REASONING GP · Clinical algorithm · Quick reference

Pelvic pain in women — triage and diagnostic approach

Daytime GP and OOH/111, face-to-face or remote. Pregnancy test first, exclude the emergencies, then establish whether the pain is cyclical. Ongoing management of each diagnosis is in the full Steps pathway.
 Page 1 / 2
AdultsGP + OOHβ-hCG firstv1.0 · Sep 2026
Core rule. Urine β-hCG in every woman of reproductive age with pelvic pain, before anything else. Pain with a positive test is an ectopic pregnancy until the early pregnancy unit says otherwise. Ascites or a pelvic mass goes straight to the urgent ovarian cancer route without waiting for CA-125, and new IBS-type symptoms aged 50 or over are an ovarian cancer red flag, not a new diagnosis of IBS. A normal examination and a normal scan do not exclude endometriosis (NG73).
0
Before any history: is this an emergency now? Stop the consultation and call 999 if any of these is present
Shock or peritonism · syncope or feeling faint with the pain · shoulder-tip pain · heavy vaginal bleeding with haemodynamic compromise · positive pregnancy test with severe pain · fever with rigors and severe pelvic pain · severe pain after 20 weeks of pregnancy, or BP ≥160/110 with headache, visual change or epigastric pain. ABCDE, observations, IV access if available, nil by mouth. Do not delay transfer for a scan, a CA-125, swabs or analgesia given orally.
1
Define the pain in four lines Enough to place the patient in the table below

Time

Acute (hours to days) or chronic — chronic pelvic pain is intermittent or constant pain in the lower abdomen or pelvis for at least 6 months, not exclusively with periods or intercourse. Sudden onset, or gradual and progressive.

Character

Cyclical or not — the single most useful question. Tracks the cycle → endometriosis, adenomyosis, dysmenorrhoea, mittelschmerz. Constant or unrelated → PID, adhesions, IBS, bladder pain syndrome, musculoskeletal, neuropathic. Site, radiation, relation to bowels and micturition.

Context

LMP and cycle · contraception and IUD · previous ectopic, PID or STI, new or multiple partners · previous pelvic surgery, caesarean or mesh (adhesions, nerve entrapment) · subfertility · recent instrumentation, IUD insertion or termination · age ≥50 · IBD or rheumatoid disease.

Associated

The NG73 endometriosis cluster: period-related pain affecting daily activities, deep dyspareunia, cyclical bowel symptoms (especially painful defaecation), cyclical urinary symptoms, infertility. The NG12 ovarian cluster: persistent bloating or distension, early satiety or loss of appetite, urinary urgency or frequency. Also discharge, abnormal bleeding, weight loss.
2
Red-flag screen: trigger → concern → destination → what to do before handover One row is enough; do not add up reassuring features
Trigger / red flagLeading concern · destinationDo now · do not delay
Positive pregnancy test with pain, with or without bleeding; amenorrhoea with a period that was slightly late; shoulder-tip pain, syncope or shock. Ectopic pregnancy · ruptured ectopic
Same-day early pregnancy unit 999 if shock, syncope or shoulder-tip pain		 Do the test — do not discuss whether she could be pregnant. Pain frequently precedes bleeding. Record LMP, contraception, previous ectopic. Speak to the EPAU directly; not an outpatient scan or a review tomorrow. Repeat a negative test if the LMP is uncertain.
Sudden severe unilateral pain with vomiting, often with a known cyst, in pregnancy or after ovulation induction. Ovarian torsion
Same-day gynaecology		 The ovary is salvageable for only a few hours — delay converts it into an oophorectomy in a young woman. Nil by mouth, analgesia, transfer. Do not wait for an outpatient ultrasound slot.
Peritonism, shock, or rebound tenderness with pelvic pain. Ruptured ectopic or cyst with haemoperitoneum · perforated appendix · tubo-ovarian abscess
999 now		 ABCDE, IV access, nil by mouth. Appendicitis is the commonest non-gynaecological cause and is frequently mislabelled as a gynaecological problem in young women — and vice versa.
Fever with rigors and pelvic pain, or severe pain with an IUD in situ, or after instrumentation, IUD insertion or termination. PID with sepsis · tubo-ovarian abscess · endometritis · perforation
Same-day admission		 Observations and NEWS2. Do not remove an IUD before antibiotics are started and pregnancy risk assessed — discuss the same day. Systemically well PID is treated in primary care (section 7); febrile PID is admitted for IV antibiotics.
Ascites, or a palpable pelvic or abdominal mass not obviously fibroids. Or persistent or frequent (>12 times a month) bloating or distension, early satiety, appetite loss, pelvic or abdominal pain, urinary urgency/frequency — especially new IBS-type symptoms aged ≥50, weight loss, fatigue or bowel-habit change. Ovarian cancer
Mass or ascites: urgent referral · NICE NG12 Otherwise CA-125; if ≥35 IU/mL urgent pelvic/abdominal ultrasound		 With a mass or ascites refer urgently — do not wait for a CA-125: measuring it and waiting days is the commonest misapplication. Examine for shifting dullness and a mass arising from the pelvis; true IBS rarely presents first after 50. A normal CA-125 with persisting symptoms is not a discharge — normal in up to half of early-stage cancers: re-examine and refer. Add FIT if bowel symptoms dominate (≥10 µg Hb/g → colorectal route).
Post-menopausal bleeding aged ≥55; or a cervix that looks friable, irregular or bleeds on contact; or an unexplained vulval lump or ulceration. Endometrial · cervical · vulval cancer
2WW gynaecology · NICE NG12		 A normal smear history does not exclude cervical cancer — screening tests asymptomatic pre-invasive change, not symptomatic disease; refer on appearance alone. Direct-access ultrasound for PMB where available.
Pregnancy ≥20 weeks or up to 6 weeks postpartum: pain with hypertension, headache, visual change, epigastric pain, bleeding, reduced fetal movements or contractions. Abruption · pre-eclampsia and HELLP · preterm labour · uterine rupture
Immediate maternity assessment 999 if BP ≥160/110, seizure or heavy bleeding		 Record BP, gestation or postpartum interval, urine protein if available. Speak directly to the maternity unit; never route through routine GP or midwife follow-up.
Safety rule. A normal examination and a normal ultrasound exclude very little: superficial peritoneal endometriosis is invisible on ultrasound and undetectable bimanually, and NG73 states that normal imaging and examination do not rule it out. Average time to diagnosis in the UK is around 8 years, and normalising severe period pain is the largest contributor. Safeguarding: where sexual violence or coercion is disclosed or suspected, ask alone and in private, offer a chaperone and document it, and follow local safeguarding/SARC routes; read the whole record before adding another prescription.
3
Focused examination and investigation Consent, chaperone offered and documented; remote assessment that cannot deliver these is an escalation criterion

Observations

Temperature, pulse, BP, RR, NEWS2 if unwell, pallor. Tachycardia with pain and a positive pregnancy test is a surgical emergency, whatever the BP.

System examination

Abdomen: site of maximal tenderness, guarding and rebound, a mass arising from the pelvis, ascites and shifting dullness, hernial orifices, scars. Carnett's sign — pain worse on tensing the abdominal wall means an abdominal wall origin, not intra-abdominal pathology.

Targeted signs

Speculum: cervix inspected directly, discharge, IUD threads, swabs. Bimanual: uterine size and mobility, fixed retroverted uterus, tender nodularity or thickening of the posterior fornix or uterosacral ligaments (deep endometriosis), adnexal mass, cervical excitation. Palpate the levator ani — reproducing the pain identifies myofascial pain. Hip, sacroiliac and pubic symphysis; allodynia over scars.

Investigations

Urine β-hCG first. Urine dip and MSU; vulvovaginal NAAT for chlamydia and gonorrhoea (self-taken acceptable); FBC, CRP, U&Es, ferritin, coeliac serology if bowel symptoms; CA-125 per NG12, then urgent pelvic/abdominal USS if ≥35 IU/mL; FIT if bowel symptoms dominate. Not from primary care: laparoscopy, MRI pelvis (specialist-requested), CT.
Colour is semantic: red = emergency now · amber = same-day acute assessment · blue = define/assess · green = benign diagnosis established · purple = uncertain / specialist route. Continued on page 2: classification, cause classifier, routine referral, primary-care treatment, endpoint.
REASONING GP · Pelvic pain in women — triage and diagnostic approach
 Page 2 / 2
4
Classify: three exits, not two A negative laparoscopy does not exclude a non-gynaecological cause

Emergency or serious cause likely

Positive pregnancy test with pain, any red flag, deranged physiology, a pelvic mass or ascites, or post-menopausal bleeding. Output: name the concern, use the destination above, and hand over the pregnancy test result, LMP, observations and contraception.

Benign cause established

A coherent pattern: cyclical pain fitting the NG73 cluster, systemically well PID, IBS, bladder pain syndrome, or reproducible myofascial pain — with a negative pregnancy test and no red flags. Output: name it, treat it today, and set a 3-month review.

Unclassified / uncertain

Chronic pain with no single cause, several coexisting contributors, remote assessment, or examination not possible. Output: do not default to "probably endometriosis" or "just IBS". State the uncertainty, treat what is treatable, and name the review owner and date.
5
Cause classifier — four systems, frequently coexisting Assess all four from the outset, not sequentially over years
GynaecologicalEndometriosis (suspect on the NG73 cluster alone; up to 10% of women of reproductive age), adenomyosis, fibroids, chronic PID with adhesions, ovarian cysts, pelvic congestion, ovarian remnant, cervical stenosis, mittelschmerz.
GastrointestinalIBS (very commonly coexistent rather than an alternative), chronic constipation, coeliac disease, diverticular disease, IBD. Constipation amplifies all pelvic pain and is worth treating properly on its own.
UrologicalBladder pain syndrome / interstitial cystitis — pain worse with a full bladder and relieved by voiding, with repeatedly culture-negative "recurrent UTIs". Repeated antibiotics for negative cultures neither help nor are harmless. Also urethral pain syndrome, stones, detrusor overactivity.
Musculoskeletal and neuropathicThe most under-diagnosed group: pelvic floor myalgia and overactivity, pubic symphysis dysfunction, sacroiliac and hip pathology, coccydynia, abdominal wall trigger points, and ilioinguinal or iliohypogastric nerve entrapment after a Pfannenstiel incision or mesh repair. Hormonal treatment will not help these.
MalignancyOvarian (the great mimic), endometrial, cervical, vulval, bowel and bladder cancer. Any change in the character of a long-standing pain, or a new mass, bloating, satiety or weight loss, reopens this.
Do not label by default"Probably endometriosis", "just IBS", "recurrent UTI" on negative cultures and "it's stress" all need positive evidence and a review date. Chronic pelvic pain is usually multifactorial — partial response to treatment more often means a second coexisting cause than treatment failure. Central sensitisation becomes part of the pathology in long-standing pain.
6
Refer routinely from this consultation Not same-day, not 999 — the cases that leave by letter
Routine gynaecology (NG73): suspected endometriosis with severe symptoms, or after a 3-month primary-care trial has failed; fibroids with pressure symptoms; an adnexal mass needing assessment; subfertility with pain. Specialist endometriosis centre (NG73): suspected deep endometriosis involving bowel, bladder or ureter — outcomes are materially better with the multidisciplinary team, and this referral is routinely missed. Pelvic health physiotherapy: reproducible levator tenderness, pelvic floor overactivity, pubic symphysis dysfunction, post-surgical scar or nerve pain. Pelvic pain clinic (NG193): long-standing pain with central sensitisation or opioid use — pain medicine, physiotherapy and psychology together, rather than another diagnostic laparoscopy. Sexual health: partner notification and complex or treatment-failure PID. Interim advice: start the treatment in section 7, begin a pain and cycle diary, and give the safety-net below.
7
The only treatment decisions that belong in this consultation Start treatment without waiting for diagnostic certainty
Ectopic, torsion, peritonism, septic PID, obstetric emergencyTransfer is the treatment. Nil by mouth, IV access if available, analgesia that does not delay transfer. Do not arrange an outpatient scan, do not remove an IUD, and do not start oral antibiotics in place of admission for febrile PID.
PID, systemically wellTreat empirically on clinical suspicion — do not wait for swabs (BASHH; swabs are frequently negative in genuine PID and each week of delay raises the risk of tubal infertility, ectopic pregnancy and chronic pain). Ceftriaxone 1 g IM single dose plus doxycycline 100 mg twice daily plus metronidazole 400 mg twice daily for 14 days; or ofloxacin 400 mg twice daily plus metronidazole 400 mg twice daily for 14 days. Partner notification, abstinence until both treated, review at 72 hours.
Suspected endometriosis or dysmenorrhoea — and the analgesic ceilingNG73: offer paracetamol and/or an NSAID for a 3-month trial (mefenamic acid 500 mg three times daily, or naproxen 250–500 mg twice daily with food), started just before the period. Do not wait for a scan or laparoscopy. If inadequate at 3 months, move to hormonal treatment: a combined hormonal contraceptive (consider continuous or tricycling) or a progestogen — desogestrel, medroxyprogesterone, or the 52 mg levonorgestrel IUS, particularly useful for adenomyosis with heavy bleeding. For neuropathic or centrally mediated pain: amitriptyline, duloxetine, gabapentin or pregabalin. Do not escalate opioids — NG193 recommends against initiating opioids for chronic primary pain; they cause dependence, constipation and hyperalgesia without improving chronic pelvic pain. Set goals of function and sleep, not abolition of pain.
Bladder pain syndrome or IBS-predominant painBladder: stop the unnecessary antibiotics, reduce caffeine, alcohol and acidic triggers, timed voiding and bladder retraining, amitriptyline 10–25 mg at night for pain. IBS: mebeverine or hyoscine butylbromide, soluble fibre, dietitian-led low-FODMAP trial, low-dose amitriptyline — but CA-125 first if the symptoms are new and she is ≥50.
Name the diagnosis and validate the painTreatment, not preamble. Explain the working diagnosis, the plan, the timescale, and explicitly that a normal scan does not mean nothing is wrong. Raise fertility early in endometriosis and PID. Add the non-drug components now: heat or TENS, pelvic floor relaxation rather than strengthening where the floor is overactive, pacing, sleep, and psychological therapy offered as pain management — never as a suggestion that the pain is imagined.
8
Endpoint and documentation Finish with one of four conclusions and a named owner

1 · Time-critical

999 or same-day EPAU/gynaecology route taken; pregnancy test result, LMP, observations, contraception and IUD status, previous ectopic, analgesia given, and who was spoken to.

2 · Serious cause possible

Same-day route or urgent test arranged; state the question being excluded and the deadline. CA-125 and ultrasound requested by name where indicated — or the urgent referral made without waiting for them.

3 · Benign cause established

Named diagnosis, treatment with dose and duration, PID partner notification, 3-month review booked as a decision point (not a repeat prescription), fertility conversation recorded, diary started, safety-net given.

4 · Unclassified

Uncertainty stated; all four systems considered and recorded; treatable elements treated; a normal CA-125 with persisting symptoms explicitly not treated as reassurance; review owner, date and escalation criteria.
Why a benign conclusion is safe today, in one line: negative pregnancy test (repeated if the LMP is uncertain) · normal observations, no peritonism, no mass and no ascites · no post-menopausal bleeding and a normal-looking cervix · the ovarian symptom cluster considered and CA-125 arranged where NG12 applies · a coherent cause with treatment started and a 3-month decision point booked · written safety-net given. Safety-net wording: call 999 if the pain suddenly becomes severe, you faint or feel faint, you get pain at the tip of your shoulder, or you bleed heavily; contact us the same day if you have a positive pregnancy test with any pain or bleeding, a fever with shivering, vomiting with the pain, or new swelling of your tummy — and come back if the pain changes character or the treatment has not helped by your review.
OOH / remote limitation. Convert to face-to-face or emergency assessment if a pregnancy test cannot be done; observations, abdominal examination or a speculum and bimanual examination are needed and cannot be obtained; a chaperone is not available where one is wanted; the pain is severe, sudden or changing during the call; she is pregnant or postpartum; or safeguarding concerns cannot be explored privately. Under time pressure the default is the safer destination.
Clinical decision support only; follow local emergency-transfer, safeguarding and referral policies and check doses against the current BNF. Source hierarchy: NICE guidelines first, then BNF/MHRA for doses and safety, then national specialty guidance. Sources: NICE NG73 Endometriosis: diagnosis and management · NG12 Suspected cancer: recognition and referral · CG122 Ovarian cancer: recognition and initial management · NG193 Chronic pain (primary and secondary) in over 16s · NG126 Ectopic pregnancy and miscarriage · NG88 Heavy menstrual bleeding · DG56 Quantitative faecal immunochemical testing · NICE guidance — Pelvic pain · RCOG Green-top 41 Chronic pelvic pain and GTG 21 Ectopic pregnancy · BASHH Pelvic inflammatory disease guideline · BNF. Review after any guidance or medicines-safety update, otherwise every 6 months. © Reasoning GP · gpreasoning.uk