One-liner#

Female pelvic pain requires differentiation between gynecologic, urologic, GI, and musculoskeletal causes—with urgent evaluation for ectopic pregnancy, ovarian torsion, and PID.

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• Positive pregnancy test + pelvic pain → ectopic pregnancy until proven otherwise
• Sudden severe unilateral pain + nausea/vomiting → ovarian torsion; needs emergent imaging
• Fever + pelvic pain + cervical discharge → PID; if severe or unable to tolerate PO, needs IV antibiotics
• Hemodynamic instability + pelvic pain → ruptured ectopic, ruptured ovarian cyst with hemorrhage
• Peritoneal signs (rebound, guarding, rigidity) → surgical abdomen

Key history#

Characterize the pain:

• Location: unilateral vs bilateral vs midline; suprapubic vs adnexal
• Quality: sharp, crampy, dull, pressure
• Severity: 1-10 scale
• Timing: constant vs intermittent; relation to menstrual cycle
• Duration: acute (hours-days) vs chronic (>6 months)
• Radiation: to back, thigh, rectum

Menstrual history:

• LMP: always ask; pregnancy must be ruled out
• Cycle regularity
• Dysmenorrhea: primary (since menarche) vs secondary (new onset)
• Menorrhagia, intermenstrual bleeding
• Menopausal status

Relationship to cycle:

• Midcycle pain (mittelschmerz—ovulation)
• Premenstrual/menstrual (dysmenorrhea, endometriosis)
• No relationship (less likely gynecologic)

Associated symptoms:

• Vaginal discharge, bleeding → GYN cause
• Dysuria, frequency → UTI, interstitial cystitis
• GI symptoms (nausea, vomiting, constipation, diarrhea) → GI cause or referred
• Dyspareunia → endometriosis, PID, vaginismus
• Fever → infection (PID, TOA, appendicitis)

Sexual and reproductive history:

• Sexually active; contraception use
• STI history and risk factors
• Prior PID
• Prior ectopic pregnancy
• Infertility

Surgical history:

• Prior pelvic/abdominal surgery (adhesions)
• C-sections
• Tubal ligation (increased ectopic risk)

Psychosocial:

• History of sexual trauma
• Depression, anxiety
• Relationship stressors

Focused exam#

Vital signs:

• Fever → infection
• Tachycardia, hypotension → hemorrhage, sepsis

Abdominal exam:

• Tenderness location and severity
• Peritoneal signs (rebound, guarding)
• Masses
• Bowel sounds

Pelvic exam:

• External: lesions, discharge at introitus
• Speculum: vaginal discharge, cervical discharge, cervical lesions, bleeding
• Bimanual: cervical motion tenderness (CMT), uterine tenderness, adnexal tenderness/masses

Key exam findings:

• CMT → PID, ectopic, ovarian pathology
• Adnexal mass → ovarian cyst, ectopic, TOA
• Uterine tenderness → PID, adenomyosis
• Fixed, tender uterus → endometriosis with adhesions

Rectal exam: if needed to assess rectovaginal nodularity (endometriosis) or rectal pathology

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

All reproductive-age women with pelvic pain:

• Urine pregnancy test (ALWAYS—even if “no way I’m pregnant”)

Acute pelvic pain:

• Pregnancy test
• UA (rule out UTI)
• Pelvic ultrasound if: adnexal mass, concern for ectopic, torsion, cyst
• NAAT for chlamydia/gonorrhea if sexually active

Suspected PID:

• NAAT for CT/GC
• Consider HIV, syphilis, hepatitis B
• Pelvic ultrasound if: not improving, TOA suspected, diagnostic uncertainty

Chronic pelvic pain (>6 months):

• Pregnancy test
• UA
• NAAT for STIs if not recently done
• Pelvic ultrasound (evaluate for endometriomas, fibroids, ovarian pathology)
• Consider: TSH, CBC, ESR/CRP if inflammatory cause suspected

When to image:

• Adnexal mass on exam
• Concern for ectopic pregnancy
• Concern for torsion (emergent)
• Chronic pain not responding to empiric treatment
• Abnormal bleeding

When NOT to order:

• Do NOT delay pregnancy test—it changes everything
• Do NOT order CT for routine pelvic pain evaluation (ultrasound is first-line for GYN pathology)
• Do NOT order laparoscopy from primary care—this is a GYN decision

Initial management#

Ectopic pregnancy suspected:

• ED immediately if pregnancy test positive and pelvic pain
• Do NOT attempt outpatient management

Ovarian torsion suspected:

• ED immediately for emergent ultrasound and likely surgery

PID (mild-moderate, outpatient criteria met):

• Empiric antibiotics (see management section)
• Close follow-up in 48-72 hours

Ovarian cyst (simple, <5 cm, asymptomatic or mild pain):

• Observation
• Repeat ultrasound in 6-8 weeks
• NSAIDs for pain

Dysmenorrhea:

• NSAIDs (start 1-2 days before expected menses)
• Hormonal contraception if NSAIDs insufficient

Chronic pelvic pain:

• Multidisciplinary approach often needed
• Address GYN, GI, urologic, MSK, and psychological components
• GYN referral if endometriosis suspected

Management by diagnosis#

Dysmenorrhea#

Education:

• Painful periods are common; primary dysmenorrhea is not dangerous
• Pain is caused by prostaglandins; NSAIDs block prostaglandins
• Hormonal contraception can significantly reduce or eliminate pain
• Secondary dysmenorrhea (new or worsening) needs evaluation

Treatment:

If not responding to NSAIDs + hormonal therapy:

• Consider endometriosis
• GYN referral for further evaluation

Follow-up: 2-3 months to assess response to treatment.

Ovarian Cyst (Functional)#

Education:

• Functional cysts are normal; they form during ovulation
• Most resolve on their own within 1-3 menstrual cycles
• Pain is usually from stretching or rupture
• Surgery rarely needed for simple cysts

Management by type:

• Simple cyst <5 cm: Observation; repeat ultrasound in 6-8 weeks
• Simple cyst 5-7 cm: Observation vs GYN referral; repeat ultrasound
• Simple cyst >7 cm or complex: GYN referral
• Hemorrhagic cyst: Usually resolves; repeat ultrasound in 6-8 weeks

Symptomatic treatment:

• NSAIDs for pain
• Hormonal contraception may prevent new functional cysts (does not treat existing cyst)

Follow-up: Repeat ultrasound in 6-8 weeks to confirm resolution.

PID (Pelvic Inflammatory Disease)#

Education:

• Infection of uterus, tubes, and/or ovaries
• Usually from STI ascending from cervix
• Can cause infertility, chronic pain, ectopic pregnancy if untreated
• Partners MUST be treated

Outpatient criteria (all must be met):

• Mild-moderate symptoms
• Tolerating oral intake
• Can return for follow-up in 48-72 hours
• Not pregnant

Treatment:

ED referral indications:

• Severe illness, high fever
• Unable to tolerate PO
• Pregnant
• TOA suspected
• No improvement after 48-72 hours
• Surgical emergency cannot be excluded

Follow-up: 48-72 hours to assess response. If not improving, imaging and possible hospitalization.

Endometriosis#

Education:

• Tissue similar to uterine lining grows outside the uterus
• Causes pain, especially with periods, sex, and bowel movements
• Can cause infertility
• Definitive diagnosis requires laparoscopy, but empiric treatment is reasonable

Symptoms suggesting endometriosis:

• Progressive dysmenorrhea (getting worse over time)
• Dyspareunia (deep)
• Dyschezia (painful bowel movements, especially with menses)
• Chronic pelvic pain
• Infertility

Empiric treatment (PCP can initiate):

GYN referral indications:

• Not responding to empiric hormonal therapy
• Desire for definitive diagnosis (laparoscopy)
• Infertility
• Endometrioma on imaging
• Considering GnRH agonist therapy (specialist-initiated)

Follow-up: 2-3 months to assess response to empiric treatment.

Chronic Pelvic Pain#

Education:

• Pain lasting >6 months
• Often multifactorial: GYN, GI, urologic, MSK, psychological
• May not find single “cause”
• Goal is pain management and improved function, not necessarily cure

Approach:

1. Rule out treatable causes (endometriosis, adhesions, IBS, IC, MSK)
2. Address each contributing factor
3. Multidisciplinary approach often needed
4. Consider pain psychology, pelvic floor physical therapy

Components to address:

• GYN: Empiric endometriosis treatment; GYN referral if not responding
• GI: IBS management (see GI section); consider gastroenterology
• Urologic: Interstitial cystitis evaluation if bladder symptoms
• MSK: Pelvic floor physical therapy; myofascial pain treatment
• Psychological: Address depression, anxiety, trauma history; consider pain psychology

Medications for chronic pain:

Avoid:

• Opioids for chronic pelvic pain (ineffective long-term, risk of dependence)
• Repeated surgeries without clear indication

Referral: GYN, pain management, pelvic floor physical therapy as indicated.

Mittelschmerz (Ovulation Pain)#

Education:

• Normal pain from ovulation; occurs midcycle
• Caused by follicle rupture and fluid irritating peritoneum
• Alternates sides (whichever ovary ovulates)
• Not dangerous; no treatment needed unless bothersome

Treatment:

• Reassurance
• NSAIDs PRN
• Hormonal contraception if recurrent and bothersome (suppresses ovulation)

Follow-up: None needed unless symptoms change.

Follow-up#

Acute pelvic pain (resolved):

• Return if symptoms recur or worsen

Ovarian cyst:

• Repeat ultrasound in 6-8 weeks
• GYN referral if persistent or enlarging

PID:

• 48-72 hours to assess response
• Ensure partners treated
• Rescreen for STIs in 3 months

Dysmenorrhea/endometriosis:

• 2-3 months to assess response to treatment
• GYN referral if not improving

Chronic pelvic pain:

• Regular follow-up (monthly initially, then as needed)
• Multidisciplinary involvement

Return precautions:

• Fever
• Worsening pain
• Vomiting, unable to keep fluids down
• Vaginal bleeding (heavy or with positive pregnancy test)
• Feeling faint or dizzy

Patient instructions#

For ovarian cyst:

• Most ovarian cysts go away on their own within a few weeks
• Take ibuprofen or naproxen for pain
• We’ll repeat an ultrasound in 6-8 weeks to make sure it’s gone
• Call or return if: severe pain, fever, vomiting, or feeling faint

For dysmenorrhea:

• Start taking ibuprofen or naproxen 1-2 days BEFORE your period starts—this works better than waiting for pain
• Take it regularly through your heaviest days, not just when pain is bad
• Birth control pills can significantly reduce period pain if NSAIDs aren’t enough
• Call if pain is getting worse over time or not controlled with these measures

For PID:

• Take ALL your antibiotics as prescribed—this is very important
• Your partner(s) MUST be treated, or you will get reinfected
• Do not have sex until you and your partner have finished treatment
• Call or return if: fever, pain getting worse, vomiting, or not improving after 2-3 days

Smartphrase snippets#

Acute pelvic pain, pregnancy ruled out: “Acute pelvic pain evaluated. Pregnancy test negative. Exam: [findings]. Differential includes [ovarian cyst/dysmenorrhea/other]. Plan: [pelvic ultrasound/empiric treatment/observation]. Return precautions given for worsening pain, fever, or vomiting.”

PID, outpatient treatment: “Pelvic pain with CMT and cervical discharge consistent with PID. Meets outpatient criteria. Treated with ceftriaxone 500 mg IM + doxycycline 100 mg BID x 14 days + metronidazole 500 mg BID x 14 days. NAAT sent. Partner treatment discussed. Follow-up in 48-72 hours. ED precautions given.”

Dysmenorrhea, starting treatment: “Primary dysmenorrhea—cyclic pelvic pain with menses since menarche, normal exam. Starting scheduled NSAIDs (ibuprofen 400 mg TID starting 1-2 days before expected menses). Discussed hormonal contraception as option if NSAIDs insufficient. Follow-up in 2-3 months or sooner if worsening.”