Pelvic Pain in Women

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

• Pelvic inflammatory disease

• 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).

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.

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

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.

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.

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.

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).