Some Causes of Pelvic Pain in Women

Cause	Common Features†	Diagnostic Approach‡
Cyclic pain, related to the menstrual cycle
Endometriosis	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 Occurs a few days before or during a menstrual period Often is most intense about 24 hours after periods begin and subsides after 2–3 days Sometimes headache, nausea, constipation, diarrhea, or an urge to urinate often (urinary frequency)	Transvaginal ultrasound to exclude other causes
Uterine adenomyosis	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 Occurs in the middle of a menstrual cycle (usually about 2 weeks after the first day of the last menstrual period, when ovulation occurs [the egg is released]) Begins suddenly Can occur on either side but on only one side at a time Is most intense when it begins, then subsides over 1–2 days 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 Begins suddenly Is at first confined to one area of the lower abdomen, then spreads 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 Begins suddenly Is most severe when it begins Often rapidly decreases over a few hours 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 Begins suddenly Occurs on one side Peaks quickly Occasionally pain that comes and goes (as the ovary twists and untwists) Usually nausea, vomiting and sometimes light-headedness or fainting	Transvaginal ultrasound Laparoscopy
Cancer of the ovaries	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
Pelvic inflammatory disease	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 Develops gradually Often becomes chronic Occurs in women who have had abdominal surgery or an infection in the pelvis 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
Appendicitis	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
Urinary tract infection	Sometimes pain just above the pubic bone An urgent need to urinate, more frequent urination, and/or burning during urination	A urine test
Diverticulitis	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 Crohn disease Ulcerative colitis	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)
Kidney stones	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.

Cause

Common Features†

Diagnostic Approach‡

Cyclic pain, related to the menstrual cycle

Endometriosis

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

Occurs a few days before or during a menstrual period
Often is most intense about 24 hours after periods begin and subsides after 2–3 days

Sometimes headache, nausea, constipation, diarrhea, or an urge to urinate often (urinary frequency)

Transvaginal ultrasound to exclude other causes

Uterine adenomyosis

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

Occurs in the middle of a menstrual cycle (usually about 2 weeks after the first day of the last menstrual period, when ovulation occurs [the egg is released])
Begins suddenly
Can occur on either side but on only one side at a time
Is most intense when it begins, then subsides over 1–2 days

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

Begins suddenly
Is at first confined to one area of the lower abdomen, then spreads

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

Begins suddenly
Is most severe when it begins
Often rapidly decreases over a few hours

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

Begins suddenly
Occurs on one side
Peaks quickly

Occasionally pain that comes and goes (as the ovary twists and untwists)

Usually nausea, vomiting and sometimes light-headedness or fainting

Transvaginal ultrasound

Laparoscopy

Cancer of the ovaries

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

Pelvic inflammatory disease

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

Develops gradually
Often becomes chronic
Occurs in women who have had abdominal surgery or an infection in the pelvis

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

Appendicitis

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

Urinary tract infection

Sometimes pain just above the pubic bone

An urgent need to urinate, more frequent urination, and/or burning during urination

A urine test

Diverticulitis

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

Crohn disease
Ulcerative colitis

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)

Kidney stones

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.

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Pelvic Pain in Women