PELVIC PAIN SERIES
PART 6: PELVIC PAIN & HYPERMOBILITY
If you have hypermobility and pelvic pain, you might be wondering whether the two are connected - and you’re not imagining the overlap.
Hypermobility can affect people in very different ways. Some people are naturally very flexible and experience little or no difficulty, while others can experience a wide range of symptoms across different parts of the body, including the joints, gut, bladder, bowel and nervous system. It really is a spectrum.
For people with hypermobility spectrum disorder (HSD) or hypermobile Ehlers-Danlos syndrome (hEDS), pelvic pain and pelvic floor dysfunction can also be part of the picture. Research is still developing, and we don’t yet have all the answers, but studies suggest that some pelvic pain conditions are more common in people with HSD/hEDS.
So, what might the connection be? And if hypermobility is contributing to your pelvic pain, what can you actually do about it?
What types of pelvic pain can be associated with hypermobility?
Pelvic pain is not one single condition. There are many different reasons someone might experience pain in or around the pelvis, and understanding what is contributing to your symptoms is an important first step.
Some of the pelvic pain conditions that may occur alongside hypermobility include:
Painful periods (dysmenorrhea)
Dysmenorrhea means painful periods. Some cramping and discomfort can be a normal part of menstruation, but for some people the pain can be debilitating or last beyond their period.
Pain with sex (dyspareunia)
Dyspareunia refers to pain with sexual intercourse. This can include pain at the entrance of the vagina or deeper pain within the pelvis. Conditions associated with pain with penetration can include vulvodynia, vestibulodynia and vaginismus.
Endometriosis and adenomyosis
Endometriosis is a chronic inflammatory condition where endometrium-like tissue is found outside the uterus. Adenomyosis occurs when endometrial tissue grows within the muscle of the uterus. Both can contribute to pelvic pain.
Pelvic congestion syndrome
Pelvic congestion syndrome involves ovarian and pelvic varicose veins associated with chronic pelvic pain. Pain may increase with prolonged standing, sex and menstruation.
Bladder pain syndrome (interstitial cystitis)
Bladder pain syndrome involves chronic pelvic pain, pressure or discomfort perceived to be related to the urinary bladder, alongside urinary symptoms such as urgency or frequency. Other conditions need to be excluded when making this diagnosis.
Pudendal neuralgia
Neuralgia means pain within the distribution of a nerve. The pudendal nerve is located within the pelvis, and pudendal neuralgia can occur due to compression or dysfunction of the nerve. It is often worse with sitting.
Pelvic floor muscle disorders
The pelvic floor muscles can also be a significant contributor to pelvic pain. Pelvic floor tension myalgia involves increased tension and pain in the muscles, while vaginismus involves involuntary spasm that can interfere with vaginal penetration. Anismus refers to spasm of the anal sphincter with defecation or penetration.
There are also conditions involving bowel function, including irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and functional anorectal pain.
There is a lot of overlap between these conditions, which is one reason pelvic pain can sometimes be difficult to untangle. Seeing a gynaecologist can help investigate and rule in or out some conditions with appropriate testing and scans, while a pelvic health physiotherapist can assess how the muscles, joints and other factors may be contributing to your symptoms.
Is pelvic pain more common with hypermobility?
Research into the relationship between hypermobility and pelvic pain is still developing, but the studies we do have suggest there may be a higher prevalence of pelvic floor dysfunction and genitopelvic pain in people with HSD/hEDS.
For example, one survey found painful intercourse in 30–61% of people with EDS/HSD, compared with 7.5–20% in the general population. Overactive pelvic floor muscle dysfunction was reported in 90.5% of the EDS/HSD group in another small survey, compared with an estimated 30–50% in the general population.
Other pelvic conditions, including pudendal neuralgia and bladder pain syndrome, have also been reported at higher rates in people with EDS/HSD.
However, it is important to put these numbers into context. The studies looking specifically at EDS/HSD are often based on relatively small sample sizes, so we need more research before we can say exactly how common these conditions are or why the relationship exists. What the research does give us is a reason to consider the bigger picture when someone with hypermobility is experiencing pelvic pain.
Why might hypermobility contribute to pelvic pain?
So, if someone is hypermobile, why might that make pelvic pain or pelvic floor dysfunction more likely?
One piece of the puzzle is the role of the pelvic floor muscles. The pelvic floor is a deep group of stabilising muscles that helps support the pelvis. When the ligaments around the joints are more lax, these muscles may have to work differently to provide stability. For some people, this can contribute to the pelvic floor becoming overactive or remaining tense. Overactive pelvic floor muscles have been found to contribute to conditions such as vulvodynia, and pelvic floor overactivity is commonly associated with genitopelvic pain disorders.
There is also the nervous system to consider. Chronic pain is common in HSD/hEDS, and ongoing pain can contribute to a process called central sensitisation. This is where the nervous system becomes more sensitive and can start responding to sensations as though they are a greater threat than they actually are. This does not mean that the pain is “in your head”. The pain is real. It means that the nervous system can become more protective over time, particularly when it has been dealing with ongoing pain or other stressors.
There may also be connections between hypermobility, mast cell activation and some genitopelvic pain disorders. The relationship is still being investigated, but this is an emerging area of research and may help explain why some people experience multiple overlapping symptoms.
Ultimately, there probably isn’t one single reason why someone with hypermobility develops pelvic pain. For many people, it is likely to be a combination of factors involving the muscles, joints, nerves, other body systems and the individual condition causing their pain.
How can pelvic floor physiotherapy help with hypermobility and pelvic pain?
Pelvic health physiotherapy can be an important part of managing pelvic pain alongside your GP, gynaecologist and other healthcare professionals. Your physio can look beyond the pelvic floor itself, including the lumbar spine, hips, bowel function and how the pelvic floor muscles are working.
Depending on your symptoms, treatment may include pelvic floor assessment and biofeedback, exercises or stretches to help relax the muscles, dilator therapy, bladder diaries and strategies to manage pain and reduce sensitivity.
The focus is on understanding what is contributing to your symptoms and developing a plan that works for your body.
What can I do to manage pelvic pain and hypermobility long term?
Managing pelvic pain with hypermobility often requires an individual approach, particularly when several symptoms or conditions overlap.
It can be helpful to have a plan for managing flare-ups, including knowing which pain relief strategies, exercises, stretches or lifestyle changes help you. This can be particularly useful around predictable triggers such as menstruation. Having this plan written down can make it easier to follow when you’re managing multiple health issues or simply have a lot going on.
Ultimately, it often takes a team of professionals to address the different pieces of the puzzle. With the right support and an individualised approach, pelvic pain can become more manageable.
You don’t have to untangle it all at once
Having hypermobility doesn’t automatically mean you will develop pelvic pain, and pelvic pain doesn’t necessarily mean hypermobility is the cause. But if you have HSD or hEDS and are experiencing pelvic pain, pain with sex, bladder or bowel symptoms, painful periods or pelvic floor tension, it can be worth looking at the bigger picture.
Some helpful resources we'd love to shoutout!
Blog Post: Understanding Mast Cell Mediated Genitopelvic Pain
Linked here: https://pelvicpainrehab.com/blog/understanding-mast-cell-mediated-genitopelvic-pain/
Podcast: The Neurodivergent Women: EDS, POTS and MCAS with Dr Megan Thomas and Bianca Comfort
Link to listen on Spotify here: https://open.spotify.com/episode/3AafjMy5OYmn8dPpLzw8nz?si=358qqeyWSZqZswkWPX6q5Q
Other Blogs in the Pelvic Pain Series
Deep dive into education written by our pelvic physiotherapist, Claire, all about the pelvic pain – including symptoms, treatment & understanding the range of associated factors and conditions.
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