and voluntary movements. It communicates with our Central Nervous System. 

There is also a lesser known part of the Peripheral Nervous System called the Enteric Nervous System, which communicates with gut bacteria and facilitates digestion. It has connections to the Nervous System via the Vagus nerve. 

The Polyvagal Institute defines the vagus nerve as a very important messenger between the brain and the body. It also regulates the “heart rate, digestion, immune response, and inflammation modulation.” The vagus nerve innervates the organs above the pelvis while pelvic organs are innervated by sacral spinal nerves (S2-S4). Even though the pelvis isn’t directly innervated by the vagus nerve, the sacral spinal nerves can influence the vagal pathways through the Central Nervous System pathways. 

It’s All Connected: the Deep Front Line

One other connection is the fascial Deep Front Line. The Deep Front Line is composed of connective tissue called fascia that connects the tongue, diaphragm, psoas, pubic symphesis, muscles of the pelvic floor, to the feet. 

Fascial Deep Front Line

I want to particularly highlight how two parts of this fascial line connect and affect our nervous system: the psoas muscles and the respiratory diaphragm.

The respiratory diaphragm aids with breathing and sits below the lungs. On the inhale, the respiratory diaphragm moves down and flattens to provide space for the lungs to expand. On the exhale, the diaphragm pushes back up to move air out. 

The respiratory diaphragm both directly and indirectly affects the Central Nervous System. It is innervated by the phrenic nerve, which helps move the diaphragm. The Vagus nerve also plays a part in indirectly affecting the diaphragm. 

Furthermore, as the respiratory diaphragm moves down, the pelvic floor responds and also lowers and widens to make space for organs and the inhale. 

As demonstrated in the diagram, pelvic floor plays a very important part in breathing. Breathing can become impacted by pelvic floor dysfunction. Breath can become less efficient, which affects our nervous system and mood. 

The psoas muscles, also called ilipsoas muscles, help to connect the torso to the legs. It starts at the lumbar spine, weaves through the pelvis, and attaches at the femur. It is innervated by the lumbar spine and the femoral nerve. 

The psoas is very responsive to the nervous system and stress. The Psoas Muscle: A Hidden Bridge Between Body, Stress, and Safety, describes the connection between the psoas and the diaphragm: “When the psoas is tight, it can restrict the diaphragm’s movement, leading to shallow breathing.” Without a full breath, the vagus nerve can’t do its job to regulate the nervous system. 

With the psoas chronically in a contracted state of self-protection, it might be difficult to access “curiosity, openness, or connection.”

For years, it felt like my nervous system was shot. I felt extremely anxious, jumped at noises, cried easily, and simply couldn’t remain in a relaxed state. Furthermore, practices like Yoga became unattainable due to pain flares. 

Illness Representation

A person’s perspective can also affect their sense of well-being. 

A study seeking to understand the psychological factors linking pelvic pain and health-related quality of life in endometriosis showed results that show how illness representation and the coping strategies used “can substantially influence the impact of [chronic pelvic pain] on her quality of life.” Illness representations are a person’s “individual beliefs about their conditions.”

The study revealed that a higher level of threat illness perception is positively correlated with maladaptive coping strategies such as pain catastrophization and pain avoidance. These strategies are connected with “negative emotional responses, poorer functioning, and reduced [health-related quality of life.]”

Somewhere along the line, I created an internal narrative that my pelvic issues are all my fault. It must have been how I ate, sat, smoked, x, y, z …. I adopted maladaptive coping strategies. The longer the laundry list of my conditions became, the more hopeless and catastrophic the situation felt. Nothing was fixable because it’s all chronic. 

Furthermore, I began to avoid a lot of activities out of fear of creating a flare. This led to more pain because I wasn’t moving enough and made my life smaller. I was less engaged and out in the world. 

Implications

In The Complicated Truth About Chronic Pelvic Pain by Dr. Ashley Rawlins, she describes the experience of pain is unique to each person because it is based on emotional, physical, and social influences. However, when there is pain in the pelvis or genitals, there are further implications. 

As mentioned earlier, the pelvic floor muscles are intimately connected with our nervous system, which includes the brain. The pelvic floor responds to trauma and stress by guarding (increasing in tension). For example, it increases in tension due to pelvic pain, which can further perpetuate the cycle of pain. 

The nervous system also adapts to chronic pain and can become less efficient. It can amplify the pain making it feel more severe, create pain in parts of the body that weren’t painful in the first place, make it hard to focus, and even make it difficult to locate the source of pain. 

Our nervous system again plays a part here. In Why Your Mental Health Might Be Causing Physical Symptoms (and What to Do About it) by Dr Ashley Rawlins, the relationship between the mind and pain is “bi-directional, so your mental state can also influence how you feel pain. When you're stressed, anxious, or emotionally overwhelmed, your pain may feel more intense and harder to manage.” The cycle of pain is again perpetuated. 

As discussed in the previous section, there are many nerves that run through the pelvis and communicate for the bladder, bowel, and sexual function. There are only a few routes up to the brain. Because of these overlapping communications for multiple functions, it can lead to overlapping pelvic pain disorders.

Lastly, the pudendal nerve innervates many parts of the pelvic floor. It is a mixed nerve, which means it provides feeling and function. When the pudendal nerve senses pain, it affects both feeling and function. Some areas of the pelvic floor may end up feeling painful and other parts may not fully function. 

The Psychology of Chronic Pelvic Pain study shows that on a neural level, pain and negative emotions are “built from many common pieces.” Chronic pain can already be a complicated matter - add CPP into the mix, and it results in a widespread effect throughout the body and mind. 

I have lived the connection of pelvic pain and emotion getting mixed up with each other. I have felt crazy because of it. It has taken a long time to understand this and to have compassion for myself. 

Systemic Factors

Lack of Education

One other huge issue is that medical education and OB/GYN training doesn’t include chronic pelvic pain or pelvic issues beyond pregnancy and childbirth.This lack of education leads to major delays in diagnoses and care. 

In 2023, a group of sexual health specialists sent a letter to the Council on Resident Education in OB/GYN (CREOG) requesting to include chronic vulvovaginal pain on CREOG’s Educational Objectives. It is 2026, and it has yet to happen. 

It took me about eight years to get a diagnosis for Endometriosis. Since then, I have seen countless doctors for further chronic pelvic issues. Because a lot of medical training doesn’t include pelvic pain, it has forced me to find out-of-network specialists. It wasn’t until I received more specialized care, that I got further answers. I am lucky enough to have family and financial support to see specialists. Not everyone can, and that is a real heartbreak. 

Putting this information to work

If you’re feeling crazy, I want you to know that you’re not. Chronic pelvic pain or any kind of pelvic floor dysfunction affects almost every part of a person’s life. While medical systems have a lot to catch up on to provide appropriate care for pelvic health, there are still things you can do. 

In the study The Psychology of Pelvic Pain, “A comprehensive treatment strategy that addresses both the physical and psychological symptoms appears to result in the best outcomes. This is because pain and emotion are inextricably linked.”

It wasn’t until I started to address my pelvic pain from multiple modes of treatment that I saw progress. One particularly important part was addressing my mental health. If your doctor isn’t offering you mutli-modal treatment, I suggest you bring this up with them or to find a doctor who does. 

Ask for care so you need, so you can get it.