Pelvic Pain in Women

ByShubhangi Kesavan, MD, Cleveland Clinic Learner College of Medicine, Case Western Reserve University
Reviewed/Revised Jun 2024
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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

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

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

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:

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.

Table
Table

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

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.

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