← Full pelvic pain in women algorithm
Reasoning GP · Diagnostic Compass · decision tree

Pelvic pain in women1 PAGE

Acute or chronic pelvic pain: is it dangerous, how urgent, and what is the likely cause?
NICE NG73 · NG12 (Apr 2026) · NG126 · NG193
HTG690 · RCOG GTG 41 · BASHH PID
Reviewed Oct 2026 · next review Apr 2027
Applies to: women with acute or chronic pelvic pain (chronic = at least 6 months), face to face or remote. Pregnancy test early in anyone who could be pregnant. ≥20 weeks or ≤6 weeks postpartum → maternity.
Pelvic pain presents

Shock or peritonism, syncope with pain (ruptured ectopic or cyst, perforated appendix, tubo-ovarian abscess) · Positive test + pain with instability, shoulder-tip pain, syncope, severe pain or significant bleeding · ≥20 weeks or ≤6 weeks postpartum with seizure, collapse, neuro signs, major bleed · PID with sepsis

Emergency?
YES
CALL 999
While waiting: nil by mouth, IV access if available; no scan, CA-125 or swabs first. A positive test with pain is ectopic until proven otherwise.
NO

Positive test + pain (any gestation), or bleeding ≥6 weeks → EPAU immediate, by phone · ≥20 weeks or ≤6 weeks postpartum → maternity immediate; BP ≥160/110 same-day admission · Torsion: sudden severe unilateral pain (normal Doppler does not exclude) · severe PID · recent instrumentation, IUD or termination · Cancer: ascites or pelvic mass (do not wait for CA-125); PMB 55+; suspicious cervix; vulval lump or ulcer · Weight loss, poor appetite, bowel change → ovarian and colorectal assessment

Same day or cancer pathway?
YES
IMMEDIATE · SAME DAY · CANCER PATHWAY
Same-day emergency gynae. Suspected cancer pathway referral; CA-125 at 40+, FIT if criteria met. Sexual violence or coercion: ask in private; safeguarding and SARC.
NO
Which pattern?
Acute, not pregnanthours to days
  1. Obs, abdomen, speculum, bimanual; urine; NAAT.
  2. PID, well: treat today (ceftriaxone, doxycycline, metronidazole, 14 days).
  3. Think appendicitis, UTI, colic, cyst, torsion; review 48–72 h.
Cyclical: endometriosiscycle, deep dyspareunia
  1. Treat on symptoms: NSAID trial, CHC or progestogen.
  2. TVUS; hormones and referral in parallel.
  3. 3 months is a decision point; deep disease → endometriosis centre.
Non-cyclicalbowel or bladder linked
  1. IBS: eased by defaecation; bladder pain: culture-negative "UTIs".
  2. Stop needless antibiotics; amitriptyline 10–25 mg nocte.
  3. New IBS-type symptoms ≥50 → CA-125 first.
MSK, neuropathiclevator tender, Carnett's +
  1. Pelvic floor, hip, SIJ, symphysis, scars.
  2. Pelvic floor physiotherapy; hormones will not help.
  3. Sensitisation or opioids → pelvic pain clinic.
EVERY PATIENT

Tests that change management

  • Urine β-hCG; timing uncertain → repeat or serum.
  • Urine dip, MSU; NAAT chlamydia and gonorrhoea (self-swab fine); HVS if discharge or PID.
  • TVUS for suspected endometriosis; CA-125 at 40+ with ovarian cluster.
  • Not: CA-125 for acute pain or endometriosis; FIT for pain alone.

Safety-net · follow up

  • 999: sudden severe pain, fainting, shoulder-tip pain, heavy bleeding with dizziness, fever with severe pain.
  • Same day: positive test with pain or bleeding; new or worse pain; fever; vomiting; cannot pass urine.
  • PID 48–72 h; endometriosis 3 months; chronic 3–6 months: no response → re-open, including cancer.
Never: Reassure by a negative test with uncertain timing, a normal scan (endometriosis) or a normal Doppler (torsion) · Treat "recurrent UTI" on negative cultures; accept new "IBS" at ≥50 · Delay hormones awaiting a scan, or wait for swabs to treat PID
Reasoning GP · Pelvic pain in women · decision tree · v1.0 · Oct 2026 · Full algorithm: gpreasoning.uk/tools/algorithms/pelvic-pain-women.htmlDecision support, not a substitute for clinical judgement. Check doses in the SPC and your local formulary.