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 (Stephens and Wand, 2012). This is a result of the pelvic stress reflex response, where the pelvic floor muscles will actively contract in response to physical, or mental stress (Stephens and Wand, 2012).
What happens when the body is under stress?
Muscular component - Pelvic Stress Reflex Response
The pelvic floor will contract and relax to control the urethral sphincter, which are the muscles that allow the passage of urine in the urinary bladder, through the urethra (Thüroff, Casper, and Heidler, 1987).
There is a passive and active component to the contraction of the urethral sphincter (Thüroff, Casper, and Heidler, 1987). The passive component involves transmitting intra-abdominal pressure to the urethra, which mainly regulates the pressure at the bladder neck. 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 active pelvic stress reflex response which can lead to tightness and weakness of the pelvic floor muscles (Thüroff, Casper, and Heidler, 1987).
Hormonal component – HPA Axis and Cortisol
I) HPA Axis When the body identifies a stressor, it responds via the hypothalamic-pituitary-adrenal (HPA) axis (Petrelluzzi et al., 2008). This is a feedback system that maintains various body systems such as digestion, immunue function, mood, energy, and sex (Petrelluzzi et al., 2008). Upon exposure to stress, the body perceives it using the hypothalamus, which releases corticotropin-releasing hormone (CRH) (Petrelluzzi et al., 2008). 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 (Petrelluzzi et al., 2008).
Epinephrine and norepinephrine are released immediately after the body senses a stressor, and these hormones break down just as fast (Petrelluzzi et al., 2008). In contrast, cortisol is released about 10 minutes after and can circulate in the body for about one to two hours after identifying the first stressor (Petrelluzzi et al., 2008).
Role of cortisol and immune function
I) Cortisol a. Normal levels (short term effects) – Cortisol is understood as the stress hormone of the body. Levels of cortisol varies throughout the day, where it is increased in the morning to help wake up the body, and decreases as the day passes (Stephens and Wand, 2012). Cortisol levels follow the body’s circadian rhythm which helps immune functions such as cell repair (Stephens and Wand, 2012). Symptoms of high cortisol levels can include anxiety, agitation, poor sleep, ‘wired but tired’ feeling, and a high pulse (Stephens and Wand, 2012).
b. Abnormal levels leading to exhaustion (long term effects) – When the body is under stressful conditions, constant activation of the HPA axis may occur (Stephens and Wand, 2012). The adrenal glands releases high levels of cortisol, which accumulate in the body (Stephens and Wand, 2012). Constant stressors demands a constant release of cortisol, which can deplete the body of nutrients needed to produce cortisol. Exhaustion occurs when the body is not capable of producing more cortisol, which compromises immune function and increases symptoms of pain, slower wound healing, decreased ability to handle smaller stressors, emotional issues, and poor sleep (Stephens and Wand, 2012).
II) Impact of low cortisol levels on pelvic pain In numerous causes for pelvic pain, cortisol levels are lower than usual because the body has reached the ‘exhaustion’ phase (Stephens and Wand, 2012). 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 (Stephens and Wand, 2012). a. Endometriosis: The amount of cortisol released to help wake up in the morning was lower among women with endometriosis compared to control groups (Friggi, Garcia, and Petta, 2012). 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 (Friggi, Garcia, and Petta, 2012).
b. Interstitial Cystitis (IC):
Women with IC who had lower amounts of cortisol in the morning, also had a higher rate of nocturnal urinary frequency (nocturia) (Schrepf et al., 2016). In addition, they were likely to have greater pain in the lower abdomen as the bladder became full with fluid, and an increase in nocturia and frequency of urination throughout the day (Schrepf et al., 2016).
c. 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 (Petrelluzzi et al., 2008).
d. Vulvodynia:
Women with vulvodynia had lower levels of cortisol in the morning and also had more symptoms of stress compared to control groups (Petrelluzzi et al., 2008).
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 (pelvic organ prolapse or urinary incontinence). This increases the likelihood that these disorders can be identified, and individuals can begin appropriate treatment (Faubion et al., 2012). In contrast, NPFD is not commonly identified because individuals can present with a wide range of nonspecific symptoms. For example, symptoms include pain, problems with defecation, urination, and sexual function, which indicate the pelvic floor muscles and urinary and anal sphincters require relaxation, and co-ordination instead of tightening. These symptoms may 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 (Faubion et al., 2012). 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 (Faubion et al., 2012).
Treatment Options
i) Physiotherapy
a) Increasing cortisol levels a. It is evident that individuals with pelvic pain have factors that disrupt the usual cortisol cycle (Friggi et al., 2012). 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 the appropriate treatments. 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 https://www.physio-pedia.com/Pelvic_Floor_Dysfunction_-_A_patient_guide for more information to how physiotherapy can be the solution to addressing pelvic pain.
b) Relaxation, being mindful of pelvic floor
The PT can use various strategies to increase awareness of the pelvic floor muscles, to help the patient build self-management skills to cope with stress and contributing factors to NPFD (Faubion et al., 2012). The key is to introduce strategies early as possible, efficiently, and effectively through 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 (Faubion et al., 2012). ii) Naturopathy Naturopathic doctors can address NPFD by examining the ‘whole picture’ and trying to identify the cause of the problem (Priolo, 2018). 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 (Priolo, 2018).
