Pelvic pain is a common symptom in women.
The pelvic area is the lower area of the abdomen. The pelvic area contains the intestines, lower ureters, and bladder. The female pelvic area also contains the ovaries, fallopian tubes, uterus, and cervix. Pelvic pain may be caused by a problem with any of these organs or by a musculoskeletal, neurologic, or mental health condition.
Pelvic pain may start suddenly or gradually. The pain may gradually increase in intensity, sometimes occurring in waves. It may be constant or come and go. It may be sharp or dull or crampy (like menstrual cramps), or some combination. Pelvic pain is considered chronic if it continues for more than 6 months.
The pelvic area may feel tender if touched. Depending on the cause, women may have vaginal bleeding or discharge. The pain may also be accompanied by fever, nausea, vomiting, and/or light-headedness.
Internal Female Reproductive Anatomy
Causes of Pelvic Pain
Pelvic pain is often related to the menstrual cycle or common gynecologic issues. Most causes of pelvic pain are noncancerous, but cancerous causes can occur.
Disorders that can cause pelvic pain include
Gynecologic disorders—those that affect the female reproductive organs (vagina, cervix, uterus, fallopian tubes, and ovaries)
Disorders that affect other organs in the pelvis, such as the bladder, lower part of the ureters, urethra, intestines, rectum, appendix, or pelvic floor (the muscles, ligaments, and tissues that support pelvic organs)
Disorders that affect structures near but outside the pelvis, such as the muscles of the abdominal wall and pelvis, kidneys, or upper part of the ureters
Neurologic and mental health conditions
Sometimes, it is difficult for doctors to identify what is causing pelvic pain.
Gynecologic disorders
Some gynecologic disorders cause pelvic pain that is cyclic (for example, pain recurs during the same phase of each menstrual cycle). In other gynecologic disorders, pain comes and goes in a pattern that is not related to the menstrual cycle or is constant.
Overall, the most common gynecologic causes of pelvic pain include
Menstrual cramps (dysmenorrhea)
Endometriosis or uterine adenomyosis (tissue that normally lines the uterus is found elsewhere in the pelvis or uterine muscle)
Ovarian cysts
Scar tissue inside the pelvic or abdomen (usually due to prior infection or surgery
A swollen fallopian tube (called a hydrosalpinx)
Fibroids in the uterus are noncancerous masses composed of muscle. Most uterine fibroids do not cause pelvic pain, but they can cause pain if they put pressure on other organs (such as the bladder or intestines) or cause excessive menstrual bleeding with cramping.
Many other gynecologic disorders can cause pelvic pain (see table Some Causes of Pelvic Pain in Women).
Nongynecologic disorders
Causes of pelvic pain that are not related to gynecologic disorders include
Digestive tract disorders: Gastroenteritis, constipation, celiac disease, diverticulitis, irritable bowel syndrome, inflammatory bowel disease, abdominal or groin hernia, and colorectal cancer
Urinary disorders: Urinary tract infections, kidney stones that have passed into the lower urinary tract, inflammation of the bladder without infection (such as interstitial cystitis), and bladder cancer
Musculoskeletal disorders: Fibromyalgia or chronic myofascial pain (pain that is caused by tension and tenderness in areas of muscle called trigger points)
Neurologic disorders: Neuropathic pain (caused by damage to or dysfunction of the nerves, spinal cord, or brain)
Vascular disorders (related to arteries, veins, and vessels): Aortic aneurysm and pelvic congestion syndrome
Related to mental health conditions: Depressive disorders, anxiety, somatic symptom disorder, and substance use disorders
Psychological factors, especially stress and depression, may contribute to any kind of pain, including pelvic pain, but, by themselves, rarely cause pelvic pain. Women or girls that have had sexual trauma may develop chronic pelvic pain.
Evaluation of Pelvic Pain
Most causes of pelvic pain are not emergencies, but some require urgent medical attention. If a woman has severe pain in the lower abdomen or pelvis that is new and starts abruptly or increases in intensity over time until it becomes severe, medical attention should be sought as soon as possible. For some medical conditions, emergency surgery is required. Disorders that usually require emergency surgery include
Appendicitis or malrotation of the intestines (volvulus)
A ruptured ectopic pregnancy (an abnormally located pregnancy—not in its usual place in the uterus)
Twisting of an ovary (adnexal torsion)
A ruptured ovarian cyst causing excessive bleeding inside the abdomen or abscess in the pelvis
A ruptured abscess (contained area of infection) in the abdomen or pelvis
A tear in the intestine or obstruction of abdominal or pelvic hernia
Warning signs
In women with pelvic pain, certain symptoms are cause for concern:
Light-headedness or sudden loss of consciousness (fainting)
Dangerously low blood pressure with a racing heart (this may be a sign of shock)
Sudden, severe pain, especially when accompanied by nausea, vomiting, excessive sweating, or agitation
Fever or chills
Vaginal bleeding after menopause
When to see a doctor
Women with most warning signs should see a doctor immediately.
Women should contact their doctor and may need to be seen the same day or within a few days if they have
Vaginal bleeding after menopause
Pain that is constant or steadily worsening
Women who have pain that is not severe or accompanied by warning signs should schedule a visit when practical, but a delay of several days is usually not harmful.
Many women have mild menstrual cramps. Menstrual cramps do not require evaluation unless they are severely painful.
What the doctor does
Doctors ask the woman questions about her symptoms and medical history. Doctors then do a physical examination. The information from the history and physical examination often suggests a cause and additional tests that may be needed (see table Some Causes of Pelvic Pain in Women).
Doctors ask about the pain:
When did it start
How severe it is
Whether it is sharp, dull, or crampy
Whether it began suddenly or gradually
Whether it is constant or comes and goes
If it occurs in relation to the menstrual cycle, eating, sleeping, sexual intercourse, physical activity, urination, or bowel movements
Whether any other factors worsen or ease the pain
Women are asked about other symptoms, such as vaginal bleeding, a discharge, and light-headedness.
Women are asked to describe past pregnancies and menstrual periods. Doctors also ask about disorders that can cause pelvic pain and any prior abdominal or pelvic surgery.
Doctors may ask about stress, depression, and other psychological factors, including domestic violence, to determine whether these factors may be contributing to the pain, especially if the pain is chronic.
Certain groups of symptoms that accompany pelvic pain suggest a type of medical condition. For example:
Fever and chills and/or a vaginal discharge suggest an infection, such as pelvic inflammatory disease.
Pain near the umbilicus (belly button) or upper abdomen, a change in bowel movements, or rectal bleeding suggests a digestive tract disorder.
Vaginal bleeding during pregnancy suggests an ectopic pregnancy or a possible miscarriage.
The physical examination starts with checking vital signs, such as temperature, blood pressure, and pulse. Then doctors focus on the abdomen and pelvis. Doctors gently feel the abdomen. During an examination, the abdomen or other areas may feel tender if touched. Doctors then do a pelvic examination to help determine which organs are affected and whether an infection is present. Often, doctors also check the rectum for abnormalities.
Some Causes of Pelvic Pain in Women
Cause | Common Features† | Diagnostic Approach‡ |
|---|---|---|
Cyclic pain, related to the menstrual cycle | ||
Moderate to severe menstrual cramps Pelvic pain may also be unrelated to the menstrual cycle Sometimes pain in the pelvis during sexual intercourse and/or during bowel movements Sometimes infertility | Transvaginal ultrasound MRI if ultrasound results are inconclusive Laparoscopy (insertion of a thin viewing tube into the abdomen) to check for abnormal tissue and to obtain a sample for biopsy; infrequently, laparotomy (a larger incision into the abdomen enabling doctors to directly view organs) Infrequently, sigmoidoscopy (insertion of a flexible viewing tube to examine the lower portion of the large intestine, the rectum, and the anus) or cystoscopy (insertion of a flexible viewing tube to examine the bladder) | |
Painful menstrual periods (dysmenorrhea) | Crampy pain that
Sometimes headache, nausea, constipation, diarrhea, or an urge to urinate often (urinary frequency) | Transvaginal ultrasound to exclude other causes |
Painful menstrual periods or pelvic pain not related to menstrual periods; pain can be mild to severe | Transvaginal ultrasound MRI if ultrasound is inconclusive | |
Mittelschmerz (pain in the middle of the menstrual cycle) | Moderate to severe, sharp pain that
Sometimes light spotty bleeding | Transvaginal ultrasound to exclude other causes |
Related to pregnancy | ||
An ectopic pregnancy (an abnormally located pregnancy—not in its usual place in the uterus) | Pelvic or abdominal pain and/or vaginal bleeding during early pregnancy If the ectopic pregnancy ruptures, severe pain that
Sometimes light-headedness, fainting, a racing heart, or dangerously low blood pressure (shock) due to severe internal bleeding | A pregnancy test Transvaginal ultrasound Sometimes laparoscopy or laparotomy |
Constant or intermittent pain, related to the reproductive system but not the menstrual cycle or pregnancy | ||
An ovarian cyst or a noncancerous ovarian tumor | Dull or sharp persistent pelvic or abdominal pain, often on one side | Transvaginal ultrasound Occasionally a CT or MRI of the pelvis and abdomen |
A ruptured ovarian cyst | Pain that
Sometimes happens after sexual intercourse Sometimes light-headedness, fainting, slight vaginal bleeding | Transvaginal ultrasound CBC (if significant bleeding is suspected) |
Adnexal torsion (twisting) of an ovary | Severe pain that
Occasionally pain that comes and goes (as the ovary twists and untwists) Usually nausea, vomiting and sometimes light-headedness or fainting | Transvaginal ultrasound Laparoscopy |
Dull or sharp persistent pelvic or abdominal pain, often on one side Digestive or urinary symptoms that are new and persistent (bloating, difficulty eating or feeling full quickly, feeling an urgent need to urinate, or needing to urinate frequently) Sometimes unexplained weight loss | Transvaginal ultrasound Sometimes blood tests to measure substances secreted by tumors Often a CT or MRI of the pelvis and abdomen | |
Gradual, aching pelvic pain that may be felt on one or both sides Sometimes pain during sexual intercourse Sometimes fever Usually a vaginal discharge that sometimes has a foul odor and, as infection worsens, can become yellow-green | Tests to detect sexually transmitted infections using a sample of secretions taken from the cervix, CBC, and urine test Transvaginal ultrasound | |
Adhesions (bands of scar tissue between normally unconnected structures in the uterus or pelvis) | Pelvic pain that
Pain during sexual intercourse No vaginal bleeding or discharge Rarely nausea and vomiting (suggesting a blockage of the intestine) | Laparoscopy or sometimes laparotomy |
Myofascial pelvic pain | Chronic or recurring pain in one or more genital tract (vulva, vagina) or other pelvic structures (bladder, rectum, buttocks, hips, abdomen) | A doctor's evaluation |
Not related to the reproductive system | ||
Pain that usually starts around the umbilicus and then settles in the lower right part of the abdomen Loss of appetite and usually nausea and vomiting Often fever | CT of the abdomen; ultrasound or MRI may be done if CT is not available | |
Sometimes pain just above the pubic bone An urgent need to urinate, more frequent urination, and/or burning during urination | A urine test | |
Pain or tenderness in the lower left part of the abdomen, usually on the left side Fever | CT of the abdomen | |
Inflammatory bowel disease including
| Crampy abdominal pain Diarrhea, which in ulcerative colitis is often bloody Loss of appetite and weight | CT of the small and large intestine (CT enterography) to check for Crohn disease Endoscopy (usually colonoscopy or sigmoidoscopy) Sometimes x-rays of the upper digestive tract after barium is given by mouth (barium swallow) or of the lower digestive tract after insertion of barium into the rectum (barium enema) |
Excruciating intermittent pain in the lower abdomen, side, or lower back, depending on the stone's location Nausea and vomiting Blood in the urine | Urine tests (urinalysis) Imaging tests, such as CT, ultrasound, or x-ray of the abdomen | |
* Some causes of pain in the lower abdomen are included. | ||
† Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present. | ||
‡ In women of childbearing age, a pregnancy test is done to check whether there is a pregnancy-related cause and, if a woman is pregnant, to ensure that tests and treatments are safe during pregnancy. | ||
CBC = complete blood count; CT = computed tomography; MRI = magnetic resonance imaging. | ||
Testing
A pregnancy test is done in all girls and women of childbearing age who have pelvic pain. A urine pregnancy test is usually done first. If a very early pregnancy is possible and the urine test is negative, a blood test for pregnancy is done. The blood test is more accurate than the urine test when a pregnancy is less than 5 weeks.
Other tests depend on which disorders are suspected. Tests may include
Complete blood count (CBC)
Urine tests or testing of samples from the vagina or cervix to check for infections that can cause pelvic pain
Pelvic ultrasound or computed tomography (CT), or magnetic resonance imaging (MRI) of the abdomen and pelvis to check for masses
If other tests do not identify the cause of severe or persistent pain and a serious cause (such as a ruptured ectopic pregnancy) is suspected, sometimes surgery (laparoscopy or laparotomy)
Urinalysis is a simple, fast urine test that is a first step to check for many common causes of pelvic disorders, such as a bladder infection or most kidney stones. A urine culture is done if a urinary tract infection is suspected.
For ultrasound, doctors use a handheld ultrasound device that is placed on the abdomen or inside the vagina (transvaginal ultrasound). If the ultrasound results are unclear, other tests, such CT or MRI, are done to look for a mass or other abnormality.
For laparoscopy, doctors make a small incision just below the navel and insert a viewing tube (laparoscope) to directly look for an ectopic pregnancy or other causes of pelvic pain. If laparoscopy cannot be done or doctors cannot diagnose or treat a medical condition with laparoscopy, laparotomy (a large incision into the abdomen enabling doctors to directly view organs) may be done.
Treatment of Pelvic Pain
If the cause of the pelvic pain is identified, it is treated directly, if possible.
Pain related to the menstrual cycle (such as cramps or endometriosis) may be treated with birth control pills or other hormonal contraceptives.
If the pain involves muscles, rest, heat, or physical therapy may help.
In addition, pelvic floor physical therapy, sex therapy, or cognitive-behavioral therapy is recommended in women with myofascial pelvic pain or pain associated with mental health conditions.
Rarely, when women have severe pain that persists despite treatment with medications, surgery, such as laparoscopy to treat endometriosis or an ovarian cyst or hysterectomy (surgery to remove the uterus) or other procedures, can be done.
Essentials for Older Women: Pelvic Pain
In older women, common causes of pelvic pain may be different because some disorders that cause pelvic pain or discomfort become more common as women age, particularly after menopause.
Common disorders in older women include
Bladder problems, including infections (urinary tract infection)
Cancers of the reproductive tract, including cancers of the lining of the uterus (endometrial cancer), ovaries, and vulva (labia)
After menopause, estrogen levels decrease, weakening many tissues, including bone, muscles (such as those supporting the bladder), and tissues around the vagina and urethra. As a result, bladder infections become more common.
Symptoms that affect the vagina and urinary tract after menopause are called the genitourinary syndrome of menopause (formerly called vaginal atrophy or atrophic vaginitis). These symptoms include vaginal dryness, pain during sexual intercourse, urinary urgency, and urinary tract infections. This condition may make sexual intercourse painful, and women may describe or experience this pain as pelvic pain.
Evaluation
Evaluation is similar to that for younger women, except doctors pay particular attention to symptoms of urinary and digestive tract disorders that are common in older women. Older women should see a doctor promptly if they
Have vaginal bleeding
Suddenly lose weight or their appetite
Suddenly start having indigestion
Feel bloated
Have a sudden change in bowel movements
The doctor then does a physical examination and other tests to make sure that the cause is not ovarian or endometrial cancer.
If a thin vaginal lining seems to be the cause of pelvic pain, doctors may suggest vaginal moisturizers or vaginal hormone therapy (estrogen or dehydroepiandrosterone).
Key Points
Pelvic pain is a common symptom in women.
Many disorders (related to reproductive organs or other nearby organs) can cause pelvic pain.
Doctors can determine likely causes based on a description of the pain, its relationship to the menstrual cycle, and results of a physical examination.
If women are of childbearing age, a pregnancy test is always done.
Urine tests and usually other tests, such as blood tests and ultrasound of the pelvis, are done to confirm the suspected diagnosis.
