Cramps Years After Hysterectomy: Common Causes, What Helps and When to Worry

ByThe PartialHysterectomy.net Editor

Feeling cramps that remind you of period pain months or even years after a hysterectomy can be confusing and worrying. Without a uterus there is no womb lining to shed and no uterine muscle to contract, so true menstrual cramps cannot happen. But the pelvis still holds your bowel, bladder, pelvic floor muscles and, for many people, one or both ovaries and the cervix. Any of these can produce a crampy, period-like ache. Ongoing pain after a hysterectomy is more common than many people are told: in a Danish nationwide study, about 1 in 3 women reported some pain one year after surgery for a non-cancer reason, and about 1 in 7 had pain more than two days a week.[1] This guide walks through the most common causes, what usually helps, and which symptoms need prompt medical attention.

Can you still get “period cramps” without a uterus?

Not in the strict sense. Period cramps come from the uterus contracting as it sheds its lining. Once the uterus is removed, that mechanism is gone. What people describe as cramps after a hysterectomy is pain from a nearby organ or tissue that happens to feel similar, because the nerves of the pelvic organs share pathways and the brain is not good at telling exactly where deep pelvic pain comes from.

Two details about your own surgery make a big difference to the likely causes, so it helps to check your operation notes or ask your surgeon:

  • Were your ovaries kept or removed? If at least one ovary was kept, it usually goes on working until natural menopause, with the same monthly hormone cycle as before. You no longer bleed, but you can still feel ovulation, cycle-related bloating or breast tenderness.
  • Was your cervix kept? In a subtotal (supracervical) hysterectomy the cervix stays in place, and a small amount of tissue that responds to hormones can remain with it. Learn more in our guide to partial vs total hysterectomy.

In the Danish study, most women who still had pain a year after surgery had already had pelvic pain before the operation; only about 15% of them had developed it new.[1] Pain before surgery, pain as the main reason for the hysterectomy, a previous cesarean and pain problems elsewhere in the body were the main risk factors. Across studies, between 5% and 32% of women report chronic pain after a hysterectomy.[2] In other words, persistent pelvic pain is a recognized problem, not something you are imagining.

Causes linked to your ovaries or cervix

Ovulation and monthly hormone changes (ovaries kept)

If you kept your ovaries, they still release an egg most months. Ovulation pain is a dull ache or sharp twinges on one side of the lower belly that can last from a few minutes to a day or two, and the side can switch from month to month.[3] Without periods, it is harder to notice that the pain comes back roughly every four weeks, so a simple symptom diary is very useful. If your cramps follow a monthly pattern, together with bloating, breast tenderness or mood changes, your ovaries are a likely source. Mild ovulation pain is harmless and usually eases with a warm bath or an over-the-counter painkiller.[3] Our article on menopause after hysterectomy with ovaries intact explains how to tell when the ovaries are winding down.

Ovarian cysts and residual ovary syndrome

Ovaries that stay behind can still form cysts. Most are functional cysts that come and go on their own, but some cause pain. A small group of women develop what doctors call residual ovary syndrome: an ovary that was kept becomes painful, often because it is stuck in scar tissue, and may cause chronic pelvic pain, a pelvic mass or pain during sex.[4] An ultrasound is usually the first test. For more detail, see our guides to ovarian cysts after hysterectomy and ovary pain after hysterectomy.

Ovarian remnant syndrome (ovaries removed)

If both ovaries were removed but your pain still seems to follow a monthly cycle, one rare explanation is ovarian remnant syndrome. A small piece of ovarian tissue is accidentally left behind, often because the ovary was stuck to the pelvic wall by endometriosis or adhesions, and it keeps responding to hormones.[5] In the largest published series, from the Mayo Clinic, 186 women had surgery for confirmed remnant tissue; about half had pelvic pain and over half had a pelvic mass, and more than 9 in 10 reported that their symptoms went away or improved markedly after the remnant was removed.[6] Doctors usually look for it with an ultrasound and, if you are not taking hormone therapy, sometimes with blood hormone levels that show the tissue is still active. The treatment is surgery to remove the tissue completely, partly because cancer has occasionally been found in remnant tissue.[5]

Cervical stump after a subtotal hysterectomy

When the cervix is kept, some women go on having light cyclical bleeding, sometimes with crampy discomfort. A Cochrane review of randomized trials found that ongoing cyclical bleeding was much more likely after subtotal than after total hysterectomy.[7] Light, predictable spotting in this situation is often expected, but any new or unexplained bleeding should be checked by your doctor. Read more in our guide to bleeding after hysterectomy.

Endometriosis that persists or comes back

Endometriosis lives outside the uterus, on the pelvic lining, ovaries, bowel or bladder, so removing the uterus does not always remove it. Pain can continue or return, and it often feels exactly like the period pain you had before surgery. The risk depends a lot on what was done at the operation:

  • In a Cleveland Clinic study, 77% of women who kept their ovaries at hysterectomy for endometriosis had not needed another operation after 7 years, compared with about 92% of those whose ovaries were removed.[8]
  • A larger population study from British Columbia, with a median 10 years of follow-up, found that reoperation was uncommon overall (about 9 in 10 needed no further surgery). It was more frequent when the ovaries were kept (13% vs 5%), but visits to doctors for pelvic pain and opioid use were very similar whether or not the ovaries had been removed.[9]
  • A review of the evidence concluded that the most important factor in whether pain returns is how completely the endometriosis itself was removed, not just whether the uterus was taken out.[10]

Hormone therapy after removal of the ovaries is linked to a return of pelvic pain in a small minority of women with endometriosis, reported at around 3.5% in one review.[10] That is rarely a reason to avoid it, but it is worth telling your doctor if your pain started after beginning hormone therapy. Our article on hysterectomy for endometriosis covers this in more depth.

Scar tissue (adhesions)

Adhesions are bands of scar tissue that can join organs to each other or to the inside of the belly wall. According to the US National Institute of Diabetes and Digestive and Kidney Diseases, they form in more than 9 in 10 people after open abdominal surgery and less often after keyhole surgery, but most people never have symptoms from them.[11] When they do cause problems, chronic belly pain is the most common symptom. Ultrasound and scans usually cannot show adhesions, which is one reason this cause is hard to confirm.[11]

Many people assume surgery to cut the adhesions will fix the pain. For chronic pelvic pain in general, the American College of Obstetricians and Gynecologists (ACOG) advises against routine laparoscopic adhesion removal, because studies show no benefit and a risk of more pain and bowel injury.[12] Adhesions matter most when they block the bowel, which is an emergency (see the warning signs below).

Pelvic floor muscle tension

The pelvic floor is a sling of muscles under the pelvic organs. After surgery, years of pain, or as a habit of bracing against pain, these muscles can become tight and tender, with painful knots called trigger points. This is often called myofascial pelvic pain. It can feel like a deep cramp, an ache in the vagina or rectum, or pain during or after sex, and it can be set off by sitting for long periods. Many people are told to do more Kegel exercises, but when the muscles are already too tight, squeezing harder can make things worse.

ACOG recommends considering pelvic floor physical therapy for myofascial pelvic pain, alone or combined with cognitive behavioral therapy or sex therapy.[12] A specialist physical therapist can check the muscles and teach relaxation, stretching and other techniques. See our guide to pelvic floor physical therapy after hysterectomy. Pelvic muscle and joint problems can also cause pain felt in the lower back, covered in our article on back pain after hysterectomy.

Your bowel and bladder

The bowel and bladder sit right next to where the uterus used to be, and they are among the most common sources of crampy lower belly pain at any age. ACOG lists bowel and bladder conditions among the conditions doctors should look for in anyone with chronic pelvic pain.[12]

  • Irritable bowel syndrome (IBS): cramping belly pain linked to bowel movements, with constipation, diarrhea or both, and bloating.[13]
  • Constipation: hard stools and straining can cause cramps low in the belly. Our guide to constipation after hysterectomy has practical tips.
  • Diverticular disease: more common with age; diverticulitis typically causes constant pain, usually in the lower left side of the belly, sometimes with fever.[14]
  • Bladder pain syndrome (interstitial cystitis): pressure or pain in the bladder area that often worsens as the bladder fills and eases after urinating, with frequent urination.[15] Urinary infections can also cause cramps low in the belly with burning when you pee. See bladder problems after hysterectomy.

A useful clue: if your cramps change with eating, bowel movements or a full bladder, mention it to your doctor. That points the investigation in the right direction.

Nerve pain and a sensitized nervous system

Nerves can be stretched, cut or caught in scar tissue during any pelvic or abdominal operation. Nerve pain is often burning, shooting or electric, and it may be felt near a scar or spread into the groin or inner thigh. After a long time in pain, the nervous system itself can become more sensitive, so that normal signals from the bowel, bladder or muscles are felt as pain. Because of this sensitization, ACOG notes that a single treatment rarely fixes chronic pelvic pain and that care from several specialists working together is often needed.[12]

Less common causes not to miss

  • Ovarian cancer (if you kept your ovaries). Early symptoms are vague: bloating, pelvic or belly pain, feeling full quickly or trouble eating, and needing to urinate urgently or often. The American Cancer Society advises seeing your doctor if these symptoms are new for you and happen more than 12 times a month.[16] They usually have a harmless cause, but they should not be ignored.
  • A hernia at a scar or keyhole site, which may show as a bulge that gets bigger when you cough or stand.
  • Problems at the top of the vagina (vaginal cuff) after a total hysterectomy, such as a rare late opening of the cuff, especially after sex or heavy straining. See our guide to vaginal cuff healing.

How doctors work out the cause

There is rarely a single test for pelvic pain, so the history you give is the most important tool. Before your appointment, it helps to write down:

  • What kind of hysterectomy you had, why, and whether your ovaries and cervix were kept.
  • When the cramps happen and whether there is a monthly pattern (a calendar or app for 2-3 months is ideal).
  • Whether the pain changes with eating, bowel movements, urinating, sex, sitting or exercise.
  • What it feels like (dull, crampy, sharp, burning), where it is and where it spreads.
  • Any hormone therapy or other medicines you take.

ACOG advises that the exam include the belly, the pelvic floor muscles, the lower back and the joints of the pelvis, and that blood tests and imaging be used when the story suggests a specific cause.[12] A pelvic ultrasound is a common first test, especially if your ovaries are still in place. Depending on your symptoms, you may be referred to a gynecologist, a gastroenterologist, a urologist, a pelvic floor physical therapist or a pain clinic.

What can help

Treatment depends on the cause, but these approaches are commonly used:

  • Heat and simple painkillers for short-lived cramps such as ovulation pain, if they are safe for you.[3]
  • Treating the specific cause, for example bowel care for IBS or constipation, treatment of a urinary infection, or surgery to remove an ovarian remnant or a painful ovary when that is the source.[5][6]
  • Pelvic floor physical therapy for tight, tender pelvic muscles.[12]
  • Trigger point injections into painful muscle knots, which ACOG says can help myofascial pain.[12]
  • Medicines for nerve pain, used in some cases once other causes have been addressed, although the evidence for them is limited.[12]
  • Psychological support such as cognitive behavioral therapy, which ACOG recommends as part of care. This is not because the pain is “in your head,” but because long-term pain changes how the nervous system and mood work, and treating that helps.[12]

ACOG does not recommend opioids for chronic pelvic pain.[12] If your pain has lasted six months or more and is not improving, ask about a referral to a clinic that specializes in pelvic pain.

When to call your doctor or get urgent help

Go to the emergency room or call 911 if you have:

  • Sudden, severe belly or pelvic pain.
  • Pain with vomiting and a swollen belly, especially if you cannot pass gas or stool, which can mean a bowel blockage.[11]
  • Pain with a fever, chills or a fast heartbeat.
  • Heavy vaginal bleeding, or a sudden gush of watery fluid or a feeling that something is bulging into the vagina.

Make an appointment with your doctor if:

  • Your cramps are new, getting worse, or keep coming back.
  • You have any vaginal bleeding after a total hysterectomy.
  • You have bloating, feeling full quickly, or urinary urgency on most days and you kept your ovaries.[16]
  • The pain comes with burning when you urinate, blood in your urine or stool, or a lasting change in your bowel habits.
  • The pain is affecting your sleep, work, relationships or sex life.

Frequently asked questions

Is it normal to have cramps years after a hysterectomy?

It is common but it is not something you should simply accept. Cramps after a hysterectomy always have a cause outside the uterus, such as the ovaries, bowel, bladder, pelvic floor muscles or endometriosis, and many of these can be treated.

Can I still have PMS after a hysterectomy?

If you kept at least one ovary, yes. The ovaries continue their monthly hormone cycle until menopause, so bloating, breast tenderness, mood changes and ovulation twinges can continue even though you no longer have periods.

Can endometriosis come back after a hysterectomy?

Yes. Pain can persist or return, especially if some endometriosis was left behind or the ovaries were kept. Studies show further surgery is needed by a minority of women, and the risk is lower when the ovaries are removed and the endometriosis is excised completely.[8][9][10]

Will another operation fix my pain?

Only if there is a clear surgical cause, such as an ovarian remnant, a painful ovary or a hernia. Surgery just to cut scar tissue is not recommended for chronic pelvic pain, because it has not been shown to help and can cause harm.[12]

Sources

  1. Brandsborg B, Nikolajsen L, Hansen CT, Kehlet H, Jensen TS. Risk factors for chronic pain after hysterectomy: a nationwide questionnaire and database study. Anesthesiology. 2007;106(5):1003–1012. pubmed.ncbi.nlm.nih.gov
  2. Brandsborg B, Nikolajsen L, Kehlet H, Jensen TS. Chronic pain after hysterectomy. Acta Anaesthesiologica Scandinavica. 2008;52(3):327–331. pubmed.ncbi.nlm.nih.gov
  3. NHS. Ovulation pain. nhs.uk
  4. Fu SC, Su HY. Residual ovarian syndrome: a case report with classic symptoms, imaging and pathology findings, and treatment. Taiwanese Journal of Obstetrics & Gynecology. 2018;57(5):753–754. pubmed.ncbi.nlm.nih.gov
  5. Kho RM, Abrao MS. Ovarian remnant syndrome: etiology, diagnosis, treatment and impact of endometriosis. Current Opinion in Obstetrics & Gynecology. 2012;24(4):210–214. pubmed.ncbi.nlm.nih.gov
  6. Magtibay PM, Nyholm JL, Hernandez JL, Podratz KC. Ovarian remnant syndrome. American Journal of Obstetrics and Gynecology. 2005;193(6):2062–2066. pubmed.ncbi.nlm.nih.gov
  7. Lethaby A, Mukhopadhyay A, Naik R. Total versus subtotal hysterectomy for benign gynaecological conditions. Cochrane Database of Systematic Reviews. 2012;(4):CD004993. pubmed.ncbi.nlm.nih.gov
  8. Shakiba K, Bena JF, McGill KM, Minger J, Falcone T. Surgical treatment of endometriosis: a 7-year follow-up on the requirement for further surgery. Obstetrics & Gynecology. 2008;111(6):1285–1292. pubmed.ncbi.nlm.nih.gov
  9. Long AJ, Kaur P, Lukey A, et al. Reoperation and pain-related outcomes after hysterectomy for endometriosis by oophorectomy status. American Journal of Obstetrics and Gynecology. 2023;228(1):57.e1–57.e18. pubmed.ncbi.nlm.nih.gov
  10. Rizk B, Fischer AS, Lotfy HA, et al. Recurrence of endometriosis after hysterectomy. Facts, Views & Vision in ObGyn. 2014;6(4):219–227. pubmed.ncbi.nlm.nih.gov
  11. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Abdominal adhesions. niddk.nih.gov
  12. American College of Obstetricians and Gynecologists. Chronic pelvic pain. ACOG Practice Bulletin No. 218. Obstetrics & Gynecology. 2020;135(3):e98–e109. acog.org
  13. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Irritable bowel syndrome (IBS). niddk.nih.gov
  14. NHS. Diverticular disease and diverticulitis. nhs.uk
  15. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Interstitial cystitis (painful bladder syndrome). niddk.nih.gov
  16. American Cancer Society. Signs and symptoms of ovarian cancer. cancer.org

This article is for general information and is not a substitute for medical advice. Always discuss ongoing or new pelvic pain with your gynecologist or doctor, and contact emergency services if you have sudden severe pain, vomiting with a swollen belly, fever or heavy bleeding.

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