Pelvic pain: causes, red flags and when to seek urgent help

The pelvis contains the womb, fallopian tubes and ovaries in women, the prostate and seminal vesicles in men, the bladder and the lower bowel, all surrounded by muscles, ligaments and nerves. Pain from any of these can feel similar, which is why clinicians pay close attention to timing, relationship to periods, sex, passing urine and opening the bowels, and to any bleeding or discharge.

This page concentrates on pain felt low in the tummy and pelvis in people with a womb, which is the commonest presentation, while recognising that urinary, bowel and musculoskeletal conditions can cause the same discomfort in anyone. Pain in the testicle has its own guide.

The NHS says an ectopic pregnancy is when a fertilised egg implants outside the womb, usually in a fallopian tube, and that it cannot be saved and usually has to be removed using medicine or an operation. The symptoms tend to develop between the 4th and 12th week and can include a missed period and other signs of pregnancy, tummy pain low down on one side, vaginal bleeding or a brown watery discharge, pain in the tip of the shoulder and discomfort when peeing or pooing. It advises contacting your GP or NHS 111 if you have a combination of these symptoms and might be pregnant, even without a positive test.

Call 999 or go to A&E immediately, the NHS says, for a combination of sharp, sudden and intense tummy pain, feeling very dizzy or fainting, feeling sick and looking very pale, because a fallopian tube may have ruptured. A rupture can be life threatening but is treatable if dealt with quickly.

• Call 999 or go to A&E if you think you have pelvic inflammatory disease symptoms and pain between the tummy and thighs is severe, getting worse, or hurts when you move or touch the area.

• Call 999 or go to A&E for pelvic pain with heavy vaginal bleeding, a sharp sudden intense pain in the lower tummy, pain under the right ribs and in the right shoulder, feeling dizzy or faint, a very high temperature or feeling hot, cold or shivery, or being sick and very unwell, as the NHS PID page advises.

• Call 999 or go to A&E for sudden sharp intense pain with fainting, sickness and paleness, which may indicate a ruptured ectopic pregnancy.

• Ask for an urgent GP appointment or contact NHS 111 for sudden severe pelvic pain, or pain in the tummy with nausea or vomiting; the NHS says this for ovarian cysts, since a cyst can split or twist.

• Ask for an urgent GP appointment or contact NHS 111 if period or pelvic pain is severe or worse than usual and painkillers have not helped, or if pelvic pain keeps coming and going and PID is possible.

• See a GP if periods become more painful, heavier or irregular, pain interferes with daily life, you have pain during sex or when peeing or pooing, bleeding between periods, a swollen tummy, loss of appetite or unexplained weight loss, as the NHS period pain page lists.

• Tell the clinician at once if you could be pregnant, are using an IUD or have a new partner and unusual discharge.

Expect questions about the pain pattern (constant, cyclical, with sex, with periods or bowel movements), your cycle and last period, contraception including any coil, pregnancy possibility, discharge, bleeding, urinary and bowel symptoms, sexual partners, previous infections or surgery, and family history of endometriosis. The NHS says a GP may ask about recent sexual partners, the contraception you use and whether you could be pregnant.

The examination includes the tummy and pelvis, and often a vaginal examination with a speculum and swabs for infection. You can ask for a female doctor and for a chaperone, and you are in control of the examination and can ask the doctor or nurse to stop at any time, as the NHS PID page states.

A pregnancy test is almost always the first test in someone who could be pregnant. The NHS lists blood tests, a pregnancy test, an ultrasound scan and referral to a sexual health clinic for suspected PID. Ultrasound, which may be done on the tummy or inside the vagina, is the usual imaging test for cysts, fibroids and endometriosis, and the NHS says an MRI scan or a laparoscopy, in which a camera is passed through a small cut in the tummy, can confirm endometriosis and sometimes allow it to be treated at the same time.

For an ovarian cyst the NHS says a probe-based ultrasound is usual, with a repeat scan in a few weeks or gynaecology referral if a cyst is found; blood tests for cancer-related chemicals are done if there is concern, and high levels do not necessarily mean cancer because endometriosis, a pelvic infection, fibroids and periods can raise them too.

For period pain the NHS suggests a warm bath or shower, a heat pad or hot water bottle wrapped in a tea towel, massage, gentle exercise such as yoga, swimming, walking or cycling, and painkillers such as paracetamol or ibuprofen. A GP may recommend stronger anti-inflammatory medicines, a TENS machine, or contraception that thins the womb lining. Antibiotics are the usual treatment for PID, and the NHS says that if diagnosed early it can be easily treated.

Endometriosis cannot be cured, but the NHS says treatment can manage symptoms, starting with painkillers and hormones and progressing to surgery if other treatments do not work. Ovarian cysts often disappear within a few months, with surgery reserved for large, symptomatic or potentially cancerous cysts. Persistent pelvic pain with no clear cause often benefits from a multidisciplinary approach including pelvic physiotherapy and pain management.