Pelvic pain in women

Pelvic pain, also known as lower abdominal pain, in women is any pain that occurs in the area below your belly button. Pain may be sudden and severe or mild and persistent. It is important to see your GP to investigate what may be causing your pelvic pain. Although in some cases your doctor may not be able to identify a cause, they may still be able to advise you on how best to manage your pelvic pain. 

There are many different reasons that you may have pelvic pain, such as an infection in your pelvis or pain coming from the bones, joints, muscles, blood vessels, nerves or organs in your pelvis.

Organs in your pelvis include your bowel and bladder. In women, who are more likely to experience pelvic pain than men, the womb, ovaries, fallopian tubes, cervix (the neck of the womb) and vagina also sit in the pelvis. A problem affecting one or several of these reproductive organs is often the cause of lower abdominal pain in women. Your GP may therefore refer you to a doctor specialising in the female reproductive system (a gynaecologist)  to investigate your pelvic pain. 

Types of pelvic pain

Pelvic pain can be acute or chronic (long-term). In either case, you should see your GP so your pain can be investigated and treated.

Acute pelvic pain

Acute pelvic pain comes on suddenly and unexpectedly.

Chronic pelvic pain

Around one in six women have chronic pelvic pain, which is pelvic pain that lasts for at least six months. It may be continuous or come and go, and is more severe and longer-lasting than your usual period pain.

Pelvic pain causes

Common causes of acute pelvic pain in women

If you are not pregnant, there are several common causes of acute pelvic pain, which can be grouped into those affecting your reproductive organs and those affecting your non-reproductive organs.

Causes affecting reproductive organs

• Acute pelvic inflammatory disease — a bacterial infection of your reproductive organs ie fallopian tubes, ovaries and/or womb that most commonly occurs after becoming infected with chlamydia or gonorrhoea; it needs urgent treatment with antibiotics
• Ovarian cysts — fluid-filled sacs that develop on or in your ovaries and are usually harmless and go away on their own (functional ovarian cysts) but cause pelvic pain if they burst or become twisted; they can occur when an ovarian follicle, which contains an egg, doesn’t open to release the egg during ovulation, or when the follicle does open but then recloses and swells with fluid
• Painful ovulation — also known as mittelschmerz (meaning ‘middle pain’ in German); it goes away after a few hours and may switch from the left side to the right side of your body month-to-month
• Premenstrual syndrome and menstrual cramps — you may experience painful cramps in your lower abdomen or lower back in the lead up to your period or during your period; cramps usually last for one to three days
• Sexually transmitted infections (STIs) — not all STIs cause symptoms but when they do, symptoms may include pelvic pain, pain when urinating, bleeding in between your periods and unusual vaginal discharge

Causes affecting non-reproductive organs

• Appendicitis — painful swelling of your appendix (a tube-shaped sac attached to the start of your large intestine); symptoms include pain on the lower right-hand side of your abdomen, vomiting and fever; it needs urgent treatment, which may involve surgery, as the appendix can burst and spread infection throughout your body
• Bowel spasms – sudden, spontaneous contractions of your bowel muscles; causes include dietary changes, certain medications, Crohn’s disease, irritable bowel syndrome, ulcerative colitis and in rare cases, bowel obstruction
• Constipation — infrequent or difficult bowel movements; causes include dietary changes, certain medications, irritable bowel syndrome and in rare cases, bowel obstruction
• Peritonitis — Inflammation of your peritoneum (the thin, inner lining of your abdomen); the pain is sudden and severe and gets worse; it needs urgent medical treatment 
• Urinary tract infection (UTI) — symptoms include pelvic pain, pain or a burning feeling when you urinate and urinating more frequently; if your UTI spreads to your kidneys, you may experience symptoms of a kidney infection, which includes pain on one side of your lower back, fever, nausea and vomiting

Less common causes of acute pelvic pain in women

Less common acute pelvic pain causes include endometriosis, where tissue similar to the lining of your womb (endometrium) starts to grow elsewhere. During your periods when the tissue breaks down, it can’t be released from your vagina and consequently causes pain and may form scar tissue which can reduce your fertility. You may also experience some vaginal bleeding, which is darker than your period bleeding

Pelvic abscesses can also acute pelvic pain in women. These pus-filled structures develop between your womb and vagina, and need urgent medical treatment. 

A type of ovarian cyst called a corpus luteum cyst can cause acute pelvic pain too if it ruptures. Pain is severe and on one side of your pelvis. If you experience this pelvic pain in early pregnancy ie the first 12 weeks of pregnancy, you should contact your midwife or your doctor.

Acute pelvic pain in pregnancy

Acute pelvic pain in pregnancy usually needs urgent medical treatment.

An ectopic pregnancy can cause acute pelvic pain. An ectopic pregnancy occurs when the embryo implants and starts growing outside of your womb. Symptoms include sharp pelvic pain or cramps often on one side of your abdomen, bleeding from your vagina, dizziness and nausea. You will need urgent treatment as an ectopic pregnancy can be life-threatening.

A miscarriage ie loss of a pregnancy in the first 23 weeks can cause acute pelvic pain and/or cramps and bleeding from your vagina. You may also pass tissue that looks like a large blood clot from your vagina.

Placental abruption ie when the placenta starts to detach from the wall of your womb, also causes acute pelvic pain. If it occurs before week 24 of your pregnancy this is called a miscarriage; after week 24 of your pregnancy, emergency treatment is needed to deliver your baby. 

Premature labour ie labour before week 37 of your pregnancy can cause pelvic pain, period-like pains, regular contractions, tightening across your abdomen, fluid leaking from your vagina and backache that is not usual for you. Call your midwife immediately if you experience these symptoms

Common causes of chronic pelvic pain in women

The three most common causes of chronic pelvic pain in women are chronic pelvic inflammatory disease, endometriosis and irritable bowel syndrome (IBS).

Chronic pelvic inflammatory disease is a bacterial infection of your reproductive organs that most commonly occurs after becoming infected with chlamydia or gonorrhoea. It needs urgent treatment with antibiotics. Symptoms include, fever, pain during sex or urination, pelvic pain and unusual vaginal discharge.

Endometriosis occurs when tissue similar to the lining of your womb (endometrium) starts to grow elsewhere.

IBS is a common condition affecting your bowel, which can cause pelvic pain, stomach cramps, bloating, and recurring diarrhoea and constipation. The causes aren’t clear but it can be treated with dietary changes, reducing stress levels and taking certain medications.

Less common causes of chronic pelvic pain in women

Less common causes of chronic pelvic pain in women can be grouped into those affecting your reproductive organs and those affecting your non-reproductive organs.

Causes affecting reproductive organs

Adenomyosis

This is a type of endometriosis where the tissue lining the womb grows into the muscular wall of the womb. Symptoms include painful, heavy periods.

Fibroids

Fibroids are non-cancerous growths in or around your womb. They may cause heavy or painful periods if they deteriorate or become twisted. Around one in five women aged 30-50 years has fibroids. Other symptoms include difficulty getting pregnant, lower back pain, painful sex, pelvic pain and pressure in your abdomen.

Prolapse of the womb

This occurs when your womb slips down into your vagina causing a dragging pain or discomfort. This is more common in post-menopausal women and women who have had multiple vaginal births but it is not usually a serious problem.

Recurring ovarian cysts

Ovarian cysts are fluid-filled sacs that develop on or in your ovaries. They are usually harmless and go away on their own (functional ovarian cysts) but cause pelvic pain if they burst or become twisted.

Causes affecting non-reproductive organs

Chronic interstitial cystitis

This is also known as painful bladder syndrome. The causes are unclear but the result is long-term inflammation of your bladder. Symptoms include severe pelvic pain, sudden strong urges to urinate, urinating more frequently and waking up often at night to urinate.

Frequent urinary tract infections (UTIs)

Symptoms of UTIs include pelvic pain, pain or a burning feeling when you urinate and urinating more frequently.

Hernia

A hernia is where part of the tissue inside your body pushes through the muscle or tissue holding it in. Inguinal hernias are most common and occur when part of your bowel pushes through your abdominal muscle, which can cause severe pain, especially if the blood supply to the bowel is cut off (strangulated hernia).

Inflammatory bowel disease (IBD)

IBD includes two similar but different conditions that affect your gut, Crohn's disease and ulcerative colitis.

Kidney stones

Kidney stones are deposits of salt and minerals that vary in size, from as small as a grain of sand to as large as a golf ball. Small kidney stones may pass out of your urine on their own but larger kidney stones may need treatment.

Lower back pain

There are many causes of lower back pain including muscle damage, pinched nerves and spinal abnormalities, which can all cause pain to spread to your pelvis.

Other less common causes of chronic pelvic pain affecting non-reproductive organs include:

• Cancer of the cervix, ovaries or womb 
• Pelvic congestion syndrome — swollen, twisted veins in the abdomen that prevent proper blood flow and cause a dull pelvic pain that worsens when sitting or standing; this condition is hard to diagnose and treat
• Scar tissue — surgery on or infection of your abdomen can cause scar tissue to form, specifically adhesions ie tough, bands of tissue that cause organs or other structures to become inappropriately stuck to each other 
• Trapped or damaged nerves in the pelvis — this causes nerve pain that is sharp, stabbing or aching; certain movements usually worsen the pain

Pelvic pain symptoms

Pelvic pain symptoms vary considerably depending on the underlying cause eg you may experience a sharp, stabbing pain in your pelvic area or feel a dull pressure in your lower abdomen. Depending on which organ or structure is involved you may have pelvic bone pain or pelvic muscle pain.

You may find that your pelvic pain is worse after a bowel movement or that it is worse during your period eg if you have menstrual pain or menstrual cramps. Other symptoms associated with pelvic pain include:

• Blood on your stools
• Constipation, diarrhoea, bloating or gas
• Fever or chills
• Pain during sex
• Pain when urinating or difficulty urinating
• Vaginal bleeding, discharge or spotting

Pelvic pain can also occur alongside or lead to hip and/or groin pain. 

Diagnosis and tests for pelvic pain

If you have pelvic pain, whether it is acute or chronic, it’s important to see your doctor. They will ask you questions about your symptoms and medical history, as well as conduct a physical examination. If you are a woman of reproductive age, your doctor may suggest taking a pregnancy test. 

Further tests for the diagnosis of pelvic pain, which your doctor may recommend, include scans of your abdomen and pelvis, such as: 

• A CT scan — specialised X-ray equipment and a computer are used to create images of the inside of your body
• An ultrasound scan — high-frequency sound waves are used to create images of the inside of the body; if you are pregnant and your doctor suspects you may be having a miscarriage or have an ectopic pregnancy, you may be referred for an urgent ultrasound scan
• An X-ray — a small dose of ionising radiation (X-rays) is used to create images of your bones as well as some of the organs in your abdomen and pelvis

Your doctor may recommend a more invasive test using special, thin telescope-like tubes that have a camera on the end (scopes) so they can see directly inside your body. These tests include: 

• Diagnostic laparoscopy — a laparoscope is inserted via a small cut in your abdomen to examine the inside of your abdomen and pelvis; this is performed under a general anaesthetic and is often used when the cause of persistent pelvic pain can’t be found using non-invasive tests  
• Hysteroscopy — a hysteroscope is inserted via your vagina to examine the inside of your womb; this can be carried out under local or general anaesthetic, depending on whether your doctor is just having a look or if they plan on carrying out treatment too
• Lower endoscopy ie a colonoscopy or sigmoidoscopy — an endoscope is inserted via your anus to look inside your rectum; it is performed without anaesthesia but sedation is offered to help you feel relaxed

Other tests to help diagnose your pelvic pain include: 

• Blood and urine tests to check for a variety of proteins and other markers that change in response to infection, inflammation or disease
• Stool guaiac test — your stools will be examined to check for blood that isn’t visible to the naked eye (microscopic blood) 
• Vaginal swabs to check for sexually transmitted diseases eg chlamydia and gonorrhoea

Pelvic pain treatments

Pelvic pain treatments vary depending on the underlying cause, as well as the frequency and intensity of your pain. 

Treatments include medications, such as painkillers and antibiotics. If you are certain that your pelvic pain is caused by your period you can try taking the painkillers paracetamol and/or ibuprofen. 

However, in some cases, you may need surgery or another medical intervention, especially if the pain is caused by damage to or disease of an organ or tissue.

Physiotherapy can help treat some causes of pelvic pain. A physiotherapist can put together a specific programme tailored to your symptoms. 

If you have chronic pelvic pain, treatment may not just be limited to physical interventions. You may want to consider seeing a counsellor, psychologist or psychiatrist to help you cope with the stress of managing chronic pain. 

If you don’t know what’s causing your pelvic pain or your pain is severe, see your doctor. You may need medical treatment and in some cases, this may be needed urgently.