Impact of stress and cortisol levels on pelvic pain and pelvic stress reflex response

Introduction

Oftentimes, people who experience pelvic pain do not realize stress is highly correlated to their symptoms.[1] This is a result of the pelvic stress reflex response, in which the pelvic floor muscles actively contract in response to physical, or mental stress.[1]

What happens when the body is under stress?

Muscular component - Pelvic Stress Reflex Response

The second layer of the pelvic floor includes the

  • Urethral sphincter (sphincter urethrae)
  • Compressor urethrae
  • Sphincter urethral vaginalis

These muscular structures help control the flow of urine through the urethra.[2] There is a passive and active component to the contraction of the sphincters.[2] The passive component involves transmitting intra-abdominal pressure to the urethra which mainly regulates the pressure at the neck of the bladder. The active component mainly controls the pressure distal to the bladder neck, which is important for urethral closure during stress conditions. The active component involves the reflexive contraction of external sphincter muscles. Thus, daily life stressors will increase the contraction via the pelvic stress reflex response which can lead to tightness and weakness of the pelvic floor muscles.[2]

Hormonal component – HPA Axis and Cortisol

Response of HPA axis to stressors

HPA Axis

When the body identifies a stressor, it responds via the hypothalamic-pituitary-adrenal (HPA) axis.[3] This is a feedback system that maintains various body systems such as digestion, immune function, mood, energy and sex.[3] Upon exposure to stress, the body perceives it using the hypothalamus which then releases corticotropin-releasing hormone (CRH).[3] CRH then triggers the pituitary gland to release adrenocorticotrophic hormone (ACTH) and finally signals the adrenal gland to release epinephrine (or adrenaline), norepinephrine and cortisol.[3]

Epinephrine and norepinephrine are released immediately after the body senses a stressor and these hormones break down just as fast.[3] In contrast, cortisol is released about 10 minutes after the stressor is detected and can circulate in the body for about one to two hours after.[3]

Role of cortisol and immune function

I) Cortisol
  • Normal levels (short-term effects): Cortisol is understood as the stress hormone of the body. Levels of cortisol vary throughout the day, increasing in the morning to help wake up the body and decreasing as the day passes.[1] Cortisol levels follow the body’s circadian rhythm which helps immune functions such as cell repair.[1] Symptoms of high cortisol levels can include anxiety, agitation, poor sleep, ‘wired but tired’ feeling and a fast pulse.[1]
  • Abnormal levels (long-term effects): When the body is under stressful conditions, constant activation of the HPA axis may occur.[1] The adrenal glands release high levels of cortisol which accumulate in the body.[1] Constant stressors demands a constant release of cortisol, thus depleting the body of nutrients needed to produce the hormone. Exhaustion occurs when the body is not capable of producing more cortisol which compromises immune function as well as increasing symptoms of pain, slower wound healing, decreased ability to handle smaller stressors, emotional issues and poor sleep.[1]
II) Impact of low cortisol levels on pelvic pain

In numerous conditions related to pelvic pain, cortisol levels are lower than usual because the body has reached the exhaustion phase.[1] Long-term stressors have demanded the body to produce increased levels of cortisol for a prolonged time and now the body is depleted of nutrients to produce cortisol.[1]

  • Endometriosis: The amount of cortisol released to help wake up in the morning was lower among women with endometriosis compared to control groups.[4] In fact, there were overall lower levels of cortisol in the endometriosis group. As well, women who reported intense pain with sex and women experiencing infertility had lower cortisol levels than control groups.[4]
  • Interstitial Cystitis (IC): Women with IC which lower amounts of cortisol in the morning also had a higher rate of nocturnal urinary frequency (nocturia).[5] In addition, they were likely to have greater pain in the lower abdomen as the bladder became full with fluid as well as an increase in nocturia and frequency of urination throughout the day.[5]
  • Vulvovaginal Candidiasis (vaginal yeast infection): Women who experienced repeated cases of yeast infections had a lower increase in cortisol in the morning and throughout the day compared to controls.[3]
  • Vulvodynia: Women with vulvodynia had lower levels of cortisol in the morning and also had more symptoms of stress compared to control groups.[3]

Stress can lead to nonrelaxing pelvic floor dysfunction (NPFD)

It is more commonly understood that various pelvic floor disorders are due to over-relaxed muscles (e.g. pelvic organ prolapse or urinary stress incontinence). This increases the likelihood that these disorders can be identified and individuals can begin appropriate treatment.[6] In contrast, NPFD is not as easily identified because individuals can present with a wide range of nonspecific symptoms including pain, sexual dysfunction as well as problems with defecation or urination. This presentation may indicate that the pelvic floor muscles and urinary and anal sphincters require relaxation and co-ordination rather than tightening. These symptoms are likely to have negative impact on the quality of life thus clinicians can use psycho-social questionnaires to assess the variety of stressors that may be impacting the patient’s pelvic health.[6] Interventions can focus on managing stressors, such as patient education to help adopt healthy habits to control stress levels, or referring to individual to seeking further counselling if indicated by the questionnaires.[6]

Treatment Options

Physiotherapy

Increasing cortisol levels

It is evident that individuals with pelvic pain have factors that disrupt the usual cortisol cycle.[4] The combined effect of physiotherapy and psychotherapy treatments in women with chronic pelvic pain can help to increase cortisol levels after treatment and attain similar levels of cortisol as women without symptoms. Pelvic floor physiotherapists (PTs) can perform external and internal exams of the abdomen and pelvic area to assess if the muscles are weak or tight and administer appropriate treatment. If the muscles are weak, PTs can teach exercises to strengthen the pelvic floor. If the muscles are tight, PTs can perform internal releases of the pelvic floor muscles to help relieve the tension in the muscle and prescribe exercises to promote normal motor patterns in the muscles. Please see this Physiopedia article for more information to how physiotherapy can be the solution to addressing pelvic pain.

Relaxation, being mindful of pelvic floor

The PT can use various strategies to increase awareness of the pelvic floor muscles in order to help the patient build self-management skills to cope with stress and contributing factors to NPFD.[6] The key is to introduce strategies early as possible, efficiently and effectively, by identifying the wide range of factors that can lead to NPFD. Strategies include patient education about factors that influence the structure and function of the pelvic floor and conducting tests to confirm a diagnosis. The PT and patient can collaboratively develop appropriate goals to address the cause of pelvic pain and increase their quality of life.[6]

Naturopathy

Naturopathic doctors can address NPFD by examining the ‘whole picture’ and trying to identify the cause of the problem.[7] If long-term stressors are over-producing cortisol leading to the depletion of nutrients, then the body lacks specific nutrients for healthy functioning adrenal glands. The naturopath may recommend taking specific vitamins or supplements which can increase the production of cortisol.[7]

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Stephens MA, Wand G. Stress and the HPA axis: Role of glucocorticoids in alcohol dependence. Alcohol research: current reviews. 2012.
  2. 2.0 2.1 2.2 Thüroff JW, Casper F, Heidler H. Pelvic floor stress response: reflex contraction with pressure transmission to the urethra. Investigative Urology 2 1987 (pp. 124-130). Springer, Berlin, Heidelberg. Available from: https://link.springer.com/chapter/10.1007/978-3-642-72735-1_19
  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Petrelluzzi K, Garcia M, Petta C, Grassi-Kassisse D, Spadari-Bratfisch R. Salivary cortisol concentrations, stress and quality of life in women with endometriosis and chronic pelvic pain. Stress. 2008;11(5):390-397. doi:10.1080/10253890701840610.
  4. 4.0 4.1 4.2 Friggi Sebe Petrelluzzi K, Garcia M, Petta C et al. Physical therapy and psychological intervention normalize cortisol levels and improve vitality in women with endometriosis. Journal of Psychosomatic Obstetrics & Gynecology. 2012;33(4):191-198. doi:10.3109/0167482x.2012.729625.
  5. 5.0 5.1 Schrepf A, O’Donnell M, Luo Y, Bradley C, Kreder K, Lutgendorf S. Inflammation and Symptom Change in Interstitial Cystitis or Bladder Pain Syndrome: A Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network Study. Urology. 2016;90:56-61. doi:10.1016/j.urology.2015.12.040.
  6. 6.0 6.1 6.2 6.3 6.4 Faubion SS, Shuster LT, Bharucha AE. Recognition and management of nonrelaxing pelvic floor dysfunction. InMayo Clinic Proceedings 2012 Feb 1 (Vol. 87, No. 2, pp. 187-193). Elsevier. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3498251/pdf/main.pdf
  7. 7.0 7.1 Priolo, A. Stress, Cortisol and Pelvic Pain. 2018. Retrieved from https://www.proactiveph.com/blog/2018/05/16/stress-cortisol-and-pelvic-pain.html