Pelvic pain in women — triage and diagnostic approach

Ectopic pregnancy occurs in roughly 1 in 80 pregnancies in the UK and is a leading cause of early maternal death; the pain frequently precedes any bleeding, and a substantial proportion of women do not initially believe they could be pregnant — which is why the test is performed rather than discussed. Ovarian torsion is the time-critical gynaecological emergency: the ovary can be salvaged if detorsion happens within hours, and delay converts a conservable ovary into an oophorectomy in a young woman. The NG12 distinction on ovarian cancer matters practically: ascites or a pelvic mass means immediate urgent referral, whereas the symptom cluster of bloating, early satiety, pelvic pain and urinary frequency triggers a CA-125 first. Cervical cancer deserves a specific mention because of a common false reassurance — a visibly abnormal cervix requires urgent referral regardless of a normal or up-to-date cervical screening history, since screening detects pre-invasive change in asymptomatic women and is not a test for symptomatic disease.

Cyclicity does most of the diagnostic work, but the more important message from NICE NG73 is about listening: the average delay from first symptom to diagnosis of endometriosis in the UK is around eight years, and the largest single contributor is the normalisation of severe period pain — by clinicians and by the women themselves. NG73 therefore lowers the threshold deliberately, directing clinicians to suspect endometriosis on the symptom cluster alone, to ask about cyclical bowel and urinary symptoms which are frequently missed, and explicitly to offer treatment without waiting for a definitive diagnosis. The ovarian cancer cluster is the mirror image and is why symptom-triggered CA-125 testing exists: the symptoms are vague, they overlap almost exactly with IBS, and true IBS very rarely presents for the first time after the age of 50 — so the new "IBS" in an older woman should prompt a CA-125 rather than a low-FODMAP leaflet.

Chronic pelvic pain is genuinely multifactorial in most women, and the search for a single culprit organ is the reason so many end up with repeated negative laparoscopies. It is common for endometriosis, IBS and pelvic floor myalgia to coexist in the same patient, each amplifying the others, and treating only one produces partial benefit that is then misread as diagnostic failure. This is why the RCOG's approach to chronic pelvic pain emphasises assessing all three systems — gynaecological, gastrointestinal and musculoskeletal — plus the psychosocial dimension from the outset rather than sequentially over years. Musculoskeletal and neuropathic causes are the most under-diagnosed group in primary care: pelvic floor myalgia is identifiable on examination by reproducible tenderness of the levator muscles, nerve entrapment after a Pfannenstiel incision produces a discrete tender point with altered sensation, and both respond to specific treatment rather than to hormones or laparoscopy.

Two examination findings change management more than any other and are both quick. Carnett's sign distinguishes abdominal wall pain from visceral pain in seconds: if tensing the rectus makes the pain worse, the source is the wall, and further pelvic imaging is unlikely to help. Reproducing the presenting pain by palpating the pelvic floor muscles identifies the substantial group of women whose pain is myofascial and who benefit from specialist pelvic floor physiotherapy rather than hormonal suppression or surgery. The negative findings need equal emphasis: examination for endometriosis has poor sensitivity, and superficial peritoneal disease — which can cause severe pain — is invisible on ultrasound and undetectable bimanually. A woman told that her scan and examination were normal often hears that her pain is not real, and NG73 exists partly to prevent that consultation. The one exception to reassurance is that a pelvic mass or ascites on examination is actionable immediately, on the urgent ovarian cancer pathway, without waiting for a CA-125.

CA-125 is a symptom-triggered test with genuinely awkward performance characteristics, and both errors are common. It is raised by a long list of benign gynaecological conditions, so a mildly elevated result in a young woman with endometriosis generates avoidable alarm; and it is normal in a substantial minority of early ovarian cancers, so a normal result cannot close a case where symptoms persist. NICE NG12's structure accommodates this: ascites or a pelvic mass bypasses the blood test entirely and goes straight to urgent referral, and the test is reserved for the vaguer symptom cluster. The corresponding trap in chronic pelvic pain is the woman treated for years for "recurrent UTIs" on the basis of symptoms and negative cultures — that pattern is bladder pain syndrome, and repeated antibiotics neither help her nor are harmless. The final point is the most practical: in suspected endometriosis, waiting for imaging or laparoscopy before starting treatment is the mechanism by which the eight-year diagnostic delay accumulates, and NG73 explicitly permits treating on the symptom cluster alone.

The NG12 ovarian pathway is one of the most commonly misapplied in general practice, and the error is usually the same: measuring CA-125 in a woman who has a palpable pelvic mass or ascites, and waiting several days for the result. Where a mass or ascites is present the referral is immediate and the blood test adds nothing to the decision. The specialist endometriosis centre referral is the other under-used route — NG73 directs referral to a centre with the expertise for deep endometriosis involving the bowel, bladder or ureter, because surgery in those cases requires a multidisciplinary team and outcomes are materially better. Finally, referral to a pelvic pain clinic is not an admission of failure but a recognition of mechanism: in long-standing chronic pelvic pain, central sensitisation becomes part of the pathology, and the evidence favours a multidisciplinary approach including physiotherapy and psychological therapy over further diagnostic laparoscopy, which frequently finds nothing new and reinforces the search for a single fixable lesion.

The most consequential shift in NICE NG73 was permitting — indeed encouraging — treatment of suspected endometriosis in primary care without diagnostic confirmation, because requiring laparoscopy first is the main structural cause of the diagnostic delay. A three-month analgesic trial followed by hormonal treatment can be delivered entirely in general practice, and for many women that is sufficient. PID follows the same logic for different reasons: BASHH and NICE both advise empirical treatment on clinical suspicion because swabs are frequently negative even in genuine PID, and each week of delay increases the risk of tubal infertility, chronic pain and ectopic pregnancy. On analgesia, the evidence for opioids in chronic pelvic pain is poor and the harms are substantial — NICE NG193 recommends against initiating opioids for chronic primary pain, and the realistic goals are function and sleep rather than abolition of pain. The single most valued intervention reported by women with chronic pelvic pain, consistently, is being believed and given an explanation.

The symptom diary earns its place because cyclicity is the highest-value diagnostic feature and is frequently invisible in a single consultation — women with severe, constant pain often cannot recall whether it worsens premenstrually until they track it. Down-training rather than strengthening the pelvic floor is a genuinely counterintuitive point: the standard advice to do pelvic floor exercises is actively harmful in women with an overactive, painful floor, and this group is common in chronic pelvic pain. Raising fertility early matters because both endometriosis and PID reduce fertility, and women repeatedly report finding out too late that their condition had implications they were never told about. Finally, the psychological component must be framed carefully. Psychological therapy is offered because chronic pain involves nervous system sensitisation and because living with pain is difficult — not as a hint that the pain is not real. Women with chronic pelvic pain describe that misframing as the single most damaging thing that happens in their consultations, and it is what makes them stop returning.

Pelvic pain is a presentation where the diagnosis often emerges over several consultations, which makes the review structure the real clinical instrument. Two specific safety-nets deserve to be built in from the start. First, a normal CA-125 with continuing symptoms is not reassurance: a substantial minority of early ovarian cancers have a normal marker, so the plan must include re-assessment rather than discharge. Second, the three-month endometriosis review must actually happen and must be a decision point — the commonest pattern in the records of women who waited years for diagnosis is a series of repeat prescriptions with no review of whether the treatment worked. Reading the whole record before adding another treatment is the other habit that shortens delay: the diagnosis of endometriosis, ovarian cancer and chronic PID is frequently visible in the pattern of six previous consultations even when no single consultation was inadequate. And the discipline of re-opening the diagnosis when a chronic pain changes character is what catches the malignancy that develops in a woman already carrying a benign label.